REVIEW
Urinary tract infection in
obstetrics and
gynaecology
Natasha Curtiss
Iranthi Meththananda
Jonathan Duckett
Abstract
Urinary tract infections are an important cause of morbidity affecting
women of all ages. Escherichia coli is the most common causative
pathogen for urinary tract infections. Diagnosis is best made by symp-
toms or culture as dipstick testing for leucocytes and nitrites is unre-
liable.
There is an increased risk of UTIs in pregnancy. They are common
and warrant investigation and treatment as even asymptomatic bacte-
ria can be associated with adverse pregnancy outcomes. Fetal compli-
cations include preterm labour, still birth and low-birth weight. The
maternal complication of pyelonephritis has a high recurrence rate.
Urinary tract infection is one of the main differentials for pelvic pain
in a gynaecological patient. In addition, UTIs must be excluded before
diagnoses of overactive bladder or bladder pain syndrome are made.
UTIs are most commonly treated using antibiotics, however,
research is underway into further novel treatment options for UTI
which may be available in the future.
Keywords asymptomatic bacteriuria; cystitis; pyelonephritis;
recurrent urinary tract infections; urinary tract infection
Introduction
Worldwide each year 150 million people suffer from urinary tract
infections (UTI). UTIs can either results from a bladder infection
in the lower urinary tract (cystitis) or a kidney infection of the
upper tract known as pyelonephritis. Typical features of urinary
tract infection are urgency, frequency, and dysuria. The woman
may feel generally unwell and her urine may be odorous, cloudy
or contain blood. UTIs are a significant public health burden and
substantially affect the quality of life of affected individuals.
Females are more susceptible to UTIs; about 10e20% of all
women will experience a symptomatic UTI in their life time. The
high incidence of UTI in young women means UTIs are
Natasha Curtiss MRCOG Specialty Trainee in Obstetrics and
Gynaecology at Medway Maritime Hospital, Gillingham, Kent, UK.
Conflicts of interest: none.
Iranthi Meththananda Specialty Trainee in Obstetrics and
Gynaecology at Medway Maritime Hospital, Gillingham, Kent, UK.
Conflicts of interest: none.
Jonathan Duckett MD(Res) FRCOG Consultant Urogynaecologist at
Medway Maritime Hospital, Gillingham, Kent, UK. Conflicts of
interest: none.
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 27:9
commonly seen in obstetrics and gynaecology with associated
morbidity and mortality both in and outside pregnancy.
The scope of this review is to highlight the current evidence of
surrounding urinary tract infections in obstetrics and gynaecol-
ogy. The focus of this review will be uncomplicated UTIs
affecting the lower urinary tract.
Predisposing factors
The female urethra is short in comparison with males and
therefore the chance of bacteria ascending into the bladder to
cause an infection is higher. The interplay in the embryological
development of the urinary and genital tracts means women with
uterine anomalies may have co-existing urinary tract anomalies.
Abnormalities of the renal tract and neurological conditions such
as multiple sclerosis all predispose to UTI. Any condition
affecting the immune system will also contribute to an increase
susceptibility to urinary tract sepsis e.g. Diabetes which affects
women of all ages. Other genetic and acquired immune defi-
ciency (e.g. HIV) will likewise increase the chances of developing
a UTI. Sexual intercourse can encourage ascending bacteriuria.
There was an association between coital frequency and UTI in a
cohort of unmarried women. Women with mothers prone to UTIs
are more susceptible and any condition that results in the bladder
not emptying completely e.g. cystocele will predispose to urinary
tract infection.
Catheterisation and instrumentation of the bladder
increase the risk of a urinary tract infection with UTIs accounting
for about 40% of all hospital acquired infections. Each time a
catheter is passed into the bladder there is a 1e2% risk of urinary
infection (EUA guidelines). Catheterisation is done routinely in
obstetrics for caesarean sections and in laparoscopic gynaecology
to protect the bladder. The ability to manage urinary tract
infection is therefore an important skill in an obstetrician and
gynaecologist.
Investigations
Urinalysis
When a UTI is suspected the first investigation is dipstick urinalysis
testing for the presence of nitrites and leucocyte esterase. Studies
have reported a wide range of sensitivity and specificity for dipstick
investigations when diagnosing UTIs. 70 publications were
included in a meta-analysis by Deville et al. this showed that the
sensitivity of the urine dipstick for nitrites was low (45%e60%)
and the specificity ranged between 85% and 98%. The dipstick test
sensitivity of leucocyte esterase again was low (48%e86%) and the
specificity of leucocyte esterase had a very large range of specific-
ities between studies (17%e93%). It is possible to increase the
specificity and sensitivity by combining these tests.
