A 35-year-old woman, gravida 1 para 0, at 35 weeks gestation is evaluated in the labor and delivery unit for fever and chills. Three days ago, she was admitted for acute pyelonephritis and started on broad-spectrum intravenous antibiotics. The patient continues to have a fever and developed chills an hour ago. She has had no painful contractions, leakage of fluid, or vaginal bleeding. Fetal movement is normal. Temperature is 38.3 C (101 F), blood pressure is 118/64 mm Hg, and pulse is 112/min. Fetal heart rate monitoring is 180/min with moderate variability, multiple accelerations, and no decelerations. Tocometry reveals irregular contractions. There is tenderness over the right flank. On pelvic examination, the cervix is 1 cm dilated and 25% effaced. Amniotic membranes are intact, and the fetal presentation is vertex. Which of the following is the best next step in management of this patient?

Question

A 35-year-old woman, gravida 1 para 0, at 35 weeks gestation is evaluated in the labor and delivery unit for fever and chills.  Three days ago, she was admitted for acute pyelonephritis and started on broad-spectrum intravenous antibiotics.  The patient continues to have a fever and developed chills an hour ago.  She has had no painful contractions, leakage of fluid, or vaginal bleeding.  Fetal movement is normal.  Temperature is 38.3 C (101 F), blood pressure is 118/64 mm Hg, and pulse is 112/min.  Fetal heart rate monitoring is 180/min with moderate variability, multiple accelerations, and no decelerations.  Tocometry reveals irregular contractions.  There is tenderness over the right flank.  On pelvic examination, the cervix is 1 cm dilated and 25% effaced.  Amniotic membranes are intact, and the fetal presentation is vertex.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_da90_9d2b_bc81_d3e3391692fa_MD0003_00 This patient with persistent fever most likely has a renal abscess. Renal and perinephric abscesses typically form in the setting of complicated urinary tract infections or acute pyelonephritis (as in this patient), but they can also develop through hematogenous spread (eg, bacteremia, endocarditis). Risk factors include pregnancy (due to relative immunosuppression and physiologic hydronephrosis), diabetes mellitus, and urinary tract abnormalities. Most cases of acute pyelonephritis improve within 48-72 hours of broad-spectrum intravenous antibiotics; however, when infected renal tissue becomes necrotic, it can progress to form a cavity (ie, abscess) that becomes walled-off and less susceptible to antibiotic penetration. Therefore, patients with a renal abscess typically have no clinical improvement or worsening symptoms despite antibiotic therapy, as in this patient with persistent fever and continued flank pain. In pregnant women, a worsening renal infection can also manifest as fetal tachycardia, uterine contractions (due to peritoneal inflammation), and/or pulmonary edema. Diagnosis of a renal abscess is with renal ultrasound (preferred in pregnancy) or CT scan of the abdomen, and treatment is with continued broad-spectrum antibiotics and possible ultrasound-guided percutaneous drainage. (Choice A) Amniocentesis and amniotic fluid culture can help diagnose an intrauterine infection (IAI), which may also present with fever and fetal tachycardia; however, this patient's persistent flank pain is more consistent with a renal abscess. In addition, she has intact amniotic membranes, making IAI less likely. (Choice B) Emergency cesarean delivery may be indicated in cases of imminent fetal or maternal compromise. Although this patient's fetal heart rate tracing reveals tachycardia, it shows moderate variability with no decelerations, meaning the patient does not require immediate delivery. (Choice D) Terbutaline tocolysis can be used to inhibit contractions in patients with preterm labor at <34 weeks gestation or in laboring patients with fetal distress due to uterine tachysystole. This patient has irregular contractions and a reassuring fetal heart rate tracing (eg, moderate variability, no decelerations). (Choice E) Voiding cystourethrograms are used to assess for vesicoureteral reflux, which is often a normal finding in pregnancy due to progesterone-induced ureteral valve relaxation. Testing does not change management and is not recommended. Educational objective: Patients with acute pyelonephritis who do not improve within 48-72 hours of broad-spectrum intravenous antibiotic therapy require evaluation with renal ultrasound to assess for a renal abscess. References: ACR Appropriateness Criteria acute pyelonephritis. (http://www.ncbi.nlm.nih.gov/pubmed/30392592) Medical and infectious complications associated with pyelonephritis among pregnant women at delivery. (http://www.ncbi.nlm.nih.gov/pubmed/24194632)

A 35-Year-Old Woman, Gravida 1 Para 0, at 35 Weeks