Download The disorder of urinary tract during pregnancy

The Disorder Of Urinary Tract During Pregnancy
4th year 2016-2017
Assistant professor dr Esraa AL-Maini
Physiological changes:
The kidneys enlarge during pregnancy because of increase of
renal parenchyma as well as an increase in intra renal fluid.
Dilatation of the calyces, renal pelvis and ureter, these changes
are more marked on the right than left side and can be seen as
early as the 1st trimester of pregnancy.
By the 3rd trimester 97% of women have evidence of
hydronephrosis due to both mechanical and hormonal influence
,as pregnancy progress ureteric dilatation becomes more marked
above the pelvic brim ,right more due to pressure of right
ovarian vein ,which crosses the ureter.
GFR measured by 24hours creatinine clearance increased by 6-8
weeks of gestation
s. creatinine and urea which average of 70micromol /l and 5
micromol /l respectively in non pregnant women decrease to
mean value of 50 micromolo/l and 3 micromol/l during
pregnancy ,at term GFR decrease by 15-20% which affect
s. creatinine minimally.
During pregnancy glucose excretion soon increase soon after
conception and may be as high as 10 times that in a non
pregnant women.
2/3 of healthy pregnant women will develop glucose urea
detectable on urine analysis at same time of pregnancy .increase
clearance of other urine constituents.
Terminology:
Bacteriurea: means the presence of bacteria in the urine.
Sgnificant bacteriurea: presence of bacterial colony count
of105or more per ml of urine in a properly collected clean –catch
specimen in an asymptomatic patient.
Asymptomatic bacreiurea:is significant bacteriurea with or
with out pyuria in a patient without symptoms of UTI.
Pylelonephritis:is a bacterial infection of the renal parenchyma
and the renal pelvicaliceal system(acute or chronic) .
Persistence of bacteriuria: is the presence of microorganisms
that were isolated at the start of treatment and continue to be
isolated while the patient is receiving therapy
Causes:inadequate drug therapy and poor patient compliance
resistant organisms.
Relapse :occurs with the recurrence of significant bateriuria
with the same species and serological strain of organism.relapse
usually appears within 2-3 weeks of completion of
therapy(perineal colonization).
Reinfection: is an infection occurring after cessation of therapy
with a different strain of micro-organism or a different serologic
type of the original infecting strain.
Typically, reinfection occure 2-12 weeks after a previous
episode of infection and indicate recurrent bladder bacteriuria.
Superinfection: is the appearance of a different organism while
a patient is still receiving therapy .the new organism may be a
different strain or a different serological type.
Asymtomatic bacteriuria:
Bacteriuria is considered significant if there are at least 105
bacterial colonies per ml in freshly voided urine collected the
mid-stream clean catch technique,with or with out pyuria ,if
there are no symptoms of acute urinary tract infection so
bacteriuria is asymptomatic,
Prevalence during pregnany 2-7%.
Optimal time for screening has been shown to be 16 weeks of
gestation
30% with asymptomatic bacteriuria will develop symptomatic
UTI if not treat .
Risks:
-PTL
-Low birth weight baby.
Pathogenesis:
Bacteria may gain entry to the urinary tract by three pathways:
Ascending ,descending, hematogenous and lymphatic route.
Ascending infection:female is more susceptible because of the
short length of the urethra ,urethral contamination by rectal
pathogens introital and vestibular colonization by pathogenic
bacteria.
Treatment:
E coli from bowel and colonize the urinary tract via the
perineum responsible for 75-85% of infections
Other group B-streptococcus ,proteus ,klebsiela ,pseudomonas
women with bacteriuria of renal origin (40-45%) appears to be
at greatest risk of symptomatic UTI.
Nitrofurantoin 100 mg daily is the treatment of choice for 10-14
days,
cure rates 85% for single dose amoxicillin 3grams
cephlexin 2gram
Urin culture should be repeated 1 week after completion of
therapy and at regular intervals 15-20%will have recurrent
bacteriuria during the same pregnancy, recurrent infection by
same organism so renal origin treat by 3 weeks coarse ,but
different organism is likely to represent bladder infection and
can usually be eradicated with short term therapy.
Persistent AB despite 2-3 course of treatment 100mg
nitrofurantoin daily usually prevent symptomatic infection
Acute symptomatic UTI:
Acute cystitis:is an inflammation of the urinary bladder patient
usually have symptoms of lower urinary tract irritation such as
dysuria ,frequency with small amounts of voided
urine,urgency,nocturia suprapubic discomfort,some time urinary
incontinence and hematuria.
Treatment:
As asymptomatic bacteriuria and additional general
measureinclude:
Rest
Hydration (dilution of bacteria frequent bladder empty)
Ascorbic acid twice daily increase antibiotic activity of urine)
Urinary analgesia.
