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Urinary tract infection during pregnancy treatment. Urinary tract infections: asymptomatic bacteriuria. Treatment of cystitis in pregnant women

About 7% of all pregnant women suffer from urinary tract infections, and 2% have inflammation of the renal pelvis (pyelonephritis). Approximately 30% of pregnant women carry urinary tract infections undetected. In general, this is one of the most frequent complications of pregnancy and more serious than anemia (anemia), premature bleeding and contractions.
Untreated urinary tract infections can be a source of future problems. Dialysis is often the result of poorly treated inflammation of the renal pelvis.
At the body level, the cause of this disease during pregnancy can be explained in terms of mechanics: the pressure of the uterus on the renal pelvis and ureters provokes urinary stagnation and creates ideal conditions for the "subversive" activity of infectious agents. Like life, bodily fluids must also flow. Where they stagnate, there is a threat of infection, which again is an expression of conflict. This is why it is so important to have regular urinalysis.
At the level of the soul, the bladder is a wastewater collector and is the first to indicate that a person is under pressure. In the kidneys, first of all, problems in partnerships appear. That is, we are dealing with two fundamental problem clusters of our time.
Pregnant women are under tremendous pressure today, and partnerships are not as reliable as they once were. In Austria, an example of which is quite indicative in this regard, the divorce rate is 40%, specifically in Vienna - even 50%, in a number of other regions - 70%, and it does not stand still. And if earlier the parents had four children, today, rather, children have four parents.
In modern society, the pressure on the pregnant woman has increased - both collectively and individually - as the growing double burden of motherhood and career presses on her. If pressure also arises in partnerships, then the pregnant woman, for understandable reasons, will tend to displace it, rather than meet with an open visor, and the conflict can "move" into the body. A mother's nest-building instinct and concern for the protection and safety of her baby naturally reinforce her tendency to hide, hide and remain silent.
Added to the above is an increased susceptibility to mental wastewater. A pregnant woman reacts incomparably more sharply even to news on television and radio, and what she does not allow to "drain" gets stuck in the urogenital area and easily becomes inflamed against the background of conflicts.
Almost always we are dealing with the so-called ascending urinary tract infections - from the vagina to the bladder, and from there to the renal pelvis. And since the tissues are loosened, penetration through the intestinal walls is also possible. Microorganisms, completely harmless in the intestinal environment, can provoke serious problems elsewhere. Thus, at the level of meaning, we are talking about conflicts that in all respects come "from below". Whether they rise from the bladder, whether they penetrate from the intestines, they move from the “latrine”, that is, from the darkest, deepest sphere of the body, and, therefore, correspond to the shadow theme. Naturally, in such a new situation as pregnancy, everything that has not been worked out and pushed into the depths of the psyche easily floats to the surface, since the soul, like the body, wants to get rid of any ballast in order to approach the moment of childbirth as less burdened as possible.
If there is a partner next to a woman who at this stage does not see his task in unloading her and helping her to find balance, and who, in fact, does the opposite, then the unconscious conflict in the field of partnership and internal balance easily goes to the level of the body.
It also happens that a woman feels as if her partner is making exorbitant sexual demands on her, and does not dare to bring this conflict up for discussion, as, for example, with the so-called honeymoon cystitis.
In a society in which such topics come to the fore, this picture of the disease as a whole indicates problems with internal balance, proportionality and harmony in partnerships. Many relationships and marriages, obviously, do not bring these valuable qualities, not only to the situation of building a nest, but also to the very sacrament of conceiving a new life.

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Infections are more likely late in pregnancy, but can occur at any time during pregnancy. As already mentioned, the weight of the uterus, in addition to pressing on the vena cava, can also squeeze the tubes (ureters) that carry urine from the kidneys to the bladder. Like a garden hose that has been stepped on, pipes can stretch when compressed to what is called a physiological hydroureter of pregnancy. It is fertile ground for bacteria that gather and thrive here. A bladder infection differs from a kidney infection in that the bladder is a muscular vessel from which you pee, and your kidneys are an active, complex organ that has many functions besides cleaning your blood of unnecessary substances. It is difficult for antibiotics to reach them (the end of the biochemical road), and those that manage to do so in sufficient concentration are constantly expelled along with the waste. With a kidney infection, you will be admitted to the hospital for a course of intravenous antibiotics.
Do all kidney infections start in the bladder and then travel to the kidneys? No. There are infections only of the bladder and only of the kidneys, individual infections caused even by different bacteria.

The classic symptom of a kidney infection is pain in the middle of the back, left or right, that is sensitive to touch. The diagnosis is made when there are accumulations of white blood cells (pus), red blood cells, or bacteria in the urine. A sample taken with a catheter is more reliable because simple urination can introduce common bacteria on the skin into the sample. Antibiotics that are not dangerous for pregnancy are used until an analysis is ready, which consists in growing bacteria from urine and then exposing them to many antibiotics. If you have been prescribed an antibiotic that the bacteria are resistant to, then it's time to switch to another.
A kidney infection (pyelonephritis) can be quite difficult: A high temperature is possible, of the order of 39-40 degrees, and this temperature fry your red blood cells, causing rapidly progressive anemia. Usually, after the temperature returns to normal, IV antibiotics are replaced with oral antibiotics and you leave the hospital.
Infections of just (just?) The bladder are treated with oral antibiotics. Bladder infections are common during pregnancy, when swelling can make the opening of the urethra (when urinating) more open to the outside world and all its dangers. In addition, there is a mechanical irritation of the bladder by your child, which forces you not only to frequent the toilet, but at the first opportunity, using this hidden process, will trigger an infection. It is also not very good that your bladder on the other front receives punishment from the penis from time to time. You can relive honeymoon cystitis again! You ask, why on earth are you designed so that so many important things are stuffed in the same place.
For some reason, women with bladder infections are more prone to preterm labor. If you complained of unexpected contractions, you would have a urinalysis done to check your urinary tract for infection.

