Asymptomatic bakteriuriya at pregnant women
Asymptomatic bakteriuriya at pregnant women — the pathological state which is laboratory defined in the period of a gestation at which the repeated research of urine with a break at 24 o'clock and more allows to reveal in analyses the same microorganism in a caption from 100 000, WHICH. The clinical symptomatology is absent. Frustration is diagnosed by means of the general analysis of urine, bacteriological crops, the screening photocolorimetric TTH-test. Treatment is carried out with use of fosfomitsin, semi-synthetic penicillin, tsefalosporin, synthetic nitrofurans, vegetable uroantiseptik.
Asymptomatic bakteriuriya at pregnant women
The asymptomatic bakteriuriya (BBU, the symptomless or hidden chronic bakteriuriya) comes to light at 2,5-26% of pregnant women. At patients with the low social and economic status the syndrome develops 5 times more often. Often not inflammatory bacterial colonization of an urinary path precedes a gestation. At 52,3% of pregnant women the asymptomatic bakteriuriya is revealed in the I trimester, at 35,4% — in II and at 12,3% — in III. According to WHO recommendations, increase in keeping of bacterial agents to 100 thousand and more WHICH is clinically significant. However on observations of experts in the sphere of urology, obstetrics and gynecology, the risk of the complicated current of a gestation arises even at credits from 100 to 10000 WHICH.
The reasons of an asymptomatic bakteriuriya at pregnant women
Pathology is caused by the microorganisms-kommensaly normal colonizing periuretralny and perianalny areas. At 95% of patients the monoinfection is sown. Almost in 2/3 cases of an etiopatogena of a gramotritsatelna: at 51,7% of pregnant women colibacillus decides on an asymptomatic bakteriuriya in analyses, proteas, a klebsiyell, the enterobakter, a tsitrobakter, the pseudo-monads which are not fermenting a bacterium meet less often. Grampolozhitelny microflora is presented by stafilokokka (epidermalny, hemolytic, saprofitny), a piogenny streptococcus, a fecal enterokokk.
The risk of development of a pathological state increases at women with a bacterial vaginosis, earlier postponed urogenital infections, congenital anomalies of development of urinary bodies, nefrolitiazy in the anamnesis, long smoking, diabetes, frequent quinsies and ORZ. The specific factors promoting development of the hidden chronic bakteriuriya in the gestational period are characteristic metabolic, urodinamichesky changes and mechanical influences:
- Stagnation and return throwing of urine. At pregnant women expansion cup systems, hypotonia of mochetochnik and a bladder, the relaxation of a sphincter of an urethra caused by reaction of gladkomyshechny fibers to increase in concentration of progesterone are observed. A part of patients has puzyrno-mochetochnikovy and mochetochnikovo-lokhanochny refluxes. The situation is aggravated with 1,5-fold acceleration of a glomerular filtration and mechanical squeezing of urinary bodies the increased uterus.
- Change of the chemical composition of urine. Influence of kontrinsulyarny hormones (cortisol, a placentary lactogene, a horionichesky gonadotrophin) promotes development in pregnant women of physiological insulin resistance. In combination with the strengthened glucose synthesis by a liver it leads to development of a tranzitorny glucosuria, and at insufficiency of compensatory mechanisms — gestational diabetes. Glucose serves as a suitable substratum for food and growth of the microorganisms which got on urotely.
- Decrease in immunity. Reorganization of immune system of the pregnant woman is directed to preservation of a gestation. To prevent rejection of genetically alien fruit, in the woman's organism activity T-supressorov increases twice, T-killers, fagotsitarny neutrophils of blood, macrophages are oppressed, concentration of immunoglobulins G decreases. As a result the patient's susceptibility to a bacterial infection raises that promotes asymptomatic activation of kommensal.
The mechanism of development of an asymptomatic bakteriuriya in pregnant women is based on the ascending distribution of microorganisms-kommensalov on an urinary path. Extremely seldom infection happens in the hematogenic way. Usually etiopatogena, persistiruyushchy on mucous membranes of a periuretralny zone, get into an urinary system through the relaxed urethra sphincter. The insufficient immune answer does not provide full elimination of bacteria which concentration is insufficient for emergence of classical inflammatory reaction. Thanks to existence of adgezin, a haemo lysine and other factors of virulence infectious agents colonize uroteliya. The accelerated bacterial growth is promoted by physiological increase in pH of urine and a possible glucosuria.
