Study of Prevalence of Asymptomatic Bacteriuria in Gestationaldiabetes Mellitus
N. NikathNasreen, R.Yuvarani *
Department of Obstetrics &Gynaecology, SreeBalaji Medical College & Hospital Affiliated to Bharath Institute of Higher Education and Research, Chennai, Tamil Nadu, India.
*Corresponding author e-mail id: [email protected]
ABSTRACT
To study the prevalence of asymptomaticbacteriuria in gestational diabetes mellitus. To screen the women with gestational diabetes mellitus for the prevalence of asymptomatic bacteriuria And to study the commonest organism which causes asymptomatic bacteriuria in gestational diabetes mellitus. Prevalence of asymptomatic bacteriuria among the women with gestational diabetes mellitus attending our antenatal clinic assessed using percentage with 95%
confidence interval is18% (11.4 -26.5%) The commonest organism which causes the asymptomatic bacteriuria in gestational diabetes mellitus was assessed using percentage of occurrence to the total. 61% of asymptomatic bacteriuria in GDM is due to E.coli.
Keywords:diabetes mellitus, pyelonephritis, preeclampsia, anaemia and glucose intolerance.
1. INTRODUCTION
“Urinary tract infections have plagued mankind long before bacteria were recognized.” 1 Infection of urinary tract is one of the most common problems in pregnancy due to anatomical and physiological changes that take place in the genitourinary tract in pregnancy. It may be symptomatic or asymptomatic. “Asymptomatic Bacteriuria,” or asymptomatic urinary infection, is isolation of a quantitative count >105 cfu/ml of bacteria in an appropriately collected urine specimen obtained from a person without symptoms or signs referable to urinary infection. 2 The prevalence of Asymptomatic Bacteriuria (ASB) in pregnancy varies from 2 -10% 3, 4 In 1962, Edward Kass was the first one to study in detail about ASB and he observed significant bacteriuria in 6% of asymptomatic pregnant women presenting for their first antenatal visit. Maternal and
fetal complications attributed to it are symptomatic urinary tract infection (UTI), pyelonephritis, preeclampsia (PE), anaemia, low birth weight (LBW), intrauterine growth retardation (IUGR), preterm labour (PTL), preterm premature rupture of membrane (PPROM) and post-partum endometritis. 5 , 6
The American College of Obstetrics and Gynecology recommends that a urine culture be obtained at the first prenatal visit for all pregnant women. 7 The American Academy of Family Physicians (AAFP) strongly recommends that all pregnant women be screened for asymptomatic bacteriuria using urine culture at 12 to 16 weeks gestation or at the first antenatal visit if after that time. Gestational diabetes is carbohydrate intolerance of variable severity with onset or first recognition during pregnancy and may or may not persist after delivery. (American Diabetes Association 2006). In the Indian context, screening is essential in all pregnant women as the Indian women have 11 fold increased risk of developing glucose intolerance during pregnancy compared to Caucasian women. 8 The recent data on the prevalence of GDM in India is 16.55%. 9 According to the Diabetes In Pregnancy Study group India (DIPSI) 75 gram oral glucose challenge test more than 140mg/dl is diagnostic.
Women with Diabetes Mellitus are considered immunocompromised and are therefore possibly more prone to develop infections of which the urinary tract is one of the most prevalent sites of infection. 10 , 11 Moreover women with Diabetes Mellitus and a Urinary Tract Infection are more susceptible to severe and rare complications of UTI such as Xanthogranulomatous Pyelonephritis. 12 , 13 Seeing these deadly complications of asymptomatic bacteriuria and increasing incidence of GDM in our population this study was carried out to identify these patients early, treat them with appropriate antibiotics and to emphasise the importance of screening in all pregnant women and especially in GDM. As always prevention is better than cure. Aim of good antenatal care is to ensure the wellbeing of both mother and child.
2. MATERIALS AND METHODS
This study was conducted after getting ethical clearance from the University ethical committee. In the present study, the prevalence of asymptomatic bacteriuria in 100 pregnant women with GDM and singleton pregnancy attending the antenatal clinic was calculated and they were given appropriate treatment based on urine culture and
sensitivity reports to prevent the complications of asymptomatic bacteriuria. Apart from GDM, other factors like age, parity and socioeconomic class during pregnancy also were evaluated as a risk factor for asymptomatic bacteriuria.
TYPE OF STUDY: Prospective study
STUDY POPULATION: 100 pregnant women with singleton pregnancy having GDM based on the inclusion and exclusion criteria.
STUDY SETTING: Department of Obstetrics and Gynaecology, SreeBalaji Medical College and Hospital, Chrompet, Chennai.
