Laura Lopez-Roca MS3

Obstetrics case

Name: A.L.G.
Chief Complaint:
A 20 y/o F G2A1P0 with intrauterine pregnancy at 27 4/7 WGA presents with c/o
increasing pelvic pain radiating to back for 4 days duration.
History of present Illness:
A 21 year old female with intrauterine pregnancy at 27 4/7 WGA with 2 prenatal visits
was feeling well until 4 days prior to admission when a continuous right sided back
pain started. The pain has gotten worse. Patient informs that her urine is cloudy and
somewhat foul-smelling but denies increase in frequency or burning upon urinating;
she c/o of nausea and decreased appetite. Patient refers having fetal movements,
and denies vaginal discharge, bleeding, fever, drills, or shortness or difficulty
breathing. Patient has had little pre-natal care, she is non-compliant with her
doctors appointments and recommendations.
LMP: 10/7/2015
EDD: 07/16/2016
OB Gyn/sexual Hx:
G2 P0 A1 (She had a 1st trimester spontaneous abortion 2 yrs ago.)
Marital Status: Single (in a relationship)
Religion: Catholic
Sexual Partners: 3
First Coitus: 14 years old
Menarche: 11 years
Menses: regular 28-32 days cycles, flow lasts 7 days, 4 pads/day, menstrual pain is
4/10,
LMP: 10/7/2015
Dysmenorrhea: No
Dyspareunemia: No
STDs: No
Contraceptives: condoms.
Past Hx.
Patient has had no previous surgeries, no allergies, and has no medical
conditions. Patient only takes prenatal vitamins.
Social Hx: Patient currently in college and is catholic. Denies Smoking or drinking.
She eats fatty foods but exercises regularly.
Family Hx: Diabetes Mellitus, Hypothyroidism and Hypertension. Her sister had
gestational
Diabetes on her 2 nd and 3rd pregnancies.
Physical Exam on Admission:

BP: 122/70

HR: 92

Gen. Appearance
Lungs
Heart
Abdomen
Pelvic Exam
External
Genitalia
B. U. S.
Vagina
Cervix
Uterus
Adnexa
Rectal
Bimanual Examination
Extremities

RR: 20

T: 38.3

Active, Oriented x3, Acutely Ill

Clear to Auscultation bilaterally; Flank Pain
RRR, no m/r/g, normal S1 S2
+ Bowel sounds, Soft and depressible, no rebound or
shifting dullness
Adequate for Sex and Age, no ulcers or warts.
No MINT
W/E, W/S
Nulliparous, regular OS, pink, no discharge masses or
lesions
Anteverted
No palpable masses
Deferred
CVA tenderness,
No edema or cyanosis

Differential Diagnosis:
Most probable diagnosis is pyelonephritis, kidney infection most commonly
caused by E.coli, although klebsiella, staph Aureus and Proteus are also relatively
common causes.
Classic clinical presentation is CVA tenderness, flank pain, fever, chills, dysuria. U/C
with >100,00 is diagnostic. Other common symptoms are Nausea, vomiting,
respiratory distress, Pyuria, Bacteuria, urgency and burning with urination. This
patient in particular presented with CVA tenderness, flank pain, fever, U/C with
>100,00, pyuria, Bacteuria, positive nitrites. These physical, history and lab results
support the diagnosis of pyelonephritis.
Pyelonephritis is the most common cause of sepsis in pregnant females and can
cause preterm labor/delivery, abortions, ARDS etc, thus this condition should be
taken particularly serious in a pregnant female.
Another possibility is cystitis, which is an infection of the bladder. This would
present with dysuria, frequency, hematuria or suprapubic pain, Pyuria and
bacteuria. Although this patient has most of these symptoms, the additional
presence of CVA, positive urine culture and fever, indicates that this infection has
probably already traveled from the bladder to the kidneys, making cystits less likely
than pyelonephritis.
Another possible cause would be nephrolithiasis. This would present with sterile
pyuria (thus negative U/C) nausea and vomiting, gross or microscopic hematuria,
fever, and flank pain that is intermittent and radiates to the groin area. The pain

would be changing in intensity and possibly location while the renal calculus is
descending through the ureter. This patient has several of these symptoms making
kidney stones a possibility. Yet, the positive u/c, the non radiating constant pain and
absence of hematuria makes this less likely. A history of previous stones would help
make this a more likely etiology.

