Symtomatic urinary tract infections during pregnancy


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Symtomatic urinary tract infections during pregnancy

  1. 1. 1 SYMPTOMATIC URINARY TRACT INFECTIONS DURING PREGNANCYSubudhi K B, Behera Susanta Kumar, Subudhi Monalisha, Das Sudhansu Kumar,JenaSoubhagya KumarDepartment of Obstetrics and Gynecology, MKCG Medical College, Berhampur, OrissaABSTRACTObjectives: to find out the obstetric outcome symptomatic urinary tract infections in pregnanciesand type of organisms responsible for symptomatic UTI and response to treatment in thosepatients. Materials & Methods: Patients with symptoms (n=100) subjected urine culture andsensitivity and colony count. The antibiotic which is relatively safe during pregnancy, dependingupon sensitivity is implicated for that particular patient. If she is not found to be cure ofsymptoms or bacteriological cure after a course of antibiotic, repeat urine culture done andaccording to sensitivity repeat course of antibiotic given. Results: Common age group affected is21-30 yrs (83%), primigravida (66%) of ‘O’ group(77%) and low SES(53%). Most of thempresented with frequency of micturition, dysuria (81%) in 3 rd trimester (60%). Among all women66% are terminated in 28-37 wks, vaginally (82.7%) and most common organism isolated is Ecoli (69%).63% women delivered babies within 2-2.5 kg, preterm contraction (22%), andneonatal asphyxia (27%), Breast complications (15%), LBW (80%), Prematurity (60%).Conclusion: Symptomatic urinary tract infections in pregnancy should be diagnosed and treatedearly.INTRODUCTION During pregnancy UTI is as high as 8% out of which 20% to 40% are symptomatic.Recurrence of UTI in subsequent pregnancy is about 4-5% and same is risk of pyelonephritis. 1,2A significant bacteriuria is the major risk factor for developing symptomatic urinary tractinfection during pregnancy leading to hypertension, preeclampsia, LBW, fetal wastage and
  2. 2. prematurity. UTI in pregnancy can take the forms of asymptomatic bacteriuria, acuteuncomplicated cystitis, urethritis, pyelonephritis.3 The organisms responsible for producing UTIin pregnancy can be of following types:(a) Gram Negative : E.Coli in 80% of Cases, ProteusMirabilis, Klebsiella, (b) Gram Positive : Mycoplasma, Group-B Streptococus, Staphylococusareus.4 Urinary tract infections are common in pregnancy due to increase susceptibility to certainorganisms, ureteral dilatation during pregnancy causing stasis of urine in the urinary tract leadingto more chance of infections. Most of the pregnant women develop glycosuria during pregnancywhich favours bacterial growth.5MATERIAL AND METHOD The present study was conducted in the Department of Obstetrics and Gynecology,MKCG Medical College, Berhampur, Orissa from October 2008 to November 2010. Patientswith symptoms (n=100) subjected for history taking and meticulous clinical examinationfollowed by urine culture and sensitivity and colony count. The organism isolated and thesensitivity of antibiotic is taken into account. The safe antibiotic during pregnancy, dependingupon sensitivity is implicated for that particular patient in a standard regimen and response isobserved. She is subjected for urine culture and sensitivity within one week of completion ofantibiotic course. If the pregnant women is cured of the infection as evidenced by both clinicaland bacteriological evidence, she is advised the methods of prevention of UTI during pregnancy.If she is not found to be cure of symptoms or bacteriological cure after a course of antibiotic,repeat urine culture done and according to sensitivity repeat course of antibiotic given. Withinone week of completion of second course of antibiotic she is evaluated for cure, both
