Antepartum Pyelonephritis Research Articles

696 Trends in Antepartum Pyelonephritis Hospitalizations and Risk for Associated Sepsis and Severe Maternal Morbidity

696 Trends in Antepartum Pyelonephritis Hospitalizations and Risk for Associated Sepsis and Severe Maternal Morbidity

Postpartum Pyelonephritis and Risk of Severe Maternal Morbidity.

Pyelonephritis is the most common nonobstetric cause for hospitalization during pregnancy. The maternal and obstetric complications associated with antepartum pyelonephritis are well described. However, it is not clear whether these risks extend into the postpartum period. The primary objective of this study was to describe the morbidity associated with postpartum pyelonephritis, by comparing the morbidity associated with pyelonephritis in the postpartum period to morbidity seen during pregnancy or delivery. A retrospective cohort study was performed using the Nationwide Readmissions Database (NRD), an all-payor sample of discharges from approximately 60% of U.S. hospitalizations. Discharges between October 2015 and December 2018 were included. Maternity-associated hospitalizations, diagnosis of pyelonephritis, comorbid conditions, and incidence of severe maternal morbidity were identified using International Classification of Disease-10th Revision (ICD-10) diagnosis and procedure codes. Bivariate statistics, weighted to account for the complex survey methods in the NRD, were used to evaluate the association between antepartum, delivery, and postpartum hospital stays associated with pyelonephritis and maternal morbidity. Weighted regression models were used to evaluate the association between admission timing and maternal outcomes. A total of 32,850 pyelonephritis admissions were identified, corresponding to a national estimate of 61,837 admissions. Of these, 1,465 (2.4%) were postpartum, 55,056 (89.0%) were antepartum, and 5,317 (8.6%) involved a delivery stay. Rates of severe maternal morbidity were higher in the postpartum group than the antepartum or delivery hospitalization groups (59.5 vs. 12.9 and 15.8%, respectively, p < 0.001); when compared with antepartum hospitalizations, the adjusted relative risk for composite severe maternal morbidity for postpartum hospitalizations was 4.68 (95% confidence interval [CI]: 4.33, 5.05). Most of this difference was driven by rates of sepsis (53.2 vs. 11.0 vs. 10.9%). Though relatively uncommon, postpartum hospitalizations for pyelonephritis are associated with higher rates of severe maternal morbidity, driven by differential rates of sepsis, than are antepartum or delivery-associated hospitalizations.

Serum procalcitonin to differentiate acute antepartum pyelonephritis from asymptomatic bacteriuria and acute cystitis during pregnancy: A multicenter prospective observational study.

To examine whether serum procalcitonin (PCT) is useful for differentiating acute pyelonephritis (APN) from asymptomatic bacteriuria and acute cystitis during pregnancy. A multicenter prospective observational study was conducted to compare serum white blood cell (WBC) counts, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) level, and PCT level among pregnant women with asymptomatic bacteriuria, acute cystitis, and APN and healthy pregnant women (controls). Utility of WBC count, ESR, CRP, and PCT biomarkers for the prediction of APN during pregnancy were measured. Area under the curve (AUC) values of PCT, CRP, ESR, and WBC count for predicting asymptomatic bacteriuria were 0.576, 0.628, 0.542, and 0.532, respectively; those for predicting acute cystitis were 0.766, 0.735, 0.681, and 0.597, respectively; and those for predicting acute pyelonephritis 0.859, 0.763, 0.711, and 0.732, respectively. Compared with the other inflammatory markers used to predict APN, PCT exhibited the highest AUC (0.859 [95% confidence interval (CI) 0.711-0.935]). A cutoff value of >0.25ng/ml had a sensitivity of 87% and a specificity of 79%. Serum PCT can be a valuable addition to existing methods of differentiating asymptomatic bacteriuria, acute cystitis, and APN during pregnancy and can facilitate the early identification of APN during pregnancy.

