Fetal urinary tract obstruction: is active intervention before delivery indicated?

Obstruction of the urinary tract was diagnosed by ultrasound in four fetuses at 16-30 weeks: three of these diagnoses were confirmed after delivery; the fourth fetus had multicystic kidneys with hydroureter and hydronephrosis but no obstruction. The fetus with obstruction diagnosed at 16 weeks was terminated: it had lung hypoplasia with the prune-belly syndrome. The other two fetuses with obstruction were diagnosed at 25 and 34 weeks; the urinary tracts of both were drained for 5-14 days with reduction of distension. Both were born alive but that diagnosed at 25 weeks died of lung hypoplasia, the other survived, required nephrectomy and at the age of 3 is small but developing normally. Fetal urinary tract obstruction may prevent normal development of the lungs, be associated with other anomalies which cannot be diagnosed before delivery and retard infant development in survivors. Drainage of the dilated urinary tract does not harm the fetus or mother but has not been shown to improve neonatal survival or infant development.     

Low urinary tract symptoms after Thierry's spatula delivery at first pregnancy

OBJECTIVE: This study was undertaken to evaluate prevalence of low urinary tract symptoms (LUTS) after Thierry's spatula delivery at first pregnancy. PATIENTS AND METHODS: A retrospective study of 236 primiparous with instrumental delivery or spontaneous delivery who had delivered from January 2001 to December 2002. Low urinary tract symptoms (LUTS) were evaluated one year after delivery with a questionnaire. Incidence of LUTS was compared depending on mode of delivery. RESULTS: Of the 236 patients included, 88.1% replied to the questionnaire, 106 who delivered spontaneously and 102 who underwent Thierry's spatula delivery. The incidence of urinary incontinence was similar after instrumental deliveries and after spontaneous vaginal deliveries (34.9 versus 24.5%, p=0.10). In univariate analysis, symptoms of urinary urgency and urinary frequency were higher after instrumental delivery than after spontaneous delivery, respectively, 34.9 versus 22.5%, p=0.049 and 19.8 versus 8.8%, p=0.03. After controlling for confounding factors, no difference in LUTS was observed between the two groups; the respective adjusted odds-ratios (95% IC) were 1,5 (0.8-3) for urinary incontinence, 1.7 (0.9-3.5) for urgency and 2.5 (0.9-6.3) for urinary frequency. DISCUSSION AND CONCLUSION: One year after delivery, one third of patients will present urinary incontinence and more than 50% will complain of bladder instability symptoms. Compared to spontaneous vaginal delivery, the use of Thierry's spatulas at first pregnancy does not induce higher risk of LUTS.     

Indwelling urinary catheters in cesarean delivery.

OBJECTIVES: A prospective randomized study was used to determine the effect of urinary bladder catheterization on first-void discomfort, time of ambulation, hospital stay, and urinary tract infection in women undergoing cesarean delivery. METHODS: We randomly assigned 270 women delivered by cesarean section to urinary bladder catheterization or no catheterization. Prospective methods were used to assess patient discomfort with the first postoperative void after, time of ambulation, time of hospital stay, and need for recatheterization. RESULTS: Of 135 women who did not receive an indwelling urinary catheter after cesarean delivery, six (4.4%) patients needed postoperation urinary catheterization. The time of first postoperative voiding was 8-11 h in 54 (42.5%) of cases. The ambulation time in the uncatheterized group was 6.8 h, vs. 12.9 h in the control group. Uncatheterized patients had a shorter hospital stay. Urinary tract infection was not assessed in this study. CONCLUSIONS: Routine use of indwelling urinary catheter in cesarean delivery patients with a stable hemodynamic condition is not necessary.     

Fetal urinary tract obstruction: is active intervention before delivery indicated?

Summary. Obstruction of the urinary tract was diagnosed by ultrasound in four fetuses at 16—30 weeks: three of these diagnoses were confirmed after delivery; the fourth fetus had multicystic kidneys with hydroureter and hydronephrosis but no obstruction. The fetus with obstruction diagnosed at 16 weeks was terminated: it had lung hypoplasia with the prune-belly syndrome. The other two fetuses with obstruction were diagnosed at 25 and 34 weeks; the urinary tracts of both were drained for 5–14 days with reduction of distension. Both were born alive but that diagnosed at 25 weeks died of lung hypoplasia, the other survived, required nephrectomy and at the age of 3 is small but developing normally. Fetal urinary tract obstruction may prevent normal development of the lungs, be associated with other anomalies which cannot be diagnosed before delivery and retard infant development in survivors. Drainage of the dilated urinary tract does not harm the fetus or mother but has not been shown to improve neonatal survival or infant development.     