  3. 3. 3symptomatic and bacteriological. If she is not being cured she is subjected for reculture andretreatment.RESULTS AND DISCUSSION It is most common in age group of 21-30 yrs (83%) of age and 66% in primigravida,77% in ‘O’ blood group, presented in 3-7 days in 76% and in low SES (53%). Maximum, 87%presented with frequency of urination which is almost in agreement with that of Nkudic et al,frequency in 80% of cases.6 It is highest in 3rd trimester of pregnancy accounting to 60%, similarto the study conducted by Lee M et al of highest in 3 rd trimester of about 54% cases.7 Most of thepregnancies, 66% are terminated in 28-37 wks, similar to the study of Winberg J et al reporting28-37 weeks is 77%8.E coli is isolated in majority (69%), followed by S. areus (18%),Pseudomonas(4%), Klebsiella(3%), Candida albicans(2%),Proteus(2%), similar result byRahman MA et al revealing E Coli(75%) and Staphylococcus(15%). 9 85% are not presented inlabor, among which 63% are without preterm contraction, majority and 37% with pretermcontraction. It is similar to Kass EH et al revealing, majority (70%) of without pretermcontraction.10 Here 9% cases were presented in labor. Majority, 92% of cases are having colonycount > 105 CFU per ml, 6% of 102 to 104 CFU per ml and 2% of cases have less than 10 2CFU/ml or no growth found over 48 hrs of incubation. It is not coinciding to the study ofOnifade AK, et al revealing 98% of > 105 CFU/ml and 2% of < 105 CFU/ml.11 Table-I : Antepartum complicationsSl No Ante Partum Complications No of Cases % 1 Anemia (< 7 gm %) 4 4 2 13 13 Leaking of Membrane
  4. 4. 3 22 22 Preterm Contraction 4 IUD 2 2 5 Multiple Pregnancy 1 1 Majority, 63% of pregnant women delivered low birth weight of 2-2.5 kg and 17% ofcases in < 2.0 kg implicating UTI as a significant contributor for this outcome. In this study 20%cases are resulted out as > 2.5 kg, concurrent to the study done by Laura A et al reflecting 68% of2-2.5 kg where as < 2 kg in 22% cases and > 2.5 Kg in 20% cases.12 Table-II : Intrapartum complications Table-III : Postpartum complicationsSl Intra Partum No of Sl Post Partum No of % %No Complication Cases No Complication Cases 1 Fetal Distress 4 4 1 PPH 2 2 Neonatal 2 27 27 2 Puerperal Pyrexia 6 6 Asphyxia Breast 3 PPH 4 4 3 15 15 Complications 4 Eclampsia 1 1 4 Pyelonephritis 1 1 Instrumental 5 8 8 5 Anemia (< 7 gm %) 6 6 Delivery Non Progress of Chronic 6 1 1 6 1 1 Labor Hypertension Table-IV : Fetal complications Table-V : Sensitivity of antimicrobials Fetal No of E. Klebsi Pseudo % Agent Proteus CandiaComplications Case Coli ella monas Abortion 2 2 Nitrofurantoin MS WS R WS NA Prematurity 66 66 Amoxicillin MS SS R SS NA
  5. 5. 5 Low Birth Cefuroxime MS SS MS WS NA 80 80 Weight IUGR 17 17 Amox+Clav SS SS SS SS NA Fluconazole NA NA NA NA SS IUD 3 3 Pip+Tazo SS SS SS SS NA Among fetal complications, low birth weight is the most common (80%), followed byprematurity (66%) (Table-IV). Similar study conducted by Brumfitt et al showed low birthweight (75%) and prematurity (62%) as 2nd most common complication.15. Most of the cases,62.3% are of appropriate for gestational age (AGA), 37.7% of cases are small for gestational age(SGA) and no case of large for gestational age (LGA) is detected. It is similar to Fihn SD et alrevealing 57% of SGA, 40% of AGA and 3% of LGA. 13The commonest ante partumcomplication detected in this study is preterm contraction (22%) which is similar to study ofNaeye RL et al (Table-I). Neonatal asphyxia (27%) is highest, followed by fetal distress (4%)indicating increased incidence of intra partum complications. (Table-II). The postpartumcomplication is highest as breast complications (15%), followed by puerperal pyrexia (6%). It isnot similar to the study of Naeye RL et al which revealed that commonest postpartumcomplication as puerperal pyrexia (21%) (Table-III).14Most common mode of delivery is vaginal(82.7%), followed by LSCS (17.3%). Almost Similar study was conducted by Patton JP, et al 16revealing most common mode of delivery as vaginal in 75% of cases & LSCS in 25% of cases.Pre labor rupture of membrane is highest (47%) which is not similar with that of Valiquette et alrevealing PROM > 24 hrs accounting for 15% of cases.17 E Coli is strongly sensitive (SS) to Amoxicillin+Clavulinic acid &Piperacillin+Tazobactum. Klebsiella is strongly sensitive (SS) to Amoxicillin, Cefuroxime,
  6. 6. Amoxicillin+Clavulunic acid and Piperacillin+Tazobactm Proteus species is strongly sensitive(SS) to Amoxicillin, Amoxicillin+Clavulunic acid and Piperacillin+Tazobactam. Pseudomonas isstrongly sensitive (SS) to Amoxicillin+Clavulunic acid and Piperacillin+Tazobactum. All theCandida species is strongly sensitive (SS) to Fluconazole (table-VI). It is similar to that of M RKhatoon et al except that E Coli is strongly sensitive to Cefuroxime. Pseudomonas is weaklysensitive to amoxicillin.CONCLUSION So any evidence of symptomatic urinary tract infection during pregnancy should bediagnosed as early as possible by urine culture and to be treated judiciously to prevent andimprove maternal and perinatal outcome of every pregnancy. 1) Patterson TF Androl VT. Bacteriuria in Pregnancy. Infect. Dis Clin North Am. 2007; 7; 1:807-22. 2) Foxman : Epidemiology of Urinary tract infections, Incidence; Am J Med 2002;113:5S- 13S 3) Kass EH: Pyelonephritis and Bacteriuria,a major complication in Preventive Medicine.N. Am J. Urol; 2004; 56:46-53. 4) Barr BJ, Ritche JW and Others , Microaerophilic/ Anerobic bacteria as a cause of urinary tract infections in Pregnancy, Br J Obst 7 Gyne :2005;92:506-10 5) Lucas MJ , Cunninghams Urinary Infections in Pregnancy, Clin Obst & Gyn: 2003; 36:855-68 6) NKUDIC et al. National Kidney and Urologic Diseases Information Clearing House: Urinary Tract Infections in Adults. NIH Publication2005; No. 06-2097
  7. 7. 77) Lee M, Bozzo P, Einarson A. Urinary tract infections in pregnancy. Can F. Ph. 2008;54: 853-48) Winberg J. Treatment trials in urinary tract infection (UTI) with special reference to the effect of antimicrobials or the fecal and periurethral flora. Clin. Nephrol 2003; 1:142-8.9) Rahman MA, Talukder SI, Khatoon MR Dinajpur et al. Med Col J ;2010 ; 3 (2):59-6210) Kass EH. Demographic and Prognostic characteristics of bacteriuria in pregnancy. N Am J Med. 2007;46:385-40711) Onifade AK. Incidence of UTIs among pregnant women attending antennal clinics in government hospitals in Nigeria. J. Food Agric. Environ. 3(1):2004: 37-38.12) Laura A. Schieve, MS, Arden Handler. UTI during Pregnancy ;Br J Obste Gynecol: 2004:32-2413) Fihn SD. Acute uncomplicated urinary tract infections in women. N Engl J Med, 2003; 349: 259-6614) Naeye RL. Urinary tract infections and the outcome of pregnancy. Adv Nephrol.2006; 15:95-10215) Brumfitt W. The effects of bacteriuria in pregnancy on maternal and fetal health. Int Kidney J.2005;8:S113-S11916) Patton JP et al. Urinary tract infection: Economic considerations. Med Cl Am 75 (2):2009: 495-513.17) Valiquette L. Urinary tract infections in women. Canadian journal of urology,2001, 8(1):6