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Urinary tract infection in pregnant women. Urinary tract infections: asymptomatic bacteriuria

Every tenth pregnant woman suffers from one or another type of urinary tract infection. Among them, acute cystitis and pyelonephritis are most common. The latter is especially dangerous for future mother and baby. How to identify and treat these diseases will be discussed in this article.

Urinary tract infections: why are pregnant women at risk?

In the body of the expectant mother, various changes occur in all organs. After all, they now have to work for two, or even three. In addition, during pregnancy, conditions are created that contribute to the development of certain diseases. Here are the factors that predispose to infection urinary tract(MVP):

mechanical compression of the uterus urinary tract, first of all, the ureters, which contributes to the violation of the passage of urine, its stagnation and the reproduction of various pathogens;
decreased ureteral tone and Bladder due to an increase in the level of progesterone - a hormone that supports the growth of the fetus;
excretion of sugar in the urine (glucosuria) and an increase in its acidity (ph), which supports the growth and reproduction of various microorganisms;
decrease in general and local immunity.

The result of these processes are infectious processes of the lower (cystitis, urethritis, asymptomatic bacteriuria) and upper (pyelonephritis and kidney abscess) urinary tract.

In 60-80% of pregnant women, urinary tract infections are caused by Escherichia coli (E. Coli), in the remaining 40-20% - by Klebsiella, Proteus, Staphylococcus, Streptococcus, Enterobacter, etc.

The consequences of urinary tract infections during pregnancy can be very tragic. Here are the main complications:

anemia (decreased hemoglobin level);
hypertension (increased blood pressure);
premature birth;
early rupture of amniotic fluid;
the birth of children with low body weight (less than 2250 g);
fetal death.

Given the danger of urinary tract infections, it is necessary to carefully approach the issue of their timely detection.

Urinary tract infections: urinalysis

As you know, the main method for assessing the state of the urinary system is a general urine test. Diagnosis of urinary tract infections is based on the detection in the general analysis of urine of leukocytes (leukocyturia) or pus (pyuria) - the main signs of an existing inflammatory process.

The presence of leukocyturia is indicated when 6 or more leukocytes are found in the remainder of centrifuged urine in the field of view of the microscope.

However, the method is not always informative. Therefore, in some cases, additional examination is required to clarify the diagnosis.

Urinary tract infections: asymptomatic bacteriuria

The problem is that most expectant mothers with an existing urinary tract infection do not care. No complaints, if any a large number pathogens in the urine is called asymptomatic bacteriuria. This condition is detected, on average, in 6% of pregnant women (from 2 to 13%) and is characterized by a high frequency of development of acute cystitis, pyelonephritis and the onset of complications: premature birth, the birth of a baby with low body weight, etc.

To detect bacteriuria alone general analysis urine is not enough, since in this condition leukocyturia (pyuria) may be absent.

As an additional screening, it is necessary to use a culture (bacteriological, or cultural, study) of urine. Asymptomatic bacteriuria is diagnosed when there is a large number microorganisms (more than 10 5 CFU / ml) of the same species in the crops of the average portion of urine collected in compliance with all the rules, taken twice with an interval of 3-7 days and the absence of a clinical picture of infection.

Given the asymptomatic course of bacteriuria, screening bacteriological examination urine is necessary for all pregnant women at the first visit to the doctor in the first trimester or the beginning of the second (16-17 weeks), when the uterus extends beyond the small pelvis.

With a negative result, the risk of subsequent development of cystitis or pyelonephritis is only 1-2%, therefore, in this case further culture studies of urine are not carried out. If the diagnosis of "asymptomatic bacteriuria" is confirmed, antibiotic treatment is prescribed, which I will discuss later.

Urinary tract infections: acute cystitis

Acute cystitis is called inflammation of the mucous membrane of the bladder with a violation of its function. At the same time, the patient has complaints characteristic of this disease:

cramps when urinating,
frequent urges,
feeling of incomplete emptying of the bladder,
discomfort or pain in the lower abdomen.

If a woman has these symptoms, she should see a doctor. Diagnosis of acute cystitis is based on complete clinical trial urine, first of all, to detect leukocyturia (pyuria). For this purpose, the following methods are performed:

general urine analysis;
study of non-centrifuged middle portion of urine; allows you to detect infection with normal urinalysis; the presence of infection is indicated by the content of more than 10 leukocytes in 1 μl of urine;
urine culture; in acute cystitis, bacteriuria is detected (for E. coli - more than 10 2 CFU / ml, for other microorganisms - more than 10 5 CFU / ml).

Urinary tract infections: treatment of asymptomatic bacteriuria and acute cystitis

Treatment asymptomatic bacteriuria and acute cystitis is carried out on an outpatient basis, these conditions do not require hospitalization. Especially carefully it is necessary to treat the selection of an antibacterial drug, because it must be not only effective, but also safe.

The choice of medicines is carried out by the doctor. For the treatment of asymptomatic bacteriuria or acute cystitis, fosfomycin trometamol (monural) 3 g once or a 7-day course of one of the following antibiotics is prescribed:

amoxicillin / clavulanate 375-625 mg 2-3 times a day;
cefuroxime axetil 250-500 mg 2-3 times a day;
ceftibuten 400 mg once a day;
cefixime 400 mg once a day;
nitrofurantoin 1000 mg 4 times a day.

After 7-14 days from the start of treatment, a urine culture is performed. If the analysis confirms positive effect, then no further treatment is required, and the patient remains under medical supervision. At the same time, once a month, she needs to take a control urine culture.

If the treatment is ineffective, the woman is prescribed the so-called "suppressive" (suppressive) therapy until the end of the pregnancy and within 2 weeks after childbirth with monthly bacteriological control. Recommended schemes of "suppressive" therapy: fosfomycin trometamol (monural) 3 g every 10 days or nitrofurantoin 50-100 mg 1 time per day.

Also, with the ineffectiveness of the antibacterial treatment it is necessary to exclude urolithiasis and strictures (narrowing) of the ureter, which aggravate the infectious process. In this case, the issue of the need for catheterization of the ureters is resolved - the introduction of a catheter into them.

Urinary tract infections: acute and chronic pyelonephritis

In 20-40% of pregnant women with an infection of the lower urinary tract (cystitis, urethritis, asymptomatic bacteriuria), acute pyelonephritis develops - an inflammatory disease of the kidneys, which is characterized by damage to the cups and pelvis with impaired organ function.

Gestational pyelonephritis often occurs in the II and III trimesters, 10-30% of pregnant women have relapses. In the majority (75%) of women, only the right kidney is affected, in 10-15% - only the left, in 10-15% - both.

In addition to urination disorders, acute pyelonephritis, unlike cystitis, has pronounced common manifestations. Here are the main complaints of patients with this disease:

a sharp increase in body temperature, chills,
nausea, vomiting,
weakness, lethargy,
pain in the lumbar region,
muscle pain and headaches,
decreased appetite.

