Pyelonephritis
Patient Presentation:
S.D., a 31 year old G3P2 at 33 weeks gestation, presented to the labor & delivery unit complaining of back pain, preterm contractions, nausea, and a fever. She woke up with 9/10 left sided flank pain that radiated to her left lower abdomen. Her BP was 137/76; pulse was 104; pulse ox 100.0% on room air; and a temperature of 38.4 degrees Celsius. She denied dysuria, frequency, or urgency. She vomited four times in the previous 24 hours. On the external fetal monitor, she was contracting every 2-3 minutes. Of note, she also had congenital absence of her right kidney.
Differential:
She was ordered for a renal sonogram to rule out an obstruction or a kidney stone because of the congenital absence of her right kidney. She also was evaluated to make sure she was not in preterm labor.
Diagnosis:
A CBC showed her WBC’s to be 19.3 k/uL. A UA showed positive large leukocyte esterase, 12 WBC, trace RBC, negative nitrites, and many bacteria. A clean catch urine culture showed 10,000-50,000 cfu/ml of staphylococcus aureus. The renal sonogram showed the left kidney with compensatory hypertrophy (from absence of the right kidney), moderate hydronephrosis with mild dilation of the proximal ureter. There were no obvious renal calculi. The left ureteral jet suggested non-obstructive flow into the bladder. A vaginal exam revealed the patient’s cervix to be long and closed. S.D. was diagnosed with pyelonephritis.
Treatment:
Once the patient received a 1000ml bolus of IV hydration, her contractions subsided. She was started on IV ceftriaxone sodium 1gm daily. She was given IV Dilaudid® q4 hours for the pain. She received 4mg of IV Zofran® q8 hours for the nausea. After one day, the patient’s temperature went down to 37.5, and her flank pain went down to a 3/10. She was switched from the IV Dilaudid® to PO Tylenol® which managed her pain well.
Outcome:
Upon discharge three days later, S.D.’s vital signs were stable (BP 105/56; Temp 37.1; Pulse 90: O2 Sat 100% on RA), had mild left CVA tenderness (rated as 1/10), and her WBCs were 13. She was sent home on PO Macrobid® 100mg BID for 14 days. She was then placed on prophylactic antibiotics for the rest of the pregnancy. She was also told to follow up with nephrology as an outpatient because of her unilateral kidney. The patient returned to labor and delivery 7 weeks later and delivered a healthy 6lb 4oz little girl.
Case created by Sarah Davis, 2011.