ANSWER
Activity for Continuing Education
In pregnant women, urinary tract infections (UTIs) are common. Pyelonephritis is the most common serious medical condition seen in pregnancy. It can present similarly to urinary tract infections and can even result from inadequate treatment. As a result, providers must be able to distinguish between normal and abnormal urinary tract and kidney findings, evaluate abnormalities, and treat disease. Urinary tract infections in pregnancy, fortunately, are usually easy to treat and respond well to treatment. This activity reviews the evaluation and management of urinary tract infection in pregnancy and emphasizes the role of interprofessional team members in providing well-coordinated care and improving outcomes for affected patients.
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Objectives:

Determine the cause of urinary tract infections during pregnancy.
Describe how to detect urinary tract infections in pregnant women.
Summarize the available treatment options for urinary tract infections in pregnant patients.
Examine interprofessional team strategies for improving care and outcomes in pregnant patients suffering from urinary tract infections.
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Introduction
In pregnant women, urinary tract infections (UTIs) are common. The most common serious medical condition seen during pregnancy is pyelonephritis. As a result, it is critical for obstetric care providers to understand normal urinary tract findings, abnormalities, and disease treatment. Fortunately, UTIs in pregnancy are frequently treatable with excellent results. Pregnancies complicated by pyelonephritis can occasionally result in significant maternal and fetal morbidity.

Pregnancy-related urinary tract changes and immunologic changes predispose women to urinary tract infection. Dilation of the ureter and renal calyces is a physiologic change of the urinary tract caused by progesterone-related smooth muscle relaxation and ureteral compression from the gravid uterus. Ureteral dilation may be noticeable. Urinary frequency is frequently caused by a decrease in bladder capacity. There may be vesicoureteral reflux. These modifications raise the risk of urinary tract infections.

Visit: Etiology
Urinary tract changes during pregnancy predispose women to infection. The ureters are compressed by the gravid uterus, causing ureteral dilation. Progesterone’s hormonal effects may also cause smooth muscle relaxation, resulting in dilation and urinary stasis, as well as an increase in vesicoureteral reflux. The organisms that cause UTI in pregnancy are the same uropathogens that cause UTI in non-pregnant people. These uropathogens, like non-pregnant patients, have cell-surface proteins that promote bacterial adhesion, resulting in increased virulence. Urinary catheterization, which is commonly performed during labor, may introduce bacteria, resulting in UTI. Changes in bladder sensitivity and bladder overdistention may predispose to UTI in the postpartum period.

Pregnancy causes a state of immunocompromise. This immunodeficiency could be another reason for the increased frequency of UTIs seen during pregnancy.

Visit: Epidemiology
Asymptomatic bacteriuria is the most important factor predisposing women to UTI during pregnancy (ASB). ASB is defined as more than 100,000 organisms/mL on an asymptomatic patient’s clean catch urinalysis. If asymptomatic bacteriuria is left untreated during pregnancy, the risk of subsequent UTI is about 25%. [1] Because of the high prevalence and potential severity of pyelonephritis, all pregnant women should be screened for ASB at their first prenatal visit. This is most commonly accomplished with a clean catch urine culture. ASB treatment reduces the rate of clinical infection to 3% to 4%.

Non-pregnant women have a 5% to 6% rate of asymptomatic bacteriuria, which compares to a 2% to 7% rate in pregnancy. ASB is more common in parous women and women with low socioeconomic status. Women who carry the sickle cell trait are more likely to develop ASB. [1]

Pregnancy-related UTIs are a common source of serious infection. According to one study, UTI accounted for 3.5% of antepartum admissions. [2] The most common cause of septic shock in pregnant women is pyelonephritis. Low socioeconomic status, young age, and nulliparity are all risk factors for UTIs in pregnancy. As with ASB, some patients may be predisposed to infection and may have a history of ASB, cystitis, or pyelonephritis. Pyelonephritis is typically right-sided, but it can be bilateral in up to 25% of cases.

Pathophysiology is a good place to start.
The organisms that cause UTI in pregnancy are the same uropathogens that cause UTI in non-pregnant patients. The most common organism isolated is Escherichia coli. An 18-year retrospective study discovered that E. coli was the causative agent in 82.5% of cases of pyelonephritis in pregnant women. [3] Klebsiella pneumoniae, Staphylococcus, Streptococcus, Proteus, and Enterococcus species are among the bacteria that can be found.

Visit the following pages: History and Physical
Patients with asymptomatic bacteriuria have no symptoms; therefore, screening for the disease is essential. These patients may have a history of recurrent UTIs or have had ASB in a previous pregnancy.

