Diseases of the urinary tract during pregnancy. Urinary tract infections: acute cystitis. Causes and factors

14.05.2019

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 by the uterus of the urinary tract, primarily 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 pelvis.

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 study 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 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!

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 partnership, 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 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 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.

The main prerequisites for the emergence inflammatory diseases of the urinary system are: short urethra; the proximity of the rectum and genital tract, which are highly colonized by various microorganisms; physiological changes in the urinary system during pregnancy under the influence of hormonal influences (dilatation of the urinary tract, hypotension of the calyx-pelvic system).

By localization, inflammatory diseases of the urinary system are divided into infections of the upper sections (pyelonephritis, abscess and carbuncle of the kidney, apostematous pyelonephritis) and infections of the lower sections of the urinary tract (cystitis, urethritis). In addition, asymptomatic bacteriuria is isolated. By the nature of the course, uncomplicated and complicated inflammatory diseases of the urinary system are distinguished. Uncomplicated infections occur in the absence of structural changes in the kidneys, obstruction of the urinary tract, and in the absence of serious concomitant diseases (for example, diabetes mellitus, etc.).

In most cases of inflammatory diseases of the urinary system, microorganisms from the perianal region penetrate into the urethra, bladder, and then through the ureters into the kidneys. A urinary infection during pregnancy can present with asymptomatic bacteriuria, acute cystitis, and / or acute pyelonephritis (exacerbation of chronic pyelonephritis).

Asymptomatic bacteriuria

The incidence of asymptomatic bacteriuria among pregnant women varies from 2 to 9% or more (on average, about 6%), depending on their socio-economic status. Asymptomatic bacteriuria, despite the absence of clinical manifestations, can lead to premature birth, anemia, preeclampsia, neonatal malnutrition and intrauterine fetal death. Asymptomatic bacteriuria most often develops between the 9th and 17th weeks of pregnancy.

The main E. coli is the causative agent of asymptomatic bacteriuria... The diagnostic criterion confirming the presence of asymptomatic bacteriuria is the growth (105 CFU / ml) of the same microorganism in two cultures of an average portion of urine taken with an interval of 3-7 days (at least 24 hours). If asymptomatic bacteriuria is confirmed in a pregnant woman, it is necessary to carry out antibacterial treatment, starting from the second trimester of pregnancy. When choosing an antimicrobial drug, you should consider its safety for the fetus. Treatment is carried out only on the basis of the prescription of the attending physician and under his supervision. Self-medication is a health hazard.

Acute cystitis

Acute cystitis (inflammation of the lining of the bladder) is the most common type of inflammatory disease of the urinary system in women. Among pregnant women, acute cystitis develops in 1-3% of women, more often in the first trimester, when the uterus is still in the small pelvis and puts pressure on the bladder. Clinically, cystitis is manifested by frequent and painful urination, pain or discomfort in the bladder, urging, blood in the urine. Symptoms such as malaise, weakness, low-grade fever are also possible. For diagnosis, it is important to identify leukocyturia (pyuria), hematuria, bacteriuria.

The main pathogen is Escherichia coli, 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" may 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.

