Gestational pyelonephritis: diagnosis

Physical examination with gestational pyelonephritis

Clinically, gestational pyelonephritis takes place in acute or chronic form. With exacerbation of chronic pyelonephritis, the disease should be considered as an acute inflammation. The clinical picture of gestational pyelonephritis in different periods of pregnancy has its own typical features. They are caused, mainly, by the degree of violation of the passage of urine from the upper urinary tract. If in the first trimester of pregnancy there can be pronounced pain in the lumbar region with irradiation to the lower abdomen, external genitalia, resembling renal colic, in the II and III trimesters pain is less intense.

For acute pyelonephritis, pregnant women are characterized by symptoms of general intoxication of the body, fever with chills and excessive sweating, arthralgia and muscular pain, which is combined with complaints of pain in the lumbar region, often with irradiation to the upper abdomen, inguinal region, thigh. They also note discomfort during urination, dysuria. In an objective examination, painfulness is noted when pressing in the bone-vertebral corner on the side of the lesion, a positive symptom of effleurage. With simultaneous bimanual palpation of the lumbar and subcostal areas, local soreness in the lumbar region and muscle tension of the anterior abdominal wall are noted.

In some patients, the symptoms of general intoxication prevail over local manifestations, and in order to clarify the diagnosis it is necessary to conduct a laboratory study.

Chronic pyelonephritis during the gestational process can occur with exacerbations (clinical picture of acute pyelonephritis), and also in the form of asymptomatic bacteriuria.

Laboratory and instrumental methods of investigation in gestational pyelonephritis

• In the clinical analysis of blood leukocytosis more than 11x10 ⁹ / l, neutrophilic shift of the leukocyte formula to the left due to an increase in stab-shaped forms, hypochromic anemia (hemoglobin below 100 g / l), increased ESR.
• Blood chemistry. The level of total protein, cholesterol, residual nitrogen in pyelonephritis is usually normal; Diagnostic value has disproteinemia (increased levels of alpha2 and gamma globulin), increased levels of sialic acids, mucoproteins, a positive reaction to the C-reactive protein.
• Analysis of urine. Pyuria is present in almost all patients with pyelonephritis, this is an early laboratory symptom. Leucocyturia more than 4000 in 1 ml (Nechiporenko's test). When microscopic urine sediment in parallel with leukocyturia can detect cylindruria, mainly due to hyaline or leukocyte cylinders (detection of the latter against pyuria with a high degree of probability confirms the diagnosis of pyelonephritis), minor proteinuria, and sometimes - microhematuria. Most often an alkaline urine reaction is detected due to the vital activity of urea-producing bacteria.
• Reberg's test: the filtration function of the kidneys is disrupted only in case of severe disease.
• Microbiological study.

The presence of a large number of ejaculated epithelium in the swabs of urine testifies to the contamination of urine by the vaginal flora, in connection with which a repetition of the analysis is necessary.

• The detection of 1 or more bacterial cells in the field of view of the microscope indicates the presence of 10 ⁵ or more microorganisms in 1 ml of urine .
• The standard method of microbiological research is the culture of urine with the determination of the sensitivity of pathogens of infection to antibacterial drugs.

The diagnostic value of a bacteriological study of urine can be determined as high when the growth of the pathogen is detected in an amount of ≥ 10 ⁵ cfu / ml. A necessary condition for the reliability of the results of bacteriological examination is the correctness of urine sampling. Taking urine for bacteriological examination is performed after a careful toilet of the external genital organs with the exclusion of vaginal discharge in the urine. The average portion of urine is collected in a sterile container with a lid in an amount of 10-15 ml. Urine for microbiological examination should be taken before the start of antibacterial therapy. If the patient receives antibacterial drugs, they should be canceled 2-3 days before the test. Interpretation of the results of bacterioscopy and sowing of urine should be made taking into account clinical data. In urine, in 10% of patients with urinary tract infections, two microorganisms can be present, each of which can be considered as the main causative agent of the disease. If more than two types of microorganisms are detected, the results are assessed as a suspicion of contamination and require a repetition of the analysis.

• In 10-20% of patients with pyelonephritis, the causative agent of the infection is isolated from the blood. Usually found in the blood microorganism is similar to that in urine.
• Ultrasonic scanning of the kidneys is an auxiliary method of investigation. Indirect signs of acute pyelonephritis - an increase in the size of the kidney, a decrease in the echogenicity of the parenchyma as a result of edema. Renal ultrasound in chronic pyelonephritis is of little informative.

Diagnostic criteria of gestational pyelonephritis

The diagnosis of gestational pyelonephritis is given in the presence of a pregnant woman:

• a characteristic clinical picture (acute febrile onset of the disease, dysuric phenomena, a positive symptom of effleurage);
• leucocyturia more than 4000 in 1 ml;
• bacteriuria more than 10 ⁵ cfu / ml;
• leukocytosis more than 11 × 10 ⁹ / L, shift the blood formula to the left.

[1], [2], [3], [4], [5], [6], [7], [8], [9], [10]

Differential diagnosis of gestational pyelonephritis

Differential diagnosis should be carried out with the following diseases and pathological conditions:

• appendicitis;
• acute cholecystitis;
• renal colic on the background of urolithiasis;
• ectopic pregnancy;
• rupture of the ovarian cyst;
• infections of the respiratory tract (with fever);
• toxoplasmosis.

[11], [12], [13], [14], [15], [16], [17], [18], [19], [20]