Acute Pyelonephritis in Pregnancy
James B. Hill, MD, Jeanne S. Sheffield, MD, Donald D. McIntire, PhD, and
George D. Wendel Jr, MD
OBJECTIVE: To examine the incidence of pyelonephritis and
the incidence of risk factors, microbial pathogens, and
obstetric complications in women with acute antepartum
pyelonephritis.
METHODS: For 2 years, information on pregnant women
with acute pyelonephritis was collected in a longitudinal
study. All women were admitted to the hospital and treated
with intravenous antimicrobial agents. We compared the
pregnancy outcomes of these women with those of the
general obstetric population received at our hospital dur-
ing the same time period.
RESULTS: Four hundred forty cases of acute antepartum
pyelonephritis were identified during the study period (in-
cidence 1.4%). Although there were no significant differ-
ences in ethnicity, pyelonephritis was associated with nul-
liparity (44% versus 37%, P ⴝ .003) and young age (P ⴝ
.003). Thirteen percent of the women had a known risk
factor for pyelonephritis. Acute pyelonephritis occurred
more often in the second trimester (53%), and the predom-
inant uropathogens were Escherichia coli (70%) and gram-
positive organisms, including group B ␤ Streptococcus
(10%). Complications included anemia (23%), septicemia
(17%), transient renal dysfunction (2%), and pulmonary
insufficiency (7%).
CONCLUSION: The incidence of pyelonephritis has re-
mained low in the era of routine prenatal screening for
asymptomatic bacteriuria. First-trimester pyelonephritis
accounts for over 1 in 5 antepartum cases. Gram-positive
uropathogens are found more commonly as pregnancy
progresses. Maternal complications continue, but poor ob-
stetrical outcomes are rare. (Obstet Gynecol 2005;105:
18 –23. © 2005 by The American College of Obstetricians
and Gynecologists.)
LEVEL OF EVIDENCE: II-3
Acute pyelonephritis is one of the most common medical
complications of pregnancy. It occurs in 1–2% of preg-
nant women and may result in significant maternal mor-
bidity, as well as fetal morbidity and mortality. The
clinical course of pyelonephritis in pregnancy was well
described 20 –30 years ago.1,2 These early studies have
From the Department of Obstetrics and Gynecology, University of Texas South-
western Medical Center at Dallas, Dallas, Texas.
VOL. 105, NO. 1, JANUARY 2005
18 © 2005 by The American College of Obstetricians and Gynecologists.
Published by Lippincott Williams & Wilkins.
defined how we diagnose and manage pyelonephritis
today. However, recommendations for screening for
asymptomatic bacteriuria during pregnancy,3 newer di-
agnostic techniques, the development of antibiotic resis-
tance, changing microbial virulence factors, and new
antimicrobials may affect diagnosis, clinical course, and
management of pyelonephritis today.
We sought to readdress the incidence, risk factors,
microbial pathogens, and the clinical complications of
pyelonephritis in pregnancy. Said another way, have we
been able to alter the frequency and outcomes of pyelo-
nephritis in the past 30 years?
MATERIALS AND METHODS
Beginning January 2000, all pregnant women with acute
pyelonephritis admitted to Parkland Hospital, Dallas,
Texas, were enrolled in a specialized prenatal clinic for
women with infectious diseases. This clinic was staffed
by faculty and fellows in the Division of Maternal–Fetal
Medicine at the University of Texas Southwestern Med-
ical School. All pregnant women with antepartum pye-
lonephritis had been treated as inpatients with intrave-
nous antibiotics. All women admitted from January 2000
through December 2001 were included in this study.
The diagnosis of acute pyelonephritis was made on
the basis of clinical findings of fever (temperature ⱖ
38°C), flank pain, and costovertebral angle tenderness,
and of laboratory findings of either bacteriuria (20 bac-
teria per high-power field) or pyuria.2 Other common
symptoms included nausea, vomiting, and chills. The
diagnosis was established before the results of urine
cultures were known, and all women were evaluated by
residents and faculty before admission to the hospital.