STUDY PERIOD: December 2013- December 2015 INCLUSION CRITERIA:
Singletonpregnancy
Women having gestational diabetes at gestational age above 12weeks.
Women who are willing to participate in thisstudy EXCLUSION CRITERIA:
Pregnant women having overtdiabetes
Women diagnosed to haveanemia.
Women with h/o intake of any antimicrobials in this pregnancy
H/o increased frequency of urine, burning micturition (symptoms ofcystitis)
H/o preterm delivery, recurrent UTI, PROM, PPROM, IUGR in previouspregnancy.
History of Gestational Diabetes Mellitus in the previouspregnancy
Women with multiplepregnancy METHODOLOGY:All women who meet the inclusion and exclusion criteria were taken into the study
after signing an informed written consent. Detailed history was taken and thorough general physical examination was done at the onset of the study. 100 women attending the antenatal clinic atSreebalaji medical college and hospital with GDM according to DIPSI guidelines ( OGCT >140 g/dl) was taken for the study.
Sample collection:
The subjects were instructed to collect clean catch midstream specimen urine after proper periurethral to perineal toileting with tap water. With labia held apart midstream urine was collected in a sterile universal container and sent to the central Microbiology laboratory without any delay.
STATISTICAL ANALYSIS:
Demographic variables in categorical/dichotomous were given in frequencies with their percentages.Bio chemical variables were given in mean and standard deviation.Prevalence of asymptomatic bacteriuria among the women with gestational diabetes mellitus attending our antenatal clinic assessed using percentage with 95%
confidence interval.To study the commonest organism which causes the asymptomatic bacteriuria in gestational diabetes mellitus was assessed using percentage of occurrence to the total.To correlate whether factors like socioeconomic class, parity and age has any influence on the infection Using chi square test.FBS and OGCT values differences between no growth and positive was calculated using student independent t - test.Simple bar diagram, Multiple bar diagram and Box plot were used to represent the data.P<0.05 was considered statistically significant.
3. RESULTS
Majority of this study sample -54% belonged to age group between 20 and 25 years, 38% women aged between 26 and 30, 8% were between 31 and 35 years.
Figure 1: AGE DISTRIBUTION
Table 1: DISTRIBUTION OF WOMEN ACCORDING TO GRAVIDA
Gravida No. of women %
I 42 42.0
%
II 37 37.0
%
III 19 19.0
%
IV 2 2.0%
Total 100 100.
0%
42% of these study samples were primigravida, 37% second gravida, 19% third gravida and only 2% were fourth gravida.
31 -35 years 26 -30 years
20 -25 years 0%
8.0%
30%
20%
10%
38.0%
50%
40%
54.0%
60%
AGE DISTRIBUTION
% of women
Figure2: RESULTS OF THE URINE CULTURE IN GDM AND THE DISTRIBUTION OFORGANISMS
Table2 : PATTERN OF DISTRIBUTION OF ORGANISMS CAUSING ASYMPTOMATIC BACTERIURIA INGDM
Organism No. of
women
%
E.coli 11 61.0
%
Klebsiellasp 2 11.0
%
Proteus sp 1 5.6%
Staph aureus 1 5.6%
Staph saprophyticus 1 5.6%
Enterococci sp 1 5.6%
B haemolytic streptococcus 1 5.6%
Total 18 100.
0%
ORGANISM
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
82.0%
11.0%
2.0% 1.0% 1.0% 1.0% 1.0% 1.0%
% of women
Among the positive urine cultures 61% is due to E.coli, 11% due to Klebsiella species, 5.6% caused by Proteus species, 5.6% Staph aureus, 5.6% Staph saprophyticus, 5.6% Enterococci species and 5.6% caused by B heamolytic streptococcus.
Figure 3: ASSOCIATION BETWEEN INFECTION AND GRAVIDA
Table 3: ASSOCIATION BETWEEN INFECTION AND FBS & OGCT
Investiga tion
U rin e cul tur e
n M e a n
Std.
Devia tion
Student independen t t-
test
100%
90%
80%
70%
60%
50%
40%
I II III IV
30%
20%
10%
0%
No growth Positive
% of women 85.7% 83.8% 78.9% 21.1% 100.0%
FBS mg\dl
No gro wt h
8 2
1 1 6 . 6 1
17.85 9
t=0.70p=0.
48
notsignifica nt
Pos itiv e
1 8
1 2 0 . 1 1
23.88 4
OGCT mg\dl
No gro wt h
8 2
1 7 5 . 0 2
22.51 7
t=1.51p=0.