It's just that your pregnancy and urinary tract don't get along well. In addition to the possible retention of urine in the first trimester and the postpartum period, there is also incontinence of the third trimester. All this happens due to the violation of anatomy, when two people use the territory of one.
As mentioned, your body cannot stand standing water. If you have urinary retention (urine stays in the bladder after you empty it), this provides a fertile ground for infection. During pregnancy, you are more prone to infection and the usual symptoms are not always present. Instead of a burning sensation when urinating, you may experience pressure in your bladder, urge to urinate, and even increased urination (which is a sneaky joke because you are writing your brains out for pregnancy anyway).
A bladder infection is important to treat because it can cause contractions that can be mistaken for premature birth.

Kidney infection
Any bladder infection can literally rise up to become a kidney infection, but the latter can happen on its own. The bladder is just a muscle sac (my apologies to specialists), and the kidneys are a complex organ. Infection with one of these is a serious problem, usually requiring IV antibiotics in the hospital. Your doctor may also invite a urologist.

Hydroureter
How can something that sounds so awful be so commonplace? The weight of your uterus puts pressure on your ureters (the tubes that carry urine from your kidneys to your bladder). This results in partial obstruction and distension of the ureters in addition to uterine obstruction, causing severe flank pain. While this is normal, it can be very painful. Tubes, designed to carry anything through the system, complain when they are stretched - be it gas colic in the intestines, a stone in the bile duct, or obstruction of the ureter (caused by a stone or pregnancy pressure on it). If the obstruction is severe enough to obstruct urine removal, a tube, called an endoprosthesis, may need to be inserted to keep the canal open. This endoprosthesis is a temporary remedy. It can be removed if it hurts itself or increases the chance of infection.

Hydronephrosis
This is the same mechanism as with hydroureters, only the "retained" fluid can cause a congestion in the kidneys. The use of an endoprosthesis provides the same relief.

Kidney stones
Because kidney stones are more likely to affect men than women, they are not, in fact, a problem with pregnancy. But they are possible. Usually composed of calcium, they should be suspected if a kidney infection does not respond appropriately to antibiotic therapy. A kidney stone acts like a foreign body, making it difficult to treat the infection. The real possibility of having kidney stones during pregnancy is one in thousands.

Kidney pathology is often found during the period of bearing a child, because pregnancy itself predisposes to the development of these diseases or exacerbation of pre-existing chronic processes.

The main causes of changes in the urinary system during pregnancy:

  1. Hormonal changes(an increase in the synthesis of progesterone, estrogens, glucocorticoids, chorionic gonadotropin);
  2. Weakening of the ligamentous apparatus of the kidney, which leads to the development of her pathological mobility;
  3. Change in topographic and anatomical relationships due to an increase in the size of the uterus and its deviation to the right side. In this regard, great pressure is exerted on the area of ​​the right kidney;
  4. Decreased tone and contractions of the ureters from the second trimester of pregnancy.

To the most common diseases of the urinary system during pregnancy include:

  1. Glomerulonephritis;
  2. Urolithiasis disease;
  3. Asymptomatic bacteriuria.

Complications of diseases of the urinary system

dangerous Diseases of the urinary system during pregnancy pose a great danger, both for the development of the child and for the health of the woman herself, and lead to a number of serious complications.

  1. Severe gestosis;
  2. Chronic fetal hypoxia;
  3. Intrauterine infection of the fetus;
  4. Intrauterine fetal death.

Pyelonephritis

Pyelonephri t is an infectious kidney disease that affects the calyx-pelvis system. Infection can spread by hematogenous (from the gallbladder, carious teeth, pharyngeal tonsils) or ascending (from the urethra and bladder). Causative agents this disease are Pseudomonas aeruginosa, Proteus, Escherichia coli, Staphylococcus aureus, Candida fungi.

Clinical picture

Pyelonephritis during pregnancy may appear for the first time (acute form) or be an exacerbation of a pre-existing chronic process. Most often, this disease appears in the periods of 12-14, 24-28, 32-34 and 39-40 weeks, often develops in the first days after childbirth.

Symptoms of the acute form of pyelonephritis:

  1. Sudden onset of the disease;
  2. (up to 39-40 degrees Celsius);
  3. Expressed deterioration in health;
  4. Terrific chill followed by cold sweat;
  5. , decreasing when taking a forced position (with legs pressed to the stomach).

With chronic course disease symptoms are practically not pronounced, sometimes pulling pains in the lumbar region may appear. With an exacerbation of the disease, the clinical picture is similar to the signs of an acute form of pyelonephritis.

Diagnostic measures for suspected pyelonephritis

  1. (characterized by an increase in the number of leukocytes, ESR, stab forms, a drop in the level of hemoglobin);
  2. Biochemical blood test (possibly in severe cases, an increase in the level of urea and creatinine);
  3. (characterized by an increase in the level of leukocytes, the appearance of protein and bacteria, an increase in the number of red blood cells is possible);
  4. Urine analysis according to Nechiporenko (increase in the number of leukocytes);
  5. Analysis of urine according to Zimnitsky (characterized by a violation of the concentration function of the kidneys);

Treatment of pyelonephritis during pregnancy

To determine the tactics of treating pyelonephritis, it is important to determine the degree of risk for a woman:

  1. First degree(uncomplicated first-onset pyelonephritis);
  2. Second degree(chronic form of uncomplicated pyelonephritis);
  3. Third degree(complicated pyelonephritis or pyelonephritis of a single kidney).

important With the third degree of risk, further preservation of pregnancy is strictly prohibited, because there is a high risk to a woman's life.

Treatment activities:

  1. Drinking mineral waters;
  2. Antibiotic therapy, taking into account the possible risk to the fetus;
  3. Antispasmodic drugs (,);
  4. (bearberry, kidney tea);
  5. (suprastin, diphenhydramine);
  6. Detoxification therapy (rheopolyglucin, albumin);
  7. Physiotherapy;
  8. Catheterization of the ureters in the absence of the effect of the treatment.

Glomerulonephritis

Glomerulonephritis Is an infectious and allergic disease that causes damage to the glomerular apparatus of the kidneys. Causative agent the disease is hemolytic streptococcus. Most often, glomerulonephritis occurs 2-3 weeks after angina, scarlet fever, erysipelas.

Clinical picture

Glomerulonephritis can also be acute and chronic.

The main symptoms of the acute form and exacerbation of the chronic form:

  1. Deterioration of health, headaches;
  2. Increased blood pressure;
  3. Frequent urination;
  4. Swelling on the face, legs, anterior abdominal wall.