Risk factors for urinary tract infection in the postpartum period.

OBJECTIVE: We sought to examine risk factors for urinary tract infection in postpartum women.Study Design: Subjects (n = 931) with maternal urinary tract infections and control subjects (n = 1862) were identified by using a linked Washington State birth certificate and Birth Events Records Database for the years 1987-1993; stratified analysis was performed by using Mantel-Haenszel procedures. RESULTS: Increased risk for postpartum urinary tract infection was associated with black, Native American, or Hispanic race-ethnicity (odds ratio, 1.30; 95% confidence interval, 1.03-1.64) and unmarried status (odds ratio, 1.33; 95% confidence interval, 1.11-1.58). Cesarean delivery (odds ratio, 2.70; 95% confidence interval, 2.27-3.20) and tocolysis (odds ratio, 3.30; 95% confidence interval, 2.15-5.06) also contributed to maternal risk of acquiring a urinary tract infection. Maternal risk factors included renal disease (adjusted odds ratio, 3.89; 95% confidence interval, 1.80-8.41) and preeclampsia-eclampsia (adjusted odds ratio, 3.21; 95% confidence interval, 2.36-4.38). Among women undergoing vaginal delivery, renal disease (odds ratio, 5.47; 95% confidence interval, 2.04-14.64) and abruptio placentae (odds ratio, 5.02; 95% confidence interval, 1.84-13.64) were risk factors. Length of hospital stay was significantly associated with urinary tract infection. CONCLUSION: Maternal medical conditions and procedures that predispose to urinary tract infections are those that also are associated with urethral catheterization. In addition, maternal urinary tract infections may contribute significantly to duration of postpartum hospital stay.     

Urogynaecological problems in pregnancy

The majority of urogynaecological problems can manifest during pregnancy or as a direct result of pregnancy and delivery. Those most commonly occurring during pregnancy are urinary tract infection, filling and voiding disorders, urinary incontinence, pelvic organ prolapse and faecal incontinence. The development of these may be as a result of physiological changes that occur in pregnancy or as a result of previous pregnancies. There may also be urogynaecological sequelae that occur as a result of trauma sustained during delivery. These include perineal and anal sphincter trauma, bladder or ureteric injuries during caesarean section or operative deliveries, and the development of vesico-vaginal or recto-vaginal fistulae.     

Enterovesical fistula complicating pregnancy. A case report

BACKGROUND: Enterovesical fistula is a rare cause of recurrent urinary tract infections. This condition is unusual in young people as common etiologies include diverticular disease and cancer. When an enterovesical fistula occurs in women of childbearing age, Crohn's disease is a likely cause. To our knowledge, enterovesical fistula complicating pregnancy has not been reported before. CASE: A pregnant woman with recurrent urinary tract infections was evaluated. Cystoscopy was suggestive of an enterovesical fistula, which was confirmed by charcoaluria following oral charcoal administration. The prenatal course was complicated by two episodes of hemorrhagic cystitis despite antibiotic prophylaxis. The patient had an uncomplicated term spontaneous vaginal delivery. An upper gastrointestinal series performed postpartum was suggestive of Crohn's disease and confirmed an enterovesical fistula. Surgical repair was successfully performed three months following delivery, revealing Crohn's disease. CONCLUSION: Enterovesical fistula may be an unusual cause of recurrent urinary tract infections in pregnancy. In this case, enterovesical fistula was the presenting symptom of Crohn's disease.     

Urethral syndrome and associated risk factors related to obstetrics and gynecology

OBJECTIVE: To evaluate the risk factors related to gynecology and obstetrics, and the incidence of urethral syndrome in our gynecological practice. STUDY DESIGN: The study comprised 35 patients without urinary tract infection who admitted to our department of gynecology with the complaints of recurrent urinary irritation symptoms, sensation of incomplete emptying and burning sensation during urination after sexual intercourse. A total of 200 women served as controls. RESULTS: We found urethral syndrome in 15% of patients. The incidence of grandmultiparity and the delivery without episiotomy were significantly higher in the study group than controls using univariate analysis. Considering logistic regression analysis, we found that grandmultiparity, two or more abortus, hospital delivery, delivery without episiotomy and pelvic relaxation were risk factors for the urethral syndrome. CONCLUSION: Although urethral syndrome is often detected in gynecological practice, it has not yet been reached utmost importance. Grandmultiparity and delivery without episiotomy are the major risk factors accompanying urethral syndrome.     