In the general analysis of urine, in addition to leukocyturia, protein and red blood cells can be detected. Laboratory markers of pyelonephritis in the study of urine, including microscopy and bacteriological culture, similar to those in acute cystitis:

leukocyturia (more than 10 leukocytes in 1 µl of non-centrifuged urine);
bacteriuria (the number of microorganisms is more than 10 4 CFU / ml).

Also, to assess the patient's condition, clinical and biochemical analysis blood, which can be found:

increase in the level of leukocytes,
decrease in hemoglobin,
ESR acceleration,
an increase in the concentration of urea and creatinine, etc.

Urinary tract infections: management of pregnant women with acute pyelonephritis

Unlike cystitis, pyelonephritis is treated exclusively in a hospital, as there is a high probability of complications that are formidable and dangerous for mother and baby. Thus, 2% of patients with gestational pyelonephritis may develop septic shock, a severe life-threatening condition. All this confirms the need for special monitoring of the condition of the mother and baby.

In the urology department, the patient is monitored vitally important functions(respiration, blood circulation, etc.), bacteriological examination of blood and urine. One of the following antibiotics is also given intravenously:

amoxicillin/clavulanate;
cefuroxime sodium;
ceftriaxone;
cefotaxime.

The duration of antibiotic therapy for pyelonephritis should be at least 14 days: intravenous administration is carried out for 5 days, then they switch to tablet preparations.

The lack of improvement within 48-72 hours can be explained either by obstruction of the urinary tract (urolithiasis or narrowing of the ureter), or by the resistance (resistance) of microorganisms to the treatment.

In the first case, it is necessary: catheterization of the ureter with its narrowing, surgical treatment - with urolithiasis; in the second - the change of the antibacterial drug under bacteriological control.

Also, if the treatment is ineffective, it is necessary to prescribe a "suppressive" therapy or conduct a culture study of the urine every 2 weeks before delivery.

Urinary tract infections: errors in treatment

Unfortunately, the treatment of urinary tract infections is not always chosen correctly. Among the mistakes in the choice of therapy are most often noted: the use of unsafe and / or ineffective antibiotics. In this regard, I give a list of antibiotics that cannot be used during pregnancy:

sulfonamides (cause destruction of red blood cells and anemia in newborns);
trimethoprim (lead to deficiency in the body folic acid responsible for protein metabolism and cell division);
nitrofurans (destroy red blood cells in the third trimester of pregnancy);
aminoglycosides (have a toxic effect on the kidneys, the organ of hearing);
quinolones and fluoroquinolones (cause joint pathology);
nitroxolia (provoke multiple damage to the nerves, including the visual one).

It is also important to know that according to the multicenter study ARIMB (2003) in Russia, there is resistance of Escherichia coli to following antibiotics: apmicillin - in 32% of pregnant women, co-trimoxazole - in 15%, ciprofloxacin - in 6%, nitrofurantoin - in 4%, gentamicin - in 4%, amoxicillin / clavulanate - in 3%, cefuraxime - in 3%, cefotaxime - at 2%. Resistance to ceftibuten and fosfomycin was not detected.

The factors of resistance and toxicity should be known not only to doctors, but also to pregnant women suffering from urinary tract infections.

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One of the most common complications of the gestational process are infectious and inflammatory diseases of the urinary tract (UTI). In recent decades, this pathology complicates from 18 to 42% of all pregnancies and its frequency is steadily increasing. This is due to a number of factors. First, with the initial predisposition of pregnant women to the development of UTIs. Here we mean those physiological changes in the kidneys, ureters and bladder, which occur under the influence of hormonal and mechanical factors, namely, the expansion of cavities, a decrease in the tone of smooth muscle elements, and the hydrophilicity of tissues. All this contributes to the violation of the passage of urine, the formation of a system of refluxes and the unhindered implementation of the infectious process in the presence of a pathogen. In addition, it is of great importance modern features microbiological spectrum with a predominance of resistant opportunistic flora, as well as a decrease general level somatic health in women of childbearing age.

Basic hallmark urinary tract diseases in pregnant women is the prevalence of erased, low-symptomatic forms with a minimum number of clinical manifestations and laboratory markers.
However, it implements Negative influence infectious process during pregnancy, the number of complications increases sharply both on the part of the mother and the fetus. In this regard, the issues of timely diagnosis and full treatment of urinary tract infections at all stages of gestation should be given special attention.

It is customary to isolate infections of the upper and lower urinary tract. The first ones are
pyelonephritis (serous and purulent), the second - urethritis, cystitis and asymptomatic bacteriuria (BB). Uncomplicated UTIs are acute cystitis and acute pyelonephritis. The remaining diseases are considered complicated UTIs. Any form of urinary tract infection in pregnant women requires active therapy, including asymptomatic bacteriuria.
It has been shown that in the absence of antibacterial treatment, BD progresses to gestational pyelonephritis in 14-57% of cases.

Causes of urinary tract infection:

The main cause of urinary tract infection is considered to be an infectious agent. Among nonspecific pathogens, the most common (44%) are representatives of enterobacteria: Escherichia coli (leading in frequency), Klebsiella, Proteus, Enterobacter. The second place in frequency is occupied by gram-positive cocci (36%) - staphylococci, enterococci, streptococci. The share of fermenting and non-fermenting Gram-negative bacteria accounts for 19-20%. An essential role belongs to the non-spore-forming anaerobic flora (Peptostreptococcus, Veillonella, etc.). In 7% of patients, fungi of the genus Candida are a causally significant pathogen.
Microbial associations are detected in 8% of cases. It is known that in recent years the sensitivity of microorganisms to antibacterial agents has changed significantly. In particular, the number of resistant strains of E. coli to semi-synthetic penicillins reaches 30-50%, to protected penicillins exceeds 20%. The same resistance is recorded in relation to most non-fluorinated quinolones, and nitroxaline is ineffective in more than 80% of cases.

The role of specific pathogens (chlamydia, members of the mycoplasma family, viruses) is determined by their special tropism for the tissues of the urinary tract, leading to the formation of long-term interstitial nephritis. Chlamydia, mycoplasmas and ureaplasmas are found in 45% of pregnant women with urinary tract infections, viruses (herpes simplex virus, cytomegalovirus, enteroviruses) - in 50%. As a rule, these microorganisms are associated with certain representatives of nonspecific flora - staphylococci, enterococci, Klebsiella, non-spore-forming anaerobes. At the same time, Escherichia coli is more often cultured in patients who do not have specific infections.

The source of urinary tract infection can be any infectious and inflammatory focus in the body, but in pregnant women highest value have pathogens localized in the genital tract and intestines, and not only inflammatory, but also dysbiotic processes play a role. In this regard, the risk group for the development of urinary tract infections in pregnant women includes patients with inflammatory processes of the genitals and bacterial vaginosis, women who have a partner with an inflammatory pathology of the genital apparatus, leading an intense sex life. Long-term use of COCs or spermicides on the eve of pregnancy matters. In addition, risk factors are intestinal dysbacteriosis and inflammatory processes in it. They indicate the role of the features of the anatomical structure of the pelvis, when the distance between the anus and the external opening of the urethra is less than 5 cm.