Diagnostic measures for suspected glomerulonephritis

  1. (characterized by an increase in the number of leukocytes, eosinophils, a decrease in platelets);
  2. Biochemical blood test (characterized by an increase in the level of urea, creatinine, gamma globulins);
  3. Coagulogram of venous blood (shortening of prothrombin time, increasing prothrombin index);
  4. (characterized by a decrease in the volume of urine, an increase in the relative density, the appearance of protein, traces of blood, a change in the color of urine to red or the color of "meat slops");
  5. Immunological tests (increased levels of immunoglobulins M and A, circulating immune complexes, high titer of antibodies to antigens of hemolytic streptococcus).

Treatment of glomerulonephritis during pregnancy

At the onset of the disease in the early stages of pregnancy, a thorough examination of the woman is necessary and a decision on the possibility of maintaining the pregnancy is necessary.

dangerous In acute glomerulonephritis, termination of pregnancy is indicated, regardless of the gestational age. An exacerbation of the chronic form with a pronounced increase in blood pressure and impaired renal function is also a contraindication for maintaining pregnancy.

Treatments for glomerulonephritis:

  1. Antibacterial therapy;
  2. Antihypertensive drugs (calcium antagonists, alpha and beta blockers);
  3. Diuretic drugs;
  4. Complete fortified food with restriction of salty, spicy, smoked, fatty foods;
  5. Physiotherapy;
  6. Antiplatelet agents (,);
  7. Intravenous administration of protein preparations (albumin, dry plasma, protein).

Urolithiasis disease

Urolithiasis disease Is a disease manifested by the formation of stones in the kidneys and other organs of the urinary system. Infections play an important role in the development of this pathology, so, for example, about 80% of cases of pyelonephritis are complicated by the development of urolithiasis. Changes in urodynamics during pregnancy, in turn, also contribute to the development of the disease.

Clinical picture

The clinical picture of urolithiasis is presented three classic signs:

  1. Sudden onset of lower back pain radiating to the groin, labia, leg;
  2. Blood in the urine
  3. Removal of stones.

Renal colic is characterized by severe pain, therefore, patients take a forced position, slightly alleviating the condition (on the side, knee-elbow position).

Diagnostic measures

During pregnancy, a detailed diagnosis of urolithiasis can be difficult due to the lack of the possibility of a comprehensive examination: for example, X-ray examination is contraindicated when carrying a child.

Diagnosis is based on the following symptoms:

  1. Clinical picture;
  2. Positive Pasternatsky's symptom (soreness when tapping in the lumbar region with subsequent hematuria);
  3. (the presence of erythrocytes, leukocytes, crystals is characteristic);

Treatment of urolithiasis

Surgical treatment during pregnancy is carried out only in emergency cases:

  1. Long-term non-relieved colic;
  2. Lack of urine outflow;
  3. Signs of acute pyelonephritis.

information In most cases, treatment consists in stopping an attack of renal colic and relieving pain by prescribing antispasmodic drugs (no-shpa, papaverine, baralgin).

Asymptomatic bacteriuria

Asymptomatic bacteriuria- This is a condition in which a certain number of microorganisms exceeding normal values ​​are found in the urine of women, in the absence of clinical symptoms. The number of microorganisms must exceed 100,000 in 1 ml of urine on two subsequent urine tests.

When diagnosing this condition, it is necessary to carry out comprehensive examination of a woman to exclude diseases of the urinary system:

  1. Sowing urine for flora;
  2. Urine analysis according to Nechiporenko;
  3. Urine analysis according to Zimnitsky;
  4. Ultrasound of the urinary system.

To prevent possible infectious complications, it is necessary to carry out antibacterial treatment taking into account the possible risk to the fetus.

Prevention of diseases of the urinary system

  1. Regular monitoring of the general analysis of urine;
  2. Examination to exclude the presence of diseases of the urinary system during the planning period of the child;
  3. Drinking enough fluids;
  4. Compliance with a rational diet with the exception of spicy, fatty, salty foods;
  5. Avoid hypothermia;
  6. Timely treatment of infectious diseases under the supervision of a physician.

Every tenth pregnant woman suffers from some type of urinary tract infection. Among them, the most common are acute cystitis and pyelonephritis. The latter is especially dangerous for the expectant mother and baby. We will discuss how to identify and treat these diseases in this article.

Urinary tract infections: why are pregnant women at risk?

In the body of the expectant mother, various changes occur in all organs. After all, they now have to work for two, or even three. In addition, during pregnancy, conditions are created that contribute to the development of certain diseases. Here are the factors that predispose to urinary tract infections (UTIs):

  • mechanical compression of the uterus of the urinary tract, primarily of the ureters, which contributes to the violation of the passage of urine, its stagnation and the multiplication of various pathogens;
  • a decrease in the tone of the ureters and bladder due to an increase in the level of progesterone, a hormone that supports the growth of the fetus;
  • excretion of sugar in the urine (glucosuria) and an increase in its acidity (ph), which supports the growth and reproduction of various microorganisms;
  • decrease in general and local immunity.

The result of these processes are infectious processes of the lower (cystitis, urethritis, asymptomatic bacteriuria) and upper (pyelonephritis and kidney abscess) of the urinary tract.

In 60-80% of pregnant women, MEP infections are caused by E. coli, in the remaining 40-20% - Klebsiela, proteus, staphylococcus, streptococcus, enterobacter, etc.

The consequences of urinary tract infections during pregnancy can be very tragic. Here are the main complications:

  • anemia (decreased hemoglobin levels);
  • hypertension (increased blood pressure);
  • premature birth;
  • early rupture of amniotic fluid;
  • the birth of children with low body weight (less than 2250 g);
  • fetal death.

Considering the danger of urinary tract infections, it is necessary to carefully approach the issue of their timely detection.

Urinary Tract Infections: Common Urinalysis

As you know, the main method for assessing the state of the urinary system is the general analysis of urine. Diagnosis of urinary tract infections is based on the identification of leukocytes (leukocyturia) or pus (pyuria) in the general analysis of urine - the main signs of an existing inflammatory process.

The presence of leukocyturia is indicated when 6 or more leukocytes are detected in the remainder of centrifuged urine in the field of view of the microscope.

