Gestational pyelonephritis: tactics of antibacterial therapy

Pyelonephritis is caused only by pathogenic microorganisms - staphylococci, E. coli, streptococci, because a pregnant woman’s body cannot resist infection at full strength.

Cost of services in our clinic

Inflammation of the kidneys occurs in 18% of pregnant women, but the disease tends to develop in a latent form. It is quite possible that the woman had the first signs of pyelonephritis long before pregnancy, but the signs of the disease were not pronounced, the inflammation occurred in a sluggish form.

The woman did not see a doctor, was not examined or treated, she did not have an exacerbation, so the disease only manifested itself during pregnancy. The earlier it is detected, the easier it is to treat. Patients who have had kidney problems before should be examined before pregnancy.

Pyelonephritis in itself is not an obstacle to pregnancy. The main thing is to prevent complications. It is advisable to undergo a full special examination before conception; this service is also provided by our clinic. The epicenter of infection is not always the bladder or kidneys. Boils, gastritis and even caries can cause infection to transfer through the lymph to the kidney.

If antibiotic treatment is not started on time, there is a high probability of miscarriage, because the immune system begins to fight pathogenic microorganisms. Immune cells can perceive the fetus as a foreign body and cause spontaneous abortion. To avoid tragedy, a urologist together with a gynecologist select suitable antibiotics for the woman. It must be said that some of them are prohibited for expectant mothers.

They have a certain toxicity, especially the tetracycline group, and in the 1st trimester this poses a threat to the embryo, which is not yet protected by the placenta. For this reason, self-treatment is prohibited.

Generally, gestational pyelonephritis appears at 22-28 weeks. A woman complains of nagging pain in the lumbar region, increased temperature and frequent urge to go to the toilet. In this case, the patient is sent for a special examination, which includes:

• general blood analysis;
• determination of fibrin in blood serum;
• biochemical blood test for AST, ALT, bilirubin and glucose;
• determination of creatinine;
• general urine test for protein;
• urine analysis according to Nichiporenko;
• Ultrasound of the urinary system.

Tests for gestational pyelonephritis

Not in all cases, kidney problems during pregnancy mean a serious pathology. An important indicator is a urine test, in which the leukocyte rate should not exceed 6 units. Protein should also not be lost in a urine test. Excess means an inflammatory process in the kidneys. A blood test only confirms the diagnosis if the ESR and leukocyte counts are increased.

The doctor should be wary of exceeding the norm of urea and creatinine. Considering the condition of a pregnant woman, any instrumental manipulations and radiography are prohibited, therefore ultrasound remains an acceptable and informative diagnostic method.

Before prescribing an antibiotic, a woman undergoes bacteriological culture of urine for flora and selection of an antibiotic for treatment.

Ultrasound diagnostics confirms the expansion of the renal pelvis and an increase in the size of the kidney. Of great importance is not so much the well-being of the mother, although it is important, but the condition of the fetus, because with gestational pyelonephritis it is he who suffers the most. In 30% of cases of the disease, the baby is born with low height and weight.

Intrauterine infection leads to placental abruption, and this is fraught with intrauterine fetal death. Frequent bleeding and anemia in the mother have an extremely negative impact on the development of the baby.

The ultrasound equipment in our clinic is intended to accompany pregnant women with kidney pathologies. An ultrasound machine with various functions allows you to see any, even the most minor, abnormality in the fetus.

The cardiotocography (CTG) function is used to assess the fetal heartbeat at rest and during movement. This method allows you to identify oxygen starvation of the fetus caused by kidney problems in the mother.

Cardiotocography is completely harmless, because for pregnant women an external sensor is used that records fetal movements and uterine contractions. Based on the results of the analysis, the doctor judges the condition of the woman and her baby.

In addition to CTG, Doppler ultrasound is used. It is needed in order to see any changes in the placenta: discrepancy between thickness and maturity and gestational age, presentation, areas of detachment, changes in structure, etc. Based on the state of blood flow, the doctor judges whether the fetus is receiving sufficient oxygen.