Acute pyelonephritis in pregnancy: an 18-year retrospective analysis

We sought to describe the incidence of acute pyelonephritis in pregnancy, and to assess its association with perinatal outcomes in an integrated health care system. A retrospective cohort study was performed using medical records on 546,092 singleton pregnancies delivered in all Kaiser Permanente Southern California hospitals from 1993 through 2010. These medical records include the perinatal service system along with inpatient and outpatient encounter files. Adjusted odd ratios (ORs) and 95% confidence intervals (CIs) were used to estimate associations. The incidence of acute antepartum pyelonephritis was 0.5% (2894/543,430). Women with pyelonephritis in pregnancy were more likely to be black or Hispanic, young, less educated, nulliparous, initiate prenatal care late, and smoke during pregnancy. Pregnancies of women with pyelonephritis compared to those without were more likely to be complicated by anemia (26.3% vs 11.4%; OR, 2.6; 95% CI, 2.4-2.9), septicemia (1.9% vs 0.03%; OR, 56.5; 95% CI, 41.3-77.4), acute pulmonary insufficiency (0.5% vs 0.04%; OR, 12.5; 95% CI, 7.2-21.6), acute renal dysfunction (0.4% vs 0.03%; OR, 16.5; 95% CI, 8.8-30.7), and spontaneous preterm birth (10.3% vs 7.9%; OR, 1.3; 95% CI, 1.2-1.5). Most of the preterm births occurred between 33-36 weeks (9.1%). We characterize the incidence of pyelonephritis in an integrated health care system where routine prenatal screening for asymptomatic bacteriuria is employed. Maternal complications are commonly encountered and the risk of preterm birth is higher than the baseline obstetric population.

Is postpartum pyelonephritis associated with the same maternal morbidity as antepartum pyelonephritis?

Objective: Pregnant women with pyelonephritis are at higher risk for significant morbidty than nonpregnant women with pyelonephritis. The risk from pregnancy may continue into the postpartum period. Many of the physiologic and hormonal changes that occur during pregnancy persist after delivery. The objective of this study was to compare maternal morbidity in postpartum and antepartum pyelonephritis. Methods: A retrospective cohort analysis included all pregnant and postpartum women hospitalized for pyelonephritis at a single tertiary care hospital between January 2004 and June 2007. The postpartum period was defined as up to 6 weeks from delivery. The primary outcome measure was maternal morbidity measured by length of hospitalization. Results: 256 cases of antepartum pyelonephritis and 23 cases of postpartum pyelonephritis were included in the analysis. Women in both groups were admitted for a mean of 4 days (p = 0.3). Women who were diagnosed in the postpartum period were more likely to be febrile (91.3% vs. 51.7%, p = 0.0001) and had a higher temperature on presentation (102.9°F vs. 99.1°F p < 0.0001). Discussion: Pyelonephritis was equally morbid in the postpartum and antepartum periods. Postpartum pyelonephritis may warrant the same close inpatient observation as antepartum pyelonephritis.

Acute antepartum pyelonephritis in pregnancy: a critical analysis of risk factors and outcomes

To test the incidence and sonographic parameters of pyelonephritis during pregnancy, and to examine risk factors and pregnancy outcomes of women with acute antepartum pyelonephritis. A retrospective population-based study comparing all singleton pregnancies of patients with and without acute antepartum pyelonephritis was performed. Patients lacking prenatal care as well as multiple gestations were excluded from the study. Multiple logistic regression models were used to control for confounders. Out of 219,612 singleton deliveries in 1988-2010, 165 women (0.07%) suffered from acute antepartum pyelonephritis. Abnormal sonographic findings were found in 85.7% of the patients with pyelonephritis. Pyelonephritis was significantly associated with nulliparity (46.1% vs. 24.4%, p<0.001), younger maternal age (26.3 ± 6.0 vs. 28.6 ± 5.8 years, p<0.001), intrauterine growth restriction (IUGR) (6.7% vs. 2.1%, p<0.001), placental abruption (3.6% vs. 0.7%, p<0.001), low 1 min Apgar scores (10.3% vs. 6.0%, p<0.05), urinary tract infection (UTI) (4.2% vs. 0.4%, p<0.001) and preterm delivery (less than 37 weeks gestation; 20.0% vs. 7.8%; p<0.001). Using a multivariable analysis, independent risk factors for acute antepartum pyelonephritis were nulliparity (OR 2.0; 95% C.I 1.4-2.9; p<0.001), UTI (OR 10.3; 95% C.I 4.8-22.1; p<0.001) and younger maternal age (OR 0.96; 95% C.I 0.93-0.99; p=0.009). Using another multivariable analysis, with preterm delivery as the outcome variable, acute antepartum pyelonephritis was found as an independent risk factor for preterm delivery (OR 2.6; 95% C.I 1.7-3.9; p<0.001). Acute antepartum pyelonephritis is associated with adverse perinatal outcomes and specifically is an independent risk factor for preterm delivery.