Acute pyelonephritis

Acute pyelonephritis in pregnant women (or exacerbation of chronic pyelonephritis) is infectious and inflammatory kidney disease... Pyelonephritis ranks first in the structure of extragenital pathology in pregnant women and postpartum women, its frequency reaches 10% and more. Most often (about 80%), pyelonephritis occurs at the end of the second trimester (22-28 weeks) of pregnancy. After childbirth, the risk of developing pyelonephritis remains high for another 2 to 3 weeks (usually on the 4th, 6th, 12th days of the postpartum period), while the dilation of the upper urinary tract and the risk of postpartum inflammatory diseases persist. Postpartum pyelonephritis is, as a rule, an exacerbation of a chronic process that existed before pregnancy, or a continuation of a disease that began during pregnancy. About 10% of women who have had acute pyelonephritis during pregnancy subsequently suffer from chronic pyelonephritis. In turn, in 20-30% of women who have had acute pyelonephritis in the past, an exacerbation of the process is possible during pregnancy, especially at a later date. Gestational pyelonephritis can have an adverse effect on the course of pregnancy and the condition of the fetus, which is due to the high frequency of gestosis, characterized by early onset and severe course, spontaneous abortion at various times 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 develops in 35-42% of women who have had gestational pyelonephritis. The factors that contribute to the development of acute pyelonephritis in pregnant women include asymptomatic bacteriuria, malformations of the kidneys and urinary tract, kidney and ureteral stones, vesicoureteral reflux in cystitis, inflammatory diseases of the female genital organs, metabolic disorders, neurogenic bladder. The risk of urinary infection is also increased by chronic kidney disease in women: chronic glomerulonephritis, polycystic kidney disease, spongy kidney, interstitial nephritis, and other kidney diseases. The most significant causative agents of gestational pyelonephritis are: Escherichia coli, Klebsiella and Proteus, Pseudomonas aeruginosa. Group B streptococci, enterococci, staphylococci are relatively less common.

Clinically acute pyelonephritis in pregnant women usually begins with 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), leukocyturia (pyuria), bacteriuria, flakes, cloudy urine join. Proteinuria (protein in the urine) is usually mild. Possible hematuria (the presence of blood elements in the urine). In severe cases, there is a moderate decrease in the level of hemoglobin and protein in the blood. In severe pyelonephritis, there may be signs of impaired renal function. In 3-5% of cases of acute pyelonephritis, acute renal failure may develop.

Treatment of gestational pyelonephritis should be carried out taking into account the gestational age (trimester), begin after the restoration of the normal passage of urine, determination of the pathogen, taking into account its sensitivity to drugs, urine reaction and renal dysfunction. For the treatment of pyelonephritis in pregnant women, the following are used: antibacterial drugs (antibiotics, uroantiseptics), positional therapy, ureteral catheterization, including a stent catheter, surgery (kidney decapsulation, opening of purulent foci, nephrostomy, nephrectomy), detoxification therapy. Throughout pregnancy, treatment with antibiotics of the tetracycline, chloramphenicol series, as well as biseptol, long-acting sulfonamides, furazolidone, fluoroquinolones, streptomycin is categorically contraindicated due to the danger of adverse effects on the fetus (bone skeleton, hematopoietic organs, vestibular apparatus and hearing organ), nephrotoxicity. Antibiotic therapy for pregnant women with acute pyelonephritis (exacerbation of chronic pyelonephritis) should be carried out in a hospital and begin with intravenous or intramuscular administration of drugs, followed by a switch to oral administration. The total duration of treatment is at least 14 days. With the development of acute pyelonephritis, if the patient's condition is severe and there is a threat to life, treatment begins immediately after taking urine for sowing with broad-spectrum drugs that are effective against the most common causative agents of pyelonephritis. The effectiveness of drugs can be assessed within 48 hours from the start of therapy. In a less severe condition, it makes sense to postpone the appointment of antimicrobial drugs until data on the sensitivity of the pathogen to certain antibiotics are obtained.

Acute and exacerbated pyelonephritis are not indications for termination of pregnancy in an uncomplicated course of the disease, in the absence of severe arterial hypertension. In case of impaired renal function, the addition of a severe form of gestosis, poorly amenable to therapy, abortion is performed. Prevention of gestational pyelonephritis is aimed at detecting early signs of the disease and preventing its exacerbations. Throughout pregnancy, dynamic observation with urine examination (cytological, bacteriological according to indications) is necessary at least once every 14 days, early detection of urodynamic disorders, and timely appointment of the necessary therapy.

Acute renal failure

Acute renal failure (ARF) is a life-threatening complication of pregnancy... Pregnant women account for 15-20% of all cases of acute renal failure, which, as a rule, complicates the second half of pregnancy or the postpartum period. ARF is a sharp decrease in renal function, accompanied in 80% of cases by a decrease in urine production of less than 400 ml / day. The frequency of ARF currently does not exceed 1 in 20,000 births. More than half of cases of acute renal failure of pregnant women, in addition to septic abortion, are associated with the development of severe forms of gestosis (nephropathy of pregnant women), with obstetric bleeding (premature placental abruption, hypotonic uterine bleeding). In 3-5% of cases of ARF is caused by gestational pyelonephritis, in 15-20% - intrauterine death of the fetus, amniotic fluid embolism and other reasons. ARF usually develops in women with the development of vascular spasm and a decrease in blood volume, which leads to impaired renal circulation.

