The close proximity of the urinary tract to the re- productive organs means that women frequently call their gynecologic provider for management of
urinary tract symptoms. In pregnancy, lower uri- nary tract infections become more common, and asymptomatic bacteriuria is associated with an in- creased risk of preterm labor. Office evaluation and management of uncomplicated cystitis is an essen- tial skill for midwives, as are prompt recognition and triage of the more serious pyelonephritis.
Acute Cystitis
Uncomplicated acute cystitis can be identified as the presence of as few as 100 colonies per milliliter of urine in symptomatic women, or more traditionally, as 100,000 colonies per milliliter whether or not symptoms of urinary tract infection (UTI) are pres- ent. The predominant organism is E. coli, with S.
saprophyticus, Enterobacter, and Enterococci species making up most other pathogens. Symptoms include pain on urination and increased voiding fre- quency. In healthy young women, those who are sexually active will have a higher risk, primarily as- sociated with delayed voiding after genital sex and the use of spermicides and diaphragms (which may promote the growth of bacteria in the periurethral area) [61]. In office practice, identification of posi- tive leukocyte esterase on a urinalysis is adequately sensitive to initiate therapy. Most of the pathogens associated with UTIs remain sensitive to any of sev- eral standard drug regimens (see Table 7-13).
The Group Health Cooperative of Seattle de- veloped clinical guidelines for triage of patients based on symptoms of UTI, which demonstrated decreased use of cultures, increased utilization of recommended drug regimens for treatment of cysti- tis, and no increase in adverse outcomes due to missed diagnoses or delayed treatment [62]. Their guidelines are shown in Figure 7-3.
Three-day antibiotic regimens are generally ad- equate for uncomplicated bladder infections.
Single-day treatments are effective as a clinical cure, but they are associated with a higher rate of recur- rent infection. The former “gold standard” of seven-day therapy is highly effective but not neces- sary in most women. Those who would benefit
Anti-Infectives Commonly Used in the Treatment of Uncomplicated Urinary Tract Infections TABLE 7-13
Trimethoprim/sulfamethoxazole (Bactrim) 160 mg/800 mg po BID ¥3 days*
Nitrofurantoin (Macrodantin) 100 mg po BID ¥3 days*
Amoxicillin (Amoxil) 500 mg po TID ¥3 days
Cephalexin (Keflex) 500 mg po QID ¥3 days
During pregnancy, treat with 7-day therapy at the same dose.
*Avoid use in term pregnancy.
from longer regimens include pregnant women, im- munosuppressed patients, diabetics, and patients whose symptoms had persisted for several days be- fore beginning therapy.
Pyelonephritis
Acute pyelonephritis, an inflammation of the kidneys, might also have been included in the section on ab- dominal pain, as its characteristic presentation is se- vere flank pain and fever with associated nausea. The diagnosis should be confirmed by a urinalysis positive for white cells or pyuria and by culture. Physician consultation or referral is required when pyelonephri- tis is diagnosed. Outpatient treatment of healthy non- pregnant women can be appropriate if the infection is diagnosed early. However, many women will require hospitalization for intravenous antibiotics in the ini- tial stage of treatment. A 10- to 14-day course of IV/oral therapy is required. Cephalosporins (e.g., Rocephin), quinolones (e.g., Cipro), and trimetho- prim/sulfamethoxazole (Bactrim) are all effective [61]. During pregnancy, ampicillin plus gentamycin,
cefazolin (Ancef), and ceftriaxone (Rocephin) have each been demonstrated to be effective. When pyelonephritis is treated effectively in pregnancy, it is not associated with an increase in adverse pregnancy outcomes [63].
Diabetes
Because of the increased rates of obesity in the United States, diabetes has become an increasingly common disease. Approximately ten times as many adults have Type II diabetes as Type I; 8 percent of American adults have Type II diabetes according to the most re- cent National Health and Nutrition Examination Survey (NHANES) data [64]. Diabetes is more com- mon among the obese and women of color, and its prevalence increases with age. The disorder is associ- ated with increased risks of hypertension, hyperlipi- demia, and coronary heart disease, and it may also produce damage that will result directly in vascular disease, renal failure, and retinopathy.
Patient is triaged to a primary care consulting nurse Eligible woman telephones or presents to clinic with predominant symptoms of dysuria or urgency
Patient offered the choice of either an office visit with a healthcare provider or telephone management. Does the patient request an office visit?
Prescribe one from the following prioritized list:
1) Trimethoprim (100 mg orally twice a day for three days); or
2) Nitrofurantoin (100 mg four times daily for three days); or
3) Ciprofloxacin (250 mg orally twice a day for three days)
Yes
Yes
Schedule visit with a healthcare provider
Does the patient have an allergy to a sulfa-containing medication?
No
No
Prescribe trimethoprim- sulfamethoxazole (1 double-strength tablet twice a day for three days)
FIGURE 7-3 Guidelines for the treatment of urinary tract infections.
