A 19-year-old woman, gravida 1 para 0, comes to the emergency department for evaluation of right-sided abdominal pain and fever for the past 2 days. The pain has progressed over the last few hours and is now unbearable. The patient has had increasing fatigue, nausea, and anorexia but no vomiting or diarrhea. She has had some nonpainful contractions but no vaginal bleeding or discharge. The patient has had no prenatal care and is at 24 weeks gestation by date of her last sure, regular menstrual period. She has no chronic medical conditions and has had no prior surgeries. The patient does not use tobacco, alcohol, or illicit drugs. Temperature is 102.2 F (39 C), blood pressure is 116/70 mm Hg, and pulse is 120/min. There is tenderness over the right flank, but no abdominal rebound or guarding. The uterus is nontender. The cervix is closed, and amniotic membranes are intact. The fetal heart rate tracing is shown in the exhibit. Which of the following is the most likely diagnosis for this patient?

Question

A 19-year-old woman, gravida 1 para 0, comes to the emergency department for evaluation of right-sided abdominal pain and fever for the past 2 days.  The pain has progressed over the last few hours and is now unbearable.  The patient has had increasing fatigue, nausea, and anorexia but no vomiting or diarrhea.  She has had some nonpainful contractions but no vaginal bleeding or discharge.  The patient has had no prenatal care and is at 24 weeks gestation by date of her last sure, regular menstrual period.  She has no chronic medical conditions and has had no prior surgeries.  The patient does not use tobacco, alcohol, or illicit drugs.  Temperature is 102.2 F (39 C), blood pressure is 116/70 mm Hg, and pulse is 120/min.  There is tenderness over the right flank, but no abdominal rebound or guarding.  The uterus is nontender.  The cervix is closed, and amniotic membranes are intact.  The fetal heart rate tracing is shown in the exhibit.  Which of the following is the most likely diagnosis for this patient?

Quizplus · Accepted Answer

11ec25c8_da8f_d9da_bc81_3d83c8aeede4_MD0003_00 Pregnant women are at increased risk for acute pyelonephritis due to increased urinary stasis, mild immunosuppression, and progesterone-related ureteral dilation. Like most patients, pregnant women with pyelonephritis typically have nausea, high-grade fever, and flank pain. Maternal fever and tachycardia also lead to fetal tachycardia (ie, >160/min), as seen in this patient. On examination, costovertebral angle tenderness is common due to retroperitoneal inflammation. fetal tachycardia Retroperitoneal inflammation can also extend to the abdominopelvic cavity. This can cause obstetric symptoms, such as uterine irritability (eg, nonpainful contractions, as seen in this patient) that can progress to preterm labor (ie, painful contractions with cervical dilation). Severe pyelonephritis can also cause maternal sepsis, acute respiratory distress syndrome, and fetal compromise (eg, premature birth, low birth weight). Due to the high risk of severe complications, management of acute pyelonephritis in pregnancy is with hospitalization and empiric intravenous antibiotics (eg, ceftriaxone). (Choice A) Acute appendicitis in pregnancy can present with fever, nausea, anorexia, and right-sided or upper abdominal pain due to uterine displacement of the appendix cephalad; however, appendicitis typically causes peritoneal signs including rebound or guarding, which are not seen in this patient. upper abdominal pain (Choice C) A degenerating uterine fibroid in pregnancy can cause abdominal pain and low-grade fever; however, patients typically have focal uterine tenderness. This patient's uterus is nontender. (Choice D) Intraamniotic infection (IAI) is a common cause of abdominal pain in pregnancy. IAI is defined as maternal fever (without a clear source of infection) plus either maternal or fetal tachycardia, purulent amniotic fluid, or leukocytosis. Although this patient has fever and maternal and fetal tachycardia, IAI is a diagnosis of exclusion and this patient has flank tenderness that makes acute pyelonephritis more likely. In addition, this patient's nontender uterus, closed cervix, and intact membranes make IAI less likely. (Choice E) Ovarian torsion can present with unilateral abdominal pain, anorexia, and low-grade fever (ie, peritonitis); however, it typically begins as intermittent pain followed by sudden-onset, severe pain consistent with complete vessel occlusion. It is not typically associated with flank tenderness. Ovarian torsion Educational objective: Acute pyelonephritis in pregnancy typically presents with fever, maternal and fetal tachycardia, and flank pain or costovertebral angle tenderness. Due to the high risk of severe complications (eg, maternal sepsis, preterm delivery), management is with hospitalization and empiric intravenous antibiotics (eg, ceftriaxone). References: Medical and infectious complications associated with pyelonephritis among pregnant women at delivery. (http://www.ncbi.nlm.nih.gov/pubmed/24194632) Pyelonephritis in pregnancy: an update on treatment options for optimal outcomes. (http://www.ncbi.nlm.nih.gov/pubmed/20731473)

A 19-Year-Old Woman, Gravida 1 Para 0, Comes to the Emergency