妊娠期合併先天性泌尿道異常患者急性腎盂腎炎與腎積水的臨床處理

吳冠儒¹、陳祺方¹

¹台灣基督長老教會馬偕醫療財團法人馬偕紀念醫院泌尿科

Management of Acute Pyelonephritis and Hydronephrosis in a Pregnant Patient with a History of Urinary Tract Anomalies

Kuan-Ju Wu¹、Chi-Fang Chen¹

¹Department of Urology, MacKay Memorial Hospital, Taipei, Taiwan

Introduction –

Acute pyelonephritis is a significant complication in pregnancy, especially in patients with pre-existing urinary tract abnormalities. This case report presents a pregnant woman with a history of congenital urinary tract conditions, diagnosed with right acute pyelonephritis and right hydronephrosis at 16 weeks of gestation. We discuss the clinical challenges, diagnosis, and management strategies for treating acute pyelonephritis and hydronephrosis in a pregnant patient, with a focus on mitigating risks to both maternal and fetal health.

Case Presentation –

A 28-year-old pregnant woman at 16 weeks gestation presented with a 3-day history of right flank soreness. She has a complex medical history, including bilateral vesicoureteral reflux (VUR), right ureteropelvic junction obstruction (UPJO) and ureterovesical junction obstruction (UVJO) with surgical correction in 1999, a right ectopic kidney, and dysfunctional voiding with bilateral hydronephrosis. Additionally, she had undergone a laparoscopic right partial oophorectomy due to an ovarian serous cystadenoma and a congenital occlusion of the right ureteropelvic junction. Her prenatal care was being followed in an obstetric clinic, where preliminary assessment suggested pyelonephritis, prompting referral to the emergency department.

On initial examination, her vital signs were within normal limits, and physical examination revealed right costovertebral angle tenderness. Laboratory findings showed leukocytosis with a left shift, elevated C-reactive protein (CRP), and pyuria with bacterial presence. Renal ultrasound confirmed right hydronephrosis. Empirical antibiotic therapy with ceftriaxone was initiated. Recent imaging showed right hydronephrosis with cortical thinning and recurrent flank pain. Urologist was consulted and after discussing options, including ureteroscopy (URS) with double-J stent placement or needle aspiration, the patient chose percutaneous pigtail drainage for symptomatic relief of her hydronephrosis. Uroflowmetry and renal ultrasound have been planned to further assess voiding function and residual urine volume.

Discussion –

Acute pyelonephritis during pregnancy presents a unique challenge, especially in patients with congenital urinary tract anomalies. Pregnancy-induced physiological changes, such as increased renal blood flow and urinary stasis from ureteral dilation, can exacerbate pre-existing conditions like hydronephrosis, increasing susceptibility to infections. In this case, the patient's previous diagnoses of UPJO, VUR, and ectopic kidney created anatomical predispositions to urinary tract infections and complications during pregnancy.

Management strategies included empirical antibiotic therapy, close monitoring, and multidisciplinary collaboration between obstetrics and urology. Although double-J stenting is an option for relief in cases of symptomatic hydronephrosis, it was deemed unnecessary due to the patient's stable condition and gradual pain improvement. The absence of fever and improvement in lab findings supported this conservative approach.

In summary, this case highlights the importance of individualized management in pregnant patients with complex urinary tract histories, focusing on safeguarding both maternal and fetal outcomes. Through collaborative and vigilant care, we achieved favorable outcomes without invasive intervention.