ASYMPTOMATIC BACTERIURIA IN PREGNANCY
& ITS EFFECT OF SCREENING & TREATMENT ON MATERNAL AND FETAL OUTCOME
Dissertation submitted for partial fulfilment of the requirements for the degree
M.D. (OBSTETRICS AND GYNAECOLOGY) BRANCH II
DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY, TIRUNELVELI MEDICAL COLLEGE,
TIRUNELVELI - 620711.
THE TAMILNADU
DR.M.G.R.MEDICAL UNIVERSITY, CHENNAI.
APRIL 2013.
CERTIFICATE
This is to certify that this dissertation entitled “Asymptomatic bacteriuria in pregnancy & its effect of screening & treatment on maternal and fetal outcome”, is a bonafide work done by Dr.P.Shankari, at the Department of Obstetrics and Gynaecology, Tirunelveli medical college, under our supervision and guidance in partial fulfillment of the regulations laid down by the Tamil Nadu Dr.M.G.R.
Medical University, Chennai, for the award of the degree of M.D. in Obstetrics and Gynaecology in the examination to be held in April 2013.
The Dean,
Tirunelveli Medical College, Tirunelveli – 627 011
CERTIFICATE
This is to certify that this dissertation entitled “Asymptomatic bacteriuria in pregnancy & its effect of screening & treatment on maternal and fetal outcome”, is a bonafide work done by Dr.P.Shankari, at the Department of Obstetrics and Gynaecology, Tirunelveli medical college, under our supervision and guidance in partial fulfillment of the regulations laid down by the Tamil Nadu Dr.M.G.R.
Medical University, Chennai, for the award of the degree of M.D. in Obstetrics and Gynaecology in the examination to be held in April2013.
Prof.Dr.MEENA MD(OG).,DGO.,DNB.
Professor and HOD,
Department of Obstetrics and Gynecology, Tirunelveli Medical College,
` Tirunelveli– 627011.
DECLARATION
I hereby solemnly declare that this dissertation entitled
“Asymptomatic bacteriuria in pregnancy & its effect of screening &
treatment on maternal and fetal outcome”, was done by me at Tirunelveli Medical College, Tirunelveli-11 during February 2012- November 2012 under the guidance and supervision of Professor Dr.MEENA MD(OG).,DGO.,DNB. This dissertation is submitted to the Tamil Nadu Dr.M.G.R. Medical University towards the partial fulfillment of requirement for the award of M.D. Degree Branch II (Obstetrics and Gynaecology).
Place:Tirunelveli Signature of the Candidate Date: Dr.P.Shankari,
PostgraduateStudent ,
M.D. Obstetrics and Gynaecology,
Department of Obstetrics and Gynaecology, Tirunelveli Medical College,
Tirunelveli.
ACKNOWLEDGEMENT
I gratefully acknowledge and sincerely thank Dr.Prof.M.Manoharan,M.S., Dean, Tirunelveli Medical College, Tirunelveli for granting me permission to utilize the facilities of the Department for my study.
I am extremely grateful to Dr.MEENA MD(OG).,DGO,DNB, our Director, Professor and Head of the Department of Obstetrics and Gynaecology, Tirunelveli for her guidance and encouragement given in fulfilling my work.
I am extremely thankful to Dr.Muthuprabha.M.D(O.G) for her extensive support, advice and guidance in the analysis and successful completion of this study.
I sincerely thank all the UNIT CHIEFS for their support. I am extremely thankful to all the Assistant Professors of the department of obstetrics and gynecology for their guidance and support.
I thank Prof. Dr.Palaniappan MD, HOD, Department of Microbiology,Tirunelveli medical college,Tirunelveli for allowing me to use the hospital resources.
I thank all the medical and paramedical staff for assisting me in completing my work.
Last but not the least, I am extremely thankful to all the patients who have readily consented and cooperated in the study.
CONTENTS
S.NO. CONTENTS PAGE NO.
1. INTRODUCTION 1
2. AIMS OF THE STUDY 5
3. REVIEW OF LITERATURE 6
4. MATERIALS & METHODS 46
5. OBSERVATIONS & RESULTS 53
6. DISCUSSION 79
7. SUMMARY & CONCLUSION 87 8. BIBLIOGRAPHY
9. ANNEXURE
a. ABBREVIATION b. PROFORMA c. MASTER CHART
d. ETHICAL COMMITTEE APPROVAL ORDER
ABBREVIATIONS
ACOG - American College of Obstetricians and Gynaecologists
AN OP - Antenatal Out Patient ASB - Asymptomatic Bacteriuria
ARDS - Adult Respiratory Distress Syndrome BP - Blood Pressure
CFU - Colony Forming Unit E.COLI - Escherichia Coli
FDA - Food and Drug Administration G - Gravida
G6PD - Glucose 6 Phosphate Deficiency GBS - Group B Streptococcus
GDM - Gestational Diabetes Mellitus GFR - Glomerular Filtration Rate H/O - History Of
H2O2 - Hydrogen peroxide HB - Haemoglobin HCT - Hematocrit
HPF - High Power Field
IUGR - Intra Uterine Growth Restriction LBW - Low Birth Weight
LE - Leucocyte Esterase LLP - Left Lateral Position
LSCS - Lower Segment Caesarean Section O2 - Oxygen
PET - Pre-eclamptic Toxaemia
PROM - Premature Rupture Of membranes PTD - Preterm Delivery
RBC - Red Blood Corpuscles SE - Socio Economic
UTI - Urinary Tract Infection WBC - White Blood Corpuscles
1
INTRODUCTION
UTI is the most common renal problem occurring in pregnancy.
The urine of gravidas supports bacterial growth better than that of non- pregnant women because of its increased nutrient content. This, as well as ureteral dilation, stasis and occasional obstruction, would be expected to increase the susceptibility of pregnant women to UTI.
UTI can be classified as follows:
Asymptomatic bacteriuria is the presence of more than 105 colonies/ml of urine, without any symptoms of an acute urinary tract infection (Schnarr&Smaill, 2008). [1,2,3]
Lower tract infection and upper tract infections, according to the part of the urinary tract affected (Joseph DiPiro et al., 2011).
Lower urinary tract infection: site of the infection could be either bladder (cystitis) and/or the urethra (urethritis) (Joseph DiPiro et al., 2011).
Upper urinary tract infection: The kidney is the site of the infection (pyelonephritis - inflammation of the renal parenchyma, calices and pelvis) (Wagenlehner et al., 2009).
2
Uncomplicated UTIs:
Infections occurring in the absence of structural or functional abnormalities of the urinary tract that interfere with the normal flow of urine or voiding mechanism (Joseph DiPiro et al., 2011).
