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Acute pyelonephritis in pregnancy — MSRA MCQ

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Hardall topics relevant for this examAcute pyelonephritis in pregnancyMSRA

A 29-year-old woman at 24+5 weeks’ gestation presents with 24 hours of dysuria and urinary frequency followed by left flank pain, fever and vomiting. She has type 1 diabetes mellitus. She has vomited four times today and has been unable to retain oral fluids or regular medication since the morning. She appears unwell but is alert. Temperature is 38.4°C, pulse 104 beats/minute, blood pressure 112/68 mmHg, respiratory rate 18 breaths/minute and oxygen saturation 98% on air. There is left costovertebral-angle tenderness. Urine dipstick is positive for nitrites, leucocytes and blood. There is no vaginal bleeding, uterine tenderness or rupture of membranes. What is the most appropriate immediate management?

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Correct answer: B — Arrange same-day hospital assessment for parenteral antibiotics and intravenous rehydration, obtaining a midstream urine sample before antibiotics if this does not delay transfer

This is acute pyelonephritis, indicated by fever, systemic upset and costovertebral-angle tenderness following lower urinary tract symptoms. It is not uncomplicated lower UTI. Pregnancy itself warrants consideration of hospital referral, while type 1 diabetes increases her risk of complications. More decisively, she is significantly dehydrated and unable to retain oral fluids or medicines; NICE advises hospital referral or specialist advice in this situation. She therefore requires same-day assessment for intravenous fluids and parenteral antimicrobial treatment, with a urine specimen obtained before antibiotics where feasible without delaying transfer. Oral cefalexin is the NICE first-choice oral option for pyelonephritis in pregnancy only when intravenous treatment is not required and the patient can take oral treatment. Nitrofurantoin is appropriate for lower UTI but should not be used for suspected pyelonephritis because adequate renal tissue concentrations are not expected. Empirical co-amoxiclav is not recommended in pregnancy for pyelonephritis unless susceptibility is known, because of resistance and treatment-failure concerns. Waiting for culture would inappropriately delay treatment of a potentially progressive upper urinary tract infection.

Reference: NICE NG111: Pyelonephritis (acute): antimicrobial prescribing — Recommendations (2018) — https://www.nice.org.uk/guidance/ng111/chapter/recommendations NICE NG111: Pyelonephritis (acute): antimicrobial prescribing — Table 2 (2018) — https://www.nice.org.uk/guidance/ng111/chapter/recommendations NICE NG111: Pyelonephritis (acute): antimicrobial prescribing — Summary of the evidence (2018) — https://www.nice.org.uk/guidance/ng111/chapter/summary-of-the-evidence