A 36-year-old primigravida at 26 weeks gestation comes to the office for evaluation of painful urination. She has had urinary frequency since her first month of pregnancy, but a week ago she developed dysuria. The patient has also had chills and fatigue for the past 2 days. She has intermittent, nonpainful contractions but no vaginal bleeding or leakage of fluid. Fetal movement is normal. Three years ago, the patient was treated for pyelonephritis. She has no chronic medical conditions and has had no surgeries. Temperature is 100.4 F (38 C), blood pressure is 110/60 mm Hg, and pulse is 110/min. Fundal height is 26 cm and fetal heart tones are 170/min. There is tenderness over the right costovertebral angle. The uterus is nontender and the cervix is closed. Urinalysis is positive for leukocyte esterase and blood; a urine culture is collected. Which of the following is the best next step in management of this patient?

Question

A 36-year-old primigravida at 26 weeks gestation comes to the office for evaluation of painful urination.  She has had urinary frequency since her first month of pregnancy, but a week ago she developed dysuria.  The patient has also had chills and fatigue for the past 2 days.  She has intermittent, nonpainful contractions but no vaginal bleeding or leakage of fluid.  Fetal movement is normal.  Three years ago, the patient was treated for pyelonephritis.  She has no chronic medical conditions and has had no surgeries.  Temperature is 100.4 F (38 C), blood pressure is 110/60 mm Hg, and pulse is 110/min.  Fundal height is 26 cm and fetal heart tones are 170/min.  There is tenderness over the right costovertebral angle.  The uterus is nontender and the cervix is closed.  Urinalysis is positive for leukocyte esterase and blood; a urine culture is collected.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d986_a761_bc81_9fa5c3077b3e_MD0003_00 This patient has acute pyelonephritis, an upper urinary tract infection. Pyelonephritis is more common in pregnancy, likely due to the increased risk of recurrent, asymptomatic bacteriuria and physiologic maternal immunosuppression. In addition, progesterone-induced ureteral dilation, ureteral valve laxity, and bladder compression from the gravid uterus may facilitate bacterial ascent from the lower urinary tract. Patients with pyelonephritis can have preceding symptoms of cystitis (eg, dysuria) followed by fever, chills, maternal and fetal tachycardia, and costovertebral angle tenderness. Diagnosis is confirmed with urinalysis (eg, leukocyte esterase, blood), as in this patient. Pregnant patients with pyelonephritis are at high risk for severe maternal (eg, sepsis, acute respiratory distress syndrome, preterm labor) and fetal (eg, preterm birth) complications. Therefore, these patients require inpatient admission and empiric intravenous antibiotics (eg, ceftriaxone) while urine culture results are pending. Once patients remain afebrile for 24-48 hours and have symptomatic improvement, they may be transitioned to oral antibiotics (Choice C). (Choices A and D) Renal imaging (eg, CT scan of the abdomen and pelvis, renal ultrasound) is not required to diagnose acute pyelonephritis. However, if this patient does not improve within 48-72 hours of intravenous antibiotics, a renal ultrasound would be recommended to evaluate for renal abscess or nephrolithiasis. (Choice E) A voiding cystourethrogram assesses for vesicoureteral reflux, which can be a normal finding in pregnancy due to progesterone-induced relaxation of the ureteral valves. Therefore, this test is not indicated. Educational objective: Acute pyelonephritis in pregnancy typically presents with fever, maternal and fetal tachycardia, and costovertebral angle tenderness. Due to the high risk of severe maternal and fetal complications (eg, sepsis, preterm delivery), management is with inpatient admission 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 36-Year-Old Primigravida at 26 Weeks Gestation Comes to the Office