Complicated urinary tract infections:
Infection that occurs in persons who have abnormalities of urinary tract which hinders natural path of urine & urinary tract defensive mechanisms. The probable factors that lead to such complicated UTI are congenital anomalies, renal calculi, cathetrisation or block in the tract Masson et al., 2009).
Urinary tract infection in pregnant women is said to be complicated UTI.
Factors associated with complicated UTI:
Increased age
Nosocomial infection Pregnant women Catheterisation
Recurrent instrumentation Abnormalities of urinary tract Childhood Urinary Tract Infection Antibiotics used recently
3
Symptomatic UTI lasting for more than seven days Immunocompromised individuals
Diabetes mellitus.
ASB in pregnancy is 4 to 7 % prevalent which is comparable to women who are not pregnant.
The natural history of asymptomatic UTIs is, however, quite different in pregnancy. Although in the non-pregnant state asymptomatic bacteriuria is quite benign, progression to overt cystitis or pyelonephritis occurs in up to 40% of affected gravidas.
Therefore, screening all pregnant women for the presence of asymptomatic bacteriuria and treating those with positive urine cultures will prevent most of the symptomatic urinary tract infections including pyelonephritis and decreases premature and low birth weight infants.
Acute pyelonephritis during antenatal period may lead to anemia (23%), sepsis (17%), transient renal failure (2%), and pulmonary insufficiency (7%) . Multi-organ failure due to endotoxin & sepsis occurs in about one-fifth of the antenatal women. ARDS occurs in 1 in 50 women suffering from pyelonephritis.
4
On the other hand, an increased incidence of occult urinary tract pathology is present in these gravidas. Therefore, women with bacteriuria during pregnancy may benefit from evaluation of their urinary tract postpartum, especially those in whom the infection is resistant to therapy.
Screening of all antenatal mothers for asymptomatic bacteriuria not only reduces the maternal and fetal morbidity but also identifies urinary tract abnormalities.
5
AIMS OF THE STUDY
To find out the prevalence of ASB in antenatal women attending AN OP at our hospital.
To know the affliation of bacteriuria with age, parity and socioeconomic status.
To study the antimicrobial susceptibility pattern of pathogens isolated.
To study the effect of screening and treatment of ASB on maternal & fetal outcome.
6
REVIEW OF LITERATURE
UTI is a common clinical problem found in men and women belonging to all age groups.(Mananchie et al)
The various factors responsible for UTI to be more prevalent in females are anatomic differences, hormonal changes and behavior patterns.
The clinical presentations of Urinary tract infection depends upon 1. The part of the urinary tract affected.
2. The causative pathogen.
3. The extent of the infection.
4. The immunity of the patient.
The patient usually presents with pyrexia, chills, dysuria, urgency, frequent urination and cloudy or foul smelling urine.
The peak incidence of UTI is found amongst young women. The prevalence is about 1-3% in women, increasing to 20% in those over 65 years.
At least 50% of all females suffer from asymptomatic UTI at some part of time in their life.
50% of the women supposed to have UTI will show a negative culture and the symptoms are commonly due to urethral syndrome (inflammation of the urethra).
7
Among the antenatal women the prevalence of ASB is about 2-5%, which when left untreated leads to complications like preterm birth and pyelonephritis.
The frequency of urinary tract infection (UTI) in antenatal women is comparable to women who are not pregnant accounting to 0.3-1.3%.
On the whole, Urinary tract infections are 14 times common among female compared to males.
Such variation is due to multiple factors like:
Females have short urethra.
Distal part of the urethra in women is constantly exposed to vaginal & rectal flora.
Women do not empty the bladder completely.
Sexual intercourse exposes the urogenital tract of females to pathogens.
UTI is the most common infectious disease to occur in pregnancy resulting in five times as many febrile episodes as viral infections (Maranchie et al, 1997).
It also carries a much greater risk of progressing to recurrent symptomatic UTI and chronic renal disease (Kinningham, 1993).
8
The evidence that UTI in pregnancy may lead to premature birth and LBW babies (Mitterdorf et al, 1992)supports screening for asymptomatic bacteruria in pregnancy (Nicolle, 1994).
Studies have shown that the screening and subsequent treatment of asymptomatic bacteriuria in pregnancy is effective method for the reduction of symptomatic UTI and premature birth (Mitterdorf et al, 1992; Gratacos et al, 1994).
Various studies have determined the occurrence of ASB in pregnancy (Brown et al, 1987; Hooton, 1990; Kinningham, 1993).
The prevalence ranged from 2 to 7% of normal pregnancies.
9
DEFINITIONS:
BACTERIURIA:
Bacteriuria describes the presence of bacteria in urine.
Bacteriuria may result from the presence of bacteria in the urine, in the bladder or from contamination of urine during micturition through contact with the normal bacterial flora of the urethra, vagina, or perineum.
CLINICALLY SIGNIFICANT BACTERIURIA:
The term is used to discriminate true bacteriuria and contamination.
When more than 105 CFU of a same type of bacteria is present per ml of urine it is defined as significant bacteriuria.
Contaminated sample usually yields lesser number of bacteria per ml and/or bacteria of mixed species.
ASYMPTOMATIC BACTERIURIA:
ASB is referred as persistently proliferating bacteria in the urinary tract of women who have no symptoms of acute UTI.
PYURIA :
When more than five WBCs are present per HPF in the urine it is defined as pyuria(grade C).
It indicates inflammatory changes due to infection.
10
RENAL AND URINARY TRACT CHANGES DURING PREGNANCY
Pregnancy is a condition which has unique changes in urinary system both anatomically and physiologically.
Though ASB does not cause any serious effect in women who are not pregnant, it makes antenatal women more susceptible to pyelonephritis .
The following physiological changes take place during pregnancy:
Ureteric and renal pelvic dilatation starts as early as the 8th week of gestational age which is frequently found on the right side (86% ) .The degree of dilatation of calyx is also pronounced on the right( 15 mm vs 5 mm).[12,13,14]
There is anterior and upward shift in the position of bladder.
Vascularity increases.
Bladder volume increases to 1500 ml.
The compressing effect of the gravid uterus is the principle reason of hydroureteronephrosis.[13]
The progestrogenic effect on smooth muscle causes relaxation of it which in turn causes reduced ureteric peristalsis, increase in bladder volume & stasis of urine.
Urinary pH, osmolality ,glycosuria due to pregnancy and aminoaciduria facilitates growth of bacteria. Glycosuria occurs
11
because of impairment of resorption by collecting tubule &Henle’s loop. Though the mechanism of aminoaciduria is not known, it influences the adhesion of E.coli to urothelium.[12,13,14]
GFR (50%) and urine output are increased due to increase in blood volume.