However, the method is not always informative. Therefore, in some cases, additional examination is required to clarify the diagnosis.

Urinary tract infections: asymptomatic bacteriuria

The problem is that most expectant mothers with an existing urinary tract infection are not worried about anything. The absence of complaints in the presence of a large number of pathogens in the urine is called asymptomatic bacteriuria. This condition is detected, on average, in 6% of pregnant women (from 2 to 13%) and is characterized by a high frequency of development of acute cystitis, pyelonephritis and the onset of complications: premature birth, birth of a baby with low body weight, etc.

To detect bacteriuria, a general urine test alone is not enough, since in this condition, leukocyturia (pyuria) may be absent.

As an additional screening, it is necessary to use a culture (bacteriological, or culture, study) of urine. Asymptomatic bacteriuria is diagnosed in the presence of a large number of microorganisms (more than 10 5 CFU / ml) of the same type in crops of an average portion of urine collected in compliance with all the rules, taken twice with an interval of 3-7 days and the absence of a clinical picture of infection.

Given the asymptomatic course of bacteriuria, screening bacteriological examination of urine is necessary for all pregnant women at the first visit to the doctor in the first trimester or early II (16-17 weeks), when the uterus extends beyond the pelvic floor.

With a negative result, the risk of subsequent development of cystitis or pyelonephritis is only 1-2%, therefore, in this case, further culture studies of urine are not carried out. If the diagnosis of asymptomatic bacteriuria is confirmed, antibacterial treatment is prescribed, which I will discuss later.

Urinary Tract Infections: Acute Cystitis

Acute cystitis is an inflammation of the mucous membrane of the bladder with impaired function. In this case, the patient develops complaints characteristic of this disease:

  • cramps when urinating,
  • frequent urge
  • feeling of incomplete emptying of the bladder,
  • discomfort or pain in the lower abdomen.

If a woman has these symptoms, she needs to see a doctor. Diagnosis of acute cystitis is based on a complete clinical examination of urine, primarily on the detection of leukocyturia (pyuria). For this purpose, the following methods are performed:

  • general urine analysis;
  • examination of a non-centrifuged midstream urine sample; allows you to detect an infection with normal indicators of a general urine test; the presence of infection is indicated by the content of more than 10 leukocytes in 1 μl of urine;
  • urine culture; in acute cystitis, bacteriuria is detected (for E. coli - more than 10 2 CFU / ml, for other microorganisms - more than 10 5 CFU / ml).

Urinary tract infections: treatment of asymptomatic bacteriuria and acute cystitis

Treatment of asymptomatic bacteriuria and acute cystitis is carried out on an outpatient basis, these conditions do not require hospitalization. It is especially necessary to be careful about the selection of an antibacterial drug, because it must be not only effective, but also safe.

The choice of medicines is made by the doctor. For the treatment of asymptomatic bacteriuria or acute cystitis, fosfomycin trometamol (monural) 3 g is prescribed once or a 7-day course of one of the following antibiotics:

  • amoxicillin / clavulanate 375-625 mg 2-3 times a day;
  • cefuroxime axetil 250-500 mg 2-3 times a day;
  • ceftibuten 400 mg once a day;
  • cefixime 400 mg once a day;
  • nitrofurantoin 1000 mg 4 times a day.

After 7-14 days from the start of treatment, urine culture is performed. If, according to the results of the analysis, a positive effect is confirmed, then no further treatment is required, and the patient remains under the supervision of a doctor. At the same time, once a month, she needs to take a control urine culture.

If the treatment is ineffective, the woman is prescribed the so-called "suppressive" (suppressive) therapy until the end of pregnancy and within 2 weeks after delivery with monthly bacteriological control. Recommended schemes of "suppressive" therapy: fosfomycin trometamol (monural) 3 g every 10 days or nitrofurantoin 50-100 mg once a day.

Also, if the antibacterial treatment performed is ineffective, it is necessary to exclude urolithiasis and strictures (narrowing) of the ureter, aggravating the infectious process. In this case, the question of the need for catheterization of the ureters is resolved - the introduction of a catheter into them.

Urinary tract infections: acute and chronic pyelonephritis

20-40% of pregnant women with lower urinary tract infections (cystitis, urethritis, asymptomatic bacteriuria) develop acute pyelonephritis, an inflammatory kidney disease characterized by damage to the cups and pelvis with impaired organ function.

Gestational pyelonephritis often occurs in the II and III trimesters, relapses are noted in 10-30% of pregnant women. In the majority (75%) of women, only the right kidney is affected, in 10-15% - only the left, in 10-15% - both.

In addition to urinary disorders, acute pyelonephritis, in contrast to cystitis, has pronounced general manifestations. Here are the main complaints of patients with this disease:

  • a sharp increase in body temperature, chills,
  • nausea, vomiting,
  • weakness, lethargy,
  • pain in the lumbar region,
  • muscle aches and headaches,
  • decreased appetite.

In the general analysis of urine, in addition to leukocyturia, protein and erythrocytes can be detected. Laboratory markers of pyelonephritis in urine examination, including microscopy and bacteriological culture, are similar to those in acute cystitis:

  • leukocyturia (more than 10 leukocytes in 1 μl of non-centrifuged urine);
  • bacteriuria (the number of microorganisms is more than 10 4 CFU / ml).

Also, to assess the patient's condition, a clinical and biochemical blood test is performed, in which the following can be found:

  • an increase in the level of leukocytes,
  • decrease in hemoglobin,
  • acceleration of ESR,
  • an increase in the concentration of urea and creatinine, etc.

Urinary tract infections: management of pregnant women with acute pyelonephritis

Unlike cystitis, treatment of pyelonephritis is carried out exclusively in a hospital setting, since there is a high probability of the onset of complications that are formidable and dangerous for the mother and baby. Thus, 2% of patients with gestational pyelonephritis may develop septic shock, a severe life-threatening condition. All this confirms the need for special monitoring of the condition of the mother and baby.

In the urology department, the patient is monitored for vital functions (respiration, blood circulation, etc.), bacteriological examination of blood and urine. One of the following antibiotics is also given intravenously:

  • amoxicillin / clavulanate;
  • cefuroxime sodium;
  • ceftriaxone;
  • cefotaxime.

