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Obstetrics

Urinary Tract Infection (UTI) in Pregnancy

Bacterial infection of the urinary tract during pregnancy, ranging from asymptomatic bacteriuria (ASB) to cystitis (bladder infection) and pyelonephritis (kidney infection). Poses risks if untreated.

Also known as: Pregnancy UTI, Cystitis Pregnancy, Pyelonephritis Pregnancy

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Referral and warning signs

When to refer

Refer ALL suspected Pyelonephritis to hospital. Refer recurrent UTIs, treatment failure, suspected abnormalities.

Red flags

  • Fever (>38°C) with flank pain/tenderness
  • Signs of sepsis
  • Inability to tolerate oral intake
  • Failure to improve on oral Rx within 48-72h

Signs and symptoms

  • Asymptomatic Bacteriuria (ASB): No symptoms.
  • Cystitis (Lower UTI): Dysuria, Frequency, Urgency, Suprapubic pain.
  • Pyelonephritis (Upper UTI): Fever, Chills, Loin/Flank pain, Costovertebral angle tenderness, Nausea/Vomiting, +/- cystitis symptoms.

Risk factors

  • Physiological changes (stasis, glycosuria).
  • History of recurrent UTIs.
  • Diabetes Mellitus.
  • Sickle Cell Trait/Disease.
  • Urinary tract abnormalities.

Diagnosis

Clinical assessment

Symptoms suggestive of cystitis/pyelonephritis. Assess for fever, flank tenderness.

Investigations

  • Urinalysis (Dipstick): Nitrites +/or Leukocyte Esterase positive.
  • Urine Microscopy: WBCs, RBCs, Bacteria.
  • Urine Culture & Sensitivity (C&S): Gold standard. Confirms ASB, guides Rx.
  • FBC (Leucocytosis in pyelo).
  • Renal function (if severe pyelo).

Diagnostic criteria

ASB: Culture positive without symptoms. Cystitis: Symptoms + Urinalysis +/- Culture. Pyelonephritis: Systemic symptoms + Urinalysis +/- Culture.

Management

Non-pharmacological management

  • Increased oral fluid intake.
  • Regular bladder emptying.
  • Hygiene practices.

Pharmacological treatment

  • ASB & Cystitis: TREAT. Nitrofurantoin 100mg PO BID x 5-7d (AVOID 1st tri/term/G6PD) OR Amoxicillin 500mg PO TID x 5-7d OR Cephalexin 500mg PO BID/QID x 5-7d. Repeat culture post-Rx for ASB.
  • Pyelonephritis: HOSPITAL ADMISSION. IV Hydration. IV Antibiotics: Ceftriaxone 1g IV OD OR Ampicillin IV + Gentamicin IV. Switch to oral (e.g., Cefixime/Cephalexin) when afebrile 48h to complete 10-14d course.
  • Avoid: Trimethoprim(-Sulfamethoxazole) (esp 1st tri/term), Fluoroquinolones.

Monitoring

Monitor symptom resolution. Follow-up urine culture (ASB/pyelo). Monitor renal function (pyelo).

Complications

  • Pyelonephritis.
  • Preterm labour/delivery.
  • Low birth weight.
  • Maternal sepsis (rare).
  • Increased pre-eclampsia risk.

Prevention

  • Screening for ASB (urine culture).
  • Good hygiene.
  • Adequate hydration.
  • Post-coital voiding.

Patient education

  • Explanation of UTI and importance of Rx in pregnancy.
  • Complete full antibiotic course.
  • Increase fluid intake.
  • Hygiene measures.
  • Symptoms of worsening infection.
  • Need for follow-up tests.

Uganda-specific notes

ASB screening often not feasible; dipstick common. Nitrofurantoin/Amoxicillin common for lower UTI. Ceftriaxone +/- Gentamicin for pyelo.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 16, Section 16.2.6

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