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Urinary Tract Infections in Pregnancy

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

Practice Essentials

Pregnancy causes numerous changes in the woman’s body. Hormonal and mechanical changes increase the risk of urinary stasis and vesicoureteral reflux. These changes, along with an already short urethra (approximately 3-4 cm in females) and difficulty with hygiene due to a distended pregnant belly, increase the frequency of urinary tract infections (UTIs) in pregnant women. Indeed, UTIs are among the most common bacterial infections during pregnancy.

In general, pregnant patients are considered immunocompromised UTI hosts because of the physiologic changes associated with pregnancy (see Pathophysiology). These changes increase the risk of serious infectious complications from symptomatic and asymptomatic urinary infections even in healthy pregnant women. (See Urinary Tract Infection in Females.)

Oral antibiotics are the treatment of choice for asymptomatic bacteriuria and cystitis. The standard course of treatment for pyelonephritis is hospital admission and intravenous antibiotics. Antibiotic prophylaxis is indicated in some cases. (See Treatment of UTI in Pregnancy and Urethral Catheterization in Women.) Patients treated for symptomatic UTI during pregnancy should be continued on daily prophylactic antibiotics for the duration of their pregnancy.

Annual health costs for UTI exceed $1 billion. Although the condition-specific cost of asymptomatic bacteriuria or UTI in pregnancy is unknown, screening for these conditions in pregnant women is cost-effective as compared with treating UTI and pyelonephritis without screening. Goals for future research include targeting low-income groups and women in developing countries for screening and early treatment, as well as determining whether a causal relation exists between maternal UTI and childhood neurologic consequences.

For patient education information, see the Kidneys and Urinary System Center and Pregnancy and Reproduction Center, as well as Urinary Tract Infections, Pregnancy, Bladder Control Problems, and Blood in the Urine.

Definitions of key terms

Urinary tract infection

UTI is defined as the presence of at least 100,000 organisms per milliliter of urine in an asymptomatic patient, or as more than 100 organisms/mL of urine with accompanying pyuria (>7 white blood cells [WBCs]/mL) in a symptomatic patient. A diagnosis of UTI should be supported by a positive culture for a uropathogen, particularly in patients with vague symptoms. UTIs are associated with risks to both the fetus and the mother, including pyelonephritis, preterm birth, low birth weight, and increased perinatal mortality.

Asymptomatic bacteriuria

Asymptomatic bacteriuria is commonly defined as the presence of more than 100,000 organisms/mL in 2 consecutive urine samples in the absence of declared symptoms. Untreated asymptomatic bacteriuria is a risk factor for acute cystitis (40%) and pyelonephritis (25-30%) in pregnancy. These cases account for 70% of all cases of symptomatic UTI among unscreened pregnant women.

Acute cystitis

Acute cystitis involves only the lower urinary tract; it is characterized by inflammation of the bladder as a result of bacterial or nonbacterial causes (eg, radiation or viral infection). Acute cystitis develops in approximately 1% of pregnant patients, of whom 60% have a negative result on initial screening. Signs and symptoms include hematuria, dysuria, suprapubic discomfort, frequency, urgency, and nocturia. These symptoms are often difficult to distinguish from those due to pregnancy itself.

Acute cystitis is complicated by upper urinary tract disease (ie, pyelonephritis) in 15-50% of cases.

Acute pyelonephritis

Pyelonephritis is the most common urinary tract complication in pregnant women, occurring in approximately 2% of all pregnancies. Acute pyelonephritis is characterized by fever, flank pain, and tenderness in addition to significant bacteriuria. Other symptoms may include nausea, vomiting, frequency, urgency, and dysuria. Furthermore, women with additional risk factors (eg, immunosuppression, diabetes, sickle cell anemia, neurogenic bladder, recurrent or persistent UTIs before pregnancy) are at an increased risk for a complicated UTI.

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Pathophysiology

Infections result from ascending colonization of the urinary tract, primarily by existing vaginal, perineal, and fecal flora. Various maternal physiologic and anatomic factors predispose to ascending infection. Such factors include urinary retention caused by the weight of the enlarging uterus and urinary stasis due to progesterone-induced ureteral smooth muscle relaxation. Blood-volume expansion is accompanied by increases in the glomerular filtration rate and urinary output.

Loss of ureteral tone combined with increased urinary tract volume results in urinary stasis, which can lead to dilatation of the ureters, renal pelvis, and calyces. Urinary stasis and the presence of vesicoureteral reflux predispose some women to upper urinary tract infections (UTIs) and acute pyelonephritis.