Ways of distribution of an infection are various. The ascending pathway predominates in infections of the lower urinary tract, as well as in conditions of disruption of normal urodynamics, the formation of a reflux system with a gradual reflux of urine from the vestibule of the vagina into the renal pelvis. However, with the development of pyelonephritis, the main route of infection is hematogenous.
It is believed that for the implementation of the infectious process, in addition to the microbial agent, the presence of predisposing pathogenetic factors is necessary, among which the most important are: a change in the immunoreactivity of the organism, a violation of urodynamics (obstructive or dynamic), endocrine pathology(especially diabetes), an existing pathology of the urinary system, hereditary predisposition. As a rule, every pregnant woman has a combination of several factors.

The most natural of them is a dynamic violation of the outflow of urine. In the first trimester, it is associated mainly with hormonal changes in the body (increased progesterone levels), in the second and third trimesters, with a mechanical factor of compression of the kidneys and ureters due to the growth and rotation of the uterus. Compression events are typical for the following categories of women (risk groups for the development of pyelonephritis): large fruit, multiple pregnancy, polyhydramnios, narrow pelvis. Impaired carbohydrate metabolism in the form of reduced glucose tolerance - the most common variant of gestational diabetes mellitus, found in 3-10% of cases in relation to all pregnancies - is associated with UTI in 100% of cases. Among hereditary factors special meaning has a history of UTI in the mother, which increases the risk of recurrent urinary tract infections in a pregnant woman by 2-4 times.

Pyelonephritis:

Infectious-inflammatory disease with a primary lesion of the interstitial tissue of the kidney, its renal tubules, as well as cavities. From the point of view of the negative impact on the course of the gestational process, among various urinary tract infections, it is pyelonephritis that is of the greatest importance. Pyelonephritis during pregnancy may be a continuation of a chronic process that a woman had earlier. In this case, it is usually latent (in 75%) or is accompanied by exacerbations. If pyelonephritis is detected for the first time at any time, it is considered associated with pregnancy - gestational, while an acute, latent or recurrent variant of the course is possible. Clinical and laboratory manifestations and tactical principles are the same in both cases, but the chronic process determines the worst starting conditions and the complexity of treatment (for example, flora resistance).

Types of pyelonephritis:

serous pyelonephritis (97%), in which a multifocal leukocyte infiltration of the connective tissue of the kidney is formed with compression and dysfunction of the renal tubules; Treatment is predominantly conservative.

purulent pyelonephritis (3%) is non-destructive (apostematous) and destructive (subcapsular abscess and carbuncle of the kidney), always requires surgical treatment.

Pyelonephritis is more often found in nulliparous women (66%), usually manifests itself in the second or third trimesters of pregnancy (starting from 22-28 weeks). However, in Lately an earlier onset of the disease is increasingly observed - in the first trimester (in about 1/3 of cases). Kidney damage is often bilateral, but on the one hand (usually on the right) the process is more pronounced.

Symptoms of pyelonephritis in pregnant women
Acute pyelonephritis is an infectious and inflammatory disease with general and local symptoms. General symptoms appear first, they are associated with intoxication of the body. This is a general weakness, malaise, headaches, loss of appetite. Possible nausea and vomiting liquid stool. There are muscle pains and aches all over the body. Temperature from subfebrile to hectic, chills, sweating. On the 2-3rd day of the disease, local symptoms appear. First of all, it is a pain syndrome. In pregnant women, it is usually not pronounced even with a purulent process (otherwise, one should think about urolithiasis). The pains are localized in the lower back, are unilateral or girdle in nature, can radiate to the leg, intensify in the position on the contralateral side, as well as with deep inspiration, coughing, sneezing. Forced position in bed - on a sore side.

Pasternatsky's symptom may be positive, but negative does not indicate the absence of pyelonephritis. Pain is more reliable on palpation of the ureteral points located at the level of the navel, retreating from it in both directions by 3-4 cm (if the duration of pregnancy allows). With irritation of the parietal peritoneum, peritoneal signs may appear. Dysuric disorders are considered another typical manifestation. Diuresis is adequate or slightly increased, nocturia is characteristic. A decrease in diuresis is a symptom indicating a violation of the passage of urine due to blockage of the ureters by inflammatory detritus. This is a dangerous sign indicating a possible rapid transformation of the serous process into a purulent one and requiring immediate intervention in the form of ureteral catheterization. Exacerbations of chronic pyelonephritis, as well as recurrent gestational pyelonephritis, are similar to acute process clinical manifestations, but the symptoms are usually more erased, and sometimes minimal.

Latent pyelonephritis:

This condition is characterized by poor clinical symptoms, inconstancy and mosaic of deviations in urine tests. At the same time, some minimal activity of the pathological process is permanently present. It is far from always being assessed and treated in a timely manner.

It is believed that one should think about latent PN in cases where a combination of three to four of the following signs is found:
a history of recurring cystitis;
periodic subfebrile condition;
complaints of weakness, night sweats, headaches;
pallor, grayish complexion, bags under the eyes;
pastosity of the face and hands;
aching pain in the lower back, appearing in connection with physical activity or hypothermia;
sudden onset and spontaneously disappearing episodes of dysuria;
steady decline specific gravity urine;
periodic appearance of small proteinuria, leukocyturia, microhematuria, crystalluria, bacteriuria;
changes in the echostructure of the kidneys.

Laboratory diagnosis of pyelonephritis:

Changes in urine tests
1. Pyelonephritis is accompanied by a violation of the concentration function of the kidneys, a decrease in water reabsorption, therefore, the most constant symptom is a decrease in the specific gravity of urine below 1015 against the background of a slight increase in diuresis and nocturia (Zimnitsky's test is required).
2. The acidity of urine, which is normally 6.2-6.8, often changes with pyelonephritis, shifting to the alkaline side.
3. Glycosuria is detected, as a rule, when the inflammatory process is activated and is associated with a violation of reabsorption processes in the tubules of the kidneys.
4. Proteinuria is often observed, but it does not reach high numbers and daily protein excretion does not exceed 1 g.
5. Leukocyturia usually corresponds to the severity of the inflammatory process. With a latent course of pyelonephritis, it is minimal. Normally, the number of leukocytes in one field of view during microscopy of a stained urine sediment does not exceed 4. Leukocytes are destroyed if several hours have passed before the start of the study (centrifugation), and also when alkaline reaction urine.

