Although the most common bacterial infection during pregnancy, the incidence of UTI in pregnancy is similar to that reported in sexually active nonpregnant women of childbearing age. Up to 40% of pregnant women with untreated bacteriuria in the first trimester develop acute pyelonephritis later in pregnancy. Premature births and perinatal mortality are increased in pregnancies complicated by UTI. Therefore, in pregnant women, asymptomatic bacteriuria should be actively sought and aggressively treated with at least one urinalysis, preferably toward the end of the first trimester.
Nitrofurantoin, ampicillin, and the cephalosporins have been used most extensively in pregnancy and are the regimens of choice for treating asymptomatic or minimally symptomatic UTI. TMP-SMX should be avoided in the first trimester because of possible teratogenic effects and should be avoided near term because of a possible role in the development of kernicterus. Fluoroquinolones are avoided because of possible adverse effects on fetal cartilage development. For pregnant women with overt pyelonephritis, admission to the hospital for parenteral therapy should be the standard of care; beta-lactam agents with or without aminoglycosides are the cornerstone of therapy. Prevention of UTI, including pyelonephritis, can be accomplished during pregnancy with nitrofurantoin or cephalexin taken prophylactically after coitus or at bedtime without relation to coitus. Such prophylaxis should be considered for patients who have had acute pyelonephritis during pregnancy, patients with bacteriuria during pregnancy who have had a recurrence after a course of treatment, and patients who had recurrent UTI before pregnancy that required prophylaxis.
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