Urinary tract infections are common in pregnancy and can cause complications for both mother and baby if left untreated. Screening and treatment are important. UTI in pregnancy includes asymptomatic bacteriuria, cystitis, and pyelonephritis. Escherichia coli is the most common cause. Risk factors include prior UTIs, poor hygiene, and medical issues. Treatment involves antibiotics and hydration. Complications of untreated UTI include preterm labor, low birthweight, and infrequent maternal issues like renal insufficiency. Prevention focuses on hygiene and screening high risk women.

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2.  INTRODUCTION
 CLASSIFICATION
 EPIDEMIOLOGY
 AETIOLOGY
 PATHOPHYSIOLOGY
 RISK FACTORS
 MANAGEMENT
 COMPLICATIONS
 PREVENTION
 CONCLUSION
 REFERENCES
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3.  Urinary tract infection (UTI) is the single
commonest bacterial infection of all age groups
and especially in pregnancy (Muhammad A et al; 2019)
 It describes microbial colonization or inflammation
of the urethra, bladder, or renal pelvis and kidneys
 Anatomical, physiological and mechanical changes
influence the occurrence, progress and outcome of
UTI
 Clinical diagnosis may be challenging since it is
usually mistaken for normal physiological changes
during pregnancy (Obiora CC et al 2014)
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4.  UTI in pregnancy includes
◦ Asymptomatic bacteriuria
◦ Urethritis
◦ Cystitis
◦ Acute pyelonephritis
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5.  UTI is defined as the presence of at least 100,000 organisms per
milliliter of urine in an asymptomatic patient, or as more than 100
organisms/mL of urine with accompanying pyuria (> 7 white blood
cells/mL) in a symptomatic patient (Kalinderi K. et al 2018)
 Significant bacteriuria : Defined as >100,000 bacteria of same
specie per ml of urine, present in 2 consecutive specimens.
 Cystitis involves only the lower urinary tract; it is characterized by
inflammation of the bladder as a result of bacterial causes.
 Acute cystitis is complicated by upper urinary tract disease (ie,
pyelonephritis) in 15-50% of cases. (Clinical obstetric by Eugene Okpere)
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6.  Anatomical location
 lower UTI
 upper UTI
 Symptoms
 Symptomatic UTI
 Asymptomatic UTI
 Degree of the disease
 Uncomplicated
 Complicated
 Recurrent UTI
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7.  An estimated 40% of women present with UTI at some
point in life, this doubles with pregnancy
 Asymptomatic bacteriuria (ASB) occurs in 2 to 7% of
pregnant women (Fournié A, et al 2008; Société de Pathologie Infectieuse de
Langue Française. 2015)
 Without treatment, as many as 20 to 30% of
pregnant women with ASB will develop a
symptomatic UTI during pregnancy (Smaill FM et al 2015; Wing
DA et al 2014)
 Prevalent rate of UTI in pregnancy was found to be
31% in Ogun state( ochei john et al 2018 Microbiology research journal)
 UDUTH prevalence of ASB is 7.8% (unpublished 2019)
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8.  Prevalence of Symptomatic UTI in pregnant
women was found to be 1-18%
 Estimated incidence of acute pyelonephritis
during pregnancy is 0.5 to 2% (Wing DA et al 2014; Société de
Pathologie Infectieuse de Langue Française. 2015)
 UTI accounted for 14.6% and 15.8% of the
pregnant women in a hospital based research in
Enugu and Kano respectively (Muhammad A et al; 2019; Obiora
CC et al 2014)
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9.  Uncomplicated;
 80-90% - Escherichia coli (E. coli)
 10-20% - proteus, klebsiella, enterococcus, group B
Streptococcus and Staphylococcus species
 Complicated;
• 10-20% - E. coli
• 80-90% - proteus, klebsiella, enterobacter,
serratia, pseudomonas, enterococcus,
staphylococcus epidermidis, staphylococcus
aureus.
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10.  Virulence factors of uro-pathogenic E.coli
◦ Urotoxins
◦ Adhesins- pili and fimbriae
◦ Polysaccharide capsule
◦ Invasins
◦ Haemolysin
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11. 11

12.  Length of kidneys increase by 1-1.5cm with
proportional increase in weight.
 Dilatation of the renal calyces and pelves with the
volume of the renal pelves increased by about 6-fold
compared to the non-pregnant state.
 Ureters elongate, widen and become more curved.
 The entire dilated collecting system may contain about
200ml of urine, which predisposes to ascending UTI.
 Physiological proteinuria and glycosuria promote
microorganism growth in the urine of pregnant woman
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13.  Faecal flora  periurethral zone  urethra
 Infection of urethra  bladder  cystitis
 Bladder infection moves up  ureters
into the kidney
 Inter play of three factors contributes to the
development of UTI in pregnancy namely;
 Hormonal
 Mechanical
 Hypertrophy
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14.  Progesterone;
◦ smooth muscles relaxation of the whole tract
◦ dilatation of the pelvis & ureter
◦ vesico-ureteric reflux
◦ stasis of urine
◦ predispose to infection
 The immunomodulatory effect of Progesterone
may reinforce the above process
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15.  The gravid uterus:
◦ Bladder wall gets pushed superio-anteriorly into the
abdomen :
  intravesical pressure  urine stasis
  frequency of urination, urgency, nocturia
◦ Ureters at pelvic brim obstruction of the calyces and
renal pelvis  obstruction of the ureters
hydronephrosis & hydro-ureter.
◦ Pressure effect more on the right due to dextro rotation
of the gravid uterus.
◦ The dilatation appears to begin at about 8weeks
gestation, increases throughout pregnancy, resolving at
about 6 to 12 weeks postpartum.
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16.  Functional Hypertrophy:
◦  Renal Blood Flow up to 80%
◦  GFR by 40%
◦ Glycosuria and aminoaciduria- due to altered renal
threshold and filtration by the kidneys
  RBF & GFR  tubular re-absorption  loss of
glucose, amino-acids…etc  Na and fluid retention
16