The duration of antibiotic therapy for pyelonephritis should be at least 14 days: intravenous administration is carried out within 5 days, then they switch to tablet preparations.

The lack of improvement within 48-72 hours can be explained either by obstruction of the urinary tract (urolithiasis or narrowing of the ureter), or by the resistance (resistance) of microorganisms to the treatment.

In the first case, it is necessary: ​​catheterization of the ureter with its narrowing, surgical treatment - with urolithiasis; in the second, the change of the antibacterial drug under bacteriological control.

Also, if the treatment is ineffective, it is necessary to prescribe "suppressive" therapy or conduct a culture of urine every 2 weeks before delivery.

Urinary tract infections: treatment errors

Unfortunately, the treatment of urinary tract infections is not always correct. Among the mistakes in the choice of therapy, the most often noted: the use of unsafe and / or ineffective antibiotics. In this regard, I give a list of antibiotics that cannot be used during pregnancy:

  • sulfonamides (cause destruction of red blood cells and anemia in newborns);
  • trimethoprim (lead to a deficiency in the body of folic acid, which is responsible for protein metabolism and cell division);
  • nitrofurans (destroy red blood cells in the third trimester of pregnancy);
  • aminoglycosides (have a toxic effect on the kidney organ of hearing);
  • quinolones and fluoroquinolones (cause joint pathology);
  • nitroxols (provoke multiple damage to the nerves, including the visual one).

It is also important to know that according to the multicenter study ARIMB (2003) in Russia, E. coli is resistant to the following antibiotics: apmicillin - in 32% of pregnant women, co-trimoxazole - in 15%, ciprofloxacin - in 6%, nitrofurantoin - in 4%, gentamicin - in 4%, amoxicillin / clavulanate - in 3%, cefuraxime - in 3%, cefotaxime - in 2%. Resistance to ceftibuten and fosfomycin has not been identified.

The factors of resistance and toxicity should be known not only to doctors, but also to pregnant women suffering from urinary tract infections.

Love yourself! Appreciate your health! Use the most modern medical advances!

MOSCOW GOVERNMENT DEPARTMENT OF HEALTH

DIAGNOSTICS AND TREATMENT OF URINARY TRACT INFECTION IN PREGNANT WOMEN

Chief Nephrologist, Department of Health

N.A. Tomilina

Moscow 2005

Developer Institution: Sechenov Moscow Medical Academy, Department of Nephrology and Hemodialysis, Faculty of Postgraduate Professional Education of Doctors

Compiled by: Ph.D. N.B. Gordovskaya, Ph.D. N.L. Kozlovskaya, MD V.A. Rogov, edited by:

d.m.s. Professor E.M. Shilova, MD Professor T.A. Protopopova

Reviewer: Head of the Department of Nephrology of the Russian Academy of Postgraduate Education, Dr. med. Professor V.M. Ermolenko

Purpose: for general practitioners of polyclinics and general hospitals, antenatal clinics and maternity hospitals, obstetricians-gynecologists

This document is the property of the Department of Healthcare of the Moscow Government and may not be replicated or distributed without permission.

Introduction

Urinary tract infection (UTI) is a general term that reflects the introduction of microorganisms into a previously sterile urinary system. UTIs are common in outpatient and nosocomial practice and mainly affect women. The prevalence of UTIs in them increases with age, amounting to 20% at the age of 16-35 and 35% at the age of 36-65 (in men, respectively, 1 and 20%).

The high frequency of UTI in women is due to the anatomical, physiological and hormonal characteristics of the female body. These include:

- short urethra;

- the proximity of the urethra to the rectum and genital tract, which are highly colonized by various microorganisms;

- violation of hormonal levels due to the use of oral contraceptives;

- atrophy of the vaginal mucosa, a decrease in pH, a decrease in mucus formation, a weakening of local immunity, a violation of microcirculation in the pelvic organs during menopause.

During pregnancy, additional factors appear that contribute to the high incidence of UTIs. It:

- hypotension and enlargement of the PS of the ureter, noted already in early pregnancy, which is caused by hyperprogestinaemia. As the gestational age increases, mechanical causes of dilatation (the effect of an enlarged uterus) join the hormonal causes. These changes lead to impairment of urodynamics;

- an increase in urine pH due to bicarbonaturia, which develops as a compensatory reaction in response to hypercapnia (the development of respiratory alkalosis as a result of physiological hyperventilation characteristic of pregnant women).

UTIs are classified by localization (UTI of the upper and lower urinary tract), by etiology (bacterial, viral, fungal), by the nature of the course (uncomplicated and complicated). Upper urinary tract infections include pyelonephritis, abscess

è kidney carbuncle, apostematous pyelonephritis; lower urinary tract infections - cystitis, urethritis. In addition, asymptomatic bacteriuria is isolated. Complicated infections occur in the presence of structural changes in the kidneys and other parts of the urinary tract, as well as serious concomitant diseases (for example, diabetes mellitus, etc.); uncomplicated develop in the absence any pathology.

Most cases of female UTI are ascending infection, when microorganisms from the perianal region penetrate into the urethra, bladder, and then through the ureters into the kidneys.

Urinary infection in pregnant women

Urinary infection during pregnancy can manifest as asymptomatic bacteriuria, acute cystitis, and acute pyelonephritis (exacerbation of chronic pyelonephritis).

Asymptomatic bacteriuria (BB)

BB is understood as bacteriuria, quantitatively corresponding to the true (more than 100,000 bacteria in 1 ml of urine) in at least two samples in the absence of clinical symptoms of infection.

The prevalence of BB in the population of women aged 15-34 is about 3%, and among pregnant women - 6%, varying from 2 to 9% or more, depending on their socio-economic status. In most patients, bacteriuria reflects pre-pregnancy colonization of the periurethral region and is considered a risk factor for acute gestational pyelonephritis, which develops in 30-40% of women with untreated BB before pregnancy. BB, despite the absence of clinical manifestations, creating a deceptive impression of well-being, is associated with a high incidence of obstetric complications: premature birth, preeclampsia, antenatal fetal death, and neonatal malnutrition. Pregnant women with BB are more likely to develop anemia. The persistence of bacteriuria is facilitated both by the characteristics of the host organism (defects in local defense mechanisms - insufficient production of neutralizing antibodies) and by a microorganism with a certain set of virulence factors (adhesins, hemolysin, K-antigen, etc.). The main causative agent of BB (like other types of UTIs) is Escherichia coli. In the absence of structural changes in the urinary tract, immunodeficiency, etc., predisposing to the development of UTIs, BB does not have significant clinical significance and does not require treatment, however, controlled studies conducted in recent years have convincingly shown the need for BB treatment in pregnant women.

