Pyelonephritis during pregnancy
Pyelonephritis during pregnancy is a kidney disease of an inflammatory and infectious nature. The process first involves the interstitial tissue of the organ, and then the calyx and pelvis.
According to statistics, during the carrying of a child, the right kidney is more often affected. In about 7% of women, bacteriuria is diagnosed, in 1-4% it causes pyelonephritis. In recent years, there has been a tendency for an increase in pyelonephritis during pregnancy with destructive-purulent kidney damage. The problem of pyelonephritis during pregnancy is of particular relevance due to the risk of complications that threaten the life of the child and mother.
The causative agent of gestational pyelonephritis is mainly E. coli, but it can be Klebsiella, Enterococcus and Proteus. These representatives of enterobacteriaceae cause disease in 70-80% of cases. Much less often, inflammation is provoked by staphylococci and Pseudomonas aeruginosa. In addition, cases of the development of gestational pyelonephritis are known to be caused by candida, ureaplasma and mycoplasma, as well as viruses and intracellular parasites. Most often they act in association with bacteria and give a start for the development of the disease.
Mostly gestational pyelonephritis occurs at 22 to 28 weeks of gestation. Of the total number of pregnant women, pyelonephritis occurs in 1-4% of cases.
Content:
- Symptoms of pyelonephritis during pregnancy
- Causes of pyelonephritis during pregnancy
- Consequences of pyelonephritis during pregnancy
- Diagnostics of the pyelonephritis during pregnancy
- Treatment of pyelonephritis during pregnancy
Symptoms of pyelonephritis during pregnancy
Symptoms of pyelonephritis during pregnancy will depend on whether the disease is acute or chronic.
The acute phase has the following symptoms:
- The condition of a pregnant woman deteriorates sharply.
- The body temperature rises, it can rise to high levels.
- Lethargy and weakness occurs.
- The woman complains of chills and severe headaches.
- Perhaps the addition of nausea and vomiting. Vomiting is often repeated.
- A plaque is found on the tongue, the tongue itself is dry.
- Appetite disappears.
- There are severe pains that are localized on the side from which the kidney is located. Pain is given to the thigh, groin, all this happens against the background of pulling pains in the lumbar spine.
- Often women complain of painful urination, a feeling of incomplete emptying of the bladder, gross hematuria may occur.
- If the disease is purulent in nature, then the temperature rises abruptly.
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Signs of renal colic may increase.
When pyelonephritis occurs in the first trimester of pregnancy, symptoms of the inflammatory process with fever, chills and headaches are more common. When pyelonephritis occurs at a later date, then local manifestations of the disease with severe pain sensations come to the fore.
If the disease worsens during childbirth, then its symptoms are mild and lost against the background of labor.
If the disease is chronic, the symptoms are mild. There may be complaints of recurring painful sensations in the lumbar region of an aching or dull nature. Pregnant women experience headaches (see also: Headache during pregnancy), lethargy, weakness, drowsiness. As a rule, women do not pay the doctor's attention to such symptoms, attributing them to their position. Therefore, the chronic course of the disease can often be detected only by laboratory tests.
Causes of pyelonephritis during pregnancy
The direct cause of pyelonephritis is bacteria and microbes that begin to multiply in the kidney tissue.
There are two ways the infection can spread during pregnancy:
- Hematogenous pathway from the existing focus of infection.
- Urinogenic pathway against the background of vesicoureteral reflux. Most often, this is how bacteria reach the kidneys. Already in the early stages of pregnancy, 80% of healthy women experience a dysfunction of the urinary tract: their tone and peristalsis decrease, hypotension and hypokinesia develop. It is against this background that some pregnant women develop vesicoureteral and pelvic-renal reflux, the pressure inside the renal pelvis increases, urine, microbes and toxins penetrate into them. As a result, the woman begins to suffer from acute pyelonephritis.
Naturally, despite the changes in the functioning of the urinary system during the gestational period, not every pregnant woman gets pyelonephritis.
