Cystitis in pregnant women is an acute or chronic inflammation of the inner lining of the bladder that has arisen or worsened during gestation. It is manifested by frequent painful urination, heaviness or pain over the pubis, turbidity of urine, in severe cases — subfebrility, weakness, other signs of general intoxication. It is diagnosed based on the data of general analysis and bacterial examination of urine, ultrasound, cystoscopy. Penicillin, cephalosporin, nitrofuran antibiotics, preparations from the group of phosphonic acid derivatives, uroantiseptics are used for treatment.
Cystitis is one of the most common urological diseases in female patients. 20-25% of women have had it in one form or another at least once in their lives, and 10% suffer from recurrent inflammation of the bladder. Acute infectious-inflammatory process or exacerbation of the disease with a chronic course is diagnosed in 0.3-1.3% of pregnant women, while the frequency of the disorder directly correlates with the prevalence of asymptomatic bacteriuria.
The disease more often affects sexually active women of reproductive age with a low socio-economic status, abnormalities in the development of urinary organs, diabetes mellitus, recurrent infections of the urological tract in the anamnesis. Timely detection and treatment of asymptomatic bacteriuria can significantly reduce the prevalence of pathology.
The etiology of cystitis during pregnancy can be infectious and non-infectious. The main causes do not differ from those outside of gestation:
- Infectious causes. In 86% of patients, the disease develops due to activation of uropathogenic Escherichia coli. Infectious cystitis can also be caused by Klebsiella, staphylococci, streptococci, enterococci, candida, much less often — Clostridium, Mycobacterium tuberculosis. In some pregnant women, the inflammatory process in the bladder mucosa becomes a consequence of the spread of sexually transmitted infections — gonorrhea, syphilis, chlamydia, ureaplasmosis.
- Other reasons. The causes of non-infectious cystitis during pregnancy: mechanical damage to the mucous membrane by a urinary stone or a medical instrument during invasive examination, toxic effects of medications and other chemicals secreted by the kidneys, radiation loads. Aseptic inflammation in the future is usually complicated by infection.
In addition to the usual provoking factors contributing to the development of cystitis in non—pregnant women – a relatively short urethra, hypothermia, hypovitaminosis, dysbiosis, bacterial vaginosis, inflammatory diseases of the female genital organs (colpitis, endocervicitis), weakened immunity after colds, prerequisites for the occurrence of pathology during gestation are characteristic physiological changes in the urinary system:
- Hypotension of the bladder. Under the influence of progesterone, the level of which increases in pregnant women, the tone of the muscular wall of the organ progressively decreases. In the 3rd trimester, the volume of urine contained in the bladder cavity without the appearance of discomfort in the patient is doubled. As a result of the formation of vesicoureteral reflux, urodynamics is disrupted, the removal of infected urine slows down, which contributes to the spread of infection.
- Changes in the chemical composition of urine. A certain role in the development of cystitis is played by the characteristic increase in urine pH, glucosuria, aminoaciduria for pregnant women. In such a chemical environment, uropathogenic microorganisms replicate better, which leads first to asymptomatic bacteriuria, and subsequently to colonization of the mucous membranes of the organs of the urinary system with ascending or descending spread of infection.
The occurrence of cystitis during gestation and after childbirth is also facilitated by changes in the immune system aimed at preserving pregnancy, weakening of the urethral sphincter, facilitating the penetration of infectious agents into the urinary tract, violation of natural urodynamics due to the pressure of the pregnant uterus on the ureters, kidneys and bladder, catheterization after delivery.
Although pathogens can enter the bladder mucosa hematogenously or lymphogenously, the leading ways of spreading infection are ascending (from the urethra) and descending (from the ureters and kidneys in gestational pyelonephritis, urethritis and other infectious and inflammatory processes). Pathogenic and conditionally pathogenic flora that lives in the periurethral region or is contained in the urine, in the presence of prerequisites (stagnation of urine, decreased local and general immunity, mechanical, chemical, radiation damage to the mucous membranes) colonizes the epithelium.
Damaging factors of microorganisms potentiate the release of cytokines and other inflammatory mediators, activation of macrophages and lymphocytes, microcirculation disorders. An inflammatory reaction develops with alteration, exudation and subsequent reparative restoration of tissues.
