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.)
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.
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% , 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.
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]
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.
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.
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.
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