All of these women were treated with intravenous fluid
and antimicrobial agents according to previously de-
scribed protocols.4 Diagnosis was confirmed by urine
culture, from midstream clean catch or urethral catheter-
ization. In most women, a complete blood cell count and
serum creatinine were measured. Blood cultures were
obtained in the presence of temperature greater than
38.5°C or if the patient had signs of sepsis. Respiratory
0029-7844/05/$30.00
doi:10.1097/01.AOG.0000149154.96285.a0
insufficiency was defined as dyspnea, tachypnea, hypox- Table 1. Demographic Characteristics in Women With An-
emia, and radiological signs of pulmonary infiltrates. tepartum Pyelonephritis Compared With the Gen-
Women were admitted to an obstetric extended care unit eral Population
if they had signs of respiratory insufficiency, clinical Antepartum General Obstetric
signs of sepsis, or multiorgan system dysfunction.5 Pyelonephritis Population
(n ⫽ 440) (n ⫽ 31,842) P
After recovery from pyelonephritis (afebrile ⬎ 24
hours with resolution of symptoms), the women were Maternal age (y) 23.1 ⫾ 5.1 24.8 ⫾ 5.6 ⬍ .001
discharged and seen in the obstetrics infectious disease ⱕ 15 10 (2) 491 (2) .215
ⱖ 35 18 (4) 1967 (6) .072
clinic. All women were placed on urinary suppression Race .082
with nitrofurantoin, 100 mg daily, for the duration of Hispanic 361 (82) 25,896 (81)
their pregnancy to prevent recurrent bacteriuria and Black 52 (12) 4,336 (14)
pyelonephritis.1,2,6 In the majority of women, another White 22 (5) 1,040 (3)
urine specimen was obtained for culture after recovery Other 5 (1) 642 (2)
Nulliparity 162/368 (44) 11,684/31,842 (37) .003
from the acute infection.
Data are reported as n (%) or mean ⫾ standard deviation.
Research nurses routinely entered pregnancy out-
comes and complications for all women delivered at
Parkland Hospital into a computerized database. The As demonstrated in Table 2, the majority (53%) of our
data are then assessed for consistency and completeness cases of acute pyelonephritis occurred in the second
before electronic storage. Antepartum data on women trimester. The predominant organism was Escherichia coli,
with acute pyelonephritis were entered into a separate accounting for approximately 70% of cases. Other or-
research database and linked electronically to pregnancy ganisms responsible for infection included Klebsiella-
outcome data. This analysis excluded cases of recurrent Enterobacter (3%), Proteus (2%), and gram-positive organ-
pyelonephritis admission data. isms, including group B Streptococcus (10%). Although E
Statistical analysis was performed using SAS 6.12 coli was the most common uropathogen in the third
(SAS Institute, Cary, NC). Comparisons were made with trimester, there were fewer third-trimester cases caused
␹2 for categorical data, and Student t test or analysis of by E. coli compared with the earlier trimesters (P ⫽ .004).
variance was used for continuous data. Statistical nor- Similarly, the frequency of gram-positive uropathogens
mality was evaluated using the Shapiro-Wilk statistic. nearly doubled by the third trimester. We performed a
For statistically nonnormal data, Wilcoxon rank-sum subanalysis of women with positive urine cultures, ex-
and Kruskal-Wallis tests were substituted for Student t cluding those women with sterile, unsatisfactory, or un-
test and analysis of variance, respectively. Approval for available urine results. Overall, 83% of these women had
this study was obtained from the Institutional Review pyelonephritis secondary to E. coli, 11.6% to other gram-
Board of the University of Texas Southwestern Medical positive organisms, predominantly group B Streptococcus,
Center at Dallas. 3.5% to Klebsiella-Enterobacter, and 2.2% to Proteus.
We analyzed the maternal risk factors for pyelone-
phritis by trimester (Table 3). Overall, 13% of women
RESULTS had a maternal risk factor for antepartum pyelonephritis.
During the 2-year study period, we identified 440 cases The most common risk factor was previous history of
of acute pyelonephritis in pregnancy; complete delivery pyelonephritis and asymptomatic bacteriuria. For
data were available for 368 women and their infants.
Women delivering at our hospital during the same time Table 2. Occurrence of Uropathogens in Urine Culture by
period were used for comparison. There were 32,282 Trimester
deliveries during this period, resulting in an incidence Urine Culture 1st 2nd 3rd
of antepartum acute pyelonephritis of 14 per 1,000 Results Trimester Trimester Trimester
deliveries.
Escherichia coli 70 (77) 171 (74) 66 (56)
The demographic characteristics of the women with Klebsiella-Enterobacter 0 11 (5) 2 (2)
acute pyelonephritis are described in Table 1. The ma- group
ternal mean age at delivery was less than that of the Proteus species 0 5 (2) 3 (3)
typical patient in our general obstetric population. There Other 7 (8) 19 (8) 17 (15)
uropathogens*
was no difference in ethnic background between women
Total 91 (21) 231 (53) 117 (26)
with and those without pyelonephritis. There were sig-
Data are reported as n (%).
nificantly more nulliparous women with pyelonephritis * Other uropathogens include group B ␤ Streptococcus and other
(44% versus 37%, P ⫽ .003). gram-positive organisms.

