Seminar 5 - Urinary Tract Infection in Pregnancy

I would like to tell you something…Will you listen to
me…?
URINARY TRACT
INFECTIONS
• What are the
changes in
Urinary System
that occur in
pregnancy ?
CHANGES IN PREGNANCY
• Increased renal parenchymal volume due to intrarenal
fluid accumulation, hence…
• massive dilatation of renal calyces and ureter.

[approximately 90 % of pregnant women develop
ureteral dilatation, which will remain until delivery,
and up to 12th – 16th postpartum week.]
• By 2nd trimester, there is increased renal blood flow

up to 70-80 % and also GFR by 45-50%.
• If the measurement on one clean-catch specimen is at least 2+
(100mg/dL) OR
if there is persistent 1+ proteinuria (30mg/dL), a 24 hour urine

specimen should be obtained.
• In the absence of preeclampsia, when the 24 hour urine protein

excretion exceeds 500mg/24h, it is obviously abnormal, and the
patient should be evaluated for underlying renal disease.
• The excretion of glucose may present up to 20-100 mg/day. Why?

(and Glycosuria promotes bacteria growth in urine).
• There is a vesicoureteral reflux seen in pregnancy.

INTRODUCTION
• An urinary tract infection (UTI): Bacteriuria:
i] presence of at least 100,000 organisms/mL of urine in an

asymptomatic patient
ii] as more than 100 organisms/mL of urine with

accompanying pyuria (>7 WBCs/mL) in a symptomatic
patient
can be lower/upper UTI
• Pregnant women are at increased risk for UTI's

starting in week 6 through week 24.
CLASSIFICATION
• Uncomplicated (normal renal tract & f(x))
• Complicated (abnormal renal/GU tract,voiding
difficulty/outflow obstruction, decrease renal
f(x), impaired host defences)
• Recurrent UTI
• Relapse UTI
How ?
Blood-volume expansion is accompanied by increases in the
glomerular filtration rate (GFR) and urinary output.
The ureters undergo tonic relaxation because of the mass production of

hormones, particularly progesterone.
This loss in tone, along with the increased urinary tract volume, results
in urinary stasis,
can lead to dilatation of the ureters and the calyceal pelvis.
Urinary stasis and the presence of vesicoureteral reflux predispose some

women to upper tract UTIs and acute pyelonephritis
• The infections can be symptomatic or
asymptomatic.
• Symptomatic :
1) Lower UTI : acute cystitis
2) Upper UTI : acute pyelonephritis
CYSTITIS AND URETHRITIS
• Symptomatic bacteriuria.
• Common symptoms: Suprapubic pain, urgency, frequency and

dysuria.
Mucopurulent cervicitis usually co-exists.
• Haematuria/pyuria are present.
• If symptoms are present but urine are STERILE, the agent

could be Chlamydia trachomatis. (Antibiotic: erythro.)
ACUTE PYELONEPHRITIS
• Potentially life threatening in pregnancy.
• In contrast to non pregnant, acute pyelonephritis in

pregnancy leads to acute renal failure if not treated.
• Cx: Septic shock, renal abscess and renal vein

thrombosis.
ACUTE PYELONEPHRITIS: PATHOLOGY
• 1%-2% incidence.
• Presents as high fever + loin pain + vomiting + rigors .

Oliguria (if acute renal failure).
• Dysuria pyuria + bacteriuria are present.
• Most cases are bilateral or right sided. Why?
• ~15% of APN also have bacteraemia.

ACUTE PYELONEPHRITIS: COMPLICATION
• Moderate Cx: -PROM

-Fetal death
• Severe Cx: -Perinephric cellulitis or abscess

-Septicaemia
-Septic shock
-ARDS
-Death
FACTORS LEAD TO UTI IN
PREGNANCY & POSTPARTUM
• Urine stasis during pregnancy.
• Perineal discomfort in postpartum period due to

tears / episiotomy / injury.
• Bladder insensitivity to increased urinary tension in

immediate postpartum period.
• Catheterization due to overdistension.

