eMedicine Specialties > Urology > Infections and Related Inflammatory Conditions

Urinary Tract Infections in Pregnancy

Author: Leticia A Jones, MD, Clinical Instructor, Department of Obstetrics and Gynecology, Indiana University Hospital, Clarian Health Partners
Coauthor(s): 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; Henry E Ruiz, MD, Chief, Reconstructive Urology and Urodynamics, Urology Associates of South Texas, PA and Radiation Oncology Center
Contributor Information and Disclosures

Updated: Oct 9, 2008

Introduction

Background

Pregnancy causes numerous changes in the body of a woman. 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.

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 per milliliter of urine with accompanying pyuria (>7 WBCs/mL) in a symptomatic patient. Particularly in asymptomatic patients, a diagnosis of UTI should be supported by a uropathogen found in the culture.

Two clinical entities are recognized in patients with symptomatic UTI: lower UTI (ie, cystitis) and upper UTI (ie, pyelonephritis). In general, pregnant patients are considered immunocompromised UTI hosts because of the physiologic changes associated with pregnancy, increasing the risk of serious infectious complications from symptomatic and asymptomatic urinary infections in a healthy pregnant woman. These changes are discussed in Pathophysiology.

Asymptomatic bacteriuria (ASB) is commonly defined as the presence of more than 100,000 organisms per milliliter in 2 consecutive urine samples in the absence of declared symptoms. Untreated ASB 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 involves only the lower urinary tract; it is characterized by inflammation of the bladder due to bacterial or nonbacterial causes (ie, radiation, viral). 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. 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 (immunosuppression, diabetes, sickle cell anemia, neurogenic bladder, recurrent or persistent UTIs prior to pregnancy) are at an increased risk of a complicated UTI.

Vaginal infections can cause or mimic UTIs, which are common in women of reproductive years, affecting 25-35% of women aged 20-40 years. The main method of discriminating between the two depends on vaginal and urinary cultures.

Annual health costs for UTI exceed $1 billion. Although the condition-specific cost of ASB or UTI in pregnancy is unknown, screening for ASB and UTI in pregnant women has been shown to be cost-effective compared with treating UTI and pyelonephritis without screening.

Pathophysiology

The physiologic changes during pregnancy predispose such women to bacteriuria. These physiological changes include urinary retention caused by the weight of the enlarging uterus and urinary stasis due to ureteral smooth muscle relaxation (caused by increases in progesterone). 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. In addition, glucosuria and aminoaciduria during pregnancy provide an excellent culture medium for bacteria in areas of urine stasis.

Escherichia coli infection is the most common cause of UTI, accounting for 80-90% of cases. It originates from fecal floras that colonize the periurethral area (ascending infection). Klebsiella, Enterobacter, and Proteus species cause most of the remaining cases. Gram-positive organisms, particularly Enterococcus faecalis and group B Streptococcus (GBS), are also clinically important pathogens. Infection with Staphylococcus saprophyticus, an aggressive community-acquired organism, can cause upper urinary tract disease, and the infection is more likely to be persistent or recurrent.

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.

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 nonbacterial UTIs.

Frequency

United States

The prevalence of ASB in pregnant women is 2.5-11% (as opposed to 3-8% in nonpregnant women). Risk factors include increases age, low socioeconomic status, sexual activity, multiparity, and untreated pathologies.

The frequency of UTI in pregnant women (0.3-1.3%) is similar to that in nonpregnant women. Changes in coital patterns (eg, position, frequency, postcoital antibiotics) can offset recurrence in at-risk individuals. However, Leigh and colleagues (1990) reported a 34% rate of symptomatic bacteriuria in women during the first 5 days following cesarean delivery that may be due to catheterization or prolonged rupture of membranes (PROM).

Parkland hospital reported a reduction in cases of acute pyelonephritis (from 4% to 1-2%) after implementing a screening and treatment program for ASB in pregnant women. Residual cases occur in unscreened women (ie, lack of prenatal care) or in women with recurrences. The incidence is increased in the puerperium to approximately 8%.