VOL. 105, NO. 1, JANUARY 2005 Hill et al Pyelonephritis in Pregnancy 19

Table 3. Selected Risk Factors in Women With Antepartum Pyelonephritis Compared by Trimester
1st Trimester 2nd Trimester 3rd Trimester Total P
Maternal age (y) 23.8 ⫾ 5.2 22.7 ⫾ 4.9 23.2 ⫾ 5.4 23.1 ⫾ 5.1 .180
Asymptomatic bacteriuria 3 (3) 7 (3) 2 (2) 12 (3) .645
Sickle cell disease/trait 2 (2) 1 (0.4) 2 (2) 5 (1) .322
Diabetes 5 (5) 2 (1) 1 (1) 8 (2) .013
Recurrent pyelonephritis 3 (3) 9 (4) 7 (6) 19 (4) .574
Human immunodeficiency virus 0 0 1 (1) 1 (0.2) .252
Prior preterm birth 0 3 (1) 3 (3) 6 (1) .285
Chronic hypertension 0 0 1 (1) 1 (0.2) .252
Drug abuse 1 (1) 5 (2) 0 6 (1) .252
Any (excluding age) 14 (15) 26 (11) 17 (15) 57 (13) .516
Prenatal care before admission 60/61 (98) 203/206 (99) 94/99 (95) 357/366 (98) .149
Data are reported as n (%) or mean ⫾standard deviation.

women with type 1 diabetes, the majority of infections erage hospital stay was 3.5 days, and the mean length
occurred in the first trimester (P ⫽ .013). When analyzed of intravenous antibiotic administration was 3.4 days.
by trimester, there were no significant differences seen in Of the 368 women delivered at Parkland Hospital, 19
women with sickle cell disease/trait or prior preterm (5%, 95% CI 3– 8%) delivered a preterm infant at less than
births. In more than 90% of the cases, women received 37 weeks of gestation. Six of these women delivered at less
prenatal care before admission. than 32 weeks. Interestingly, only 4 of the 19 women who
The hospital course of women with antepartum pye- delivered at less than 37 weeks delivered during their acute
lonephritis is described in Table 4. One hundred three pyelonephritis admission. Twenty-six women (7%, 95%
women (23%, 95% confidence interval [CI] 20 –28%) CI 5–10%) delivered an infant weighing less than 2,500 g.
developed anemia, and only 7 (2%, 95% CI 0.6 –3%) had Thirty-two women (7%, 95% CI 5–10%) with acute
transient renal dysfunction. Nearly 1 in 5 women had pyelonephritis developed respiratory insufficiency, and
septicemia when blood cultures were obtained. The av- their hospital course is described in Table 5. These
women received more intravenous fluids during the first
Table 4. Hospital Course of Women With Antepartum 48 hours of admission than those who did not develop
Pyelonephritis respiratory insufficiency. Their maximum temperature
Total (39.6°C versus 38.5°C, P ⬍ .001) and heart rate (129.5
versus 110 beats per minute, P ⬍ .001) were significantly
Hospital days (mean ⫾ SD) 3.5 ⫾ 2.0
Days of IV antibiotic treatment 3.4 ⫾ 2.1 higher compared with those who did not develop respi-
(mean ⫾ SD) ratory insufficiency. More women with respiratory in-
Anemia (hematocrit ⬍ 30%) 103 (23) sufficiency developed anemia, with a significantly lower
Blood transfusion 5 (1) hematocrit (25.3 versus 29.1, P ⬍ .001), than those who
Renal dysfunction (creatinine ⱖ 7 (2)
1.2 mg/dL)
did not. The incidence of septicemia (28% versus 5%,
Respiratory insufficiency 32 (7) P ⬍ .001) was significantly higher in the respiratory
Oxygen saturation ⬎ 90% (1st 24 414 (94) insufficiency group. Escherichia coli was the most frequent
hours) urinary isolate in both groups and accounted for more cases
Maximum temperature (°C) 38.6 (38.1, 39.1) of respiratory insufficiency than any other uropathogen.
关median (Q1, Q3)兴
Extended Care Unit admission 43 (10) There was no association between respiratory insufficiency
Positive blood culture 30/172 (17) and infection with any specific uropathogen.