The disease manifests itself under the influence of additional provocative factors, including:
- A history of genitourinary infection before the 20th week of pregnancy.
- Anatomical disorders in the development of the kidneys and urinary tract;
- Kidney stone disease.
- Violation of the rules of personal hygiene.
- Fetal presentation.
- Inflammation of the female genital organs.
- Urodynamic disorders that developed during pregnancy.
- The presence of extragenital diseases: diabetes mellitus and chronic tonsillitis.
- Low socio-economic status of women.
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Untreated bacteriuria, which is asymptomatic, leads to the development of pyelonephritis in 20-40% of cases. Therefore, doctors consider bacteriuria a risk factor for the development of gestational pyelonephritis during pregnancy.
In addition, pregnancy itself is already a predisposing factor for the development of the disease:
- As a result of the effect of the hormone progesterone, the smooth muscles of all organs of the pregnant woman relax. This includes the kidneys. The tone of the ureters falls, their peristalsis deteriorates. Urine from the bladder as a result of vesicoureteral reflux is thrown into the kidneys, which leads to an inflammatory process.
- As the fetus grows, the uterus grows in size. She begins to press on the kidneys, on the bladder, on the ureters. As a result, blood circulation in them is disrupted, urine is excreted with a delay.
- Do not forget about a decrease in the body's immune forces during pregnancy, which increases the risk of developing any diseases, including pyelonephritis.
The most common cause of kidney inflammation is E. coli. Although the development of the disease is possible as a result of the pathological activity of enterobacteria, gram-negative microorganisms, chlamydia, mycoplasma, Trichomonas, fungi and viruses.
Consequences of pyelonephritis during pregnancy
A long course of the disease can lead to the destruction of renal tissue, which causes the development of serious complications:
- Anemia;
- Sepsis;
- Renal failure;
- Premature birth;
- Hypertension.
The development of pyelonephritis while carrying a child is an extremely undesirable and dangerous process.
Experts distinguish between three degrees of risk of pyelonephritis that can occur during pregnancy:
- The first degree is characteristic of an acute inflammatory process that occurs during pregnancy. In this case, the pregnancy itself and the process of childbirth proceed without complications. Possible threats - anemia, termination of pregnancy, toxicosis in late stages - occur with a frequency that does not exceed the frequency of development in healthy pregnant women. However, the likelihood of intrauterine infection of the fetus is not excluded.
- If a woman has chronic uncomplicated pyelonephritis, which had a history before conception, then doctors regard this condition as a second degree of risk. At the same time, the risk of developing complications increases by 20-50% compared to healthy women. In this case, the risk of spontaneous abortion, onset of premature birth, fetal hypoxia, late toxicosis and perinatal mortality increases. However, if there is no toxicosis, hypertension and the functionality of the kidneys is not clearly impaired, then the pregnancy is preserved.
- If a woman has pyelonephritis against a background of hypertension, there is a chronic organ failure, or pyelonephritis of a single kidney develops, then experts regard this condition as the third degree of risk. In this case, pregnancy is contraindicated for a woman. (read also: Causes and Symptoms of Kidney Failure)
Diagnostics of the pyelonephritis during pregnancy
Diagnosis of pyelonephritis is based on the collection of anamnesis, on clinical signs, on the laboratory data obtained. Recently, doctors increasingly use the MRI method to detect the disease. It is highly informative and is not contraindicated in pregnancy.
The following laboratory tests are recommended for pyelonephritis in pregnant women:
- Performing a hemogram.
- Performing a general urinalysis.
- Performing urine analysis according to Nechiporenko.
- Bacteriological examination of urine.
- Performing the Zimnitsky test.
- Performing ultrasound of the kidneys. However, with chronic pyelonephritis, it is not very informative.
A feature of the diagnosis of pregnant women is that not all methods can be used to detect the disease. So it is recommended to abandon X-ray research methods, chromocystoscopy, and radionuclide research methods.