Mid-stream urine microscopy & culture
Sample: In order to accurately diagnose a UTI it is recommended
that contamination of the sample is minimised. Most clinicians
opt for diagnosis with a clean catch mid stream urine culture. As
this method is better tolerated than suprapubic bladder aspira-
tion or catheter samples.
Microscopy: The presence of 10 or more white blood cells
(WBC)/mm3 in fresh urine (pyuria) can be associated with UTI.
261 Ó 2017 Elsevier Ltd. All rights reserved.
 REVIEW
However, infection may not always show pyuria. Although
bacterial count correlates with pyuria, 15% of samples from
urine with bacterial counts of >105 do not have pyuria at
microscopy.
Many laboratories will test for the presence of pyuria before
going on to perform a culture. It is possible to underestimate
pyuria rates as there is a decline in the wcc following sampling
with 40% of white cells are still lost by 4 hours. Refrigeration and
boric acid slow this process but there will often be a delay be-
tween a specimen being produced and arrival and processing in
the laboratory. This could result in a sample being discarded as
being free from infection.
Culture: A urine culture can show the concentration of bacteri-
uria, identify the organism responsible and the antibiotic sensi-
tivity of that pathogen. Assuming that the sample is collected,
stored and analysed appropriately there is a high sensitivity and
specificity for urine cultures to be used to diagnose significant
bacteriuria. Routine culture is not recommended for uncompli-
cated urinary tract infections in the non-pregnant women.
However, where there is non-resolution of symptoms, compli-
cations or in the pregnant women cultures should be sent. Clean
catch mid-stream urine cultures can guide the choice of antimi-
crobial therapy and provide a diagnosis where there is clinical
uncertainty. Currently a urinary tract infection by MSU culture is
diagnosed where
105 colony forming units per millilitre (CFU/
ml) of a single species of bacteria are isolated from direct-plating
of the urine sample. Routine hospital MSU culture in the United
Kingdom is performed in aerobic conditions looking for known
uropathogens. Some less common pathogens require longer in-
cubation times and prefer anaerobic conditions. Studies have
shown positive routine blood cultures in women with acute py-
elonephritis to be between 15 and 17%.
Imaging: There is no role for imaging in an uncomplicated uri-
nary tract infection. However, in recurrent UTIs imaging may be
undertaken, if the history is suggestive, to rule out structural
anomalies. There is, however, a low rate of detecting an abnor-
mality in uncomplicated recurrent UTIs. Recurrent UTIs in
pregnancy likewise can be an indication to image the upper renal
tract. If a uterine anomaly (e.g. didelphys) is diagnosed the upper
renal tract should be checked for co-existing anomalies.
Pathogens
The vast majority of UTIs are caused by bacteria. Escherichia coli
is the most common cause of UTI. An international study of the
urinary cultures from 4734 women with UTI found E. coli to be
implicated in 53.3%. The next most common pathogen was
Proteus mirabilis at 4.4%. Other common species to cause UTIs
include Staphylococcus saprophyticus a coagulase negative cocci,
Klebsiella pneumonia, Enterococci and Pseudomonas. Other
pathogens include Staphylococcus aureus and Mycobacterium
tuberculosis can be haematologically inoculated. The bacteria
responsible for UTI in pregnancy are similar to those in non-
pregnancy.
Urinary tract infections have also been shown to be caused by
other bacteria that are not identified by routine culture. Actino-
baculum schaalii has been found to be a cause of urinary tract
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 27:9
infection in the elderly. This bacterium is a slow growing facul-
tative anaerobe. Other rarer causes of urinary tract infections
include non-bacterial infections such as Chlamydia and Candida
albicans.
It is understood that in many infections there is an initial
phase in which the pathogen attaches to a particular site of the
host. This early adhesion helps the pathogen to compete effec-
tively with the host’s own micro-flora and helps overcome other
factors that might inhibit the pathogen becoming established.
This ability confers an important factor in the virulence of the
bacteria. Bacterial cell surface structures that are responsible for
the promotion of adhesion are known as adhesins. These are
often encoded by plasmids and may be in the form of fimbriae
and non-fimbrial adhesins.
