The effect of Ramadan on asymptomatic bacteriuria, urinary tract infections and amniotic fluid index in pregnancy

Objective

To show the effect of 12 hours fasting in a day during Ramadan on asymptomatic bacteriuria, urinary tract infections and amniotic fluid index in pregnant patients.

Methods

This study was carried out in Obstetrics and Gynecology Department of Gaziantep University Hospital, between September 23th and October 23th in year 2006 (during Ramadan). Fourty-one consecutive healthy women with uncomplicated pregnancies of 20 weeks or more who were fasting during Ramadan were included in the study group (Group 1). The control group (Group 2) consisted of 31 healthy pregnant women who were not fasting during the study period.All of these patients evaluated with urinary dipstick test in the morning and at 5 pm.for urine osmolality,leucocyteuria, and bacteriuria.After determinated a positive dipstick urine culture was performed.Urinary osmolality was also measured by dipstick test. Doppler ultrasonography was performed in all subjects in the beginning and at the end of Ramadan for the following the change of amniotic fluid index.

Results

The mean of urinary osmolality was higher in the fasting group.There was no statistically difference between two groups for asymptomatic bacteriuria and urinary tract infections rate.Amniotic fluid index was similar in two groups.

Conclusion

Twelwe hours fasting in a day during Ramadan causes hypohydration and leads an increase urinary osmolality but, it does not changes the rate of asymptomatic bacteriuria and urinary tract infections in pregnancy.

Keywords

Ramadan, pregnancy, asymptomatic bacteriuria, urinary tract infections, amniotic fluid index

Introduction

During the religious festival of Ramadan, practising Muslims refrain from eating, drinking, smoking and sexual relationships during the hours of daylight throughout the lunar month (1).Generally, meal frequency is reduced during Ramadan fasting, which it has been found often leads to reduced energy intake and loss of body mass and body fat.Any loss in body mass index is usually relativelly small and it may also be attributed to a decrease of glycogen-bound water stores, extracellular volume concentration secondary to a lower sodium intake, and a moderate degree of hypohydration with little loss of body tissue (2).Hypohydration is a risk factory for asymptomatic bacteriuria and urinary tract infections in pregnancy.Pregnant women with asymptomatic bacteriuria have an increased risk of pyelonephritis and there is a strong association between asymptomatic bacteriuria and preterm and low birth weight delivery (3, 4,5). Our aim was to evaluate the effect of Ramadan fasting on asymptomatic bacteriuria and urinary tract infections in pregnant women.

Methods

This study was carried out in Obstetrics and Gynecology Department of Gaziantep University Hospital, between September 23th and October 23th in year 2006 (during Ramadan). Fourthy-one consecutive healthy women with uncomplicated pregnancies of 20 weeks or more who were fasting during Ramadan were included in the study group (Group 1). The control group (Group 2) consisted of 31 healthy pregnant women who were not fasting during the study period. For evaluating Ramadan’s effect on asymptomatic bacteriuria and urinary tract infections in pregnant women , we evaluated all patients with dipstick urinanalysis in the morning and just before breaking the fasting (at 5 pm)..Positive urinanalysis was defined as a dipstick result that shows positive nitrites and/or more than 1+ leucocytes, blood or protein.Any patient who has a positive dipstick test evaluated with a midstream urine culture.A positive midstream urine specimen was defined as a pure growth >100 000 organisms in urine on laboratory culture.Asymptomatic bacteriuria was treated with oral cephalexin in all cases. Examinations by Doppler ultrasonography were performed once a week to all subjects for the moniterization of amniotic fluid index (AFI) during the Ramadan. High definition image (HDI; A 3.5 MHz convex transducer, Applio- Toshiba, Otamara, Japan) was used to obtain AFI . Amniotic fluid index was calculated by the sum of deepest vertical pocket in 4 uterine quadrants measured in sonography. Oligohydramnios is defined as amniotic fluid index of ≤5 cm (6). To remove the effect of other factors causing oligohydramnios and polihydramnios, all cases with urinary or skeletal anomalies, intrauterine growth retardation, multiple pregnancy, diaphragmatic hernia, diabetes, fetal hydrops and premature rupture of membrane were excluded from the study.

Results

All comparisons between the groups were done by t-test or Mann Whitney Rank Sum test where it is appropriate. Sigma Stat 3.0 was used for statistical analysis. P value<0.05 was accepted as significant. 
No significant difference was found between the two groups for maternal age, and pregnancy weeks.There was no statistically difference between two groups for asymptomatic bacteriuria (p=0.490).Ten patients in Group 1 ten patients (2.4 %), in Group 2 eight pateints (2.5%) had asymptomatic bacteriuria and treated by oral cephalexin.In Group 1,there are only two patients had urinary tract infections (4.8 %), in first case midstream urine culture was posite for E.Coli and treated successfully with intravenous cephalexin in 27th pregnancy weeks.In second patients, midstream urine culture was posite for β streptococus, and treated with parenteral amphicilline-sulbactam.In Group 2, only one patients (3.2%) had urinary tract infection due to E.Coli and treated with parenteral cephalexin in 25 th pregnancy weeks.There was no statistically difference between two groups for urinary tract infections (p=0.54).
AFI was did not change during the Ramadan and there was no difference between two groups (p=0.434).Urine osmolality was significantly increased in fasting group during the Ramadan (p=0.01).

