A 29-year-old primigravida at 12 weeks gestation comes to the office for a prenatal visit. The patient feels some pelvic pressure but has no vaginal bleeding or discharge. She completed a course of antibiotics at 10 weeks gestation after a urine culture grew ≥100,000 colony-forming units of Escherichia coli. The patient has had some urinary frequency but no dysuria, urgency, or hematuria. She has no chronic medical conditions and has had no surgeries. Temperature is 98.6 F (37 C), blood pressure is 96/68 mm Hg, and pulse is 90/min. Fetal heart rate is 170/min on Doppler ultrasound. The uterus is nontender and palpable just above the pubic symphysis. Which of the following is the best next step in management of this patient?

Question

A 29-year-old primigravida at 12 weeks gestation comes to the office for a prenatal visit.  The patient feels some pelvic pressure but has no vaginal bleeding or discharge.  She completed a course of antibiotics at 10 weeks gestation after a urine culture grew ≥100,000 colony-forming units of Escherichia coli.  The patient has had some urinary frequency but no dysuria, urgency, or hematuria.  She has no chronic medical conditions and has had no surgeries.  Temperature is 98.6 F (37 C), blood pressure is 96/68 mm Hg, and pulse is 90/min.  Fetal heart rate is 170/min on Doppler ultrasound.  The uterus is nontender and palpable just above the pubic symphysis.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d994_6317_bc81_4b755d06fbd3_MD0003_00 Urinary symptoms (eg, frequency) are common in pregnancy due to bladder compression by the enlarging uterus. Because it is often difficult to distinguish between cystitis and normal urinary symptoms related to pregnancy, all women undergo a screening urine culture at the initial prenatal visit to evaluate for urinary tract infection. Pregnant women have an increased risk of acute pyelonephritis (and subsequent maternal-fetal complications [eg, pulmonary edema, preterm labor]) due to progesterone-related smooth muscle relaxation that causes ureteral dilation, which allows bacteria to ascend readily to the upper urinary tract. Therefore, patients with ≥100,000 colony-forming units/mL of bacteria (eg, Escherichia coli) on urine culture require treatment even in the absence of symptoms (ie, asymptomatic bacteriuria). Treatment is with oral antibiotics (eg, nitrofurantoin). However, a third of patients do not completely eradicate the bacteriuria with initial treatment. Therefore, a repeat urine culture (ie, test of cure) is performed a few weeks after completion of antibiotic therapy and should be obtained in this patient. Patients with a negative repeat urine culture may resume routine prenatal care (Choice D). In contrast, those with another positive urine culture require retreatment and another test of cure. (Choice A) Daily antibiotic suppression may be indicated in patients with persistent bacteriuria on repeat urine culture or acute pyelonephritis during pregnancy. (Choice B) Postvoid residual volume is measured in patients with symptoms of urinary retention (eg, urgency, inability to void), but it is not used to evaluate asymptomatic bacteriuria. (Choice E) A voiding cystourethrogram is commonly performed to assess for vesicoureteral reflux (VUR) in children, who may benefit from surgical treatment to prevent recurrent UTIs. In contrast, mild VUR can be a normal finding in pregnancy that resolves after delivery; therefore, even if mild VUR is diagnosed in pregnancy, it typically requires no treatment. Educational objective: Pregnant patients with asymptomatic bacteriuria are at increased risk for complications (eg, pyelonephritis, preterm labor) and require antibiotic treatment even in the absence of symptoms. Because a third of patients do not completely eradicate the bacteriuria with initial treatment, a repeat urine culture (ie, test of cure) is required. References: Urinary tract infection and bacteriuria in pregnancy. (http://www.ncbi.nlm.nih.gov/pubmed/26475951) Interventions for preventing recurrent urinary tract infection during pregnancy. (http://www.ncbi.nlm.nih.gov/pubmed/26221993)

A 29-Year-Old Primigravida at 12 Weeks Gestation Comes to the Office