During the treatment of acute renal failure in pregnant women it is necessary to exclude the presence of latent uterine bleeding, which is a triggering or provoking factor of acute renal failure, to correct hemodynamic disturbances and resolve the issue of indications for immediate delivery. With a sufficient gestational age (over 30-34 weeks), rapid delivery is recommended, which allows to exclude growth retardation or intrauterine death of the fetus and improves the further prognosis of the mother. With prerenal ARF, it is necessary, first of all, to eliminate hypovolemia - to restore the intravascular volume of fluid by infusion of saline, plasma, large-molecular dextrans, albumin; correct water-electrolyte disturbances, hypoproteinemia. In acute tubular necrosis of pregnant women, treatment is aimed at combating ischemia (restoring blood supply to the kidneys), maintaining fluid and electrolyte balance, and treating infection. With the development of obstructive acute renal failure, it is necessary to restore the passage of urine, if necessary, massive antibacterial, detoxification therapy (gestational pyelonephritis), the fight against vascular insufficiency with complications by bacteremic shock.

The most common inflammatory diseases of the urinary system include asymptomatic bacteriuria (detection of a significant amount of bacteria in the urine), cystitis (inflammation of the mucous membrane of the bladder) and pyelonephritis - an infectious and inflammatory process, accompanied by damage to the kidney tissue and the calyceal system.

Asymptomatic bacteriuria

The diagnosis of "asymptomatic bacteriuria" is established when 100,000 microbial cells are found in 1 milliliter of urine and there are no symptoms of urinary tract infection. Pregnant women with asymptomatic bacteriuria should be thoroughly examined for latent forms of urinary tract disease. First of all, laboratory research methods are used - blood and urine tests. Pathological changes are observed in the quantitative study of urine sediment (urine analysis according to the Nechiporenko method), as well as in studies of the excretory and filtration capacity of the kidneys (urine analysis according to Zemnitsky, Reberg). Ultrasound of the kidneys has become an integral part of the complex of diagnostic measures. Against the background of asymptomatic bacteriuria, acute pyelonephritis develops in about 30% -40% of cases, therefore, such pregnant women need to carry out timely preventive treatment. The effectiveness of treatment is monitored by sowing urine on the flora: the urine is placed on a special nutrient medium and it is observed whether colonies of microorganisms grow on the nutrient medium.

Cystitis of pregnant women

Cystitis accompanies a variety of pathological conditions of the urinary tract and genitals. It can be the first manifestation of pyelonephritis or other urological diseases.

Acute cystitis is characterized by a decrease in working capacity, weakness, an increase in temperature up to 37.5 ° C and local symptoms that allow one to suspect, and in many cases - to make an unmistakable diagnosis. These include: painful urination (cramps at the end of urination), pain in the suprapubic region, aggravated by palpation and filling of the bladder, frequent urination (every 30 to 60 minutes).

The diagnosis must be confirmed by laboratory data: with a disease, urine analysis reveals leukocyturia (the presence of a large number of leukocytes), bacteriuria (the presence of bacteria). Pathological changes can also be observed in a blood test. Acute cystitis lasts 7-10 days; if it drags on, the doctor will prescribe an examination necessary to exclude inflammatory kidney damage. Treatment of cystitis is carried out with tableted antibacterial agents (semi-synthetic penicillins, cephalosporins) for 5-7 days. Timely recognition and treatment of asymptomatic bacteriuria and cystitis during pregnancy leads to a significant reduction in the risk of acute pyelonephritis and its immediate consequences for both the mother and the fetus (most often it is the threat of termination of pregnancy or premature birth).

