••• Chapter 14^ Management of Medical and Surgical Conditions in Pregnancy^139
❍ On which side is pyelonephritis more common?
Pyelonephritis is unilateral and right sided in more than half of cases.
❍ What are the most common organisms causing pyelonephritis?
Escherichia coli is isolated in 70% to 80% of infections, Klebsiella pneumoniae in 3% to 5%, Enterobacter or Proteus
in 3% to 5% and gram-positive organisms including group B Streptococcus (GBS) in up to 10%.
❍ How often is bacteremia present in women with acute pyelonephritis?
15% to 20%.
❍ What are the complications of pyelonephritis?
20% of patient develop renal dysfunction, 1/3 develop acute anemia due to hemolysis, and 1% to 2% develop
respiratory insufficiency that may lead to acute respiratory distress syndrome (ARDS).
❍ What is the initial treatment of acute pyelonephritis in pregnancy?
Hospital admission, blood and urine cultures, IV hydration to ensure adequate urine output, empiric IV
antibiotics with ampicillin and gentamicin or cefazolin or ceftriaxone.
❍ After a woman with pyelonephritis is afebrile, what are the next steps in management?
She should be changed to oral antibiotics. Discharge can be considered when she has been afebrile for 24 hours.
Antibiotics should be continued for 7 to 10 days and a repeat urine culture should be obtained 1 to 2 weeks after
treatment is completed.
❍ What should be done if a woman does not improve clinically within 48 to 72 hours after initiation of
treatment of pyelonephritis?
Urinary tract imaging to rule out an obstruction.
❍ Which stones are most common during pregnancy?
Calcium phosphate.
❍ What are indications for kidney stone removal?
Obstruction, infection, intractable pain, and heavy bleeding.
❍ Which stones are associated with Proteus or Klebsiella?
Struvite stones.
❍ How does acute glomerulonephritis affect pregnancy?
There is an increased rate of fetal loss and perinatal mortality, prematurity and growth restriction, hypertension,
and worsening of proteinuria.
❍ What are the two most important factors in predicting pregnancy outcome in women with chronic renal disease?
Degree of hypertension and renal insufficiency.