CC JUANICO, CLAREEN MAE 17/07/2020

UTI IN PREGNANCY

Urinary tract infection can be defined as the translocation of normal bacteria of the periurethral
area to the sterile areas of the urinary tract namely, kidneys,, bladder and the ureters. Aside from the
ascension of organisms to this sterile organs, it can also invade the blood stream and the lymphatic
drainage. It is more likely to occur in women due to the following reasons: females have very short
urethra as compared to males; the urethra is contiguous to vagina and anus, during sexual intercourse
there is direct inoculation of bacteria from other surfaces towards the urethra; and distance of anus to
urethra is shorter in females than males. If a woman is pregnant, likelihood of UTI to occur increases as
there are structural changes in the urinary tract. These changes include the following: kidneys increase
in size, marked dilatation of the renal calyces during mid-pregnancy, vesicoureteral reflux occurs,
intrarenal vasodilatation and serum creatinine and urea decreases. Predisposing factors in UTI in
pregnancy are previous UTI, recent sexual activity, DM, obesity congenital anomalies and urinary tract
canaliculi.

Organisms causing UTI in pregnancy are the same uropathogens causing UTI in non-pregnant
patients. Escherichia coli is the most common organism isolated. UTI can be categorized as
Uncomplicated or complicated. It has 3 common clinical manifestations of UTIs in pregnancy are:
asymptomatic bacteriuria, acute uncomplicated cystitis and acute uncomplicated pyelonephritis. All
pregnant women should be screened for ASB and should be given antibiotic immediately without delay.
UTI is always considered in pregnancy. The gold standard in diagnosing UTI is urine culture and
sensitivity. Urinalysis is not highly recommended as a standalone modality.

Asymptomatic Bacteriuria is the most common presentation of UTI during pregnancy. This is
usually discovered during prenatal care. There is persistent active multiplication of bacteria with the
urinary tract of the asymptomatic patient. As its name suggests, patients has no symptoms indicating
infection. ASB in pregnancy is the presence of growth of > 100,000 CFU/ml of the same uropathogen on
2 consecutive midstream urine specimens. As mentioned in the conference, any value below this with
the patient being asymptomatic does not warrant the provision of antibiotics to pregnant patients. But
if the patient is symptomatic and growth is >10 000CFU/mL, antibiotics should be given already. UTI in
pregnancy is diagnosed by using standard urine culture of clean-catch midstream urine which is the test
of choice (gold standard) in screening for ASB. It is highly recommended that screening of ASB should be
done to all pregnant women once, between the 9th to 17th weeks AOG (preferably on the 16th week of
gestation). This is for the reason that early diagnosis is important to prevent further complication not
only to the pregnant woman but also to her developing child. ASB if not detected early may increase
chance of developing Acute Cystitis by 40% and may further develop to Acute Pyelonephritis by 25 to
30%. If not treated, UTI may result to increase incidence of maternal hypertension, pre-eclampsia and
anaemia. Negative effects on the developing child are of Low Birth weight, intra uterine growth
retardation and preterm delivery. Neonates may also harbour bacteria from an untreated mother that
would result to sepsis or long term sequelae of infection such as failure to thrive. ASB should be
monitored monthly or at 24 weeks and 32 weeks AOG. Aggressive treatment via use of antibiotics
(Nitrofurantoin is the drug of choice) should immediately done to avoid further infection.

Acute uncomplicated cystitis as mentioned above is developed if ASB is not detected early. It is
characterized by urinary frequency, urgency and dysuria and bacteriuria without fever. Gross or
microscopic hematuria may also be present; suprapubic tenderness on palpation or tingling may also be
elicited. Suspected patients having acute uncomplicated cystitis should get pre-treatment-urine culture
and sensitivity test of midstream clean-catch specimen. If not possible, urinalysis of centrifuged and
uncentrifuged urine is requested. Result would reveal presence of significant pyuria: > 8 pus cells/mm3
of uncentrifuged urine; > 5 pus cells/hpf of centrifuged urine and (+) leukocyte esterase and nitrite test.
Once confirmed antibiotics instituted immediately to prevent acute pyelonephritis. Single dose therapy
of antibiotics against E. coli (most common organism to be isolated) is highly recommended. As
mentioned in the conference, drug of choice is 3rd generation of Cephalosporins.

Acute uncomplicated pyelonephritis, most common serious medical complications of pregnancy is

characterized by abrupt onset of fever (temp > 38 °C), shaking chills, flank pain with or without signs of
lower UTI, and a physical finding of costovertebral angle tenderness. To diagnose acute pyelonephritis,
urinalysis and Gram stain (uncentrifuged urine to differentiate gram (+) from gram (-) bacteria) are
recommended. Gram stain of Urine culture and sensitivity should also be performed routinely to
facilitate cost-effective use of antimicrobial agents. Results of laboratory findings include pyuria (>5
WBC/HPF of centrifuged urine) on urinalysis and bacteriuria with counts of > 10,000 CFU/mL on urine
culture. CBC leukocytosis with left shift can also be noted. Patients are admitted if: patient is unable to
maintain oral hydration; concern regarding compliance; presence of possible complicating conditions;
severe illness with high fever; severe pain; and if there are signs of preterm labor and sepsis. Treatment
regimen for this is IV antibiotics for 24-48 hrs. If patient becomes afebrile and costovertebral angle
tenderness has disappeared, oral antibiotics should be continued for 7- 14 days. Post treatment urine
culture are obtained after completion of antibiotic treatment to confirm resolution of the infection.
Patient is also followed up for symptoms of recurrent infection and monthly urine cultures should be
performed until delivery.

It is important to detect UTI in pregnant women as early as possible to prevent further

complications not only to the mother but to the new born.