Work Up:
- U/A: Routinely ordered as part of a blood work up. Particularly important in
this patient due Necessary for establishing the presence of a urinary
infection, to r/o preeclampsia and renal failure. Altered levels of bacteria,
WBC, presence of Nitrites or esterase indicate UTI. Hematuria can indicate an
infection as well and kidney stones. Proteinuria may be a sign of renal failure
and/or preeclampsia.
- U/C: necessary to establish the presence and identity of a specific pathogen
causing the bacteria and if it has any antibiotic resistance. Knowledge of the
specific offending pathogen can be indispensible to better tailor patient
management and treatment. Especially in a pregnant patient where all
infections present a higher risk, identification of specific pathogen is of
greater importance.
- CBC: Measures amount of WBC and the size, amount and density of RBC.
Indicated in this patient to help establish presence of an infection (seen
through high WBC) and to r/o presence of blood abnormalities or anemia,
both of which could be harmful to both mom and fetus.
- CMP: broad screening tool to evaluate organ function and check for
conditions such as diabetes, liver disease, and kidney disease. In this patient
it is necessary to make sure there is no renal failure (seen by abnormal
creatinine and BUN values), and also to
Labs:
-CBC:
WBC: 17.20 mm3
Hb: 11
%Neut: 75%
-U/A:
WBC: 13 mm3
Nitrites: positive
Bacteria: many
-U/C:
>100,000 E. coli
-CMP:
- Gluc: 88
- BUN: 16
- Creatinine: 1

Plan:
Patient was given IV fluids.
Labs were ordered: CBC, U/A, U/C, CMP and B/C.
Patient was admitted to OB-GYN ward on the diagnosis of Right sided
pyelonephritis.
Patient was given Morphine, Demerol, Phenergan and Reglan on this first day
of admission. Patient was started on Cefazolin 2gram IV every 8 hours, pepcid
20 mg IV every 12 hours and prenatal vitamins once daily as well as single
dose of fluconazole 150mg orally, Acetaminophen 1gm PO every 6hrs.
Patient was discharged on day 6, due to significantly better lab values and
absence of CVA or flank pain. Patient was instructed to take oral Cefazolin for
3 more days.
Treatment Discussion:
The treatment for pyelonephritis can be either inpatient or outpatient. It can be
treated in the outpatient setting in the absence of: underlying medical conditions or
anatomic abnormalities. In most cases pregnant women with Pyelonephritis should
be admitted to the hospital, since Pyelonephritis can have severe consequences
during (sepsis, abortion, premature labor etc.).
Inpatient treatment consists of antibiotics IV with the following regiment:
Ceftriaxone, 1 g Q24 hours,
Gentamicin, 1 mg/kg (+ ampicillin) Q8 hours
Ampicillin, 1-2 g (plus gentamicin) Q6 hours
Ticarcillin-clavulanate (Timentin) 3.2 g Q8 hours
Piperacillin-tazobactam 3.375 g Q8-12 hours
Imipenem-cilastatin, 250-500 mg Q6-8 hours
Treatment usually consists of 10 day treatment or until asymptomatic with IV
treatment and then continue treatment with oral therapy in outpatient setting for 7
more days. Which antibiotic is selected will depend on many factors: severity of
symptoms, medication allergies, weather or not the patient is pregnant, presence or
any renal or liver problems that might affect absorption, or of any chronic conditions
that might be made worse by medication side effects. Also once the U/C results are
obtained, knowledge of the specific offending pathogen may prompt a change of
the initial Antibiotic prescribed, to one better suited for this pathogen. In

pyelonephritis the most common pathogen is E.coli, other posibilities are Klebsiella,
Staph Aureus, and Proteus Mirabilis.

Summary:
A 21 year old patient G2P0A1 with 27 4/7 WGA that has had pelvic pain radiating to
back which has increased in severity over the period of 4 days and is said to be 8/10
at the time of admission. Patient denied any vaginal bleed or discharge; patient
informed she had fetal movements. On physical exam, the patient showed a heart
rate of 92, with adequate pressure, respiratory rate and a fever. Patient had CVA
tenderness and flank pain, but showed no abdominal pain on exam. Fetal monitor
was placed with adequate fetal heart rate, variability with no signs of distress. Her
U/A showed Pyuria, bacteuria and positive nitrites. U/C showed >100,00 E.coli.
Patient was admitted to hospital after a Diagnosis of Pyelonephritis was established.
She was treated with Antibiotics, and discharged on day 6 after significant
improvement and almost complete elimination of infection. Pt was instructed to
take 3 more days of antibiotics.