There are three degrees of risk of pregnancy and childbirth in women with pyelonephritis:

I degree - an uncomplicated course of pyelonephritis that arose during pregnancy;

II degree - chronic pyelonephritis, which develops before pregnancy;

III degree - pyelonephritis, proceeding with arterial hypertension (increased blood pressure), pyelonephritis of a single kidney.

The most severe complications occur at the III degree of risk, therefore, women with pyelonephritis should be observed not only by an obstetrician-gynecologist, but by a therapist and nephrologist. The outcome of pregnancy and childbirth depends not only on the degree of risk, but also on the duration of the disease, the degree of kidney damage and the general condition of the mother's body.

Pyelonephritis of pregnant women

Pyelonephritis, which occurs for the first time during pregnancy, is called "gestational pyelonephritis" or "pyelonephritis of pregnancy." It occurs in 6-7% of expectant mothers, more often in the second half of pregnancy. Pyelonephritis existing before pregnancy can worsen against its background or proceed in a chronic and worn out form. Women with pyelonephritis are at high risk for complications of pregnancy such as miscarriage, preeclampsia2, intrauterine infection and fetal malnutrition (growth retardation). The most formidable complication is acute renal failure, a condition in which the kidneys stop working completely or partially.

Changes in the urinary system are predisposing factors for the development of acute gestational pyelonephritis and exacerbation of chronic pyelonephritis during pregnancy. Namely: impaired urination (due to an increase in the size of the uterus), restructuring of the hormonal and immune status, as well as the presence of recurrent (exacerbated) cystitis before pregnancy, malformations of the kidneys and urinary tract (duplication of the kidney, ureter), urolithiasis, diabetes mellitus, etc. etc.

To assess the clinical picture of an infectious kidney disease, and especially for the choice of a treatment method, identification of the pathogen is of great importance. The close anatomical proximity of the urethra, vagina, rectum, a decrease in antimicrobial immunity during pregnancy contribute to the colonization of the entrance to the urethra with bacteria from the intestine. A short urethra and a close location of the bladder, impaired movement of urine along the urinary tract contribute to the ascending path of infection. This, apparently, explains the significant predominance of E. coli and other microbes living in the intestine, among the causative agents of diseases of the urinary system, which occupy the first place during pregnancy. In addition, in pregnant women, yeast-like fungi of the genus Candida (thrush), mycoplasma and ureaplasma are often sown in the urine. The infection can also spread by the hematogenous route (through the blood) from the focus of inflammation - the pharyngeal tonsils, teeth, genitals, gallbladder.

Most often, acute pyelonephritis occurs at 22-28 weeks of pregnancy (as well as at certain stages of pregnancy: 12-15 weeks, 32-34 weeks, 39-40 weeks) or on the 2-5th day of the postpartum period (these periods are associated with the peculiarities hormonal levels and an increase in the functional load on the kidneys, late periods - with a deterioration in the outflow of urine).

In the acute period of the disease, pregnant women complain of a sudden deterioration in health, weakness, headache, fever (38-40 ° C), chills, back pain, dysuric disorders - frequent urination, pain during urination. It must be remembered that against the background of the underlying disease, signs of a threatening and incipient miscarriage or premature birth may appear (due to the presence of an infectious process).

Pyelonephritis can start early and initially be latent (in this case, the symptoms of the disease are not pronounced), therefore, to identify it, the entire complex of diagnostic tests should be used with mandatory urine culture in all pregnant women.

Diagnosis of pyelonephritis is based on the above clinical signs, supported by laboratory data. Research of average portions of morning urine and counting the number of corpuscles in the urine sediment (leukocytes, erythrocytes, various cylinders - a kind of casts of renal tubules and epithelial cells). Methods of Nechiporenko are used to calculate the ratio of leukocytes and erythrocytes (normally in a pregnant woman the ratio of leukocytes and erythrocytes is 2: 1, i.e. 1 milliliter of urine contains 4000 leukocytes and 2000 erythrocytes) and Zemnitsky to determine the relative density and violations of the ratio of daytime and nighttime diuresis ... In all pregnant women with kidney pathology, urine culture is performed to identify microflora and determine its sensitivity to antibiotics, a general and biochemical blood test, as well as an ultrasound examination of the kidneys to identify the state of the calyceal-pelvic system. If pyelonephritis is suspected, the pregnant woman is admitted to the antenatal department of the maternity hospital, and long-term treatment is recommended (at least 4 to 6 weeks).