17.  Poor hygiene
 Low socio-economic status
 Multiparity
 Genitourinary pathology
 Medical conditions (SCA, DM, HIV)
 Increasing Age
 Past history of UTI
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18.  Defined as the presence of actively multiplying
bacteria in the urinary tract excluding the distal
urethra in a patient without any obvious symptoms.
 Diagnosis is by isolation of bacteria organism with
a colony count of >10^5 organisms per ml of urine
in a clean catch specimen
 Untreated 40% will develop symptoms of UTI
 About 25 – 30% will develop acute
pyelonephritis, but with treatment the rate is
only 10%
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19.  It is defined as significant bacteriuria with
associated bladder mucosal invasion presenting
as urgency, frequency, dysuria, pyuria and
haematuria without evidence of systemic
illness.
 Urine may be cloudy and malodorous and
should be cultured
 Has similar causative agents as asymptomatic
bacteriuria- E.coli implicated in almost 80% of
cases
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20.  It is defined as significant bacteriuria with
associated inflammation of the renal
parenchyma, calyces and pelves
 Usually follows asymptomatic bacteriuria
 Maternal effects include fever, toxic shock,
renal insufficiency, anemia
 Preterm labour and fetal death can occur in
severe cases
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21.  HISTORY
 EXAMINATION
 TREATMENT
21

22.  Asymptomatic
 Urethritis:
Dysuria
urethral discharge.
 Cystitis:
Frequency of micturition
Supra-pubic pain/discomfort
Urgency
Pyuria
 Pyelonephritis:
Fever with chills
Flank pain
Nausea / vomiting
Haematuria
Cloudy urine
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23.  On examination, there may be;
◦ Painful distress
◦ Pallor
◦ Febrile
◦ Tachycardia
◦ Features of shock
◦ Supra-pubic tenderness
◦ Renal angle/flank tenderness
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24.  Urine Culture and sensitivity; A mid stream specimen
of urine collected in a sterile manner is used
 Periodic cultures for screening should be performed
in women with
◦ recurrent UTI
◦ urine dipstick suggesting bacterial growth (e.g.,
positive nitrite) (Rakel E. R. 2014)
 On-site midstream urine Gram-staining is
recommended over the use of dipstick tests
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25.  Urine examination (microscopy):
◦ White blood cell casts
◦ RBC
◦ Pus cell
 Urinalysis
◦ Proteinuria
◦ Glycosuria
◦ Blood
◦ Nitrite
◦ Leukocytes
 Full blood count
 Renal function test – EUCr
 Ultrasound scan- Renal and obstetric 25

26.  Adequate hydration
 Analgesia
 Antibiotics
 Prevention
26

27.  ASYMPTOMATIC BACTERIURIA/CYSTITIS
 Hydration
 Antibiotics:
 Provide a seven day antibiotic regimen for pregnant
women with ASB to prevent persistent bacteriuria
(WHO 2016)
 Oral antibiotics is the treatment of choice for
ASB and cystitis (Ampicllin, Amoxicillin, Amoxicillin-
Clavulanate, Nitrofurantoin)
 A test for cure-urine-culture should show
negative findings 1-2 weeks post therapy 27

28.  PYELONEPHRITIS
 Treatment should be more aggressive
 Admit to hospital
 Rehydration.
 Antibiotics:
 Empirical treatment with IV antibiotics
 Types of Antibiotics given:
 Amoxicillin-Clavulanate
 3rd generation cephalosporins
 Switch to oral 48 hours after being afebrile
 Repeat culture after 2 weeks, because of risk of
persistence
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29.  25% of patients with mild acute pyelonephritis who
are pregnant have a recurrence
 These patients should have monthly urine cultures
or antimicrobial suppression with oral
nitrofurantoin 100 mg/day, until 4 to 6 weeks
postpartum (Rakel E. R. 2014)
 Recommended therapy in recurrent UTI is by
antibiotics prophylaxis throughout pregnancy
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30.  Relapse is the recurrence of bacteriuria
caused by the same organism, usually within
6 weeks of the initial infection
 Reinfection is the recurrence of bacteriuria
involving a different strain of bacteria after
successful eradication of the initial infection.
 Reinfection usually occur more than 6 weeks
after treatment and in most patients are
limited to the bladder.
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31.  MATERNAL
Preterm labor
PROM
Chorio-amnionitis
Maternal anemia
Renal insufficiency
Bacterial endotoxic shock
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32.  FETAL
Prematurity
Low birth weight
Increase perinatal morbidity
Fetal loss
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33.  Drink about 8-10 glasses of water per day (3L)
 Drink juice/ eat fruits (acidification of urine)
 Use liquid soap instead of bar soap to prevent
colonization
 Good perineal hygiene
 Avoid wearing tight jeans and wet panties.
 Screening of patients especially the high risk ones at
ANC
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34.  UTI in pregnancy is associated with
significant morbidity for both mother and
baby.
 Early detection and treatment with antibiotics
will significantly reduce complications
associated with UTI
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13. Clinical obstetric by Eugene Okpere
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15. presentation by dr wakawa Y.S delivered in department O&G FMC Birnin kebbi 2020
16. Lecture by dr Loto o.m
17. Medscape
18. Comprehensive obstetrics in the tropics
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36. THANK YOU
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