Violation of uteroplacental blood flow occurs quite often in gestational pyelonephritis, and this is the cause of cerebrovascular accident in the fetus. Thanks to timely diagnosis, it is possible to identify pathology in time and take appropriate measures.

Causes of pyelonephritis in pregnant women

Doctors point to factors for the development of the disease in expectant mothers:

1. Hormonal background. It changes from the first days after conception. The ureters lengthen and expand, their tone decreases - the risk of infection increases;
2. Increased volume of the uterus. It puts pressure on the ureters - the situation is aggravated with multiple pregnancies or with a large fetus;
3. Dilation of the pelvic veins. The vessels put pressure on the ureters, disrupt the outflow of urine - the pelvis expands;
4. High estrogen levels. Microbes feel comfortable in such an environment.

Pyelonephritis in pregnant women can develop at any stage. That is why, from the first trimester, a woman is sent for laboratory tests - they allow her to monitor her kidney function and diagnose abnormalities in a timely manner.

Pregnancy and cystitis

Cystitis occurs quite often in pregnant women. Every 10th woman complains of a feeling of incomplete emptying of the bladder and discomfort when urinating.

The structure of the female urinary system is such that infection easily spreads from the bladder to the kidneys. In 6% of pregnant women, cystitis turns into gestational pyelonephritis. Sometimes a woman feels symptoms of false cystitis.

This is typical in the early stages of pregnancy up to 8 weeks, when the attached fertilized egg increases the blood supply to the uterus, which has a common innervation with the bladder. Squeezing the latter causes frequent urges, but the woman does not feel pain like with cystitis.

By the 2nd trimester, hormonal levels return to normal and the uterus rises above the bottom without squeezing the bladder. To avoid troubles, before pregnancy it is worth taking a vaginal smear for bacterial culture, because the main source of infection is opportunistic vaginal microflora, as well as STIs.

ONLINE REGISTRATION at the DIANA clinic

You can sign up by calling the toll-free phone number 8-800-707-15-60 or filling out the contact form. In this case, we will contact you ourselves.

If you find an error, please select a piece of text and press Ctrl+Enter

Urinary tract infections in pregnant women. Modern approaches to treatment

In the first Russian manual on obstetrics, compiled by N.M. Maksimovich-Ambodik, “The Art of Weaving, or the Science of Womanhood” (1784), indicated close anatomical connections between the genital and urinary organs in women. What are the tactics for nephroureterolithiasis, nephroptosis, and other diseases that require surgical correction in pregnant women? The answer is clear: it is advisable to eliminate urological diseases before pregnancy. Pregnancy is a risk factor for the development of both uncomplicated (in 4-10% of cases) and complicated urinary tract infections.

Figure 1. Etiology of urinary tract infections in pregnant women (ARIMB 2003)

Figure 2. Screening examination of pregnant women to detect asymptomatic bacteriuria

Recommendations of the European and American Urological Associations for the treatment of NUTI, 2007

Table 1. Prevalence of asymptomatic bacteriuria in the population

Table 2. Diagnosis of UTI in pregnant women

Table 3. Risk categories for the use of various antimicrobial drugs in pregnant women (US FDA approved)

Table 4. Antibacterial therapy for infections of the lower parts of the bladder in pregnant women in Russia (Chilova R.A., 2006)

Table 5. Risk of using medications during pregnancy

Table 6. Methods of drainage of the urinary tract during pregnancy with acute pyelonephritis (5)

Table 7. Antibacterial therapy for pyelonephritis in pregnant women in Russia (Chilova R.A., 2006)

Table 8. Resistance of E.coli isolated from patients with outpatient UTIs in Russia to oral antibiotics, % (Rafalsky V.V., 2005)

Table 9. Grading system for evaluating recommendations in clinical practice guidelines proposed by the Infectious Diseases Society of America and the US Public Health Service

Urinary tract infections in pregnant women can manifest as asymptomatic bacteriuria, uncomplicated lower urinary tract infections (acute cystitis, recurrent cystitis) and upper urinary tract infections (acute pyelonephritis).

