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

Table 2.16  Upper and lower urinary tract infection symptoms 

Check
  • Calculate REWS — AVPU, RR, O2 sats, pulse, BP, Temp
  • Weight, BGL 
  • 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

  • Calculate REWS — AVPU, RR, O2 sats, pulse, BP, Temp
  • Weight, BGL 

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