PAIN IN PREGNANCY
A 40-year-old woman presents with a fever and abdominal pain. She is 18 weeks preg- nant in her third pregnancy. The pregnancy has been unremarkable so far and she has no significant gynaecological or medical history.
She has felt unwell for 10 days but has become worse in the last 48 h. She is nauseated and has vomited several times. She is intermittently hot and cold. Her abdominal pain is generalized and constant with some right-sided loin pain.
She denies any dysuria and says that she has frequency which has been present through- out the pregnancy. She has had no recent change in bowel habit. There has been no vaginal bleeding and she has a mild thin vaginal discharge.
She appears flushed and unwell. Her temperature is 38.2°C, blood pressure 115/68 mmHg and pulse 112/min. Cardiac and chest examination is normal. The fundal height is approxi- mately 2 cm below the umbilicus, and the uterus is soft and non-tender. The rest of the abdomen is tender on deep palpation, maximally in the right lower quadrant. There is right renal angle tenderness. The fetal heart is heard at 160/min with hand-held Doppler.
· What is the diagnosis?
· How would you investigate and manage this woman?
The diagnosis is of pyelonephritis, which occurs in 1–2 per cent of pregnancies. Women can be very unwell with non-specific symptoms. In this case specific factors are evident (loin pain and positive urinalysis).
Urinary tract infections (UTIs) are common in pregnancy due to progesterone causing stasis of urine and pressure of the gravid uterus causing ureteric obstruction.
The diagnosis should be confirmed with urine microscopy, culture and sensitivity, and blood cultures should be sent prior to commencing antibiotics. Renal tract ultrasound scan is necessary to rule out any congenital abnormality (such as duplex ureters) that may predispose to renal tract infection, and to rule out an infected obstructed kidney which could need urgent drainage by nephrostomy. Renal tract ultrasound, however, can be dif- ficult to interpret in pregnancy as physiological dilatation of the ureters occurs from pres- sure from the uterus.
Intravenous antibiotics should be started, usually cephalosporins, until culture and sensi- tivities are available, with regular paracetamol to control the temperature and pain. It may take several days for the temperature to settle and for the woman’s pain and symptoms to resolve, but improvement should be monitored with daily white blood count, C-reactive protein and urea and electrolytes. Intravenous rehydration is needed as the woman is vomiting and pyrexial with raised urea, suggesting dehydration.
After completion of treatment (total 2 weeks) a repeat urine culture is needed to confirm cure. Some women with recurrent infection need a daily prophylactic antibiotic regime.
Maternal sepsis is a risk for miscarriage and preterm labour, so treatment should not be delayed. In addition, recurrent UTI, even asymptomatic bacteriuria, is associated with intrauterine growth retardation and preterm labour.