Gestation complications at an asymptomatic bakteriuriya
Clinically hidden bakteriuriya is shown by nothing, however even at a low caption of microorganisms (100-10 000 WHICH) is observed the complicated course of pregnancy authentically more often. Sharp gestational pyelonephritis develops in 20-40% of cases against the background of an asymptomatic bakteriuriya at pregnant women. Strengthening of local and system synthesis of prostaglandins which are stimulators a miometriya provokes premature birth. The risk of gestoz, anemias of pregnant women, fetoplatsentarny insufficiency, a pre-natal hypoxia of a fruit, a delay of its development, infectious complications increases (a horioamnionita, a postnatal endometritis). Indicators of prematurity and neonatal mortality at BBU raise by 2-2,9 times. It is indicative that treatment of in due time diagnosed asymptomatic bakteriuriya significantly reduces probability of complications.
Complexity of identification of a syndrome is connected with lack of symptomatology and patognomonichny complaints. The asymptomatic bakteriuriya is diagnosed for pregnant women laboratory. Diagnostic vigilance the accompanying violations — increase of an urination at the expense of a possible tranzitorny or constant glucosuria cause, the vaginal allocations, gripes, burning, pain, discomfort in external genitals demonstrating probable infectious and inflammatory process.
Taking into account risk of complications microbiological screening is shown to all pregnant women at registration in antenatal clinic. The diagnosis of an asymptomatic uroinfektion is established only when at identification of bacteria in urine there are no clinical, laboratory and tool symptoms of infectious and inflammatory diseases of urinary bodies. The plan of inspection usually includes:
- General analysis of urine. For an exception of casual pollution the average portion of morning urine is investigated. In the analysis bacteria, at a part of pregnant women - leukocytes come to light. Also the raised indicator of pH and glucose in urine can be defined.
- Crops of urine on microflora. The analysis is made twice with an interval between researches not less than 24 hours. The diagnosis of a bakteriuriya is made at repeated identification of the same bacterium in concentration 100 thousand. Which.
- TTH-test. The photocolorimetric screening method of diagnostics allows to reveal the increased maintenance of bacteria in test within 4 hours. Sensitivity of reaction with a trifeniltetrazoliya chloride reaches 90%.
For an exception of inflammatory urological diseases and assessment of functionality of kidneys as additional researches the analysis of urine across Nechiporenko, kidney tests (a nephrological complex), the general and biochemical blood tests, ultrasonography of kidneys, UZDG of kidney vessels are recommended. Radiological or endoscopic methods apply only in difficult diagnostic cases taking into account possible negative consequences to the woman or a fruit. The true asymptomatic uroinfektion is differentiated with a false bakteriuriya owing to material pollution, pyelonephritis, cystitis, uretrity. Except the obstetrician-gynecologist, the patient is examined by the therapist, the urologist, the nephrologist.
Medical tactics at an asymptomatic bakteriuriya at pregnant women
Identification of microorganisms in urine during pregnancy even in the absence of clinical symptomatology and other signs of an inflammation forms the sufficient basis for purpose of antibacterial therapy. Treatment is, as a rule, carried out on an outpatient basis with the empirical choice of one of the recommended schemes. To pregnant women it can be appointed:
- One-day course. Single reception of an antibiotic of a broad spectrum of activity from group of fosfomitsin allows to eliminirovat the majority of the bacteria colonizing urinary tract. Thanks to simplicity of application, high efficiency, safety the method is considered preferable at pregnant women.
- Three-day course. As antibacterial monomedicine apply semi-synthetic β-laktamny penicillin, tsefalosporina of the II-III generation. In the I-II trimester purpose of synthetic nitrofurans is admissible, in the III trimester they can provoke a hemolytic disease of newborns.
In 14 days after the end of course reception of an antibiotic the repeated bacteriological research of urine is carried out. If the bakteriuriya is absent, dynamic observation of the pregnant woman continues. For fixing of therapeutic effect use non-drug methods: strengthening of urination at the expense of plentiful drink, decrease in pH by means of the use of sour drinks (cranberry drink, etc.). If the factors increasing risk of development of an asymptomatic uroinfektion are revealed phytotherapy with use of vegetable anti-septic tanks of complex action is shown. At repeated detection of the hidden bakteriuriya other antibacterial scheme or the medicine which is picked up taking into account sensitivity of microorganisms is appointed. A preferable method of a rodorazresheniye of pregnant women who transferred BBU is natural childbirth. Cesarean section is carried out only in the presence of obstetric or ekstragenitalny indications.
Forecast and prevention
Efficiency of short antibacterial courses at treatment of an asymptomatic bakteriuriya reaches 79-90%. The forecast of pregnancy and childbirth at timely identification and adequate therapy of a syndrome favorable: at 70-80% of pregnant women with signs of BBU it is possible to prevent development of pyelonephritis, at 5-10% — prematurity of the child. Primary prevention of an asymptomatic uroinfektion is directed to elimination of the factors promoting emergence of a bakteriuriya: predgravidarny sanitation of urogenital bodies, refusal of smoking, correction of weight for decrease in probability of development of insulin resistance, drink of fruit drinks for urine acidulation, preventive reception of uroantiseptik by pregnant women from risk group.