Risk factors for UTI
• A new sex partner or multiple partners.
• More frequent intercourse.
• A history of diabetes, sickle-cell anemia, stroke, kidney stones

or any problem that causes the bladder not to empty
completely.
• Pregnancy increases your risk for developing a UTI.
• Use of contraceptives such as diaphragms, condoms exposure

and spermicides.
Risk factors for UTI
• A history of UTI's, especially if the infections
were less then six months apart.
• Waiting too long to urinate.
• Decrease host defences (immunosupp, DM)
• Urinary tract: obstruction; stones; catheter;

malformation.
What are the complaints?
• Pain or burning (discomfort) when urinating
• Frequent urination
• A feeling of urgency when you urinate
• Blood or mucus in the urine
• Cramps or pain in the lower abdomen
• Pain during sexual intercourse
• Chills, fever, sweats, leaking of urine (incontinence)
• Waking up from sleep to urinate
• Change in amount of urine, either more or less
• Urine that looks cloudy, smells foul or unusually
strong
• Pain, pressure, or tenderness in the area of the bladder
• When bacteria spreads to the kidneys : back pain,
chills, fever, nausea, and vomiting.
Physical examination
• ASYMPTOMATIC BACTERIURIA :
– Often, no physical findings are present.
– Symptoms may arise intermittently, only to be
overlooked because of lack of persistence or
severity.
• CYSTITIS : Patients may have suprapubic

tenderness upon palpation.
• PYELONEPHRITIS :
– Patients have fever (usually >38°C), flank
tenderness upon palpation, and an ill appearance.
– Based on gestational age, include fetal heart rate as
part of the evaluation. Often, owing to maternal
fever, the fetal heart rate is elevated to more than
160 beats per minute.
Common Uropathogen
• Escherichia coli (most common,70% of cases)
• Group B Streptococcus (10%) (Quite rare, but has

important implication!)
• Klebsiella or Enterobacter species (3%)
• Proteus species (2%)

What
GBS
infection
can
cause to a
pregnant
woman ?
Group B Streptococcal Infection
• Group B streptococcal (GBS) vaginal colonization is known to
be a cause of neonatal sepsis and is associated with preterm
rupture of membranes, and preterm labor and delivery.
• GBS is found to be the causative organism in UTIs in

approximately 5-10% of patients.
• It is unclear if GBS bacteriuria is equivalent to GBS vaginal

colonization, but pregnant women with GBS bacteriuria
should be treated as GBS carriers and should receive a
prophylactic antibiotic during labor.
Diagnosis
• Hx Taking and PE + temperature + abdominal examination +
assessment of costovertebral angle for tenderness.
• Urine C&S : Culture results can be used to identify specific

organisms and antibiotic sensitivities. (Should be performed in
all pregnant women)
• Urine analysis (dipstick) :

Positive results for nitrites (to detect what?), leucocytes
esterase (to detect what?) , WBCs, RBCs, and protein suggest
UTI.
Differential Diagnosis
• Vaginitis
• Cervicitis
• PID
• Gonorrhea
Are you ok or blur ?
COMPLICATION
 UTIs are associated with risks to both the fetus and
the mother
* pyelonephritis
* preterm birth
* low birth weight
* increased perinatal mortality
Treatment
• Medical care :
1) Oral antibiotics are the treatment of choice for asymptomatic
bacteriuria (ASB)x3 days and cystitis x7 days.
* A test-for-cure urine culture should show negative findings 1-2
weeks post-therapy
2) Standard course of treatment for pyelonephritis is admission with

intravenous antibiotics.
3) Manage fever with antipyretics (eg, acetaminophen).

