Urinary Tract infections in Pregnancy- Clinical Features and Management, HIV in pregnancy: Management

1. UTIs In Pregnancy
Shreya Susan Koshy

2. INTRODUCTION
 By convention, UTI is defined either as a lower tract (acute cystitis)
or upper tract (acute pyelonephritis) infection
 UTI may be asymptomatic (subclinical infection) or symptomatic
(disease).
 Thus, the term UTI encompasses a variety of clinical entities,
including asymptomatic bacteriuria (ABU), cystitis, prostatitis, and
pyelonephritis.
 ABU occurs in the absence of symptoms attributable to the bacteria in
the urinary tract and does not usually require treatment
 UTI has more typically been assumed to imply symptomatic disease
that warrants antimicrobial therapy.

3. IN PREGNANCY
 These are the most common bacterial infections
during pregnancy.
 Asymptomatic bacteriuria is the most common
 In pregnant women, ABU has clinical
consequences, and both screening for and
treatment of this condition are indicated
 Specifically, ABU during pregnancy is associated
with preterm birth and perinatal mortality for the
fetus and with pyelonephritis for the mother.

4. ETIOLOGY
 Normal perineal flora
 E.coli (75-90% of isolates), Klebsiella, Proteus,
Citrobacter, Enterococcus
 Complicated UTI – All the above, plus
Acinetobacter species, Morganella species, and
Pseudomonas aeruginosa

5. ASYMPTOMATIC BACTERIURIA
 The incidence during pregnancy is similar to that in
nonpregnant women and varies from 2 to 7 percent
 Recurrent bacteriuria is more common during pregnancy
 Typically occurs during early pregnancy, with only
approximately a quarter of cases identified in the second
and third trimesters
 A clean-voided specimen containing more than 100,000
organisms/mL is diagnostic.
 there have been instances of counts from 20,000-
50,000/ml resulting in pyelonephritis

6. SIGNIFICANCE
 If not treated, approximately 25 percent of infected
women will develop symptomatic infection during
pregnancy.
 In some, but not all studies, covert bacteriuria has been
associated with preterm or low-birthweight infants
 Schieve and coworkers (1994) reported urinary tract
infection to be associated with increased risks for low-
birthweight infants, preterm delivery, pregnancy
associated hypertension, and anemia.

7. Screening And Treatment
 Performed at 12 to 16 weeks gestation (or the first prenatal
visit, if that occurs later) with a urine culture
 Reasonable to rescreen women at high risk for infection
(eg, history of UTI or presence of urinary tract anomalies,
diabetes mellitus, hemoglobin S, or preterm labor)
 Specimen – Mid stream clean catch
 Diagnosis – one specimen growing organisms ≥105
 Treatment - antibiotic therapy tailored to culture results
and follow-up cultures to confirm sterilization of the urine.
For those women with persistent or recurrent bacteriuria,
prophylactic or suppressive antibiotics may be warranted in
addition to retreatment

8. Oral Antimicrobial Agents Used for Treatment of Pregnant Women with Asymptomatic Bacteriuria
Single-dose treatment
Amoxicillin, 3 g
Ampicillin, 2 g
Cephalosporin, 2 g
Nitrofurantoin, 200 mg
Trimethoprim-sulfamethoxazole, 320/1600 mg
3-day course
Amoxicillin, 500 mg three times daily
Ampicillin, 250 mg four times daily
Cephalosporin, 250 mg four times daily
Ciprofloxacin, 250 mg twice daily
Levofloxacin, 250 or 500 mg daily
Nitrofurantoin, 50 to 100 mg four times daily or
100 mg twice daily
Trimethoprim-sulfamethoxazole, 160/800 mg two
times daily
Other
Nitrofurantoin, 100 mg four times daily for 10 days
Nitrofurantoin, 100 mg twice daily for 5 to 7 days
Nitrofurantoin, 100 mg at bedtime for 10 days
Treatment failures
Nitrofurantoin, 100 mg four times daily for 21 days
Suppression for bacterial persistence or recurrence
Nitrofurantoin, 100 mg at bedtime for pregnancy
remainder

9. ACUTE CYSTITIS
 CLINICAL MANIFESTATIONS
 The typical symptoms of acute cystitis in the
pregnant woman are the same as in nonpregnant
women
 Include the sudden onset of dysuria and urinary
urgency and frequency. Hematuria and pyuria are
also frequently seen on urinalysis.
 Systemic symptoms, such as fevers and chills, are
generally absent in isolated cystitis

10. DIAGNOSIS AND TREATMENT
 Acute cystitis should be suspected in pregnant women who
complain about dysuria
 The presence of fever and chills, flank pain, and
costovertebral angle tenderness should raise suspicion for
pyelonephritis
 Urinanalysis, and culture
 Prior to confirming the diagnosis, empiric treatment is
typically initiated in a patient with consistent symptoms
and pyuria on urinalysis
 it is reasonable to use a quantitative count ≥103 cfu/mL in
a symptomatic pregnant woman as an indicator of
symptomatic UTI
 Treatment is by the same drugs used in treatment of
asymptomatic bacteriuria

