Urinary tract infections in pregnant women. How to avoid urinary tract infection during pregnancy? How to identify an infection

In addition to congenital infections, a bacterial infection that complicates pregnancy is a significant problem for obstetricians. The most common infections of the kidney and lower urinary tract.

Pyelonephritis is a particularly serious infection during pregnancy. Another infection, asymptomatic bacteriuria, can be identified and treated. As a rule, as a result of treatment, the incidence of pyelonephritis is significantly reduced. A number of factors predispose to the onset of kidney infection in pregnant women: the action of hormones (presumably progesterone with its relaxing effect on smooth muscles), decreased ureteral tone, decreased peristalsis and pressure of the enlarged uterus on the ureters at the pelvic entrance.

Asymptomatic bacteriuria

By definition, asymptomatic bacteriuria is a condition where a significant number of virulent microorganisms are present in a woman's urine without any symptoms of a urinary tract infection. The number of colonies of 100,000 or more per ml is considered significant. urine taken with a catheter.

The incidence of asymptomatic bacteriuria is 2-3% in the group of women with high and 7-8% in the group of women with a low standard of living. It is estimated that overt urinary tract infection occurs during pregnancy in only 1–2% of women without asymptomatic bacteriuria. With its presence, about 25% of women develop an acute infection, often pyelonephritis, if timely treatment is not carried out. Antibiotic therapy, aimed at eliminating asymptomatic infections, reduces the incidence of pyelonephritis to 1-3%.

The most common causative agent is Escherichia coli, found in 73% of patients; 24% of other pathogenic microorganisms were Klebsiella and Enterobacter, the remaining 3% were proteins. Sometimes the causative agent of urinary tract infection in pregnant women is hemolytic streptococcus of groups A and B. Short-term antimicrobial therapy for asymptomatic bacteriuria is just as effective as long-term antibiotic treatment.

Of course, in this case, it is necessary to control the effectiveness of treatment by planting flora.

Clinically manifest infection

Urine tests reveal white blood cells, often in the form of clumps, casts of leukocytes and bacteria. An immunofluorescence test that detects antibody-coated bacteria can confirm the presence of kidney damage. Although the majority of patients with treatment quickly improve and in 85% - 48 hours after its start, the body temperature returns to normal, some women may develop bacteremic shock and, in rare cases, die.

Influence on the condition of the fetus

In recent years, many conflicting studies have been published on the effects of maternal urinary tract infection on the fetus. The incidence of preterm birth is significantly higher in women with bacteriuria than in women without a urinary tract infection. In addition, perinatal mortality associated with the most common abnormalities of the placenta or fetus was significantly higher in women with urinary tract infection.

All deaths occurred in patients who developed a urinary tract infection within 15 days of labor. The highest mortality rate was observed with a combination of urinary tract infection in a mother with hypertension and acetonuria. Only one of the disorders - a growth retardation of the placenta - was registered much more often in pregnancies complicated by bacteriuria. The increase in mortality was mainly associated with those disorders, the frequency of which did not change significantly. This suggests that a urinary tract infection makes a child who already has some changes more vulnerable.

In the presence of a urinary tract infection in the mother, the child was found to have the following changes: low birth weight, stillbirth, Rh incompatibility, eye infection, and impaired motor activity by the age of 8 months. A number of these manifestations, obviously, are not associated with a cause-and-effect relationship, but represent a coexisting disease.

Quite a few studies have been conducted to determine the possible effect of asymptomatic bacteriuria on neonatal outcome or on prematurity. The research results were contradictory, they were divided almost equally; some authors defend the connection between urinary tract infection with prematurity and the development of late toxicosis, while others do not find this connection reliable.

Preventive and therapeutic measures

Asymptomatic bacteriuria and cystitis

1. In all women, at the first visit to the doctor, a screening examination should be carried out in order to detect bacteriuria.
2. For the treatment of the initial infection, sulfa drugs, ampicillin, cephalosporins, or furadonin are used. Treatment should continue for 7-10 days. Sulfonamides can increase hyperbilirubinemia in the neonatal period in those children whose mothers took the drug before childbirth. The mechanism of their action is associated with competition for the protein that binds bilirubin, and, possibly, with a direct effect on glucuronyl transferase. Sulfanilamide drugs can be replaced with ampicillin in the absence of allergic reactions in women. Cephalosporins reach high concentrations in the urinary tract and can be used when indicated in an antibiotic susceptibility study. Furadonin is also effective in treating primary infection, but it may increase hemolysis in women with G-6-PD deficiency. During pregnancy, it is better to avoid prescribing tetracycline drugs, they can cause discoloration of milk teeth in young children. In addition, tetracycline should not be prescribed to pregnant women with impaired renal function, since in this condition its concentration can reach a level that has a toxic effect on the liver. Treatment with Bactrim during pregnancy has certain contraindications; it has a teratogenic effect in rats (mainly causing cleavage of the hard palate), although in limited studies such an effect when used in pregnant women has not been reported.
3. Repeated cultures should be done after treatment to ensure that it is effective. The culture should then be repeated at 6 week intervals. for the timely detection of reinfection.

