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Urinary Tract Infections in Pregnancy Clinical Presentation

  • Author: Emilie Katherine Johnson, MD, MPH; Chief Editor: Edward David Kim, MD, FACS  more...
 
Updated: Jul 24, 2016
 

History

The presentation varies according to whether the patient has asymptomatic bacteriuria, a lower urinary tract infection (UTI; ie, cystitis) or an upper UTI (ie, pyelonephritis).

Burning with urination (dysuria) is the most significant symptom in pregnant women with symptomatic cystitis. Other symptoms include frequency, urgency, suprapubic pain, and hematuria in the absence of systemic symptoms. The usual complaints of increased frequency, nocturia, and suprapubic pressure are not particularly helpful, because most pregnant women experience these as a result of increased pressure from the growing uterus, expanding blood volume, increased glomerular filtration rate, and increased renal blood flow.

Pyelonephritis symptoms on presentation vary. They often include fever (>38°C), shaking chills, costovertebral angle tenderness, anorexia, nausea, and vomiting. Right-side flank pain is more common than left-side or bilateral flank pain. Patients may also present with hypothermia (as low as 34°C). Lower UTI symptoms are common but not universal.

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Physical Examination

During the physical examination, the findings should be considered in relation to the duration of pregnancy. The differential diagnoses may change from one trimester to the next, and the increasing size of the gravid uterus may mask or mimic disease findings. A thorough physical examination is recommended, with particular attention to the abdomen. Suprapubic or costovertebral tenderness may be present.

In asymptomatic bacteriuria, no physical findings are typically present. Symptoms may arise intermittently, only to be overlooked because of lack of persistence or severity.

Pelvic examination is recommended in all symptomatic patients (with the exception of third-trimester patients with bleeding) to rule out vaginitis or cervicitis. In patients with cystitis, tenderness can often be elicited with isolation of the bladder on pelvic examination.

Patients with pyelonephritis have fever (usually >38°C), flank tenderness upon palpation, and an ill appearance. Flank tenderness occurs on the right side in more than half of patients, bilaterally in one fourth, and on the left side in one fourth. Pain may also be found suprapubically with palpation.

Assessment of the fetal heart rate on the basis of gestational age should be included as part of the evaluation. Often, owing to maternal fever, the fetal heart rate is elevated to more than 160 beats/min.

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Complications

The primary complication of bacteriuria during pregnancy is cystitis, though the primary morbidity is due to pyelonephritis. Other complications may include the following:

  • Perinephric cellulitis and abscess
  • Septic shock (rare)
  • Renal dysfunction (usually transient, but as many as 25% of pregnant women with pyelonephritis have a decreased glomerular filtration rate)
  • Hematologic dysfunction (common but seldom of clinical importance)
  • Hypoxic fetal events due to maternal complications of infection that lead to hypoperfusion of the placenta
  • Preeclampsia [15]
  • Premature delivery leading to increased infant morbidity and mortality

Pulmonary injury may also complicate UTI in pregnancy. Approximately 2% of women with severe pyelonephritis during pregnancy have evidence of pulmonary injury due to systemic inflammatory response syndrome and respiratory insufficiency. Endotoxins that alter alveolar-capillary membrane permeability are produced; subsequently, pulmonary edema and acute respiratory distress syndrome develop.

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Contributor Information and Disclosures
Author

Emilie Katherine Johnson, MD, MPH Head of Clinical Research, Attending Physician, Division of Urology, Ann and Robert H Lurie Children’s Hospital of Chicago; Assistant Professor of Urology, Assistant Professor, Center for Healthcare Studies, Institute for Public Health and Medicine Northwestern University, The Feinberg School of Medicine

Emilie Katherine Johnson, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Urological Association, National Medical Association, Society of Women in Urology

Disclosure: Nothing to disclose.

Chief Editor

Edward David Kim, MD, FACS Professor of Surgery, Division of Urology, University of Tennessee Graduate School of Medicine; Consulting Staff, University of Tennessee Medical Center

Edward David Kim, MD, FACS is a member of the following medical societies: American College of Surgeons, Tennessee Medical Association, Sexual Medicine Society of North America, American Society for Reproductive Medicine, American Society of Andrology, American Urological Association

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Repros.