Total IV fluid 1st 24 hours (mL) 3,500 (2,850, 4,075) Twelve women (2.7%, 95% CI 1.4 – 4.7%) were read-
关median (Q1, Q3)兴 mitted for recurrent pyelonephritis. Ten of the 12 women
Total IV fluid 2nd 24 hours (mL) 2,350 (120, 2,960) had a positive urine culture. One woman had nephrolithi-
关median (Q1, Q3)兴
Preterm birth ⬍ 37 wk 19/368 (5) asis with a negative urine culture. All 12 women were
Preterm birth ⬍ 32 wk 6/368 (2) noncompliant with their antimicrobial suppression.
Birth weight ⬍ 2,500 g 26/368 (7)
Maternal EGA at admission (wk) 22.5 (16.5, 29.5)
关median (Q1, Q3)兴 DISCUSSION
SD, standard deviation; IV, intravenous; Q1, first quartile; Q3, third
quartile; EGA, estimated gestational age. We report a large prospective longitudinal study of a
Data are reported as n (%), unless otherwise indicated. cohort of women hospitalized for acute antepartum py-

20 Hill et al Pyelonephritis in Pregnancy OBSTETRICS & GYNECOLOGY

Table 5. Hospital Course of Women With Respiratory Insufficiency and Pyelonephritis
Respiratory Insufficiency No Respiratory Insufficiency
Outcome (n ⫽ 32) (n ⫽ 408) P
IV fluid, 1st 24 hours (mL) 4,058 (3,175, 4,950) 3,500 (2,800, 4,000) .009
IV fluids, 2nd 24 hours (mL) 2,575 (1,350, 3,500) 2,350 (0, 2,960) .029
Tachypnea (RR ⬎ 28 breaths/min) 22 (69) 0 ⬍ .001
Maximal temperature (°C) 39.6 (39.1, 40.2) 38.5 (38.0, 39.0) ⬍ .001
Maximal heart rate (Bpm) 129.5 (120, 140) 110 (100, 120) ⬍ .001
Hematocrit 25.3 (22.8, 27.8) 29.1 (26.6, 31.4) ⬍ .001
Creatinine (mg/dL) 0.6 (0.5, 0.7) 0.5 (0.5, 0.6) .013
Positive blood cultures 9 (28) 21 (5) ⬍ .001
Chest X-ray abnormalities 8 (25) 33 (8) .002
Organism .529
Escherichia coli 26 (81) 282 (69)
Klebsiella-Enterobacter 1 (3) 12 (3)
Proteus 1 (3) 7 (2)
Other 4 (12) 42 (10)
IV, intravenous; RR, respiratory rate.
Data are reported as median (1st quartile, 3rd quartile) or n (%).

elonephritis. We used a systematic review of the preg-
nancies with a codified management scheme of maternal
treatment and follow-up.7 We found that the incidence
of hospitalization for acute pyelonephritis at our hospital
was 1.4%. This incidence is less than the 3– 4% rate
reported in the 1970s before universal screening for
asymptomatic bacteriuria was used.7,8 It is similar to the
1–2% incidence reported with antepartum universal
screening.7,8
Gilstrap and colleagues2 at this institution observed
that 82% of women with pyelonephritis were less than 25
years of age, 70% were multiparous, and 71% were black
women. We also noted an association between acute
pyelonephritis and young maternal age in the current
cohort. However, we observed no association of pyelo-
nephritis with ethnicity or increasing parity. In fact, we
noted the opposite association with parity: pyelonephri-
tis was associated with nulliparity in the contemporary
group. In 2000, maternal demographic risk factors for
acute pyelonephritis have changed to young age and
nulliparity, but not ethnicity.
Acute pyelonephritis is generally described as an in-
fection of late pregnancy and the puerperium. Up to 90%
of cases have been reported to occur in the second and
third trimesters.2 This is thought to occur because of the
increasing urinary tract obstruction with stasis caused by
the gravid uterus. In our contemporary cohort, we found
that 79% of cases of acute pyelonephritis occurred in the
last 2 trimesters of pregnancy, but more than 1 in 5 cases
occurred in the first trimester. Overall, we noted more
first-trimester cases and fewer third-trimester cases than
found in historical reports.
We next examined whether the microbiology of uri-
nary pathogens had changed in our cohort. Among
women with positive urine cultures, 83% of the cultures
were E. coli. This frequency of infection from E. coli is
similar to that reported in 1981. However, the pattern of
other microorganisms is different. We noted markedly
fewer infections from the Klebsiella-Enterobacter group of
organisms (3%) than the 23% noted by Gilstrap and
coworkers in 1981.2 Further, we noted a large increase in
infection from other organisms, predominantly group B
Streptococcus and other gram-positive organisms, account-
ing for nearly 1 in 8 hospitalized cases of acute pyelone-
phritis with positive urine cultures.