Calyceal and ureteral dilatation are more common on the right side; in 86% of cases, the dilatation is localized to the right. The degree of calyceal dilatation is also more pronounced on the right than the left (average 15 mm vs 5 mm). This dilatation appears to begin by about 10 weeks’ gestation and worsens throughout pregnancy. This is underscored by the distribution of cases of pyelonephritis during pregnancy: 2% during the first trimester, 52% during the second trimester, and 46% in the third trimester.

Although the influence of progesterone causes relative dilatation of the ureters, ureteral tone progressively increases above the pelvic brim during pregnancy. However, whether bladder pressure increases or decreases during pregnancy is controversial.

Glycosuria and an increase in levels of urinary amino acids (aminoaciduria) during pregnancy are additional factors that lead to UTI. In many cases, glucose excretion increases during pregnancy over nonpregnant values of 100 mg/day. Glycosuria is due to impaired resorption by the collecting tubule and loop of Henle of the 5% of the filtered glucose, which escapes proximal convoluted tubular resorption.

The fractional excretion of alanine, glycine, histidine, serine, and threonine is increased throughout pregnancy. levels of cystine, leucine, lysine, phenylalanine, taurine, and tyrosine are elevated in the first half of pregnancy but return to reference range levels by the second half. The mechanism of selective aminoaciduria is unknown, although its presence has been postulated to affect the adherence of Escherichia coli to the urothelium.

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Etiology

Infection

E coli is the most common cause of urinary tract infection (UTI), accounting for approximately 80-90% of cases. It originates from fecal flora colonizing the periurethral area, causing an ascending infection. Other pathogens include the following[1] :

  • Klebsiella pneumoniae (5%)
  • Proteus mirabilis (5%)
  • Enterobacter species (3%)
  • Staphylococcus saprophyticus (2%)
  • Group B beta-hemolytic Streptococcus (GBS; 1%)
  • Proteus species (2%)

Gram-positive organisms, particularly Enterococcus faecalis and GBS, are clinically important pathogens. Infection with S saprophyticus, an aggressive community-acquired organism, can cause upper urinary tract disease, and this infection is more likely to be persistent or recurrent.

Urea-splitting bacteria, including Proteus, Klebsiella, Pseudomonas, and coagulase-negative Staphylococcus, alkalinize the urine and may be associated with struvite stones. Chlamydial infections are associated with sterile pyuria and account for more than 30% of atypical pathogens.

GBS colonization has important implications during pregnancy. Intrapartum transmission that leads to neonatal GBS infection can cause pneumonia, meningitis, sepsis, and death. Current guidelines recommend universal vaginal and rectal screening in all pregnant women at 35-37 weeks’ gestation rather than treatment based on risk factors.

Preeclampsia

The development of preeclampsia is associated with maternal UTI (asymptomatic bacteriuria or symptomatic infection) during pregnancy. A recent case-control study demonstrated an increased odds (1.22-fold) of preeclampsia in women with any UTI during pregnancy versus those without UTI.[2] Furthermore, a retrospective review of the perinatal database at a major tertiary center revealed a UTI rate of 16.2% in normotensive patients, but this increased to 27.3% in women with mild preeclampsia and 35.9% in women with severe preeclampsia. The authors hypothesize that underlying renal damage weakens patients’ systemic defense mechanisms against ascending infection.

Cesarean delivery

Cesarean delivery is associated with UTI (increasing the likelihood 2.7-fold), but this association may be confounded by bladder catheterization or prolonged rupture of membranes (PROM). The incidence of symptomatic UTI is 9.3%, and that of asymptomatic bacteriuria is 7.6%.

Orthotopic continent urinary diversion

Many women who, in the past, would have been counseled against pregnancy are now attempting pregnancy. In orthotopic continent diversion (OCD), an ileal-ascending colon conduit is made (OCD, Kock pouch) and reattached to the in situ urethra (OCD) or a continent abdominal stoma (Kock pouch).

Typical candidates are patients born with congenital exstrophy of the bladder in whom primary reconstruction has failed. Recurrent UTI and hydronephrosis are common because of outflow obstruction of the orthotopic stoma secondary to uterine compression or uterine prolapse. Indwelling catheterization of the urethra or continent stoma may be necessary, particularly during the later stages of pregnancy. In rare cases, a percutaneous nephrostomy tube or antegrade passage of a ureteral stent may be indicated.

Beta streptococci

Beta streptococci are important pathogens in pregnancy because early and late complications of neonatal beta-streptococcal infection are well documented. Incidental documentation of beta-streptococcal bacteriuria suggests a higher colonization count than is revealed by a screening vaginal or rectal culture. Beta-streptococcal colonization in the urine warrants immediate treatment and antibiotic prophylaxis when the patient presents in labor.