Treatment of pyelonephritis in pregnant women is carried out according to the general principles of therapy for the inflammatory process. The first stage of complex treatment is positional therapy. This is the position of the pregnant woman on the side opposite to the localization of pyelonephritis (on the "healthy" side), which contributes to a better outflow of urine and accelerates recovery. The knee-elbow position serves the same purpose, which a woman should periodically take for 10-15 minutes several times a day.

Antibacterial drugs are prescribed depending on the type of pathogen and its sensitivity to antibiotics. In this case, preference is given to drugs that do not have a pronounced negative effect on the condition of the fetus (very important) - semi-synthetic penicillins, cephalosporins. To enhance the effect of therapy, antibiotics are combined with uroantiseptics (5-NOK, FURAGIN, NEVIGRA-MON).

An important point in the attraction of pyelonephritis is to improve the outflow of urine. For this, antispasmodics and herbal diuretics are prescribed, which can be purchased in ready-made forms at a pharmacy or prepared by yourself. The treatment regimen also includes vitamin complexes. In the presence of symptoms of intoxication (fever, weakness, weakness), infusion detoxification therapy is performed (various solutions are injected intravenously - HEMODEZ, REOPO-LIGLUKIN, ALBUMIN).

In chronic pyelonephritis, without exacerbation, there are dull pain in the lower back, the urine contains a small amount of protein, a slightly increased number of leukocytes. During pregnancy, the disease can worsen - sometimes twice or thrice. With each exacerbation, the woman should be hospitalized. Treatment of exacerbation of chronic pyelonephritis is not much different from therapy for acute illness. During pregnancy, an appropriate diet is recommended, limiting the consumption of spicy, salty foods, drinking plenty of fluids, vitamin therapy, herbal uroseptics, antibacterial drugs.

I would like to emphasize that in parallel with the treatment of pyelonephritis, it is necessary to carry out complex therapy aimed at maintaining pregnancy and improving the condition of the fetus. Delivery is carried out through the natural birth canal, since a cesarean section in an infected organism is extremely undesirable and is performed according to strictly obstetric indications.

It is worth saying about the prevention of pyelonephritis. Due to the fact that 30-40% of pregnant women with asymptomatic bacteriuria develop acute urinary tract infection, timely detection and treatment of bacteriuria is necessary.

In conclusion, I would like to draw your attention to two main points concerning the postpartum period. Children born to mothers with pyelonephritis constitute a risk group for the development of purulent-septic diseases; and as for mothers, as a rule, after gestational pyelonephritis, renal function is restored in most women.

We are treated with herbs

It is known that medicinal plants have a diuretic, antibacterial and anti-inflammatory effect. In the phase of active inflammation with pyelonephritis, the following collection can be recommended: sage (leaves) - 1 dessert spoon, bearberry (leaves) - 2 teaspoons, horsetail (grass) - 1 teaspoon, chamomile (flowers) - 2 teaspoons. All these herbs must be mixed and insisted for 30 minutes in 400 milliliters of boiled water, and then be sure to strain. The infusion should be taken hot, 100 milliliters 3 times a day before meals in courses of 2 months with two-week breaks. During the period of remission, it is possible to recommend collecting medicinal plants with a pronounced effect on the regeneration process. For example: dandelion (root) - 1 teaspoon, birch (buds) - 1 teaspoon, chamomile (flowers) - 1 teaspoon, nettle (leaves) - 1 teaspoon, lingonberry (leaves) - 2 teaspoons. Mix everything, leave for 30 minutes in 350 milliliters of boiling water, drain. It is recommended to drink the infusion hot, 100 milliliters 3 times a day, half an hour before meals for 2 months with a two-week break.

The kidneys can be divided into two parts - the medulla (the part where urine is formed) and the renal pelvis system, which excretes urine. With pyelonephritis, the latter is affected.

