7 Urinary tract infections complicating pregnancy

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Summary

Urinary infections, with a spectrum from covert bacteriuria to severe pyelonephritis, commonly complicate pregnancy. Serious infections follow untreated silent bacteriuria in a fourth of cases, and routine screening can be justified in high-risk populations, particularly those from lower socioeconomic strata. Despite an initial salutary response to a number of antimicrobial regimens, covert bacteriuria recurs in one-third of treated women whose risk of pyelonephritis remains at 25%. Acute cystitis may be unrelated to these other infections and responds readily to a number of regimens; however, single-dose therapy is not recommended since early pyelonephritis can be mistaken for uncomplicated cystitis.

Pyelonephritis is the most common severe bacterial infection complicating pregnancy. These women are frequently quite ill, and hospitalization is recommended. Since 85% to 90% respond within 48 hours to intravenous fluids and antimicrobials, continued fever and evidence of sepsis after two or three days should prompt a search for underlying obstruction. Perhaps 20% of women with severe pyelonephritis develop complications that include septic shock syndrome or its presumed variants. These latter include renal dysfunction, haemolysis and thrombocytopaenia, and pulmonary capillary injury. In most of these women, continued fluid and antimicrobial therapy result in a salutary outcome, but there is occasional maternal mortality.

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      Endotoxin-mediated renal dysfunction with depressed glomerular filtration rate and hematologic abnormalities, such as anemia and thrombocytopenia, are relatively common complications of renal infection. Less commonly, acute pyelonephritis can result in respiratory insufficiency, which occurs in 1 in 50 women with severe infection.13 Alveolar-capillary membrane permeability is altered by endotoxin release leading to pulmonary edema, which is transient and responds to supplemental oxygen in most women; however, in rare cases, the alveolar damage can lead to life-threatening respiratory distress syndrome.14

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