Extracellular substances, pili, flagella and extracellular DNA
are able to form a biofilm scaffold which might support a
multicellular bacterial community. In this way protecting the
pathogens from antimicrobials, immune response and other
stressors enabling them to persist and cause recurrent infections.
Within this micro-ecosystem a variety of microbial strains may
exist and co-operate in order to efficiently derive nutrition.
Pseudomonas aeruginosa is an important cause of UTIs associ-
ated with catheter use. It forms biofilms on catheters by pro-
ducing auto-inducers that bind to transcriptional regulators up
regulating exopolysaccharides that promote a biofilm matrix. P.
aeruginosa can also adopt a filamentous morphology and flagella
promoting pathogenesis.
Traditionally urine was thought to be sterile, however, there is
increasing evidence that there is a healthy flora of bacteria, or
microbiome, that co-exist in the healthy bladder without causing
an infection. These bacteria are present at much lower levels
than are detected by routine hospital cultures but have been
identified by using expanded culture techniques and next gen-
eration sequencing of the gene for the 16S RNA subunit present
in all bacteria.
UTIs in obstetrics
UTIs have three main presentations in pregnancy. Asymptomatic
bacteriuria is the persistent colonisation of the urinary tract by a
significant number of bacteria in women without symptoms.
Acute cystitis on the other hand is defined as the presence of
symptoms including dysuria, urgency, frequency, nocturia,
haematuria and suprapubic discomfort with no evidence of sys-
temic illness. The third presentation is pyelonephritis e signifi-
cant bacteriuria in the presence of systemic illness which may
include pyrexia, rigors, renal angle pain, nausea and vomiting
and fetal tachycardia.
Increased risk in pregnancy
There are a unique set of circumstances in pregnancy which
contribute to the increase in susceptibility to UTIs. There is an
increase in bladder volume and a coexisting decrease in detrusor
tone. Progesterone can cause ureteric dilatation due to relaxation
of smooth muscle and the gravid uterus may also compress the
ureters causing hydronephrosis. Predominantly this is seen on
more on the right side (the left is protected by the sigmoid colon).
The kidney in pregnancy allows more glucose into the urine with
the majority of women developing glycosuria, this may
262 Ó 2017 Elsevier Ltd. All rights reserved.
 REVIEW
contribute to bacterial growth. In addition, Pregnancy alters the
immune response and these changes may confer an increase risk
to some infections.
Complications
It has been described as early as 1962 by Edward Kass that
asymptomatic bacteriuria is associated with adverse maternal
(pyelonephritis, cystitis) and fetal (preterm labour, still birth, low
birth weight, perinatal mortality) outcomes. Many other studies
have also described rates of 28% pyelonephritis and 12.8% pre
term delivery. Other associations of pre-eclampsia, anaemia and
chorioamnionitis and endometritis have also been described. The
pathophysiology of which is thought to be due to increased in-
flammatory burden due to endotoxins causing cell membrane
damage.
Asymptomatic bacteriuria
Bacteriuria in the absence of any symptoms occurs in 2e10% of
all pregnancies. Treatment of bacteriuria has been shown to
reduce the rate of pyelonephritis in pregnancy which if left un-
treated will occur in up to 30% of women. The administration of
antibiotics to those women with asymptomatic bacteria reduces
the rate of pyelonephritis by 75%. The same Cochrane review
has concluded that the treatment may also prevent preterm birth
and intrauterine growth restriction but the evidence base is not
strong. For these reasons routine screening is performed in early
pregnancy. This is done by MSU culture of the urine as reagent
strips are inadequate for screening for asymptomatic bacteriuria
due to poor sensitivity and specificity. Treatment should be
directed by cultures for a duration of 7 days. MSUs should be
repeated regularly until delivery as these women are susceptible
to recurrence (nice guidance antepartum care).
Group B Streptococcus, a gram-positive coccus, when found in
the urine is associated with a high vaginal colonization. This can
be associated with preterm labour and an important cause in
neonatal sepsis. It is therefore recommended by the RCOG if this
is cultured in the urine, treatment should be given. It is also
important for the woman to be recommended to have antibiotic
prophylaxis in labour to prevent group B Streptococcus in the
newborn (RCOG guidance).