Gestosis is a complication of the second half of pregnancy, in which there is a spasm of the vessels of the mother and the fetus, while both the pregnant woman and the baby suffer. More often, gestosis is manifested by an increase in blood pressure, the appearance of protein in the urine and edema.

Pyelonephritis is a rather dangerous disease, especially during pregnancy. This disease can provoke serious complications, in particular, infection of the fetus. Physiological changes in the urinary tract during the period of bearing a child create many prerequisites for the development of this disease, even in healthy women.

Gestational pyelonephritis

Pyelonephritis is an inflammation of the pelvic system and the interstitial tissue of the kidneys. The disease is quite common and occurs in 10% of women. Pyelonephritis during pregnancy is called gestational pyelonephritis. The disease may first appear during childbearing.

Pyelonephritis is an inflammation of the pelvic system and interstitial tissue of the kidneys

If a woman has previously been diagnosed with a chronic form of pyelonephritis, then there is a high probability of an exacerbation of the disease during pregnancy.

The likelihood of the disease increases with:

urolithiasis;
inflammation of the genital tract (colpitis, cervicitis, bacterial vaginosis);
diabetes mellitus;
chronic foci of infection in the body (caries, tonsillitis and others).

Why is a kidney infection dangerous during pregnancy (video)

The effect of the disease on the course of pregnancy and the condition of the fetus

Like any infectious disease, pyelonephritis has a negative effect on the course of pregnancy and the condition of the fetus. Bacteria, as well as their toxins, can penetrate the uteroplacental barrier and cause intrauterine infection.

In the first trimester, infection can cause the death of the embryo.
After the formation of the placenta, from the 14th week, against the background of pyelonephritis, fetal-placental insufficiency may develop. This chronic circulatory disorder causes a lack of oxygen in the fetus and a delay in its intrauterine development.

The infection may not appear immediately, but play a role during the first years of a baby's life. Such children are often sick, especially during periods of seasonal epidemics of respiratory diseases.

The main danger of pyelonephritis during pregnancy is the high likelihood of developing severe pathology, late toxicosis, or gestosis. This pregnancy complication combines a number of symptoms:

increased blood pressure;
loss of protein in the urine;
chronic intrauterine fetal suffering.

The most severe degree of preeclampsia is eclampsia, or convulsions. This emergency, threatening the life of the woman and the fetus, can occur during pregnancy, before childbirth and directly in the process. In rare cases, eclampsia develops in the early postpartum period.

In addition, the presence of an infectious focus in the kidneys after childbirth can provoke inflammatory processes in the uterus - postpartum endometritis.

Causes

Inflammation of the kidney tissue is caused by bacteria:

Escherichia coli;
streptococci;
staphylococci;
Proteus and others.

If the urine does not stagnate and is evacuated from the body in a timely manner, the conditions for active reproduction of bacteria become less, respectively, the risk of developing pyelonephritis is low.

The reasons for the violation of the outflow of urine in pregnant women:

During pregnancy, hormonal changes in the body occur, as a result of which the muscle tone of the walls of the ureters and bladder decreases. This leads to intermittent episodes of urinary stagnation.
As the uterus grows, mechanical compression of the ureters occurs. They can bend, elongate and bend. As a result, there is a violation of the passage of urine and blood circulation in the kidney tissue.

Thus, favorable conditions are created for the penetration of infection into the kidney tissue:

From the lower urinary tract (urethra and bladder) through the epithelial tissue ascending.
From other foci of infection in the body by hematogenous and lymphogenous pathways: caries, tonsillitis and others.

It is these changes in the urinary system during pregnancy that cause a high likelihood of developing pyelonephritis with cystitis and colpitis.

Symptoms of the disease during pregnancy

Pyelonephritis is acute and chronic.

During pregnancy, the chronic form can worsen, most often it occurs at 22 - 28 weeks. It is during this period that the growing uterus begins to put pressure on the ureters and urinary stagnation develops.

Often there is a latent form of chronic pyelonephritis, which during pregnancy does not have pronounced clinical symptoms and is diagnosed only by changes in laboratory parameters.