Fall in serum creatinine & blood urea nitrogen.
Rate of flow of urine & rate at which sodium is excreted alters with change in position -2 times greater with LLP than supine position.
Renin starts to rise from 1st trimester & rises till term.
Less susceptible to the effects of angiotensin 2.
12
EPIDEMIOLOGY OF ASYMPTOMATIC BACTERIURIA IN PREGNANCY:
UTI is the bacterial infection which occurs commonly in pregnant women.
Many recent studies state that ASB occurs in 2 to 10 % of all pregnant women which is found to be similar in most countries.[15,16,17] [Eyalsheiner et al,Abdullah et al,samad et al,Shameel et al]
13
UTI & ITS NATURAL COURSE IN WOMEN Relapse:
Infections occuring within 7 days of initial treatment it is called as relapse.
It is commonly due to the presence of proximal urinary tract infection or functional & anatomical abnormalities in urinary system.
However reinfection is not related to abnormal urinary tract.
Recurrent UTI:
Recurrent UTI is more common in women.
More than three episodes of urinary tract infections confirmed with culture in the past one year or two episodes in the past six months.
It occurs in females with normal urinary tract because of increased ability of Escherichia coli to adhere to the urothelium and because of E.coli colonizing the vagina in abundance.
Other important external factor leading to recurrence of UTI in a healthy female is sexual activity.
14
UTI IN PREGNANCY
It occurs in 5% of pregnant women during 1st trimester.
Its incidence increases with age & with successive pregnancies.[6]
UTI is bacteriuria in the bladder or upper urinary tract.
Catheterizing and aspirating from the bladder are meddlesome procedures to collect urine sample.
Urine obtained after voiding is easier for collection but it could not be interpreted reliably due to high chance of contamination.[8]
Significant bacteriuria is the amount of organisms in urine that reliably differentiates true bacteriuria and contaminated sample.
Correlation between urinary tract infections and quantity of pathogens present in the urine was studied by E.H Kass & others.
They reported colony forming units of more than 105 organisms /ml of the sample differentiated contaminated samples and symptomatic pyelonephritis and similar count is to be obtained from consecutive samples of urine to confirm ASB.
UTI in pregnant women can be grouped into asymptomatic or symptomatic.
Asymptomatic bacteriuria is the presence of significant bacteriuria without any symptoms of urinary tract infection.
15
Symptomatic UTI is further classified into, 1. lower tract( cystitis) and
2. Upper tract (acute pyelonephritis) infections.
ACUTE CYSTITIS:
Cystitis is the significant bacteriuria in association with invasion of bladder mucosa.
It can be differentiated from ASB by the presence of symptoms such as dysuria, urgency and frequency, but has no systemic involvement.
Cystitis should be confirmed by culture sensitivity/more than eight WBCs seen per mm3of unspun urine/more than five WBCs seen per mm3 of spun urine (grade C).
These symptoms are commonly given by pregnant women even in the absence of UTI.
About 81% of antenatal women have complaints of frequent urination at certain period during pregnancy.
16
Acute cystitis occurs in approximately 1% of pregnancies and may develop without antecedent covert bacteriuria.
Cystitis usually requires 7 to 10 day course of antibiotic therapy.
Single dose therapy is less effective. For simple cystitis, urine culture should be repeated after 1 to 2 weeks of completion of therapy.
17
Differential diagnosis:
Vaginitis Urethritis Pyelonephritis
18
ACUTE PYELONEPHRITIS:
Pyelonephritis is the significant bacteriuria along with renal parenchymal, calyceal and pelvic inflammation. (Kazenier et al) It could lead to septicaemia and preterm delivery.[4]
It is more frequent during 2nd trimester.
Nulliparity and young age are associated risk factors.
It is unilateral and more common in right side whereas ¼th of the women exhibit bilaterally.(Williams)
Onset is acute rise in temperature, chills & renal angle tenderness .It may be associated with vomiting and anorexia.
Bacteraemia is demonstrated in 15 to 20 % of cases.
DIFFERENTIAL DIAGNOSIS:
Labour
Chorioamnionitis Appendicitis
Placental abruption Infarcted myoma
19
COMPLICATIONS:
There is a long list of complications associated with ASB.
Females with ASB are associated with treatment for infertility, repeated pregnancy loss, diabetes mellitus & hypertension.
But the compliance among these patients is found to be less than the expected since ASB by definition, has no symptoms.
20
ASYMPTOMATIC BACTERIURIA AND PYELONEPHRITIS The important risk factor for symptomatic infection is ASB.
If ASB is not treated, it leads to acute pyelonephritis in 30% of them in comparison with controls where the chance is 1.8%.
A retrospective study showed that chills and back ache were the chief complaints in 82% of them. Renal angle tenderness was present in almost all.[18,19]
ACUTE RESPIRATORY DISTRESS:
Important sequela of sepsis is ARDS.
It is noted in 1 in 50 women having acute pyelonephritis .
Respiratory insufficiency is due to endotoxin mediated damage to alveoli.[20,21,56]
This could be further aggravated by inadvertent use of fluids &
tocolytics.
RENAL FAILURE:
Renal dysfunction occurs in 25% of the antenatal patients with pyelonephritis, however it is usually benign.[58]
ANAEMIA:
Maternal anaemia (Hct less than 30%) is caused by endotoxin mediated hemolysis.
It is found in 25to 66% of cases and typically resolves following treatment.
21
PRE-ECLAMPTIC TOXAEMIA:
Preeclamptic toxaemia predisposes antenatal women for urinary tract infections.
The rate of urinary tract infections in women with normal BP is 16.2% where as this increases to 27.3% in mild PET & 35.9% in severe cases according to a retrospective study.
It was speculated from various studies that the basic renal pathology in PET predisposes to upper urinary tract infection by hindering the defensive mechanisms.
FETAL SEQUELAE:
Pyelonephritis in antenatal women leads to various complications in the babies like bacteraemia, respiratory distress, anaemia, renal disease, prematurity and LBW.(Mittendorf et al)[60]
Decreased blood flow to uterus resulting from dehydration,anaemia
& toxin mediated damage to vessels of placenta causes reduced blood flow to fetal brain.
If ASB is more than 2% prevalent & the incidence of pyelonephritis is more than 13% the need to screen for ASB is cost effective & could be accepted.[26,44]
22
MANAGEMENT OF PYELONEPHRITIS:
Early and intensive treatment is vital to prevent complications caused by pyelonephritis.