The prevalence of asymptomatic bacteriuria in the population of pregnant women averages 6%. Acute cystitis and acute pyelonephritis are somewhat less common - in 1-2.5%. However, 20-40% of pregnant women with asymptomatic bacteriuria develop acute pyelonephritis in the second and third trimesters (13). Acute pyelonephritis develops in the third trimester in 60-75% of cases (7). Approximately 1/3 of patients suffering from chronic pyelonephritis develop an exacerbation during pregnancy (8).

Urinary tract infections can cause a number of serious complications of pregnancy and childbirth: anemia, hypertension, premature birth, premature rupture of membranes, low birth weight babies (

The indications for termination of pregnancy, regardless of the period, are as follows.

Progressive renal failure, established based on the following criteria:

• creatinine value more than 265 µmol/l (3%);
• glomerular filtration rate below 30 ml/min.

Increasing severity of hypertension, especially in malignant forms of its course.

The high prevalence of urinary tract infections in pregnant women is explained by the following factors: a short wide urethra, its proximity to natural reservoirs of infection (vagina, anus), mechanical compression of the ureters by the uterus, decreased tone of the urinary tract, glycosuria, immunosuppression, changes in urine pH, etc.

The most common etiological factor in the development of urinary tract infections in pregnant women is Escherichia coli. The data is presented in Figure 1.

However, in his work on urinary tract infections during pregnancy, A.P. Nikonov (2007) gives higher figures for the occurrence of E. coli

as a causative agent of urinary tract infections - up to 80%.

Diagnostics

According to the guidelines of the European Association of Urology from 2001, severe bacteriuria in adults:

1. ≥ 103 pathogenic microorganisms/ml in midstream urine in acute uncomplicated cystitis in women;
2. ≥ 104 pathogenic microorganisms/ml in the midstream urine in acute uncomplicated pyelonephritis in women;
3. ≥ 105 pathogens/ml in midstream urine in men (or in urine collected by direct catheter in women) with complicated UTI;
4. In a urine sample obtained by suprapubic puncture of the bladder, any number of bacteria indicates bacteriuria.

Asymptomatic bacteriuria in pregnant women

is a microbiological diagnosis that is based on the examination of urine, collected with maximum sterility and delivered to the laboratory in the shortest possible time, which allows the growth of bacteria to be limited to the greatest extent. The diagnosis of asymptomatic bacteriuria can be established by detecting 105 CFU/ml (B-II) of one strain of bacteria in two urine samples taken more than 24 hours apart in the absence of clinical manifestations of urinary tract infections.

Considering the high probability of developing an ascending urinary tract infection in pregnant women with asymptomatic bacteriuria, the possibility of developing complications during pregnancy with the risk of death for the mother and fetus, all patients are advised to undergo screening examination and treatment of asymptomatic bacteriuria in pregnant women. The algorithm is presented in Figure 2.

Clinical symptoms of acute cystitis in pregnant women are manifested by dysuria, frequent imperative urge to urinate, and pain over the pubis. Laboratory tests reveal pyuria (10 or more leukocytes in 1 μl of centrifuged urine) and bacteriuria: 10 2

CFU/ml for coliform microorganisms and 10
5
CFU/ml for other uropathogens.

In acute pyelonephritis, fever, chills, nausea, vomiting, and pain in the lumbar region appear. Pyuria and bacteriuria more than 104 CFU/ml persist. In this case, in 75% the right kidney is affected, in 10-15% the left kidney is affected, in 10-15% there is a bilateral process (1).

Particular attention should be paid to the diagnosis of frequently recurrent cystitis, since they can occur against the background of urogenital infections, and in such cases, neither urine culture nor clinical urine analysis may reveal changes. Such patients need to undergo an examination aimed at excluding sexually transmitted infections: scraping from the urethra for STIs using PCR, ELISA, and, if necessary, the use of serological diagnostic methods.

The algorithm for diagnosing urinary tract infections in pregnant women is presented in Table 2.

