History

Fact Explanation
Asymptomatic [1] As other systems in the body, kidney and urinary tract also undergoes several physiological changes during pregnancy. There is upper tract dilatation, urethral dilatation [3] which starts as early as 6 weeks of gestation and reaches the maximum during 22-24 weeks [1] and urinary stasis is also associated with reduced glomerular filtration rate. Renal threshold for glucose is also reduced making glycosuria is a normal phenomenon during the pregnancy. Asymptomatic bacteriuria may develop into symptomatic stage if left untreated. [1] Escherichia coli and S. aureus are the commonest bacteria associated with UTI in pregnancy. [1,2,6] Other gram-negative rods such as Proteus mirabilis and Klebsiella pneumoniae are also common.
Suprapubic pain [4] Inflammation of the bladder in case of cystits [6,10] or associated calculi may cause the suprapubic pain.
Dysuria Dysuria [7,8] is the pain that occurs during micturition. May be related to either urinary tract infection itself or to the calculi which may contributes to the recurrent UTI
Fever [1] Inflammation releases cytokines that may cause fever. Cystitis may not cause the fever. Usually lower urinary tract infections and pyelonephritis will cause the fever.[1]
Frequency,urgency [4] Frequent passage of urine and inability to hold the urge "urgency" [7,8] is associated with UTI. Culture-negative symptoms of urinary frequency, urgency and dysuria is called 'urethral syndrome', and is difficult to treat. [7]
Haematuria [8,9] Passage of blood with urine may be associated with infection. [8]
Froth in the urine This is due to the proteinuria associated with infection.[5]
Hyperemesis and loss of appetite [2] May be related to associated cytokine production. Pregnancy may also contribute to these symptoms. But in a case of hyperemesis (exssesive vomiting) [2] UTI should be included in the differential diagnosis.
Loin/abdominal pain [5] Due to the pyelonephritis or associated calculi[11] that may contribute to the superadded UTI. [5]
History of urinary calculi [2] May predispose the individual to develop the UTI. [2,11]
History of immunesuppression Immunesuppression (diabetes mellitus [7], HIV/AIDS, malignancy etc )is a risk factor for the development of UTI.
References
  1. HAMDAN HZ, ZIAD AH, ALI SK, ADAM I. Epidemiology of urinary tract infections and antibiotics sensitivity among pregnant women at Khartoum North Hospital Ann Clin Microbiol Antimicrob [online] :2 [viewed 19 August 2014] Available from: doi:10.1186/1476-0711-10-2
  2. MCGREADY R, WUTHIEKANUN V, ASHLEY EA, TAN SO, PIMANPANARAK M, VILADPAI-NGUEN SJ, JESADAPANPONG W, BLACKSELL SD, PROUX S, DAY NP, SINGHASIVANON P, WHITE NJ, NOSTEN F, PEACOCK SJ. Diagnostic and Treatment Difficulties of Pyelonephritis in Pregnancy in Resource-Limited Settings Am J Trop Med Hyg [online] 2010 Dec 6, 83(6):1322-1329 [viewed 20 August 2014] Available from: doi:10.4269/ajtmh.2010.10-0332
  3. LEE M, BOZZO P, EINARSON A, KOREN G. Urinary tract infections in pregnancy Can Fam Physician [online] 2008 Jun, 54(6):853-854 [viewed 10 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2426978
  4. CHRISTIAENS TC, DE MEYERE M, VERSCHRAEGEN G, PEERSMAN W, HEYTENS S, DE MAESENEER JM. Randomised controlled trial of nitrofurantoin versus placebo in the treatment of uncomplicated urinary tract infection in adult women. Br J Gen Pract [online] 2002 Sep, 52(482):729-734 [viewed 10 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1314413
  5. BROOKS D. The management of suspected urinary tract infection in general practice. Br J Gen Pract [online] 1990 Oct, 40(339):399-401 [viewed 10 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1371378
  6. KNOTTNERUS BART J, GEERLINGS SUZANNE E, VAN CHARANTE ERIC P, TER RIET GERBEN. Women with symptoms of uncomplicated urinary tract infection are often willing to delay antibiotic treatment: a prospective cohort study. Array [online] 2013 December [viewed 13 September 2014] Available from: doi:10.1186/1471-2296-14-71
  7. DEL MAR CHRIS. Urinary tract infections in healthy women: a revolution in management?. Array [online] 2010 December [viewed 13 September 2014] Available from: doi:10.1186/1471-2296-11-42
  8. GIESEN LEONIE GM, COUSINS GRAINNE, DIMITROV BORISLAV D, VAN DE LAAR FLORIS A, FAHEY TOM. Predicting acute uncomplicated urinary tract infection in women: a systematic review of the diagnostic accuracy of symptoms and signs. Array [online] 2010 December [viewed 13 September 2014] Available from: doi:10.1186/1471-2296-11-78
  9. EMMERT-STREIB FRANK, ABOGUNRIN FUNSO, DE MATOS SIMOES RICARDO, DUGGAN BRIAN, RUDDOCK MARK W, REID CHERITH N, RODDY OWEN, WHITE LISA, O'KANE HUGH F, O'ROURKE DECLAN, ANDERSON NEIL H, NAMBIRAJAN THIAGARAJAN, WILLIAMSON KATE E. Collectives of diagnostic biomarkers identify high-risk subpopulations of hematuria patients: exploiting heterogeneity in large-scale biomarker data. Array [online] 2013 December [viewed 13 September 2014] Available from: doi:10.1186/1741-7015-11-12
  10. GROVER S, SRIVASTAVA A, LEE R, TEWARI AK, TE AE. Role of inflammation in bladder function and interstitial cystitis Ther Adv Urol [online] 2011 Feb, 3(1):19-33 [viewed 13 September 2014] Available from: doi:10.1177/175628721139825
  11. RULE AD, BERGSTRALH EJ, MELTON LJ III, LI X, WEAVER AL, LIESKE JC. Kidney Stones and the Risk for Chronic Kidney Disease Clin J Am Soc Nephrol [online] 2009 Apr, 4(4):804-811 [viewed 13 September 2014] Available from: doi:10.2215/CJN.05811108

