Introduction

Urinary tract infection (UTI) is one of the most common infections where one or more part of urinary system become infected usually after bacteria overcome the natural defence mechanism of urinary tract (Al-Dujiaily, 2000). Although UTI could affect both sexes, women are more frequently affected than men due to short urethra, loss of prostatic secretion, ease of urinary tract contamination by faecal flora and various other reasons. In women however, the incidence of UTI is more frequent in pregnant women as compared to non pregnant ones due to the pregnancy-associated physiological changes, extended abdomen and difficulty of personal hygiene (Awaness et al., 2000).

The diagnosis of UTI may be made on the basis of clinical signs and symptoms in combination with urinalysis results. Urine culture remains an important test in the diagnosis of UTI, because it helps in the documentation of the infection, by determining the identity of infecting bacteria and its antimicrobial susceptibility (Stamm and Hooton, 1993; Wing et al., 2000).

In pregnant women, many risk factors could contribute to the occurrence of UTI. This includes age, socio economic level, general health status, personal hygiene as environmental health factor, sexual activities and other factors. In Canada, the prevalence rate varies from 4–7%. The prevalence is higher among individuals in lower socioeconomic classes and those with a past history of asymptomatic urinary tract infection (Nicolle, 1994). Higher standards of living in the industrialized world may contribute to the lower incidence rates of UTI (Amiri et al., 2009; Kiningham, 1993; Sheikh et al., 2000). The risk for UTI complications, and fungal-related UTIs, is also aggravated with diabetes. Diabetes can cause sugar to be excreted in the urine, providing an excellent medium for bacterial growth (Lye et al., 1992; Stapleton, 2002).

The aim of the current study was to assess the influence of some selected risk factors on the frequency of occurance of UTIs among pregnant women attending Obstetrics and Gynecology clinics at the main Maternity and Children Hospital in Mecca, KSA.

Materials and Methods

Study population and collection of data

A total of 200 women with age range of 18 – 45 years were subjected to the study after obtaining their consent. Pregnant women were selected from the Clinic of Obstetrics and Gynecology of Maternity and Children Hospital. Mecca, KSA during the period from May 2010 April 2011. Selected data related to demographic characteristics and medical history of studied women was collected by using of structured questionnaire. The collected data included age, Socio-economic level, stage of pregnancy, number of previous deliveries (parity), history of complicated pregnancy, type of used contraceptives if any, history clinical status, personal hygiene and life style (panties material).

Sampling

Sterile urine samples for urinalysis and urine culture were collected from all studied cases. Urinalysis and urine cultures were used for the detection of UTI. All women were instructed how to give a clean-catch midstream urine specimen. Briefly, they were asked to clean the area around urethral opening with clean water and alcohol swab, dry it and then collect a midstream urine sample by discarding the first part of urine and collecting 10-20 ml of the midstream in clean and sterile containers. Each sample of urine was divided into 2 parts and were properly labeled and sent to the laboratory with a request for complete urinalysis and urine culture.

Urine examination

The first part of urine sample was examined by dipstick tests using Comber 10 reagent test strips (Analyticon, Germany) that have panels to detect protein, blood, nitrite and leukocyte esterase in urine (Smith et al., 2003). In addition, wet preparations were made from sediment of each urine sample after centrifugation and were microscopically examined at X40 for detection of white blood cells as an indicator of pyuria. Samples with ≥ 10 WBC/field were regarded as pyuric. The second part of urine sample was cultured on plates of blood, MacConkey and CLED (cystine-lactose-electrolyte-deficient) agar with standard calibrated loop delivering 0.01 mL of urine. After streaking, plates were incubated at 37ºC for 24 to 48 hours. The plates were then examined macroscopically and microscopically for bacterial growth. Urinary tract infection was positive diagnosed by growth of ≥100,000 colony forming unit (CFU) of urinary tract pathogen per ml in culture of midstream urine sample, regardless of the presence or absence of leukocytes (Stamm and Hooton, 1993). Urine cultures with one pathogen were regarded as suspected infections. Cultures with more than one species were considered contaminated, while cultures with no growth of bacteria were said to be negative.

Statistical analysis

Descriptive statistics of the study population data that included frequencies were conducted using SPSS 16.0 (SPSS for Windows, Chicago, Ill, USA). A measure of association- Odds ratios (ORs) and 95% confidence intervals (CIs) – were calculated to estimate the relative risk for the various potential risk factors and UTI. Positive UTI cases were compared with negative UTI cases. Odds ratio is a way of comparing whether the probability of the given risk factor is the same for the two groups (UTI infected and UTI-uninfected pregnant women groups). An odds ratio of 1 was interpreted as the event is equally likely in both groups. An odds ratio greater than 1 was interpreted as the event is more likely in the first group. An odds ratio less than 1 was interpreted as the event is less likely in the first group (Townsend et al., 2009).

