UTIs in pregnancy is common and a serious cause of maternal and perinatal morbidity and mortality. Clinical presentations include asymptomatic bacteriuria , acute cystitis and pyelonephritis

1. UTIs in Pregnancy
Presenting by
Dr. MD. ZOHIR UDDIN
Intern doctor, CIMCH

2. What is UTI…?
 Any infection anywhere along the urinary
system is known as UTI
 Urinary system consists of
• 2 Kidneys
• 2 Ureters
• Bladder
• Urethra
Upper urinary tract
Lower urinary tract

3. Anatomy of Urinary System

4. Which gender is more prone to UTIs
and Why…?

5. FEMALE(About 14 times more frequent)
And this is due to some female anatomy
These are…

6. 01.Female urethra is more
and
than male
Shorter Straighter

7. 02.Female urethral meatus close
proximity to Vulva and Vagina
 That is why lower 1/3rd of urethra is continually
contaminated with pathogens from the Vagina and
rectum as well
03.Urogenital system is exposed to
bacteria during intercourse

8. Among female who are more prone to
UTIs and Why…?

9. The answer is…
PREGNANT WOMEN
This is due to some physiological changes
in the urogenital system that take place
during pregnancy

10. These changes are…
01.Dilatation of ureters and renal
pelvis mostly at Six weeks of
gestations due to Progesterone
related smooth muscle relaxation

11. 02.Gravid Uterus
UTIs
Multiplication of Bacteria
Stasis of urine in the bladder as well as in the ureters also
Its increased weight can block the drainage of urine from the bladder
Uterus grows during pregnancy
Uterus sits directly on top of the bladder

12. 03.Immunocompromised state
Pregnancy is the state of
relative immunocompromise
which may lead to UTIs

13. Other physiological changes in urinary
systems during pregnancy are…
In KIDNEYs
 Increase size of kidneys approximately by
1.5 cm
 Increase GFR and renal blood flow

14. In URETERs
 Growing uterus compresses and laterally
displaces the ureters at pelvic brim leads to
hydroureter and some time sometimes
obstructive nephropathy

15. In BLADDER
 Marked thickening of bladder trigone
due to persistent pressure of gravid
uterus leading to Vesico-ureteral
refluxes causing ascending Urinary
tract infections

16. Difficult hygiene due to a
distended pregnant belly is also
one of the cause of increase
incidence of UTIs in pregnancy

17. Etiopathogenesis
 E.Coli (~70%)
 Klebsiella Pneumoniae (~10%)
 S. aureus (up to 8%)
 Coagulase-negative Staphylococcus
(up to 15%)
 Group B streptococci (GBS) (2–7%).

18. Predisposing factors
 P/H/O UTI (increases the chance by 50%)
 Presence of ASB (Increases the chance by 25%)
 Abnormality in the renal tract is found in about
25%
 Primi gravida
 Dextrorotation of gravid uterus causing
compression right ureter.
 Low socioeconomic condition
 Diabetes
 Sickle cell anaemia

19. Types of UTI in pregnancy
UTI can occurs as 3 types:
1) Asymptomatic Bacteriuria
2) Acute Cystitis
3) Acute Pyelonephritis

20. EPIDEMIOLOGY
 • Asymptomatic Bacteriuria 2-10%
 • Acute Cystitis 1 – 4%
 • Acute Pyelonephritis 0.5% - 2%
• 2% during 1st trimester
• 52% during 2nd trimester
• 46% during 3rd trimester

21. Though, incidence of bacteriuria in
pregnant women is only slightly higher
than nonpregnant women, the chances
of progression to pyelonephritis is
significantly higher i.e. 40%

22. CLINICAL PRESENTATION
 The most common form of UTI in pregnancy is
Asymptomatic Bacteriuria.
(It is caused by E.coli in over 90% of all ASB)
However, it may also present as Acute Cystitis or
Acute Pyelonephritis after an untreated primary
Asymptomatic Bacteriuria.

23. ASYMPTOMATIC BACTERIURIA
 When a bacterial count of same species over 105
CFU/mL in mid stream clean catch urine on Two
occasions is detected without symptoms of urinary
infection this is known as ASB
Or ≥ 102 CFU/ml in urine collected from single urinary
bladder catheterization

24. SCREENING
Recommend screening for bacteriuria at the
first prenatal visit or at 12 weeks, whichever
is earlier.
SIGNIFICANCE
If asymptomatic bacteriuria is not treated,
approximately 40 percent of infected women
will develop symptomatic infection during
pregnancy.

25. ACUTE CYSTITIS
• Acute cystitis affects
approximately 1% of all pregnant
women.
• Acute cystitis in pregnancy
almost always result from
ascending infection in long
standing asymptomatic
bacteriuria.

