Acute pyelonephritis in pregnancy

Pyelonephritis is an infectious and inflammatory kidney disease, mainly affecting the tubulointerstitial tissue pyelocaliceal system and often with the involvement of the parenchyma.

Acute pyelonephritis in pregnancy - risk factors

Acute pyelonephritis in pregnancy - Causes

most important pathogens of gestational pyelonephritis are representatives of the Enterobacteriaceae family (Gram-negative bacilli), of which the share of E. coli accounts for 75-85%Klebsiella and Proteus - 10-20%, Pseudomonas aeruginosa - 7%, relatively less common gram-positive cocci - about 5% (group B streptococci, enterococci, staphylococci).A. Hart et al.(1996), exploring on the O-antigen of E. coli as the cause of gestational pyelonephritis from 57 pregnant women found that in the I trimester prevail 01, 03, 06, 015 and 075 serotypes in the III trimester - 075 serotype.These strains were seeded at most other diseases of the urinary tract.Also found a link between the presence of the K-receptor-rich strains of E. coli a

nd involvement in the infectious process of renal parenchyma in pregnant women.In recent years, increased the role of hospital strains of gram-negative bacteria that are highly virulent and multiple antimicrobial resistance as agents of severe pyelonephritis.May play a role chlamydia, mycoplasma and ureaplasma.

Acute pyelonephritis in pregnancy - symptoms

pathogenetic basis for the development of infection is poor circulation in the kidney, mainly venous outflow due urodynamics disorders.Increasing vnutrilohanochnogo and vnutrichashechnogo pressure due to impaired urine passage leads to compression of thin-walled veins of the renal sinus, rupture zones fornikalnyh cups with a direct hit from a pelvic infection in renal venous channel.

Clinically acute pyelonephritis of pregnant women typically begins with acute cystitis (frequent and painful urination, in the area of ​​the bladder pain, terminal hematuria), after 2-5 days (especially without treatment) joined fever with chills and sweats, pain in the lumbar region, the phenomenonintoxication (headache, sometimes vomiting, nausea), leucocyturia (Piura), bacteriuria, cereal, cloudy urine.Proteinuria is usually small, there may be hematuria (gross hematuria in renal colic, papillary necrosis), cylindruria;blood - leukocytosis with neutrophilic shift in (possible leukemoid reaction), in severe cases - a moderate decrease in hemoglobin, Dysproteinemia.Oliguria and high relative density of urine are dependent on the volume of lost fluids due to fever and catabolism.In severe gestational pyelonephritis may experience signs of impaired renal function, manifested a decrease in glomerular filtration rate and an increase in serum creatinine.In 3-5% of cases of acute pyelonephritis may develop acute renal failure, which contribute to make the heavy inflammation of the kidney and caused them hypercatabolism, drop in blood pressure, as well as local intravascular hemodynamic instability.The latter is believed to be due to the high sensitivity of the vascular walls during pregnancy to the vasoactive effects of bacterial endotoxins or cytokines [Petersson S. et al., 1994].

Acute pyelonephritis in pregnancy - diagnosis

To establish a diagnosis of gestational pyelonephritis are important local symptoms (pain and muscle tension in the lumbar region, positive symptom effleurage), urine sediment quantitative research methods, urine culture, ultrasound scan of the kidneys.Ultrasound reveals concrements, large ulcers, dilation of renal pelvis system.In II and III trimester of pregnancy is possible to use MRI, which has a high diagnostic accuracy, which allows to obtain images in any plane, visualization of all structures of the kidney, and is safe for both mother and fetus.Radiological research methods (survey and excretory urography), radionuclide renografiya used only in the postpartum period.Application Review urography is permissible after the 2nd month of pregnancy when the indications for surgery.

differential diagnosis of gestational pyelonephritis in the presence of fever should be carried out with respiratory tract infection, viremia, toxoplasmosis (serum screening), acute abdominal pain - acute appendicitis, acute cholecystitis, biliary colic, acute pancreatitis, gastroenteritis, uterine fibromatosis, placental abruption andother causes.

for acute appendicitis is characterized by localized pain in the middle or in the lower right quadrant of the abdomen, vomiting, fever (usually not as high as in pyelonephritis) without fever and sweating.For acute cholecystitis and cholelithiasis characterized by pain in the upper right quadrant of the abdomen radiating to the right shoulder, possible jaundice, fever and leukocytosis.Decisive for the differential diagnosis is an abdominal ultrasound.The latter is important for the diagnosis of acute pancreatitis.In acute pancreatitis, the pain is localized in the middle and upper quadrant of the abdomen, often radiating to the back, accompanied by fever and leukocytosis, it is necessary to investigate amylase levels, lipase, serum free fatty acids.

Persistent pain and hematuria with pyelonephritis may be associated with its complications, as well as other reasons.For example, sometimes anatomical changes due to pregnancy, can manifest a very significant stretching pelvis and ureter, leading to the so-called "over-stretching syndrome" and / or hypertension intrarenal [Satin S. et al., 1993].Some guidance is improvement in symptoms after positional therapy (position in the "healthy" side, knee-elbow position), in the absence of relief is a catheter including a catheter, a stent, or even nephrostomy.Threatening complication of gestational pyelonephritis is adult respiratory distress syndrome, accompanied by hepatic and hematologic disorders [Cunningham F. G., Lucas M. J., 1994, etc.], Sepsis, shock bakteriemicheskogo, nontraumatic fractures of the urinary tract.Diagnosis of latent current of a chronic pyelonephritis in pregnancy may complicate accession nephropathy pregnant women with severe hypertensive syndrome, masking the underlying disease.