Examination

Fact Explanation
Febrile Fever is seen in lower UTI and pyelonephritis. [4]
Loin/abdominal tenderness [2] Due to associated calculi/pyelonephritis causing renal angle tenderness. [2]
Ballotable kidneys [3] Polysystic kidney disease is a risk factor for the development of UTI. Hypocitruria, aciduria and low urinary magnesium are common metabolic defects in polycystic kidney disease that will cause stone formation and predisposition to UTI. [3]
Hypotension Sepsis and shock during pregnancy can be occurred due to the pyelonephritis. [1]
Dyspnea Pyelonephritis is known to cause acute respiratory distress during the pregnancy. [1]
References
  1. HAMDAN HZ, ZIAD AH, ALI SK, ADAM I. Epidemiology of urinary tract infections and antibiotics sensitivity among pregnant women at Khartoum North Hospital Ann Clin Microbiol Antimicrob [online] :2 [viewed 19 August 2014] Available from: doi:10.1186/1476-0711-10-2
  2. MCGREADY R, WUTHIEKANUN V, ASHLEY EA, TAN SO, PIMANPANARAK M, VILADPAI-NGUEN SJ, JESADAPANPONG W, BLACKSELL SD, PROUX S, DAY NP, SINGHASIVANON P, WHITE NJ, NOSTEN F, PEACOCK SJ. Diagnostic and Treatment Difficulties of Pyelonephritis in Pregnancy in Resource-Limited Settings Am J Trop Med Hyg [online] 2010 Dec 6, 83(6):1322-1329 [viewed 20 August 2014] Available from: doi:10.4269/ajtmh.2010.10-0332
  3. MAO Z, XU J, YE C, CHEN D, MEI C. Complete staghorn calculus in polycystic kidney disease: infection is still the cause BMC Nephrol [online] :168 [viewed 20 August 2014] Available from: doi:10.1186/1471-2369-14-168
  4. WILKINSON R. Management of unilateral chronic pyelonephritis. J R Soc Med [online] 1985 Apr, 78(4):278-281 [viewed 10 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1289675