Adherence to evidence-based guidelines for the management of pyelonephritis in pregnancy

Pyelonephritis occurs in approximately two per cent of pregnancies and can cause significant maternal and fetal morbidity and mortality. Evidence-based guidelines recommend appropriate antibiotic therapy, urine culture for test of cure after treatment and monthly follow-up cultures until delivery. To evaluate adherence to guidelines for the management of antepartum pyelonephritis within an Australian obstetric population and to assess associations with noncompliance. A retrospective study was performed for the 103 pregnant women admitted with pyelonephritis between January 2001 and December 2009 at the Royal Brisbane and Women's Hospital, a tertiary referral obstetric hospital. We assessed baseline characteristics, the frequency of appropriate treatment and follow-up, and any associations among these. The guideline recommended antibiotic treatment was prescribed in 90.3% of women. Of the women with antibiotic-resistant organisms, 31.6% had their antibiotics changed appropriately. The test of cure urine culture was performed in only 35.0% of women after treatment completion. Inadequate long-term follow-up occurred in 60.2% of the cohort studied. Inappropriate follow-up was associated with low socioeconomic status (P=0.04), unemployment (P=0.04) and the absence of a test of cure urine culture (P=0.001). The empiric treatment of antepartum pyelonephritis is generally appropriate; however, antibiotic changes for bacterial resistance are inadequate. Test of cure and monthly follow-up urine cultures are infrequently performed despite their recommendation in published treatment guidelines.

Ampicillin Resistance and Outcome Differences in Acute Antepartum Pyelonephritis

Objective. To measure the incidence of ampicillin-resistant uropathogens in acute antepartum pyelonephritis and to determine if patients with resistant organisms had different clinical outcomes. Study design. This was a secondary analysis of a prospective cohort study of pregnant women admitted with pyelonephritis, diagnosed by standard clinical and laboratory criteria. All patients received ampicillin and gentamicin. Results. We identified 440 cases of acute pyelonephritis. Seventy-two percent (316 cases) had urine cultures with identification of organism and antibiotic sensitivities. Fifty-one percent of uropathogens were ampicillin resistant. The patients with ampicillin-resistant organisms were more likely to be older and multiparous. There were no significant differences in hospital course (length of stay, days of antibiotics, ECU admission, or readmission). Patients with ampicillin-resistant organisms did not have higher complication rates (anemia, renal dysfunction, respiratory insufficiency, or preterm birth). Conclusion. A majority of uropathogens were ampicillin resistant, but no differences in outcomes were observed in these patients.

Acute pyelonephritis in pregnancy: A retrospective study

To examine the incidence, risk factors, microbial pathogens, and pregnancy outcomes of pregnant women with acute antepartum pyelonephritis. Among all pregnant women admitted to Patan Hospital, Nepal from 14 April 2004 to 13 April 2005, pregnant women with acute pyelonephritis were retrospectively studied. Furthermore, the pregnancy outcomes of these women were compared with those of the general obstetric population received at our hospital during the same time period. Of 7034 pregnant women delivered at our hospital, 94 cases of acute antepartum pyelonephritis were diagnosed during the study period (incidence: 1.3%). Maternal mean age for the infection was 22 +/- 3.41 years. Acute pyelonephritis was most frequently occurred in nulliparous women (75%), and in the second trimester (60%). Of 94 cases, 62 (65.95%) showed positive urine culture, with the predominating organism Escherichia coli in 81% (50 of 62) of cases. E. coli was found most sensitive to nitrofurantoin (82.1% of cases), followed by ceftriaxone (81.55% of cases), gentamicin (77.01% of cases), ofloxacin (60.57% of cases), and ciprofloxacin (59% of cases). The incidences of low-birthweight babies (14%) and preterm babies (7.81%) in the cases with acute antepartum pyelonephritis were not significantly different compared to that of all births in our hospital during the same period (13% and 8%, respectively; P > 0.05). Acute pyelonephritis requiring admission to hospital most frequently occurs in nulliparous women, and in the second trimester. The predominating organism responsible for acute pyelonephritis is E. coli. Ceftriaxone, because of its safety and negligible side-effect, should be the drug of choice for acute antepartum pyelonephritis.

