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Pyelonephritis in Pregnancy: Symptoms & Treatment

Instructor: Megan Gilbert

Megan has a master's degree in nursing and is a board certified Women's Health Nurse Practitioner. Her area of clinical focus is the impact of infectious disease on pregnancy. She has experience teaching college allied health classes. She is also a certified EMT and holds a certificate of added qualification in electronic fetal monitoring.

Pyelonephritis, a urinary tract infection that has spread into the kidneys, is a potentially serious condition in pregnancy. This lesson covers the symptoms and treatment of this condition.

A late night call

It's 3 a.m. and your phone rings, waking you up. It's your good friend. She's 28 weeks pregnant and miserable. You thought every woman entering her third trimester was miserable but your friend, Melissa, sounds different. When you ask her what's going on she tells you she's been feeling increasingly sick since about 6 o'clock last evening. Over the last couple days she noticed she was urinating more than normal - but she's entering her third trimester so she wasn't worried about it. Now she notices blood every time she goes to the bathroom, has awful back pain, and feels like she has a fever.

What do you do?

You tell her to quickly get to the nearest hospital equipped to handle pregnant women to get evaluated.

What advice would you give your friend?
pregnancy

Pyelonephritis

The doctor at the hospital does an exam, checks the baby, and runs some labs. The baby is doing well and Melissa is having a few irregular contractions, but her urine shows signs of an infection.

Her temperature is 102.3°F and she reported significant pain when the doctor evaluated her for Costovertebral angle (CVA) tenderness, or pain in the mid-back directly over the lower ribs.

The doctor explains that she has pyelonephritis, a specific type of urinary tract infection where the infection has moved into one or both of the kidneys.

Symptoms

Patients with pyelonephritis in pregnancy will generally report:

  1. Urinary urgency (feeling that you need to rush to make it to the bathroom in time)
  2. Urinary frequency (going to the bathroom very often)
  3. Dysuria (painful urination)
  4. Hematuria (blood in urine)
  5. Fever (above 100.3°F)
  6. Chills
  7. Flank pain (pain in their back over their lower ribs) and CVA tenderness
  8. Uterine contractions and preterm labor
  9. Septic shock (when the infection overwhelms the body, making the person very sick)

Treatment

Treatment needs to be tailored to the individual patient. Some patients are able to be treated outpatient (without being admitted to the hospital) if their case is mild, but due to the additional risk of complications in pregnancy, most women will require at least a short hospitalization to make sure they are improving.

Pyelonephritis is treated with antibiotics. The antibiotics the patient is given should be determined by a urine sample that has had a culture and sensitivity analysis done to determine the specific bacteria found in the sample. This will tell us what type of bacteria is present, how much bacteria is present, and what antibiotics will work best. These tests can take several days until the results are available. As the healthcare team, we must make the best guess we can and watch the patient carefully for improvement - or worsening.

Because pyelonephritis is an infection inside the kidney, it will also be important to make sure that the antibiotic chosen is able to get into the kidney at a high enough concentration to treat the infection. Additionally, we need to pick the safest antibiotic for the pregnancy; many antibiotics can be potentially harmful to a developing fetus. We will need to keep in mind how far into the pregnancy the woman is because at various points in the pregnancy, different medications have different levels of safety. Last, but certainly not least, we need to consider the mother's allergies. For example, if your friend is allergic to penicillin medications, we would be careful to avoid them.

Common medications that are used initially include:

  • Ceftriaxone (Rocephin) or
  • Cefepime (Maxipime) or
  • Cefotaxime (Claforan) or
  • Ceftazidime (Fortaz, Tazicef) or
  • Cefazolin (Ancef) or
  • Ampicillin plus gentamicin

Intravenous (IV) treatment is generally given until the patient has had no fever for at least 24 hours and symptoms have improved. Oral antibiotics should then be given until the patient has had 14 days of total treatment.

Some oral antibiotic choices include (based on what antibiotics are known to treat the specific infection):

  • Cephalexin (Keflex) or
  • Amoxicillin or
  • Amoxicillin-clavulanate (Augmentin) or
  • Trimethoprim/sulfamethoxazole (Bactrim) - Avoid near term and in first trimester

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