Determination of Prevalence of Urinary Tract Infection Among the Pregnant Women with Lower Abdominal Pain

Chandra Bala Sekharan1*, Devarajan Dinesh Kumar2, Koneru Ratna Kumari1, Cecilia Alphonce Joachim1

1Department of Biochemistry, International Medical and Technological University, Dar Es Salaam, Tanzania - 77594

2Department of Anatomy, International Medical and Technological University, Dar Es Salaam, Tanzania - 77594

Received: 25-Sep-2016 , Accepted: 29-Jun-2017

Keywords: Urinary tract infection, Diagnosis, E.coli, Mount meru hospital, Arusha

Full-Text PDF      

Google Scholar  

How To Cite       

Abstract

The present study was aimed to determine the prevalence of urinary tract infection among the pregnant women with lower abdominal pain and its aetiological micro-organism. Cross sectional study was done at Mount meru hospital laboratory, Arusha, Tanzania.  225 pregnant women attending an antenatal clinic in Levolosi hospital (Arusha, Tazania) were enrolled. To diagnose urinary tract infection in the enrolled participants, mid stream urine was collected and culture on Macconkey agar media and blood agar media. Urine analysis was done using dipstick test, urine microscopy and biochemical tests. The prevalence of urinary tract infection was found to be 31.6%.  High incidence of infection was found in 33-40 years age group (41.6%). The incidence of infection was high in the third trimester of pregnancy compared to first and second trimester. The prevalence of infection is more in participants who had past history of infection. The bacterial pathogens isolated include E.coli (40.8%), Staphylococcus species (30.0%), Klebsiella species (14.1%), Proteus species (11.3%), Citrobacter species (1.4%) and Enterobacter species (1.4%). Diagnosis of urinary tract infection in pregnant women during all antenatal visits should be considered a vital care in the community. This helps to keep away from complications in pregnancy at an early stage. 

1 Introduction

A variety of micro organisms can attack the urinary tract and is responsible for the pathogenesis of urinary tract infection1-4. These are the most common bacterial infections during pregnancy accounting to 10% of hospital visits by women5. Urinary tract infection and its associated complications are responsible for the death of nearly 150 million per year, worldwide. The disease can be developed in 40-50% of women6. Urinary tract infections are the second common complications in pregnant women after anemia. If urinary tract infection is not controlled, it can badly affect the health of fetus and pregnant women7,8. Urinary tract infection during pregnancy may be symptomatic or asymptomatic9,10. The involvement of lower and upper urinary tract can lead to asymptomatic bacteriuria and symptomatic bacteriuria, respectively. Asymptomatic bacteriuria is mostly responsible for the cause of urinary tract infection in women during pregnancy. The symptomatic bacteriuria is characterized by acute Pyelonephritis11. The prevalence of symptomatic and asymptomatic urinary tract infection in pregnant women was observed as 17.9% and 13%, respectively. The asymptomatic infection may lead to various clinical manifestations in pregnant women and newborn10, 12 if not treated properly.

The factors that increase the risk of urinary tract infections in pregnant women include increased age, number of intercourses per week, number of childbirths, recessive sickle cell anemia, diabetes, immunodeficiency and urinary tract abnormalities13,14. Microorganisms responsible to cause urinary tract infections are: Saprophyticus Staphylococcus, Escherichia coli, Proteus, Acinetobacter, Pseudomonas aeruginosa and Klebsiella pneumonia11-15.

The probability of urinary tract infection initiated around the sixth week and reaches the maximum during 22-24 weeks of gestational age. The increased probability of infection in pregnant women is most likely due to increased bladder volume, its expansion and expanded ureter13,16.

Considering the importance of urinary tract infection in pregnant women, the present investigation was aimed to study the prevalence of urinary tract infection among pregnant women.  The prevalence of urinary tract infection among pregnant women in Arusha (Northern part of Tanzania) is not known. Therefore, the study was carried out at Mount meru hospital and Levolosi hospital, located at Arusha.

