61 Urinary Tract Infections

Pregnancy Issues

All pregnant women should be offered routine screening for asymptomatic bacteriuria by an MSU culture in early pregnancy, followed by prompt treatment. UTI in pregnancy has been shown to be associated with pre-term birth and low birth weight, although this is controversial1,3,4.

Generally, if adequately treated, there are no significant effects on the fetus. If the mother has reflux nephropathy as a predisposing cause for UTI there is an increased risk that the baby may also suffer from this condition.

If the organism responsible for the UTI is Group B Streptococcus (GBS), this will need to be treated with antibiotics at the time of diagnosis. Intrapartum antibiotics will also be advised. GBS bacteriuria is associated with an increased risk of early onset neonatal sepsis; although the risk is increased, it is not quantified10.

Medical Management and Care

• Treat confirmed UTI including asymptomatic bacteriuria, promptly11

• Ensure antibiotic chosen is safe in pregnancy

• Avoid trimethoprim in the first trimester, as it is a folate antagonist12

• Augmentin increases the risk of neonatal necrotising enterocolitis if taken around the time of a premature delivery13

• Consider prophylactic antibiotics to prevent recurrent UTI

• In the case of acute pyelonephritis, hospitalise, commence iv antibiotics, converting to oral when tolerated, iv hydration and adequate analgesia

• Monitor renal function and consider renal ultrasound Midwifery Management and Care

Monthly MSU - more frequently if clinically indicated by:

• Increased frequency of micturition

• Urine dipstick positive for haematuria/proteinuria or nitrates

• Lower abdominal pain or renal tenderness

Always do a test of cure MSU after any treatment of UTI and encourage compliance with prescribed antibiotic regime.

Advise:

• Drinking 2 l of fluid daily

• Empty bladder after intercourse

• Always wipe from front to back after urinating

• Drinking 200-300 ml cranberry juice (or capsule) daily may reduce the risk of recurrent UTI7,8,9

If GBS is the causative organism, inform the woman, placing an alert note on the case notes for antibiotic cover in labour10.

Pyelonephritis:

• Refer to hospital if acute pyelonephritis suspected

• Administer analgesia and antibiotics as prescribed

• Observations: hourly temperature, BP, pulse

• Record fluid balance accurately

Labour Issues

If the mother has a UTI in labour, and is pyrexic and tachycardic, this may result in fetal tachycardia. In this case electronic monitoring of the fetal heart rate in labour is indicated.

Urinary catheterisation increases the risk of UTI, so avoid if possible, but if this is required utilise a strict aseptic technique.

Medical Management and Care

• Commence antibiotics and monitor fetal wellbeing especially if the mother is pyrexic in labour. Otherwise manage as normal.

Midwifery Management and Care

• Encourage regular emptying of the bladder

• Avoid urinary catheterisation as this increases the risk of UTI

• Administer any prescribed treatment

• Ensure adequate hydration, if pyrexic iv fluid may be required

Postpartum Issues

If mother has recurrent UTI due to reflux nephropathy, then there is a risk that the baby could also have this condition.

Early detection and prompt treatment of urinary infections in the newborn can help prevent renal scarring and chronic kidney disease later in life.

Medical Management and Care

• Liaise with the GP if there have been recurrent UTIs in pregnancy

• If UTI persists postpartum further investigation is warranted

• A renal ultrasound scan, for reflux nephropathy, should be arranged for the baby

Midwifery Management and Care

• Postnatal care can usually be managed from a normal perspective by the midwife

• The mother may need reassurance that antibiotics are safe to be taken when breast-feeding

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