Urinary tract infections (UTIs) are frequently encountered in pregnant women. Pyelonephritis is the most common serious medical condition seen in pregnancy. Thus, it is crucial for providers of obstetric care to be knowledgeable about normal findings of the urinary tract, evaluation of abnormalities, and treatment of disease. Fortunately, UTIs in pregnancy are most often easily treated with excellent outcomes. Rarely, pregnancies complicated by pyelonephritis will lead to significant maternal and fetal morbidity. Changes of the urinary tract and immunologic changes of pregnancy predispose women to urinary tract infection. Physiologic changes of the urinary tract include dilation of the ureter and renal calyces; this occurs due to progesterone-related smooth muscle relaxation and ureteral compression from the gravid uterus. Ureteral dilation may be marked. Decreased bladder capacity commonly results in urinary frequency. Vesicoureteral reflux may be seen. These changes increase the risk of urinary tract infections. During pregnancy, urinary tract changes predispose women to infection. Ureteral dilation is seen due to compression of the ureters from the gravid uterus. Hormonal effects of progesterone also may cause smooth muscle relaxation leading to dilation and urinary stasis, and vesicoureteral reflux increases. The organisms which cause UTI in pregnancy are the same uropathogens seen in non-pregnant individuals. As in non-pregnant patients, these uropathogens have proteins found on the cell-surface which enhance bacterial adhesion leading to increased virulence. Urinary catheterization, frequently performed during labor, may introduce bacteria leading to UTI. In the postpartum period, changes in bladder sensitivity and bladder overdistention may predispose to UTI.

1. UTI IN PREGNANCY
DR ALKA MUKHERJEE
DR APURVA MUKHERJEE
NAGPUR M.S. INDIA

2. DR ALKA MUKHERJEE
MBBS DGO FICOG FICMCH PGDCR PGDMLS MA(PSY)
Director & Consultant At Mukherjee Multispecialty Hospital
MMC ACCREDITATED SPEAKER
MMC OBSERVER MMC MAO – 01017 / 2016
Present Position
 Director of Mukherjee Multispecialty Hospital
 Hon.Secretary INTERNATIONAL COUNCIL FOR HUMAN RIGHTS
 Hon.Secretary NARCHI NAGPUR CHAPTER (2018-2020)
 Hon.Secretary AMWN (2018-2021)
 Hon.Secretary ISOPARB (2019-2021)
 Life member, IMA, NOGS, NARCHI, AMWN & Menopause
Society, India, Indian medico-legal & ethics association(IMLEA),
ISOPRB, HUMAN RIGHTS
 Founder Member of South Rapid Action Group, Nagpur.
 On Board of Super Specialty, GMC, IGGMC, AIIMS Nagpur,
NKPSIMS, ESIS and Treasury, Nagpur for “ WOMEN SEXUAL
HARASSMENT COMMITTEE.”
mukherjeehospital@yahoo.com
www.mukherjeehospital.com
https://www.facebook.com/
Mukherjee Multispeciality
https://www.instagram.com/
Achievement
 Winner of NOGS GOLD MEDAL – 2017-18
 Winner of BEST COUPLE AWARD in Social
Work - 2014
 APPRECIATION Award IMA - MS
 Past Position
 Organizing joint secretary ENDO-GYN
2019
 Vice President IMA Nagpur (2017-2018)
Vice President of NOGS(2016-2017)
Organizing joint secretary ENDO-GYN
Organizing secretary AMWICON – 2019

3. • Urinary tract infections (UTIs) are frequently encountered in
pregnant women.
• Pyelonephritis is the most common serious medical
condition seen in pregnancy - significant maternal and fetal
morbidity.
• Changes of the urinary tract and immunologic changes of
pregnancy predispose women to urinary tract infection.
• Physiologic changes of the urinary tract due to progesterone-
related smooth muscle relaxation and ureteral compression
from the gravid uterus - increase the risk of urinary tract
infections.
Introduction

4. Urinary tract symptoms in pregnancy
• Key learning points
• Common urinary symptoms are often related to
physiological changes in pregnancy
• Repeated urinary infections can be a sign of underlying renal
disease
• Routine antenatal urinalysis is important to detect UTI and
pre-eclampsia.

5. • Common symptoms include urinary frequency, nocturia,
dysuria, urgency, incontinence (urgency and stress), and
inability to pass urine.
• It is important to identify whether these symptoms are
reflections of normal physiological changes in pregnancy or
whether they represent an underlying pathology.