Treatment considerations
Glomerular filtration rates increase in pregnancy and can cause
increased elimination of renally excreted medications. Bioavail-
ability in pregnancy also decreases with physiological increased
maternal plasma volume. This can affect Beta lactams,
Penicillin and Cephalosporins. Efficacy may be modified by dose
change or to consider alternative hydrophilic medications.
It is also important to consider the effect of teratogenicity of
some medications particularly in the first trimester. Trimetho-
prim should be prescribed alongside folic acid in the first
trimester or avoided as it is folate antagonist (The UK Teratology
Information Service). Even with completion of organogenesis
potential fetal effects can occur. Maternal treatment with ami-
noglycosides can be associated with risk of auditory or vestibular
nerve damage in children (BNF).
Simple analgesia can provide symptomatic relief. In preg-
nancy non-steroidal anti inflammatories (NSAIDs) should be
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 27:9
avoided due to their teratogenicity. There is limited evidence
supporting the use of topical local anaesthetic for dysuria.
Symptomatic treatment for acute cystitis may be offered by
increasing oral fluids however there is little evidence to support
this. Historically many women have been advised to take Cran-
berry juice or related supplements but there is no good quality
evidence to support this. Urine alkalinsing agents have been used
to alleviate symptoms in pregnancy however complications such
as hypernatraemia secondary to sodium citrate means that it
should be avoided.
Acute infection
The incidence of acute UTI is hard to determine but is quite
common and most estimates are of approximately 8%. All
women with symptoms suggestive of UTI in pregnancy should
have a MSU sent for culture. Due to the increased risk of com-
plications in pregnancy this should be followed by a repeat cul-
ture as a test of cure. UTI should be treated with empirical
antibiotics in pregnancy because of the increased risk to the fetus
of death, cerebral palsy and developmental delay in UTI infec-
tion. Usually empirical antibiotics are commenced before results
of culture however re-evaluation should be made of the correct
antimicrobials following availability of results. A 7e10 days
course is usually administered. Shorter courses can lead to
inefficient treatment and progression to pyelonephritis. A sys-
tematic review of different treatment regimens was unable to
detect any benefit to one treatment.
The incidence of pyelonephritis is 2% with 23% of women
having recurrences during their pregnancy. Symptoms suggestive
of pyelonephritis such as fever, rigors and a women being sys-
temically unwell will require admission to hospital as there are
risks of pre term labour and renal complications. Careful moni-
toring is required of mother and fetus with administration of IV
antibiotics alongside supportive treatment.
Recurrent urinary tract infections (RUTI)
Recurrent UTIs are common and occur in approximately 4e5%
of pregnancies. The possible adverse outcome is the same for the
initial UTI; pyelonephritis and adverse pregnancy outcomes.
Although good evidence exists for the treatment of recurrent
UTIs with prophylactic antibiotic in the non-pregnant population
there is less robust evidence in pregnancy. Schneeberger et al.
when defining recurrent UTIs in pregnancy as UTI where there
has been another UTI either inside or outside pregnancy found
only one trial to use in their systematic review of treatments for
recurrent UTIs in pregnancy. That trial included 200 subjects and
compared low dose nitrofurantoin with close monitoring alone. It
showed no benefit in the use of prophylactic nitrofurantoin with
close surveillance for the prevention of pyelonephritis and
adverse pregnancy outcomes of low-birth weight, miscarriages
and Apgar score. There was a role in the use of prophylactic
nitrofurantoin in preventing asymptomatic bacteriuria in women
with >90% clinic attendance.
UTIs in gynaecology
Urinary tract infections can cause diagnostic difficulties in the
gynaecological patient. They can also be introduced
263 Ó 2017 Elsevier Ltd. All rights reserved.
 REVIEW
iatrogenically by instrumentation of the bladder during gynae-
cological procedures.
Pelvic pain
Urinary tract infections are part of the differential for pelvic pain
in a gynaecological patient. Other conditions can mimic symp-
toms of acute cystitis e vulvitis, cervicitis and vaginitis caused
by herpes simplex. Urethritis with discharge maybe indicative of
gonococcal or chlamydia urethritis. This highlights the impor-
tance of undertaking a thorough history and examination in these
patients.