Paraplegia and quadriplegia: special considerations during pregnancy and labor and delivery

Patients with spinal cord injury resulting in paraplegia or quadriplegia increasingly desire to bear children. Management by a health care team attentive to the special problems that may complicate pregnancy offers the best chance for a successful pregnancy outcome. Life-threatening autonomic hyperreflexia may occur in patients with lesions above the T5-6 level. Precautions should be taken to avoid an unsupervised delivery. Vaginal delivery is appropriate unless there is an obstetric indication for cesarean section. Surveillance for urinary tract infection, anemia, and skin ulcers is advisable.     

Pregnancy, childbirth and the pelvic floor

Pregnancy and vaginal delivery are responsible for the onset of genuine stress urinary incontinence, and pelvic floor damage. A striking dearth of prospective studies exists regarding the relationship of pregnancy and delivery to these problems. The vast majority of published data is based on analysis retrieved from questionnaires. Most damage of the pelvic floor obviously occurs during first delivery. Objective findings have demonstrated pudendal nerve damage mostly found after forceps delivery, increased duration of second stage of labour, third degree perineal tear and high birth weight. Episiotomy offers no protection against perineal tears and should be restricted to specified feto-maternal indications. Longitudinal studies are needed to assess long term consequences of pregnancy and child birth on both, lower urinary tract and pelvic floor function.     

Lower urinary tract symptoms in primiparous women before and during pregnancy

Objective  

Lower urinary tract symptoms (LUTS), in particular urinary incontinence (UI), commonly develops during pregnancy or following delivery. This study was conducted to investigate the prevalence of the LUTS before and during pregnancy, and to demonstrate the relationships between various obstetric parameters and UI.     

Pregnancy and delivery in patients with surgically corrected congenital extrophy of the bladder, through the operations of the continent urinary derivation

Authors present two cases of pregnancy and delivery of patients with bladder extrophy. Both had undergone various and different reconstructive surgical operations in childhood, which gave them the opportunity to lead a normal life, to become pregnant and deliver. A total of three deliveries are observed--one with Caesarian, one--normal vaginal delivery and one--normal delivery with breech presentation. Bladder extrophy is a rare and severe innate anomaly of the genital-urinary tract, associated with genital, urologic and orthopedic malformations. The main complications during pregnancy are infections and calculosis of the urinary tract, prematurity, malpresentations, genital prolapse. Premeditated Caesarian section is the method of delivery in almost every case with bladder extrophy, while normal vaginal delivery remains casuistic.     

Erkrankungen der Niere und der ableitenden Harnwege in der Schwangerschaft

During pregnancy physiological changes of the urinary tract occur due to hormonal and anatomical alterations. Dilatation of the upper urinary tract is the most important of these changes and causes an increased susceptibility for symptomatic urinary tract infections redulting from asymptomatic bacteriuria. Screening for asymptomatic bacteriuria and antibiotic treatment is therefore recommended. Symptomatic urinary tract infections are treated according to the results of urine cultures. The preferred antibiotics are penicillin, cephalosporin and fosfomycin trometamol. Stones in the urinary tract are treated with spasmoanalgetic medications. If there is no spontaneous stone passage after a reasonable time, uncontrollable pain or persistent fever, a ureteral stent or percutaneous nephrostomy tube are inserted. Functional or morphological abnormalities of the urinary tract can cause problems during pregnancy. The presence of a kidney transplant does not preclude a successful pregnancy; however in these cases an interdisciplinary approach is mandatory.     

Discordant lower urinary tract obstruction in early twin gestations: management and outcome