Hospitalisation is indicated in
1. Patients with evidence of sepsis.
2. Patients complaining of vomiting & not able to maintain hydration.
3. Patients having uterine contractions.
Intravenous hydration
Monitoring of urinary output, blood pressure and temperature.
Urine culture and sensitivity.
Antimicrobials are started empirically after taking urine sample for urineculture. Ampicillin plus gentamicin, cefazolin or ceftriaxone have been shown to be effective in 95% of cases.
Parenteral antibiotics should be continued until patient is afebrile.
Patient can be discharged if afebrile for 24 hours.
Since acute pyelonephritis has an increased risk of recurrent UTI and recurrent pyelonephritis, continuous antibiotic prophylaxis is given for the rest of the pregnancy.[23]
Nitrofurantoin 100mg once daily is effective.
23
Treatment failure may occur due to the following reasons:
1. Resistance of the infecting organisms to the antibiotics.
2. Possible structural or anatomical renal abnormalities.
3. Persistent infection due to urolithiasis.
4. Rarely due to perinephric abscess.
These could be diagnosed by renal ultrasound or abbreviated intravenous pyelography.
Ambulatory treatment in pyelonephritis:
Pyelonephritis can be treated as outpatient basis if patients are carefully selected.
Various study results recommend outpatient treatment of pyelonephritis upto 24 weeks of pregnancy..[31,32]
24
ASYMPTOMATIC BACTERIURIA AND PRETERM DELIVERY:
Preterm delivery is the main cause of neonatal mortality and morbidity worldwide.
The causal mechanisms remain unknown.
One of the hypothesis is that endotoxins released by bacteria cause uterine contractions leading to preterm delivery (<37 weeks) Mittendorf et al.
Pathogenesis of preterm delivery [9]:
The various biochemical changes that are attributed to preterm labour following asymptomatic bacteriuria are
1. elevated pH
2. increase in the amount of diamides&polyamines
3. Production of sialide, mucinases, nonspecific proteases, and phospholipase A2 and C.
The toxins synthesized by proliferating pathogens stimulate the fetal membrane & decidua to elaborate cytokines.
Toxins and cytokines together stimulate & release PG which in turn results in production of proteases which induces preterm labour.
25
Pathogenesis of preterm delivery
26
NEED FOR SCREENING AND TREATING ASYMPTOMATIC BACTERIURIA:
Symptomatic bacteriuria is the tip of an iceberg of total bacteriuria.
Pregnancy provocates the asymptomatic infections to become symptomatic infections.
About 10% of those with asymptomatic bacteriuria develop symptomatic bacteriuria during pregnancy (Efray major dray).
Symptomatic bacteriuria is easily diagnosed and treated due to its overt symptoms.
But asymptomatic bacteriuria is difficult to diagnose and it is more common in pregnant women than non-pregnant women.
If not treated about ¼th of the antenatal women with bacteriuria in pregnancy will end up in symptomatic urinary tract infection.[9]
If treated the risk is reduced to 80-90% (Group A).
Therefore there is a need to routinely screen& treat all pregnant women for ASB.[9,10,11]
27
ORGANISMS CAUSING URINARY TRACT INFECTIONS:
Organisms causing bacteriuria are alike in pregnant and non-pregnant women.
The organisms commonly causing UTI in pregnancy are members of the gastrointestinal and vaginal flora.
These include
1. Escherichia coli (80 -90%) 2. Klebsiellapneumoniae (5%) 3. Proteus mirabilis (5%) 4. Enterobacter species (3%)
5. Staphylococcus saprophyticus (2%)
6. Group B beta-hemolytic Streptococcus (GBS; 1%) 7. Proteus species (2%)
Gram-negative organisms -> Escherichia coli, Klebsiella, Enterobacter, Citrobacter and Proteus.
Gram-positive organisms-> Group B Streptococci, Enterococci, Staphylococcus saprophyticus and Staphylococcus epidermidis.
28
Escherichia coli:
E. coli is the common (70 to 80 %) organism related to symptomatic
&asymptomatic bacteriuria.
Virulence factors responsible for colonization of E.Coli are 1. P-fimbriae & S-fimbriae adhesions.
2. Toxins.
These virulence factors
1. Favour the bacteria to adhere to urothelium . 2. Prevent from urinary lavage.
3. Allow the bacteria to multiply.
4. Help to invade the tissue.
Virulence determinants are more frequently found in E. coli causing pyelonephritis (75%) than that is seen in ASB (22%).
Group B Streptococcus (Streptococcus agalactiae):
GBS obtained from the urine of pregnant women is found to cause PROM, preterm labour& sepsis in newborn.
Randomized trials show that there is reduction in PROM &
preterm labour if antenatal women are treated for GBS bacteriuria.
It is recommended to properly treat and give intrapartum prophylaxis in GBS bacteriuria to avoi
&chalas et al).
PILI HELPS IN ADHESION OF BACTERIA TO UROTHELIUM
HOST INFLAMMATORY RESPONSE
INFLUX OF NEUTROPHILS
APOPTOSIS
EXFOLIATIAN OF BLADDER EPITHELIUM
29
Group B Streptococcus (Streptococcus agalactiae):
GBS obtained from the urine of pregnant women is found to preterm labour& sepsis in newborn.
Randomized trials show that there is reduction in PROM &
preterm labour if antenatal women are treated for GBS bacteriuria.
It is recommended to properly treat and give intrapartum prophylaxis in GBS bacteriuria to avoid neonatal sepsis
PILI HELPS IN ADHESION OF BACTERIA TO UROTHELIUM
HOST INFLAMMATORY
INFLUX OF NEUTROPHILS
APOPTOSIS
EXFOLIATIAN OF BLADDER EPITHELIUM
GBS obtained from the urine of pregnant women is found to
Randomized trials show that there is reduction in PROM &
preterm labour if antenatal women are treated for GBS bacteriuria.
It is recommended to properly treat and give intrapartum neonatal sepsis (Hankins
30
In cases of GBS UTI, vaginal carriage should be investigated.
Antibiotic treatment, notably penicillin, during labor or after membrane rupture, has been recommended for pregnant women who have a GBS UTI or who have had a baby with GBS disease,or those who are found to be GBS carriers (Hankins and Chalas, 1993).
After delivery, cotrimoxazole or ciprofloxacin can be used to treat subsequent UTIs.
CHOICE OF ANTIBIOTICS:
The range of antibiotics that can be used in pregnancy is rather limited because of the possibility of fetal damage (Bukhari and Livsey, 2000).
1. Ampicillin can be used selectively for Gram-negative organisms and remains the best choice for group B Streptococcus.
2. Ciprofloxacin, while fairly effective across the board, is contraindicated in pregnancy because of safety.
3. For the Gram negative organisms, cephalexin remains a sound choice, provided urine culture and an antibiogram support its use.