13 not
significant Pos
itiv e
1 8
1 8 4 . 4 4
29.66 7
The mean FBS value is higher 120.11 mg/dl in asymptomatic bacteriuria compared to only 116.61 mg/dl in other GDM women without bacteriuriaand also OGCT mean value is higher 184.44 mg/dl compared to only 175.02 mg/dl in GDM women without bacteriuria. There is an association between infection and FBS, OGCT. It was tested using student independent t -test. P value was higher; hence there is no statistical significance. Still there is an increasing trend in infection in women with higher blood sugars.
Nogrowth Positive
Urine culture
OGCT mg\dl 0
FBS mg\dl 100
200 300
Figure 4: BOX PLOT COMPARES THE MEAN FBS AND OCGT VALUE AMONG INFECTION GROUP
This box plot shows that prevalence of asymptomatic bacteriuria was higher in GDM women with high values of blood sugars (both FBS and OGCT) compared to GDM women with lower blood sugar values.
DISCUSSION
An autopsy sequence published in the 1940s discovered a connection between urinary tract infection (UTI) and diabetes mellitus. 12 and 13 In diabetes, the urinary tract is the most common source of infection. The prevalence of diabetic cystopathy and microvascular disease in the kidneys, as well as changes in host defense mechanisms, may all play a role in the higher occurrence of UTI in diabetic patients. 14 Urinary tract infections are the most prevalent bacterial infections, responsible for almost seven million office visits and one million emergency room visits, with 100,000 mothers, the elderly, and patients with spinal cord injury and/or catheters, multiple sclerosis, HIV, and diabetes being hospitalized. 15 Asymptomatic bacteriuria is becoming more prevalent as
people become older. According to Turpin et al69, the highest prevalence of 13 percent ASB in pregnant women was observed in the age range 35–39 years, with the lowest rate of 0 percent in the age groups 15–19 years. In a study conducted by Ansari et al70 in 2011, he examined 125 pregnant women, of which 113 (90.4%) were between the ages of 15 and 25, and 12 (9.6%) were between the ages of 26 and 35. There were 21 (16.8%) severe bacteriuria cases out of 125 women. In the 15-25 and 26-35 age ranges, culture positivity was observed in 17 women (15.04%) and 4 women (33.3%), respectively.
Increased co morbid conditions, such as neurogenic bladder and increased residual urine volume or urinary reflux, may contribute to the high prevalence with increasing maternal era. Asymptomatic bacteriuria seems to be more common in multiparous women. 16 In a 2007 study of 580 antenatal mothers, Fatima et al discovered that 3.18 percent of Primigravida and 6.04 percent of Multigravida had asymptomatic bacteriuria (p=0.0039).
In 2011, Obirikorang et al conducted a study on 200 pregnant mothers. Women that were primigravida were 35 (17.5%), with 3 (8.6%) reporting positive for bacteriuria, and multiparous women were 165 (82.5%), with 16 (9.7%) positive findings. Bad sanitation, a lack of general hygiene, and a reluctance to attend antenatal clinic on a daily basis are all factors that contribute to the increased incidence of ASB in those with a low socioeconomic status. 17-19 years old
In 2010, Alvarez et al discovered that gravidas with pregestational diabetes mellitus have a higher chance of asymptomatic bacteriuria than non-diabetic gravidas. It was a case- control sample that included 150 pregnant women with pregestational diabetes and 294 non-diabetic monitors. 20 When compared to non-diabetic gravidas, the prevalence of ASB was higher in pregestational diabetics (18 percent versus 8.2 percent , odds ratio [OR] 2.47, 95 percent confidence interval [CI] 1.37 to 4.45). The prevalence of ASB is higher in diabetics, according to several research conducted in non-pregnant diabetics.
There aren't a lot of research papers on GDM.
Following an analysis of all the trials, 100 GDM women who had no signs of urinary tract infection after 12 weeks of pregnancy were selected. Women with diabetes who were not open about their condition were excluded from the study. 21-23 years In India, the prevalence of ASB during pregnancy is just 2-10%. However, the frequency of GDM (the current study) was measured using a percentage with a 95 percent confidence
interval of 18 percent (11.4 percent -26.5 percent), which is higher than the usual antenatal population. As a result, the relevance of screening of GDM women is highlighted.
CONCLUSION
This study results, taken together with existing literature, suggest that there is high prevalence of asymptomatic bacteriuria in women with gestational diabetes mellitus.India is marching forward as the diabetic capital of the world. Let us not burden even the unborn child of the GDM mother with infections in the form of ASB.
We must prevent infections by screening the high risk groups, at the earliest.
Funding: No funding sources
Ethical approval: The study was approved by theInstitutional Ethics Committee CONFLICT OF INTEREST
The authors declare no conflict of interest.
ACKNOWLEDGMENTS
The encouragement and support from Bharath University, Chennai is gratefully acknowledged. For provided the laboratory facilities to carry out the research work.
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