6. Physiological changes
● Causes:
o High progesterone levels
reduce ureteric tone,
peristalsis, and
contraction pressure
o Mechanical compression
at the pelvic brim—right
side > left side
o Uterine enlargement
causes elongation and
lateral displacement of
ureters
● Small increase in urine output
● Increase in renal perfusion and
glomerular filtration rate
● Resulting from widespread
vasodilation, increased vascular volume,
and increased cardiac output
● Increased renal size
● Increase in size by 1 to 1.5 cm during
pregnancy
● Increase in volume of up to 30%
● Dilation of renal pelvices
(hydronephrosis) and dilatation of the
ureters (hydroureter)
Vesicoureteral reflux

8. Occurs in up to 80% of
pregnancies
● Commonly asymptomatic
● Right side is aff ected more
than the left
● Results in increased volume
of urine in the collecting
system (200–300 mL)
o Reservoir of urine
o Increased risk of
pyelonephritis and UTI

9. Bladder changes
● Progesterone-induced
bladder wall relaxation can
increase capacity
● Compression from enlarging
uterus causes displacement
and reduced capacity
● Intermittent vesicoureteric
reflux
●
● Causes:
o Incompetence of the
vesicoureteral valve
o Increased intravesical
pressure
o Decreased intraureteral
pressure
Biochemical changes—fall in serum creatinine and urea due to
increased renal plasma flow.

10. History and symptoms
● Frequency
● Definition: voiding >7 times a day
● Very common
● Typically begins in first trimester
● Causes are multifactorial:
o Mechanical factors mentioned
o Increased urine output

11. Nocturia
● Definition: voiding ≥2 times a night
● Increases with advanced gestation
Causes:
o Greater excretion of sodium and water at night, compared
with non-pregnant women
o Mobilization of dependent edema when lying down
• Dysuria
• ● Painful urination
• ● During and/or after urination

12. Urgency and incontinence
● Urgency—a sudden desire to pass urine which is diffi cult to defer
● Urge incontinence—a sudden urge to urinate, followed by
incontinence
● Stress incontinence—an episode of incontinence with activities
resulting in increases in intra-abdominal pressure, e.g. cough, laugh,
exercising.
Due to:
o Current pregnancy (temporary)
o Previous childbirth and pelvic floor damage (potentially resulting in
permanent problems)
● Inability to pass urine (retention)
● Frequent small volumes of urine, suggestive of incomplete emptying
● Followed by an acute episode of retention

13. Bloodstained urine (haematuria)
● Presence of red blood cells in the urine
● Often difficult to distinguish from liquor if it occurs with
membrane rupture
● Microscopic or macroscopic
● Foul-smelling, concentrated urine
● Common presentation for UTI.
Physical examination
● Routine observations—to identify pyrexia or signs of sepsis
● Abdominal findings: pain either suprapubic, bilateral, or
unilateral flank
● Urine inspection.

14. • Causes:
• The organisms which cause UTI in pregnancy are the same
uropathogens seen in non-pregnant individuals.
• As in non-pregnant patients, these uropathogens have proteins found on
the cell-surface which enhance bacterial adhesion leading to increased
virulence.
• Approximately 16 weeks’ gestation with incarceration of the retroverted
uterus (pressure on thebladder neck with elongation of the urethra)
• In labour due to deeply engaged head
• Urinary catheterization, frequently performed during labor, may
introduce bacteria leading to UTI.
• In the postpartum period, changes in bladder sensitivity and bladder
overdistention may predispose to UTI.
• Pregnancy is a state of relative immunocompromised state

15. Pathophysiology
Organisms causing UTI in pregnancy are the same
uropathogens which commonly cause UTI in non-pregnant
patients.
Escherichia coli is the most common organism isolated.
Other bacteria - Klebsiella pneumoniae, Staphylococcus,
Streptococcus, Proteus, and Enterococcus species.

16. Investigations
● Urine tests: urinalysis
● Urine test strip—to assess for leucocytes, nitrite, protein, blood,
ketone bodies, glucose, bilirubin, specifi c gravity, and pH
● Midstream urine sample (MSU)
o Microscopy—to assess for haematuria, pyuria, red or white cell
casts
o Microbiological culture
● Renal tract USS
● Catheterization—to test for retention
● Urine output charts
● Biochemistry—blood serum electrolytes, urea and creatinine
assessment to assess renal function.

