Genital and urinary tract infections in pregnancy in southern India : diagnosis, management and impact om perinatal outcome

Background: Prevalence of sexually transmitted infections varies in different parts of the world. These infections, occurring during pregnancy, can result in adverse outcome. There is paucity of information on the prevalence, effects and management of such infections in pregnancy in India. Similarly, urinary tract infection (UTI) is a common medical problem in pregnancy. But, very little is known about the patterns and mechanism of antimicrobial resistance among bacteria causing UTI and the prescription practices for this condition. Diagnostic methods, used for early onset sepsis (EOS) in the new-born also need evaluation.

Methods: Endocervical samples from consecutive pregnant women at 26 to 36 weeks of gestation were tested to detect infection with Chlamydia trachomatis. Association of this infection with adverse pregnancy outcome was determined In another retrospective cohort study, information related to pregnancy and outcome was collected from pregnant women with reactive Venereal Disease Research Laboratory (VDRL) test, which was done as part of antenatal care. Data on susceptibility patterns of bacteria isolated in significant counts from urine of pregnant women suspected to have urinary infection were collected. To understand the mechanism of resistance, the prevalence of integrons among these E. coli were determined Prescribing patterns for these infections were ascertained using a questionnaire and based on antibiotics dispensed to pregnant women. To evaluate the use of CRP in diagnosing EOS, CRP levels in cord blood and neonatal blood at 24 hrs were estimated in two groups of neonates, one at risk of developing infection and the other at low risk of infection.

Results: Prevalence of C trachomatis infection was 3.3% and this infection did not contribute significantly to adverse pregnancy outcome. Prevalence of syphilis was also low. However, fetal loss occurred in 32% of the infected women. The difference in outcome between those receiving antenatal care and those without was significant (P = 0.01; RR 7.53 95% Cl 1.1 - 51.9). In 2002, > 90% of E. coli causing UTI was susceptible to nitrofurantoin, a relatively inexpensive and safe drug. However, less than 25% of doctors used it for treatment of cystitis. The choice and duration of therapy varied greatly.

Resistance to ampicillin (p< 0.001), nalidixic acid (p = 0.001), chloramphenicol (p = 0.02), tetracycline (p = 0.004), and gentamicin (p = 0.02) were significantly more common in isolates with integrons. Several intrapartum risk factors can cause elevation in CRP levels. At 24 hours, elevated CRP levels were associated with primiparity (p= 0.006), more than three vaginal examinations after membrane rupture (p=0.02), meconium staining of amniotic fluid (p =0.02) and amnioinfusion (p =0.02). In the group at risk of infection, 10 (4%) babies developed EOS. The negative predictive value for elevated CRP levels for diagnosing EOS at 24 hrs was 99%.

Discussion: The prevalence of STIs among antenatal women is low. However, syphilis is an unrecognised cause of pregnancy loss in the area. There are several lacunae in the diagnosis and treatment of infections in pregnancy - both UTI and STIs. A major reason probably is the lack of locally relevant uniform guidelines for the diagnosis and management of these conditions. There is also complacency because of low prevalence of STIs in pregnancy. We also observed that auditing the management of syphilis in pregnancy could be an effective and simple tool to assess the quality of antenatal care. High prevalence of resistance among E coli is associated with integrons. Since CRP levels rise in babies without infection, this test may be useful only in excluding infection.

List of scientific papers

I. Alexander R, Mathai E, Nayyar V, Mathew M, Jasper P (1993). "Low prevalence of chlamydial endocervical infection in antenatal south Indian women." Genitourin Med 69(3): 240-1
https://pubmed.ncbi.nlm.nih.gov/8335319

II. Mathai E, Mathai M, Prakash JA, Bergstrom S (2001). "Audit of management of pregnant women with positive VDRL tests." Natl Med J India 14(4): 202-4
https://pubmed.ncbi.nlm.nih.gov/11547524

III. Mathai E, Thomas RJ, Chandy S, Mathai M, Bergstrom S (2004). "Antimicrobials for the treatment of urinary tract infection in pregnancy: practices in southern India. " Pharmacoepidemiol Drug Saf 13(9): 645-52
https://pubmed.ncbi.nlm.nih.gov/15362088

IV. Mathai E, Grape M, Kronvall G (2004). "Integrons and multidrug resistance among Escherichia coli causing community-acquired urinary tract infection in southern India. " APMIS 112(3): 159-64
https://pubmed.ncbi.nlm.nih.gov/15153157

V. Mathai E, Christopher U, Mathai M, Jana AK, Rose D, Bergstrom S (2004). "Is C-reactive protein level useful in differentiating infected from uninfected neonates among those at risk of infection? " Indian Pediatr 41(9): 895-900
https://pubmed.ncbi.nlm.nih.gov/15475630