4. Cefuroxime may give even better results, as it does in vitro.
5. Cotrimoxazole showed impressive activity against both Gram- positive and Gram negative organisms; however it must be used with caution in pregnancy.
31
6. From various studies, the oral drug of choice for the empirical treatment of suspected UTI in pregnancy is cefuroxime, assuming that the Enterobacteriaceaeare the most frequent pathogens.
7. Cephalexin is recommended only when initial urine for culture and sensitivity is available and patients can readily be followed up.
TIMING OF SCREENING FOR ASB:
The literature does not provide clear guidelines regarding appropriate time and frequency to screen ASB.
A Swedish study made prospectively analysed the risk of procuring bacteria in antenatal period.
The risk of procuring bacteriuria expanded from 0.8% at 12th week of gestation to 1.93% towards term.[27]
The risk of acquiring bacteriuria was found to be maximum between the 9thand 17th gestational week & 16th week of gestation was the ideal time to screen& treat since this provides the maximum number of bacteriuria free gestational weeks during the antenatal period(Stenquist et al).
Hence the rational method would be to screen the antenatal women during 2nd trimester when the chance of acquiring bacteriuria is maximum.
32
US Preventive Services Task Force & ACOG recommends to perform urine culture between 12th & 16th gestational age.(“A”
recommendation.)[22]
URINE SPECIMEN COLLECTION:
In all antenatal women, a urine sample is to be collected for during 1st antenatal checkup or at 12th & 16th week of gestation for analysis of urine culture & sensitivity (Group A).
This helps in identification of ASB and incidental finding of glycosuria.
Midstream clean catch sample is the ideal sample for urine culture.
The following instructions are to be followed by the patients:
1. Labia are spread with one hand.
2. Using opposite hand with a towel urethral meatus is wiped from above down towards rectum & discarded.
3. First portion of urine is voided out.
4. Mid portion of the bladder content is caught in a sterile container, while the labia are kept spread apart using the first hand.
Unfortunately the study conducted on pregnant women suggested that the above process does not completely eliminate the risk of getting contaminated.
33
METHODS TO EVALUATE THE URINE SAMPLE
Though there are numerous methods for evaluating the sample obtained, each of it has its own advantages & disadvantages.
The probability of contamination is reduced with clean catch specimen but is not completely eliminated.
If more than one pathogen is obtained from the culture, it is considered that contamination has occurred.
The sample must be sent for analysis as early as possible.
False positive results are obtained if there is delay in transportation and if kept in room temperature.
If immediate transport is not possible, the sample should be refrigerated at 4 °C.
URINE CULTURE:
An important point to be noted in diagnosing symptomatic &
asymptomatic urinary tract infection is to differentiate contaminated sample & true bacteriuria.
Urine culture is the gold standard in the evaluation for UTI in the antenatal period (Pereira et al).
34
Indications for urine culture:
1. Recurrent UTI 2. Pyelonephritis
3. Not responding to initial treatment regimens 4. Any instrumentation done recently
5. Hospital admission Culture positive:
105 CFU/ml or more of same bacterial species obtained from 2 consecutively voided samples is the historical definition for culture positivity. (Gerber et al)
Single catheterised sample showing a colony count of at least 100 colony forming units /mL also has a diagnostic value.
Counts less than 105 colony forming units per mL, having two or more organisms, indicate contaminated sample and not infection.
Culture & sensitivity identifies specific organisms and their sensitivity to antibiotics.
Drawbacks of urine culture:
• Time lag(results are available after 24 hours if there is no significant growth)
• High cost
35
URINALYSIS:
Positivity for nitrites, leukocyte esterase, white blood cells, red blood cells (RBCs) & proteins indicate Urinary Tract Infection.
Bacteria seen in the specimen can help in diagnosing
Negativity for pus cells is not an acceptable criterion for the absence of ASB in antenatal women.
Thus, all urine specimens, regardless of leukocyte count, should be sent for culture and sensitivity.
Urinalysis shows a specificity of 97-100% has a sensitivity of 25- 67% in comparison with culture in diagnosing ASB in antenatal women.
1-2 bacteria in uncentrifuged catheterized sample or greater than 20 bacteria per HPF in centrifuged sample correlates with bacterial colony counts greater than 105 colony forming units per mL in a urine culture (Millar & Cox).
Dipstick test:
Urine dipstick test for nitrites and leukocyte esterase for screening of ASB has been reported in several studies.
When compared with culture, the sensitivity ranges between 50%
& 97% & specificity is between 86% &97%.
36
Dipstick testing is useful & less expensive in screening patients with symptoms but leukocyte esterase test is not reliable in cases having less number of pus cells. (5-20 WBCs per High Power Field).
Dipstick test for nitrites is acceptable & cost effective approach to screen patients in developing countries where other methods of screening may not be feasible(kodikara et al).
ROLE OF VARIOUSOTHER SCREENING TESTS FOR ASYMPTOMATIC BACTERIURIA
Other screening tests for bacteriuria
Microscopic examination for bacteria and pus cells.
Tests for bacterial products
1. Griess test-Nitrite reduction test 2. Catalase test
Screening test for pyuria – Leucocyte esterase test.
Microscopic examination:
Gram stain of urine is an inexpensive method but it is not used as a screening test because methodically reviewing the smears is too labor intensive.
Gram staining of centrifuged urine has a good sensitivity but specificity is low. Therefore Gram stain is not an accepted test to screen ASB.
37
Urine analysis has a false negativity of 19.4%.
Reagent strip testing has a false negativity of 52.8%.
Griess Test (Nitrite reduction test):
The rationale is that most uropathogens are nitrate reducing.
False positive results may occur if the specimen is delayed in transit and overgrown with nitrate reducing bacteria.
It is a rapid screening test taking 2 minutes to read by eye and pink color denotes positive test.
Limitations:
False negative results occur if the organism is not nitrate reducing (e.g. Enterococcus) or if the patient is on vegetable free diet (loss of an important source of nitrate) or if insufficient time has elapsed since the last void for nitrites to appear at detectable levels.
Leucocyte esterase test:
It is an enzyme produced by neutrophils.
A reagent strip is used to detect its activity.
The advantage is that the leucocytes need not be viable for LE activity to be detected.
False positive LE test: may be due to high urinary levels of ascorbic acid or albumin level of more than 300mg/dl or from the effects of preservatives and detergents.
38
False negative LE test: when urine WBC counts are in the marginal range of 5-10/HPF, when correlated with >10WBCs/HPF the sensitivity lies between 70 & 84% & specificity varies between 70
&94%.
