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Urinary Tract Infections (UTI's)

Urinary Tract Infections in Pregnancy
The anatomical and hormonal changes of pregnancy cause a woman to be susceptible to urinary tract infections (UTI).  Some of these changes include: an enlarged uterus, elevated pregnancy hormones, an increase in blood volume, changes in posture, physical activity and nutritional intake displaced, compressed, and elongated ureters, decreased bladder tone.  


Around the 10th week of pregnancy the renal pelvis and ureter dilate.  The smooth-muscle walls of the ureters undergo hyperplasia and hypertrophy and relaxed muscle tone.  The ureters elongate.  In later pregnancy  the enlarging uterus displaces the sigmoid colon to the right and the right renal pelvis and ureter dilate more than the left.  These changes cause a larger volume of urine to be held in the ureters, and urine flow to be slower.  This leads to urinary stasis or stagnation.  Stagnated urine is an excellent medium for the growth of microorganisms. 

Renal function is most efficient when the woman lies on her left side.  This increases renal perfusion, urinary output and decreases edema.

In normal pregnancy, renal function is altered from it's prepregnant state.  The woman's kidneys must manage the increased metabolic, circulatory, and excretory demands of her pregnant body  The urine of pregnant women is high in nutrients, high in glucose, and is more alkaline.  These conditions make the urine an even more excellent medium for growth of microorganisms.  This causes women to be more susceptible to urinary tract infections.

A woman's urine can be checked at her regular prenatal visits for signs of infection.  This is important to rule out asymptomatic bacteriuria (bacteria in the urine).

Symptoms of UTI

Common symptoms of cystitis include:
*  Painful, burning urination (dysuria)
*  Urinary urgency and pressure
*  Fever
*  Rapid pulse
*  Lower back pain (with kidney involvement)
*  Lower abdominal (suprapubic) pain
*  Nausea and vomiting
*  Hematuria (blood in the urine)

Symptoms of acute pyelonephritis (kidney infection) are the same but more severe.

To check for lower back pain, make a fist and lightly pound the woman's back (not so hard to confuse your results)  with the outside, fleshy part of your fist.  Start at the top and move down on either side of the spine. If kidney involvement is present, there will be tenderness just below the bottom rib beside the spine, called the costovertebral angle.  This is called Costovertebral Angle Tenderness (CVAT).
Urine Analysis

If infection is present the following may be present:

*  Odor may be fishy
*  Color may be milky or bloody
*  White Blood Cells
*  Red Blood Cells
*  Nitrites
*  Protein with kidney involvement

If infection is suspected the urine should be cultured to find out which organism is causing the infection.   The antibiotic prescribed will depend on which organism is present in the urine. The following are possible pathogenic organisms that may be found in urine:

*  Escherichia coli - normally found in the colon.
*  Staphylococcus aureus - commonly on the skin.
*  Beta-hemolytic Streptococcus (Group B Strep)
*  Enterococcus (Streptococcus)
*  Pseudomas aeruginosa - found in soil
*  Proteus - normally found in the intestines
*  Neisseria gonorrhoeae - gonorrhea
*  Klebsiella - common cause of respiratory infection
*  Corynebacterium - causes Gardnerella

Obtaining a Urine Specimen

A "clean catch" specimen is collected the following way:
* A sterile container and lid are used.  The container should be carefully handled on the outer surfaces only.  Do not touch the container to the legs or genitals while voiding.
* The hands are washed.  The genital area is cleaned with three cloths.  The first one is used to wipe one side front to back, the second to wipe the other side front to back.  The third is used to wipe down the center.
* While still holding the labia apart, begin to void into the toilet.  After voiding about an ounce, void into the specimen container and then finish voiding into the toilet.  This is called a mid-stream catch and the flow of urine should not be stopped at any time.  Cap the container immediately.

Complications

UTI's in pregnancy can cause preterm labor.  It is very important to prevent infection if possible and to be alert to signs and symptoms of UTI's so treatment can be started quickly.  If a woman does present with preterm labor, a UTI should be ruled out.

Maternal fever can adversely affect the unborn baby by causing an increased fetal heart rate. Maternal fevers have also been shown to cause birth defects.  Tylenol is usually the drug of choice to decrease the mother's temperature.

Prevention

Sometimes a woman may be asymptomatic and not know she has a UTI.  Whether she is symptomatic or not, UTI's present a risk to both the mother and the baby. Once a woman has had a UTI she is more susceptible to getting another infection.  She will need to take extra precautions to prevent another occurrence.

Important ways to prevent infection include:

  • Women should always wipe from back to front, and use a clean pieceof toilet paper for each wipe.  This prevents bacteria from the rectal area from being spread to the urethral opening.
  • Toilet paper should be white, soft, unscented.  Harsh, scented, or printed paper may cause irritation and inflammation where bacteria could grow.
  • Women should wear underwear with a cotton crotch.  Bacteria thrive in moist heat trapped by synthetic fibers.
  • Tight fitting pants should be avoided.
  • Panty shields should be changed often.
  • Drink 2 - 3 quarts of liquid a day.
  • Drink one glass of cranberry juice a day or take 1 cranberry tablet per day.
  • Urinate frequently, and do not ignore the need to urinate.
  • Urinate before and after intercourse.
  • Do Kegel exercises regularly, but not during urination as this could cause retention of urine.
  • Avoid bubble baths and bath oils.
  • Avoid a lot of sugar, caffeine, and pop.
Treatment
  • If the woman has a full blown infection, antibiotics should be started right away.  
  • Increase fluid intake to eight ounces of liquid per hour.
  • Eliminate sugar from the diet.  Bacteria thrives on sugar.
  • Eliminate all soda pop and caffeine.

Natural Remedies

Cranberry juice:  Cranberry juice is more acidic than other fluids and lowers the pH of urine, making it harder for bacteria to grow.  It should be unsweetened because sugar promotes bacterial growth.  Cranberry capsules may be taken instead if preferred.  Take 3 cranberry tablets 3x day until the infection is gone.  For prevention take 1-2 tablets per day.  

Vitamin C:  2000 mg per day, decreased to 500 mg per day when infection is gone.

Uva Ursi:  Prepare by brewing 1 ounce of Uva Ursi leaves in a quart of boiling water, and letting sit for eight hours.  Drink one cup every twelve hours for 2 days.  If infection is severe drink one cup every four hours for 2 days.  Drink one cup a day for another 3 days.  Do not use for more than 10 days.

Nettles:  1 cup of infusion every day.



Sources:

Jonquil, Sharon Glass, No More Cranberry Juice!, Midwifery Today Winter 1995, Eugene OR
Bobak and Jensen, Maternity and Gynecological Care, 5th Edition, Mosby, St. Louis, MI, 1993
Frye, Anne, Holistic Midwifery, Labrys Press, Portland, OR, 1995
Frye, Anne, Understanding Diagnostic Tests in the Childbearing Year, 5th Edition,  Labrys Press, Portland, OR, 1993
Weed, Susan S., Wise Woman Herbal for the Childbearing Year, Ash Tree Publishing, Woodstock, NY, 1986
Varney, Helen, Nurse-Midwifery, 2nd Edition, Jones and Bartlett Publishers, Sudbury,  MA, 1987

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