2 Materials and methods

2.1 Study Design

A Cross sectional study type of research design was used to access the prevalence of urinary tract infections in pregnant women. The study involved the collection of data from the subjects in the form of questionnaires. Data regarding demographic and reproductive characteristics were collected.

The participants were randomly selected among women attending antenatal clinics in Levolosi hospital (Arusha, Tazania) with lower abdominal pain. The inclusion and exclusion criterion was applied. Clean catch urine specimens were collected from each of the 225 study participants. This was tested with urine dipsticks, microscopy. The samples are cultured for bacterial growth and subjected to isolation of bacterial species causing urinary tract infections by performing biochemical tests.

2.2 Study Area

The study was conducted at Mount meru hospital laboratory. For culture technique, samples were collected from the clinic of maternal at Levolosi hospital. This maternity clinic was chosen since it is a referral hospital with many patients of varied socio-demographic & reproductive characteristics and large number of patient turn over making it easy to achieve the desired sample size. Dipstick tests, urine microscopy tests and culture &biochemical tests were done at the Mount meru hospital laboratory.

2.3 Sample size

The sample size was determined by using formula17.

N =( Z2 P (1-P))/E2

Where,

N = minimum sample size required;

Z = Standard normal deviation set at 1.96 (corresponding to confidence level of 95%);

P = prevalence of urinary tract infections in pregnancy women which was estimated from previous studies=17.9%10;

E = maximum error allowed, assumed to be 5%

N = (1.962 x 17.9(100 – 17.9))/52

N =225

Therefore, the minimum sample size required was 225 and the same number of pregnant women was sampled for the study.

2.4 Study Population

All pregnant women having signs of urinary tract infections and abdominal pain during the period of the study were included. A total number of 225 of pregnancy women were considered.

2.5 Inclusion criteria and exclusion criteria

Pregnant women attending the antenatal clinic in Levolosi hospital with lower abdominal pain and willing to participate in the study by giving informed consent were included. No prior treatment in the preceding one week with antibiotics or any other medications that may affect the culture results and ≥20 weeks of gestation were included. Pregnant women who are already on antibiotics treatment for any other reason were excluded from the study.

2.6 Ethical consideration

Permission to conduct the study at regional Mount meru hospital, Levolosi hospital was obtained from Regional Medical Officer, District Medical Officer, Doctor of city referring to city nursing and laboratory officer at Mount meru hospital and Levolosi hospital. Pregnant women permission was obtained by their consent, 225 consent forms were filled. All the information obtained from the participants was treated confidentially.

2.7 Sampling procedure

Simple random sampling was used to choose women to include in study with strict application of the inclusion criteria. Eligible participants were approached and requested to give a voluntary consent to participate in the study. Upon consenting, a study number with a code was assigned for identification. Inclusion into the study was done consecutively until the required sample size of 225 women was achieved.

2.8 Social demographic profile   

A prior prepared set of specific questions was administered to participants with regard to their socio demographic information (age, socio economic status, personal hygiene, education level of mother, pregnancy duration, postcoital washing and use of contraceptives) and any other information of relevance to the study.  This was done in Levolosi clinics labour ward.

2.9 Urine sample collection

Urine samples were collected with clear instructions for the participants. The participants are instructed to collect mid stream urine after vulval swabbing with clean water. The specimen was kept in a cool box packed with ice and delivered to the laboratory within one hour of collection.

2.10 Urinary dipstick test, urine microscopic & culture technique and biochemical tests

The clean catch midstream urine collected from the participants was subjected to a dipstick test, urine microscopy, culture and biochemical tests. The results were entered into the data base. The urine specimens were cultured on Macconkey media agar and blood agar media to determine the microorganisms involved. Any organism isolated with colony counts of greater than 100000/ml of urine was considered significant and indicative of a urinary tract infection. Bacterial identification was done by performing biochemical tests.

3 Results

225 pregnant women with lower urinary tract pain were recruited in this study. The majority of women were aged between 25-32yrs (60.4%), married (74.2%), with above standard seven level (68%) and employed (70.6%). Among 225 pregnant women, greater percentage of women was in 35-39 weeks of gestation (14.6%) with no previous urinary tract infection (83.1%) and kidney & bladder problems (94.2%). The results are shown in Table 1.