OBJECTIVE: To report our experience with the management of twin pregnancies discordant for lower urinary tract obstruction. METHODS: Cases of twin pregnancies discordant for lower urinary tract obstruction were identified from our fetal medicine database. Information on ultrasonographic findings, antenatal course, pregnancy complications, and perinatal outcome was obtained by reviewing medical records or contacting the referring obstetricians. RESULTS: Five twin pregnancies discordant for lower urinary tract obstruction were diagnosed between 11 and 15 weeks of gestation. There were 3 dichorionic and 2 monochorionic pregnancies (1 diamniotic and 1 monoamniotic). The dichorionic pregnancies were managed conservatively, resulting in a pregnancy loss of both twins in 1 case, a single fetal death at 29 weeks in 1 case, and an early neonatal death due to lung hypoplasia of the affected twin in 1 case. On the other hand, both monochorionic twin pregnancies were managed with serial vesicocenteses. In both cases, the prenatal course was complicated, 1 by premature rupture of the membranes and the other by cord entanglement, requiring delivery at 29 and 31 weeks, respectively. Among the 4 continuing pregnancies with complete perinatal outcome, none of the affected twins survived, and the structurally normal twins were delivered between 29 and 36 weeks and discharged from the hospital in good condition. CONCLUSION: Twin pregnancies discordant for lower urinary tract obstruction are at high risk of perinatal death and premature delivery. Prenatal intervention seems not to be associated with an improved perinatal outcome of the affected twin, but it may be beneficial in selected cases to attain viability of the unaffected twin.     

Bacteriuria in the puerperium. Risk factors, screening procedures, and treatment programs

Screening for bacteriuria by culture of voided midstream urine was done in 6803 puerperal women; significant growth was found in 8.1%. The urine was recollected by suprapubic aspiration and bacteriuria was confirmed in 52%, corresponding to an incidence of bladder bacteriuria of 3.7%. A history of past urinary tract infection, bacteriuria in pregnancy, operative delivery, epidural anesthesia, and bladder catheterization increased the risk of postpartum urinary tract infection. Only 21% of the women complained of dysuria; this symptom occurred significantly more often after operative delivery and in patients with previous urinary tract infection. Two hundred fifty-one women with bladder bacteriuria were subjected to different treatments by randomized allocation: 153 patients with amoxicillin-susceptible bacterias were selected for amoxicillin treatment of 1, 3, and 10 days' duration. The cure rates were 84%, 94%, and 98%, respectively; the single-dose therapy was significantly less effective than 10 days' treatment (p less than 0.05). Forty-six women with amoxicillin-resistant bacterial infections received cephalexin or nitrofurantoin therapy of 7 days' duration; the cure rate was 91%. Fifty-two women served as control subjects and received no treatment. Ten weeks later 27% still had persistent bacteriuria in their suprapubic aspiration control specimens. All therapeutic regimens except the single-dose method showed a cure rate that was significantly higher than the spontaneous cure rate (p less than 0.05). Multiparity seemed to be a predisposing factor for persistence of bacteriuria. The study indicates that puerperal patients with positive midstream urine specimens should not be automatically treated, but more thoroughly examined. In cases of confirmed bladder bacteriuria, treatment should be recommended; 3 days' therapy appears to be sufficient.     

Recurrent urinary tract infection in the female

PURPOSE OF REVIEW: Recurrent urinary tract infection is a common problem and can affect women of all ages, particularly the elderly and pregnant women. Obstetricians and gynaecologists need to have up-to-date knowledge of the diagnosis, pathophysiology and management of this condition. RECENT FINDINGS: The diagnosis of urinary tract infection is made on the basis of symptoms and bacteriuria of more than 103 bacteria per ml. Host and bacterial virulence factors are important in the pathogenesis of recurrent urinary tract infections. General host factors predisposing to recurrent infection are genetic factors, ageing, the menopause, urogenital dysfunction, sexual behaviour, and previous pelvic surgery. Urinary tract infection is common in pregnancy, and recent studies have suggested an association with mental retardation and developmental delay. Women with recurrent urinary tract infection in pregnancy should be considered for long-term antibiotic prophylaxis. Intravaginal oestrogens and cranberry juice have been found to be effective for prevention, although more research is required. Women with recurrent urinary tract infection should have at least a 3-day course of trimethoprim or cotrimoxazole, or a 5-day course of beta-lactams or nitrofurantoin, with perhaps a 10-day course in the elderly. Women with frequent urinary tract infection (more than three episodes per year) should be offered prophylactic antibiotics, which can be patient-initiated, postcoital, or long-term low-dose therapy. In the future, vaccines against specific uropathogenic bacteria may be useful in urinary tract infection prophylaxis. SUMMARY: More research is required, by all medical disciplines, on various aspects of urinary tract infection.     