To detect latent leukocyturia, counting of formed elements in 1 ml of urine is used (there should not be more than 2000 leukocytes and 1000 erythrocytes). You can use a test with a prednisolone load (counting leukocytes in two portions of urine - before and after the introduction of 30 mg of prednisolone intramuscularly). This test is considered positive if in the second portion the number of leukocytes is at least 2 times higher than in the first and more than 4 (for example, it was 2-3 - it became 4-6).
6. With pyelonephritis, microhematuria is possible. In the absence of urolithiasis, glomerulonephritis, hydronephrosis or tuberculosis of the kidney, the persistent nature of microhematuria, which does not disappear after sanitation, indicates a high probability of interstitial nephritis caused by specific pathogens (chlamydia, mycoplasmas, viruses).
7. Cylinders - only hyaline are characteristic. Other variants of cylindruria are possible with severe kidney pathology.
8. Salt crystals indicate dysmetabolic nephropathy - a violation of the anti-crystallization stability of urine. The reasons for the latter are different, including the role of inflammatory processes. The significance of a non-random event is only persistent oxalate and urate crystalluria. A link has been established between oxaluria and chlamydial infection.
9. Bacteria in the urine may be present in a minimal amount, their content in 1 ml of urine should not exceed 104 CFU.

Besides:
Representatives of the intestinal group (E.coli, Klebsiella spp., Proteus spp., etc.), as well as Enterococcus in the urinary tract are considered pathogenic agents always and regardless of concentration require mandatory elimination;
Staphylococcus epiderm. not allowed in a titer of more than 103 CFU;
In the presence of manifestations of process activity or against the background of antibiotic therapy, any monoculture of the pathogen in a titer of more than 102 CFU is considered causally significant.
To detect bacteriuria, methods of counting the number of bacteria by microscopy of a stained urine sediment, a nitrite test and the "gold standard" - sowing urine on media with the identification of microorganisms and counting CFU are used. When evaluating seeding results, consider the following:
The results of 2-3 consecutive cultures or one culture with provocation (furosemide at a dose of 20 mg) are informative;
Sterile cultures are not proof of the absence of infection, since a number of uropathogens (anaerobes, intracellular bacteria, viruses) do not grow on ordinary media;
Low (not true) bacteriuria may be associated with slow growth on the media of some uropathogenic strains;
False positive results observed in 20% of cases due to incorrect examination (the sample should be delivered to the laboratory within 1 hour or stored for up to a day at a temperature of + 2-4 °)
in all cases, the pathogen identified in the culture may not be causally significant in the pathogenesis of this inflammatory process.

Changes in blood tests:

Acute and exacerbation of chronic PI are accompanied by inflammatory blood changes (leukocytosis, shift to the left, lymphopenia, a significant increase in ESR) varying degrees severity, the appearance of C-reactive protein, anemia, hypo- and dysproteinemia. Negative dynamics of blood tests in the presence of clinical symptoms PN should be alarming in terms of the risk of transformation of the serous process into a purulent one.

With a latent process (chronic and gestational), a general blood test may show (not always) a slight lymphopenia, as well as signs of an iron deficiency state.
An increase in the content of nitrogenous slags (usually not residual nitrogen, but its fractions) is possible with a severe course of the disease, or with layering of PN on the initial pathology of the kidneys (glomerulonephritis, nephropathy various origins, HPN). The study of the functions of filtration (Reberg's test) and reabsorption is carried out according to indications (required for a combination of PN and preeclampsia).

Additional research methods:

During pregnancy, there are significant limitations regarding additional, especially radiation, research methods. The following are allowed:
1. Ultrasound of the urinary system. The criteria for the presence of pyelonephritis are:
asymmetric changes in the kidneys;
expansion and deformation of the renal pelvis;
coarsening of the contour of the cups, compaction of the papillae;
heterogeneity of the parenchyma;
shadows in the pelvis;
expansion of the upper ureters (indicates a violation of the passage of urine).
2. Chromocystoscopy and retrograde catheterization of the ureters. They allow to clarify the side of the lesion and, most importantly, to establish and eliminate the delay in the passage of urine. Shown up to 36 weeks of pregnancy.
3. Radioisotope renography with technetium. Allowed in the 2nd and 3rd trimesters. Radiation exposure is minimal.

Complications of pregnancy associated with urinary tract infection. Least bad influence pregnancy is affected by uncomplicated urinary tract infections - acute cystitis and pyelonephritis, provided they proper treatment. With inadequate therapy, there is a risk of developing infectious complications in the fetus. However, acute pyelonephritis in the 1st trimester of pregnancy is an indication for its termination due to the need for antibiotic therapy. Asymptomatic bacteriuria is dangerous, mainly due to the fact that very often (in more than half of cases) in the absence of treatment it is realized in pyelonephritis. Most often, complications of pregnancy are associated with recurrent and latent forms of gestational and especially chronic pyelonephritis.

The most typical complications in pregnant women:

1. Threat of abortion (30-60%); more often in the 1st and 2nd trimesters, has a persistent course, poorly responds to tocolytic therapy, usually stops against the background of antibacterial and anti-inflammatory treatment.
2. Chronic feto-placental insufficiency against the background of morpho-functional rearrangement of the placenta (especially with a specific infection); taking into account compensated and subcompensated forms, the frequency reaches 100% of cases. May lead to IUGR, chronic and acute fetal hypoxia. Perinatal mortality ranges from 60 to 100%.
3. Infectious pathology of the placenta, membranes, fetus (placentitis, chorionamnionitis, polyhydramnios, IUI). Contamination by causative agents of elements gestational sac carried out predominantly by the hematogenous route.
4. Preeclampsia complicates up to 30% of pregnancies against the background of pyelonephritis, is characterized by an early onset and a tendency to progression.
5. Infectious pathology of the genitals - in 80% of cases, and almost half of the women have sexually transmitted infections. Almost in 100% of observations - dysbiotic processes.
6. Iron deficiency states (usually in the form of a latent deficiency) - in 80-90%; it should be remembered that the appointment of iron-containing drugs is permissible only after stopping the activity of the infectious-inflammatory process, due to their ability to provoke the inflammatory process.
7. Insufficient readiness (immaturity) of the cervix for childbirth (not less than 40%) - due to a violation of the processes of transformation of the connective tissue (in particular, collagen fibers), which ensures the elasticity and extensibility of this organ.
8. High frequency of untimely rupture of membranes, abnormal contractile activity of the uterus. The nature of SDM anomalies is different, and in case of a specific infection it is closely related to the type of pathogen.
In particular, for infection with representatives of the mycoplasma family, the formation of a pathological preliminary period, primary weakness and discoordination of SDM is typical (45%). With chlamydial infection, very often (about 25%) there is excessive contractile activity of the uterus, leading to rapid and rapid labor.
9. Acute urinary retention after childbirth is associated with a violation of the passage of urine due to a mechanical obstruction in the ureter (detritus). In such cases, catheterization of the bladder is ineffective. Requires intravenous administration of crystalloids, antispasmodics, saluretics, followed by ureteral catheterization (in the absence of effect).
10. Infectious and inflammatory complications in postpartum period- endometritis, suture divergence.

Risk groups in pregnant women with urinary tract infections:

1 (minimum) - uncomplicated urinary tract infection, asymptomatic bacteriuria;
2 (medium risk) - chronic pyelonephritis (any variant of the course), recurrent and latent gestational pyelonephritis;
3 (high risk) - chronic pyelonephritis of a single kidney, pyelonephritis with chronic renal failure; in these cases, pregnancy is contraindicated, however, with pyelonephritis of a single kidney, there is a positive experience in managing pregnant women in hospitals of the 1st level.