17. • ASB and acute cystitis - treated with antibiotic therapy.
• Antibiotic choice can be tailored based on organism
sensitivities when available from urine culture results.
• One-day antibiotic courses are not recommended in
pregnancy - 3-day courses are effective.
• Antibiotics commonly used include amoxicillin, ampicillin,
cephalosporins, nitrofurantoin, and trimethoprim-
sulfamethoxazole.
• Fluoroquinolones are not recommended as a first-line
treatment in pregnancy due teratogenicity.
• Short courses are unlikely to be harmful to the fetus
• Use this class of drugs with resistant or recurrent infections.
TREATMENT

19. • Sulfa derivatives and nitrofurantoin - congenital disabilities when prescribed in
the first trimester - to avoid if alternatives are available.
• Because the potential consequences of untreated uti in pregnancy are significant,
it is reasonable to use these medications when needed as the benefit strongly
outweighs the risk of use.
• Patients with G6P deficiency should not be prescribed sulfa derivatives or
nitrofurantoin as these medications can precipitate hemolysis.
• In the late third trimester, trimethoprim-sulfamethoxazole should be avoided due
to the potential risk for development of kernicterus in the infant following
delivery.
• If group b streptococcus (GBS) is noted on urine culture, patients should receive
intravenous (iv) antibiotic therapy at the time of delivery in addition to indicated
treatment for ASB or UTI. This is to prevent the development of early-onset GBS
sepsis which may occur in the infants of women who are colonized with GBS.

20. • Pyelonephritis in pregnancy - serious condition usually
requiring hospitalization.
• Treatment consists primarily of directed antibiotic therapy
and iv fluids to maintain adequate urine output.
• Fever should be treated with a cooling blanket and
acetaminophen
• 1st line - second or third generation cephalosporins
• Alternatives -ampicillin and gentamicin or other broad-
spectrum
• Monitor closely for the development of worsening sepsis.

21. Differential Diagnosis
• Differential diagnosis includes
Acute intraabdominal disease such as
 Appendicitis,
 Pancreatitis, or
 Cholecystitis as well as
Pregnancy-related complications such as
 Preterm labor,
 Chorioamnionitis, or
 Placental abruption.

22. Hydronephrosis or hydroureters
● Due to physiological changes or calculi
● For urological team review if symptomatic
Urinary retention—due to:
● Mechanical changes or obstruction: retroverted uterus in first
trimester, compression from presenting part in labour
● Infection

23. ASB (asymptomatic bacteriuria)
● 5% of pregnant women have asymptomatic, previously
unidentified urinary infection
● 30% of which will go on to develop symptomatic infections
o Increased risk of pregnancy complications (premature labour,
IUGR, pre-eclampsia).
● Important for regular antenatal urinalysis screening

24. Key information for the interpretation of urinary tract
symptoms and signs in pregnancy
Symptom/sign Physiological Physiological but requiring treatment Pathological
• Frequency ✔ ✘ ✔
• Nocturia ✔ ✘ ✔
• Dysuria ✘ ✘ ✔
• Urgency ✔ ✘ ✔
• Incontinence ✔ ✘ ✔
• Retention ✔ ✔ ✔
• Incomplete ✔ ✔ ✔
• Haematuria ✘ ✘ ✔

25. Patients with pyelonephritis are at risk for several
significant complications.
• ICU Admissssion - Sepsis resulting in hypotension,
tachycardia, and decreased urine output..
• Pulmonary complications are not uncommon - up to 10% of
pregnant patients undergoing treatment for pyelonephritis -
due to endotoxin-mediated alveolar damage - pulmonary
edema or acute respiratory distress syndrome (ARDS).
• Monitor Urine output and oxygen status closely
• May require ICU admission for respiratory support.

27. • Endotoxin release may lead to anemia, this typically resolves
spontaneously following treatment - common complication
seen with pyelonephritis - in up to 25% of patients.
• Endotoxin release may also cause uterine contractions -
preterm labor – caution in use of tocolytic therapy as the risk
of pulmonary edema is increased in the setting of UTI.
• A small number of patients may experience persistent
infection - urinary obstruction or renal abscess.
• Antibiotic choice should be re-evaluated and culture results
reviewed.