Among the 225 pregnant women, some of them were having the symptoms like discharge, pain during urination and itching at genital part. The results are summarized in Table 2. This sign indicated characteristics of positive urinary tract infection. When culture was done to the urine sample of those participants, most of them were positive for urinary tract infection.

In the present investigation, two hundred and twenty five (225) urine samples were collected from the participants and analyzed. Seventy one (71) samples showed significant bacterial growth, which amounted to a prevalence of 31.6%.  The percentage of prevalence of urinary tract infection according to age, gestation week and marital status is presented in Table 3. From the results, it was found that the prevalence of urinary tract infection is more in the unmarried (48.2%), age group 33-40 years (41.6%) with gestational age 35-39 weeks (44.1%).

Among 225 pregnant women screened for urinary tract infection, 68 (30.2%) cases were dipstick positive and 40 (17.7%) cases were urine microscopic positive Table 4. Among a urine dipstick positive and urine microscopic positive, 71 (65.7%) were culture positive. Hence these predict that screening of urinary tract infection by dipstick and urine microscopic tests valid to sensitivity test.

Bacterial identification was done using biochemical tests. The frequency of various pathogens isolated is shown in Table 5. Out of 225 urine samples, 154 urine bacterial samples had no growth and 71 urine samples were positive for urinary pathogens. Among the significant isolates, E.coli had the highest percentage of isolation (40.8%), while the lowest was citrobacter and enterobacter species (1.4 %). 

4 Discussions

To establish the prevalence of urinary tract infection in pregnant women at Mount meru hospital (Arusha, Tanzania) and Levolosi hospital (Arusha, Tanzania), cross sectional study was conducted.  The results shown that the prevalence of urinary tract infection (31.6%) is one fourth of 225 pregnant women presenting with lower abdominal pain had bacterial urinary tract infection. The prevalence of urinary tract infection reported in Addis Ababa18, Nirobi19 Sudan20 and Dhaka21 were 11.6%, 26.7%, 14.0%, 26.0%, respectively. 

From the results, it was observed that the prevalence of urinary tract infection in the current study is higher than the former reports. The variation in the prevalence of urinary tract infection in the current and earlier reports may be due to the differences in the environment, the standard of personal hygiene, social habits of the community and education.

The microbial profile included E.coli, Staphylococcus species, Klebsiella species, Proteus species, citrobacter species and enterobacter species. E. coli was the major pathogen with overall isolation rate of 40.8%. Comparable findings have been reported by Vazquez & Villar22 and Nabbugodi et al.19 In the present study, there was no relationship between age and marital status with the urinary tract infection. This was same as with studies by Mohamed in Tanzania 23. In the present study, in the 3rd trimester the frequency of urinary tract infection was higher when compared to the 1st and 2nd trimester. This is in agreement with Leigh24, who reported the same. However, this report does not agree with Onuh et al.25 According to Onuh et al. prevalence of urinary tract infection is higher in the 2nd trimester when compared to the 1st and 3rd. This variation may be either due to change in vesicoureteral reflux and urinary stasis or may be due to decrease in urinary progesterones and oestrogens in the various trimester of pregnancy.

In this study, past history of urinary tract infection was the important risk factor. In our study, out of 225 pregnant women 38 (16.9%) women had past history of urinary tract infection. Symptoms of urinary tract infection like bleeding from birth canal (2 cases, 0.88%), pain during urination (36 cases, 16.4%), itching at a genital organ (72 cases, 32%) and discharge (26 cases, 11.6%) are seen in the pregnant women. 

All the samples from the pregnant women with the above symptoms showed positive for bacterial culture.  In study of Gulfareen et al.26 prevalence of bacteriuria was 100% in women who previously had urinary tract infection. The study of Nabbugodi et al.19 had shown that previous episode of urinary tract infection was not a risk factor for urinary tract infection in pregnancy.