Treatment

When choosing an antimicrobial drug (AMP) for the treatment of UTIs in pregnant women, in addition to microbiological activity, level of resistance, pharmacokinetic profile, proven effectiveness of the drug, we must take into account its safety and tolerability.

Rational and effective use of antimicrobial drugs during pregnancy requires the following conditions:

• it is necessary to use drugs only with established safety during pregnancy, with known metabolic pathways (FDA criteria);
• When prescribing drugs, the duration of pregnancy should be taken into account: early or late. Since the time period for the final completion of embryogenesis cannot be determined, it is necessary to be especially careful when prescribing an antimicrobial drug for up to 5 months. pregnancy;
• During treatment, careful monitoring of the condition of the mother and fetus is necessary.

If there is no objective information

confirming
the safety of using a medicinal product
,
including antimicrobial drugs
,
during pregnancy or breastfeeding
,
they should not be prescribed to these categories of patients
.

According to the 2007 Guidelines of the European and American Urological Associations, the following groups of drugs can be used for the treatment of uncomplicated urinary tract infections in pregnant women:

• aminopenicillins/BLI;
• cephalosporins I-II-III generation;
• fosfomycin trometamol.

The following risk categories for the use of drugs during pregnancy, developed by the American Food and Drug Administration (FDA), are widely used throughout the world:

• A –
  as a result of adequate, strictly controlled studies, there was no risk of adverse effects on the fetus in the first trimester of pregnancy (and there is no data indicating a similar risk in subsequent trimesters);
• B
  – animal reproduction studies have not revealed a risk of adverse effects on the fetus, and adequate and strictly controlled studies have not been conducted in pregnant women;
• C –
  animal reproduction studies have revealed adverse effects on the fetus, and adequate and strictly controlled studies have not been conducted in pregnant women, but the potential benefits associated with the use of the drug in pregnant women may justify its use, despite the possible risk;
• D
  – there is evidence of the risk of adverse effects of the drug on the human fetus, obtained through research or practice, but the potential benefits associated with the use of the drug in pregnant women may justify its use despite the possible risk.

Treatment of asymptomatic bacteriuria

in early pregnancy can reduce the risk of developing acute pyelonephritis in later stages from 28% to less than 3% (9).
Considering that pregnancy is a risk factor for the development of complicated infections, the use of short courses of antimicrobial therapy for the treatment of asymptomatic bacteriuria and acute cystitis is ineffective. An exception is fosfomycin trometamol (Monural) in a standard dosage of 3 g once, since in concentrations close to the average and maximum level, Monural leads to the death of all pathogens that cause acute cystitis within 5 hours, the activity of Monural against E. coli
exceeds the activity of norfloxacin and co-trimoxazole (4). In addition, the concentration of the drug in urine in doses exceeding the MIC is maintained for 24-80 hours.

Fosfomycin trometamol is an ideal first-line drug in the treatment of acute cystitis in pregnancy. It has the necessary spectrum of antimicrobial activity, minimal resistance of primary uropathogens, resistant clones of microbes are damaged. It overcomes acquired resistance to antibacterial drugs of other groups and has bactericidal activity. According to Zinner, when using fosfomycin trometamol (n=153) 3 g once, the cure rate for asymptomatic bacteriuria after 1 month was 93%.

Thus, for the treatment of lower urinary tract infections and asymptomatic bacteriuria in pregnant women, the use of monodose therapy is indicated - fosfomycin trometamol at a dose of 3 g; cephalosporins for 3 days – cefuroxime axetil 250-500 mg 2-3 times a day ,

aminopenicillins\ BLI for 7-10 days (amoxicillin\clavulanate 375-625 mg 2-3 times / day; nitrofurans - nitrofurantoin 100 mg 4 times / day - 7 days
(only the second trimester
).

In Russia, a study was conducted on the use of various drugs for the treatment of uncomplicated lower urinary tract infections in pregnant women, the data is presented in Table 4. At the same time, the frequency of incorrect prescriptions was 48%!!!

Table 5 presents the main adverse events when a number of drugs are prescribed during pregnancy.

