Urinary Tract Infections in Pregnancy and Puerperal Infection

        Urinary Tract Infections in Pregnancy and Puerperal Infection

significance of UTI in Pregnancy
•    Urinary tract infections (UTI) are common in pregnancy.
     UTI. is an infection which involves urinary tract system
•    8% of pregnant women have asymptomatic bacteriuria if untreated; 25% of these may progress to symptomatic UTI.
•    UTI can be simple cystitis (bladder infections) or pyelonephritis (kidney infections)
•      This may lead to:
o Preterm deliveries and premature rupture of membranes, and as a result:
      Perinatal mortality and morbidity
      Low birthweight

Common Causes, Predisposing Factors and Clinical Features of UTI in
Pregnancy
Common Causes of UTI
•    Organisms that cause urinary infections are those from the normal perineal flora.
o Commonest is Escherichia coli, less commonly implicated are Streptococci, Proteus,Pseudomonas and Klebsiella

Predisposing Factors for UTI in Pregnancy
•    Physiological and anatomical changes during pregnancy i.e. dilatation of ureter and kidneys leading to increased stasis
•  History of recurrent cystitis
o Renal tract abnormalities (duplex system, scarred kidneys, ureteric damage and stones)
o Immunosupression e.g. HIV and AIDS, Diabetes
o Bladder emptying problems
o Haemoglobinopathies (i.e., sickle cell anaemia or trait)

Clinical Features of UTI in Pregnancy
• Symptoms may include:
o Lower back pain
o General malaise

o The classic presentation of frequency, dysuria and haematuria are often not seen.
• Signs
o Tachycardia
o Pyrexia
o Dehydration
o Flank/loin tenderness

Management of UTI in Pregnancy
Investigations
• Full blood count
• Midstream urine for microscopy, culture and sensitivity
• Renal ultrasound scan
Treatment
• Uncomplicated cystitis
o Oral fluids, amoxicillin or cephalosporins. Bactrim can be used in 2nd trimester only.
o Avoid quinolones due to risk of cartilage abnormalities to fetus
• Pylenophritis
o Hospitalize
o IV fluids
o 3rd generation cephalosporins
o may need to add gentamycin
o Simple analgesics and antipyretics to keep temp <101°F/38°C. Avoid NSAIDS e.g., Paracetamol, acetaminophen

Postpartum Infection and Impact on Maternal Mortality in Tanzania
•    Postpartum infections comprise a wide range of infections that can occur after vaginal and caesarean delivery or during breastfeeding.
•    Puerperal infections refer to both chorioamnionitis and postpartum endometritis or could be any infection that arises in the peripartum period.
•   Puerperal fever is a non specific term that could be cause by infections and non infectious
causes.
• Chorioamnionitis is the infections that arise during the course of labour.
Fever is common in labour but does not always represent infections.

• Differential diagnosis of fever in the peripartum period:
chorioamnionitis (onset during labor),
endomyometritis (begins after 24 hrs after delivery),
.pyelonephritis,
. wound infections,
.breast engorment,
.mastitis,
.Pulmonary embolisms,
.pneumonia, and other
.respiratory tract infections
• Endometritis is the most common infection in the postpartum period. In endometritis, fever begins 24 hrs after delivery.

• Other postpartum infections include:
o Postsurgical wound infection

o Perineal cellulitis
o Mastitis
o Respiratory complications from anaesthesia
o Retained products of conception (placenta or membranes)
o Urinary tract infections (UTIs)
o Septic pelvic phlebitis
o Wound infection (more common with caesarean delivery)
Impact on Maternal Mortality inTanzania

•   Postpartum (Puerperal) infection is one of the major causes of maternal disability and deaths in Tanzania.
It accounts for about 11% of all maternal deaths.
o Mothers dies of sepsis

Predisposing Factors for Postpartum Infection
• Frequent vaginal examinations
• Prolonged and obstructed labour
• Premature rupture of membranes
• Premature delivery
• Episiotomies, instrumental delivery, uterine inversion, retained products of conception and manual removal of the placenta
• Poor maternal hygiene
• Anaemia
• Sexually transmitted infections

Features for Diagnosis of Postpartum Infection
Diagnosis
•     The common sites associated with puerperal pyrexia include, breasts, urinary tract, pelvic organs, caesarean or perineal wounds, and lower limbs.
•    The diagnosis of puerperal pyrexia is usually established based on clinical features and investigations.
• Puerperal Pyrexia: A temperature of 38°C or higher during puerperium exclusive of the first 24 hours.
• Genital tract infection is usually characterized by fever, lower abdominal pain, offensive vaginal discharge, vaginal bleeding, delayed involution and tender uterus, bogginess in the pelvis (abscess).

• Investigations:
.Midstream urine for microscopy,
. culture and sensitivity,
.pelvic ultrasound scan,
.full blood count,
.endocervical swabs (microscopy, culture, and sensitivity)

Postpartum Infection – Strategies for Prevention and Treatment
Approaches
Strategies for Prevention
• Reduce the duration of labour by proper use of partogram, ambulation, labour support and appropriate augmentation of labour.
• Reduce the time of rupture of membranes (delay artificial rupture of membranes)
• Reduce number of vaginal examinations
• Use of aseptic techniques during delivery (safe and clean delivery)

Treatment Approaches
• Treatment should be directed towards the cause and clinical severity.

For Severe Disease
• Resuscitate with IV fluids, lower body temperature with antipyretics and administer intravenous antibiotics:
o Ampicilin every six hours
o Gentamycin every 8 hours
o Metronidazole every 8 hours (if caesarean delivery)  Continue for 24 – 48 hours depending on severity
 
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