Acute pyelonephritis in pregnancy

Introduction to pregnancy with acute pyelonephritis Acute pyelonephritis is one of the most common and serious medical complications during pregnancy. It is usually bilateral infection. If it is unilateral, it is mainly on the right side. Unlike bacteriuria and cystitis, acute pyelonephritis during pregnancy The risk is significantly increased. Delayed urinary emptying and bacteriuria caused by relative obstruction of urinary tract during pregnancy. Secondly, pregnant women contain nutrients in the urine, glucoseuria and amino acid urine are beneficial to the reproduction of pathogens. There are several predisposing factors in the onset of acute pyelonephritis in pregnancy. The symptoms of bacteriuria are the same, and the adhesion of bacteria plays a major role in the occurrence of acute pyelonephritis during pregnancy. Although its exact mechanism is unclear, Stenguist et al reported that acute pyelonephritis in pregnancy compared with asymptomatic bacteriuria in pregnant women, acute pyelonephritis bacterial culture, P-pilus E. coli strain dominated. basic knowledge The proportion of illness: 0.0002% Susceptible population: pregnant women Mode of infection: non-infectious Complications: septic shock anemia pulmonary edema hypotension

Pregnancy with acute pyelonephritis

(1) Causes of the disease

This disease is caused by the ascending bladder infection, and it can also be infected through the lymphatic system or blood. Occasionally, the infection of the surrounding tissues of the kidney spreads.

(two) pathogenesis

The pyelonephritis lesion is not limited to the cavity of the urinary tract, and the renal parenchyma is often involved. Most of the pathogens of acute pyelonephritis in pregnancy (about 90%) are Escherichia coli, and the strain of Klebsiella pneumoniae, Proteus, and Pseudosporium are cultivated in the urine. Bacillus, Streptococcus faecalis, Streptococcus, Staphylococcus are rare, and most of them are asymptomatic bacteriuria before acute attack. Therefore, acute pyelonephritis in pregnancy is a recurrent disease. Symptomatic urinary tract infections form acute symptomatic infections that are suitable for bacterial reproduction.

1. The effect of pyelonephritis on pregnancy

Acute pyelonephritis has a sudden onset of symptoms, such as chills, high fever, general malaise and other symptoms of poisoning, which can cause endotoxemia or even sepsis. High fever can cause miscarriage, premature delivery and stillbirth. If high fever occurs in early pregnancy, it can also make fetal neural tube. Developmental disorders, the incidence of no brains is significantly higher than normal pregnancy, 3% of acute pyelonephritis in pregnancy may occur toxic shock, and second, acute pyelonephritis in non-pregnant women generally does not affect renal function, but can cause obvious pregnancy The glomerular filtration rate decreased, serum creatinine, blood urea nitrogen increased, and those with pregnancy-induced hypertension were higher than those without pyelonephritis.

2. The effect of pregnancy on pyelonephritis

Due to changes in anatomy and physiology during pregnancy, the incidence of acute pyelonephritis is higher. Asymptomatic bacteriuria will have urinary tract infections in 25% to 40% during pregnancy, and 25% to 30% after delivery can develop symptoms. Sexual urinary tract infections, if not treated in time, can develop chronic pyelonephritis and even renal failure.

Pregnancy with acute pyelonephritis prevention

Strengthen the health care during pregnancy, improve the health level; pay attention to the vulva cleansing, the toilet paper should be rubbed from the front direction after defecation, reduce the chance of intestinal bacterial contamination of the vaginal vestibule and urethra, clean the vulva every night, treat asymptomatic bacteriuria, do the above Points help prevent acute cystitis.

1. The preventive measures for acute cystitis are still applicable to the prevention of this disease.

2. Active treatment of acute cystitis has positive significance in preventing its ascending infection.

3. Frequently taking the left lateral position is conducive to urine drainage and prevention of infection.

Pregnancy with complications of acute pyelonephritis Complications , septic shock, anemia, pulmonary edema, hypotension

Acute pyelonephritis during pregnancy can lead to life-threatening complications, dysfunction of multiple organ systems, including:

1. Endotoxemia and septic shock clinically appear excessive hypothermia (less than 35 ° C) and other adverse signs, often precursors of endotoxemia and septic shock aura.

2. Anemia and thrombocytopenia E. coli endotoxin contains lipopolysaccharide which destroys red blood cells and causes anemia.

3. Renal function damage glomerular filtration rate decreased, creatinine clearance decreased.

4. Lung damage Endotoxin damages the alveoli and causes pulmonary edema (recessive respiratory insufficiency and even adult respiratory distress syndrome).