When identifying atypical pathogens (urea-mycoplasma infection, chlamydial infection) in patients with frequently recurrent cystitis, the use of macrolides (josamycin, azithromycin in standard dosages) in the II-III trimester of pregnancy is indicated.

Patients with acute pyelonephritis

emergency hospitalization is indicated. The complex of laboratory diagnostic methods must include: general analysis of urine, blood, bacteriological examination of urine; Ultrasound of the kidneys and bladder. Monitor vital functions. The cornerstone of treatment for patients with gestational pyelonephritis is to resolve the issue of the need for drainage of the urinary tract and the choice of drainage method.

Indications for drainage

urinary tract during pregnancy is the presence of acute pyelonephritis in the patient against the background of impaired urodynamics.

The choice of method of drainage of the urinary tract during pregnancy depends on: the causes of urodynamic disturbances (urinary tract disease, decreased tone of the urinary tract, compression by the uterus, reflux); timing of pregnancy; stages of pyelonephritis (serous, purulent).

In Table 6 we present methods of drainage of the urinary tract depending on the stage of pyelonephritis.

Antibacterial therapy is carried out only parenterally, followed by monitoring the effectiveness of treatment after 48-72 hours. Subsequently, correction of antibacterial therapy is carried out based on the results of bacteriological examination. The duration of therapy for the serous stage of inflammation is 14 days: 5 days – parenterally, then switch to the oral regimen. Drugs approved for use in pregnant women for the treatment of acute pyelonephritis include:

• Amoxicillin/clavulanate 1.2 g IV 3-4 times a day;
• Cefuroxime sodium 0.75-1.5 g IV 3 times a day;
• Ceftriaxone 1-2 g IV 1 time per day;
• Cefotaxime 1-2 g IV 3-4 times a day.

The advantages of using amoxicillin/clavulanate are its high activity against the key causative agent of UTI - E. coli

(the level of resistance is lower than for fluoroquinolones), the drug has proven effectiveness in uncomplicated and complicated urinary tract infections, and is also the drug of choice in the treatment of urinary tract infections in children.
It should be emphasized that amoxicillin/clavulanate does not increase the risk of congenital anomalies
and deformities, which makes its use possible in the first trimester of pregnancy.

A similar study of the use of antimicrobial drugs was conducted regarding the treatment of patients with acute pyelonephritis during pregnancy and found that the frequency
of incorrect prescriptions of antibacterial drugs was 78%.
The data is presented in Table 7.

In Russia, a high level of resistance of Escherichia coli to ampicillin, amoxicillin and co-trimoxazole has been identified, and therefore the use of these drugs is inappropriate. Data on the level of resistance of Escherichia coli in Russia are presented in Table 8.

Currently, infectious diseases of the genitourinary system in women are characterized by polyetiology, a blurred clinical picture, a high frequency of mixed infections and a tendency to recur, which requires an integrated approach to diagnosis and treatment. The solution to the problem of antibacterial therapy in obstetrics and gynecology can be facilitated by: the creation of state standards and their strict compliance; creation of an expert council to revise standards; physicians' awareness of the principles of evidence-based medicine (1).

Prevention of pyelonephritis in pregnant women

The most effective preventive measure is early diagnosis of pathology. Listen to your body and how you feel:

1. If you feel unwell, change, or have alarming symptoms, consult a gynecologist;
2. Get tested, undergo examinations that your doctor refers you to;
3. Prepare for conception in advance. Cure urogenital infections;
4. In case of multiple pregnancy, large fetus or polyhydramnios, treat bacteriuria as early as possible;
5. Lead a healthy lifestyle. Stick to the drinking regime, eat healthy food;
6. Avoid hypothermia;
7. Maintain personal hygiene. This is one of the causes of infection in women;
8. Take care of your psycho-emotional state. Avoid stress - it reduces immunity;
9. Rest - it restores the body.

Don't refuse medical help. Take medications prescribed by your doctor. If hospitalization is necessary, do not write a refusal - agree. This can save lives - for you and the baby.