Acute pyelonephritis in pregnancy - treatment

Treatment of gestational pyelonephritis is a complex task, since therapy in pregnant women should be effective against the pathogen, and safe for the fetus.The risk of pathological changes in the body of the fetus is especially great in the first 8-10 weeks of pregnancy (during embryogenesis), so the treatment of gestational pyelonephritis should be carried out, taking into account the duration of pregnancy (trimester), starting after the restoration of the normal passage of urine, determination of the causative agent in view of its sensitivityto drugs, urine reactions and renal dysfunction.

to treat pregnant pyelonephritis used: antimicrobials (antibiotics, uroantiseptiki), positional therapy, catheterization of the ureters, including catheter-stent surgery (decapsulation kidney autopsy purulent foci, the imposition of nephrostomy, nephrectomy), detoxification therapy, physiotherapy.

Antibiotic therapy

basis of antibiotic therapy are antibiotics.During pregnancy, you can assign agents from the group of beta-lactams: aminopenicillin (ampicillin, amoxicillin), highly active against E. coli, Proteus, enterococci.However, their drawback is the susceptibility to the action of specific enzymes beta-lactamase, high frequency stability unsafe strains of E. coli to ampicillin (over 30%), so the drugs of choice are ingibitorzaschischennye penicillins (ampicillin / sulbactam, amoxicillin / clavulanate), active against both gram-negative bacteriathat produce beta-lactamase, and staphylococci.

a drug specifically designed to treat infections caused by Pseudomonas aeruginosa are carbenicillin, ureidopenitsilliny.Along with other penicillins and used beta-lactam antibiotics - cephalosporins, creating in urine and kidney parenchyma high concentration and possessing moderate nephrotoxicity.In I and II trimesters of optimal use of cephalosporins II generation cefaclor, cefuroxime, etc., in the III trimester is possible to use cephalosporins III and IV generations -. Ceftazidime (Fortum), ceftibuten (tsedeks), cefepime (Maxipime), etc. III generation Among cephalosporins against Pseudomonas aeruginosa - ceftazidime and ingibitorzaschischenny cephalosporin - cefoperazone / sulbactam.

Treatment aminoglizoidami

aminoglycosides (gentamicin mainly) because of the adverse effects on the fetus (nephrotoxicity, ototoxicity) is mainly used in pyelonephritis, developed after birth.In severe pyelonephritis not susceptible to the action of other antibiotics, allowed its use in the III trimester as monotherapy and in combination with penicillins and cephalosporins.Currently recommended daily dose of the drug once (in order to reduce adverse reactions and especially neoliguricheskoy acute renal failure) for the same duration of treatment.

Drug reserve intolerance to penicillins or cephalosporins, with restrictions to the use of aminoglycosides (renal failure) for the treatment of infections caused by gram-negative flora, including Pseudomonas aeruginosa, is aztreonam (a preparation for parenteral administration, is resistant to beta-lactamases displayedmainly kidneys).

Treatment of Complications in pyelonephritis

in treating the most severe complicated pyelonephritis with the generalization of infection, bacteremia, sepsis, with polymicrobial infections with the presence of atypical flora, the ineffectiveness of the previously used antibiotics, including beta-lactam, drug provision is antibioticgroup carbapenems - tienam.Clinical and bacteriological efficacy it is 98-100%.

addition to these antibiotics during pregnancy safe use of macrolides.Along with antibiotics in the treatment of pyelonephritis using antimicrobial agents that are introduced into the circuit long-term therapy after the abolition of antibiotics, often for the prevention of exacerbations of chronic pielonefrita, treatment of latent forms of pyelonephritis - nitrofurans (furadonin, furagin), drugs nalidixic acid (nevigramon, Blacks), derivatives 8-oksihinolina (nitroksolin, 5-NOC).

nitrofurans and sulfonamides should be abolished for 2-3 weeks before delivery due to the risk for fetal complications (kernicterus, hemolysis).Throughout the pregnancy is absolutely contraindicated antibiotics tetracycline, levomitsetinovogo number and Biseptol, sulfonamides prolonged action, furazolidone, fluoroquinolones, streptomycin because of the risk of adverse effects on the fetus (the skeleton, organs of hematopoiesis, the vestibular apparatus and the organ of hearing, nefrotoksichnost).

Treatment pyelonephritis postpartum

the treatment of pyelonephritis postpartum drugs of choice are fluoroquinolones (ofloxacin, pefloxacin, ciprofloxacin, and others.), High-performance in relation to almost all kinds of pathogens of the urogenital system infections, have low toxicity, good tolerabilityfor patients, the ability to use both oral and parenteral (with a temporary cessation of breastfeeding).

During lactation possible appointment of cephalosporins (cefaclor, tseftributen), nitrofurantoin (furadonin) furagin, gentamicin, aztreonam, hardly passes into breast milk.

Antibiotic therapy for pregnant women with acute pyelonephritis (acute exacerbation of chronic pyelonephritis) should be performed in a hospital and start with intravenous or intramuscular administration of drugs with a subsequent transition to a reception inside.The total duration of treatment of at least 14 days.

With the development of acute pyelonephritis, if the patient's condition serious and there is a threat to life, treatment is initiated immediately after the taking of urine for sowing a wide variety of drugs action, effective against the most common causative agents of pyelonephritis.

choice of drugs:

Alternative drugs:

duration of therapy for at least 14 days (5 days, parenteral administration of drugs, then inside).

the treatment of severe and complicated pyelonephritis postpartum use following antibiotics.

choice of drugs:

Alternative drugs:

the treatment of pyelonephritis during lactation spend antibiotics.

choice of drugs:

Alternative drugs:

effective drugs can be assessed within 48 hours from the start of therapy.In less serious condition appointment antimicrobial agents it makes sense to delay until the data on the susceptibility to certain antibiotics.