Acute Pyelonephritis in Pregnancy

To examine the incidence of pyelonephritis and the incidence of risk factors, microbial pathogens, and obstetric complications in women with acute antepartum pyelonephritis. For 2 years, information on pregnant women with acute pyelonephritis was collected in a longitudinal study. All women were admitted to the hospital and treated with intravenous antimicrobial agents. We compared the pregnancy outcomes of these women with those of the general obstetric population received at our hospital during the same time period. Four hundred forty cases of acute antepartum pyelonephritis were identified during the study period (incidence 1.4%). Although there were no significant differences in ethnicity, pyelonephritis was associated with nulliparity (44% versus 37%, P = .003) and young age (P = .003). Thirteen percent of the women had a known risk factor for pyelonephritis. Acute pyelonephritis occurred more often in the second trimester (53%), and the predominant uropathogens were Escherichia coli (70%) and gram-positive organisms, including group B beta Streptococcus (10%). Complications included anemia (23%), septicemia (17%), transient renal dysfunction (2%), and pulmonary insufficiency (7%). The incidence of pyelonephritis has remained low in the era of routine prenatal screening for asymptomatic bacteriuria. First-trimester pyelonephritis accounts for over 1 in 5 antepartum cases. Gram-positive uropathogens are found more commonly as pregnancy progresses. Maternal complications continue, but poor obstetrical outcomes are rare.

Acute pyelonephritis in pregnancy in the era of routine antepartum screening for asymptomatic bacteriuria

ANTEPARTUM SCREENING FOR ASYMPTOMATIC BACTERIURIA JAMES HILL, JEANNE SHEFFIELD, F. GARY CUNNINGHAM, GEORGE WENDEL, JR, University of Texas Southwestern Medical Center at Dallas, OB/ Gyn, Fayetteville, NC University of Texas Southwestern Medical Center at Dallas, Obstetrics and Gynecology, Dallas, TX OBJECTIVE: To examine the incidence, risk factors, microbial pathogens, and obstetric complications in women with acute pyelonephritis in the era of routine prenatal screening for asymptomatic bacteriuria (ASB). STUDY DESIGN: Prospective cohort study of all women admitted antepartum with pyelonephritis from January 2000 through December 2001. Diagnosis of pyelonephritis was made by standard clinical and laboratory evaluation. All women were treated with parenteral antibiotics and discharged on microbial suppressive therapy. Follow-up was performed in an obstetric infectious disease clinic. RESULTS: There were 440 women admitted with acute antepartum pyelonephritis during the study period (incidence of 1.1%). Women with pyelonephritis were significantly younger and more likely to be nulliparous (44% versus 37%) compared with the general obstetric population. Thirteen percent had a known risk factor, including a history of pyelonephritis (4%), ASB (3%), and diabetes (2%). Most pyelonephritis (79%) occurred in the second and third trimesters. Overall, 83%of the urine cultures grew E. coli and 12%grew group B Streptococcus and other gram-positive organisms. There was a shift in the microbiologic pattern of uropathogens by trimester with an increase in grampositive organisms later in pregnancy (15%). Anemia (Hct < 30%) was the most common complication (23%), followed by septicemia (17%), respiratory insufficiency (7%), and renal insufficiency (2%). Five percent of women delivered < 37 weeks’ gestation and 7% delivered an infant < 2500 g. CONCLUSION: The incidence of pyelonephritis has remained low with routine prenatal screening for ASB; however, several changes have occurred. First-trimester pyelonephritis now accounts for over 1 in 5 antepartum cases. Gram-positive uropathogens are found more commonly as pregnancy progresses and may influence antimicrobial choices and efficacy. Maternal complications continue; however, excess poor obstetrical outcomes are rare.