Whether beta streptococci are associated with preterm labor is controversial. In a prospective study, McKenzie et al found no relation between beta-streptococcal bacteriuria and preterm labor, but they described the use of urinary antibodies to identify at-risk women.[3] In 2043 consecutive women, those with E coli antibodies at the initial visit and at 28 weeks’ gestation and women with beta-streptococcal antibodies at 28 weeks’ gestation had a significantly higher chance of preterm delivery.

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Epidemiology

United States statistics

The frequency of urinary tract infection (UTI) in pregnant women (0.3-1.3%) is similar to that in nonpregnant women.[4] Changes in coital patterns (eg, position, frequency, postcoital antibiotics) can offset recurrence in at-risk individuals.

Overall, UTIs are 14 times more frequent in women than in men. This difference is attributed to the following factors:

  • The urethra is shorter in women
  • In women, the lower third of the urethra is continually contaminated with pathogens from the vagina and the rectum
  • Women tend not to empty their bladders as completely as men do
  • The female urogenital system is exposed to bacteria during intercourse

A difference between pregnant and nonpregnant women is that the prevalence of asymptomatic bacteriuria in pregnant women is 2.5-11%, as opposed to 3-8% in nonpregnant women. In as many as 40% of these cases, bacteriuria may progress to symptomatic upper UTI or pyelonephritis; this rate is significantly higher than that seen in nonpregnant women.[5]

Several patient-level factors are associated with an increased frequency of bacteriuria during pregnancy. Compared with nonindigent patients, indigent patients have a 5-fold increased incidence of bacteriuria. The risk is doubled in women with sickle cell trait. Other risk factors for bacteriuria include diabetes mellitus,[6] neurogenic bladder retention, history of vesicoureteral reflux (treated or untreated),[7] previous renal transplantation,[8] and a history of previous UTIs.

International statistics

Versi et al described a higher prevalence of bacteriuria in pregnant white women (6.3%) than in pregnant Bangladeshi women (2%).[9] Pregnancies that resulted in preterm deliveries were strongly associated with bacteriuria in white women; this association was not observed in Bangladeshi women. The authors hypothesized that the difference could be due to variation in hygiene practices and clothing.

A large population-based study of nearly 200,000 pregnant Israeli women demonstrated a 2.5% rate of asymptomatic bacteriuria[10] and a 2.3% rate of symptomatic UTI.[11] In this population, asymptomatic bacteriuria was found to have an association with multiple pregnancy complications, including hypertension, diabetes, intrauterine growth retardation, prolonged hospitalization, and preterm labor.

The authors suggested that these findings may be a marker for intensity of prenatal care rather than a specific causal effect of the urinary infection.[10] Additionally, their follow-up study examining women with symptomatic UTI showed a clear association between UTI and low birth weight and preterm delivery, a finding consistent with those of multiple previous investigations.[11]

Age- and race-related demographics

The prevalence of UTI during pregnancy increases with maternal age.

A retrospective analysis of 24,000 births found the prevalence of UTI during pregnancy to be 28.7% in whites and Asians, 30.1% in blacks, and 41.1% in Hispanics. When socioeconomic status is controlled for, no significant interracial differences seem to exist. A survey-based analysis of self-reported UTI found similar trends. This study also considered Native American women and found the highest prevalence of UTI in this population (24.2%) as compared with Asian (10.3%), white (16.6%), Hispanic (18.3%), and black (20.3%) women.[12]

UTI is associated with preterm delivery in persons of all races. The adjusted odds ratio in infants with very low birth weight is 2.8 in blacks and 5.6 in whites, adjusted for parity, body mass index, maternal age, marital status, cigarette smoking, education, and prenatal care. The overall relative risk of bacteriuria in blacks or whites is estimated at 1.5-5, and the relative risk of preterm birth in women with bacteriuria is 1.8-2.3.

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Prognosis

In most cases of bacteriuria and urinary tract infection (UTI) in pregnancy, the prognosis is excellent. The majority of long-term sequelae are due to complications associated with septic shock, respiratory failure, and hypotensive hypoxia (ie, extremity gangrene).

Maternal UTI has few direct fetal sequelae because fetal bloodstream infection is rare; however, uterine hypoperfusion due to maternal dehydration, maternal anemia, and direct bacterial endotoxin damage to the placental vasculature may cause fetal cerebral hypoperfusion.

Untreated upper UTIs are associated with low birth weight, prematurity, premature labor, hypertension, preeclampsia, maternal anemia, and amnionitis.[13] A retrospective population-based study by Mazor-Dray et al showed that UTI during pregnancy is independently associated with intrauterine growth restriction, preeclampsia, preterm delivery, and cesarean delivery.[10] A prospective cohort study of pregnant patients also suggested an association between maternal UTI and childhood asthma.[14]

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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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