Urine infections in pregnancy

Always consider STI as cause of dysuria (pain on passing urine) — see STI checks for women

Urinary tract infections (UTI) cause increased risk of preterm labour, low birth weight baby, perinatal death

Problems include

• Bladder infection — lower UTI
• Asymptomatic bacteriuria — no symptoms only diagnosed by testing urine
• Cystitis with symptoms eg dysuria (pain on passing urine — lower UTI)
• Pyelonephritis (kidney infection) — upper UTI

Ask

• STI symptoms — dysuria (pain on passing urine), discharge, ulcers, sores, dyspareunia (pain when having sex)
• UTI symptoms, upper and lower — can have upper and lower UTIs at same time

Check

• U/A
• Head-to-toe exam — with attention to abdomen

Do

Interpreting U/A

• If blood or protein and no infection on previous MC&S — medical consult
• If protein only — medical consult
• Positive nitrites usually means UTI — but negative nitrites does not mean no UTI
• Positive leucocytes are common in well women AND women with UTIs or STIs
• Urine for MC&S if
• Previous UTI in this pregnancy
• Nitrites or leucocytes on U/A
• UTI symptoms

Treat symptoms

• Always treat UTIs in pregnancy, including asymptomatic bacteriuria
• Encourage oral fluids
• Urinary alkalinisers (eg Ural) may help relieve symptoms but don't treat infection
• Do not give trimethoprim
• If upper UTI symptoms — see Pyelonephritis (kidney infections) in pregnancy
• If lower UTI symptoms OR nitrites on U/A — do not wait for MC&S result — give antibiotics straight away 
• Nitrofurantoin oral — 100mg, 4 times a day (qid) for 5 days — do not give if near delivery OR 36 or more weeks pregnant OR kidney disease (eGFR less than 45)
• OR Cefalexin oral — 500mg, twice a day (bd) for 5 days
• If lower UTI  GBS positive on urine culture — always treat straight away
• Give amoxicillin oral — adult 500mg, 3 times a day (tds) for 5 days
• If allergy — medical consult
• If GBS positive at any point in pregnancy — will need antibiotics in labour. Plan for hospital birth
• If STI symptoms — also see Vaginal discharge or STI checks for women

Follow-up

• Check MC&S result and antibiotic sensitivities — change antibiotic if needed
• Make sure suggested antibiotic is safe in pregnancy
• 1 week after antibiotics finished — do U/A and send urine for MC&S
• If still has infection — medical consult for repeat antibiotics
• If frequency or pain on passing urine OR nitrites on U/A but no infection on MC&S — STI check and medical consult
• After first UTI
• U/A at every antenatal visit
• MC&S every month until baby born — even if U/A normal
• If woman has second or persistent UTI in pregnancy — medical consult about preventive antibiotics or further tests
• If renal ultrasound needed — can be done at same time as obstetric ultrasound. Use separate request form

Pyelonephritis (kidney infections) in pregnancy

Pyelonephritis in pregnancy needs to be treated in hospital with IV antibiotics

• Usually only one kidney at a time but can affect both
• More common in second and third trimester

Look in file notes

• How many weeks pregnant, when baby due to be born
• Urine or kidney problems in the past
• Abnormality of urinary tract
• Urine MC&S results in current pregnancy
• Allergies
• Current medicines

Ask

• Fever — feeling hot then cold, may be shivering
• Nausea or vomiting
• Flank/loin (one sided) pain
• Abdominal pain, contractions

Check

• U/A — mid-stream urine
• Head-to-toe exam — with attention to abdomen
• Tenderness, rebound, guarding — see Abdominal assessment
• Loin tenderness
• If you feel contractions — see First stage of labour

Do

• If you suspect pyelonephritis — urgent medical consult to send to hospital
• Put in IV cannula — largest possible, insert 2 if time
• Blood cultures, FBC, UEC, urine for MC&S
• Start normal saline — 1L at 125mL/hr, or as directed by doctor
• If pain relief needed — see Pain management
• Medical consult about starting antibiotics
• Usually ceftriaxone IV — adult 1g, single dose
• If unable to give IV — give IM mixed with lidocaine (lignocaine) 1%
• If allergy — medical consult

Follow-up

• Antibiotic treatment for total of 10–14 days. Usually completed in community after discharge from hospital
• Usually oral — monitor to make sure all taken
• OR may be IV as outpatient
• If not sure — medical consult
• Urine MC&S at least 48 hours after antibiotic treatment finished
• If still positive — medical consult
• MC&S every month (even if U/A normal) until baby born
• Medical consult about need for preventive antibiotics for rest of pregnancy