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Urinary Tract Infection (Acute Cystitis and Acute Pyelonephritis) | 마이메르시 MyMerci
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Urinary Tract Infection (Acute Cystitis and Acute Pyelonephritis)

NCLEX Review Guide: Urinary Tract Infections in Pregnancy

Pathophysiology and Risk Factors

Pregnancy-Related UTI Changes

  • Physiological changes during pregnancy increase UTI risk due to urinary stasis from uterine compression and hormonal effects on smooth muscle relaxation.
  • Progesterone-induced smooth muscle relaxation causes ureter dilation and decreased bladder tone, leading to incomplete emptying and bacterial growth.
  • Increased bladder capacity and decreased sensation result in longer intervals between voiding, promoting bacterial multiplication.

Memory Aid: "PREGNANT UTI"

Progesterone relaxes muscles
Renal changes increase risk
E. coli most common pathogen
Growing uterus compresses ureters
Nitrites and leukocyte esterase positive
Asymptomatic bacteriuria requires treatment
Nephritis can cause preterm labor
Treatment prevents complications

Key Points

  • UTIs occur in 2-10% of pregnancies and require prompt treatment
  • E. coli accounts for 80-90% of pregnancy-related UTIs
  • Asymptomatic bacteriuria must be treated in pregnancy unlike non-pregnant women

Clinical Manifestations and Diagnosis

Acute Cystitis vs. Acute Pyelonephritis

FeatureAcute CystitisAcute Pyelonephritis
LocationLower urinary tract (bladder)Upper urinary tract (kidneys)
SymptomsDysuria, frequency, urgency, suprapubic painFever >101°F, chills, flank pain, N/V
SeverityMild to moderate discomfortSystemic illness, severe pain
ComplicationsMay progress to pyelonephritisPreterm labor, sepsis, ARDS
  • Pyelonephritis in pregnancy is associated with 20-50% risk of preterm labor and requires immediate hospitalization.
  • Costovertebral angle tenderness (CVA tenderness) is a classic sign of pyelonephritis and indicates kidney involvement.
  • Urine culture with >100,000 CFU/mL confirms UTI diagnosis, but treatment may begin with >10,000 CFU/mL in symptomatic pregnant women.

Clinical Scenario

A 28-week pregnant client presents with sudden onset of high fever (102.4°F), severe right flank pain, nausea, and vomiting. She reports burning with urination for the past 2 days. Vital signs show tachycardia and mild hypotension. This presentation suggests acute pyelonephritis requiring immediate hospitalization and IV antibiotics.

Treatment and Nursing Management

Pharmacological Management

  1. First-line antibiotics for cystitis: Nitrofurantoin 100mg BID x 5-7 days (avoid in 1st trimester and >36 weeks)
  2. Alternative options: Amoxicillin-clavulanate, cephalexin, or trimethoprim-sulfamethoxazole (avoid in 1st and 3rd trimesters)
  3. Pyelonephritis treatment: IV ceftriaxone or ampicillin plus gentamicin until fever-free for 48 hours, then oral antibiotics
  4. Duration: 7-14 days total treatment for pyelonephritis

Important Drug Considerations

  • Avoid fluoroquinolones (ciprofloxacin) - teratogenic effects on cartilage development
  • Avoid tetracyclines - tooth discoloration and bone growth inhibition
  • Nitrofurantoin contraindicated at term due to hemolytic anemia risk in newborn

Nursing Interventions

  • Monitor for signs of preterm labor including uterine contractions, back pain, pelvic pressure, and cervical changes.
  • Encourage increased fluid intake (2-3 L/day) to flush bacteria and prevent dehydration, especially important with fever.
  • Educate on proper perineal hygiene: wipe front to back, urinate after intercourse, avoid bubble baths and douching.
  • Administer antipyretics (acetaminophen) for fever >100.4°F to prevent maternal hyperthermia and fetal complications.

Key Points

  • Pyelonephritis requires hospitalization and IV antibiotics initially
  • Monitor fetal heart rate and uterine activity for signs of fetal distress or preterm labor
  • Follow-up urine cultures needed 1-2 weeks after treatment completion

Complications and Prevention

Maternal and Fetal Complications

  • Preterm labor and delivery occurs in 20-50% of pyelonephritis cases due to inflammatory mediators and prostaglandin release.
  • Maternal complications include sepsis, acute respiratory distress syndrome (ARDS), and anemia from hemolysis.
  • Intrauterine growth restriction (IUGR) may occur due to maternal fever and systemic inflammation affecting placental function.
  • Recurrent UTIs affect 20-30% of pregnant women after initial infection, requiring suppressive antibiotic therapy.

Prevention Strategies

  • Screen all pregnant women for asymptomatic bacteriuria at 12-16 weeks gestation with urine culture.
  • Prophylactic antibiotics may be prescribed for women with recurrent UTIs (nitrofurantoin 50-100mg daily).
  • Encourage voiding every 2-3 hours and complete bladder emptying to prevent urinary stasis.
  • Recommend cranberry juice or supplements (though evidence is limited) and adequate hydration for prevention.

Prevention Mnemonic: "CLEAN CATCH"

Complete bladder emptying
Lots of fluids (2-3L daily)
Empty bladder after intercourse
Avoid irritants (bubble baths)
Nitrofurantoin for prophylaxis if needed

Common Pitfalls and Study Tips

Frequently Missed Concepts

Common NCLEX Pitfalls

  • Remember: Asymptomatic bacteriuria MUST be treated in pregnancy (unlike non-pregnant women)
  • Nitrofurantoin is avoided in 1st trimester AND after 36 weeks (not just 1st trimester)
  • Pyelonephritis always requires hospitalization in pregnancy due to preterm labor risk
  • CVA tenderness indicates kidney involvement (pyelonephritis), not just cystitis

Quick Check Questions

  • □ Can you differentiate between cystitis and pyelonephritis symptoms?
  • □ Do you know which antibiotics are safe in each trimester?
  • □ Can you identify signs of preterm labor in a UTI patient?
  • □ Do you understand why asymptomatic bacteriuria requires treatment in pregnancy?

Remember: You're preparing to protect both mother and baby! UTI management in pregnancy requires prompt recognition, appropriate treatment, and vigilant monitoring for complications. Trust your knowledge and clinical judgment - you've got this! 🌟

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