Women with risk factors have the additional risks of a first, recurrent, or persistent UTI. These women should undergo more frequent screenings. Risk factors include diabetes mellitus, including gestational diabetes; urologic abnormalities (eg, neurogenic bladder, duplicated collecting systems); prepregnancy and antepartum history of UTI prior to initiation of prenatal care (ie, 2-3 culture-proven UTIs/y); and sickle cell hemoglobinopathy. Regarding sickle cell hemoglobinopathy, many have long thought that pyelonephritis was more common in sickle cell trait carriers (both pregnant and nonpregnant persons); however, in 2006, Thurman et al suggested that increased urinary testing did not decrease the incidence of pyelonephritis in pregnant women who carried the sickle cell trait.2

International

Versi and colleagues (1997) described a higher prevalence of bacteriuria in pregnant white women (6.3%) than in pregnant Bangladeshi women (2%).3 Pregnancies that resulted in preterm deliveries were strongly associated with bacteriuria in white women; this was not observed Bangladeshi women. The authors hypothesized that the difference could be due to differences in hygiene practices and clothing.

Mortality/Morbidity

The primary complication of bacteriuria during pregnancy is cystitis, although overt pyelonephritis occurs in 25-30% of cases. Septic shock, respiratory failure, and death are reported. Hypoxic fetal events can occur because of maternal complications that lead to hypoperfusion of the placenta (eg, hypotension due to dehydration or septic shock, maternal anemia, maternal hypoxemia). Refer to Complications for further discussion.

The American College of Obstetricians and Gynecologists recommend urine culture screening for all pregnant women at their first prenatal visit.4

Race

  • A retrospective analysis of 24,000 births indicates that the prevalence of UTI during pregnancy is 28.7% in whites and Asians, 30.1% in blacks, and 41.1% in Hispanics.
  • UTI is associated with preterm delivery in 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 (BMI), 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.

Sex

These infections occur in pregnant women.

Age

The prevalence of UTI during pregnancy increases with age.

Clinical

History

Patients with urinary tract infections (UTIs) may not have overt urinary tract symptoms. Symptomatology can be divided into lower urinary tract symptoms and upper urinary tract symptoms.

Lower urinary tract symptoms include dysuria, frequency, urgency, suprapubic pain, and hematuria in the absence of systemic symptoms. Frequency is difficult to characterize in pregnancy since most women urinate more frequently as a normal consequence of expanding blood volume, increased glomerular filtration rate, and increased renal blood flow.

Upper urinary tract symptoms include fever, chills, flank pain, nausea, and vomiting. Patients may also have lower UTI symptoms.

  • Asymptomatic bacteriuria: ASB (2-7% of pregnancies) is characterized by bacteriuria in the urine without clinical signs or symptoms of infection. In pregnant women, it is usually found on random urine screening.
  • Cystitis: This manifests as symptoms of dysuria, urgency, urge incontinence, and frequency. A positive result on urine culture or urine dipstick usually shows leukocyte esterase, nitrite, and hematuria and may show some protein. Additional symptoms may consist of lower abdominal pain or suprapubic tenderness.
  • Pyelonephritis: The symptoms on presentation vary. Symptoms often include fever (>38°C), shaking chills, costovertebral angle tenderness, anorexia, nausea, and vomiting. Right-sided flank pain is more common than left or bilateral flank pain. Patients may also present with hypothermia (as low as 34°C).

Physical

During the physical examination, the findings should be considered in relation to the patient’s current duration of pregnancy. The differential diagnoses may change in each trimester, and the increasing size of the gravid uterus may mask or mimic findings.

  • Asymptomatic bacteriuria
    • Often, no physical findings are present.
    • Symptoms may arise intermittently, only to be overlooked because of lack of persistence or severity.
  • Cystitis: Patients may have suprapubic tenderness upon palpation. Tenderness can be elicited with isolation of the bladder on pelvic examination.
  • Pyelonephritis
    • Patients have fever (usually >38°C), flank tenderness upon palpation, and an ill appearance. Flank tenderness is right-sided in more than half of patients, bilateral in one fourth of patients, and left-sided in one fourth of patients. Pain may also be found suprapubically with palpation.
    • Based on gestational age, include fetal heart rate as part of the evaluation. Often, owing to maternal fever, the fetal heart rate is elevated to more than 160 beats per minute.