Post cesarean section urinary tract infections, risk factors and prophylactic antibiotic treatment

Two hundred and seventy eight women undergoing Cesarean section were evaluated retrospectively to determine the value of prophylactic antibiotic treatment on post-operative urinary tract infection morbidity. One hundred eight women who received no prophylactic treatment, and ninety eight treated prophylactically with ampicillin and colistin (colliracin). The effect of various obstetrics parameters including parity, previous Cesarean section, duration of labor and maternal anemia on the rate of infection was studied. Significant difference in the rate of infection after the introduction of prophylactic treatment was found. Morbidity rate was reduced to 6.1% in patients treated with ampicillin and collistin compared to 16.1% in the control group (P less than 0.001). The risk group for developing urinary tract infection were those who stayed more than two hours in the delivery room or with hemoglobin blood level less than 12 gr/D.L.     

Long-term outcomes in children treated by prenatal vesicoamniotic shunting for lower urinary tract obstruction

OBJECTIVE: Limited information is available about long-term outcomes in children treated prenatally for lower urinary tract obstruction. Our aim was to evaluate outcomes in children treated in utero with vesicoamniotic shunts. METHODS: Clinical outcomes in 20 pregnancies with a singleton male fetus, oligo/anhydramnios, and lower urinary tract obstruction were studied using chart review and phone and written clinical questionnaire for parents, pediatricians, and urologists. RESULTS: Overall 1-year survival was 91%. Two neonatal deaths occurred from pulmonary hypoplasia. Mean gestational age at delivery was 34.6 weeks, mean days from shunting to delivery were 84.4, and mean birth weight was 2,574 g. Prenatal urinary prognosis was good in 13, borderline in 2, and poor in 3 of the survivors. Mean age at follow-up was 5.83 years. Posterior urethral valves were confirmed in 7 males, urethral atresia in 4, and prune belly syndrome in 7. Eight children had acceptable renal function, 4 had mild insufficiency, and 6 required dialysis and eventual renal transplant. Eleven children had normal bladder function with spontaneous voiding, 6 required catheterization, and 1 child still had a vesicostomy. Height and weight were below the 25th percentile in 9 children. Persistent respiratory problems were present in 8, musculoskeletal problems in 9, and frequent urinary tract infections were reported in 9. Health-related quality of life results in our group with lower urinary tract obstruction were similar to those in a healthy child population. CONCLUSION: Male children who underwent prenatal bladder shunting were neurodevelopmentally normal. Although one third of the surviving babies required dialysis and transplantation, the majority have acceptable renal and bladder function and report satisfactory quality of life. LEVEL OF EVIDENCE: III.     

Urinary incontinence in pregnancy and the puerperium: a prospective study.

OBJECTIVE: Pregnancy and childbirth are commonly thought to be associated with the development of urinary incontinence and lower urinary tract symptoms. The purpose of this study was to assess the relationship, if any, between pregnancy and the development of lower urinary tract symptoms.Study Design: A prospective study of lower urinary tract symptoms was carried out in a cohort of pregnant women who answered a series of symptom questionnaires and kept a 24-hour bladder chart on which frequency of urination and volumes voided were recorded throughout pregnancy and for 8 weeks after birth. RESULTS: A total of 123 women participated in the study. Mean daily urine output (P =.01) and the mean number of voids per day (P =.01) increased with gestational age and declined after delivery. Episodes of urinary incontinence peaked in the third trimester and improved after birth (P =.001). White women had higher mean voided volumes and fewer voiding episodes than did black women. Ingestion of caffeine was associated with smaller voided volumes and greater frequency of urination. CONCLUSION: Pregnancy is associated with an increase in urinary incontinence. This phenomenon decreases in the puerperium. Pregnancy and childbirth trauma are important factors in the development of urinary incontinence among women. These findings warrant further investigation.     

Lower urinary tract infection in women.

Infections of the lower urinary tract affect 10% to 20% of all women, among whom a substantial proportion go on to experience recurrent infections. Bacterial virulence factors, particularly those enhancing mucosal adherence, are important in the pathogenesis of urinary tract infection. The use of a diaphragm with spermicides predisposes to urinary tract infection, most likely through alterations of the normal vaginal flora. Urine microscopy is the most accurate rapid office test for urinary tract infection. Automated and dipstick techniques yield slightly lower sensitivity and specificity. Recent treatment trials indicate that 3-day therapy for uncomplicated lower urinary tract infection provides an optimal balance between efficacy and adverse effects when compared with single-dose therapy or treatment for 7 to 10 days. Antibiotic prophylaxis is an important strategy in treating recurrent infections and is effective for periods as long as 5 years without undue emergence of resistant bacterial strains. Interstitial cystitis remains an elusive entity without definite diagnostic criteria or clearly effective therapy.