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SYMPTOMATIC URINARY TRACT INFECTIONS DURING PREGNANCY

Subudhi K B, Behera Susanta Kumar, Subudhi Monalisha, Das Sudhansu Kumar,Jena Soubhagya Kumar

Department of Obstetrics and Gynecology, MKCG Medical College, Berhampur, Orissa

ABSTRACT

Objectives: to find out the obstetric outcome symptomatic urinary tract infections in pregnancies

and type of organisms responsible for symptomatic UTI and response to treatment in those

patients. Materials & Methods: Patients with symptoms (n=100) subjected urine culture and

sensitivity and colony count. The antibiotic which is relatively safe during pregnancy, depending

upon sensitivity is implicated for that particular patient. 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. Results: Common age group affected is

21-30 yrs (83%), primigravida (66%) of ‘O’ group(77%) and low SES(53%). Most of them

presented with frequency of micturition, dysuria (81%) in 3rd trimester (60%). Among all women

66% are terminated in 28-37 wks, vaginally (82.7%) and most common organism isolated is E

coli (69%).63% women delivered babies within 2-2.5 kg, preterm contraction (22%), and

neonatal asphyxia (27%), Breast complications (15%), LBW (80%), Prematurity (60%).

Conclusion: Symptomatic urinary tract infections in pregnancy should be diagnosed and treated

early.

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.1,2

A significant bacteriuria is the major risk factor for developing symptomatic urinary tract

infection during pregnancy leading to hypertension, preeclampsia, LBW, fetal wastage and

prematurity. UTI in pregnancy can take the forms of asymptomatic bacteriuria, acute

uncomplicated cystitis, urethritis, pyelonephritis.3 The organisms responsible for producing UTI

in pregnancy can be of following types:(a) Gram Negative : E.Coli in 80% of Cases, Proteus

Mirabilis, Klebsiella, (b) Gram Positive : Mycoplasma, Group-B Streptococus, Staphylococus

areus.4 Urinary tract infections are common in pregnancy due to increase susceptibility to certain

organisms, ureteral dilatation during pregnancy causing stasis of urine in the urinary tract leading

to more chance of infections. Most of the pregnant women develop glycosuria during pregnancy

which favours bacterial growth.5

MATERIAL 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. Patients

with symptoms (n=100) subjected for history taking and meticulous clinical examination

followed by urine culture and sensitivity and colony count. The organism isolated and the

sensitivity of antibiotic is taken into account. The safe antibiotic during pregnancy, depending

upon sensitivity is implicated for that particular patient in a standard regimen and response is

observed. She is subjected for urine culture and sensitivity within one week of completion of

antibiotic course. If the pregnant women is cured of the infection as evidenced by both clinical

and 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. Within

one week of completion of second course of antibiotic she is evaluated for cure, both

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symptomatic and bacteriological. If she is not being cured she is subjected for reculture and

retreatment.

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%, similar

to the study conducted by Lee M et al of highest in 3rd trimester of about 54% cases.7 Most of the

pregnancies, 66% are terminated in 28-37 wks, similar to the study of Winberg J et al reporting

28-37 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 by

Rahman MA et al revealing E Coli(75%) and Staphylococcus(15%).9 85% are not presented in

labor, among which 63% are without preterm contraction, majority and 37% with preterm

contraction. It is similar to Kass EH et al revealing, majority (70%) of without preterm

contraction.10 Here 9% cases were presented in labor. Majority, 92% of cases are having colony

count > 105 CFU per ml, 6% of 102 to 104 CFU per ml and 2% of cases have less than 102

CFU/ml or no growth found over 48 hrs of incubation. It is not coinciding to the study of

Onifade AK, et al revealing 98% of > 105 CFU/ml and 2% of < 105 CFU/ml.11

Table-I : Antepartum complications

Sl No Ante Partum Complications No of Cases %

1 Anemia (< 7 gm %) 4 4

2Leaking of Membrane

13 13

3Preterm Contraction

22 22

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% of

cases 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% of

2-2.5 kg where as < 2 kg in 22% cases and > 2.5 Kg in 20% cases.12

Table-II : Intrapartum complications Table-III : Postpartum complications

Sl No

Intra Partum Complication

No of Cases

%Sl No

Post Partum Complication

No of Cases

%

1 Fetal Distress 4 4 1 PPH 2 2

2Neonatal Asphyxia

27 27 2 Puerperal Pyrexia 6 6

3 PPH 4 4 3Breast

Complications15 15

4 Eclampsia 1 1 4 Pyelonephritis 1 1

5Instrumental

Delivery8 8 5 Anemia (< 7 gm %) 6 6

6Non Progress of

Labor1 1 6

Chronic Hypertension

1 1

Table-IV : Fetal complications Table-V : Sensitivity of antimicrobials

Fetal Complications

No of Case

% AgentE.

ColiKlebsiella

Pseudomonas

Proteus Candia

Abortion 2 2 Nitrofurantoin MS WS R WS NA

Prematurity 66 66 Amoxicillin MS SS R SS NA

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Low Birth Weight

80 80 Cefuroxime MS SS MS WS NA

IUGR 17 17 Amox+Clav SS SS SS SS NA

IUD 3 3

Fluconazole NA NA NA NA SS

Pip+Tazo SS SS SS SS NA

Among fetal complications, low birth weight is the most common (80%), followed by

prematurity (66%) (Table-IV). Similar study conducted by Brumfitt et al showed low birth

weight (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 al

revealing 57% of SGA, 40% of AGA and 3% of LGA.13The commonest ante partum

complication detected in this study is preterm contraction (22%) which is similar to study of

Naeye 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 postpartum

complication is highest as breast complications (15%), followed by puerperal pyrexia (6%). It is

not similar to the study of Naeye RL et al which revealed that commonest postpartum

complication 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

revealing most common mode of delivery as vaginal in 75% of cases & LSCS in 25% of cases. 16

Pre labor rupture of membrane is highest (47%) which is not similar with that of Valiquette et al

revealing 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,

Amoxicillin+Clavulunic acid and Piperacillin+Tazobactm Proteus species is strongly sensitive

(SS) to Amoxicillin, Amoxicillin+Clavulunic acid and Piperacillin+Tazobactam. Pseudomonas is

strongly sensitive (SS) to Amoxicillin+Clavulunic acid and Piperacillin+Tazobactum. All the

Candida species is strongly sensitive (SS) to Fluconazole (table-VI). It is similar to that of M R

Khatoon et al except that E Coli is strongly sensitive to Cefuroxime. Pseudomonas is weakly

sensitive to amoxicillin.

CONCLUSION

So any evidence of symptomatic urinary tract infection during pregnancy should be

diagnosed as early as possible by urine culture and to be treated judiciously to prevent and

improve maternal and perinatal outcome of every pregnancy.

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