Differential Diagnoses

Fact Explanation
Cystitis [4] Cystitis, is inflammation of the bladder, [5] that causes various symptoms and affects the bladder function. A sensation of bladder fullness, lower abdominal discomfort, suprapubic tenderness, frequency, urgency [3] , pain, [4] dysuria, nocturia may be associated. Fever is less common in cystitis.
Pyelonephritis [7] Flank pain, fever, costovertebral angle tenderness suggest upper urinary tract infection. Patient is having more systemic symptoms and also can develop complications like acute respiratory distress, sepsis ans shock in pyelonephritis. [1,7]
Calculus disease [6] These patients may also presents with frequency, urgency, pain, dysuria, haematuria with more prominent loin to groin pain. Calcium oxalate [6] , phosphate or uric acid are the most common components of calculi. Ultrasound scan of the kidney ureter bladder and X-ray kidney ureter bladder will be helpful to locate the calculus. Ultrasound will also helpful to see the kidney function.
References
  1. HAMDAN HZ, ZIAD AH, ALI SK, ADAM I. Epidemiology of urinary tract infections and antibiotics sensitivity among pregnant women at Khartoum North Hospital Ann Clin Microbiol Antimicrob [online] :2 [viewed 19 August 2014] Available from: doi:10.1186/1476-0711-10-2
  2. MAO Z, XU J, YE C, CHEN D, MEI C. Complete staghorn calculus in polycystic kidney disease: infection is still the cause BMC Nephrol [online] :168 [viewed 20 August 2014] Available from: doi:10.1186/1471-2369-14-168
  3. DEL MAR CHRIS. Urinary tract infections in healthy women: a revolution in management?. Array [online] 2010 December [viewed 13 September 2014] Available from: doi:10.1186/1471-2296-11-42
  4. PAULSON JD, DELGADO M. The Relationship Between Interstitial Cystitis and Endometriosis in Patients With Chronic Pelvic Pain JSLS [online] 2007, 11(2):175-181 [viewed 13 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3015716
  5. GROVER S, SRIVASTAVA A, LEE R, TEWARI AK, TE AE. Role of inflammation in bladder function and interstitial cystitis Ther Adv Urol [online] 2011 Feb, 3(1):19-33 [viewed 13 September 2014] Available from: doi:10.1177/175628721139825
  6. RULE AD, BERGSTRALH EJ, MELTON LJ III, LI X, WEAVER AL, LIESKE JC. Kidney Stones and the Risk for Chronic Kidney Disease Clin J Am Soc Nephrol [online] 2009 Apr, 4(4):804-811 [viewed 13 September 2014] Available from: doi:10.2215/CJN.05811108
  7. CHISHTI AS, MAUL EC, NAZARIO RJ, BENNETT JS, KIESSLING SG. A guideline for the inpatient care of children with pyelonephritis Ann Saudi Med [online] 2010, 30(5):341-349 [viewed 13 September 2014] Available from: doi:10.4103/0256-4947.68549