A prospective evaluation of the utility of blood cultures in treating antepartum pyelonephritis

A prospective evaluation of the utility of blood cultures in treating antepartum pyelonephritis

Doppler Sonography in the Diagnosis of Antepartum Pyelonephritis: Value of Intrarenal Resistive Index Measurements

Doppler Sonography in the Diagnosis of Antepartum Pyelonephritis: Value of Intrarenal Resistive Index Measurements

Doppler sonography in the diagnosis of antepartum pyelonephritis: value of intrarenal resistive index measurements.

This study aims to define the effects of pyelonephritis on intrarenal resistive indices and to determine the role of Doppler sonography in the diagnosis of pyelonephritis in pregnant patients. Twenty pregnant women with pyelonephritis underwent renal Doppler sonography with calculation of intrarenal resistive indices. The resistive index was calculated for the upper, lower, and interpolar areas of each kidney in the patients with pyelonephritis (40 kidneys) and was compared to the resistive indices for a control group of 153 normal asymptomatic pregnant women (306 kidneys). Doppler findings were correlated with the location (sidedness) of flank pain in the pyelonephritis group. The mean resistive index values of patients with pyelonephritis were 0.04 higher than in the controls, and this difference was statistically significant (P < 0.001). Four patients with pyelonephritis had a mean resistive index > or = 0.70, whereas the remaining 16 patients had resistive indices within the normal range of < or = 0.70. In patients with confirmed pyelonephritis and unilateral pain, the average resistive index in the kidney on the side of pain was 0.03 greater than that on the asymptomatic side (P = < 0.01). The mean renal resistive index is significantly greater in pregnant patients with pyelonephritis than in pregnant women without pyelonephritis. Even so, the magnitude of the differences in resistive index is too small and the overlap between the groups too large for this parameter to be of discriminating clinical value.

Doppler sonography in the diagnosis of antepartum pyelonephritis: value of intrarenal resistive index measurements.

This study aims to define the effects of pyelonephritis on intrarenal resistive indices and to determine the role of Doppler sonography in the diagnosis of pyelonephritis in pregnant patients. Twenty pregnant women with pyelonephritis underwent renal Doppler sonography with calculation of intrarenal resistive indices. The resistive index was calculated for the upper, lower, and interpolar areas of each kidney in the patients with pyelonephritis (40 kidneys) and was compared to the resistive indices for a control group of 153 normal asymptomatic pregnant women (306 kidneys). Doppler findings were correlated with the location (sidedness) of flank pain in the pyelonephritis group. The mean resistive index values of patients with pyelonephritis were 0.04 higher than in the controls, and this difference was statistically significant (P < 0.001). Four patients with pyelonephritis had a mean resistive index > or = 0.70, whereas the remaining 16 patients had resistive indices within the normal range of < or = 0.70. In patients with confirmed pyelonephritis and unilateral pain, the average resistive index in the kidney on the side of pain was 0.03 greater than that on the asymptomatic side (P = < 0.01). The mean renal resistive index is significantly greater in pregnant patients with pyelonephritis than in pregnant women without pyelonephritis. Even so, the magnitude of the differences in resistive index is too small and the overlap between the groups too large for this parameter to be of discriminating clinical value.

Ultrasonographic evaluation of central and end-organ hemodynamics in antepartum pyelonephritis

OBJECTIVE: Our purpose was to evaluate central and end-organ hemodynamic effects of antepartum pyelonephritis. STUDY DESIGN: Daily duplex ultrasonographic assessments of maternal cardiac output and resistive index values of the maternal renal and uterine arteries and the fetal umbilical arteries were performed in pregnant women admitted for acute pyelonephritis. For comparison, the same measures were repeated within 2 weeks after discharge. RESULTS: Thirty-seven women with antepartum pyelonephritis underwent serial 2-dimensional real-time and Doppler evaluation of maternal heart and duplex Doppler evaluation of maternal renal and uterine and fetal umbilical arteries. Significant differences in temperature, mean arterial pressure, and heart rate were observed during hospitalization compared with the follow-up visit. Total peripheral resistance was significantly decreased and cardiac output increased during acute infection. In women with unilateral signs and symptoms an increased resistive index was observed in the symptomatic kidney compared with the nonsymptomatic side; this difference disappeared on the follow-up study. No changes were observed in maternal uterine or fetal umbilical arteries. CONCLUSIONS: Uncomplicated pyelonephritis is associated with measurable depression of systemic vascular resistance. This likely represents an effect of infection that in the extreme would be the septic shock syndrome. It seems reasonable to attribute the increased resistive index of the symptomatic kidney to local effects of infection. (AM J OBSTET GYNECOL 1994;170:814-8.)

