A 27-year-old woman, gravida 1 para 0, at 29 weeks gestation comes to the emergency department due to 24 hours of fever and mild nausea. Two days ago, she developed urinary frequency and urgency. The patient has had no vomiting or abdominal pain. Her pregnancy has been complicated by gestational diabetes mellitus that was diagnosed 4 weeks ago and is well controlled with dietary modification. The patient has no known drug allergies.
On examination, she appears uncomfortable but is in no acute distress. Temperature is 38.9 C (102 F), blood pressure is 124/84 mm Hg, pulse is 96/min, and respirations are 18/min. Mucous membranes are moist. The lungs are clear to auscultation. There is mild tenderness to palpation in the suprapubic region but no costovertebral angle tenderness.
Laboratory results are as follows:
A urine culture is obtained.
Which of the following is the most appropriate treatment at this time?

Question

A 27-year-old woman, gravida 1 para 0, at 29 weeks gestation comes to the emergency department due to 24 hours of fever and mild nausea.  Two days ago, she developed urinary frequency and urgency.  The patient has had no vomiting or abdominal pain.  Her pregnancy has been complicated by gestational diabetes mellitus that was diagnosed 4 weeks ago and is well controlled with dietary modification.  The patient has no known drug allergies.
On examination, she appears uncomfortable but is in no acute distress.  Temperature is 38.9 C (102 F), blood pressure is 124/84 mm Hg, pulse is 96/min, and respirations are 18/min.  Mucous membranes are moist.  The lungs are clear to auscultation.  There is mild tenderness to palpation in the suprapubic region but no costovertebral angle tenderness.
Laboratory results are as follows:
 A urine culture is obtained.
Which of the following is the most appropriate treatment at this time?

Quizplus · Accepted Answer

11ec193a_968b_6d1f_853d_4b599ebc1674_MD0002_00 This pregnant patient in the third trimester has features of cystitis (eg, urinary frequency, suprapubic tenderness). The additional features of high-grade fever, peripheral leukocytosis, and marked pyuria suggest early acute pyelonephritis (despite the absence of costovertebral tenderness). Pyelonephritis during pregnancy causes an increased risk for complications such as acute respiratory distress syndrome and pulmonary edema. Adverse pregnancy outcomes include preterm labor and low birth weight. Pregnant women, particularly those in the later stages of pregnancy, are at increased risk for pyelonephritis due to anatomical changes in the urinary tract and immunosuppression caused by pregnancy. Current guidelines recommend inpatient admission and intravenous antibiotics until the patient is afebrile and demonstrates symptomatic improvement for 24 to 48 hours (Choices A, D, and E). Escherichia coli most commonly causes pyelonephritis during pregnancy, but other gram-negative bacteria and gram-positive organisms (eg, group B Streptococcus) may cause bacteriuria during pregnancy. Intravenous ceftriaxone is the treatment of choice for acute pyelonephritis in pregnancy given its efficacy and low side effect profile. Aminoglycosides are not considered first-line agents as prolonged exposure has been associated with fetal ototoxicity. (Choice C) Fluoroquinolones, including ciprofloxacin, are typically avoided during pregnancy due to possible teratogenicity. Educational objective: Pyelonephritis in pregnancy is associated with maternal (eg, acute respiratory distress syndrome) and obstetrical (eg, preterm labor) complications. Management is with inpatient intravenous antibiotics that are administered until patients are afebrile for 24 to 48 hours. __________ References: Pyelonephritis in pregnancy: an update on treatment options for optimal outcomes. (http://www.ncbi.nlm.nih.gov/pubmed/20731473) Urinary tract infections during pregnancy. (http://www.ncbi.nlm.nih.gov/pubmed/15340129)

A 27-Year-Old Woman, Gravida 1 Para 0, at 29 Weeks