Diagnostics

Bacteriuria is the presence of a growth of microorganisms (≥ 10 5 CFU / ml) of the same species in two consecutive urine samples taken at intervals of 3-7 days (at least 24 hours), if collected in accordance with the rules of asepsis.

Bacteriuria can be caused by contamination of urine samples, which should be suspected if various pathogens or neuropathogenic organisms are inoculated. To diagnose BB, it is necessary to perform a bacteriological analysis of urine.

BB should be differentiated from bacterial vaginosis, which is not diagnosed in 20% of women before pregnancy.

BB in pregnant women is an indication for the appointment of antibiotic therapy. When choosing an antimicrobial drug, you should consider its safety for the fetus. Treatment is advisable after 12 weeks of pregnancy.

Drugs of choice:

- amoxicillin inside 3-5 days for 500 mg 3 ð / day or

- cephalexin inside 3-5 days for 500 mg 4 ð / day or

- cefuroxime axetil inside 3-5 days for 250-500 mg 2 r / day. Alternative drugs:

- nitrofurantoin inside 3-5 days, 100 mg 3 r / day. Reserve drugs:

- amoxicillin / clavulanate inside 3 days at 625 mg 3 r / day. Penicillins, nitrofurans are recommended to be taken with plants.

tel drugs that acidify urine to enhance their action (cranberry or lingonberry juice).

Prophylactic antibiotic therapy of asymptomatic bacteriuria reduces the likelihood of acute pyelonephritis in 70-80% of pregnant women (Kiningham R, 1993).

Acute cystitis

Acute cystitis is the most common UTI in women. During pregnancy, it develops in 1-3% of cases, more often in the 1st trimester, when the uterus is still in the maltase and exerts pressure on the bladder.

Clinically, cystitis is manifested by frequent and painful urination, pain or discomfort in the bladder, urgency, and terminal hematuria. Common symptoms are possible - malaise, weakness, subfebrile condition. For diagnosis, it is important to identify leukocyturia (pyuria), hematuria, bacteriuria. Urine culture is usually not required because E. coli is the main causative agent, which responds well to short courses of antimicrobial therapy. It must be remembered that frequent urge to urinate, discomfort in the suprapubic region, "weak bladder", nocturia can be

caused by the pregnancy itself and are not indications for the appointment of therapy. Antibacterial drugs should be prescribed only if bacteriuria, hematuria and / or leukocyturia are detected.

Drugs of choice:

- amoxicillin inside 5-7 days for 500 mg 3 ð / day;

- cephalexin inside 5-7 days for 500 mg 4 ð / day;

- cefuroxime axetil inside 5-7 days for 250 -500 mg 2 ð / day;

- fosfomycin trometamol inside 3 g once. Alternative drugs:

- amoxicillin / clavulanate by mouth 5-7 days for 625 mg 3 ð / day;

- nitrofurantoin inside 5-7 days for 100 mg 4 ð / day.

After the completion of antimicrobial therapy, it is advisable to use herbal uroantiseptics in order to consolidate the achieved effect (phytolysin, kanephron, lingonberry leaf, etc.)

Acute pyelonephritis of pregnancy (or exacerbation of chronic pyelonephritis)

Pyelonephritis is an infectious and inflammatory kidney disease with a predominant lesion of the tubulo-interstitial tissue, the calyx-pelvic system and, often, with the involvement of the parenchyma. Pyelonephritis ranks first in the structure of extragenital pathology. During pregnancy, its frequency reaches 10% or more.

According to the Ministry of Health of the Russian Federation, in 2001, 22% of pregnant women suffered gestational pyelonephritis or exacerbation of chronic pyelonephritis. Gestational pyelonephritis is a serious illness that can have an adverse effect on the course of pregnancy and the condition of the fetus.

Recent studies have established that gestational pyelonephritis is associated with a high incidence of gestosis, characterized by early onset and severe course, spontaneous abortion and premature birth, which are observed in 15-20% of pregnant women with this pathology. A common consequence of gestational pyelonephritis is malnutrition and intrauterine growth retardation syndrome, detected in 12-15% of newborns. In addition, iron deficiency anemia often develops in women who have undergone gestational pyelonephritis (in 35-42% of cases) (Elokhina T.B. et al., 2003). During pregnancy, an exacerbation of the patient's pre-existing chronic pyelonephritis is often observed.

Among the risk factors for the development of pyelonephritis during pregnancy, the most important are: BB (in 30-40% of patients), malformations of the kidneys and urinary tract (in 6-18%), stones of the kidneys and ureters (about 6%), reflux various levels, inflammatory diseases of the female genital organs, sexual activity, metabolic disorders. The risk of urinary infection is increased by chronic kidney disease in women: polycystic kidney disease, spongy kidney, interstitial nephritis, CGN. The development of gestational pyelonephritis is also facilitated by urodynamic disorders caused by pregnancy (expansion of the intracavitary system of the kidney).

Thus, the group at increased risk for the onset of gestational pyelonephritis is:

- pregnant women who have previously had urological diseases;

- latent kidney disease;

- ÁÁ;

- the presence of intercurrent inflammatory diseases;

- local factors that violate urodynamics (large fetus, narrow pelvis, polyhydramnios, multiple pregnancies).

Etiology and pathogenesis

The most common causative agents of gestational pyelonephritis are representatives of the Enterobacteriaceae family (gram-negative bacilli), of which E. coli accounts for 75-85%, Klebsiella and Proteus 10-20%, Pseudomonas aeruginosa - 7%. Relatively less often pyelonephritis is caused by gram-positive cocci (group B streptococci, enterococci, staphylococci) - about 5% of cases. In recent years, in the development of severe forms of pyelonephritis, the role of hospital strains of gram-negative bacteria, characterized by high virulence and multiple resistance to antimicrobial drugs, as pathogens, has increased.