According to U.S. Preventive Services Task Force (USPSTF 2000), the tests used to screen for ASB in pregnancy (dipstick and direct microscopy) have poor positive and negative predictive values.
Urine culture is the recommended gold standard test to detect ABU. If ASB is more than 2 % prevalent ,urine culture is cost effective method to screen routinely(Pereira et al).
Catalase test:
O2 is released from H2O2 by the catalyzing action of catalase. This enzyme is demonstrated in this test.
One ml of H2O2 solution is poured over a 24hr nutrient agar slope culture of the test organism and the tube is held in a slanting position.
If gas bubbles are produced from the culture medium as soon as adding H2O2 it denotes a positive test.
False positivity is sometimes due to the presence of catalase in the medium.
39
This method offers no advantage over other tests. It functions similarly to nitrite test and suffers from same defects.
Various rapid screening tests reported to be available to screen asymptomatic bacteriuria are urine Gram staining, microscopic analysis of urine & bioluminescence assays.
Gram staining of urine without centrifuging is 85.1% sensitive &
has a negative predictive value of 98.8%.
All samples should be sent for culture, because none of the rapid tests, including the screening for pyuria, are reliable in screening ASB among antenatal women.
Wadland and colleague showed that screening for asymptomatic bacteriuria was cost effective unless ASB is less prevalent than 2
% or the risk to acquire pyelonephritis with ASB becomes less than 13%, or the efficiency of treatment to prevent pyelonephritis becomes less than 38%(Rouse DJ et al).
It was concluded from various studies that the simple analysis of urine is less sensitive (Group E).
The probable complications of asymptomatic bacteriuria , are to be considered and urine analysis must not be used to screen asymptomatic bacteriuria in antenatal women.[33,34]
40
TREATMENT FOR ASB IN ANTENATAL WOMEN:
Though the need to screen and treat ASB in antenatal women has been recommended in universal guidelines, there is continuing conflict with regards to the role of ASB in perinatal outcome.
There are no universally accepted guidelines regarding the duration of treatment or the choice of antibiotic.
Therefore treatments are mostly based on local resistance patterns.
The antibiotics selected must have the following criteria 1. Must be safe to the mother & fetus.
2. Have excellent potency.
3. Show low resistance rates.
Though many antibiotic regimens are suggested by many studies, increasing resistance to antibiotics complicates the use of empirical regimens.
Antibiotic treatment compared to placebo or no treatment effectively clears ASB & reduces the risk to acquire pyelonephritis in antenatal women.[29]
Preterm birth &LBW babies are reduced with use of antibiotic treatment [Smail F et al], Cochrane review.
Since E.coli is the commonly associated organism with ASB in antenatal women, empirical treatment is to be considered.
41
Desperately about 40% of Escherichia coli exhibit resistance to ampicillin & sulphonamides. Therefore they are not recommended.
Nitrofurantoin is found to have low level of resistance because of its various modes of action. But it causes hemolysis in cases with G6PDdeficiency and hence to be used cautiously in areas where it is highly prevalent.
In case if bacteria are resistant to first line drugs, Cephalosporins are preferred.
Cephalexin is commonly used in antenatal women.
But cephalosporins are ineffective against Entercoccus spp.
When opting for any drug to be used in antenatal women, it should have well-established properties and newer drugs are not preferred considering the ethics.
β-Lactams & cephalosporins are few of the earliest antibiotics made
use of in treating bacterial infection.
Though beta lactam antibiotics are not teratogenic, their use in UTI is limited because of increased resistance of E.Coli to them.
Cephalosporin & fosfomycin are approved by FDA to treat UTI in pregnancy (Gilstrap et al).
One-day nitrofurantoin was compared with seven day regimen for ASB in antenatal women (Lumbiganon P, Villar J, Laopaiboon M, et al.Pisake et al).[24]
42
No difference was found between 7-day and 1-day regimen for the outcome of symptomatic UTI, PTD & LBW (Lumbiganon et.).
According to a recent trial conducted by WHO, 1-day regimen of nitrofurantoin is not effective as 7-day regimen to treat women with asymptomatic bacteriuria(Schnarr et al).
The bacteriological cure rates for 7-day and 1-day regimen were 86.2% and 75.7% respectively. There was a difference of 10.5%.
The widespread use of antibiotics as a result of the screening program is a reason for concern.
The ORACLE Children Study II showed increased functional impairment in children from mothers using antibiotics for the prevention of preterm labour in pregnancy.
Other studies also showed an adverse effect of antibiotics on the offspring, such as increased antibiotic resistance in late onset serious bacterial infections
Considering these results, one should carefully balance the consequences of bacteriuria in pregnancy against the possible effects of antibiotics, before routinely treating all women with ASB.
43
ANTIBIOTIC REGIMENS FOR MANAGEMENT OF ASB DURING ANTENATAL PERIOD:
S.no Antibiotic Drug category
in pregnancy Dosage
1 Cephalexin B 250 mg 2-4 times
daily
2 Erythromycin B 250-500 mg 4 times
daily
3 Nitrofurantoin B 50-100mg 4 times
daily
4 Sulfisoxazole * C 1g qid
5 Amoxicillin- clavulanic acid
B 250 mg qid
6 Fosfomycin B One 3 g pack
7 Trimethoprim- Sulfamethoxazole #
C 160/180 mg bd
* Not to be used at term
#not to be used in 1st trimester & term
44
ADVANTAGES AND DISADVANTAGES OF VARIOUS ANTIBIOTICS USED TO TREAT UTI:
S.
No.
Commonly used Antibiotics In pregnancy
Advantages Disadvantages
1 AMPICILLIN No teratogenic
effects
1)high resistance rates
2)sometimes associated with allergic and anaphylactic reactions
2 CEPHALEXIN No teratogenic
effects
1)ineffective against Enterococcus species
2)sometimes associated with allergic &anaphylactic reactions
3 NITROFURANTOIN
1)safe in all trimesters 2)low level of resistance among
uropathogens
1)achieves therapaeutic levels only in the urine, so it cannot be used to treat pyelonephritis 2) ineffective against proteus spp.