Observation of pregnant women with pyelonephritis:

1. When registering with a antenatal clinic, a pregnant woman with chronic disease kidneys should be sent to a specialized hospital to clarify the diagnosis and choose a treatment method. Subsequent hospitalizations are indicated for:
PN activation;
latent process, not amenable to outpatient sanitation;
occurrence obstetric complications requiring inpatient treatment.

2. At all stages of observation - dynamic control of urine tests with an emphasis on hypostenuria, leukocyturia, microhematuria and small bacteriuria. If signs of UTI appear, appropriate outpatient or inpatient treatment.
3. Identification of foci of infection (including specific) in the body, primarily in the genital tract, adequate sanitation, correction of dysbacteriosis.
4. Regular assessment of the condition of the fetus, carrying out activities aimed at the prevention and treatment of HFPI.
5. Timely diagnosis and treatment of pregnancy complications (threat of miscarriage, preeclampsia, etc.)
6. Antenatal hospitalization at 38-39 weeks (in order to clarify the activity of UTIs, find out the degree of maturity of the cervix, conduct appropriate preparation, sanitize the genital tract, calves, saluretic-aspasmolytics, salureticoa. It is required for veterinary childbirth and discoordination to assess the condition of the fetus, choose a method of delivery).
8. Delivery is carried out at full-term pregnancy. UTI, even often recurrent and requiring repeated antibiotic therapy, is not an indication for early delivery, unless there are special circumstances - progressive fetal suffering, severe obstetric complications (preeclampsia that cannot be corrected, placental abruption, etc.), diuresis drop during compression of the ureter of a pregnant woman uterus if ureteral catheterization fails.

Treatment for urinary tract infection:

1. Mode and diet. Bed rest is necessary only if you feel unwell and have symptoms of intoxication. The supine position should be avoided, as in this case the urine output drops by 20%. It is preferable to lie on your healthy side to decompress the damaged kidney. Several times a day it is useful to take the knee-elbow position.

The exclusion of salt from the diet is not required, but too spicy and salty dishes are not recommended. There is no liquid restriction, the drink is neutral or alkaline, with the exception of cranberry (lingonberry) juice, which has a bactericidal effect in the kidneys. Persistent crystalluria requires dietary adjustments. In particular, with oxaluria, frequent consumption of milk, eggs, legumes, tea is not recommended; broths and potatoes are limited. On the contrary, they show dairy products, cereals, vegetables, fruits (especially apples). Boiled meat and fish are allowed.

2. Antibacterial therapy is the most important link in the treatment of UTIs. The basic principles of a/b therapy are as follows:
adequate choice of drug for initial empiric therapy;
transition to monotherapy after identification of the pathogen;
timely monitoring of the effectiveness of treatment (initial assessment after 48-72 hours) with frequent and rapid change of drugs in the absence of clinical and laboratory signs of improvement;
compliance with the optimal duration of treatment.

1st trimester of pregnancy:

In the first trimester of pregnancy, antibiotic therapy should be minimized in order to protect the fetus from teratogenic and embryotoxic effects. In the case of BD or latent pyelonephritis (without signs of activity), herbal medicine (phytolysin, kanefron, rensept) is allowed, subject to following conditions: the duration of therapy is at least 4-6 weeks, sanitation of the genital tract, the use of eubiotics. In the presence of clinical and laboratory markers of the activity of the inflammatory process, it is necessary to prescribe antibacterial drugs. The duration of treatment for acute cystitis is 3-5 days, for acute pyelonephritis - 7 days, for exacerbation of chronic pyelonephritis - 10 days, followed by a transition to herbal medicine. In the first trimester, semi-synthetic penicillins are allowed. Inhibitor-protected penicillins show the greatest efficiency. In particular, amoxicillin / clavulanate (amoxiclav, augmentin) - 0.625 every 8 hours or 1 g every 12 hours; in / venously 1.2-2.4 g every 8 hours.

2nd and 3rd trimesters of pregnancy:

The functioning of the placenta determines slightly different principles for the treatment of urinary tract infections at this stage of pregnancy. For acute urethritis, cystitis, and BB, a short course of treatment (3 to 7 days) and only one antibacterial drug is used, followed by herbal medicine. Inhibitor-protected penicillins are used (amoxiclav 0.625 g 3 times a day), cephalosparins of 2-3 generations (cefuroxime 0.25-0.5 g 2-3 times a day, ceftibuten 0.4 g 1 time per day). Nitrofurans are also effective: furazidin (furagin) or nitrofurantoin (furadonin) 0.1 g 3-4 times a day. A 5-day course of treatment with B-lactam antibiotics is considered to be more effective than a 3-day course, and nitrofurans should be prescribed for a minimum of 7 days. A profitable alternative is a single (with uncomplicated cystitis and urethritis) or double (with BB) administration of fosfomycin (monural), which has a wide spectrum of action and is active against E. coli in 100% of cases. The drug is prescribed 3 g orally at night after emptying the bladder.

Treatment for complicated forms of urinary tract infection:

duration of therapy for at least 14 days (otherwise, the probability of relapse is at least 60%);
mandatory combination of two drugs (usually an antibiotic and a uroantiseptic or two antibiotics) in parallel or sequential mode;
in women with a high risk of recurrence of the process, use after the main antibacterial treatment of maintenance suppressive therapy (0.1 g of furagin daily at night after emptying the bladder for up to 3 months or 3 g of fosfamycin - 1 time in 10 days).

Drugs for the treatment of urinary tract infections in pregnant women:

The drugs recommended in the first trimester are used, as well as other groups of antibacterial agents.

Cephalosporins (CS). When using these drugs for the treatment of UTIs, it should be taken into account that the 1st generation CAs are active mainly against gram-positive cocci, while the 2nd and 3rd generation CAs have predominant activity against gram-negative bacteria. IV generation CAs are more resistant to action (S-lactamase) and are active against both gram-positive and gram-negative microorganisms. However, all CAs do not act on MRSA, enterococci, and have low antianaerobic activity.

Aminoglycosides (AG). Main clinical significance AG is associated with their wide spectrum of action, special activity against gram-negative bacteria, high concentration in kidney tissues, and low allergenicity. Therefore, hypertension is indicated for initial empiric treatment of PN, especially in combination with CS. Of the adverse reactions, nephrotoxicity and ototoxicity are noted, which are most pronounced in first-generation drugs (not used in obstetrics), as well as with prolonged use (more than 7-10 days), rapid intravenous administration. The daily dose of AG (or 2/3 of it) can be used as a single injection.