Cystitis manifests itself in the same way that it does in non-pregnant people. Symptoms may include urination pain or burning (dysuria), urinary frequency, or urinary urgency. Suprapubic pain and tenderness are possible.

Patients with pyelonephritis exhibit symptoms similar to those seen in non-pregnant patients with the same disease. Flap pain, fever, and chills are possible symptoms. Non-specific symptoms such as malaise, anorexia, nausea, and vomiting may be reported, resulting in a broad differential diagnosis on initial presentation. Acute intraabdominal processes such as appendicitis, cholecystitis, and pancreatitis are differential diagnoses, as are pregnancy complications such as preterm labor and placental abruption. Patients may report contractions, or uterine monitoring may reveal contractions. This uterine activity is frequently caused by infection-induced smooth muscle irritability. Patients should be evaluated, and if cervical dilation is not found, preterm labor treatment is usually not required. Patients should be closely monitored, however, as preterm labor may develop.

Sepsis signs and symptoms may be present. Tachycardia and hypotension are two examples. Such patients require immediate evaluation and treatment.

A thorough physical examination should be performed, with special emphasis on vital signs and an examination of the heart and lungs. An abdominal examination may reveal tenderness, and costovertebral tenderness is usually elicitable. On admission, a genitourinary (GU) exam should be performed to check for cervical infection and cervical dilation. Even if pregnancy complications are not initially a concern, it is reasonable to evaluate if contractions or other abnormalities occur while hospitalized.

Visit: Evaluation
Urinalysis and a clean catch urine culture will be performed as part of the evaluation. A few considerations should be made when collecting urinary specimens during pregnancy. Patients who are well hydrated may excrete dilute urine, making some measured parameters less accurate. Hematuria can occur as a result of contamination, especially when specimens are obtained from laboring or postpartum patients. Small amounts of protein are normally excreted due to reduced reabsorption. Contamination, such as mucous discharge, may also contribute to the presence of proteinaceous material in pregnant women’s urine.

A complete blood count (CBC), electrolytes, and serum creatine should all be tested in the lab. Tailored studies should be included as needed to rule out other causes of patient symptoms, such as amylase and lipase if pancreatitis is suspected. Lactic acid and blood cultures should be obtained if sepsis is suspected. All cultures should be obtained as soon as possible and prior to the commencement of antibiotic therapy.

When the fetus is viable, the fetal heart rate and contractions should be monitored. If pregnancy-related complications develop, obtaining cervical and GBS cultures on admission should be considered. Renal ultrasound is occasionally used to look for a possible renal abscess.

Please visit: Treatment / Management
Antibiotics are used to treat ASB and acute cystitis. When urine culture results are available, antibiotic selection can be tailored based on organism sensitivities. One-day antibiotic courses are not advised during pregnancy, but three-day courses are effective. [4] Amoxicillin, ampicillin, cephalosporins, nitrofurantoin, and trimethoprim-sulfamethoxazole are common antibiotics. Due to conflicting studies on teratogenicity, fluoroquinolones are not recommended as first-line treatment in pregnancy. Short courses are unlikely to be harmful to the fetus, so this class of drugs can be used to treat resistant or recurring infections.

Recently, evidence has emerged suggesting a link between the use of sulfa derivatives and nitrofurantoin during the first trimester and congenital disabilities. Although these studies had limitations, it is now recommended to avoid using these medications in the first trimester when alternatives are available. [5] Because the consequences of untreated UTI in pregnancy are severe, it is reasonable to use these medications when necessary because the benefit far outweighs the risk of use. Additional precautions apply to these two classes of antibiotics. Sulfa derivatives and nitrofurantoin should not be prescribed to patients with G6P deficiency because they can cause hemolysis. Trimethoprim-sulfamethoxazole should be avoided in the late third trimester due to the risk of kernicterus in the infant following delivery.

If Group B Streptococcus (GBS) is detected on a urine culture, patients should be given intravenous (IV) antibiotics at the time of delivery, in addition to the usual treatment for ASB or UTI. This is done to prevent the development of early-onset GBS sepsis in infants born to GBS-infected mothers.

Pyelonephritis in pregnancy is a serious condition that typically necessitates hospitalization. Following the completion of an evaluation, treatment consists primarily of directed antibiotic therapy and IV fluids to maintain adequate urine output. Fever should be treated as needed with a cooling blanket and acetaminophen. For initial treatment, second or third generation cephalosporins are commonly used. Alternatives include ampicillin and gentamicin, as well as other broad-spectrum antibiotics. Patients should be closely monitored for signs of worsening sepsis.