3)Haemolytic anaemia in G6PD deficient cases
4 COTRIMOXAZOLE
1)neural tube defects if used in 1st trimester
2) contraindicated after 32 wks since it causes
jaundice & hemolytic anemia in G6PD deficient babies
45
NON PHARMACOLOGICAL TREATMENT OF UTI:
1. Ample consumption of fluids
2. Emptying the bladder after intercourse 3. Cranberry juice
4. Yoghurt-has lactobacillus
5 FOSFOMYCIN
1)single dose is as effective as multiple doses of other
antibiotics 2)low
incidence of resistance
needs more evidence for use in pregnancy
46
MATERIALS AND METHODS
Inclusion criteria:
1. Pregnant women between 12 to 16 weeks attending ante natal clinic irrespective of parity.
2. Pregnant women with no signs & symptoms of UTI.
3. Patients planning to get delivered at our hospital.
Exclusion criteria:
1. Symptoms suggestive of UTI (flank pain ,dysuria) 2. H/O fever
3. Diabetics, anaemia, heart disease
4. Who has taken antibiotic therapy recently (within in 7 days) 5. History of urolithiasis
6. History of preterm delivery, PROM
7. Known case of renal disease and patients with renal anomalies 8. Multiple pregnancy ,hydramnios
9. History of fetal congenital malformations
47
METHODOLOGY
The study was conducted during the period between February 2012 and November 2012 among the pregnant women attending the antenatal clinic in Tirunelveli medical college hospital.
The women included in the study belonged to 17 and 36 years of age group (mean age 28 years).
The parity ranged between 0 and 3. They were presenting to the hospital for the first time in the antenatal period.
There was no history of taking antibiotics for any reason within the last 2 weeks before which the study was started.
They had no history or complaints suggestive of UTI.
The aim of the study was explained to them and informed consent was obtained.
Patients who were not willing to participate in the study were excluded.
Apart from the routine investigations taken during the first visit, a midstream clean catch early morning sample was collected from each of them.
The method to reduce the chances of contamination was explained to them.
The sample was collected in sterile containers and sent for processing immediately or within two hours of collection.
48
The sample was separately taken for three different tests.
The urine sample of each patient was tested for the presence of nitrite by dipstick and one portion was sent for routine urine analysis and another portion sent for culture and sensitivity and colony count.
URINE CULTURE & SENSITIVITY:
Mac Conkey agar, blood agar and Sabouraud dextrose agar plate were used for culturing the sample .1/10th of the dilution were made and both the undiluted &diluted samples were coated to the culture medium.
About 0.01 ml of the sample was used. One set of the inoculated plates were incubated aerobically &the other set incubated anaerobically to detect facultative& strict anaerobes.
Incubation was done at 37°C for aerobic cultures for 24 hours and anaerobic plates were incubated for 72 hours.
The aerobic plates which showed no growth were reincubated for another 24 hours and the final report was taken.
Specimens with 105 or more bacteria per ml were considered to have significant bacteriuria.
49
Protocols of Cowan and Steel were used to identify the bacterial colonies in the culture medium. The CFU/ml was compared to the number of pus cells of the wet preparation to get significant bacteriuria.
Growth is said to be significant if 105 CFU/ml was obtained in culture & the microscopy showed more than 3–5 pus cells/HPF.
Sensitivity was obtained by disc diffusion method (multidisc Oxoid).
Interpretation was made following Zone-size interpretative chart using the Kirby–Bauer method.
PROTEINURIA:
For testing proteinuria, the tip of the reagent strip was immersed in freshly obtained sample of urine for about one second & shaken off by tapping the strip to the edge of the container.
At the end of 60 seconds the strip was correlated with the colour scale (yellow for negative & green blue for positive).
URINE MICROSCOPIC EXAMINATION:
The urine sample was studied under the light microscope.
The pathological indices noted are presence and number of RBCs, pus cells, epithelial cells & casts.
50
Counting was done with the Neubauer counting chamber, using the techniques described by Lannette et al.
For microscopy about 10 ml of sample was centrifuged at 2000xg for five minutes. The centrifuge was studied under microscope at 40 xs for the presence of WBCs, RBCs, epithelial cells, casts &
crystals.
Treatment was given to all patients with significant bacteriuria with oral cephalexin 500mg bd for 7days.
Urine culture was repeated one week after completion of treatment.
Two patients who had persistent bacteriuria were treated with Inj.
Gentamicin 80mg bd for 5days and then repeat cultures were negative.
Both bacteriurics and non bacteriurics were followed at monthly intervals.
They were examined for clinical parameters like weight gain, blood pressure and complete hemogram, routine urine analysis, blood urea, sugar and serum creatinine.
For all treated patients, urine culture was repeated once in late second trimester and once in third trimester.
51
For other patients, urine culture was repeated once in third trimester.
All patients were followed up to delivery and discharge.
The occurrence of acute symptomatic urinary tract infections (pyelonephritis and cystitis), preterm labor and delivery, hypertensive disorders, maternal anemia and low birth weight infants were noted. The perinatal outcome was studied.
Repeat urine culture & urinalysis were done one week after completing the treatment. Any drug related detrimental effects if present were noted.
If culture results were negative, it was considered as eradication of bacteriuria.
Clinical features studied were maternal age, parity, socio economic status, gestational age and incidence of anaemia.
The obstetrical risk factors studied were hypertension, GDM and PROM.
The labour characteristics and perinatal outcome like abruption placenta, induction of labour, operative vaginal delivery, caesarean section, PPH, chorioamnionitis, pyelonephritis, hydroureter, renal calculi & hospitalisation were evaluated.
52
The perinatal outcomes like gestational age at birth, birthweight, IUGR& specifically LBW (<2500 g) and perinatal mortality were evaluated.
53
OBSERVATIONS AND RESULTS
Table 1. DISTRIBUTION OF ASYMPTOMATIC BACTERIURIA
In this study, the incidence of asymptomatic bacteriuria in antenatal women at their first prenatal visit was found to be 10.80%.
Figure1 Incidence of asymptomatic bacteriuria in pregnancy
Culture positive 10.80%
Culture negative
89.20%
BACTERIURICS NON-BACTERIURICS
S.no Urine culture No.of cases Percentage
1 positive (bacteriurics) 27 10.8%
2 Negative (non bacteriurics) 223 89.2%
Table 2. DISTRIBUTION IN DIFFERENT AGE GROUPS S.No Age group
1 15 to 19 years 2 20 to 29 years 3 30 to 39 years
X2 test =3.646, P=0.1615
The incidence is more common in the age group of 20
which may be related to peak sexual activity in this age group, but it is statistically not significant.
Figure2 Incidence of bacteriuria in different age groups
0 15-19 YEARS 20-29 YEARS 30-39 YEARS
9.84%
13.67%
4%
54
Table 2. DISTRIBUTION IN DIFFERENT AGE GROUPS Total no. Of
cases Bacteriurics
15 to 19 years 61 6
20 to 29 years 139 19
30 to 39 years 50 2
test =3.646, P=0.1615
The incidence is more common in the age group of 20
which may be related to peak sexual activity in this age group, but it is statistically not significant.