26. SYMPTOMS OF ACUTE CYSTITIS
• Dysuria
• Frequency
• Urgency
• Suprapubic pain in the
absence of systemic illness
• Haematuria

27. ACUTE PYELONEPHRITIS
• It is the most common serious medical
complication of pregnancy.
• Pyelonephritis was the leading cause of
septic shock during pregnancy.
• It occurs more on the right side(70-80%) compared
to the left (10-15%) and it is bilateral in a fourth of
cases.
(Pyelonephritis is caused by E.coli in about
70-80% cases)

28. SIGNS AND SYMPTOMS
 Symptoms
• Aching pain in one or both loins, often
radiate to the groin
• Fever with chills and rigor followed by
hypothermia
• Anorexia
• Nausea and vomiting
•Myalgias

29. Signs
•Patient may look toxic
•Raised temperature
•Tachycardia
•Renal angle tenderness

30. REMEMBER
Upper UTIs mostly associated
with FEVER where as Lower UTIs
usually not so

31. INVESTIGATIONS
 Urine routine and microscopy
(Presence of pus cell 5>/high power
film)
 Urine for culture and sensitivity test
(Gold Standard)
 Complete blood count with ESR
 Blood culture (If fever is associated
with Chills and rigor)
 Dipstick culture technique

32. The diagnostic gold standard in
pyelonephritis is renal biopsy but this is
impractical in clinical practice.

33.  Dipstick testing for nitrites & leukocyte esterase
in the evaluation of asymptomatic bacteriuria:
 Sensitivity: 50% to 92% and
 Specificity: 86% to 97%.

34. Don’t forget,
Proper Midstream clean
catch urine must be ensure
to do Urine R/M/E and C/S
test to get correct
investigation result

35. Midstream clean catch:
With one hand, spread the labia With the other hand,
use a castile soap–moistened towelette to wipe the
urethral meatus downward toward the rectum, then
discard the towelette, Void the initial portion of the
bladder contents into the toilet Catch the middle
portion of the bladder contents in the sterile
collection container, while keeping the labia spread
with the first hand

36. MANAGEMENT

37. Treatment of ASYMPTOMATIC BACTERIURIA
Oral antibiotics are the treatment of
choice for asymptomatic bacteriuria
and cystitis.
The antimicrobial agents should be
appropriate to the mother and fetus

38.  Nitrofurantoin 100mg twice daily
 Cefuroxime 250 or 500mg twice daily
 Amoxicillin 500 mg three times daily
 Ampicillin 250 mg four times daily
 Ciprofloxacin 250 mg twice daily
 Any of the following drugs can be
prescribed for 10-14 days

39. FOLLOW UP of ASYMPTOMATIC
BACTERIURIA
 • All pregnant women with ASB should have
periodic screening after therapy , since as
many as one third of them experience a
recurrent infection.
 • Follow-up cultures should be obtained 1–2
weeks after treatment and then repeated
once a month.

40. MANAGEMENT OF PERSISTENT
RECURRENT BACTERIURIA
 Nitrofurantoin 50–100 mg at
bed time until the end of the
pregnancy. *

41. Management of ACUTE CYSTITIS
Plenty of fluid intake:
• Increasing oral fluid intake is frequently
advocated as a first-line treatment for
pregnant women with features of
symptomatic urinary infection
Bed rest
Frequent voiding

42. Appropriate antibiotic according to
culture and sensitivity
Empirical treatments are
Nitrofurantoin 100mg BD for 7-10 days
Cefuroxime 250mg BD for 7-10 days
Urine alkalinising agents may also be
used

43. Management of ACUTE PYELONEPHRITIS
Hospitalize the
patient.
Obtain urine and
blood cultures.
Evaluate hemogram,
serum creatinine and
electrolytes.

44. Cont…
 Monitor vital signs frequently, including
urinary output—consider indwelling catheter
if needed (because catheterization is one of
the leading cause of UTIs)
 Establish urinary output ≥ 50 mL/hr with
intravenous crystalloid solution.

45. Cont…
 Administer intravenous antimicrobial
therapy
 Change to oral antimicrobials after the
patient is afebrile for 24 hours
 Repeat urine culture 1 to 2 weeks after
antimicrobial therapy completed

46. Cont…
 Nonsteroidal anti-inflammatory drugs (NSAIDs)
can be added for symptomatic relief.
 Thromboprophylaxis should be used if the
woman has reduced mobility or a period of
bedrest.
 Tocolysis is frequently necessary.
 Antenatal steroids for fetal lung maturity should
be considered if there is evidence of threatened
preterm labor

47. ANTIMICROBIAL OF CHOICE in Pyelonephritis
Antimicrobial should be given according to culture and
sensitivity report
Before getting report Empirical treatment must be started

48. COMPICATION

49. FETAL complications
Increase risk of fetal loss due to
 Abortion
 Preterm labor
 IUD
 IUGR
 Low birthweight
 Developmental delay/mental retardation
 Perinatal mortality

50. MATERNAL complications
Anaemia
Septicemia
Septic shock
Renal Dysfunction
Pulmonary insufficiency

51. PREVENTION
Drinking plenty of safe water to
stay hydrated (at least 3-4 liters)
Maintaining local hygiene
Emptying of bladder frequently,
specially before and after sex

52. Conclusion
 UTI in pregnancy is common and a serious
cause of maternal and perinatal morbidity
and mortality.
 Clinical presentations include
asymptomatic bacteriuria, acute cystitis
and pyelonephritis.
 Screening urine culture at 1st visit or at 12
weeks of Pregnancy

53. CONCLUSION
When choosing an antimicrobial, the
pharmacokinetics and bioavailability of
the individual drug in pregnancy must be
considered along with the resistance
profiles of microorganisms.
Simple behavioural changes and
continuous antibiotic prophylaxis can
prevent recurrence of UTI in pregnancy.

54. Be sure to take the
recommended full course even if
patient start feel better midway
through treatment