Additional Contributors

J Stuart Wolf, Jr, MD, FACS David A Bloom Professor of Urology, Associate Chair for Urologic Surgical Services, Director, Division of Endourology and Stone Disease, Department of Urology, University of Michigan Medical School

J Stuart Wolf, Jr, MD, FACS is a member of the following medical societies: Catholic Medical Association, Endourological Society, Engineering and Urology Society, Society of Laparoendoscopic Surgeons, Society of University Urologists, Society of Urologic Oncology, American College of Surgeons, American Urological Association

Disclosure: Nothing to disclose.

Acknowledgements

Gamal Mostafa Ghoniem, MD, FACS Professor of Urology, Chief, Division of Female Urology, Pelvic Reconstructive Surgery, and Voiding Dysfunction, Department of Urology, University of California, Irvine, School of Medicine

Gamal Mostafa Ghoniem, MD, FACS is a member of the following medical societies: American College of Surgeons, American Urogynecologic Society, American Urological Association, International Continence Society, International Urogynaecology Association, and Society of Urodynamics and Female Urology

Disclosure: Astellas Honoraria Speaking and teaching; Coloplasty Consulting fee Board membership; Uroplasty Consulting fee Consulting

Leticia A Jones, MD Clinical Instructor, Department of Obstetrics and Gynecology, Indiana University Hospital, Clarian Health Partners

Leticia A Jones, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists

Disclosure: Nothing to disclose.

Mark Jeffrey Noble, MD Consulting Staff, Urologic Institute, Cleveland Clinic Foundation

Mark Jeffrey Noble, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, American Urological Association, Kansas Medical Society, Sigma Xi, Society of University Urologists, and Southwest Oncology Group

Disclosure: Nothing to disclose.

Henry E Ruiz, MD Chief, Reconstructive Urology and Urodynamics, Urology Associates of South Texas, PA and Radiation Oncology Center

Henry E Ruiz, MD is a member of the following medical societies: American Urological Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Patrick J Woodman, DO, Assistant Director, Urogynecology (FPMRS) Fellowship, Associate Clinical Professor, Indiana University School of Medicine; Consulting Staff, Department of Obstetrics and Gynecology, Methodist Hospital

Patrick J Woodman, DO is a member of the following medical societies: American College of Obstetricians and Gynecologists; American College of Surgeons; American Osteopathic Association; American Urogynecologic Society; Association of Professors of Gynecology and Obstetrics; Indiana State Medical Association; International Continence Society

Disclosure: Nothing to disclose.

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Twenty-nine-year-old pregnant woman with history of reflux uropathy and ureteral reimplantation at age 21 months presents with right-side flank pain and proteinuria. Renal cortical thinning suggests chronic hydronephrosis.
Color-flow Doppler highlights normal flow in right kidney of 29-year-old pregnant woman with history of reflux uropathy and ureteral reimplantation at age 21 months who presents with right-side flank pain and proteinuria.
25-year-old pregnant woman with right lower quadrant pain and hematuria has proximal ureteral obstruction consistent with urolithiasis. After 25 minutes, intravenous pyelography reveals dense right nephrogram and no filling of right collecting system. Left side shows unremarkable nonhydronephrotic collecting system. This is consistent with right ureteral lithiasis.
Table. Treatment Regimens for Pregnant Women with UTI
First-line therapy
  • Nitrofurantoin monohydrate/macrocrystals 100 mg orally twice daily for 5-7 days or
  • Amoxicillin 500 mg orally twice daily (alternative: 250 mg orally three times daily) for 5-7 days or
  • Amoxicillin-clavulanate 500/125 mg orally twice daily for 3-7 days (alternative: 250/125 mg orally three times daily for 5-7 days) or
  • Cephalexin 500 mg orally twice daily for 3-7 days
Second-line therapy
  • Fosfomycin 3 g orally as single dose with 3-4 oz. of water
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