In this presentation we describe the management of a patient at 28 weeks gestation, admitted for pyelonephritis, who ended up in respiratory failure.
The patient complained of fever, headache, and back pain. Vital signs were 37.3 C, 138 heart rate, 20 respiratory rate, 98/50 BP. She had gram negative rods on the gram stain from her urine sample, so she was admitted for pyelonephritis to our obstetric high-risk unit for continuous fetal monitoring and antibiotic and analgesic therapy.
Her temperature rose to 39.5 C and she was tachypneic. Her hemoglobin dropped to 6.8, so she was transfused. A chest x-ray was used to diagnose right lower lobe pneumonia. Her oxygen saturation rates (O2 sats) were 70 to 80%, and adult respiratory distress syndrome was suspected. The patient was transferred to the intensive care unit due to the concern that she may have to be intubated for ventilatory support. Escherichia coli grew in her urine culture. She continued with tachypnea, labored breathing, and developed a productive cough. She was considered critically ill and in respiratory failure but was able to be sustained on oxygen therapy without intubation. She eventually was weaned to room air, with O2 sats > 95%.
The patient was discharged after a week, still pregnant, with orders for monthly urine cultures and suppressive therapy. Her only readmission was when she was in labor at 40 weeks gestation. She had normal vital signs at that point and had no oxygen requirements. She delivered a healthy term infant with Apgar scores of 8 and 9.
A paucity of recent literature has addressed the relationship between pyelonephritis and respiratory distress in pregnancy. Nonetheless, we seem to be encountering this problem more frequently. The association of pyelonephritis and respiratory distress in pregnancy was first described in 1984. Pyelonephritis alone is estimated to occur in 1 to 2% of all pregnancies. Some studies suggest that one out of every 50 women admitted for pyelonephritis will develop some respiratory distress. Unfortunately, the etiology for the mechanism of the syndrome remains unknown.
Respiratory distress in pregnancy is associated with a high rate of perinatal morbidity and mortality. It is fortunate that this patient had access to an institution where she could have maternal fetal medicine and pulmonology consults. Her management prevented artificial ventilation, which would have increased her statistical risk. Providing care for this patient and others like her has increased our awareness of the possible consequences of urinary tract infections in pregnancy.