Clinical signs of pyelonephritis (table)

Sign	Acute pyelonephritis (exacerbation of chronic)	Latent form of chronic disease without exacerbation
Onset of the disease	sudden	the beginning of the process is not felt
Intoxication of the body	The temperature is over 38 ° C. Chills, fever, profuse sweating. Headache, body aches. Weakness.	not typical
	Pain in the lower back and along the ureters. Positive Pasternatsky's symptom (increased pain when tapping in the kidney area).	There may be pulling pains in the kidney area. Positive symptom of Pasternatsky.
Changes in urine	In the analysis according to Nechiporenko, the number of leukocytes is increased. Bacteria, protein and casts are found. In the analysis according to Zimnitsky - a decrease in the relative density of urine (means a decrease in the concentration function of the kidneys).	Moderate increase in leukocytes in the analysis according to Nechiporenko. Bacteria and trace amounts of protein.
Changes in blood	Increased ESR. The appearance of stab leukocytes in the leukocyte formula (a sign of acute inflammation). An increase in the total number of leukocytes. Decreased hemoglobin.	Moderate increase in ESR. Decreased hemoglobin.

Diagnostics

The diagnosis of the disease is made on the basis of anamnesis data, clinical and laboratory studies.

Diseases of the urinary system (cystitis, urolithiasis, pyelonephritis in the past) have almost 70% of pregnant women with gestational pyelonephritis.

On examination, a positive Pasternatsky symptom is found.

Additionally, the following examinations are carried out:

Urine analyzes according to Nechiporenko and Zimnitsky. Bacteria and leukocytes are found, a decrease in relative density.
Determination of bacteria in urine and their sensitivity to antibiotics.
Complete blood count with leukoformula. In the blood with an acute form of inflammation, an increased ESR, an increased number of leukocytes and a shift in the leukocyte formula to the left are determined.
Biochemical blood test (determine the loss of protein).
Ultrasound of the kidneys.

Invasive examinations such as cystoscopy and ureteral catheterization are not performed during pregnancy. They also refrain from X-ray methods (excretory urography, scintigraphy and others) due to the undesirable effect on the developing fetus.

Differential diagnosis of pyelonephritis during pregnancy is carried out with the following diseases:

acute cholecystitis;
acute appendicitis;
an attack of urolithiasis (renal colic);
ulcers of the stomach and duodenum;
food poisoning and influenza.

Treatment

Treatment of the disease during pregnancy is carried out depending on the form of the pathology.

Treatment of the chronic form

The chronic form of the disease without exacerbation, or asymptomatic bacteriuria, is not accompanied by inflammatory changes in the kidneys and does not cause a deterioration in uteroplacental blood flow. Therefore, for the treatment of this form of the disease, it is sufficient to provide a good outflow of urine to prevent the development of inflammation of the pelvic system and interstitial tissue of the kidneys, as well as to ensure the sanitation of the urinary tract.

Chronic therapy is carried out on an outpatient basis.

For treatment, it is prescribed:

Knee-elbow position. To do this, a woman needs to kneel down and lean on her elbows. In this position, the uterus will deflect anteriorly, relieving pressure on the ureters. This position is recommended to be taken as often as possible.
The course of treatment with the drug Kanefron. It contains plant components with antimicrobial, anti-inflammatory, antispasmodic and diuretic effects.

For the treatment of the chronic form of pyelonephritis, it is recommended to take the knee-elbow position as often as possible.

Treatment of the acute form

Therapy of acute inflammatory process in the kidneys is carried out by joint efforts of obstetricians and urologists in a hospital setting. Treatment principles:

Elimination of the infectious factor. For this, a course of antibiotics is prescribed, taking into account the duration of pregnancy. Until the formation of the placenta, that is, up to 14 weeks of pregnancy, semi-synthetic penicillins are used - ampicillin, oxacillin and herbal uroseptics. In the second and third trimester, after the end of the formation of the placenta, the range of antibacterial drugs expands: add cephalosporins (Zeporin, Suprex), macrolides (Cefotaxime) and nitrofurans.
Restoring the outflow of urine. Treatment begins with positional therapy: the woman is placed on the side opposite to the side on which the affected kidney is located. The knees should be bent. The foot end of the bed is raised. In this position, the pressure of the pregnant uterus on the ureters decreases. In most cases, during the day, there is an improvement in well-being, the pain sensations subside. If this does not happen, ureteral catheterization is performed. After restoring the outflow of urine, antispasmodic drugs (No-shpa, Baralgin) are prescribed, as well as diuretics of herbal origin: lingonberry leaves, birch, cranberry and lingonberry fruit drinks.
Elimination of intoxication of the body. In case of severe intoxication of the body, intravenous infusion of solutions of Gemodez, Laktosol is carried out. Anti-inflammatory drugs are prescribed (Paracetamol, Ibuprofen).
Improving uteroplacental blood flow to provide the fetus with oxygen and nutrients. Intravenous infusion of rheological solutions, vitamins is carried out, sedatives (motherwort, valerian) and antihistamines (Diazolin, Suprastin) are prescribed. According to the indications, oxygen therapy sessions are carried out.

The criteria for the effectiveness of the treatment carried out are:

Complete disappearance of the symptoms of the disease.
Absence of pathological changes in the urine (bacteria, protein, leukocytes) in a threefold study within 10 days.
Improving the condition of the renal tissue according to the results of ultrasound.

Diet for illness

If there is no edema, the fluid intake of a pregnant woman with pyelonephritis is not limited. On the contrary, it is recommended to consume at least two liters of water per day.

Such a water load will provide good diuresis and will facilitate the leaching of bacteria and salts.

The diet of pregnant women with pyelonephritis should consist of easily digestible foods. It is important to avoid constipation, as an overcrowded bowel exacerbates urinary outflow obstruction. To do this, the menu must include fresh vegetables and fruits. Special restriction of salt when cooking food is not required if there is no edema.

cereals, pasta;
yesterday's bread;
vegetarian soups with cereals and vegetables;
boiled meat and low-fat fish;
dairy products (milk, dairy products, low-fat cottage cheese and sour cream);
boiled eggs and steam omelets;
fresh, boiled and baked vegetables - except for white cabbage;
fruits.

pickles;
pickled, spicy and fatty dishes;
mushrooms, onions and garlic, cabbage in any form;
fresh bakery;
legumes, sorrel, spinach and radishes.

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Folk remedies

Medicinal infusions can be prepared independently from:

Birch leaves. Pour a spoonful of dry grass leaves with a glass of boiling water, let it brew for half an hour. The resulting product can be consumed three times a day.
Lingonberry leaves. Dry or fresh leaves (2 tablespoons) should be poured with 400 ml of hot water and kept in a water bath for 20 minutes. The ready-made broth is drunk 2-3 times a day.
Whole oats. For its preparation, a glass of cereal (not flakes) is poured with a liter of boiling water and kept on low heat for two hours. The strained mixture should be consumed three times a day 0.5 cups.

Bearberry, yarrow, parsley, licorice and juniper fruits are not used during pregnancy due to the possible increase in the tone of the uterus.

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Prevention

The risk group for the development of acute pyelonephritis during pregnancy includes women suffering from:

chronic pyelonephritis and cystitis;
urolithiasis;
chronic foci of infection (caries, tonsillitis);
inflammatory diseases of the genital tract (colpitis, cervicitis).

Therefore, first of all, it is necessary to reorganize the foci of infection.

In addition, the following guidelines must be followed:

During pregnancy, eat a diet to reduce the acidity of urine and prevent uric acid loss, as well as to prevent constipation.
Lead an active lifestyle, walk every day and do exercises for pregnant women.
Drink plenty of fluids daily.
In the second half of pregnancy, unload the urinary tract: apply the knee-elbow position at least 3 times a day for 15–20 minutes.
Empty the bladder every 3-4 hours.
Have regular urine tests.

It is important to monitor your weight: excessive weight gain indicates the presence of hidden edema. This is a reason for immediate seeking qualified help.

Almost any woman can get pyelonephritis during pregnancy. But with special attention to your health you need to treat those who are at risk for this pathology.