J Med Sci, Volume 51, Number 1, 2019 January: 31-35

Journal of the Medical Sciences

(Berkala Ilmu Kedokteran)

Volume 51, Number 1, 2019; 31-35

http://dx.doi.org/10.19106/JMedSci005101201904

Urinary tract infection in premature rupture of

membrane (PROM): an academic hospital based study

Muhammad Nurhadi Rahman*, Rivaldi D. Liligoly, Nuring Pangastuti

Department of Obstetrics and Gynaecology, Faculty of Medicine, Public Health and Nursing, Universitas
Gadjah Mada/Dr. Sardjito General Hospital, Yogyakarta, Indonesia

ABSTRACT

Submited: 2018-12-18 Premature rupture of membrane (PROM) and preterm PROM (PPROM) are
Accepted : 2019-03-23 commonly related with poor maternal and perinatal outcomes. Urinary tract
infection (UTI) has been known as one of its risk factors. The aim of study was
to ascertain the frequency and pattern of urinary symptoms as well as the risk
factors for UTI in PROM and PPROM. A retrospective study was conducted at
Dr. Sardjito General Hospital, Yogyakarta, Indonesia. All pregnancy cases with
the history of PROM/PPROM from January to December 2015 were included.
The research subjects were obtained from medical records, using the format
of basic data collection to identify the risk factors of UTI in pregnancy. One
hundred cases of complicated pregnancy with either PROM or PPROM were
obtained. The mean of maternal age, gestational age, and birth weight were 28
± 5.99 yr; 34.05 ± 4:28 wk; 2170.79 ± 835.447 g; respectively. Urinalysis was done
in 58 patients. The prevalence of bacteriuria was 55.17%. Symptomatic vs.
asymptomatic bacteriuria showed statistically significant differences (p<0.001,
OR = 0.409; CI = 0287-0584). In multivariate analysis using linear regression,
maternal age, gestational age and parity were not directly related to the
occurrence of UTI (p = 0.367; p = 0.697; p = 0.385; respectively). In conclusion,
the proportions of symptomatic bacteriuria in pregnancy are significantly
higher than asymptomatic. However, maternal age, gestational age, and parity
are not directly related to the prevalence of UTI in pregnancy complicated with
PROM and PPROM.

ABSTRAK

Ketuban pecah dini (PROM) dan preterm PROM (PPROM) umumnya berkaitan
dengan hasil maternal dan perinatal yang buruk. Infeksi saluran kemih (ISK)
telah dikenal sebagai salah satu faktor risiko. Penelitian ini bertujuan untuk
memastikan frekuensi dan pola gejala kemih serta faktor risiko ISK pada
PROM dan PPROM. Penelitian retrospektif dilakukan di Rumah Sakit Umum
Dr. Sardjito, Yogyakarta, Indonesia. Seluruh kasus kehamilan dengan riwayat
PROM/PPROM dari Januari hingga Desember 2015 diikutkan dalam penelitian
ini. Subjek penelitian diperoleh dari catatan medis. Data dikumpulkan
untuk mengidentifikasi faktor risiko ISK pada kehamilan. Sebanyak seratus
kasus kehamilan rumit dengan PROM atau PPROM dengan masing-masing
rerata usia ibu, usia kehamilan, dan berat lahir adalah 28 ± 5,99 tahun; 34,05
± 4:28 minggu; 2170.79 ± 835.447 g. Urinalisis dilakukan pada 58 pasien.
Prevalensi bakteriuria adalah 55,17%. Terdapat perbedaan yang signifikan
secara statistik (p <0,001, OR = 0,409; CI = 0287-0584) antara bakteriuria
simptomatik dengan asimptomatik. Hasil analisis multivariat menggunakan
Keywords: regresi linier menunjukkan bahwa usia ibu, usia kehamilan, dan paritas tidak
urinary tract infection, secara langsung terkait dengan terjadinya ISK (p = 0,367; p = 0,697; p =0,385).
premature rupture of Sebagai kesimpulan, proporsi bakteriuria simptomatik pada kehamilan secara
membranes, signifikan lebih tinggi daripada bakteriuria asimptomatik. Namun, pada
preterm premature kehamilan yang rumit dengan PROM dan PPROM, usia ibu, usia kehamilan,
rupture of membrane dan paritas tidak secara langsung berhubungan dengan prevalensi ISK.