Results showed that the dipstick test, and the urine microscopy tests have high sensitivity and specificity in screening for urinary tract infection. These are simple and inexpensive tests that can be used to predict urinary tract infection in centres where urine cultures are not available.  There was high correlation between positive testing on dipstick and urine microscopy and culture positive specimens. Of all 71 women with culture positive urine, 68 were also positive on the dipstick.

5 Conclusion

This study showed the prevalence of urinary tract infection in pregnant women attending the antenatal clinic in Levolosi hospital, Arusha, Tazania.  One fourth of 225 pregnant women with lower abdominal pain had bacterial urinary tract infection. E.coli was the major isolated pathogen. Good correlation was found between urine microscopy, urine dipstick test and positive urine culture in urinary tract infection. Routine diagnosis of urinary tract infection in pregnant women is important to prevent adverse results for the mother and the fetus.

6 Recommendations

Community participation in proving health education to all women about the maternal clinics should be improved. Routine screening of all antenatal women with lower abdominal pain with urine dipstick test to determine the presence of urinary tract infection should be done before initiation of antibiotics. Regular microbial screening and sensitivity profiles have to be done with a broader microbial profile to include non bacterial aetilogy like candida, mycoplasma, etc., and others. Dipstick testing of urine and simple microscopy of centrifuged urine sediment is recommended as a screening test for antenatal women with lower abdominal pains suspected of urinary tract infection. 

7 Conflicts of interest

The authors have no current conflict of interests

8 Author’s contribution

All the authors have equally contributed in the work

9 Acknowledgements

The authors would like to thank the staff of Levolosi hospital and Mount meru hospital, Tanzania and to the staff & management of International Medical and Technological University, Tanzania for their support and cooperation during the study. The authors also would like to thank the study participants for their willingness to participate in the study and for their cooperation.

