Urinary tract infection (UTI)
Patient Presentation:
Patient M.J.E., a healthy 29 year old G1P0 (Gravida 1, Para 0 implies first pregnancy) presents to Labor and Delivery at 32 weeks gestational age. She complains of mild uterine cramping, similar to cramps experienced during a menstrual cycle, dysuria and lower abdominal pain. Patient denies burning upon urination but does explain that she “always has to go”. Patient states “Being a nurse, I haven’t been drinking as much water as I probably should because I’m so busy!.” M.J.E. has had an uncomplicated pregnancy. VS upon admission were BP 118/68, HR 70 RR 18 and temp 37.1°C. The external fetal monitor shows great variability in fetal heart rate, accelerations and no decelerations (indications of fetal well-being). The tocometer (contraction monitor) shows some uterine irritability with 1-2 contractions in ten minutes. M.J.E. was given a urine cup and instructions to collect a clean catch urine specimen upon admission.
Differential Diagnosis:
Pre-term Labor (PTL), Urinary Tract Infection (UTI), Round Ligament Pain, Pyelonephritis
A sterile speculum exam was done to rule out premature rupture of membranes (PROM) (water breaking), obtain cultures and to assess the cervix to make sure the cervix was not dilating or shortening. M.J.E’s cervix was long and closed, allowing us to rule out the differential Dx of PTL. There was no fluid/pooling on the speculum showing her water bag was intact. A complete urinalysis and urine culture was sent. A CBC w/diff as well as Gonorrhea (GC) and Chlamydia cultures were sent as well. A FFN (fetal fibronectin – preterm delivery predictability test) was taken but not sent. She was also given a big jug of water to start working on to try and quiet the contractions. The contractions on the monitor decreased from 1-2 in ten minutes to 1 contraction every 40 minutes with the PO hydration.
Results:
The CBC with diff can back within normal limits (WBCs were 8.6)
The UA came back with normal specific gravity, normal pH, cloudy appearance (normal is clear), 2+ WBC Esterase (normal is Negative), 4+ protein (normal is negative/trace), Negative glucose, Negative Ketones, 3+ occult blood (normal is negative), Negative Bilirubin, negative nitrites, over 30/hpf of WBCs (normal 0-5) (hpf = high power field) and over 30/hpf of clumps of leukocytes (normal is 0-3). A diagnosis of Urinary Tract Infection is given. A urine sample was sent for Urine Culture and Sensitivity to decide on the treatment of choice for the UTI. The Urine Culture came back showing 10,000-25,000 colony of Escherichia Coli forming units per mL (cfu/ml). The sensitivity showed susceptibility to all antibiotics, so the standard drug of choice was chosen for this patient.
Treatment & Outcome:
Urinary Tract Infections (symptomatic or asymptomatic) are serious in pregnancy. The infection can travel upwards, causing a kidney infection which can complicate the pregnancy/delivery with low birth weight or pre-term delivery. UTIs can also cause pre-term contractions that can mimic PTL. Because of this, all UTIs are treated even if asymptomatic. M.J.E. was sent home with a prescription for nitrofurantoin (Macrobid®) 100mg tablets to be taken BID for 7 days. With compliance of medication regimen and increased daily PO fluids, patient M.J.E. should go on to have a great pregnancy with no complications related to the UTI. M.J.E. is instructed to always wipe front to back after using the bathroom, void before and after intercourse, and to avoid douching or sitting in a bath for the remainder of the pregnancy.
Case created by Monica Elston, 2011.