Pyelonephritis
Patient Presentation:
M.R., a 19 year-old G1P0 at 30 weeks gestation, presented with acute 8/10 abdominal pain that radiates to L flank, complaining of nausea, and vomiting. Patient’s vitals were as follows BP is 122/78, Temp 100.3, Pulse 80, RR 18, O2 100%. Patient denied urgency, frequency, and dysuria. Patient complained of abdominal tightness, states “I may be having contractions but, I don’t know what contractions are supposed to feel like”.
Differential Diagnoses:
Preterm labor, UTI, pyelonephritis, kidney stones
Diagnosis:
Continuous External Fetal Monitoring (EFM) was conducted for at least 4 hours to rule out labor progression and to evaluate for fetal distress. EFM showed mild contractions lasting 30-70 seconds, approximately 5-9 minutes apart. Fetal Heart Rate had moderate variability ranging from 118-130’s, no visible decelerations, no distress evident. Cervix thick and tightly closed upon evaluation. Clean Catch urine sample for Urine Analysis, Culture and Sensitivity shows cloudy, dark yellow urine, moderate Leukocytes, and trace hematuria, later positive for Staphylococcus Aureus. CBC showed elevated white count at 21k/uL. Renal ultrasound showed moderate hydronephrosis on the L. side, no renal calculi present at that time. Right Kidney was within normal limits. Patients’ past medical history was mostly unremarkable, although patient admitted frequent UTI’s as child and several during this pregnancy.
Treatment:
Plan was to keep patient for at least 2 days to hydrate and treat with antibiotics. Patient was hydrated intravenously with 1000ml Lactated Ringers (LR) bolus followed by additional bags of LR at 125ml/ hr. Oral Percocet® (oxycodone and acetaminophen) 5/325mg tablets, 1-2 tablets every 4-6 hrs PRN for pain. IV Zofran® 4mg every 6hrs PRN for nausea. IV Ancef® 1g every 8hrs. Patient’s current symptoms were treated and patient was monitored for increasing symptoms. Diet was regular. Physician ordered continuous fetal monitoring while patient remained in bed and hourly Doppler monitoring when patient was ambulatory, contractions spaced out and went away after about 2 L of LR, fetal heart rate maintained moderate variability with no notable decelerations.
Outcomes:
M.R. was discharged home 2 days later with mild flank pain 2/10. No contractions present, no cervical changes during the observation period. Oral 4mg Zofran® prescribed for nausea to be taken q 6 hrs PRN. Oral Keflex® 500 mg QID for 14 days. Patient was to keep next OB appointment and call the office for new or worsening symptoms.
Case created by Melissa Rogina, 2012.