Investigations - for Diagnosis

Fact Explanation
Dipstic testing [5] Urine is tested with a dipstick for the presence of nitrite and leucocyte esterase. [1,2,6]
Urine full report [2] Infections may increase the number of pus cells(WBC count of ≥ 10/HPF), [2] red cells and there will be appearance of proteinuria. Urinary cast will be helpful in differentiating the other conditions that may cause symptoms like haematuria.
Urine culture [1] Urine culture is suggestive of urinary tract infection when there is > 10000 colony forming units (CFU)/ml, two organisms in similar proportions at > 10000 CFU/ml, [7] or 10000–10000 CFU/ml of a Gram negative organism or two organisms where the Gram negative clearly predominates. [1] Antibiotic sensitivity testing may also be needed in culture proven patients.
Renal ultrasound scan [3] n be used for the evaluation of any associated hydronephrosis, hydroureter, structural abnormalities, polycystic kidney disease and function of the kidneys. [3,4]
References
  1. PATEL HD, LIVSEY SA, SWANN RA, BUKHARI SS. Can urine dipstick testing for urinary tract infection at point of care reduce laboratory workload? J Clin Pathol [online] 2005 Sep, 58(9):951-954 [viewed 19 August 2014] Available from: doi:10.1136/jcp.2004.025429
  2. MCGREADY R, WUTHIEKANUN V, ASHLEY EA, TAN SO, PIMANPANARAK M, VILADPAI-NGUEN SJ, JESADAPANPONG W, BLACKSELL SD, PROUX S, DAY NP, SINGHASIVANON P, WHITE NJ, NOSTEN F, PEACOCK SJ. Diagnostic and Treatment Difficulties of Pyelonephritis in Pregnancy in Resource-Limited Settings Am J Trop Med Hyg [online] 2010 Dec 6, 83(6):1322-1329 [viewed 20 August 2014] Available from: doi:10.4269/ajtmh.2010.10-0332
  3. MAO Z, XU J, YE C, CHEN D, MEI C. Complete staghorn calculus in polycystic kidney disease: infection is still the cause BMC Nephrol [online] :168 [viewed 20 August 2014] Available from: doi:10.1186/1471-2369-14-168
  4. HEALTH QUALITY ONTARIO. Portable Bladder Ultrasound: An Evidence-Based Analysis Ont Health Technol Assess Ser [online] , 6(11):1-51 [viewed 20 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3379524
  5. CHRISTIAENS TC, DE MEYERE M, VERSCHRAEGEN G, PEERSMAN W, HEYTENS S, DE MAESENEER JM. Randomised controlled trial of nitrofurantoin versus placebo in the treatment of uncomplicated urinary tract infection in adult women. Br J Gen Pract [online] 2002 Sep, 52(482):729-734 [viewed 10 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1314413
  6. DEL MAR CHRIS. Urinary tract infections in healthy women: a revolution in management?. Array [online] 2010 December [viewed 13 September 2014] Available from: doi:10.1186/1471-2296-11-42
  7. GIESEN LEONIE GM, COUSINS GRAINNE, DIMITROV BORISLAV D, VAN DE LAAR FLORIS A, FAHEY TOM. Predicting acute uncomplicated urinary tract infection in women: a systematic review of the diagnostic accuracy of symptoms and signs. Array [online] 2010 December [viewed 13 September 2014] Available from: doi:10.1186/1471-2296-11-78

Investigations - Fitness for Management

Fact Explanation
Full blood count [2] May show elevated white blood cells due to bacterial infections. It is also important in ruling out the other conditions that causes fever such as low platelets in dengue [2] , elevated lymphocytes in viral infections.
Blood culture Is needed in septic patients to exclude septicaemia. [1]
References
  1. MCGREADY R, WUTHIEKANUN V, ASHLEY EA, TAN SO, PIMANPANARAK M, VILADPAI-NGUEN SJ, JESADAPANPONG W, BLACKSELL SD, PROUX S, DAY NP, SINGHASIVANON P, WHITE NJ, NOSTEN F, PEACOCK SJ. Diagnostic and Treatment Difficulties of Pyelonephritis in Pregnancy in Resource-Limited Settings Am J Trop Med Hyg [online] 2010 Dec 6, 83(6):1322-1329 [viewed 20 August 2014] Available from: doi:10.4269/ajtmh.2010.10-0332
  2. HOTTZ ED, OLIVEIRA MF, NUNES PC, NOGUEIRA RM, VALLS-DE-SOUZA R, DA POIAN AT, WEYRICH AS, ZIMMERMAN GA, BOZZA PT, BOZZA FA. Dengue Induces Platelet Activation, Mitochondrial Dysfunction and Cell Death through Mechanisms that Involve DC-SIGN and Caspases J Thromb Haemost [online] 2013 May, 11(5):951-962 [viewed 10 September 2014] Available from: doi:10.1111/jth.12178