Causes

  • The most common uropathogen in the pregnant patient is E coli. This organism is isolated in 80-85% of cultures.
  • Other pathogens include the following:
    • Klebsiella pneumoniae (5%)
    • Proteus mirabilis (5%)
    • Enterobacter species (3%)
    • S saprophyticus (2%)
    • Group B beta-hemolytic Streptococcus (1%)
  • Infections result from ascending colonization of the urinary tract. The primary source of organisms is existing vaginal, perineal, and fecal flora.
  • Various maternal physiologic factors predispose to ascending infection.
    • The smooth-muscle–relaxation properties of progesterone and mechanical obstruction by an enlarging uterus cause dilatation of the renal calices, pelves, and ureters, leading to urinary stasis and potentiating infection. Calyceal and ureteral dilatation are more common on the right side; in 86% of cases, the dilatation is localized on the right side. The degree of calyceal dilatation is also more pronounced on the right than the left (15 mm vs 5 mm). This dilatation appears to begin by about 10 weeks' gestation and worsens throughout pregnancy (see Images 1-2). This is underscored by the percentage of cases of pyelonephritis during pregnancy—2% during the first trimester, 52% during the second trimester, and 46% in the third trimester.
    • Glucosuria and an increase in levels of urine amino acids during pregnancy are additional factors that lead to UTI. Glucose excretion increases in pregnancy by 100-fold over nonpregnant values of 100 mg/d. 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 E coli to the urothelium.

More on Urinary Tract Infections in Pregnancy

Overview: Urinary Tract Infections in Pregnancy
Differential Diagnoses & Workup: Urinary Tract Infections in Pregnancy
Treatment & Medication: Urinary Tract Infections in Pregnancy
Follow-up: Urinary Tract Infections in Pregnancy
Multimedia: Urinary Tract Infections in Pregnancy
References
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Further Reading

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Keywords

urinary tract infection, UTI, upper urinary tract infection, lower urinary tract infection, upper UTI, lower UTI, asymptomatic bacteriuria, ASB, bacteriuria, cystitis, urethritis, pyelonephritis, Escherichia coli, E coli, urinary stasis, ureterovesical reflux, vesicoureteral reflux, pyuria, acute cystitis, upper urinary tract disease, acute pyelonephritis, group B Streptococcus, GBS, Klebsiella pneumoniae, K pneumoniae, Proteus mirabilis, P mirabilis, Enterobacter species, Staphylococcus saprophyticus, S saprophyticus, group B beta-hemolytic Streptococcus, group B beta-hemolytic streptococci

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Contributor Information and Disclosures

Author

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.

Coauthor(s)

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, and International Continence Society
Disclosure: Glaxo-Smith-Klein Beechum Honoraria Speaking and teaching

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.

Medical Editor

Gamal Mostafa Ghoniem, MD, FACS, Fellowship Program Director, Clinical Professor of Surgery, Head, Section of Voiding Dysfunction, Female Urology and Reconstruction, Cleveland Clinic Florida
Gamal Mostafa Ghoniem, MD, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Society for Urology and Engineering, and Society of University Urologists
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

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.

CME Editor

J Stuart Wolf, Jr, MD, FACS, David A Bloom Professor of Urology, Director, Division of Minimally Invasive Urology, Department of Urology, University of Michigan Medical Center
J Stuart Wolf, Jr, MD, FACS is a member of the following medical societies: American College of Surgeons, American Medical Association, American Urological Association, Catholic Medical Association, Endourological Society, Society for Urology and Engineering, Society of Laparoendoscopic Surgeons, and Society of University Urologists
Disclosure: Terumo Corporation Consulting fee Consulting; Omeros Corporation Consulting fee Consulting

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, American Society for Reproductive Medicine, American Society of Andrology, American Urological Association, and Tennessee Medical Association
Disclosure: Lilly Consulting fee Consulting

 
 
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