Pregnancy Complicated by Emphysematous Pyonephrosis: DISCUSSION

19 Nov

Significant changes occur in both structure and function of the renal system during normal pregnancy. Urinary tract dilatation is one of the most remarkable anatomical alterations noted during gestation, encompassing the renal calyces, pelves and ureters. As such, renal and ureteral lithiasis are relatively rare complications in pregnancy. Emphysematous pyonephrosis is a grave complication of ureteric obstruction. Pathologically, this clinical entity is distinguished from infected hydronephrosis or pyelonephritis via the following: presence of gross pus and fermentative gas in an obstructed collecting system, renal parenchymal destruction, deteriorating renal function and septic complications. Treatment modalities are individualized, consisting primarily of drainage of pus, eradication of sources of obstruction, aggressive hydration, pressor therapy as indicated and intravenous antibiotic therapy. Prior to antibiotic therapy, the proposed treatment for pyonephrosis consisted primarily of an expeditious nephrectomy in order to remove a kidney that was both nonfunctioning and a source for urosepsis. With the advent of antibiotics, the treatment for pyonephrosis was subsequently modified to involve aggressive intravenous antibiotic therapy and drainage of the kidney, generally via a cytoscopical-ly inserted ureteral catheter. The diagnosis of pyonephrosis need not consistently be equated with irreversible renal damage; these procedures were performed in an attempt to salvage the infected kidney. At present, the placement of percutaneous nephrostomy has become the procedure of choice as it allows both the timely drainage of pus and the determination of residual renal function following the obliteration of infection. Percutaneous nephrostomies are not contraindicated in pregnancy. Major complications of percutaneous nephrostomies, occurring in <4% of published reports, include infection, hemorrhage, urine leak and pneumothorax. Minor complications, occurring in <15% of published reports note hematuria, catheter displace-ment/dislodgement and hematoma formation.

This case is unique as it represents the first reported case of emphysematous pyonephrosis encountered during pregnancy. It further demonstrates that early recognition and coordinated interaction with multiple medical specialists is key to survival of pregnant patients with this rarely encountered, potentially fatal clinical entity. aciphex medication