Acute pyelonephritis of pregnant women in almost half of cases develops at 20-30 weeks and in a third - at 31-40 weeks of pregnancy. After childbirth, the risk of developing pyelonephritis remains high for another 2-3 weeks, as long as the dilatation of the upper urinary tract persists. Postpartum pyelonephritis is usually an exacerbation of a chronic process that existed before pregnancy.

The pathogenetic basis for the development of infection is impaired blood circulation in the kidney, mainly venous outflow, due to disorders of urodynamics. An increase in intralocal and intracranial pressure as a result of impaired passage of urine leads to compression of the thin-walled veins of the renal sinus,

rupture of the fornical zones of the cups with direct infection from the pelvis into the venous bed of the kidney.

The clinical picture and course of pyelonephritis

Acute pyelonephritis of pregnancy usually begins with symptoms of acute cystitis (frequent and painful urination, pain in the bladder, terminal hematuria). After 2-5 days (especially without treatment), fever with chills and sweats, pain in the lumbar region, intoxication phenomena (headache, sometimes vomiting, nausea) join. In the analysis of urine - leukocyturia, sometimes pyuria, bacteriuria, microhematuria, cylindruria. Proteinuria is usually mild. Macrohematuria is possible with renal colic caused by the ICD, papillary necrosis. In the blood, leukocytosis with a neutrophilic shift is noted (leukemoid reactions are possible), in severe cases, a moderate decrease in the level of hemoglobin dysproteinemia with a predominance of α-2 globulinemia. In severe gestational pyelonephritis, accompanied by high fever and catabolism, oliguria may develop as a result of extrarenal fluid loss (profuse sweating with insufficient intake). In these cases, signs of impaired renal function may be noted: a decrease in GFR and an increase in serum creatinine levels. also local hemodynamic disorder. The latter is believed to be due to the high sensitivity of the vascular wall during pregnancy to the vasoactive effect of bacterial endotoxins or cytokines (Petersson C. et al., 1994).

Ó 20-30% of women who have had acute pyelonephritis in the past, may exacerbate the process during pregnancy, especially in the later stages.

Diagnosis and differential diagnosis

For the diagnosis of gestational pyelonephritis, local symptoms (pain and muscle tension in the lumbar region, a positive effusion symptom), quantitative urine sediment studies, urine bacteriological examination, and ultrasound kidney scanning are important. Ultrasound examination allows to detect calculi, large abscesses in the parenchyma, dilatation of the pelvic-pelvic system.

period. The use of survey urography is permissible after the 2nd month of pregnancy if there is an indication for surgery.

The differential diagnosis of gestational pyelonephritis is complex. In the presence of fever, it should be carried out with an infection of the respiratory tract, viremia, toxoplasmosis (serological screening), with acute abdominal pain - with acute appendicitis, acute cholecystitis, biliary colic, gastroenteritis, uterine fibromatosis, placental abruption and other reasons.

Acute appendicitis is characterized by localization of pain in the center or in the right lower quadrant of the abdomen, vomiting, fever (usually not as significant as in pyelonephritis) without chills and sweating.

For acute cholecystitis or cholelithiasis, pain in the upper right quadrant of the abdomen radiating to the right shoulder is characteristic, jaundice, fever and leukocytosis are possible. Ultrasound examination of the abdominal cavity is decisive for the differential diagnosis.

Persistent pain and hematuria in pyelonephritis can be associated with both its complications (apostematous pyelonephritis, kidney carbuncle) and other causes. So, sometimes the anatomical changes caused by pregnancy can be manifested by a very significant stretching of the pelvis and ureters, which leads to the so-called "syndrome of excessive stretching" and / or intralochanical hypertension. A definite guideline for the differential diagnosis is the improvement of symptoms after positional therapy (giving a position on a "healthy" side, knee-elbow position), in the absence of relief, catheterization is indicated, including a stent catheter, and even nephrostomy. Complications of gestational pyelonephritis can pose a threat to a woman's life. The most formidable of them is the adult respiratory distress syndrome, accompanied by hepatic and hematological disorders, sepsis, bacteremic shock, nontraumatic ruptures of the urinary tract. The diagnosis of latent current chronic pyelonephritis in pregnant women can be complicated by the addition of nephropathy in pregnant women with severe hypertensive syndrome, masking the underlying disease.

Treatment of gestational pyelonephritis is challenging because the antimicrobial agents used must combine efficacy against the pathogen with safety for the fetus. Features of urodynamics during pregnancy and the associated features of the course of pyelonephritis determine

principles of treatment of this type of UTI. These include: the need for long-term therapy, an integrated approach to treatment, including a combination of therapeutic and, if necessary, surgical methods; maximum individualization of therapy aimed at eliminating the specific cause of urodynamic disorders in each patient.

Therapeutic methods:

- antibacterial drugs (antibiotics, uroantiseptics);

- detoxification therapy;

Phytopreparations.

Methods for restoring urodynamics:

- positional therapy;

- catheterization of the ureters, including catheter stent. Surgical methods:

- decapsulation of the kidney;

- opening of purulent foci;

- imposition of a nephrostomy;

Nephrectomy.

Antibiotics are the mainstay of antibiotic therapy. Antibiotics can have embryo- and fetotoxic effects. The risk of pathological changes in the fetus is especially high in the first 10 weeks of pregnancy (embryogenesis), so the choice of antibiotic depends entirely on the duration of pregnancy. The condition for successful antibiotic therapy is the restoration of the normal passage of urine, identification of the pathogen with the determination of its sensitivity.

During pregnancy, it is possible to prescribe drugs from the beta-lactam group: aminopenicillins (ampicillin, amoxicillin), highly active against Escherichia coli, Proteus, enterococci. However, their disadvantage is the susceptibility to the action of specific enzymes - beta-lactamase, a high frequency of more than 30% of the resistance of community-acquired strains cases, therefore, the drugs of choice are inhibitor-protected penicillins (ampicillin / sulbactam, amoxicillin / clavulanate), which are active against both gram-negative bacteria that release beta-lactamases and staphylococci.

Drugs specifically designed for the treatment of infections caused by Pseudomonas aeruginosa are carbenicillin, ureidopenicillins.