Acute pyelonephritis

1. Women with acute pyelonephritis should be hospitalized for antibiotic therapy and intravenous fluids. Pregnant women, although infrequently, are more susceptible to toxic shock than non-pregnant women. It is necessary to monitor blood pressure, pulse, body temperature and urine output. Serum creatinine levels should also be monitored dynamically.
2. A urine culture is done prior to starting antibiotic treatment. A blood culture can be done if the infection is severe.
3. Numerous antimicrobial drugs are available for treatment. It is advisable to start therapy with ampicillin in a dose of 1-2 g intravenously at intervals of 4-6 hours. You can use drugs such as aminoglycosides, cephalosporins, carbenicillin and, possibly, chloramphenicol. If the condition of a patient already receiving treatment for acute pyelonephritis, judging by the clinical manifestations, has worsened, another drug should be used. If the clinical picture has not changed in the near term after the appointment of a new drug, then a microbial susceptibility test carried out at the initial inoculation can help in the selection of an appropriate drug.
4. With a decrease in body temperature, the patient should be transferred to oral medication. Treatment should continue for at least 10 days.
5. With regard to infection of the lower urinary tract, then to decide on the effectiveness of therapy, it is necessary to do a second culture.
6. Many infectious disease specialists recommend long-term preventive treatment during pregnancy for all women who develop pyelonephritis. For this purpose, furadonin or ampicillin can be used.

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 she is pressed by the growing double burden of motherhood and career. 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 free itself from any ballast in order to approach the moment of birth 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 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, when compressed, can stretch 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 changed to 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 into 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 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 prevent urine from flowing out, 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
Since 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.

Pregnancy is not only pleasant moments of waiting for a meeting with a baby, but also a complete transformation of the functionality of all internal systems and organs. The woman's body is under heavy strain, especially in the last trimester. During this period, the immune system decreases, physiological changes in the urinary system occur and all conditions are created for the formation of infection in the kidneys. In this article, we will talk about kidney infection during pregnancy, its symptoms, causes of formation, and treatment methods.

Reasons for the formation of infection

The formation of infections of the genitourinary system during pregnancy is considered the most common. According to statistics, 10% of pregnant women suffer from the following infections:

• pyelonephritis;
• acute cystitis;
• bacteriuria is asymptomatic.

The cause of the formation of bacteria in the genitourinary system is the anatomical feature of the structure of the female genital organs. The urinary organs are located close to the anus, which is short enough to make it easier for bacteria to move through the canal to the kidneys and bladder. During pregnancy, the urinary system:

• reduces the ability to contract muscles of different parts;
• the renal pelvis expands and increases in size;
• the ureters become elongated;
• the kidneys are displaced;
• the movement of urine slows down.

For information! Progesterone is able to relax the muscles in the body of a pregnant woman, as a result of which there is stagnation of urine and the multiplication of bacteria and microorganisms.

Typically, the main changes in the female body occur at 12 weeks of gestation, which contributes to a greater risk of infection in the kidneys. Another reason for the formation of the disease can be an elementary non-observance of the rules of personal hygiene, chronic forms of diseases and disorders of the endocrine system.

Symptoms of the disease

All infectious diseases of the urinary tract have almost the same symptoms, which are manifested in:

• a constant desire to go to the toilet, provided that the bladder is almost half empty;
• attacks of pain in the lower abdomen and in the lumbar region;
• discomfort or burning sensation during urination, intercourse;
• The urine becomes cloudy and may have an unpleasant odor or blood clots.

For information! During the infectious period, the subfebrile temperature can rise to 37.5C ​​degrees, but most often the temperature regime remains normal.

Symptoms of a kidney infection can occur both imperceptibly for a woman, and suddenly appear, they are expressed:

• increased sweating, chills;
• fever or a sharp rise in temperature;
• attacks of nausea and vomiting;
• severe pain in the lower abdomen, side, in the hypochondrium.