Macrolides (ML). They mainly have a bacteriostatic effect against gram-positive cocci (enterococci are resistant) and intracellular pathogens. In the treatment of "PN ML, they are most often used as second-line drugs in patients with a specific infection.
As a rule, josamycin (vilprafen) is prescribed, it is excreted in the urine up to 20%, the dose is 1-2 g / day in 2-3 doses.
spiramycin (rovamycin) - 10-14% is excreted in the urine, daily dose 9 million IU / day (in 3 divided doses);

Lincosamides. They have a narrow spectrum of activity (gram-positive cocci, non-spore-forming anaerobes, mycoplasmas) and bacteriostatic action. They are excreted mainly in the urine. Relevant in cases where the significance of anaerobic flora is assumed or proven (lincomycin, lincocin - a daily dose of 1.2 to 2.4 g.

Uroantiseptics. They are second-line drugs, have a bactericidal or bacteriostatic effect. As monotherapy for complicated UTIs, it can be used to treat the latent process on an outpatient basis, as well as for suppressive treatment. Not prescribed after 38 weeks of pregnancy (risk of kernicterus in the fetus). Nitrofurans have a wide spectrum of activity, create high concentrations in the interstitium of the kidney - furazidin (furagin), nitrofurantoin (furadonin) are prescribed at 300-400 mg per day for at least 7 days. Preparations of 8-hydroxyquinolones (5-NOC, nitroxalin) are of little use, since the resistance of E. coli to them is 92%. Quinolones of the 1st generation (non-fluorinated) are active against gram-negative bacteria, the most effective drugs are pipemidic acid (palin, pimidel 0.8 g / day or urotractin 1 g / day).

Evaluation of the effectiveness of treatment:

1. With properly selected treatment, improvement in well-being and a decrease in clinical symptoms occur quickly - in 2-3 days. The cessation of symptoms is achieved by 4-5 days.
2. Normalization of urine tests and hemogram - by 5-7 days (do not stop treatment).
3. Required Component The criterion for cure is eradication of the pathogen; against the background of successful a/b therapy, urine should be sterile by 3-4 days.
4. Persistence of disease symptoms and changes in laboratory parameters requires a rapid change of antibiotics (taking into account sensitivity or empirical combination with a wide spectrum).
5. Deterioration of the condition, an increase in intoxication, signs of a violation of the passage of urine (decreased diuresis, dilation of the ureters) require a solution to the issue of ureteral catheterization (temporary or permanent self-retaining stent catheter) and do not exclude surgical treatment (nephrostomy, kidney decapsulation).

The urinary system includes: the kidneys that produce urine, the ureters - thin tubes through which urine formed in the kidneys flows into the bladder - a reservoir in which urine accumulates before urination, and the urethra through which urine leaves the bladder.

Normally, human urine is sterile, that is, it does not contain any microorganisms. If bacteria appear in the urine, it is a urinary tract infection.

Are urinary tract infections more common during pregnancy?

Pregnancy does not increase the risk of asymptomatic bacteriuria or cystitis. But pyelonephritis during pregnancy happens more often. There are several reasons for this. First, the hormone progesterone reduces the tone of the ureters that connect the kidneys and bladder. They expand, and the urine in them does not flow as quickly and freely as before. In addition, the growing uterus presses on them, which makes the flow of urine even more difficult. Urine moves more slowly through the urinary tract, which gives bacteria time to multiply and attach to the wall of the urinary tract.

Bladder tone also decreases, for the same reason. It becomes more difficult to empty it completely when urinating, and conditions are created for vesicopelvic reflux, the backflow of urine from the bladder into the kidney. Reflux is the transport of bacteria from the bladder to the kidney.

Also during pregnancy, urine becomes more alkaline, contains more glucose and amino acids, which creates more favorable conditions for the growth of bacteria.

How serious is this?

This is serious. Severe pyelonephritis during pregnancy (gestational pyelonephritis) is life-threatening for the mother. Even mild gestational pyelonephritis can lead to premature termination of pregnancy - miscarriage or premature birth to the death of the fetus or newborn.

Asymptomatic bacteriuria during pregnancy also increases the risk of developing pyelonephritis. Approximately thirty percent of pregnant women with asymptomatic bacteriuria who do not receive treatment develop gestational pyelonephritis. In addition, asymptomatic bacteriuria increases the risk of premature termination of pregnancy and the birth of a small child. That is why urine tests during pregnancy are given increased attention.

What are the symptoms of cystitis?

Symptoms of cystitis may vary from case to case. Most common symptoms This:

Pain, discomfort, or burning during urination and possibly during sexual intercourse.
Discomfort in the pelvic area or pain in the lower abdomen (most often just above the pubis).
Frequent or uncontrollable urge to urinate, even though there is little urine in the bladder. Pregnancy is characterized by more frequent urge to urinate, so it will be difficult to recognize cystitis by this sign alone.
Urine may acquire bad smell or become cloudy. Sometimes with cystitis, blood is found in the urine. The temperature may rise slightly, but this temperature increase is not very typical for cystitis.

If you think you have cystitis, you should immediately contact your obstetrician-gynecologist who is watching you for a complete urinalysis and urine culture.

What are the symptoms of gestational pyelonephritis?

If you think you have gestational pyelonephritis, you should seek immediate medical attention. medical care, sometimes the symptoms increase very quickly and the situation becomes life-threatening within a few hours.

I'm pregnant and I have bacteria in my urine, what should I do?

After completing the course, you will need to retake a urine culture to monitor the effectiveness of the treatment. If necessary, treatment will be continued with another drug. Also, after a urinary tract infection, it makes sense to periodically monitor urine culture to exclude the recurrence of bacteriuria.

I am pregnant and have cystitis, what should I do?

You will also be prescribed an antibiotic that is safe for the baby. Usually, an antibiotic for cystitis during pregnancy is prescribed in a fairly short course. You should not stop taking as soon as the symptoms of cystitis pass, be sure to complete the course in order to destroy all the microbes that caused cystitis.

After treatment, it will also be necessary to monitor urine tests and, if necessary, the treatment will be repeated.

I have gestational pyelonephritis, what should I do?

You must be in the hospital. There you will be given intravenous or intramuscular injections of an antibiotic that is safe for the baby and will monitor the condition of the child and yours in order to intervene in time if either of you is in danger or if there are signs of impending preterm labor.

How to avoid urinary tract infection during pregnancy?

Drink a sufficient amount of liquid, at least one and a half liters per day (edema of pregnant women is not a contraindication to the use of large amounts of liquid).
Do not ignore the urge to urinate and try to completely empty the bladder with each urination
Wipe area after bowel movement anus moving from front to back to prevent bacteria from the intestines from entering the urethra
Keep the vulva clean with water and a mild detergent
Wash and empty your bladder before and after sexual intercourse
Eat lingonberry and cranberry fruit drinks. According to some reports, lingonberry and cranberry juice contain substances that make it impossible for bacteria to attach to the walls of the urinary tract and cause inflammation. (Unfortunately, lingonberry and cranberry fruit drinks will not help to cure an infection that has already occurred, so if you have symptoms of a urinary tract infection, you should contact your obstetrician-gynecologist who is watching you for an antibiotic).
avoid means feminine hygiene and strong detergents, which can cause irritation of the mucous membrane of the urethra and external genitalia, which will make them an excellent environment for the development of bacteria
do not use douching during pregnancy.

