RENAL AND URINARY TRACT DISORDERS IN PREGNANCY

Question 1

Why is there a lower cut-off used for pregnant women?

Answer 1

Plasma flow and glomerular filtration increase by 40% and 65%, respectively —> serum concentrations of creatinine and urea (BUN) decrease substantively across pregnancy, and values within a non-pregnant normal range may be abnormal for pregnancy

Question 2

f the serum creatinine level in pregnancy persistently exceeds ___________, intrinsic renal disease should be suspected

Answer 2

f the serum creatinine level in pregnancy persistently exceeds 0.9 mg/dL (75 umol/L), intrinsic renal disease should be suspected

Question 3

helpful in estimating a 24-hour albumin excretion rate (AER), in which ACR (mg/g) approximates AER (mg/24h)

Answer 3

Urinary albumin-to-creatinine ratio (ACR) in a spot urine sample

Question 4

Urinary albumin-to-creatinine ratio (ACR) in a spot urine sample

This level correlates with ___ correlates with a 24-hr urine CHON > or _______

Answer 4

This level correlates with >0.3 correlates with a 24-hr urine CHON > or equal to 300 mg

Question 5

most common bacterial infection during pregnancy

Answer 5

ASYMPTOMATIC BACTEURIA

Question 6

Organisms that cause urinary infections are those from the normal perineal flora

Answer 6

E. coli in non-obstructive nephritis

+ Adhesin – P or S fimbriae enhance bacterial adherence

Question 7

Risk factors that predispose a woman to UTI in the puerperium

Answer 7

Principle: Bladder stasis leads to UTI
1. Labor/trauma/conduction analgesia —> bladder sensitivity —> intravesical fluid tension is decreased

2. Bladder distention —> discomfort (d/t episiotomy, periurethral lacerations, vaginal wall hematomas)
3. Catheterization to relieve retention —> infection
4. Epidural, regional, spinal anesthesia —> return of bladder not brisk, for a certain period of time they don’t perceive the urge to urinate —> stasis —> UTI

Question 8

Asymptomatic Bacteruria more common in ______

treat even if low concentration because ___________ (number of bacteria) can develop to _________

Etiliogy: _______

Answer 8

More common in diabetics

● Treat even if low concentration – 20,000 to 50,000 can develop pyelonephritis |

● Etiology:

→ E. coli (63%), Klebsiella pneumonia (12%), Enterococcus (12%), Staphylococcus saprophyticus (7%), Staphylococcus aureus (4%), Klebsiella ozanae (2%)

Question 9

Consequence of not treating Asymptomatic Bacteruria

Answer 9

If not treated:

1. Approximately 25% of infected women will develop symptomatic infection during pregnancy (cystitis and pyelonephritis)
2. CYSTITIS & PYELONEPHRITIS - Associated with preterm delivery and low birthweight infants

Question 10

CYSTITIS & PYELONEPHRITIS - Associated with

Answer 10

1. preterm delivery

2. low birthweight infants

Question 11

Screening for asymptomatic bacteriuria at the first prenatal recommended

What is the TEST OF CHOICE?

Answer 11

Urine culture (clean-catch) – test of choice
1. >100,000 organisms/mL is diagnostic (presence of
>100,000 CFU/mL of the same pathogen in 2 consecutive midstream urine specimens)

OR

2. > or = 100,000 CFU/mL of a single uropathogen in one catheterized urine specimen

Question 12

Alternative test for Urine Culture for Asymptomatic Bacteriuria on the 1st PNCU

Answer 12

Urine gram stain of uncentrifuged urine (>1 organism in OIF)

Question 13

T/F

Urinalysis or Urine Dipstick test can be used for screening for Asymptomatic Bacteriuria in the 1st PNCU

Answer 13

FALSE

Alternative test: urine gram stain of uncentrifuged urine (>1 organism in OIF)

Not acceptable: urinalysis, urine dipstick

Question 14

Safest for Asymptomatic Bacteriuria during pregnancy

Answer 14

Penicillins and Cephalosphorins – safest

Reminder: Empiric antibiotic treatment is given regardless of whether urine culture is requested or not

Urine culture may be requested, but it is not routinely done, so empiric therapy is actually given ardless of whether urine culture is requested or not

Question 15

LOCAL GUIDELINES for ASYMPTOMATIC BACTERIURIA

Answer 15

Preferred Regimen:

1. Nitrofurantoin macrocrystals 100 mg QID x 7 days

■ Limit use to 2 nd trimester to 32 weeks only due to risk of hemolytic anemia & birth defects

2. TMP-SMX 160/800 mg BID x 7 days

■ Avoid in 1 st & 3 rd trimester due to teratogenicity and kernicterus

3. Cefalexin 500 mg BID x 7 days
4. Cefuroxime 500 mg BID x 7 days
5. Amoxicillin-clavulanate 625 mg BID x 7 days

■ Avoid for those at risk for pre-term delivery due to possible NEC complication → Fosfomycin 3 g single-dose sachet

6. Fosfomycin 3 g single-dose sachet

● Fluoroquinolones are contraindicated in pregnancy

Question 16

Follow up for asymptomatic bacteriuria

When to repeat urine CS?

What is the Recurrence rate

Answer 16

Repeat urine CS 1 week after treatment

Do monitoring (using urine culture) every trimester Because of 30% recurrence rate