*corresponding author: nurhadi.rahman@ugm.ac.id 31

J Med Sci, Volume 51, Number 1, 2019 January: 31-35

INTRODUCTION ignored asymptomatic bacteriuria may

progress to the development of cystitis
Preterm labor and birth are a and pyelonephritis.7
major cause of perinatal morbidity and Therefore, it is essential to screen for
mortality. Despite modern advances in UTI in pregnancy so that timely treatment
obstetric and neonatal management, the could be offered. The present study was
rate of preterm birth in the developed conducted to find out the symptomatic
world is increasing.1 Preterm premature and asymptomatic conditions in
rupture of membranes (PPROM) is maternal UTI cases complicated with
associated with inflammation and PROM and PPROM. In addition, the study
infection, and it may involve the loss of was also undertaken to determine the
a barrier to ascending infection from the risk outcomes of UTI in pregnancy to
vagina. It is suspected that prolonged maternal and perinatal conditions.
PPROM could be an independent risk
factor for neonatal sepsis.2 MATERIALS AND METHODS
Several maternal risk factors can
be a reason of spontaneous preterm Protocol of study
labor and delivery such as infection, The retrospective study was
short cervix or cervical dysfunction, conducted to ascertain the outcomes
genital tract hemorrhage, lower body of UTI in pregnancy complicated with
mass index, lower socioeconomic PROM and PPROM in Dr Sardjito General
status, idiopathic uterine contractions, Hospital, Yogyakarta, Indonesia from
multifetal pregnancy and spontaneous January to December 2015. Maternal age,
rupture of the fetal membranes are parity, gestational age, urinary symptoms
also associated with the condition.1 and birth weight were recorded from
Other studies mainly discuss about all pregnant women with the history
maternal lower genital tract infection of PROM or PPROM. The diagnosis of
and association with PROM and PPROM.3 PPROM and PROM were made when the
However, urinary tract infection (UTI) rupture of fetal membranes occurred
has to be investigated as the risk factors before and after 37 wk, respectively. The
of PROM and PPROM. presence of IUGR was assessed using
Urinary tract infection is a common Lubscencho birth weight curve. Low
problem in pregnancy which can birth weight was defined as less than
be classified as lower (cystitis and 2500 g birth weight. Fifty-eight women
asymptomatic bacteriuria) or upper underwent complete examinations of
(pyelonephritis) tract infections.4 urine. Dipstick test was performed on
The anatomical, hormonal changes, midstream urine. The diagnosis of UTI
also increased plasma volume was established from the presence of
during pregnancy decreases urine either bacteriuria or leucocyte esterase
concentration and pregnant women or nitrite from the urinalysis.
may develop glucosuria, which leads
to increased bacterial growth in the Data analysis
urine. Therefore, the pregnant women The odds ratio (OR) and 95%
are more prone to UTI than the non- confidence interval (95%CI) were
pregnant.5 Maternal UTI can be either calculated among the categorical
symptomatic or asymptomatic. The parameters. The multivariate analysis
presence of symptomatic UTI is using linear regression was used to
associated with an increased risk of determine the correlation between
intrauterine growth retardation (IUGR) maternal age, gestational age and parity
and low-birth weight (LBW).6 In addition; to UTI prevalence.

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 Rahman MN, et al., Urinary tract infection...

RESULTS PPROM cases). The mean of maternal

age, gestational age, birth weight were
As many as 100 cases of 28.13 ± 5.82 yr, 32.71 ± 4.16 wk, 1907.05 ±
complicated pregnancies with PROM 752.18 g, respectively. Characteristics of
and PPROM, urinalysis was performed subjects according to the presence of UTI
in 58 patients (47 PROM cases and 11 were compared, as shown in TABLE 1.