Visit Differential Diagnosis
Acute intraabdominal disease such as appendicitis, pancreatitis, or cholecystitis, as well as pregnancy-related complications such as preterm labor, chorioamnionitis, or placental abruption, are examples of differential diagnoses.

Visit: Complications
Patients suffering from pyelonephritis are at risk of several serious complications.

Severe sepsis can lead to hypotension, tachycardia, and decreased urine output. ICU admission may be necessary.

Pulmonary complications are not uncommon, occurring in up to 10% of pregnant patients receiving pyelonephritis treatment.

[4] Endotoxin-mediated alveolar damage causes this, which can manifest as pulmonary edema or acute respiratory distress syndrome (ARDS). Urine output and oxygen status should be closely monitored, and patients may need to be admitted to the ICU for respiratory support.

Endotoxin release can cause anemia, which usually resolves on its own after treatment. This is the most common complication of pyelonephritis and affects up to 25% of patients. [3]

Endotoxin release may also result in uterine contractions, and patients should be monitored for preterm labor and treated if necessary. Tocolytic therapy should be used with caution because the risk of pulmonary edema is increased in the setting of UTI.

A small percentage of patients may develop persistent infection. In these cases, urinary obstruction or renal abscess should be considered. Antibiotic selection should be reconsidered, and culture results should be reviewed.

Go to: Patient Education and Deterrence
Urine culture should be obtained 2 to 4 weeks after treatment completion to ensure that reinfection has not occurred.

Suppressive antibiotic therapy, usually with nitrofurantoin once daily, is commonly recommended, particularly in patients with a history of UTI. This is usually continued throughout the pregnancy and early postpartum period.

Visit: Improving Healthcare Team Outcomes
Interprofessional collaboration is essential in the care of these sick patients. Patients may initially worsen after receiving antibiotics due to the release of endotoxin; however, most patients improve within 72 hours. Long-term complications, such as kidney damage, are uncommon.
Why are urinary tract infections so common during pregnancy?
UTIs are extremely common during pregnancy. This is due to the growing fetus putting pressure on the bladder and urinary tract. This either traps bacteria or causes urine leakage.

Physical changes must also be considered. Almost all pregnant women experience ureteral dilation as early as six weeks gestation, when the urethra expands and continues to expand until delivery.

The larger urinary tract, combined with increased bladder volume and decreased bladder tone, causes the urine in the urethra to become more still. This allows bacteria to multiply.

To make matters worse, the urine of a pregnant woman becomes more concentrated. It also contains certain hormones and sugar. These can promote bacterial growth and reduce your body’s ability to fight off “bad” bacteria.

What are the signs and symptoms?
UTI signs and symptoms include:

Urination that is burning or painful
pelvic or lower back pain cloudy or blood-tinged urine
frequent urination the sensation that you need to urinate frequently
nausea or vomiting from a fever
A UTI affects between 2% and 10% of pregnant women, according to Trusted Source. Worryingly, UTIs tend to reoccur frequently during pregnancy.

Women who have previously experienced UTIs are more likely to experience them during pregnancy. The same is true for women who have had multiple children.

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Is a urinary tract infection dangerous during pregnancy?
Any infection during pregnancy can be extremely dangerous to both you and your unborn child. Because infections increase the likelihood of premature labor.

I discovered the hard way that an untreated UTI during pregnancy can also cause complications after delivery. I awoke with a fever of around 105 degrees Fahrenheit (41 degrees Celsius) just 24 hours after having my first child.

I was admitted to the hospital again with a raging infection caused by an undiagnosed UTI, a condition known as pyelonephritis. Pyelonephritis can be fatal to both the mother and the baby. It had spread to my kidneys, causing permanent damage to them.

What is the moral of the story? Inform your doctor if you experience any UTI symptoms while pregnant. If you’ve been prescribed antibiotics, make sure you take every last pill to eliminate the infection.

What are the available treatment options?
You can help prevent UTIs during your pregnancy by doing the following:

emptying your bladder frequently, especially before and after sex wearing only cotton underwear avoiding douches, perfumes, or sprays
To stay hydrated, drink plenty of water and avoid using harsh soaps or body wash in the genital area.
The majority of UTIs during pregnancy are treated with antibiotics. Your doctor will prescribe an antibiotic that is safe to use during pregnancy while still killing bacteria in your body.

If your UTI has progressed to a kidney infection, you may need to take a stronger antibiotic or have it administered intravenously (IV).