It is important to differentiate pyelonephritis from appendicitis, acute cholecystitis, renal colic, cyst rupture, toxoplasmosis. (read also: Toxoplasmosis - symptoms and causes)
Treatment of pyelonephritis during pregnancy
The priority tasks for the treatment of pregnant women with pyelonephritis are:
- Elimination of the main symptoms of the disease.
- Bringing laboratory parameters to normal.
- Normalization of the functioning of the bladder and the urinary system as a whole.
- Selection of adequate antibiotic therapy. In this case, the duration of pregnancy, the circumstances of the course of the disease, its duration must be taken into account.
- Prevent the development of recurrence of pyelonephritis.
- Eliminate the risk of complications.
There are several basic principles for the treatment of pyelonephritis during pregnancy, including:
- Appointment of timely antibiotic therapy, first empiric, and then, if necessary, etiotropic.
- Long-term therapy with herbal uroseptics.
- If necessary, restoration of the normal passage of urine using catheterization, nephrostomy or ureteral stenting.
- Complex therapy: infusion therapy aimed at removing intoxication, sedative, symptomatic, etc.
- Careful monitoring of the condition of both the pregnant woman herself and the fetus. Prevention of hypoxia and hypotrophy.
- In the first trimester of pregnancy, in order not to harm the embryo, exclusively natural, or semi-synthetic penicillins, or uroseptics of plant origin are used.
- In the second and third trimester, the barrier function of the placenta improves and the expansion of the antibacterial range of drugs is possible: in addition to penicillins, cephalosporins, macrolides, nitrofurans can be prescribed.
- The duration of antibacterial treatment is from a week to 10 days, depending on the severity of the disease.
Medical correction should be based on antibiotic therapy. It is selected not only taking into account the antimicrobial activity, but also taking into account its possible effect on the fetus. The beginning of therapy always comes down to the empirical choice of the drug, after which it can be canceled (according to the results of the analyzes obtained).
Depending on the trimester of pregnancy, women will be prescribed the following empiric drugs:
- Inhibitor-protected aminopenicillins - 1 trimester. These are drugs such as: Amoxicillin, Ampicillin, Benzylpenicillin.
- Cephalosporins and inhibitor-protected aminopenicillins - 2nd and 3rd trimester. These are drugs such as: Cefuroxime, Cefoperazone, Erythromycin, Spiramycin, Ofloxacin.
- In the postpartum period, the list of feed preparations listed above can be supplemented with antibacterial agents such as: Co-trimoxazole, Norfloxacin, Pefloxacin, Meronem.
Non-drug therapy is reduced to uroseptic treatment and can only be carried out in combination with the intake of antibacterial agents. In this case, such herbal preparations as Phytolysin, Kanephron, etc. can be used. Plasmapheresis is widely used in case of severe disease. In the postpartum period, it is possible, in addition to plasmaphoresis, to prescribe UFO.
A pregnant woman is shown drinking plenty of fluids and adherence to bed rest. Gestational pyelonephritis is not an indication for interrupting the gestation process.
Symptomatic therapy is possible in the 2nd and 3rd trimesters. Antispasmodics are prescribed to improve the outflow of urine, detoxification therapy should be carried out in the presence of signs of intoxication. During this period, the antibacterial regimen can be supplemented with the use of Furagin, Urosulfan, Nevigramon, 5-NOC.
The indications for surgery are an abscess or a kidney carbuncle.
Throughout the treatment, the condition of not only the pregnant woman, but also the fetus is monitored, since in connection with the infectious process and the enhanced immune response, the risk of miscarriage increases. If such a threat exists, then therapy is carried out aimed at maintaining the pregnancy.
If the treatment does not give a positive effect, then the woman is shown early delivery. A woman needs to give birth without using the caesarean section, through the natural birth canal. In the process of labor, antispasmodics are widely used.
Author of the article: Lebedev Andrey Sergeevich | Urologist
Education: Diploma in the specialty "Andrology" received after completing residency at the Department of Endoscopic Urology of the Russian Medical Academy of Postgraduate Education in the urological center of the Central Clinical Hospital No. 1 of JSC Russian Railways (2007). Postgraduate studies were completed here by 2010.
