Hematuria, Pyuria, Urinary Tract Infection And Treatment In Pregnancy

Hematuria In Pregnancy

• Microhematuria (20%) is prevalent in pregnancy and is frequently caused by the fetal head pressing against the bladder.
• Isomorphic hematuria indicates lower urinary tract origin (e.g., UTI, bladder compression), while dysmorphic hematuria suggests glomerular origin (e.g., lupus, preeclampsia).  Hemorrhagic cystitis or vaginal bleeding may be the cause of macrohematuria.
After ruling out a UTI, look for signs of severe renal illness, such as proteinuria, elevated blood pressure, or elevated creatinine.  Wait until three months after giving birth before undergoing additional testing if there is no indication of serious renal damage (around 75% recovery).  Depending on the underlying cause, different treatments are needed (antibiotics for cystitis, no treatment for glomerulonephritis unless there show signs of severe renal impairment).

Preeclampsia (with or without proteinuria), gestational proteinuria, new-onset glomerulonephritis, and unmasked systemic illness are the differential diagnoses for proteinuria in pregnancy.  Biopsy performed between 24 and 32 weeks of gestation, unless there is an emergency or fast progressing glomerulonephritis; performed before 24 weeks if nephrotic syndrome or altered creatinine is present.

Even if it occurs after 24 weeks, AKI or quickly developing glomerulonephritis is exempt from biopsy requirements.
Gestational proteinuria and preeclampsia have a natural history and resolve three months after delivery.

Treatment: There is an inverse relationship between serum albumin and birth rate; whenever creatinine levels rise, prophylactic anticoagulation is crucial; diuretics should be avoided in order to prevent decreased renal blood flow and effective arterial blood volume; and salt restriction should be avoided.

Pyuria In Pregnancy

White blood cells (WBCs) in the urine is known as pyuria. During pregnancy, isolated pyuria is frequent. Increased WBC excretion or contaminated vaginal secretions can both result in pyuria.  Pyuria frequently vanishes after childbirth. A urinary tract infection (UTI) cannot be diagnosed based solely on pyuria. Nonetheless, pyuria raises a pregnant woman's risk of urinary tract infection.

Urinary Tract Infection

The most frequent renal tract issue that arises during pregnancy is a urinary tract infection (UTI). Acute cystitis, acute pyelonephritis, and asymptomatic bacteriuria are the three forms of UTI in pregnancy. Unlike non-pregnant individuals, asymptomatic bacteriuria should be treated if the organism is more than 10^5 and positive on two or more times.

Only 1% to 2% of cases of acute cystitis occur, and organisms ought to have more than 102 or 100 colonies.  High-grade fever and chills are typical symptoms of acute pyelonephritis, and there are typically more than 10^4 colonies.

Etiology of Urinary Tract Infections (UTIs) In Pregnancy   

Urinary tract infections (UTIs) are ascending infections that start in the perineal region and progress along the urinary tract. One typical cause is pelvicalyceal system stagnation brought on by dilatation during pregnancy.

Urological abnormalities such as vesicoureteric reflux, diabetes mellitus during pregnancy, and right-sided urine stagnation are risk factors for pyelonephritis.

Most common organisms causing UTIs in the general population are:

1.  Escherichia coli

2.  Klebsiella

3.  Proteus

4.  Enterococci

5.  Staphylococci

6.  Pseudomonas

Epidemiology of UTI In Pregnancy

Two to ten percent of pregnant women experience asymptomatic bacteriuria. Only one percent of expectant mothers experience pyelonephritis. Pyelonephritis is observed in 30% of women with untreated asymptomatic bacteriuria.

By treating asymptomatic bacteriuria, pyelonephritis incidence is reduced by 80%. Pyelonephritis can cause septicemia and is challenging to treat during pregnancy. Pregnancy-related asymptomatic bacteriuria should be treated to avoid pyelonephritis.

Clinical Features

Found during screening and usually asymptomatic. Because pyuria is common during pregnancy, it cannot be trusted. By secreting bacterial endotoxins, asymptomatic bacteriuria can induce labor. Pyelonephritis often manifests between weeks 20 and 28 of pregnancy. Fever, stomach pain, septicemia, and perirenal abscess are signs and symptoms of pyelonephritis.