The choice of medical tactics for inflammatory lesions of the bladder depends on the form of pathology. The systematization of cystitis occurring in pregnant women is carried out on the basis of the same criteria as outside the gestation period. Taking into account the peculiarities of the course, inflammation can be acute (with a vivid clinical picture) and chronic (occurring latently with periodic relapses).
Some specialists in the field of obstetrics and gynecology attribute the acute inflammatory process affecting the bladder during pregnancy, childbirth and in the postpartum period to secondary cystitis of extra-bubble origin. In addition, the following forms of the disease are distinguished:
- By etiology: infectious and non-infectious. In most pregnant women, cystitis is caused by the action of an infectious agent. Much less often, inflammation has a chemical, allergic, metabolic, parasitic, neurogenic, iatrogenic nature.
- By origin: primary and secondary. The primary process is spoken of in cases where inflammation begins in the bladder. Secondary cystitis is provoked by other vesicular and extra-vesicular causes (stones, foreign bodies, urethral stricture).
- By localization: diffuse (involving inflammation of the entire mucous membrane), cervical (localized in the neck of the bladder), trigonitis (with damage to the urinary triangle in the fundus). Pregnant women are usually diagnosed with diffuse cystitis.
- By the type of morphological changes. Depending on the aggressiveness of the pathogen and the reactivity of the body, the development of catarrhal, fibrinous-ulcerative, ulcerative, hemorrhagic, gangrenous, interstitial and other types of inflammation is possible.
Symptoms of cystitis in pregnant women
The most pronounced clinical manifestations are expressed in an acute process that occurred suddenly a short time after the effect of the provoking factor (hypothermia, acute respiratory infections, etc.). The pregnant woman complains of frequent urination with imperative urges that cause discomfort or pain. The intensity of sensations depends on the prevalence of inflammation, the degree of morphological changes and varies from severity in the lower abdomen to mild, moderate or severe pain at the end or during the entire act of urination, pain in the suprapubic region, which increases with palpation.
Usually a pregnant woman notes turbidity of urine, the appearance of blood impurities is possible. With severe cystitis, body temperature rises, the amount of urine decreases, signs of intoxication increase: weakness, fatigue, sweating. In mild cases, the symptoms disappear on their own after 2-3 days, but more often the disease lasts from 6-8 to 10-15 days and requires the appointment of drug therapy. Acute postpartum cystitis is characterized by urinary retention with soreness at the end of urination and turbidity of the first portion.
Urodynamic disorders during pregnancy often exacerbate the course of chronic asymptomatic cystitis, the only manifestations of which are bacteriuria and leukocyturia, determined by laboratory. The onset of relapse is indicated by frequent urination, turbidity of urine, dysuric phenomena characteristic of the acute process. Painful sensations are usually mild or moderate. General intoxication phenomena are extremely rare. In some pregnant women, chronic cystitis proceeds continuously with the presence of constant minor complaints.
In the absence of adequate therapy in the early stages, cystitis during pregnancy can be complicated by spontaneous abortion, in the late stages by premature birth. Frequent painful urination disrupts night sleep, causes asthenic and emotional disorders in pregnant women. The upward spread of infection contributes to the development of inflammation of the ureters (ureteritis) and acute gestational pyelonephritis. Involvement in the pathological process of the kidneys increases the likelihood of gestosis, intrauterine infection of the fetus, fetoplacental insufficiency, infectious septic conditions in a pregnant woman.
In the primary acute or recurrent course, the diagnostic search is usually not difficult. A typical clinical picture, confirmed by research data, allows you to quickly diagnose cystitis in a pregnant woman and prescribe adequate therapy. A more thorough examination is necessary for prolonged and chronic processes. The most informative methods are:
- General urinalysis. The study reveals leukocytes, bacteria, protein in moderate amounts, in some cases — erythrocytes. The content of epithelial cells is increased. According to the indications, the methodology is supplemented with an analysis of Nechiporenko and a breakdown of Zimnitsky.
- Bacteriological examination. Diagnostic culture on nutrient media allows you to identify the pathogen and determine its content in 1 ml of urine. The advantage of the method is to identify the sensitivity of the microorganism to antibiotics.
