A 30-year-old woman, gravida 1 para 0, at 34 weeks gestation comes to the office for a prenatal visit. The patient reports no abdominal pain, vaginal bleeding, or leakage of fluid. Fetal movement is normal. The patient has had urinary frequency throughout her pregnancy, but it has worsened over the last 4 days and is now associated with dysuria. She has no fevers, chills, nausea, vomiting, back pain, or hematuria. The pregnancy has been uncomplicated. The patient has no history of chronic medical conditions and has had no previous surgery. She takes a daily prenatal vitamin. The patient smokes half a pack of cigarettes a day but does not use alcohol or illicit drugs. Temperature is 36.7 C (98.0 F), blood pressure is 126/78 mm Hg, pulse is 76/min, and respirations are 18/min. BMI is 28 kg/m². Fetal heart rate is 140/min. On physical examination, the uterus is nontender and fundal height is 34 cm. Suprapubic tenderness is elicited with deep palpation. There is no costovertebral angle tenderness. Laboratory results are as follows: Item 1 of 2 Which of the following is the most appropriate medication for this patient's condition?

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Explanation: 11ec2b69_bfca_ebb4_8f63_33e7448b24a0_MD0005_00 During pregnancy, physiologic changes such as increased urine output and compression of the bladder by the gravid uterus often cause symptoms of urinary frequency and urgency. However, this patient also has dysuria and a urinalysis positive for bacteria and leukocyte esterase, a presentation consistent with acute cystitis. The most common pathogen for acute cystitis is Escherichia coli. Other less common pathogens include Proteus mirabilis and Klebsiella pneumoniae. Risk factors for urinary tract infection in pregnancy include the presence of asymptomatic bacteriuria, nulliparity, pregestational diabetes mellitus, and tobacco use. Pregnant patients with clinically suspected acute cystitis are treated empirically with antibiotics for 3-7 days. First-line antibiotics include nitrofurantoin, cephalexin, fosfomycin, and amoxicillin-clavulanate. A urine culture is obtained to confirm infection and to direct the modification of the antibiotic regimen should symptoms not improve with treatment. Because there is a high risk of persistent bacteriuria, a urine culture is repeated for a test of cure one week after treatment completion. (Choice B) Ciprofloxacin, a fluoroquinolone, is effective in treating acute cystitis in nonpregnant patients. Fluoroquinolones are avoided during pregnancy as they are toxic to fetal cartilage development. (Choice C) Clindamycin covers gram-positive and anaerobic bacteria. Because it does not cover gram-negative bacteria, it is not typically used to treat acute cystitis. (Choice D) Tetracyclines are avoided in pregnancy as they cross the placenta, impair fetal long-bone development, and stain fetal teeth. (Choice E) Trimethoprim-sulfamethoxazole is a first-line treatment for cystitis in nonpregnant women. However, its use in the first trimester has been associated with neural tube defects due to the folate antagonist properties of trimethoprim. Use in the late third trimester is associated with neonatal kernicterus. Educational objective: Pregnant patients with clinically suspected acute cystitis require empiric antibiotics with nitrofurantoin, cephalexin, or amoxicillin-clavulanate for 3-7 days. Fluoroquinolones and tetracyclines are contraindicated in pregnancy, and trimethoprim-sulfamethoxazole should be avoided in the first and third trimesters. References: Urinary tract infection and bacteriuria in pregnancy. (http://www.ncbi.nlm.nih.gov/pubmed/26475951) Asymptomatic bacteriuria and symptomatic urinary tract infections in pregnancy. (http://www.ncbi.nlm.nih.gov/pubmed/18826482)

A 30-Year-Old Woman, Gravida 1 Para 0, at 34 Weeks