Incidence of bacteriuria in different age groups
50 100 150
61
139 50
9.84%
13.67%
BACTERIURICS TOTAL NO. OF CASES
Table 2. DISTRIBUTION IN DIFFERENT AGE GROUPS Percentage
9.84%
13.67%
4%
The incidence is more common in the age group of 20-29 years, which may be related to peak sexual activity in this age group, but it is
BACTERIURICS TOTAL NO. OF CASES
Table3. DISTRIBUTION S.No Obstetric code
1 Primi
2 G2
3 G3 and above
P=0.0665
Maximum cases
statistically insignificant. This lack of knowledge about delayed post coital micturition.
Figure 3 Incidence of bacteriuria in
0 20 40 60 80 100 120 140 160
PRIMI G2
143
56
13.98%
55
Table3. DISTRIBUTION INDIFFERENTGRAVIDA Obstetric code
Total no. of cases
Bacteriurics
143 20
56 4
G3 and above 51 3
cases of bacteriuria occur in primigravida but statistically insignificant. This may be related to peak sexual
about hygienic habits during sexual delayed post coital micturition.
Figure 3 Incidence of bacteriuria in different gravida
G2 G3 & ABOVE
56 51
7.14% 5.8%
TOTAL NO. OF CASES BACTERIURICS
INDIFFERENTGRAVIDA
Percentage 13.98%
7.14%
5.8%
bacteriuria occur in primigravida but sexual activity and activity and
different gravida
TOTAL NO. OF CASES BACTERIURICS
Table4.SOCIO
S.no
Socioeconomic status 1 Class III & IV
2 Class V
P=0.3811
There is a high
group due to lack of knowledge, low literacy and lack of facilities to maintain
Figure 4.Incidence of
0 CLASS III & IV
CLASS V
7.7%
12.14
56
Table4.SOCIO ECONOMIC STATUS
Socioeconomic Total no.
of cases
Bacteriurics
Class III & IV 77 6
Class V 173 21
high incidence of ABU in the lower socioeconomic knowledge, low literacy and poor personal hygiene to maintain hygiene but not statistically significant.
of bacteriuria in different socioeconomic
50 100 150 200
77
173 12.14
BACTERIURICS TOTAL NO. OF CASES
Percentage
7.7%
12.14%
socioeconomic personal hygiene hygiene but not statistically significant.
socioeconomic status
BACTERIURICS TOTAL NO. OF CASES
Table 5.URINE NITRITE S.No Description
1 Bacteriurics
2 Non bacteriurics
P<0.0001
The sensitivity of
consider it as an useful initial test Figure5 Urine nitrite test
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
NITRITE POSITIVE 74.07%
1.70%
57
5.URINE NITRITE DIPSTICK TEST Description
Nitrite positive
Nitrite negative Bacteriurics 20 (74.07%) 7(25.92%)
Non bacteriurics 4 (1.7%) 219(98.2%)
of this test is83.33% and statistically significant to consider it as an useful initial test in bacteriurics.
Figure5 Urine nitrite test
NITRITE POSITIVE NITRITE NEGATIVE
25.92%
98.20%
DIPSTICK TEST Nitrite negative 7(25.92%)
219(98.2%)
test is83.33% and statistically significant to
NON-BACTERIURICS BACTERIURICS
Table
S.No. Description
1 Bacteriurics 2 Non bacteriurics
P<0.0001
Proteinuria is 300mg/dl are considered
release of protein from leucocytes.
bacteriurics. Both proteinuria &
parameters in bacteriurics.
0 2 4 6 8 10 12 14 16 18 20
44%
62.9%
58
Table 6. URINE ANALYSIS
Urine protein Urine pus cells Positive Percentage
Positive
12 44% 17
Non bacteriurics 20 8.9% 8
increased during pregnancy and levels considered normal. It is increased during UTI of protein from leucocytes. Leucocyte excretion is bacteriurics. Both proteinuria & pyuria are statistically parameters in bacteriurics.
Figure 6 Urine analysis
8.9%
3.5%
Urine pus cells Percentage
62.9%
3.5%
and levels upto UTI because of increased in pyuria are statistically significant
PROTEINURIA PYURIA
Table S.No Organisms
1 E.coli 2 Klebsiella 3 Staph Aureus
The most common causative organism is Escherichia coli accounting for 89% of
enteric bacilli. These are Figure 7
59
Table 7. CAUSATIVE ORGANISMS
Organisms No. of cases Percentage 24
2 1
The most common causative organism is Escherichia coli of cases. The organisms are usually gram
are collectively called as uropathogens.
Figure 7. Causative organisms of UTI
88.88%
7.40%
3.70% 0
Pathogens
E.coli Klebsiella Staph aureus
Percentage 88.88%
7.4%
3.7%
The most common causative organism is Escherichia coli ram negative uropathogens.
E.coli Klebsiella Staph aureus
60
Table 8. FETAL OUTCOME
P=0.5191
There was one case of preterm delivery in the bacteriuric pregnant women treated with antibiotics between 28 to34 weeks and three cases of preterm deliveries were between 34to37weeks of gestation whereas there were 5cases of preterm deliveries between28to 34weeks and19 cases after 34 weeks in non bacteriuric women. The difference is statistically not significant.
S.No Gestational
age Bacteriurics Percentage Non
bacteriurics Percentage 1 37 completed
weeks and above
23 85.18% 199 89.23%
2 34 weeks to 36.6
Weeks
3 11.11% 19 8.5%
3 28 weeks to 33.6
Weeks
1 3.7% 5 2.2%
61
Figure 8. FETAL OUTCOME
85.18%
14.82%
89.23%
10.77%
0.00% 20.00% 40.00% 60.00% 80.00% 100.00%
FULL TERM PRETERM
NONBACTERIURICS BACTERIURICS
TABLE 9. MODE OF DELIVERY S.No Mode of
delivery Bacteriurics 1 Labour
natural 2 Forceps
3 LSCS
P=0.6504
The difference in treated with antibiotics
IUGR was present in woman was good.
Figure 9
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
LABOUR NATURAL 74.07%
67.71%
62
TABLE 9. MODE OF DELIVERY Bacteriurics Percentage Non
bacteriurics
20 74.07% 151
1 3.7% 8
6 22.22% 64
in the number of operative deliveries in antibiotics and nonbacteriurics is not statistically
in woman with bacteriuria and the postnatal
Figure 9 MODE OF DELIVERY
FORCEPS LSCS
3.70%
22.22%
67.71%
3.50%
28.69%
bacteriurics Percentage 67.71%
3.5%
28.69%
in bacteriurics statistically significant.
postnatal outcome
BACTERIURICS NONBACTERIURICS