Investigations - Followup

Fact Explanation
Urine full report [1] Follow up is needed with urine full report in culture proven cases. [1]
Urine culture [1] Pregnant mothers who had been diagnosed with pyelonephritis should be reviewed weekly for 6 weeks with repeat urine dipsticks, repeat urine cultures at days 14 and 42. [1]
References
  1. MCGREADY R, WUTHIEKANUN V, ASHLEY EA, TAN SO, PIMANPANARAK M, VILADPAI-NGUEN SJ, JESADAPANPONG W, BLACKSELL SD, PROUX S, DAY NP, SINGHASIVANON P, WHITE NJ, NOSTEN F, PEACOCK SJ. Diagnostic and Treatment Difficulties of Pyelonephritis in Pregnancy in Resource-Limited Settings Am J Trop Med Hyg [online] 2010 Dec 6, 83(6):1322-1329 [viewed 20 August 2014] Available from: doi:10.4269/ajtmh.2010.10-0332

Investigations - Screening/Staging

Fact Explanation
Urine full report [1] Pregnant mothers should have screened for asymptomatic urinary tract infections at the booking visit and if indicative further investigations are needed. [1]
Renal function tests(serum creatinine, blood urea, serum electrolytes) Recurrent urinary tract infections or associated urinary calculi may cause renal damage that result in renal failure. Renal functions needs to be monitored even during the antibacterial treatment. [2]
References
  1. HAMDAN HZ, ZIAD AH, ALI SK, ADAM I. Epidemiology of urinary tract infections and antibiotics sensitivity among pregnant women at Khartoum North Hospital Ann Clin Microbiol Antimicrob [online] :2 [viewed 19 August 2014] Available from: doi:10.1186/1476-0711-10-2
  2. JANCEL T, DUDAS V. Management of uncomplicated urinary tract infections West J Med [online] 2002 Jan, 176(1):51-55 [viewed 10 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1071654

Management - General Measures

Fact Explanation
Supportive management Severely ill mothers should be admitted to hospital, [4] Symptomatic treatment [5] such as antipyretics to control the fever and anti emetics to control the vomiting should be given.
Maintain hydration [3] Intravenous fluid may be needed in a case of pyelonephritis. [3]
Prevention of urinary tract infections [2] Pregnant mothers should receive health education on proper hygienic practices, maintain adequate fluid intake and double voiding to empty the bladder after sexual intercourse. Because it is clearly shown that tha incidence of asymptomatic bacteriuria is related to the sexual activities. [6] Special attention is needed for the high risk people such as those with a history of urinary calculi, polysystic kidney disease, immunesuppression etc.
Preventive antibiotics [3] Cephalexin or nitrofurantoin in patients with recurrent UTIs will be beneficial in preventing UTI. [3]
Further evaluation during the postpartum period [1] Patients with urinary calculi, recurrent UTI (more than one episode) ,recurrent UTI while on prophylactic antibiotic therapy should undergo further evaluation specially looking for the structural abnormalities of the urinary tract. [1]
References
  1. MCGREADY R, WUTHIEKANUN V, ASHLEY EA, TAN SO, PIMANPANARAK M, VILADPAI-NGUEN SJ, JESADAPANPONG W, BLACKSELL SD, PROUX S, DAY NP, SINGHASIVANON P, WHITE NJ, NOSTEN F, PEACOCK SJ. Diagnostic and Treatment Difficulties of Pyelonephritis in Pregnancy in Resource-Limited Settings Am J Trop Med Hyg [online] 2010 Dec 6, 83(6):1322-1329 [viewed 20 August 2014] Available from: doi:10.4269/ajtmh.2010.10-0332
  2. SCHIEVE LA, HANDLER A, HERSHOW R, PERSKY V, DAVIS F. Urinary tract infection during pregnancy: its association with maternal morbidity and perinatal outcome. Am J Public Health [online] 1994 Mar, 84(3):405-410 [viewed 10 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1614832
  3. HISANO M, BRUSCHINI H, NICODEMO AC, SROUGI M. Cranberries and lower urinary tract infection prevention Clinics (Sao Paulo) [online] 2012 Jun, 67(6):661-667 [viewed 10 September 2014] Available from: doi:10.6061/clinics/2012(06)18
  4. JANCEL T, DUDAS V. Management of uncomplicated urinary tract infections West J Med [online] 2002 Jan, 176(1):51-55 [viewed 10 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1071654
  5. KNOTTNERUS BART J, GEERLINGS SUZANNE E, VAN CHARANTE ERIC P, TER RIET GERBEN. Women with symptoms of uncomplicated urinary tract infection are often willing to delay antibiotic treatment: a prospective cohort study. Array [online] 2013 December [viewed 13 September 2014] Available from: doi:10.1186/1471-2296-14-71
  6. YACOUB R, AKL NK. Urinary Tract Infections and Asymptomatic Bacteriuria in Renal Transplant Recipients J Glob Infect Dis [online] 2011, 3(4):383-389 [viewed 13 September 2014] Available from: doi:10.4103/0974-777X.91064

