Chapter 109

### Introduction

After autopsies I concluded that the newborn died of childbed fever, or in other words, they died from the same disease as the maternity patients … from hands contaminated with cadaverous particles brought into contact with the genitals of delivering maternity patients. If those particles are destroyed chemically, so that in examinations patients are touched by fingers but not by these particles, the disease must be reduced. To destroy cadaverous matter adhering to hands I used chlorine liquida … starting in May 1847 …

When I look back upon the past, I can only dispel the sadness which falls upon me by gazing into the happy future when the infection will be banished.

Ignaz Semmelweis (1818–65), Autobiographical Introduction

Semmelweis discovered the infectious nature of puerperal fever and how physicians transmitted it, but was not believed at the time. He died in a mental institution.

### Urinary tract infection

Urinary tract infection includes pyelonephritis, cystitis and asymptomatic cases (see CHAPTER 25).

##### Acute pyelonephritis

This infection, usually due to Escherichia coli, is one of the most common infective complications of pregnancy. Symptoms include fever, chills, vomiting and loin pain. Bladder symptoms such as frequency and dysuria are commonly absent. The patient should be hospitalised and usually requires intravenous antibiotic therapy and possibly rehydration.

Treatment

• amoxycillin 1 g IV 6 hourly for 48 hours, then 500 mg (o) 8 hourly (if bacteria sensitive) for 14 days1,2

• Alternatives: cephalosporins (e.g. ceftriaxone 1 g IV and cephalexin 500 mg (o))

##### Acute cystitis

Patients with acute cystitis typically have dysuria and frequency. Treat for 10–14 days.

Treatment

• cephalexin 250 mg (o) 6 hourly2

• or

• amoxycillin/potassium clavulanate (500/125 mg) (o) 12 hourly

• or

• nitrofurantoin 50 mg (o) 6 hourly, if a beta-lactam antibiotic is contraindicated

Note: Nitrofurantoin is contraindicated in the third trimester of pregnancy as it may lead to haemolytic diseases in the newborn. Cotrimoxazole and sulphonamides should be avoided. Amoxycillin is recommended only if susceptibility of the organism is proven.

• A high fluid intake should be maintained during treatment

##### Asymptomatic bacteriuria1

• 5–10% of pregnant asymptomatic women have positive cultures during pregnancy.

• Approximately 5% of such women subsequently develop pyelonephritis during pregnancy with an increased risk of preterm labour, mid-trimester abortion and pregnancy-induced hypertension.

• Ideally all women should be screened for bacteriuria at their first visit.

• Less than 1% will subsequently develop bacteraemia.

Treatment

Treatment is recommended according to culture sensitivities. It is preferable to delay it until the first trimester has passed (see CHAPTER 25).2

### Puerperal infection

Puerperal ...

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