Pulmonary complications of antepartum pyelonephritis: more alertness is needed

Three cases of pulmonary complications associated with antepartum pyelonephritis are presented, in two of them tracheal intubation and mechanical ventilation were required. All three cases were related to recurrent urinary infections with failure of first line antimicrobial therapy and a concomitant usage of tocolytic therapy. The possible etiology, risk factors and clinical approach, aimed to prevent pulmonary complications in antepartum pyelonephritis are discussed.

Mechanisms of hemolysis and anemia associated with acute antepartum pyelonephritis

International Journal of Gynecology & ObstetricsVolume 37, Issue 1 p. 69-69 Citations from the literature perinatology Mechanisms of hemolysis and anemia associated with acute antepartum pyelonephritis S.M. Cox, S.M. CoxSearch for more papers by this authorP Shelburne, P ShelburneSearch for more papers by this authorR Mason, R MasonSearch for more papers by this authorS Guss, S GussSearch for more papers by this authorF.G. Cunningham, F.G. CunninghamSearch for more papers by this author S.M. Cox, S.M. CoxSearch for more papers by this authorP Shelburne, P ShelburneSearch for more papers by this authorR Mason, R MasonSearch for more papers by this authorS Guss, S GussSearch for more papers by this authorF.G. Cunningham, F.G. CunninghamSearch for more papers by this author First published: January 1992 https://doi.org/10.1016/0020-7292(92)91001-5AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article. Volume37, Issue1January 1992Pages 69-69 RelatedInformation

Renal pelvicalyceal dilation in antepartum pyelonephritis: Ultrasonographic findings

The purpose of the present study was to determine whether pregnant women with pyelonephritis have differences of pelvicalyceal systems, compared with normal pregnant control subjects, that might predispose to upper urinary tract infection. Ultrasonographic examination of both kidneys in coronal and axial planes of 24 women with clinical pyelonephritis and positive urine cultures was compared with results in control subjects matched for gestational age, parity, and race. Women with right or bilateral pyelonephritis had increased dilation of the right calyceal system, compared with controls (1.7 em vs 0.8 em, p \\lt 0.001). Renal pelvis volume was increased as well (29.3 vs 5.5 cm3, p \\lt 0.001 ). Renal pelvicalyceal dilation in antepartum pyelonephritis was significantly increased compared with normal physiologic dilation of pregnancy. Follow-up nephrosonography in a small number of women (N = 10) after treatment of pyelonephritis did not reveal a consistent decrease in renal dilation, suggesting that dilation of the renal pelvis may antedate pyelonephritis. Further study of this phenomenon is warranted.

Pulmonary injury associated with antepartum pyelonephritis: Can patients at risk be identified?

The development of pulmonary injury in cases of antepartum pyelonephritis is rare but serious. To date, factors that might identify patients at risk have not been determined. We compared 11 patients with pyelonephritis and pulmonary injury with 119 patients with pyelonephritis only. Pulmonary injury was more likely to occur in the more severe cases; however, the presence of a maternal heart rate greater than 110 beats/min and a fever to 103 degrees F 12 to 24 hours before the occurrence of respiratory symptoms in a gestation greater than 20 weeks was highly predictive of pulmonary injury. The most significant predictive factors associated with pulmonary injury were elements of treatment such as fluid overload, use of tocolytic agents, and, to a lesser extent, choice of antibiotic. Therefore, if tocolytic agents are considered at all in the management of acute pyelonephritis in pregnancy, they should be used only in patients with documented cervical change. In addition, urinary output should be monitored very closely. These data also may suggest a cause of the pulmonary edema that is occasionally seen in the management of premature labor with the use of tocolytic agents and fluids in the presence of a possible occult infection.