Infection of the urinary system, which normal conditions must be sterile, means the presence of microorganisms in it, with the subsequent probable development of the inflammatory process. Frequency urinary tract infections in pregnant women ranges from 4 to 8%. The presence of only bacteria in the urine without visible clinical manifestations of the disease ( asymptomatic bacteriuria) is observed in 2% to 13% of cases. Diseases such as acute inflammation of the bladder ( acute cystitis) and acute inflammation of the kidneys ( acute pyelonephritis) occur in 1-2%. Chronic inflammation of the kidneys ( chronic pyelonephritis) occurs in 10-30% of pregnant women.

Inflammatory diseases of the lower urinary tract include: acute urethritis, acute cystitis, asymptomatic bacteriuria. Inflammatory diseases of the upper urinary system are: pyelonephritis, abscess and carbuncle of the kidney. Inflammatory diseases that occur against the background of an already existing pathology of the urinary system (urolithiasis, ureteral stricture, renal failure, etc.) are characterized as complicated.

The reasons that affect the predisposition of women to infection are: a short urethra, the proximity of the urethra to the rectum and to the external genitalia, changes hormonal background. During pregnancy, conditions are additionally created for stagnation of urine and a violation of its outflow due to a significant expansion of the renal pelvis, lengthening of the ureters, a decrease in the tone and contractility of the muscles of various parts of the urinary system, and displacement of the kidneys. In addition, the outflow of urine from the kidneys worsens due to the mechanical pressure of the pregnant uterus on the ureters. In this regard, in 1/3 of pregnant women there is a reverse reflux of urine from the bladder into the ureters, which contributes to the spread of infectious agents to the upper urinary system.

Risk factors for developing a urinary tract infection are: sex life And frequent change sexual partners, non-compliance with the rules of personal and sexual hygiene, previous inflammatory diseases of the genital organs (inflammation of the cervix, uterus and uterine appendages), the presence of foci of chronic infection in the body, endocrine pathology (diabetes mellitus), pathology of the urinary system ( urolithiasis, chronic cystitis, abnormal development of the kidneys).

Taking into account the predisposing circumstances and risk factors for the development of inflammatory diseases of the urinary system for all pregnant women when registering with a antenatal clinic, it is advisable to conduct a screening examination, including urinalysis with bacterial culture .

The most common causative agent of inflammatory diseases of the urinary system is coli(80%). Other typical causative agents of this group of diseases are klebsiella , enterobacter(10-15%), as well as staphylococci And streptococci (5-10%).

Asymptomatic bacteriuria characterized by the presence of bacteria in the urine without clinical manifestations of infection. This pathology is a risk factor for the development of acute pyelonephritis and requires specific antibiotic therapy. Diagnostic signs of asymptomatic bacteriuria include the detection in the urine of bacteria belonging to the same species, in an amount greater than and equal to 105 CFU / ml in two samples taken at an interval of more than 24 hours (3-7 days) in the absence of clinical signs infections.

Cystitis

Acute cystitis is one of the most common inflammatory diseases of the urinary system in pregnant women and occurs mainly in the first trimester. typical symptoms of acute cystitis are: painful urination, frequent imperative urges, pain above the pubis, the presence of blood elements in the last portion of urine. These phenomena are accompanied by common symptoms as weakness, malaise, some fever. In the analysis of urine, leukocytes and bacteria are detected.

Treatment of pregnant women, the choice of the drug and its dose is carried out only by the attending physician. In the treatment of inflammatory diseases of the lower urinary tract in pregnant women use of antibacterial drugs if possible, it should be postponed for more than 12 weeks. In the II trimester, it is possible to use amoxicillin / clavulanate, 2nd generation cephalosporins (cefaclor, cefuroxime axetil), in the III trimester it is advisable use of cephalosporins 3rd and 4th generations (cefotaxime, ceftazidime, ceftibuten, cefepime, cefaperazone/sulbactam). In this case, a single dose of the drug or a short 3-day course is sufficient, after which it is necessary to conduct a second cultural study after 7-14 days in order to assess the effectiveness of the treatment. In cases where the therapy is ineffective, a second course of treatment is carried out using other drugs. If, after the second course, the growth of microorganisms is noted, it is necessary to exclude urolithiasis, diabetes mellitus and other diseases of the urinary tract with further appropriate treatment using monural at a dose of 3 g every 10 days or furagin at a dose of 50-100 mg 1 time per day. In addition, repeated urine tests are performed before term. After completion of antibiotic therapy, it is advisable to use herbal uroantiseptics (phytolysin, kanefron, lingonberry leaf, cranberry juice).

Pyelonephritis is a nonspecific infectious and inflammatory process with a primary lesion of the pelvicalyceal system and renal tubules, followed by involvement in pathological process glomeruli and vessels, i.e. kidney parenchyma. During pregnancy, acute pyelonephritis often develops at the end of the second trimester of pregnancy, and after childbirth, the risk of its development persists for 2-3 weeks. Allocate acute (serous and purulent) and chronic (latent and recurrent) pyelonephritis.

Diagnostic signs of acute pyelonephritis are such clinical manifestations as fever, chills, nausea, vomiting, pain in the lumbar region, dysuria. Leukocytes and bacteria are detected in the urine. Most often, acute pyelonephritis affects the right kidney. This is because the right ovarian vein runs anterior to the ureter and, as it expands during pregnancy, puts additional pressure on the ureter. In addition, the pregnant uterus turns to the right and also compresses the right ureter. In cases where treatment is ineffective, inflammation can spread to the left kidney.

To detect acute or chronic pyelonephritis is widely used and ultrasonography. Sonographic signs of acute pyelonephritis are: an increase in the size of the kidney, a decrease in the echogenicity of the parenchyma of the kidney due to edema, areas of reduced echogenicity of a rounded shape, which are affected by inflammation of the pyramid of the kidney, expansion of the pyelocaliceal system, signs of edema of the perirenal tissue. In a chronic advanced process with ultrasound, a decrease in the size of the kidney is noted with a relative increase in the area of the pyelocaliceal system in relation to its parenchyma, heterogeneity of the echostructure of the renal parenchyma, uneven contours of the kidneys, and expansion of the pyelocaliceal system of the kidneys are revealed.

In the presence of acute or exacerbation of chronic pyelonephritis, all pregnant women should be hospitalized immediately to specialized institutions. In the hospital, a bacteriological examination of blood and urine is carried out, control is carried out excretory function kidneys, evaluation of their function. Antibacterial therapy is given by intravenous or intramuscular administration of antibiotics. In the absence of improvement within 48-72 hours, complicated kidney disease, a pronounced violation of the outflow of urine through the ureters, or resistance of microorganisms to antibiotics should be excluded. As an antibacterial therapy for pyelonephritis, use: amoxicillin / clavulanate 1.2 g 3-4 times a day, orally 625 mg 3 times a day, or cefuroxime sodium intravenously or intramuscularly 0.75-1.5 g - 3 times a day, or cefotaxime 1 g iv or IM 2 times a day, or ceftriaxone 1-2 g 1 time a day, or cefixime 400 mg 1 time a day. As an alternative regimen, aztreonam 1 g 3 times a day or thienam 500 mg 2 times a day can be used intravenously.

