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Pyelonephritis in Pregnancy

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Pyelonephritis in Pregnancy

  • Epidemiology
  1. Incidence: 2% of pregnancy
  2. Peak Incidence in the second and third trimesters
  • Pathophysiology
  1. Pregnancy factors that increase Pyelonephritis risk
    1. Increased GFR (results in Glycosuria, alkaluria)
    2. Increased Serum Progesterone (results in dilation of renal calyces, ureteral peristalsis stagnation)
    3. Bladder compression
  • Symptoms
  1. Fever
  2. Chills
  3. Nausea
  4. Contractions
  5. Preterm Labor
  6. Acute Cystitis Symptoms
  • Signs
  • Labs
  1. Urinalysis
  2. Urine Culture with Sensitivity
    1. Consider Urinary Catheter sample
  3. Complete Blood Count
    1. Leukocytosis
  4. Chemistry Panel (basic metabolic panel)
  5. Consider straining urine for calculi
  • Imaging
  • Management
  • Inpatient
  1. Most pregnant patients with Pyelonephritis start with inpatient care
  2. Antibiotics
    1. Ceftriaxone (Rocephin) 1-2 grams IV or IM every 24 hours
      1. Avoid in the peripartum period due to risk of newborn Kernicterus
    2. Unasyn 1.5-3g IV q6h
    3. Combination Protocol for 14 days
      1. Ampicillin 2 g IV every 6 hours
      2. Gentamycin 1.5 mg/kg (Maximum 80-100 mg) q8 hours
        1. Adjust dosing per kinetics for >1-2 days use
  3. Other Inpatient Therapy
    1. Bedrest in semi-Fowler's position
      1. Place on side opposite affected Kidney
    2. Use cooling measures as needed for Temp > 102
    3. Intravenous hydration
    4. Maintain intravenous antibiotics
      1. Oral when affebrile without CVA pain for 48 hours
      2. Complete a total of 7-14 days
      3. Consider Urinary Tract Infection prophylaxis
  • Management
  • Outpatient antibiotics
  1. Augmentin 875 mg PO bid for 14 days
  2. Macrodantin (avoid in third trimester, risk of newborn Hemolysis)
    1. Initial: 100 mg PO qid for 14 days
    2. Prophylaxis: 100 mg PO qhs until 6 weeks postpartum
  3. Keflex 250 mg PO qid for 14 days
  • Complications
  1. Acute Respiratory Distress Syndrome (in up to 8% of cases of Pyelonephritis in Pregnancy)
  2. Acute Kidney Injury
  3. Anemia
  • References
  1. Swadron, Schmitz, Bridwell, Carius in Herbert (2019) EM:Rap 19(3): 12-4