Author Information
Patel Amit*, Kshitij Jamdade**, Gupta AS***
(*First
Year Resident, ** Assistant Professor, *** Professor. Department
of Obstetrics and Gynecology, Seth GS Medical College and KEM Hospital, Mumbai,
India.)
Abstract
Recurrent
pyelonephritis is a very common complication in pregnancy. Our patient
presented with acute renal failure and recurrent preterm
labor due
to recurrent episodes of pyelonephritis in the index pregnancy and previous
pregnancy. She was managed with
antimicrobial therapy leading to good maternal and fetal
outcome.
Introduction
Acute
pyelonephritis complicates approximately 1-2% of pregnancies, and is one of the
foremost indications of non-obstetric antepartum hospitalization [1, 2].
Earlier the incidence was as high as 10% [3], but with improved
antenatal surveillance, the incidence of acute pyelonephritis has decreased in
current times. Asymptomatic bacteriuria is the most significant factor
associated with acute pyelonephritis. It is commonly acquired prior to
conception. Invasion of renal parenchyma by coliforms is the cause of acute
pyelonephritis. Escherichia coli (E.
Coli) is the commonest pathogen followed by Klebsiella and Proteus.[4]
Approximately
20 to 30% of pregnant patients with pyelonephritis develop recurrent infections
later in pregnancy. It can lead to renal failure or even acute
renal shut
down and pre-term labor. Appropriate broad spectrum or specific antibiotic
therapy according to the culture sensitivity can avoid its complications like
renal dysfunction and pre-term labor.[5,6]
Case
report
A 22 year
Gravida 2 Para 1 and FSB 1 at 22 weeks of gestation was treated
conservatively by a
physician in view of vomiting,
hypotension
and ultrasonography (USG) features of medical renal
disease. Patient presented to us at 33 weeks of gestation with preterm labor,
pyuria, fever, decrease urine output and pre-term labor. Patient had a past
history of acute pyelonephritis leading to acute renal
failure, preterm
labor and fresh still birth in her first pregnancy
in October 2012. On review of her 1st
pregnancy case records it was seen that she had an acute episode of vomiting
and reduced urine output for 4 days. Her serum creatinine levels were 4.7mg%,
her urine routine and microscopy should pyuria with 40-50 pus cells
per high power field (hpf), 5-7 RBC's/hpf,
and field full of bacteria. There were calcium oxalate/triple phosphate
amorphous crystals in the urine. Her 24 hour urine protein was 0.048gm%. Her
Blood urea nitrogen was 38.34 mg% and her blood urea was 82.10 mg%. Serum
calcium was 7.2 mg/dl, uric acid was 6.3mg/dl, parathyroid hormone was elevated
to 115 pg/ml.Her renal USG of the right kidney size as 9.6 x 4.1 cm and left
kidney size as 7.6 x 3.6 cm. Cortical echogenecity of both kidneys was
elevated. Pelvicalyceal systems of both the kidneys were full. Findings were
suggestive of Grade II bilateral medical renal disease. Her urine culture
report had shown E. Coli organism in significant numbers sensitive to the
antimicrobial Nitrofurantoin. She was treated for a month with the same.
In the present pregnancy on admission
her renal parameter was deranged. Serum creatinine was 5.2mg/dl and urine routine microscopy showed
45-50 pus cells/hpf. Patient was admitted under the physician. She was empirically
started on
parenteral Piperacillin Tazobactum combination (4.5gm ) 12 hourly. Her urine
was sent for culture sensitivity. She was treated with tocolytics for preterm
labor. Nephrologist advised
catheterization, adequate hydration, renal diet and continuation of the above
antibiotic for 14 days given. Her urine showed
no growth probably due to the use of the antibiotic Piperacillin. It was continued for 14 days. Her
preterm labor was controlled and her serum creatinine reduced to 1.1mg/dl
by the end of 2 weeks.
She
was discharged with advise of regular follow up. Later fetus showed clinical and
USG evidence of growth restriction and Doppler studies indicated uteroplacental
insufficiency. She spontaneously delivered a SGA fetus at 37 weeks of gestation vaginally. Neonate
weighed 1.9kg. Post-delivery urine
routine microscopy showed pyuria with 30-40 pus cells/hpf and bacteria. Urine
culture was sent. It grew gram positive Enterococci that was sensitive
to amoxicillin. Her serum creatinine again increased to 1.8mg/dl. Tablet
amoxicillin 500mg three
times a day was given for 14 days. Patient improved symptomatically. Her serum
creatinine levels decreased to 1.0mg/dl.
She was discharged and educated about risk of recurrence of
urinary tract infection and need for repeated urine examinations.
Discussion
Recurrent
pyelonephritis is common in pregnancy and can lead to mild renal function
impairment to sever renal dysfunction or even severe oliguria or anuria. It can
also lead to obstetric complications like pre-term labor and intra uterine
growth retardation and fetal loss.
Thus we
saw in our case that patient had acute renal failure,
preterm labor not once but twice in
successive pregnancies. Treatment of the same
restored her renal function both the times but she lost her 1st
child. Prompt institution of parenteral antibiotic without awaiting culture
report lead to resolution of her symptoms and her 2nd pregnancy
could be prolonged to term. However the intra uterine growth of the fetus was
restricted. Nevertheless she took home a live neonate. Infection again raised
its head in the puerperium but it was diligently sought and appropriately
treated.
Conclusion
Acute pyelonephritis
in pregnancy is a common medical complication and recurrence is
also very
common. It can lead to medical as well as obstetric complications. Obstetricians
should be vigilant to its possibility especially in patients with previous
history. Prompt diagnosis and vigorous treatment can not only give a good
obstetric outcome but also saves the renal parenchyma from scarring and
permanent damage.
References
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Citation