10 References

  1. Rajaratnam A, Baby NM, Kuruvilla TS, Machado S. Diagnosis of asymptomatic bacteriuria and associated risk factors among pregnant women in Mangalore, Karnataka, India. Journal of Clinical and Diagnostic Research. 2014; 8(9): OC23-OC25.
  2. Asadi KM, Oloomi M, Habibi M, Bouzari S. Cloning of fimH and fliC and expression of the fusion protein FimH/FliC from Uropathogenic Escherichia coli (UPEC) isolated in Iran. Iranian Journal of Microbiology. 2012; 4(2): 55-62.
  3. Yasemi M, Peyman H, Asadollahi K, Feizi A, Soroush S, Hematian A, Jalilian FA, Emaneini M, Alikhani MY, Taherikalani M. Frequency of bacteria causing urinary tract infections and their antimicrobial resistance patterns among pediatric patients in Western Iran from 2007-2009. Journal of Biological Regulators and Homeostatic Agents. 2014; 28(3): 443-448.
  4. Gomi H, Goto Y, Laopaiboon M, Usui R, Mori R, Mori R. Routine blood cultures in the management of pyelonephritis in pregnancy for improving outcomes. Cochrane Database Systamic Reviews. 2015; 13(2): CD009216.
  5. Millar LK, Cox SM. Urinary tract infections complicating pregnancy. Infectious Diseases Clinics of North America. 1997; 11: 13-26.
  6. Totsika M, Moriel DG, Idris A, Rogers BA, Wurpel DJ, Phan MD, David LP, Mark AS. Uropathogenic Escherichia coli mediated urinary tract infection. Current Drug Targets. 2012; 13(11): 1386-1399.
  7. Franklin TL, Monif GR. Trichomonas vaginalis and bacterial vaginosis. Coexistence in vaginal wet mount preparations from pregnant women. The Journal of Reproductive Medicine. 2000; 45(2): 131-134.
  8. Mittal P, Wing DA. Urinary tract infections in pregnancy. Clinics in Perinatology.2005; 32(3): 749-764.
  9. Schnarr J, Smaill F. Asymptomatic bacteriuria and symptomatic urinary tract infections in pregnancy. European Journal of Clinical Investigation. 2008; 38 (Suppl 2): 50-57.
  10. Alemu A, Moges F, Shiferaw Y, Tafess K, Kassu A, Anagaw B, Abebe A. Bacterial profile and drug susceptibility pattern of urinary tract infection in pregnant women at University of Gondar Teaching Hospital, Northwest Ethiopia. BMC Research Notes. 2012; 5: 197.
  11. Emamghorashi F, Mahmoodi N, Tagarod Z, Heydari ST. Maternal urinary tract infection as a risk factor for neonatal urinary tract infection. The Iranian Journal of Kidney Diseases.2012; 6(3): 178-180.
  12. Jido TA. Urinary tract infections in pregnancy: evaluation of diagnostic framework. Saudi Journal of Kidney Diseases and Transplantation. 2014; 25(1): 85–90.
  13. Giraldo PC, Araújo ED, Junior JE, Amaral RLGD, Passos MRL, Gonçalves AK. The Prevalence of urogenital infections in pregnant women experiencing preterm and full-term labor. Infectious Diseases in Obstetrics and Gynecology.2012; 2012: 1-4.
  14. Raza S, Pandey S, Bhatt CP. Microbiological analysis of isolates in Kathmandu medical college teaching hospital, Kathmandu, Nepal. Kathmandu University Medical Journal. 2011; 9(36): 295-297.
  15. Sujatha R, Nawani M. Prevalence of asymptomatic bacteriuria and its antibacterial susceptibility pattern among pregnant women attending the antenatal clinic at Kanpur, India. Journal of Clinical and Diagnostic Research.2014; 8(4): DC01-3.  
  16. Jahromi MS, Mure A, Gomez CS. UTIs in patients with neurogenic bladder. Current Urology Reports. 2014; 15(9): 433.
  17. Nyengidiki KT, Enyindah CE. Contraceptive prevalence amongst women attending the infant welfare clinic at the University of Port Harcourt Teaching Hospital. Port Harcourt Medical Journal. 2008; 3 (1): 42-48
  18. Mazor-dray E, Levy A, Francisc S, Sheine E. Maternity urinary tract infection: Is it independently associated with adverse pregnant outcome. Journal of Maternal-Fetal and Neonatal Medicine. 2009; 22 (2): 124-128.
  19. Nabbugodi WF, Gichuhi JW, Mugo NW. Prevalence of urinary tract infection, microbial aetiology, and antibiotic sensitivity pattern among antenatal women presenting with lower abdominal pains at Kenyatta national hospital, Nairobi, Kenya. The Open Access Journal of Science and Technology. 2015; 3, Article ID 101115, 6 pages.
  20. Murtaza ME. Urinary tract infection in pregnancy. A survey in women attending antenatal clinic in Kenyatta national hospital by Murtaza muzaffer Essajee-2002. M.Med (obs/gyn) Thesis University of Nairobi, 2002.
  21. Kawser P, Afroza M, Arzumath AB, Monowara B. Prevalence of urinary tract infection during pregnancy.  Journal of Dhaka National Medical College and Hospital.2011; 17 (2): 8-12.
  22. Vazquez, Villar J. Treatments for symptomatic urinary tract infections during pregnancy, Cochrane Database of Systematic Reviews. 2000, 3, CD002256.
  23. Mohamed AF. Frequency and susceptibility profiles of bacteria causing urinary tract infection among women. New York Science Journal. 2012; 5(2): 284-298.
  24. Leigh D. Urinary Tract Infections. In: Parker MT, Darden BI (ends) Topple and Wilson’s Principles of bacteriology, Virology and Immunity. Vol. 3. Philadelphia: Decker; 1989, 197-211.
  25. Onuh SO, Umeora OUJ, Igberase G, Azikem ME, Okpere EE. Microbiological isolates and sensitivity pattern of urinary tract infection in pregnancy in Benin City, Nigeria. Ebonyi Medical Journal. 2006; 5(2); 48-52.
  26. Gulfareen H, Shazia R, Saima G, Ambreen H. Asymptomatic bacteriuria in pregnancy. Pakistan Armed Forces Medical Journal. 2009; 59(4): 285-286.