TABLE 1. Characteristics of subjects

UTI Non UTI

Variable p
(n = 32) (n = 26)
Age (mean ± SD) 28.68±6.03 27.46±5.58 0.43
Gestational age (mean ± SD) 32.46±4.67 33.00±3.51 0.63
Birthweight (mean ± SD) 1858.29±815.77 1975.77±664.70 0.58
Parity
• Multipara (n, %) 17 (53.1) 12 (46.2)
0.59
• Primigravida (n, %) 15 (46.9) 14 (53.8)
Maternal age, gestational age, and birthweight were analyzed using
independent t-test

The diagnosis of UTI was established 25 (78.1%) patients with PPROM and
based on the presence of bacteriuria 7 (21.9%) patients with PROM were
in 20 (62.5%) patients and 12 (37.5%) diagnosed with UTI, which has no
patients without the finding bacteriuria differences statistically compared to
but having positive results of leukocyte patients with no UTI (p=0.53; OR=0.64;
esterase and nitrite. TABLE 2 showed 95%CI=0.16-2.51).

TABLE 2. Maternal and perinatal outcomes (n or %) associated with

urinary tract infection

UTI No UTI
Variable p OR 95%CI
(n =32) (n =26)
PPROM 25 (78.1) 22 (84.6)
0.530 0.64 0.16-2.51
PROM 7 (21.9) 4 (15.4)
Symptomatic 14 (43.8) 0 (0)
0.001 N/A N/A
Asymptomatic 18 (56.3) 26 (100)
IUGR 4 (12.5) 1 (3.8)
0.240 3.57 0.37-34.11
No IUGR 28 (87.5) 25 (96.2)
LBW 24 (77.4) 14 (63.6)
0.270 1.95 0.58-6.56
Normal 7 (22.6) 8 (36.4)
PPROM/PROM, Symptoms, IUGR, and LBW were analyzed using Chi-square (x2)

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J Med Sci, Volume 51, Number 1, 2019 January: 31-35

The study showed that symptomatic morbidity associated with symptomatic

bacteriuria cases in the presence of UTI UTIs.12 In this study, because of the
in pregnancy was different significantly small number of subjects involved, the
(p<0.001; OR=N/A). The presence of IUGR assessment of IUGR and LBW babies in
was found in 4 (12.5%) patients with UTI cases had no significant differences
UTI in pregnancy with no significant compared to those without the condition
differences statistically compared to UTI in this study. On the other hand, other
in pregnancy cases without the presence study with larger number of subjects
IUGR (p=0.24; OR=3.57; 95%CI=0.37- found that patients with UTI had
34.11). Low birth weight cases were found significantly higher rates of IUGR13 and
in 24 (77.4%) cases of UTI in pregnancy LBW.14
complicated with either PPROM or PROM
(p=0.27; OR=1.95; 95%CI=0.58-6.56). CONCLUSION

DISCUSSION The proportions of symptomatic

bacteriuria in pregnancy are significantly
Urinary tract infection in pregnancy higher than asymptomatic. However,
still becomes one of the most common maternal age, gestational age, and parity
clinical problems in pregnancy. The are not directly related to the prevalence
condition is a serious problem for of UTI in pregnancy complicated with
pregnant women. If left untreated, UTI PROM and PPROM.
can lead to pyelonephritis, preterm
labor or infection in the newborn.8 ACKNOWLEDGEMENTS
The present study was conducted to
determine the outcomes of urinary tract This research was supported
infection in pregnancy complicated with by Department of Obstetrics and
PROM or PPROM such as UTI symptoms, Gynaecology, Faculty of Medicine, Public
IUGR, and LBW. In the present study, Health and Nursing, Universitas Gadjah
it was revealed that the proportion Mada, Yogyakarta, Indonesia. We thank
of PPROM and PROM cases were not our colleagues from Department of
different significantly between those Obstetrics and Gynaecology, Faculty of
with and without UTI. There were no Medicine, Public Health and Nursing,
previous studies investigating this issue. Universitas Gadjah Mada, Yogyakarta,
Other studies mainly focusing on the Indonesia who provided insight and
association between maternal infection expertise that greatly assisted the study.
and preterm labor.3,9,10 However, a study
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