Infection & overactive bladder
Overactive bladder is a syndrome of lower urinary tract symp-
toms there is a considerable crossover in symptoms between
UTIs and overactive bladder; frequency and urgency. In order to
make a diagnosis of OAB urinary tract infection must be
excluded. For reasons detailed above dipstick testing may not be
adequate. MSU tests should be sent where there suspicion of a
chronic or recurrent UTI. There have been associations made
between bacteria that do not grow in routine urine culture con-
ditions and chronic bladder symptoms. Ureoplasma cultures
were found to be positive in 53% of 191 cases with chronic
voiding symptoms and in their tertiary unit Latthe et al. showed
in 1 year 34% of their cases with resistant overactive bladder
symptoms grew positive cultures for mycoplasma or ureoplasma.
Bladder pain syndrome
Many women with bladder pain syndrome or interstitial cystitis
may be thought to have recurrent UTIs. The absence of culture
proven UTIs may warrant further investigation. Interstitial
cystitis is diagnosed by exclusion and although the aetiology is
unclear it is a chronic inflammatory condition in the absence of
infection.
Recurrent UTIs
Recurrent UTIs are common in both the pregnant and non-
pregnant populations. In non-pregnant women there is up to a
30% recurrence rate in the first year after a urinary tract infection
and a study in Finland showed 5% of women had three or more
infections in a year after an E. coli infection. Meta-analysis has
shown 6e12 month antibiotic prophylaxis is effective in these
women compared with a placebo RR ¼ 0.21. In order to prevent
the theoretical risk of developing antibiotic resistance, rotating
low dose antibiotics can be considered. Occasionally gastroin-
testinal upset and candidiasis can result with long-term prophy-
lactic doses. Unfortunately up to 60% of women will suffer a
recurrence after stopping the designated 6-month course. If this
occurs indefinite prophylaxis maybe required.
Patient initiated treatment is a useful adjunct for women who
suffer from recurrent urinary tract infections. Women have been
shown to be able to reliably self diagnose UTIs and can then start
a course of antibiotics prescribed in advance. Alternatives for
women who identify sexual intercourse as a risk factor are to
take a single dose of antibiotic post intercourse. Other behav-
ioural modifications are pre and post coital voiding and avoiding
spermicide based contraception. In postmenopausal women
vaginal, but not oral, oestrogens have been shown to be bene-
ficial in reducing recurrent UTIs.
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 27:9
Management
Antibiotics are the mainstay of treatment of urinary tract infec-
tion. Nice guidance suggests that all non-pregnant women with a
suspected urinary tract infection should be offered antibiotics
although treatment may be delayed if a women wishes to see if
symptoms resolve. Prescriptions should follow local resistance
patterns but for most women a 3 days course should be suffi-
cient. Longer course of antibiotics may be required in the pres-
ence of abnormal urinary tract or immunosuppression (NICE
2015). Likewise, pregnant women should also be treated with
antibiotics. Cranberry juice and alkalizing agents have limited
evidence and are not recommended.
Novel treatments
Uropathogens exhibit a number of virulence factors, which
threatens the use of antibiotics.
Antibiotic resistance was listed as a global threat in 2014 and
with no new antibiotics produced since 1987 alternative treat-
ments need to be identified. Most new treatments are focused on
preventing or treating recurrent UTIs as they are more easily
studied with an risk group and the advantage of frequent re-
currences allowing useful evaluation of novel therapies.
Probiotics: Lactobacillus is an important vaginal commensal and
forms part of the normal bladder microbiome. A clinical trial
comparing Lactobacillus crispatus intravaginally to placebo
showed a similar rate of adverse events such as vaginal discharge
and itching when used after treatment for a documented UTI.
The lactobacillus arm had significantly fewer repeat UTIs in the
10 weeks of once weekly administration. Further evaluation of
probiotics to prevent UTI is under evaluation. A Cochrane review
found overall that there was no evidence of adverse effects but
that there was insufficient data to show a significant benefit for
the use of probiotics in preventing urinary tract infection.
D-mannose: D-Mannose is has a role in glycosylation in
human metabolism. It has been shown in vivo models to inhibit
the FimH adhesion of E. coli to urothelial cells. IT has been used
in horses and dogs for the treatment of UTI. A three arm trial of
women with treated UTI received either no prophylaxis, nitro-
furantoin or prophylaxis with D-mannose. There were more UTIs
in the untreated group with no significant difference between
nitrofurantoin and D-mannose.
