URINARY TRACT INFECTIONS, PYELONEPHRITIS, AND BACTERIURIA



 

A 23-year-old primigravida at 31 weeks’ gestation comes to the birthing unit with complaints of flank pain, nausea, vomiting, and shaking chills for the past 12 h. She has been diagnosed with sickle cell trait. On examination her temperature is 103°F, pulse 125 beats/min, and respirations 30 breaths/min. Her skin is grossly diaphoretic and she has exquisite right costovertebral angle tenderness. Electronic fetal monitoring shows baseline heart rate 170/min with reactivity. Uterine contractions are noted every 10 min.

 

 

Definition. UTIs may involve either the lower tract (including the bladder or urethra) or the upper tract (including the kidney). The most common organisms are gram-negative enteric bacteria withEscherichia colithe most frequent.

 

 

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Chapter 10 l Medical Complications in Pregnancy


 

 

Risk Factors. Pregnancy is a risk factor. Others include mechanical urinary obstructions andsystemic diseases (such as sickle cell trait/disease, diabetes mellitus, and gout).

Asymptomatic Bacteriuria

 

This is the most common UTI in pregnancy.

 

Clinical Findings. No symptoms or signs are present.

 

Significance. If not treated, 30% of cases will develop acute pyelonephritis.

 

Diagnosis. Made with a positive urine culture showing >100K colony-forming units (CFU) ofa single organism.

 

Treatment. Single-agent, outpatient oral antibiotics.

 

Acute Cystitis

 

This is a UTI localized to the bladder without systemic findings.

 

Clinical Findings. Urgency, frequency, and burning are common.

 

Significance. If not treated, 30% of cases will develop acute pyelonephritis.

 

Diagnosis. Made with a positive urine culture showing >100 K CFU of a single organism.

 

Treatment. Single-agent, outpatient oral antibiotics.

Acute Pyelonephritis

 

This is a UTI involving the upper urinary tract with systemic findings. This is one of the most common serious medical complications of pregnancy.

 

Symptoms. Include shaking chills, anorexia, nausea, vomiting, and flank pain.

 

Signs. Include high fever, tachycardia, and costovertebral angle tenderness (R>L).

 

Significance. Preterm labor and delivery can occur. Severe cases are complicated by sepsis, ane-mia, and pulmonary dysfunction, sometimes requiring ICU care, including intubation.

 

Diagnosis. Confirmed with a positive urine culture showing >100 K CFU of a single organism.

 

Treatment. Hospital admission, generous IV hydration, parenteral antibiotics e.g., ceftriaxone,and tocolysis as needed.

 

 

THROMBOPHILIAS

 

A 26-year-old G4 P1 Ab2 woman comes in for her first prenatal visit at 8 weeks’ gestation by dates. Her first pregnancy was a spontaneous first-trimester loss, for which she underwent a D&C. Her second pregnancy resulted in an unexplained fetal demise at 30 weeks’ gestation. Labor was induced with PGE2. The fetus was normal in appearance, without congenital anomalies. Autopsy on the fetus was unremarkable. Her last pregnancy was also a spontaneous first-trimester loss. Her sister has a history of recurrent deep venous thrombosis.

 

 

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OB Triad

Asymptomatic Bacteriuria

 

• No urgency, frequency, or burning

 

• No fever

 

• Urine culture (+)

 

OB Triad

Acute Cystitis

 

• Urgency, frequency, and burning

 

• No fever

 

• Urine culture (+)

 

 

OB Triad

Acute Pyelonephritis

 

• Urgency, frequency, and burning

 

• Fever and costovertebral angle tenderness (CVAT)

• Urine culture (+)

 

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Description. The thrombophilias are a group of disorders that promote blood clotting, becauseof either an excess of clotting factors or a deficiency of anticlotting proteins that limit clot for-mation. Prevalence is as high as 20% of the population, but most individuals are asymptomatic. Some will develop deep vein thrombosis or venous thromboembolism (VTE) that can become life-threatening. Risk factors include immobilization, surgery, or pregnancy.

Pregnant women with a thrombophilia are also at higher risk than other pregnant women of developing a VTE. Pulmonary embolus is the leading cause of maternal death in the United States. More than half of pregnant women who develop a pulmonary embolus or other VTE have an underlying thrombophilia.

 

Diagnosis. Indications for testing are history of VTE or first-degree relative with high-riskthrombophilia or VTE age <50 years.

 

Inherited thrombophilias to test for: Factor V Leiden (FVL) mutation, prothrombingene mutation (PGM) G2021 OA, protein C deficiency (PCD), protein S deficiency (PSD), antithrombin deficiency (ATD)

 

High risk thrombophilias include homozygous FVL or PGM; compound heterozy-gote FVL & PTM; and all ATD

 

Low risk thrombophilias include heterozygous FVL or PGM; and all PCD & PSD

 

Acquired thrombophilias to test for: Antiphospholipid Syndrome (APS).

 

One or more of the following 3 antiphospholipid antibodies must be positive on ≥2 occasions at least 12 weeks apart.

 

– Lupus anticoagulant

 

– Anticardiolipin antibody (lgG & IgM)

– Anti-b2-glycoprotein 1 (lgG & IgM)

 

Treatment. Anticoagulation options:

 

Unfractionated heparin (UFH) can be used antepartum & postpartum

 

– Advantages: inexpensive, can be reversed with protamine sulfate,

 

– Disadvantages: cannot use orally, short half-life, needs monitoring with aPTT levels, heparin-induced osteopenia, heparin-induced thrombocytopenia (HIT)

 

Low molecular weight heparin (LMWH) can be used antepartum & postpartum

 

– Advantages: longer half-life, less need for monitoring with antifactor Xa levels

 

– Disadvantages: cannot use orally, higher cost, can not be reversed

 

Warfarin/coumadin can be used only postpartum

 

– Advantages: oral administration, long half-life, inexpensive, OK for breast feeding

 

– Disadvantages: crosses placenta, needs monitoring with INR,

 

For anticoagulation medications, use the following guidelines:

 

Antepartum: Use LMWH from first trimester to 36 weeks; then at 36 weeks transition to UFHuntil delivery

 

None or prophylactic dose

 

Low-risk thrombophilia without VTE episode

 

Prophylactic or intermediate-dose

 

Low-risk thrombophilia with single VTE episode

 

High-risk thrombophilia without VTE episode

 

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Chapter 10 l Medical Complications in Pregnancy

 

 

Therapeutic dose

 

• High-risk thrombophilia with single VTE episode

 

• Any thrombophilia with VTE in current pregnancy

Intrapartum

 

• Discontinue UFH during immediate peripartum interval to decrease risk of hemor-rhage and permit regional anesthesia

 

• Protamine sulfate can be used to reverse UFH effect

 

Postpartum

 

• VTE risk increased 20-fold in the first week postpartum.

 

• All patients at risk should be receive postpartum anticoagulation even if they did not receive it antepartum.

 

• Resume anticoagulation 6 hours after vaginal delivery and 12 hours after cesarean section.

 

• Coumadin is safe for breastfeeding moms

 


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