Along with penicillins, other beta-lactam antibiotics are also used - cephalosporins, which create high concentrations in the kidney parenchyma and urine and have moderate nephrotoxicity.

The reproductive system is very closely connected with the kidneys, for this reason they are combined into the genitourinary system. It often happens that they have the same infections.

Types of infections

The resulting renal infection can be specific and non-specific:

  • A specific infection in the kidney is associated with pathogens that are sexually transmitted (gonococcus, Trichomonas, ureaplasma). The cause of the disease is clear. This is unprotected sex. In men, the infection immediately enters the urethra, and from there into the overlying zones of the genitourinary system. In women, the infection from the vagina enters the urethra and further moves along the same path of the genitourinary system. Infections must be treated, as rather dangerous complications are possible.
  • Non-specific... Such infections include staphylococcus, E. coli, streptococcus, enterococcus, candidal fungus and others.

A kidney infection can spread in several ways:

  • The ascending path is from the urethra and rectum during sexual intercourse.
  • Descending - passes from the renal pelvis down the ureters.
  • Hematogenous pathway - brought by blood flow from other areas.


Escherichia coli is a common causative agent of kidney infections.

Causes of occurrence

When an infection enters the human body, the kidneys are the first to suffer as they try to expel it.

A weakened body cannot always cope with such a problem, so the kidneys become infected and need adequate treatment.

The most common causes of kidney infections are:

  • Urolithiasis disease.
  • Anemia.
  • Penetration through the circulatory system.
  • Diabetes.
  • Low immunity.
  • Inflammatory processes in other organs.

Also, kidney damage can be associated with diseases of the gastrointestinal tract, uterus. Even dental caries can cause infection. Also, hypothermia and incorrect therapy for colds can be attributed here.

Symptoms of a kidney infection

You can find out the presence of infectious inflammation in the kidneys by the following signs:

  • General malaise.
  • Pain in the lower back, abdomen and groin.
  • Temperature increase.
  • Frequent urination.
  • Little urine is released, it does not come out completely.
  • Nausea.
  • Loss of appetite.
  • Itching and sometimes sharp pain when urinating.
  • Swelling of the face.
  • The color and smell of urine changes.
  • Presence.


Low back pain is a common companion of kidney infection

The most common diseases:

  • Pyelonephritis is an inflammatory process in the kidneys as a result of the penetration of microorganisms. In addition, other pathologies are associated (for example, reduced immunity, kidney stones, hypothermia, inflammation in the adrenal glands and other ailments).
  • Glomerulonephritis- the inflammatory process of the renal glomeruli, which develops against the background of an infectious allergy or due to the production of antibodies to its own organ. More often, the spread is observed in children and young adults (up to 30 years).

In an infant, kidney infections are more difficult and, due to loose immunity, are treated much worse. For this reason, it is necessary to consult a doctor when the first signs appear. The first symptoms will be changes in urine color and fever. In addition, the child becomes moody, does not sleep well, refuses to eat, and does not gain weight.

Kidney and urinary tract infections are common during pregnancy. Since the enlarged uterus compresses the organs of the genitourinary system, thereby creating good conditions for the occurrence of pyelonephritis. Its signs are brighter in a pregnant woman, and complications are more common. Therefore, in order to avoid infection of the fetus and premature birth, a woman is placed in a hospital, where she undergoes a course of treatment.


Pregnant women have an increased risk of developing a kidney infection

Diagnostics

First of all, the patient's anamnesis is collected, an examination is carried out, a urine test is taken to find out if there is a bacterial infection.

In case of complications of pyelonephritis, the patient is admitted to hospital treatment. Also, blood sampling for a general analysis is mandatory. Kidneys are checked for stones by ultrasound or X-ray.

If the infection is lingering, complications such as abscess, kidney edema, blood poisoning (the infection enters the bloodstream) can occur. Symptoms of complications are pronounced, they cannot be overlooked. The emergence of acute pathologies is more susceptible to people who have concomitant diseases.

There are also several categories of people who are at risk of complications:

  • Pregnant women.
  • Elderly people.
  • With diabetes.
  • With the presence of chronic kidney disease.
  • Weak immunity.


Bacteriological urine culture is the only way to identify the causative agent of kidney infection

Treatment

For all infectious diseases associated with the kidneys, antibacterial, anti-inflammatory and symptomatic treatment is prescribed. The following medications are prescribed:

  • Antibiotics - first, broad-spectrum drugs are prescribed, and when the causative agent of the disease is identified, an individually selected remedy is prescribed.
  • Disinfection solutions intravenously - cleanse the body and blood.
  • Anti-inflammatory drugs - to eliminate inflammation. That allows you to improve the patient's condition in a short period of time.
  • Diuretics - to improve kidney function and prevent urinary stagnation. For this, diuretics are prescribed.
  • Antihypertensive drugs - to normalize blood pressure, they usually lower it.
  • Antispasmodics - relieve spasms and improve urine flow in case of urinary tract infections.
  • Painkillers - relieve pain.
  • Antipyretic drugs - to lower body temperature.

In the presence of chronic forms of pyelonephritis, constant relapses are observed, therefore it is necessary to remove the primary focus of the disease. For this, either surgical or complex therapy is used.

Surgical intervention is urgently performed if available.

During the operation, the entire kidney or part of it is removed, then drainage is installed to ensure the release of pus.


Antibiotics are the mainstay of treatment for any kidney infection

ethnoscience

Mild forms of pyelonephritis can be treated at home. Also, during treatment, you need to follow a diet that includes low salt intake, it is also necessary to exclude protein foods.

As an additional measure, traditional medicine recipes are often used:

  • It is necessary to drink at least two liters of water per day, which will increase the amount of urine output, which removes bacteria from the body.
  • 2-3 times a day, drink a glass of water with a spoonful of soda dissolved in it, this will make it possible to cleanse the body of toxins.
  • Eating blueberry mousse will help remove disease-causing bacteria from the body.
  • Add a spoonful of vinegar to a glass of water and drink in the morning on an empty stomach. This recipe helps to stop inflammation and improve digestion.

Infectious processes in the kidneys must be treated without fail in order to avoid chronic forms of the disease, which often lead to renal failure, and sometimes can cause a person's disability.