Treatment Of Asymptomatic Bacteriuria, Acute Cystitis, And Acute Pyelonephritis In Pregnancy

Asymptomatic Bacteriuria

For three to seven days. It is possible to utilize cephalexin, amoxiclav, or nitrofurantoin. A follow-up culture is necessary following therapy. Give antibiotic prophylaxis with 250 mg of cephalexin at night if the results are still positive.

Acute Cystitis

 For five to seven days.  A follow-up culture is necessary. If left untreated, colonization takes place.  Received a single nighttime dosage of 250 mg of cephalexin as treatment.

Acute Pyelonephritis

Fourteen days of treatment.  Aminoglycoside and cephalosporin were the empirical starting points.

Aminoglycosides can be started in the second or third trimester, but they are contraindicated in the first.

A follow-up culture is necessary. Even in cases where the culture results are negative, cephalexin prophylaxis should be administered throughout the entire gestational period.

Also Read: Hypertension In Pregnancy

Antibiotic Prophylaxis in Pregnancy

Cephalexin (250 mg) and nitrofurantoin (15 mg) are the prophylactic antibiotics. The persistence of bacteriuria without symptoms in 20% of cases. Following a bout of pyelonephritis; During more than two episodes of cystitis during pregnancy.

Medication for asymptomatic bacteriuria: cephalexin, amoxiclav, or nitrofurantoin for three to seven days. Acute cystitis requires 5-7 days of antibiotic treatment, along with a follow-up culture.

Acute pyelonephritis is treated with 14 days of antibiotics, which are empirically begun with cephalosporin and aminoglycoside; aminoglycoside should not be taken during the first trimester of pregnancy. After treatment, a follow-up culture is necessary one week later.

Antibiotic Regimen For Urinary Tract Infections

Also Read: Renal Physiology In Pregnancy

Acute Cystitis

Amoxicillin, nitrofurantoin, and cephalexin were the antibiotics utilized.  Names should be known, but dosages are not necessary to recall.

Asymptomatic Bacteriuria

Cephalexin, Amoxicillin, Amoxicillin-clavulanic acid, Nitrofurantoin, Fosfomycin, and additional medications were utilized as antibiotics. No dosage information.

Recurrent Bacteriuria

Cephalexin, Nitrofurantoin, and Amoxicillin were the antibiotics used in the prophylactic usage of antibiotics. The dosages were 250 mg of Cephalexin at night, 50 mg of Nitrofurantoin at night, and 250 mg of Amoxicillin at night.

Pyelonephritis

 Aminoglycoside and cephalosporins were employed in empirical therapy.IV antibiotics are frequently used during pregnancy.  Antibiotics utilized: Ceftriaxone, Cefazolin, Ampicillin, Gentamicin, Ticarcillin, and Piperacillin

Urinary Calculi/renal Calculi In Pregnancy

 Because of the dilation of the urinary system, higher risk of UTI, and increased excretion of calcium, pregnancy creates an optimal environment for the production of calculi. Nevertheless, NCAM (nephrocalcin, citric acid, acid glycoproteins, and magnesium) contains inhibitors of the development of stones.

Despite the risk factors, inhibitors stop kidney stones from forming. Inhibitors may not always prevent the formation of calcium phosphate and calcium oxalate stones.

Also Read: Tropical Acute Kidney Injury

Clinical Features of UTI/Renal Calculi in Pregnancy

Because widespread, poorly localized stomach pain during pregnancy might be mistaken for labor pain, diagnosing renal calculi or UTIs can be challenging.  A dilated tract usually causes stone to pass on its own.  If a pregnant woman has a stone, her cell cultures and regular urine should be examined for potential UTIs. X-rays are not advised during pregnancy, so ultrasound is utilized instead for diagnosis.

Treatment of Renal Calculi in Pregnancy

It is not advised to undergo lithotripsy while pregnant.
Since calcium supplements are necessary throughout pregnancy, calcium intake shouldn't be restricted.  To lower the risk of calcium oxalate stone formation, oxalate intake in the diet can be restricted.

Treatment for superadded infections is necessary.  ESWL should not be used when pregnant.  Rarely, ureteroscopic removal, stenting, and surgical intervention may be performed. A typical calcium-rich diet is advised.
If options for treating renal calculi during pregnancy are presented, avoiding ESWL rather than restricting calcium intake is the right course of action.

Hope you found this blog helpful for your NEET SS Nephrology Preparation. For more informative and interesting posts like these, keep reading PrepLadder’s blogs.