Pregnancy with acute pyelonephritis symptoms Common symptoms Abdominal pain, bloating, urinary urgency, urinary frequency abscess, urinary dysfunction during pregnancy, nausea, nausea

Systemic symptoms

Rapid onset, often chills, high fever, general malaise, fatigue, loss of appetite, nausea and vomiting, and even abdominal distension, abdominal pain or diarrhea, such as high fever continues to retreat, more suggestive and urinary tract obstruction, renal abscess or sepsis.

2. Urinary tract irritation

Pyelonephritis is caused by ascending infection, so it is often accompanied by cystitis. The patient has urinary tract irritation such as frequent urination, urgency, and dysuria.

3. Local signs

There is pain in the kidney area on one or both sides, tenderness and snoring pain in the rib waist point, and deep tenderness in the upper ureteral point and the middle ureteral point.

Examination of pregnancy with acute pyelonephritis

1. Urine routine and bacterial culture

There is no change in urine color, such as phlegm for pyuria; urinary sediment can be seen in white blood cells, white blood cell cast, red blood cells can exceed 10 per high power field, most of the bacteria culture is positive, the common pathogen of urinary tract infection is Escherichia coli, accounting for 75% ~ 85%; followed by E. coli, Proteus, Clostridium perfringens, Staphylococcus and Streptococcus faecalis, Pseudomonas aeruginosa is rare, such as bacterial culture positive should be done for drug susceptibility test, such as urine bacterial culture is negative, It should be considered whether the patient has used antibiotics, because many patients with pyelonephritis have had urinary tract infections before, so patients may have started antibiotic treatment on their own, even if the single oral dose of antibiotics can make urine culture negative.

2. White blood cell count

The range of variation is large, and the white blood cell count can range from normal to as high as 17 x 10 ⁹ /L or >17 x 10 ⁹ /L.

3. Other laboratory inspections

(1) Serum creatinine can be elevated in about 20% of pregnant women with acute pyelonephritis, while at the same time there is a decrease in 24h urinary creatinine clearance.

(2) Some patients have a decrease in hematocrit.

4. Blood culture

If the body temperature exceeds 39 °C, blood culture should be done. If it is positive, it should be further isolated and cultured. The blood culture positive should be noted that septic shock and DIC may occur.

B-ultrasound: can understand the size and shape of the kidney, the state of renal pelvis and renal pelvis and the presence or absence of hydronephrosis.

Diagnosis and differential diagnosis of pregnancy complicated with acute pyelonephritis

diagnosis

According to clinical manifestations and laboratory tests, diagnosis is not difficult.

Differential diagnosis

High fever

It must be differentiated from upper respiratory tract infection and puerperal infection. The former has obvious respiratory symptoms, body muscle aches, white blood cell count and neutrophil classification are reduced when the virus is infected; the latter may have abnormal lochia, and there is tenderness in the uterus or the uterus. Etc., both have no abnormal findings of rib pain and urinary examination.

2. Abdominal pain

Must be differentiated from acute abdomen, persistent pyelonephritis and hematuria suggesting urinary tract rupture, should be identified with the following acute abdomen:

(1) Acute appendicitis, with low fever at the beginning, and metastatic right lower abdominal pain.

(2) biliary colic, often history of cholelithiasis, pain in the right upper abdomen, can be radiated to the right shoulder and accompanied by jaundice, fever, imaging examination of the gallbladder or bile duct can find stones.

(3) acute gastroenteritis, fever, nausea and vomiting, diarrhea, often have a history of unclean diet.

(4) uterine fibroids degeneration, mostly low fever, abdominal pain, imaging examination can find degenerative fibroids.

(5) early exfoliation of the placenta, may have abdominal pain, vaginal bleeding, uterine sensitivity or limited tenderness, may be associated with fetal heart changes, a history of trauma in the history or complicated with hypertensive disorder of pregnancy, the latter has increased blood pressure and proteinuria.

In addition to their respective characteristics, there are usually no chills, high fever and rib horn pain, and there is no obvious abnormality in urine sediment examination.

Mild laceration of the urinary tract, timely detection of conservative treatment such as position or catheter drainage; severe renal parenchymal rupture requiring surgical treatment.

3. Hysteresis

Must be differentiated from acute kidney and ureteral hydrops, acute hyporenal and ureteral hydrops with recurrent hypochondriac pain, related to posture, position, pain to the groin, symptom relief in the left lateral position or knee chest position; urine examination There are a few red blood cells, or even no red blood cells, and repeated mid-stage urine culture is characterized by negative.

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