For information! Asymptomatic bacteriuria leads to the premature birth of a low birth weight baby. If left untreated, the risk of a kidney infection rises to 40%.

Most often, a woman does not immediately notice an infection, for example, cystitis, because due to the growth of the fetus, the amount of urination increases. However, if you notice any changes, immediately contact a specialist.

Diagnosis of a kidney infection

The establishment of the diagnosis and the purpose of treatment is determined only after a laboratory study. A pregnant woman is prescribed:

• bacteriological examination of urine;
• urine analysis according to the Nechiporenko method;
• general urine analysis;
• general blood analysis.

All tests are taken once a month by every pregnant woman; if necessary, the attending physician may ask for an additional test. If a preliminary laboratory report confirms the presence of a disease, instrumental diagnosis is prescribed using:

• ultrasound examination of the urinary system, kidneys and adjacent organs;
• radioisotope research;
• X-ray examination;
• computed tomography.

For information! Ultrasound allows you to determine the size, broken structure and changes occurring in the kidneys.

Most often, the diagnosis consists exclusively of ultrasound, this is due to the possible mutagenic effect of the equipment on the fetus.

Methods for treating kidney infection during pregnancy

Treatment of infectious diseases of the urinary tract in pregnant women takes place exclusively in a hospital under the supervision of the attending physician. Only the attending physician is able to give an adequate assessment, as well as calculate the possible risks of drug exposure on the woman's body and fetal development. The method of treatment depends on the infected infection, we will analyze the most common:

• Cystitis - treatment takes place without taking antibiotics, protected drugs of penicillin or cephalosporin are prescribed, the course of treatment lasts two weeks. After elimination of symptoms, a second urine test is performed.
• Pyelonephritis - with severe symptoms of infection in a pregnant woman, she is placed in a hospital and treated with intravenous antibiotics. In the process of therapy, the general condition of the woman and the fetus is monitored, this is necessary to avoid premature birth.

For information! To avoid the formation of a relapse, it is recommended to undergo antibiotic therapy. Canephron is prescribed as a drug; it contains plant components that have a diuretic and anti-inflammatory effect.

With a pronounced exacerbation of renal infection in the third trimester and the presence of fever and intoxication of the body, a woman is given an unscheduled caesarean section to save her life and fetus.

Disease prevention

The main danger of developing infection during pregnancy lies in its irreversible processes and negative impact on the health and development of the fetus. Complications of a kidney infection can occur:

• anemia;
• the formation of preeclampsia;
• the formation of toxic shock;
• surges in blood pressure;
• insufficiency and inflammation of the placenta;
• lack of oxygen for the fetus;
• premature labor;
• death of the fetus.

As a prophylaxis and preservation of the health and life of the mother and the fetus, experts recommend the following measures:

• pregnancy planning, timely examination and treatment of all chronic diseases;
• normalize hormones with drugs;
• in the absence of severe puffiness, consume a sufficient amount of liquid;
• do not restrain yourself at every urge to urinate;
• exclude douching during pregnancy;
• follow the rules of personal hygiene, wear loose underwear and do not take a bath;
• take tests in a timely manner and report the presence of suspicious symptoms;
• in the presence of a chronic disease, take herbal medicines.

Remember, any infection of the genitourinary system during pregnancy has a number of its own characteristics and indications. Timely register with the antenatal clinic, take the necessary tests, and most importantly, always report any symptoms or phenomena that cause discomfort. Remember, timely treatment is a guarantee of health not only for a pregnant woman, but also for a future baby.

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, MD 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, 1 and 20%, respectively).

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 the formation of mucus, 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 ureteral palsy, 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 an 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 years 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 newborn malnutrition. Pregnant women with BB are more likely to develop anemia. 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 with an interval of 3-7 days (at least 24 hours), if it is collected aseptically.

Contamination of urine samples may be the cause of bacteriuria, 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, its safety for the fetus should be considered. 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 malomasis 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

are 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 preeclampsia, 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%), kidney and ureteral stones (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 with previous urological diseases;

- latent kidney disease;

- ÁÁ;

- the presence of intercurrent inflammatory diseases;

- local factors that disrupt 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, symptoms of intoxication (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 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, there may be signs of impaired renal function: 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 reveal 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 indications 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 reasons. 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 the "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 latently 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 E.coli, Proteus, enterococci. 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.