Інфекція сечовивідних шляхів під час вагітності

The symptoms of cystitis are the same in pregnant and nonpregnant patients—urinary frequency, urinary urgency, and/or dysuria, and sometimes nocturia. However, some of these symptoms occur during pregnancy without a UTI. Thus, diagnostic tests should be done before treatment.

Acute pyelonephritis occurs more frequently in the second or third trimesters. Symptoms are the same in pregnant and nonpregnant patients and usually include cystitis symptoms combined with upper urinary tract or systemic symptoms (chills, fever, flank pain, colicky abdominal pain, nausea, and vomiting). In pregnant patients, the index of suspicion for pyelonephritis should be high, and a urine test should be done even if some of the characteristic signs and symptoms are not present.

In pyelonephritis, on physical examination, costovertebral angle percussion tenderness is generally present on the infected side.

• Urine dipstick test

• Urinalysis and culture

As part of routine prenatal care, all pregnant patients should be screened for asymptomatic bacteriuria at an early prenatal visit. Testing for asymptomatic bacteriuria should be done with a urine culture.

Diagnosis of symptomatic UTI is the same in pregnant and nonpregnant patients. A dipstick test of the urine is usually done first, and a urinalysis and culture are sent to the laboratory.

• Antibiotics

• For Group B streptococcus, antibiotics during delivery

Treatment of UTI is not changed by pregnancy, with the exception that medications that may harm the fetus (eg, fluoroquinolones) are avoided (1) (see table Safety of Selected Drugs in Pregnancy).

Antibiotic selection is based on urine culture results, local susceptibility, and resistance patterns.

Because asymptomatic bacteriuria may lead to pyelonephritis, any pregnant patient with a positive urine culture should be treated with antibiotics similar to an acute UTI.

Oral antibiotics are given for asymptomatic bacteriuria or acute cystitis. In a symptomatic patient, if a urine dipstick test is positive, empiric treatment should be started immediately and then adjusted, if needed, based on urine culture results.

The usual choice for empiric treatment is cephalexin. Nitrofurantoin or trimethoprim/sulfamethoxazole may be used in the first trimester if appropriate alternatives are not available. Duration of treatment with these agents is typically 5 to 7 days. Fosfomycin given as a single dose is an option only if a culture shows sensitivity, because resistance is common.

Nitrofurantoin is contraindicated in pregnant patients at term, during labor and delivery, or when the onset of labor is imminent because hemolytic anemia in the neonate is possible. Pregnant women with G6PD (glucose-6-phosphate dehydrogenase) deficiency should not take nitrofurantoin. Incidence of neonatal jaundice is increased when pregnant women take nitrofurantoin during the last 30 days of pregnancy.

Trimethoprim/sulfamethoxazole (TMP/SMX) can cause congenital malformations (eg, neural tube defects) and kernicterus in the neonate. Folic acid supplementation may decrease the risk of some congenital malformations.

After treatment, some clinicians do a test-of-cure culture. Following a single episode of cystitis or asymptomatic bacteriuria, repeat screening in asymptomatic patients is not required.

Because of the risk of severe infection, pregnant patients with pyelonephritis are admitted to the hospital and treated initially with intravenous antibiotics, including one of the following: ampicillin and gentamicin; ceftriaxone; cefepime; or aztreonam (for patients with beta-lactam allergy). With clinical improvement, patients may be discharged and given oral antibiotics to complete a 14-day course.

Women who have pyelonephritis or have had more than one UTI may require suppressive therapy, usually with cephalexin (250 to 500 mg orally) or nitrofurantoin (100 mg orally) daily for the remainder of pregnancy and continuing until 4 to 6 weeks postpartum.

After treatment of pyelonephritis, urine should be cultured monthly.

Patients with any colony count of Group B streptococcus (GBS) in a urine culture at any time during pregnancy (which suggests heavy vaginal–rectal colonization) should be given antibiotic prophylaxis at the time of delivery (2).