Management - Specific Treatments

Fact Explanation
Management setting Hospitalization may be needed in patients who are exhibiting signs of sepsis, who are vomiting and unable to stay hydrated, and who are having contractions. [2]
Antibiotics [2] Antibiotics should be able to target the common infecting organisms (gram-negative gastrointestinal organisms), and safe for the mother and fetus. Nitrofurantoin, and cephalosporins, [2] fosfomycin are good choices. Sulfonamides should be avoided during the third trimeste due to the risk kernicterus. Fluoroquinolones and tetracyclines should also be avoided due to the toxic effects on the fetus. Duration will be 7-10 days. [1] A three-day treatment course is sufficient for the cystitis.Intravenous antibiotics are needed in pyelonephritis.
Management of asymptomatic bacteriuria [2] Asymptomatic bacteriuria in early pregnancy has a 20–30-fold increased risk of developing pyelonephritis. Duration of antimicrobial therapy is usually 3–7 days and screening for recurrent bacteriuria is needed. Amoxicillin, cephalexin ,ampicillin, fosfomycin, trimethoprim/sulfamethoxazole [3] and nitrofurontoin are the usual treatments used. Trimethoprim/sulfamethoxazole is contraindicated in 1st trimester due to teratogenicity and folic acid antagonism. [2] and in late 3rd trimester due to risk of neonatal kernicterus. Colonization with group B streptococci needs specific treatment.
References
  1. MCGREADY R, WUTHIEKANUN V, ASHLEY EA, TAN SO, PIMANPANARAK M, VILADPAI-NGUEN SJ, JESADAPANPONG W, BLACKSELL SD, PROUX S, DAY NP, SINGHASIVANON P, WHITE NJ, NOSTEN F, PEACOCK SJ. Diagnostic and Treatment Difficulties of Pyelonephritis in Pregnancy in Resource-Limited Settings Am J Trop Med Hyg [online] 2010 Dec 6, 83(6):1322-1329 [viewed 20 August 2014] Available from: doi:10.4269/ajtmh.2010.10-0332
  2. LEE M, BOZZO P, EINARSON A, KOREN G. Urinary tract infections in pregnancy Can Fam Physician [online] 2008 Jun, 54(6):853-854 [viewed 10 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2426978
  3. YACOUB R, AKL NK. Urinary Tract Infections and Asymptomatic Bacteriuria in Renal Transplant Recipients J Glob Infect Dis [online] 2011, 3(4):383-389 [viewed 13 September 2014] Available from: doi:10.4103/0974-777X.91064