Result

Description of the studied population

The descriptive analysis of the investigated population sample (200 pregnant women) with regards to different assessed risk factors including age, educational levels, socio-economical levels, pregnancy conditions,  use of contraceptives, health condition, personal hygiene based on daily wash and pre and post coital wash and life style were shown in table 1.

Table 1. Descriptive analysis of the studied pregnant women population

Table 2. Influence of Age, Education level and Socio-economic level on frequency of UTI in pregnant women:          

Influence of Risk Factor on the frequency of UTI among pregnant women

The influence and degree of association between the given risk factor and the frequency of UTI among pregnant women were evaluated based on the OR and 95% CI of each risk factor.

Influence of Age, Education level and Socio-economic level on frequency of UTI in pregnant women

The results of the current study as shown in table 2 revealed the presence of significant association between the advanced age (30 – ˃ 40) (OR=1.2, 95% CI: 0.610-2.468) and the UTI.  On the other hand, least educational level (primary and secondary) represent a risk factor that significantly influence UTI among pregnant women (OR= 1.3; 95% CI: 0.590-3.008 and OR= 2.1; 95% CI: 1.020-4.499, respectively).     In addition, significant association (OR= 2.00; 95% CI: 0.362-11.625) was found between high socio-economic level and UTI followed by low socio-economic level (OR= 1.3; 95% CI: 0.586-3.192).

Influence of pregnancy stage, number of previous deliveries and History of complicated pregnancy on frequency of UTI in pregnant women

A significant association was found between the 3^rd trimester stage of pregnancy and the occurrence of UTI among pregnant women (OR= 1.5; 95% CI: 0.765-3.075). In addition, significant association were reported between the increased number of previous deliveries (4-6 and 10-13 groups) and the occurrence of UTI among pregnant women (OR= 1.2; 95% CI: 0.556-2.666 and OR= 2.00; 95% CI: 0.362-11.625, respectively). No significant associated was found between the presence or the absence of complicated pregnancy history and the frequency of UTI among pregnant women (Table 3).

Table 3. Influence of pregnancy stage, number of previous deliveries and History of complicated pregnancy  on frequency of UTI in pregnant women:                                                     

Table 4:  Influence of contraceptives usage and other medical complications on the frequency of UTI among pregnant women:

Influence of contraceptives usage and other medical complications on the frequency of UTI among pregnant women

The frequency of UTI, as revealed in the current study, was significantly associated with past usage of IUD as a mean of contraceptives (OR= 2.8; 95% CI: 1.082-7.384). In addition, a significant association were reported between diabetes (OR= 2.6; 95% CI: 0.957-7.151)  followed by hypertension (OR= 1.1; 95% CI: 0.336-3.432), while no significant association was found between history of previous UTI and current UTI in pregnant women. On the other hand, good general health condition was in favor of no UTI among pregnant women (OR= 0.7; 95% CI: 0.373-1.528) (Table 4).

Table 5: Influence of Personal hygiene and kind of underwear materials on frequency of UTI among pregnant women:

Influence of personal hygiene and life style on frequency of UTI among pregnant women

The current results as shown in table 5 revealed that unsatisfactory personal hygiene was significantly associated with UTI among pregnant women (OR= 1.3; 95% CI: 0.676-2.723). On the other hand satisfactory personal hygiene was in favor of no UTI among pregnant women (OR= 0.7; 95% 0.367-1.478). In addition, the study of the influence of used panties materials as a part of the pregnant women life style on the frequency of UTI revealed that use of silky panties is significantly associated with UTI among pregnant women (OR= 2.1; 95% CI: 0.835-5.296), while using cotton material panties was in favour of no UTI among pregnant women (OR= 0.5; 95% CI: 0.188-1.197).

Discussion

The aim of the present study was to investigate the influence of selected risk factors on the frequency of UTI among pregnant women attending Maternity and Children hospital in Makkah.

The influence of some risk factors that might contribute to the frequent occurrence of UTI among pregnant women has been studied. The studied risk factors included age, educational level, socioeconomic level, number of previous deliveries, history of complicated pregnancy, personal hygiene as environmental health factor, history of general health, use of contraceptives and type of underwear materials. The current results revealed that some risk factors appear to have considerable influence on the frequency of UTI among pregnant women. These included advanced age (30 – ˃ 40) (OR=1.2, 95% CI: 0.610-2.468) and least educational level (primary and secondary) (OR= 1.3; 95% CI: 0.590-3.008 and OR= 2.1; 95% CI: 1.020-4.499, respectively).