Manage nausea and vomiting with antiemetics.
Medication
• Asymptomatic patients : 7-10 days regimen
(cephalexin 500 mg qid, ampicillin 500 mg qid,
nitrofurantoin 100 mg bid, or sulfisoxazole 1 g qid. )
• Acute pyelonephritis : systemically treated with

cephalosporins or gentamicin
• Tetracyclines (adverse effects on fetal teeth and

bones, congenital defects), quinolones (various
congenital defects)
Prevention
• Drink 6-8 glasses of water each day and eliminate refined foods,
fruit juices, caffeine, alcohol, and sugar.
• Take Vitamin C (250 to 500 mg), Beta-carotene (25,000 to

50,000 IU per day) and Zinc (30-50 mg per day) to help fight
infection.
• Develop a habit of urinating as soon as the need is felt and empty

your bladder completely when you urinate.
• Urinate before and after intercourse.
• Avoid intercourse while you are being treated for an UTI.

• After urinating, blot dry (do not rub), and keep your genital area clean. Make sure you wipe from the front toward the back.
• Avoid using strong soaps, douches, antiseptic

creams, feminine hygiene sprays, and powders.
• Avoid wearing tight-fitting pants.
• Don't soak in the bathtub longer than 30

minutes or more than twice a day.
Thank You For Sincerely Paying Attention…

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I would like to tell you something…Will you listen to

• massive dilatation of renal calyces and ureter.

• By 2nd trimester, there is increased renal blood flow

if there is persistent 1+ proteinuria (30mg/dL), a 24 hour urine

• In the absence of preeclampsia, when the 24 hour urine protein

• The excretion of glucose may present up to 20-100 mg/day. Why?

• There is a vesicoureteral reflux seen in pregnancy.

i] presence of at least 100,000 organisms/mL of urine in an

ii] as more than 100 organisms/mL of urine with

can be lower/upper UTI

• Pregnant women are at increased risk for UTI's

The ureters undergo tonic relaxation because of the mass production of

can lead to dilatation of the ureters and the calyceal pelvis.

Urinary stasis and the presence of vesicoureteral reflux predispose some

• Common symptoms: Suprapubic pain, urgency, frequency and

Mucopurulent cervicitis usually co-exists.

• Haematuria/pyuria are present.

• If symptoms are present but urine are STERILE, the agent

• In contrast to non pregnant, acute pyelonephritis in

• Cx: Septic shock, renal abscess and renal vein

• Presents as high fever + loin pain + vomiting + rigors .

• Dysuria pyuria + bacteriuria are present.

• Most cases are bilateral or right sided. Why?

• ~15% of APN also have bacteraemia.

• Moderate Cx: -PROM

• Severe Cx: -Perinephric cellulitis or abscess

• Perineal discomfort in postpartum period due to

• Bladder insensitivity to increased urinary tension in

• Catheterization due to overdistension.

• More frequent intercourse.

• A history of diabetes, sickle-cell anemia, stroke, kidney stones

• Pregnancy increases your risk for developing a UTI.

• Use of contraceptives such as diaphragms, condoms exposure

• Waiting too long to urinate.

• Decrease host defences (immunosupp, DM)

• Urinary tract: obstruction; stones; catheter;

• CYSTITIS : Patients may have suprapubic

• Group B Streptococcus (10%) (Quite rare, but has

• Klebsiella or Enterobacter species (3%)

• Proteus species (2%)

• GBS is found to be the causative organism in UTIs in

• It is unclear if GBS bacteriuria is equivalent to GBS vaginal

• Urine C&S : Culture results can be used to identify specific

• Urine analysis (dipstick) :

2) Standard course of treatment for pyelonephritis is admission with

3) Manage fever with antipyretics (eg, acetaminophen).

• Acute pyelonephritis : systemically treated with

• Tetracyclines (adverse effects on fetal teeth and

• Take Vitamin C (250 to 500 mg), Beta-carotene (25,000 to

• Develop a habit of urinating as soon as the need is felt and empty

• Urinate before and after intercourse.

• Avoid intercourse while you are being treated for an UTI.

• Avoid using strong soaps, douches, antiseptic

• Avoid wearing tight-fitting pants.

• Don't soak in the bathtub longer than 30

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