Acute pyelonephritis;
1-2%of pregnant female , by screening of AB will prevent 70%
of cases present with back pain ,chills, other with lower urinary
tract symptoms ,spiking fever hypotension and tachycardia 2nd
to end toxin are ominous sign
Recurrent UTIis diagnosed when two UTIs occur within 6
months or three or more occur during single year(long term
antibiotic for 6-18 months of benefit)
Risk factors for urinary tract infection in women:
-History of UTI
Frequent or recent sexual inter cours
Increase parity
DM
Obesity
Sickel cell disease
Anatomical congenital abnormality
Urinary calculi
Repeated bladder catheterization or indwelling catheter using
Daiphragm and spermicidal agent as contraceptive methods.
Other factors in general:
Mechnical urinary obstruction :stricture, stenosis
Calcli.
Functional urinaryobstruction abnormalities:incomplete bladder
empty ,pregnancy transient ureteral obstruction .
Systemic factors: DM,cystic renal disease .
Management of pregnant women with acute pyelonephritis:
1-Hospitalization.
2-GUE under microscope ,gram stain for G –ve bacteria ,
urin culture methods: midstream,urethral
catheterization,suprapubic aspiration)
3- blood culture ,full blood count ,urea and electrolyte
4- CXR(to exclude pneumonia if there is tachypnoea or chest
signs.
Microscopic pyuria not reliable sign (of UTI urine should send
for c/s
5-I.V.hydration urine >30ml/l
6-Cefuxime 750mg/8h
Ampicillin 1g/6h until a febrile then oral treatment for 10 days
Gentamycin may be added in severely ill women or if there is
resistance(nephrotoxic so monitored serum level and
s.creatinine)
7-Repeted full blood count and urea and electrolytes after 48
hours most female are febrile by 48 hours and can go home
,25% of female will have a transient but marked decline in renal
function or haemotological dysfunction (thrombocytopenia
,anemia ,DIC ,haemolysis)
More serious complications (urinary obstruction ,perinephric
abscess
8-Exclude underlying obstruction if no clinical response with in
72 hours (US to see calculi 2of 3 if in doubt x-ray with or with
out one shot urogram
Discharge once a febrile
9-Repeated urine culture 1 week after antibiotic completed and
then at regular intervals for duration of pregnancy
Post natal investigation:
20%of female with AB have IVP abn., and the percentage is
higher amongst those with acute infections in pregnancy with
recurrent infection so postpartum urography is indicated.
Chronic renal disease:
Renal dysfunction and pregnancy:
A women loss up to 50% of her renal function still maintain and
s. creatinine less than 130micromol/l ,and patient with renal
disease remain symptom free until their GFR declines to less
than 25%of normal and many serum constituent are frequently
normal until a late stage of disease .
Degree of dysfunction al impairment that do not cause
symptoms in non pregnant individuals can jeopardize
pregnancy.women with chronic renal disease are less able to
make the renal adaptations necessary for a healthy pregnancy
and pregnancy in women with renal disease therefore require
increased maternal and fetal surveillance.
Pre-pregnancy counseling:
1-Safe contraception untill pregnancy is advice
2-fertility issues if indicated
3-Genetic counselling if inherited disease
4-Risk to the mother and fetus during pregnancy
5-Low-dose aspirin for most pregnancies
6-Avoid known teratogens and contraindicated drug
7-need for anticoagulation once pregnant in some conditions
8-Management of hypertension
9-Need for compliance with strict surveillance
10- Likelihood of prolonged admission or early delivery
11-Possibility of accelerated decline in maternal renal function
12- Need for postpartum follow up.
Chronic renal disease: is classified into five stages based on
the level of renal function :
Stage 1:kidney damage with normal or raised GFR
Stage2:kidney damage with mildly low GFR
Stage 3:kidney damage with moderately low GFR
Stage 4:kidney damage with severely low GFR
Stage 5:Renal failure and dialysis.
Stage 1 and2 affect around 3%of women in child bearing age
less pregnancies occur in other stages
Some women are found to have CRD for the first time in
their pregnancy and pregnancy can unmask previously
unrecognized renal disease.
Women with normal or only mild decreased pre-pregnancy
renal function: stages 1-2
usually have an uneventful pregnancy and good renal outcome.
1-Pregnancy with a serum creatinine <110 |imol/L, minimal
proteinuria (<1 g/24 hours)
2-Absent or well-controlled hypertension
pregnancy dose not appear to adversely affect the course of
their disease.
Most female will augment GFR ,but not as much as in normal
pregnant women increased protein urea is common occurring
in50% of pregnant and nephritic rang in 50%.
Perinatal out come affected by uncontrolled HT ,and nephritic
range protein urea is already present in early pregnancy(3g/24
hours).