Source:Saint, S., Scholes, D., Fihn, S. D., Farrell, R. G., and Stamm, W. E. The Effectiveness of a Clinical Practice Guideline for the Management of Presumed Uncomplicated Urinary Tract Infection.Am. J. Med. 106:636–641 (June) 1999.
The current classification strategy for diabetes focuses not on whether insulin is necessary, but on the cause of insulin deficiency. Type I diabetes is al- most always mediated by the immune system caus- ing pancreatic B cell destruction; Type II diabetes, which is far more common, is the result of resis- tance to insulin and the inability of the pancreas to increase insulin production to compensate. The term impaired glucose tolerance is used for adults with fasting glucose values that are elevated above normal but do not meet the criteria for overt dia- betes. Other rare forms of diabetes have also been identified [65].
The diagnosis of diabetes is based on labora- tory values. The presentation of women in clinical practice depends on both the type and severity of onset. Young women with Type I diabetes generally present with clear complaints of polyuria, including the need to urinate during the night, increased thirst, hunger with associated weight loss, and weakness or fatigue. Those with Type II diabetes may also complain of thirst, frequent voiding, and weakness, but they are more likely to present with recurrent vaginal yeast infections, itching, skin in- fections, blurred vision, or even peripheral neu- ropathy. In many cases, particularly with obese women, diagnosis will only occur with laboratory screening. Women with a history of large infants and unexplained fetal losses should be considered at risk. Table 7-14 presents the laboratory criteria for diagnosing diabetes. Two consecutive fasting values greater than 125 mg/dL can also be used as diagnostic.
Hemoglobin A1Cmeasurements can be used to assess both background level of blood sugar in newly diagnosed diabetics and maintenance of glycemic control. The test results are expressed as percentage of total hemoglobin. Normal, nondia- betic samples run 4.0 to 7.0 percent. Because red
blood cells have a turnover period of 120 days, the A1Clevels will decline toward normal values as the patient develops better control.
When a woman is diagnosed with new onset diabetes, she needs a referral from the midwife to an endocrinologist and may also benefit from a nu- trition referral. Based on the severity and duration of her disease prior to diagnosis, adult women with delayed recognition of Type II diabetes may al- ready have hyperlipidemia, hypertension, and vas- cular damage. Smoking cessation, weight loss, and diet and exercise modification are essential compo- nents of maintaining health in diabetic women—as indeed they are for all women. It is in these areas that the midwife can play an important role.
Women with diabetes continue to need regular gy- necologic care and family planning, have an in- creased need for preconception counseling, and will remain prone to vaginal symptoms if glucose control is not optimal. Contraceptive methods can be chosen freely with regard to the woman’s stated preferences as to method. However, when using hormonal contraceptives, attention to choosing a drug with minimal effect on the lipid profile is im- portant. Because of the increased risk of vascular disease and hypertension experienced by diabetic women, the selection of a combined oral contra- ceptive with less than 35 mg of estrogen is recom- mended [66]. The risks of pregnancy versus those of the contraceptive method must be carefully weighed. Women choosing a barrier method should consider their individual risk for recurrent vaginal infections.
Medication for Type I diabetes is always in- sulin, which serves as a replacement for a nonfunc- tioning pancreas. Insulin is administered in split doses to maintain normal or near normal glucose levels throughout the day. Many adults with Type II diabetes are able to manage with diet, Criteria for the Diagnosis of Diabetes Mellitus
TABLE 7-14
1. Symptoms of diabetes plus casual plasma glucose concentration ≥200 mg/dl (11.1 mmol/l). Casual is defined as any time of day without regard to time since last meal. The classic symptoms of diabetes include polyuria, polydipsia, and unex- plained weight loss.
or
2. FPG≥126 mg/dl (7.0 mmol/l). Fasting is defined as no caloric intake for at least 8 h.
or
3. 2-h PG ≥200 mg/dl (11.1 mmol/l) during an OGTT. The test should be performed as described by WHO, using a glucose load containing the equivalent of 75 g anhydrous glucose dissolved in water.
In the absence of unequivocal hyperglycemia with acute metabolic decompensation, these criteria should be confirmed by repeat testing on a different day. The third measure (OGTT) is not recommended for routine clinical use.
Source:Copyright © 2003 American Diabetes Association. From Diabetes Care, Vol. 26, Supplement 1, 2003; S5-S20. Reprinted with permission from The American Diabetes Association.
exercise, and weight loss. Others move through a progression of diet and exercise, to single or multi- ple oral agents, to insulin. Common oral medica- tions include the sulfonureas—for example, glyburide (Micronase) or glipizide (Glucotrol), repaglinide (Prandin), metformin (Glucophage), and rosiglitazone (Avandia).
Women with impaired glucose tolerance need consistent counseling regarding the importance of exercise, weight loss, and dietary changes. A recent comparison of metformin therapy versus lifestyle changes to reduce the onset of Type II diabetes among persons with impaired glucose tolerance found that an intervention to promote weight loss and exercise was more effective than medication in delaying the onset of diabetes [67].