Acupuncture: There have been two trials evaluating acupunc-
ture as a treatment preventing UTIs. In both women were
randomised to acupuncture or sham acupuncture and followed
up for 6 months. The acupuncture group had significantly less
episodes of UTI.
Methenamine Hippurate: Methenamine Hippurate has been
evaluated for use in the prevention of urinary tract infections.
Formaldehyde, which is bacteriostatic, is produced from hex-
amine. It is best used for short term prevention and does not
work well in those patients with neuropathic bladder.
Bladder instillations: Replacement of the glycosaminoglycan
(GAG) layer with bladder instillation of hyaluronic acid and
chondroitin sulphate has been used for prevention of recurrent
264 Ó 2017 Elsevier Ltd. All rights reserved.
 REVIEW

UTI. A review of 27 clinical studies suggested that further trials In summary, urinary tract infections are an important cause of
are needed to evaluate this approach. morbidity affecting women of all ages. The combination of
dipstick urine testing for nitrites and proteinuria is not sensitive
Vaccines: Instead of treatment of UTIs with antibiotics, vaccines enough to exclude infection. Antibiotics remain the mainstay of
are being evaluated in the prevention of recurrent urinary tract treatment. New novel technologies will provide further treatment
infections. Uro-VaxomÒ is an oral vaccine composed of E. coli options in the future. More research is needed in this area. A
extract has been shown to be more effective than placebo. Like-
wise, the vaginal vaccine UrovacÒ slightly reduced UTI recur-
FURTHER READING
rence. UromuneÒ vaccine contains inactivated Escherichia coli,
Deville WL, Yzermans JC, van Dujin NP, Bezemer PD, van der
Klebsiella pneumoniae, Proteus vulgaris and Enterococcus faecalis
Windt DA, Bouter LM. The urine dipstick test useful to rule out
was given to 159 women with a history of recurrent urinary
infections: a meta-analysis of the accuracy. BMC Urol 2004; 4: 4.
tract infection and 160 women received antibiotic prophylaxis.
Foxman B. Urinary tract infection syndromes: occurrence, recurrence,
The vaccine group had fewer UTIs in the follow up period of
bacteriology, risk factors, and disease burden. Infect Dis Clin N Am
x months.
2014; 28: 1e13. This paper presents the most recent information
Vaccines development has also targeted bacterial adherence.
about UTIs and their socioeconomic impact.
There have been promising studies undertaken to target the CUP
Grabe M, Bartoletti R, Bjerklund Johansen TE, Cai T, Çek M, Ko € ves B,
pilli. Adhesin based vaccines have been shown to prevent
et al. Guidelines on urological infections. European Association of
adherence by pilli. Other vaccines target bacterial proteases,
Urology, 2015.
toxins and siderophores have also been studied.
National Institute for Health and Care Excellence. Urinary tract infec-
tion (lower) e women CKS. London: National Institute for Health
Molecules targeting urease & bacterial adhesion: New drug
and Care Excellence, 2015.
targets are being developed by looking at attachment (e.g.
Schwenger EM, Tejani AM, Loewen PS. Probiotics for preventing
adhesins) and establishment of bacteria (e.g. siderophores and
urinary tract infections in adults and children. Cochrane Database
urease). Some are effective in neutralising bacteria in animal
Syst Rev 2015 Dec 23; 12: CD008772. http://dx.doi.org/10.1002/
models. Urease inhibitors have been developed to treat UTIs, one
14651858.CD008772.pub2.
of the most well known being AHA (acetohydroxamic acid)
Scottish Intercollegiate Guidelines Network. Management of sus-
approved by the FDA in 1983. Although this was found to have a
pected bacterial urinary tract infection in adults (SIGN 88). Edin-
low binding and inhibitory concentration and caused neurolog-
burgh: Scottish Intercollegiate Guidelines Network, 2012.
ical, musculoskeletal problems and was teratogenic. Phosphor-
Smaill FM, Vazquez JC. Antibiotics for asymptomatic bacteriuria in
amidites are another group of urease inhibitors that are active
pregnancy. Cochrane Database Syst Rev 2015; 8: CD000490.
against P. mirabilis but were impractical due to their instability at
http://dx.doi.org/10.1002/14651858.CD000490.pub3. 2015 Aug 7.
low pHs in gastric acid.

OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 27:9 265 Ó 2017 Elsevier Ltd. All rights reserved.