a second-trimester pregnant woman with severe pyelonephritis. A.An extensive infiltrative process and complete obliteration of the diaphragm (white arrows) is seen. B. Improved aeration of lung fields bilaterally is noted as pleural disease resolves (arrows). c. Markedly improved visualization of the lung fields with residual platelike atelectasis and normal appearance of the diaphragm.
TABLE 53-2. Management of the Pregnant Woman with Acute Pyelonephritis
Evaluate hemogram, serum creatinine, and electrolytes
Monitor vital signs frequently, including urinary output-
Establish urinary output �50 mL/hr with intravenous
Obtain chest radiograph if there is dyspnea or tachypnea
Change to oral antimicrobials when afebrile
Discharge when afebrile 24 hours, consider antimicrobial therapy for 7 to 10 days
Repeat urine culture 1 to 2 weeks after antimicrobial
Modified from Lucas, 1994; Sheffield, 2005.
Endotoxin-induced hemoysis is common, and approximately a third of these women with pyelonephritis develop anemia (Cox, 1991). With recovery, hemoglobin regeneration is normal, and acute infection does not afect erythropoietin production (Cavenee, 1994).
One scheme for management of acute pyelonephritis is shown in Table 53-2. Urine cultures are taken, but prospective trials show that blood cultures are of limited clinical utility (Gomi, 2015; Wing, 2000). We obtain blood cultures if the temperature is >39°C. Intravenous hydration to ensure adequate urinay ouput is the cornerstone of treatment. Antimicrobials are also begun promptly with the caveat that they may initially worsen endotoxemia from bacterial lysis. Surveillance for worsening sepsis syndrome includes serial monitoring of urinary output, blood pressure, pulse, temperature, and oxygen saturation. High fevers are lowered with a cooling blanket and acetaminophen. his is especially important in early pregnancy because of possible teratogenic efects from hyperthermia.
Antimicrobial therapy usually is empirical, and ampicillin plus gentamicin; cefazolin or ceftriaxone; or an extended-spectrum antibiotic are all 95-percent efective in randomized trials (Sanchez-Ramos, 1995; Wing, 1998,a2000). Fewer than half of E coli strains are sensitive to ampicillin in vitro, but cephalosporins and gentamicin generally have excellent activity. Serum creatinine levels are monitored if nephrotoxic drugs are given. Initial treatment at Parkland Hospital is ampicillin plus gentamicin. Some recommend suitable substitutes if bacterial studies show in vitro resistance. With any of the regimens discussed, response is usually prompt, and 95 percent of women are afebrile by 72 hours (Hill, 2005; Sheield, 2005). ter discharge, most recommend oral therapy for a total of7 to 14 days (Hooton, 2012).