If renal function is moderately impaired (stages 3-5) are at
highest risk of complications during pregnancy and of an
accelerated decline in their renal function. Pre-existing
hypertension and proteinuria greatly increase the risk. If preeclampsia develops, maternal renal function often deteriorates
further, but any other additional complications, such as
postpartum haemorrhage or use of non-steroidal antiinflammatory drugs, can critically threaten maternal renal
function.
Infant survival rate are good,90%premature delivery 60%IUGR
high obstetric complications in these women they usually
experience functional loss more rapidly than would expected
from the natural course of their disease.
Patient with severly impaired in renal function: there are big
risk of unsuccessful obstetric out come and accelerated loss of
renal function and even terminating the pregnancy may not
reverse the decline.
Dialyis has been advocated prophylactically during pregnancy
to increase the chance of successful out come.
Dialysis:
The incidence of pregnancy on dialysis (stage 5 CKD) is
increasing. Dialysis must be adjusted to allow for the
physiological changes of pregnancy (plasma volume, fluid
retention, electrolytes), and haemodialysis is usually more
effective then peritoneal dialysis in achieving this.
Complications include preterm delivery, polyhydramnios (30-60
per cent), pre-eclampsia (40-80 per cent) and Caesarean
delivery (50 per cent). If conceived on dialysis, 50 per cent of
infants survive, but pregnancy before dialysis has a better
outcome.
Effect of CKD on pregnancy outcome
Pregnancies in mothers with CKD have increased risks of
preterm delivery, delivery by Caesarean section (40 per cent)
and FGR (increased two-fold). Diastolic blood pressure has
been suggested as the greatest risk factor for fetal death, but
overall fetal survival is reported at around 95 per cent. The risk
of adverse pregnancy outcome correlates with the degree of
renal dysfunction .
Major lines for follow up of patient with chronic renal
disease:
1-Assesment of renal function by 24 hours cr. clearance and
protein excretion.
2-Careful blood pressure monitoring for early detection of
hypertension and assessment of its severity ,early detection of
pre-eclampsia.
3 -GUE for early detection of covert bacteriuria or confirmation
of UTIand for PU detection
4-Full blood count Hb and ferritin
5-Renal US ,uterine artery Doppler 20-24 weeks foe early
detection of PE
4-Fetal US include the following:
a-Fetal anatomy
c-Fetal growt
d-Biophysical US surveillance and fetal well being.
Pregnancy in women with renal transplants
Women with end-stage kidney disease have hypothalamicgonadal dysfunction and infertility, so conception is rare.
Female fertility returns rapidly after renal transplantation and it
is estimated that 2-10 per cent of female recipients conceive. Of
pregnancies progressing beyond the third trimester, the vast
majority (>90 per cent) result in a successful pregnancy
outcome. Most transplantation centres advise that conception is
safe after the second post-transplantation year, provided the
graft is functioning well and no rejection episodes occur in the
year before conception.
All pregnancies in transplant recipients are high risk and
should be managed by a multidisciplinary team.
- Lower immunosuppressive steroid dosage,
- longer time since transplantation and better graft function
with absence of chronic rejection, are all associated with better
maternal outcomes.-
- Complications of pregnancy in renal transplant patients
include high rates of :
pregnancy-induced hypertension (30-50 per cent),
preterm delivery (40-60 per cent),
pre-eclampsia (10-40 per cent) and
urinary tract infection (20-40 per cent).
Diagnosing pre-eclampsia can be difficult due to the normal
rise in blood pressure after 20 weeks and the presence of preexisting proteinuria.
The risk of acute rejection in pregnancy is estimated at 2-10
per cent, and allograft dysfunction may also be difficult to
detect during pregnancy. Vaginal delivery is safe, with
Caesarean section considered for the usual obstetric indications.
From 5 to 15 per cent of women have worse graft function after
pregnancy.
Monitoring of renal transplant patients during pregnancy
•
Renal function
•
blood pressure
•
creatinine
•
proteinuria
•
Drug levels
•
Fetal growth
•
If renal function declines, exclude
•
obstruction
•
infection
•
rejection.
Predictors of fetal outcome include pre-pregnancy maternal
hypertension, diabetes mellitus and maternal drug treatment.
Many women have concerns about the immunosuppressive
drugs used post-transplantation, and since immunosuppressive
medications must be continued throughout pregnancy, the fetus
is inevitably exposed to potential fetotoxic and teratogenic
agents throughout development. The actual effects of
medications on growth and development are difficult to
determine and may not be obvious at birth. It is also difficult to
assess the relative effects of immunosuppressive agents, since
underlying maternal diseases, as well as the concurrent use of
other drugs confound interpretation. Prednisolone, azathioprine,
cyclosporin and tacrolimus are considered safe