PYELONEPHRITIS IN

PREGNANCY
N I LOY C H AT TE RJ E E
UM H S , M S - 3

EPIDEMIOLOGY
2% of pregnancies will experience pyelonephritis
75% of pyelonephritis cases in pregnancy occur in

nulliparous women
60% of pyelonephritis cases occur during the second
trimester
2% of pyelonephritis cases will result in ARDS
Up to 40% of pregnancies with asymptomatic
bacteriuria will result in pyelonephritis
Risk of recurrence

Up to 18% with ongoing therapeutic/prophylactic treatment

Up to 60% without ongoing therapeutic/prophylactic treatment

INTRODUCTION
What is pyelonephritis?
Inflammation of the kidneys, most commonly due to an ascending
bacterial infection from the urinary tract (most common direct
source is the bladder)
Most common urinary tract complication in pregnancy
More commonly occurs in pregnant woman than non-pregnant
women
Often considered a mid-late pregnancy issue

Maternal ureteral and calyceal dilatation occurs around the 10 th

week of gestation and progressively worsens throughout pregnancy
Hence, the rates of pyelonephritis:

1st Trimester: 2%
2nd Trimester: 52%
3rd Trimester: 46%

Other physiologic changes occurring in

pregnancy that predispose women to

pyelonephritis:

Increased bladder capacity with incomplete voiding

Vesicoureteral reflux
Hydronephrosis

MOST COMMON PATHOGENS

Most common bacteria implicated: E. coli

(~80% overall)
E. coli > Klebsiella > S. aureus > Proteus
Gram positive infections (including GBS)

account for ~10% of cases

SIGNS AND SYMPTOMS

Some women dont experience any

symptoms of infection, while other women do

Common signs and symptoms
Costovertebral angle tenderness
Flank pain (most commonly on right side)
Nausea and vomiting
Increased frequency, urgency and dysuria
Hematuria
Fever > 38C (100.4F)
Chills
Anorexia

MILD PYELONEPHRITIS
Mild Pyelonephritis Sx:

Low fever
Normal to slightly elevated WBC count
Absence of nausea or vomiting

Outpatient management may be considered if:

Initial inpatient observation did not produce concern

Inpatient IV antibiotic course was completed
14-day oral antibiotic therapy post-inpatient
observation

SEVERE PYELONEPHRITIS
Severe Pyelonephritis Sx:

High fever
Low urine output
Respiratory insufficiency
Sepsis
Unable to tolerate antibiotics
No improvement during initial inpatient observation
Management
Cooling blanket and acetaminophen may be indicated

Important to maintain lower core temperature to protect

fetus from increased risk of anomalies due to higher
temperature

Up to 20% of severe pyelonephritis

cases lead to a combination of:

Septic shock
Acute respiratory complications
Renal complications

RISK FACTORS
Immunosuppression
Diabetes
Sickle cell anemia
Neurogenic bladder
Calculi
Dehydration
Hx of recurrent/persistent urinary tract infections prior

to pregnancy
Treatment noncompliance
Urinary (anatomical) anomalies
Poor hygiene

COMPLICATIONS
Preterm delivery

Tocolytics are indicated only if:

Cervical changes and uterine contractions

Hydration and antibiotic therapy offer no resolution

Tocolytics and steroids are contraindicated in

patients with severe respiratory symptoms and
hemodynamic instability

ARDS

Occurs in 2% of pyelonephritis cases during pregnancy

Especially associated with the following:
1.
2.
3.
4.

Tachycardia > 110bpm

Fever 103F within the first 24 hours
Fluid overload
Tocolytic therapy

Anemia due to hemolysis (up to 2/3 of cases)

Impaired renal function (up to 20% of cases
Disseminated Intravascular Coagulation
Septic Shock

DIAGNOSIS
History and physical exam are important
Lower urinary tract Sx:

Urgency
Frequency
Dysuria

Systemic Sx:
Costovertebral angle tenderness
Flank pain (most commonly on the right side)
Fever > 38C (100.4F)
Nausea
Vomiting

Costovertebral angle tenderness is rather

specific for pyelonephritis

Flank pain also occurs in nephrolithiasis and
ureterolithiasis

LABS
Urinalysis (clean catch)
Present

May be present:

WBC casts
It is suggested to centrifuge the sediment sample at <2,000
rpm to avoid rupturing the WBC casts
Bacteria
Nitrites
Microscopic hematuria (but is more suggestive of calculi)
Proteinuria up to 2g/day (if >3g/day, it is more suggestive of
glomerulonephritis)

Unlikely finding:

Gross hematuria
More suggestive of hemorrhagic cystitis

Urine culture
Important for determining possibility of antibiotic
resistance
Blood culture (bacteremia)
CBC (neutrophilia)
Creatinine (renal function)
Electrolytes

MANAGEMENT
Pyelonephritis in pregnancy requires hospital

admission for inpatient observation for at

least 24 hours (regardless of whether the
symptoms are mild or severe)
Ultrasound
Pulse oximetry
Arterial blood gas (especially if respiratory
symptoms are present)

Treatment
Pyelonephritis in pregnancy needs to be

treated aggressively
1.
2.
3.
4.
5.

Hospital admission
IV hydration
IV antibiotics
Oral antibiotics
Post-infection prophylaxis

IV Hydration
IV fluids Saline, Lactated ringer
Important to maintain a urine output of >30-

50 cc/hr

IV Antibiotics
IV antibiotics are indicated until the patient is both
afebrile and asymptomatic for at least 24-48 hours
Drug of choice: IV Ceftriaxone, 1-2g/24h
Alternative IV single antibiotic therapy:

Cefazolin, Cefotetan, Cefotaxime

Disadvantage: Require > 1 dose per day

Alternative IV combination antibiotic therapy:

Ampicillin + Gentamicin, Ampicillin + Sulbactam,

Piperacillin + Tazobactam

Oral Antibiotics
Patient can be switched over to oral antibiotics once
the patient is both afebrile and asymptomatic for at
least 24-48 hours
Drug of choice:

Augmentin (Amoxicillin + Clavulanate)

Alternative oral antibiotic treatment:

Bactrim (Trimethoprim + Sulfamethoxazole)

Post-infection prophylaxis
Nitrofurantoin

PREVENTION
Universal screening and prompt treatment of

asymptomatic bacteriuria during pregnancy

Administration of prophylactic treatment
(Nitrofurantoin) for the duration of pregnancy
if any of the following criteria are met:
1.
2.
3.

1 episode of pyelonephritis
2 episodes of asymptomatic bacteriuria
Cystitis

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