Although previous studies in Pakistan and Iran showed that educational level are not among the factors that influence the occurrence of UTI (Hazhir, 2007; Sheikh et al., 2000), other study in Thailand showed that lower education level (< or = grade 6) was reported as the only risk factor that influence UTI (Kovavisarach et al., 2009), which is in agreement with our findings and could be attributed to the lack of awareness with the required personal health care and hygiene during pregnancy. This finding could also explain the significant association reported in the current study between the older age and the frequency of UTI, as usually that group of pregnant women is traditionally the least educated group.

Regarding the influence of the pregnancy stage, the higher rate of UTI among pregnant women during the 3^rd trimester is in agreement with previous study that reported that pregnant women during their 6^th and 7^th month of pregnancy had the higher incidence of UTI, while women in their early pregnancy months had lower frequency of UTI (Okonko et al., 2009). Although there is a little risk of occurrence of acute incident in early pregnancy, there will be substantial higher risk (30% to 60%) of occurrence (Abdullah and Al-Moslih, 2005) during the last trimester. This could be attributed to the pressure of gravid uterus on the ureters causing stasis of urine flow and also attributed to the hormonal & immunological changes during normal pregnancy as well as the great abdominal distention during this stage of pregnancy with the subsequent ease of fecal contamination and the difficult personal hygiene (Jabbar et al., 1991). Women with untreated UTI during third trimester of pregnancy are at risk of delivering a child with mental retardation or developmental delay (McDermott et al., 2001).

It was also reported in the current study that multi-parity pregnant women had relatively higher rate of UTI as compared to those with history of less previous deliveries numbers. Previous studies have showed that UTI is more frequent among women who have more than 3 children (Okonko et al., 2009).

Regarding the use of contraceptive, highest rate of UTI was recorded among pregnant women who used to use IUD as a mean of contraceptive as compared to those using oral or those using no contraceptives. This could be attributed to the mechanical interference of IUD with the subsequent frequent inflammation caused by its physical presence for long periods (Harrington and Hooton, 2000)

In the current study as environmental hygiene is concerned, the personal hygiene of investigated pregnant women was evaluated based on the frequency of daily wash and the pre and post coital washes. The results revealed the presence of significant association between unsatisfactory personal hygiene and frequency of UTI among women. In general, previous studies reported that the risk of urinary tract infection increase in those with conditions associated with impaired voiding or poor personal hygiene (Amiri et al., 2009). This could be attributed to the increasing risk of general infection associated with bad hygiene.

Regarding the influence of certain health conditions on the frequency of UTI among pregnant women, the current study revealed that among health conditions as diabetes, hypertension and history of previous UTI as compared to healthy subjects, diabetes represent the most influencing factor followed by hypertension. Asymptomatic bacteriuria, acute pyelonephritis and the complications of UTI are reported to be more common in patients with diabetes, and several studies have supported these observations (Robbins and Tucker, 1944). The proposition mechanism for increased susceptibility of diabetic patient to get UTI involves diminished antibacterial activity of urine as a result of dilution of inhibitory substances like urea, defect in polymorphonuclear leukocyte function or cellular immunity as a result of hyperglycemia and increased adhesive capacity of bladder epithelium. Moreover, the developed glucosurea encourages bacterial growth in the urine. (Patterson and Andriole, 1997; Zhanel et al., 1991). One study reviewing UTIs in diabetic patients at King Abdul-Aziz University Hospital in Saudi Arabia had found that the incidence has increased from 6% in 1986 to 11% in 1999 (Akbar, 2001).

The type of underwear (panties) materials used by pregnant women was studied as one of the potential risk factors that might contribute to the frequency of UTI occurrence among pregnant women. The current findings revealed that relatively higher rate of pregnant women using silky underwear were infected with UTI as compared to those using cotton materials-underwear. The current findings are in agreement with previous study (Dimetry et al., 2007) who found that silky materials of underwear, on the contrary of cotton ones, can keep the moisture and secretions that favor the conditions for bacterial growth and hence the increasing opportunity of UTI.

In conclusion, the current results show that urinary tract infection in pregnancy is a very frequent medical problem in Makkah. The study showed that many risk factor play a role to influence UTI among pregnant women. These included advanced age (30 – ˃ 40), least educational level, low socio-economic level, 3^rd trimester stage of pregnancy, use of IUD as a mean of contraceptives, unsatisfactory personal hygiene, diabetes and hypertension and the use of silky panties. The study results suggest that pregnant women should pay more attention to personal hygiene, frequent washing with drying and using absorptive underwear like cotton to diminish bacterial growth.

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