- Pregnant women with asymptomatic bacteriuria usually are diagnosed incidentally on routine urinalysis and urine culture.
- Burning with urination (dysuria) is the most significant symptom in pregnant women with symptomatic cystitis.
- The usual complaints of increased frequency, nocturia, and suprapubic pressure are not particularly helpful, because most pregnant women experience these as a result of increased pressure from the growing uterus.
- Symptoms of pyelonephritis include the following:
- Fever (Often, the temperature is very high.)
- Nausea and vomiting
- Costovertebral angle (CVA) or flank pain
- CVA tenderness may be present.
- Suprapubic tenderness may be present.
- The fetal heart rate should be noted.
- Pelvic examination is strongly recommended in all patients (with the exception of the third-trimester patient with bleeding) to rule out vaginitis or cervicitis.
- Escherichia coli (most common, in as many as 70% of cases)
- Group B Streptococcus (10%)
- Klebsiella or Enterobacter species (3%)
- Proteus species (2%)3
Other Problems to Be Considered
- In all pregnant patients, a urine specimen should be carefully collected for urinalysis and culturing during the first prenatal visit or at 12-16 weeks' gestation.
- These tests help to identify patients with asymptomatic bacteriuria as well as those with other specific complaints.
- For urine collection, a midstream clean catch is adequate, provided the patient is given careful instructions.
- Catheterization is indicated if the patient is unable to void, too ill, extremely obese, or bedridden.
- Two consecutive voided specimens with isolation of the same bacterial strain (100,000 CFU/mL) or a single catheterized specimen (100 CFU/mL) is diagnostic.7,2
- Counts of less than 100,000 CFU/mL, with 2 or more organisms, usually indicate a contamination rather than an infection.
- The leukocyte esterase test of the urine can be used as a screening examination for pyuria, although this test may be unreliable in patients with low-level pyuria (5-20 WBCs per high-power field).
- Patients with pyelonephritis often have WBC casts.
- Urine culturing should be performed in cases of suspected acute pyelonephritis, patients requiring hospitalization, and patients with a history of recent instrumentation or repeated infections.
- CBC, electrolyte, blood urea nitrogen (BUN), and creatinine tests should be ordered at the physician's discretion, although the results do not aid in the diagnosis or change treatment unless they are markedly abnormal.
- Unless anatomic abnormalities or renal disease is suspected, routine imaging studies are not necessary.
- In cases of persistent symptoms, persistent infection, or suspected urolithiasis, renal ultrasonography may be helpful.
Emergency Department Care
- Administration of appropriate antibiotics
- Administration of fluid if the patient is dehydrated
- Strongly consider admission if there is any indication of renal involvement