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Urinary Tract Infections in Pregnancy

Review literature: (Chaliha and Stanton, 2002 ) (S3 Guidelines UTI of the DGU).

Epidemiology of urinary tract infections during pregnancy

The frequency of bacteriuria in pregnancy is 4–7%, comparable to the rate of bacteriuria without pregnancy. Approximately 20–30% of pregnant women with bacteriuria develop acute pyelonephritis, especially in the third trimester.

Etiology of UTI in Pregnancy

• Decreased peristalsis of the ureter
• Mechanical obstruction of the ureter by the enlarged uterus, especially on the right side
• Urinary stasis
• Pathogens: see section acute cystitis and section urinary tract infection.

Signs and Symptoms

• Asymptomatic bacteriuria
• Acute cystitis
• Complications: urinary tract infection during pregnancy often leads to pyelonephritis. Pyelonephritis can be complicated by anemia (in 23%), renal dysfunction (in 7%), or respiratory failure (in 7%). UTI during pregnancy also increases the risk of premature birth, reduced birth weight, increased neonatal mortality, and preeclampsia.

Diagnostic Workup

Urine culture:

Mid-stream urine analysis and urine culture are basic diagnostic tools. Catheter specimens should be avoided to prevent iatrogenic urinary tract infections. Many guidelines recommend screening for bacteriuria (urine culture) in early pregnancy (12th–16th week). A second urine sample should confirm asymptomatic bacteriuria before treatment. Some authors doubt the need for urine cultures in pregnancy without symptoms.

Sonography:

Abdominal sonography is done to exclude hydronephrosis or residual urine.

Laboratory tests:

Acute pyelonephritis leads to systemic inflammation (leukocytosis, CRP). Blood cultures should be obtained in case of high fever.

Obstetric evaluation

Depending on symptoms: pelvic examination and fetal heart rate. Exclusion of premature labor.

Treatment of Urinary Tract Infection in Pregnancy

Asymptomatic bacteriuria and acute cystitis:

Asymptomatic bacteriuria and acute cystitis in pregnancy are treated with oral antibiotics, which reduces the risk of febrile pyelonephritis and probably also the risk of preterm births. After antibiotic therapy, a urine culture is repeated to demonstrate the eradication of the pathogen.

The following antibiotics are possible in pregnancy: Pivmecillinam, oral amoxicillin (possibly with clavulanic acid), oral cephalosporins, and fosfomycin single dose. Significant differences in effectiveness or side effects are not known. The duration of treatment is usually three days.

Acute pyelonephritis in pregnancy:

Hospitalization and intravenous antibiotics are necessary if high fever or other symptoms prevent successful oral treatment. Antibiotics of first choice are cephalosporins of the second, third, or fourth generation, e.g., cefuroxime 1.5 g i.v. every 12 h, ceftriaxone 1–2 g i.v. every 24 hours or cefotaxime 1–2 g i.v. every 12 hours. Treatment with ampicillin is an option if urine culture demonstrates sensitivity. In severe pyelonephritis, cephalosporins or ampicillin might be combined with gentamicin.

References

  Deutsche Version: Harnwegsinfektionen in der Schwangerschaft