For the treatment of acute pyelonephritis in the postpartum period, the drugs of choice are: amoxicillin / clavulanate 1.2 g 3 times a day, then orally 625 mg 3 times a day, or levofloxacin 500 mg orally 1 time per day. a day or ofloxacin, intravenously, orally, 200 mg 2 times a day; or pefloxacin, intravenously, 400 mg, orally, 2 times a day. Treatment of acute pyelonephritis should last at least 2-3 weeks. The criteria for cure are the absence of clinical symptoms and a three-time negative bacteriological examination of urine 5-7 days after antibiotics are discontinued.

Prevention of pyelonephritis aimed at identifying early signs disease and prevention of its exacerbation. Among the methods for preventing urinary tract infection and in particular acute pyelonephritis, the most significant is plentiful and sour drink(1.5-2 liters of liquid, cranberry or lingonberry juice). The women of the group high risk expedient also the use of phytopreparations including kanefron, lingonberry leaf, bearberry, phytolysin.

Urinary tract infections during pregnancy include infections of the kidneys, bladder, urethra, and other parts of the urinary tract. Urinary tract infections in pregnant women pose a risk to normal course pregnancy and require mandatory timely treatment. Infectious diseases genitourinary tract, complicate pregnancy, childbirth and the postpartum period, therefore, if genitourinary infections are suspected, a screening examination of pregnant women for asymptomatic bacteriuria is carried out, bacterial diagnosis and sanitation of the genitourinary tract are carried out. If necessary, to maintain pregnancy, adequate treatment and preventive measures are prescribed against recurrence of urinary tract infections. The duration of treatment for uncomplicated urinary tract infections is 7-14 days.

Classification of infections of the genitourinary system:

Asymptomatic bacteriuria is detected in 2-11% of pregnant women - persistent bacterial colonization of the organs of the urinary tract without the manifestation of dysuric symptoms.
Acute cystitis of pregnant women is detected in 1.3% of pregnant women.
Acute pyelonephritis is detected in 1-2.5%.
Chronic pyelonephritis occurs in 10-18% of pregnant women.

Risk factors for urinary tract infections in women:

short urethra;
the outer third of the urethra constantly contains microorganisms from the vagina and rectum;
women do not empty their bladder completely;
the entry of bacteria into the bladder during sexual intercourse;
the use of antimicrobial agents;
pregnancy;
low socioeconomic status;
lactating women;
chronic pyelonephritis.

Criteria for diagnosing urinary tract infections in women:

Clinical picture (dysuric disorders, frequent urination, imperative urges, symptoms of intoxication).
An increase in the number of leukocytes and protein in the urine, bacteriuria more than 100,000 microorganisms in one ml of urine.
Cultural study of urine.

List of main diagnostic measures:

research using test strips (blood, protein);
bacterioscopic examination of urine at each visit to the clinic;
study of urine sediment;
culture of urine at the first visit to the clinic, and in the detection and treatment of bacteriuria and cystitis - every month before delivery and 4-6 weeks after it;
cultural examination of urine after inpatient treatment of pyelonephritis - 2 times a month before delivery;
the concentration of creatinine in the blood (according to indications);
culture of blood for suspected pyelonephritis;
serological testing for gonorrhea and chlamydia;
Ultrasound of the kidneys.

List of additional diagnostic measures:

Therapist's consultation.
Urologist consultation.

Treatment of asymptomatic bacteriuria in pregnant women:

Asymptomatic bacteriuria. Pregnancy does not increase the incidence of bacteriuria, but if present, it contributes to the development of pyelonephritis. Does not exist scientific evidence that bacteriuria predisposes to the development of anemia, hypertension and preeclampsia, chronic kidney disease, amnionitis, endometritis.

Pregnant women with bacteriuria are at high risk for frequency spontaneous miscarriages, stillbirths and intrauterine delay fetal development. The level of neonatal mortality and prematurity increases by 2-3 times. The vast majority of pregnant women with bacteriuria can be detected at the first visit to the doctor in early pregnancy, in 1% - bacteriuria develops in more late dates pregnancy.

All pregnant women with bacteriuria are subject to treatment. Treatment of bacteriuria in early dates pregnancy prevents the development of pyelonephritis in 70-80% of cases, as well as 5-10% of all cases of prematurity.

A short course of treatment (1-3 weeks) with ampicillin, cephalosporins or nitrofurans is as effective in eliminating bacteriuria (79-90%) as the constant use of antimicrobials. No drug has an advantage over others, and therefore, the choice of drug should be made empirically based on clinical and laboratory parameters. If bacteriuria is detected, treatment begins with a 3-day course of antibiotic therapy, followed by a monthly urine culture for control. If bacteriuria is detected again (16-33%), it is necessary to prescribe maintenance therapy before delivery and another 2 weeks after delivery (single dose of the drug in the evening after meals).

The danger of drugs for the fetus:

Penicillins and cephalosporins do not pose a risk to the fetus.
Sulfonamides can cause hyperbilirubinemia and kernicterus in newborns.
Tetracyclines cause dysplasia of bones and teeth.
Nitrofurans can cause hemolysis in fetuses with glucose-6-phosphate dehydrogenase deficiency.
Aminoglycosides can cause damage to the 8th pair of cranial nerves in the fetus.

Treatment of acute cystitis during pregnancy:

Acute cystitis diagnosed by clinical picture(frequent, painful urination feeling of incomplete emptying of the bladder). Bacteriological confirmation of infection is possible only in 50% of pregnant women with dysuria.

Cases without bacteriuria are referred to as acute urethral syndrome associated with chlamydial infection.

The risk of developing acute pyelonephritis after cystitis is 6%. Pregnant women with cystitis are subject to the same treatment as pregnant women with bacteriuria.

Acute pyelonephritis during pregnancy:

Pregnant women with a clinic of acute pyelonephritis are shown mandatory hospitalization in a hospital. At the end of the treatment of pyelonephritis, the pregnant woman should be prescribed maintenance therapy until the end of pregnancy.

It is necessary to carry out a cultural study of urine 2 times a month and treat the detected bacteriuria.

Therapeutic tactics for the treatment of pregnant women:

1. Treatment of asymptomatic bacteriuria and acute cystitis in pregnant women is carried out for 3 days according to one of the following schemes:

Amoxicillin 250-500 mg every 8 hours (3 times a day);
Amoxicillin / clavulanate 375-625 mg every 8-12 hours (2-3 times a day);
Cefazolin 1 mg twice a day);
Furagin 50 mg every 6 hours.

2. If bacteriuria is detected again, it is necessary to prescribe maintenance therapy before delivery and another 2 weeks after delivery (a single dose of the drug in the evening after meals) according to one of the proposed schemes.

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