During the last half of pregnancy dilation of the upper urinary tract can occur due to compression of the ureters by the growing fetus/uterus and the linea terminalis. The compression of these is not allowing fluid passage into the bladder causing urine buildup in the kidney, this leads to dilation of the kidney that ends up causing symptomatic hydronephrosis. this can end up in infection and symptoms such as the ones present in this patient like back pain and CVA tenderness. the crying is mainly due to the pain caused by the obstruction. and just as something extra: double pigtail catheters is a safe and simple way of treating symptomatic hydronephrosis of pregnancy.
Obstructive uropathy causes a postrenal azotemia --> when prolonged, tubular damage ensues. This leads to an acute tubular necrosis, characterized by necrotic plugs in the tubular system as seen in the image
Physical exams showed tenderness of costophrenic angles, which are the places where the diaphragm (-phrenic) meets the ribs (costo-). Not the Costovertebral angle tenderness that we think to hint renal disease.I got confused with this point.
I feel like part of this is them seeing if you can recognize those are tubules.
So if you say ok these are tubules, chorioamnionitis, endometritis, and PID are probably not right.
Glomerulonephritis in my experience so far, they should probably show a glomeruli, not tubules.
Between hematgoneous spread and obstructive uropathy, I feel like I don't have enough info - but sometimes a 50/50 guess is better than playing Battleship.
Hydronephrosis
Distention/dilation of renal pelvis and calyces A . Usually caused by urinary tract obstruction (eg, renal stones, severe BPH, congenital obstructions, cervical cancer, injury to ureter, pregnancy apparently); other causes include retroperitoneal fibrosis, vesicoureteral reflux. Dilation occurs proximal to site of pathology. Serum creatinine becomes elevated if obstruction is bilateral or if patient has an obstructed solitary kidney. Leads to compression and possible atrophy of renal cortex and medulla.
costophrenic angle tenderness and fever WBC casts in tubules on that photo for example All of them is leading us to pyelonephritis. And even minor cystitis can cause pyelonephritis in pregnancy due to obstructive uropathy.
This question was a little tricky, but the way I went about it was process of elimination. You don't see costophrenic angle tenderness in A,B, C, or D.
She has fever and back pain, definitely don't see that in PID, which presents with cervical motion tenderness, and purulent discharge. Micrograph also isn't showing cervical histology.
As an added bonus: urinary stones cause excruciating pain when you're trying to pass it through your ureters, basically dragging alongside. Hence the patient crying.
You didn't need the micrograph, other than to see all those neutrophils, but we've all seen glomerulonephritis histology slides, and it doesn't even look close.
pregnancy is a risk factor for acute pyelonephritis FA 2019 pg 589
also maybe could do process of elimination...the 'costophrenic angle tenderness' clues us in to it being a renal problem, and the only renal answer choice is obstructive uropathy
submitted by โxxabi(293)
Also for those of you who are totally clueless like me, urinary tract obstruction = obstructive uropathy.