- Ultrasound of the bladder. During echographic examination in pregnant women with cystitis, the walls of the bladder are thickened, the contents are inhomogeneous. Due to its safety and non-invasiveness, the technique can be used for screening diagnostics. To search for possible prerequisites for the development of pathology, it is recommended to perform ultrasound of the kidneys and pelvic organs.
- Cystoscopy. The examination is used only in a chronic process. Signs of cystitis are edema, hyperemia, bleeding, ulceration of the mucosa, unevenness of its surface. In case of exacerbation, the method is not recommended because of the risk of spreading infection.
- Additional analyses. Indirect confirmation of cystitis is inflammatory changes in the general blood test — a slight increase in the number of leukocytes with a moderate shift of the leukocyte formula to the left and an increase in ESR. It is necessary to examine the vaginal microflora for dysbiosis, to determine the level of glucose in the blood serum, the causative agents of genital infections can also be identified by PCR analysis, revealing DNA fragments of the microbial agent.
Cystitis is differentiated with pyelonephritis, urolithiasis, urethritis, cystalgia, genital infections — vulvovaginitis, colpitis, cervicitis in urogenital candidiasis, mycoplasmosis, chlamydia, genital herpes, other STIs. Diagnosis and treatment are carried out by an obstetrician-gynecologist and a urologist.
Treatment of cystitis in pregnant women
Inflammation of the mucous layer of the bladder is the basis for antibacterial therapy with drugs to which the causative agent of the disease is sensitive. The duration of the course of active drug treatment of cystitis, according to the recommendations of urologists, is 3-7 days. In the presence of asymptomatic bacteriuria, antibacterial agents are taken within 3-5 days. Pregnant women are prescribed antibiotics with a uroseptic effect without toxic effects on the fetus:
- Semi-synthetic penicillins. Broad—spectrum drugs resistant to acidic environments have a bactericidal effect on most gram-positive and gram-negative microorganisms, including E. coli, the most common causative agent of cystitis. Combinations of penicillins with clavulanic acid, which inhibits beta-lactamases, are even more effective.
- Cephalosporins. The bactericidal effect of semisynthetic cephalosporin antibiotics is due to a violation of the synthesis of the bacterial wall of most infectious agents that cause cystitis. Drugs of the 2nd generation are resistant to the action of beta-lactamases that cause resistance of microbial flora, which increases the therapeutic effectiveness of medicines.
- Nitrofurans. Due to the inhibition of the synthesis of RNA, DNA, proteins, disruption of the formation of cell membranes, inhibition of aerobic metabolism, antibiotics of this group have a bacteriostatic and bactericidal effect on a wide range of microbial agents that cause urinary tract infections. Resistance of microorganisms to nitrofurans is rarely formed.
- Derivatives of phosphonic acid. Due to the inhibition of the initial stage of the formation of peptidoglycans of the bacterial cell membrane, the reproduction of cystitis pathogens is inhibited. Violate the adhesion of infectious effects to the epithelium of the bladder. They have a wide spectrum of action, do not have mutagenic or genotoxic effects.
An alternative to general antibacterial therapy with semi-synthetic and synthetic antibiotics is instillation of solutions with antimicrobial action directly into the bladder. Local treatment is combined with taking decoctions of diuretic herbs and uroantiseptics, which have a complex anti-inflammatory, antioxidant, antispasmodic, analgesic, antibacterial, diuretic effect. Natural childbirth is recommended for pregnant women who have had cystitis. Caesarean section is performed only for obstetric indications.
Prognosis and prevention
With timely diagnosis and an adequate treatment regimen, the prognosis for the pregnant woman and fetus is favorable. Patients suffering from chronic cystitis, when planning pregnancy, are shown early rehabilitation of the urogenital tract, treatment of bacterial vaginosis and genital infections.
To prevent the development or exacerbation of the inflammatory process during gestation, early registration in a women’s clinic with regular urine examination, exclusion of hypothermia, consumption of sufficient fluid (in the absence of contraindications), regular emptying of the bladder, refusal of alcohol, spicy, sour, salty, spicy, fried, pickled is recommended. When performing postpartum catheterization, it is important to strictly observe the requirements of asepsis.