Discussion

During the daylight hours of Ramadan fasting, practising Muslims are undoubtely dehydrating at a rate that is determined by the loss of body water minus the amount of metabolic water that is produced over this period (7). No definitive evidence has been found to show that a susceptibility to urinary tract infection is influenced by fluid intake (8).In three reports, urinary tract infections was associated with a low fluid intake or low urine output (9-11).In two prospective studies in girls, recurrent urinary tract infections was associated with infrequent urine voiding and poor fluid intake.A study in adults with urinary catheters showed that low urine output was significantly related to urinary tract infections (11).Water deprivation is functionally characterized by maximum urine concentration .In 20 Malaysian Muslims, urine was collected before, during and after Ramadan fasting each in the morning (0800-1200), afternoon (1200-1600) and overnight (1600-0800).The authors found that Ramadan fasting did not affect the overnight urine volume or osmolality (means: 649-781), indicating that the subjects were probably not subjected to severe water deprivation (12). In another study, urinary osmolality was higher during Ramadan than either before or after Ramadan (7).In our study, urinary osmolality was significantly higher just before breaking the fast (at 5 pm).
Urinary tract infections are a common complication of pregnancy.Symptomatic urinary tract infections occurs in 1% to 2% of pregnancies, while asymptomatic bacteriuria has been reported in 2% to 13% of pregnant women (3, 4). In this sudy, urinary osmolality was significantly higher just before breaking the fast (at 5 pm) but, there was not statistically difference between two groups for asymptomatic bacteriuria (2.4% versus 2.5%, and p=0.490).Pregnant women with asymptomatic bacteriuria have a 20-30 fold increased risk of developing pyelonephritis compared to women without bacteriuria (13, 14). Antimicrobial treatment of asymptomatic bacteriuria during pregnancy decreases the risk of subsequent pyelonephritis from 20-35% to 1-4% (14).Therefore, we treated all of these patients to prevent the risk of pyelonephritis.
In our study, the urinary osmolality was higher than control group but urinary tract infections rate was similar in both groups (4.8 % versus 3.3%, p=0.54).We also suggested to all patients in two groups to drink at least 2 liter water during the day.It could be prevent hypohydration and urinary tract infections.

Conclusion

Ramadan changes urinary osmolality during the fasting hours, but does not affect the rate of asymptomatic bacteriuria and urinary tract infections in pregnancy.

 

References

1) Dwyer PL, O’ Reilly M.Recurrent urinary tract infection in the female.Curr Opin Obstet Gynecol 2002; 14: 537-543.
2) Le J, Briggs GG, McKeown A, Bustillo G.Urinary Tract Infections during pregnancy.Ann Pharmacother 2004;38:1692-1701.
3) Christensen B.Which antibiotics are appopriate for treating bacteriuria in pregnancy.J Antimicrob Chemother 2000; 46: 29-34.
4) MF.A. Manning, I. Morrison, I.R. Lange, C.R. Harman and P.F. Chamberlain.Foetal assessment based on foetal biophysical profile scoring: experience in 12,620 referred high-risk pregnancies 1. Perinatal mortality by frequency and etiology.Am J Obstet Gynecol 1985; 151:343–350
5) Shirreffs SM.Markers of hydration status.Eur J Clin Nutr 2003; 57:6-9.
6) Beetz R.Mild dehydration: a risk factor of urinary taract infection.Eur J Clin Nutr 2003; 57:52-58.
7) Mazzola BL, Von Vigier RO.Behavioral and functional abnormalities linked with recurrent urinary tract infections in girls.J Nephrol 2003;16:133-138.
8) Stauffer CM, Van Der Web B.Family history qnd behavioral abnormalities in girls with recurrent urinary tract infections: a controlled study.J Urol 2003; 171: 1663-1665.
9) Wilde MH, Carrigan MJ.A chart audit of factors related to urine flow and urine tract infection.J Adv Nurs 2003; 43:254-262.
10) Cheah SH, Ch’ng SL, Husian R, Duncan MT.Effects of fasting during Ramadan on urinary excretion in Malaysian Muslims.Br J Nutr 1990;63: 329-37.
11) Nicolle LE, Bradley S, Colgan R. Infectious Diseases Society of America guidelines for the diagnosis and treatment of aymptomatic bacteriuria in adults.Clin Infect Dis 2005; 40:643-54.
12) Smaill F.Antibiotics for asymptomatic bacteriuria in pregnancy.Cochrane Database Syst Rev 2001; 2:CD000490.

	File/Dsecription
	Table 1. Comparison of the maternal data between fasting and non-fasting groups.
	Table 2. Comparison of the results between two groups.