11. ACUTE PYELONEPHRITIS
 Fever (>38ºC or 100.4ºF), flank pain, nausea,
vomiting, and/or costovertebral angle tenderness
 Pyuria is a typical finding
 Most cases of pyelonephritis occur during the second and
third trimesters
 Pregnant women may become quite ill and are at risk for
both medical and obstetrical complications from
pyelonephritis
 As many as 20 percent of women with severe pyelonephritis
develop complications that include septic shock syndrome
or its variants, such as acute respiratory distress syndrome

12. DIAGNOSIS AND TREATMENT
 Clinical symptoms + urinanalysis and culture
 Low threshold for suspicion
 Pyuria seen in a majority
 In patients with pyelonephritis who are severely ill or who also have
symptoms of renal colic or history of renal stones, diabetes, history of
prior urologic surgery, immunosuppression, repeated episodes of
pyelonephritis, or urosepsis, imaging of the kidneys can be helpful to
evaluate for complications
 Hospital admission for parenteral antibiotics, that can later be
converted to an oral regime following profiling of organism
 suppressive antibiotics are typically used for the remainder of the
pregnancy to prevent recurrence.
 Parenteral, broad spectrum beta-lactams are the preferred
antibiotics for initial empiric therapy of pyelonephritis

13. OBSTRETRIC MANAGEMENT
 Pyelonephritis is not itself an indication for
delivery
 If induction of labor or c-section is planned then
wait till patient is afebrile.

14. HIV IN PREGNANCY

15. EFFECT OF
Pregnancy on HIV
 Does not increase progression of
HIV to AIDS
 Opportunistic infections maybe less
aggressively investigated and
treated due to concerns for fetus,
causing maternal risk
HIV on pregnancy
Increased risk of
 Miscarriage
 Preeclampsia
 Preterm delivery
 IUGR
 Vertical transmission

16. DIAGNOSIS
 Positive ELISA confirmed by western blot or IF assay
 Or two positive ELISAs
 CD4 count for immunosuppression degree
 Viral load for disease progression

17. VERTICAL TRANSMISSION
Antepartum 0-14 weeks 1%
14-36 weeks 4%
>36 12%
Intrapartum 8
Postpartum with breast
feeding
Established infection 14
Primary infection 29
In India risk of vertical transmission is about 30%

18. FACTORS INCREASING VERTICAL
TRANSMISSION
Disease Factors
 Viral load
 Seroconversion
 Advanced mutant disease
 Low CD4
Obstetric Factors
 Vaginal delivery
 Prolonged rupture of membranes
 LBW
 Antepartum invasive procedure
 Breastfeeding

19. SCREENING
 All pregnant women should be offered screening
early in pregnancy
 Pretest and posttest counselling mandatory
ANTENATAL CARE
Option of MTP should be discussed earliest
HIV +ve mothers should be counselled about
nutrition, hygiene, safe sex practices, etc
Detailed anomaly scan should be a priority
Prophylaxis for pneumocystis indicated when CD4
count is <200mm3

20. ANTI RETROVIRAL THERAPY
 RCOG GUIDELINES
 They recommend either zidovudine monotherapy or HAART(advanced
disease, high viral load or low CD4 count)
 WHO GUIDELINES
 Option A- Zidovudine twice daily 14 weeks onwards, Neviparine single
dose at labor onset, Zidovudine and lamivudine twice daily during
labor and 1 week postpartum
 OPTION B triple drug prophylaxis from 14 weeks and during breast
feeding
 NACO GUIDELINES
 Neviparine single dose 200mg onset of labor, single dose of 2mg/kg to
neonate within three days of delivery

21. INTRAPARTUM MANAGEMENT
 When antiretroviral therapy was given in the prenatal,
intrapartum, and neonatal periods along with cesarean
delivery, the likelihood of neonatal transmission was
reduced by 87 percent compared with vaginal delivery and
without antiretroviral therapy
 Elective c section at 38 weeks for all women not taking
HAART and viral load >50/ml is advised
 Planned vaginal if on HAART and viral load less than 50/ml
 In Zidovudine monotherapy c section reduces infection
risk
 Universal Precautions should be followed stringently

22. BREAST FEEDING
 The probability of HIV transmission per liter of breast milk
ingested is estimated to be similar in magnitude to
heterosexual transmission with unsafe sex in adults
 Most transmission occurs in the first 6 months, and as
many as two thirds of infections in breast-fed infants are
from breast milk.
 In the Petra Study Team (2002) from Africa, the
prophylactic benefits of shortcourse perinatal anti viral
regimens were diminished considerably by 18 months of
age due to breast feeding

23. POSTPARTUM MANAGEMENT
 otherwise healthy women with normal CD4+ T-cell counts
and low HIV RNA levels may discontinue treatment after
delivery and be closely monitored according to adult
guidelines
 The exception is the woman who plans another pregnancy
in the near future

24. REFERENCES
 William’s Obstetrics 24th edition
 Textbook of Obstetrics by Sheila Balakrishnan
 Uptodate.com