Remember: expectant and new mothers who gave birth to a baby 1 - 2 weeks ago are at risk. During this period, the woman’s body is weakened and complications may appear. Follow your doctor's recommendations for prevention - and everything will be fine.

Complications of kidney inflammation

Untimely or poor-quality treatment can lead to serious complications. Sepsis, carbuncle or scarring of the kidney may begin.

Consequences include renal failure and hypertensive crises.

The acute form of pyelonephritis can develop into a more severe form - emphysematous or xanthogranulomatous. In the first case, the mortality rate of patients is more than 40%, in the second the lesion is so strong that upon histological examination it is difficult to distinguish it from a malignant tumor.

Medical Internet conferences

Analysis of medical records showed that the age of pregnant women ranged from 18 to 44 years in both groups. In the main group, the distribution of patients by age was as follows: at the age of 26-30 years - 18 (29.5%) pregnant women, 21-25 years old - 17 (27.8%), 31-35 years old - 12 (19.6%) %), 36 or more years - 11 (18%). In the control group, the overwhelming number of pregnant women were in the age range of 26-30 years - (n=5; 33.3%). Among pregnant women who underwent GP, 45 women (73.8%) were primigravidas, of which only 18 (29.5%) were primigravidas. In the control group, the proportion of primigravidas was 53.3% (n=8), and primigravidas – 37.7%. The overwhelming number of patients in the main group (72.1%) had a complicated obstetric and gynecological history. Of the gynecological diseases, chronic inflammatory processes of the uterus and appendages were registered in 42 (68.9%) pregnant women with GP, uterine fibroids - in 11 (18%), endometriosis - in 2 (3.3%). Artificial abortions and spontaneous miscarriages were traced in the history of 10 (16.4%) and 8 (13.1%) patients of the main group, respectively. Undeveloped pregnancies in the past were identified in 8 (13.1%) pregnant women with GP. In the control group, an extremely low number of pregnant women had a burdened obstetric and gynecological history. Chronic inflammatory processes of the uterus and appendages were observed in only 2 (13.3%) pregnant women, and a previous abortion was recorded in only 1 woman (6.7%). Also noteworthy is the decrease in the somatic health index of women in the main group. Of the extragenital pathologies in this group, the following prevail: chronic gastritis - (n=37; 60.6%), chronic arterial hypertension - (n=26; 42.6%), chronic tonsillitis - (n=21; 34.4%) , diffuse enlargement of the thyroid gland - (n=15; 24.5%), chronic pharyngitis - (n=12; 19.6%), diabetes mellitus - (n=9; 14.7%) chronic tonsillitis - (n= 21; 34.4%), chronic sinusitis - (n=2; 3.2%). In the control group, chronic gastritis was detected in 3 women (20%), diffuse enlargement of the thyroid gland - in 2 (13.3%), chronic pharyngitis - in 2 (13.3%) pregnant women, chronic tonsillitis - in only 1 (6, 7%). The results of our study showed that most often GP develops in the second trimester of pregnancy (n=35; 57.4%). Whereas in the first trimester, GP was diagnosed in 3 pregnant women (4.9%), and in the third trimester - in 23 (37.7%). Among the clinical symptoms of HP, hyperthermia (n=31; 50.8%) and pain syndrome (n=47; 77.04%) prevailed. And only in 4 patients (6.5%) the diagnosis of HP was made only on the basis of the results of laboratory and instrumental examination. In all cases, pregnant women with HP were prescribed antispasmodic, antibacterial and infusion therapy. Antibacterial therapy with one drug was carried out in 44 women (72.1%), combined antibacterial therapy was received by 17 patients (27.9%). Antibiotics from the group of cephalosporins (n=27; 61.4%) and penicillins (n=13; 29.5%) were used as antibacterial drugs. Macrolides were prescribed in isolated cases (n=4; 9.1%). In order to restore the outflow of urine, a drainage stent was installed in 8 (13.1%) patients. The duration of hospital stay ranged from 4 to 10 days.