When the urinary pathogens were examined by tri-
mester of pregnancy, we noted fewer cases of E. coli and
more cases caused by other pathogens as pregnancy
progresses. In the third trimester, 1 in 4 cases of pyelo-
nephritis was due to an organism other than E. coli. In
summary, we noted a preponderance of infection with E.
coli, fewer cases from the Klebsiella-Enterobacter group, and
more cases caused by gram-positive organisms. This
shift in the microbiologic pattern of infection has clinical
implications, especially in the third trimester; antimicro-
bial treatment is chosen empirically based on a presump-
tion of urine culture results.
To investigate the unexpected increased frequency of
acute pyelonephritis in the first trimester, we examined
the frequencies with common maternal risk factors. We
found that only diabetes was more common in the first
trimester cases. We were surprised to find no other
common risks associated with early acute pyelonephritis
in our cohort.
The hospital course of acute pyelonephritis is remark-
ably similar to that previously reported. However, com-
parisons may be limited because of changes in available
antibiotics and clinical practice patterns. We noted the
average hospital stay was 3 days, similar to that reported
by Wing et al in 1998.9 Cunningham et al1 also noted

VOL. 105, NO. 1, JANUARY 2005 Hill et al Pyelonephritis in Pregnancy 21

that 95% of women hospitalized for acute pyelonephritis
were afebrile within 72 hours. Nearly one in 4 women
had anemia, similar to the frequency reported in 1991
from this institution.10
Acute renal dysfunction was also uncommon, occur-
ring in only 2% of infected gravidas, markedly lower
than the 20% rate noted previously.2,11 We speculate
that this may be due to earlier presentation for care and
intravenous fluid rehydration. This observation should
reassure clinicians using empiric aminoglycoside treat-
ment in women hospitalized with pyelonephritis while
awaiting serum creatinine measurements.
High-spiking fevers were common in our cohort and
hypoxemia was uncommon. Septicemia complicated
nearly 1 in 5 hospitalized cases. In addition, nearly 1 in
10 women required management in an obstetric inten-
sive care unit. Fluid management was aggressive on the
first hospital day, with total intake of 3–5 L, or approxi-
mately 150 mL/h, compared with nearly 100 mL/h the
second day of hospitalization.
Numbers of preterm births and small-for-gestational-
age infants were not increased compared with expected
rates in our hospital (data not shown). Previous in-
creased rates of adverse pregnancy outcomes were not
observed in our cohort, possibly because of improve-
ments in acute care, as well as aggressive follow-up care
and antimicrobial urinary suppression.
The association of antepartum pyelonephritis and
acute pulmonary injury was first described in 1984.12
Yet, it not uncommonly still complicates this infec-
tion.13,14 We noted acute respiratory insufficiency in
nearly 1 in 10 women in our cohort. These women were
noted to have higher fever, more tachycardia, more
tachypnea, more anemia, and more renal dysfunction
than those without pulmonary injury. Although they
received more intravenous fluid therapy on their first
hospital day, it does not appear that they were exces-
sively hydrated. Thus, their acute care does not indicate
that acute pulmonary injury was pulmonary edema
caused by intravenous fluid overload. Similarly, there
was no association with any specific pathogen and acute
pulmonary complications.
We believe there are several issues of importance
regarding the continued observation that respiratory
insufficiency complicates pyelonephritis. Recent reports
on the association between genetic polymorphisms and
the severity of specific infectious diseases leads us to
speculate that genetic variation may predispose certain
women to a more complicated course of pyelonephritis.
This is being investigated at the molecular level with
clinical disease correlation. Furthermore, outpatient
management of pyelonephritis in pregnancy should be
approached with caution. Although reportedly effective
22 Hill et al Pyelonephritis in Pregnancy
and safe in pregnant women with uncomplicated pyelo-
nephritis,15,16 it must be stressed that 7% of women
develop pulmonary insufficiency. One woman in 10
requires admission to an extended care unit, and 17%
have septicemia at diagnosis.3
There are several limitations to our study and our
conclusions. The entire cohort was admitted for inpa-
tient treatment regardless of signs and symptoms present
at diagnosis. Applicability to those centers managing
some women with pyelonephritis as outpatients is lim-
ited. We are also unable to perform formal statistical
comparisons to the historical cohorts referenced. Given
these limitations, this serves as a large-cohort clinical
description of pyelonephritis in the 21st century in a
university setting.
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16. Millar LK, Wing DA, Paul RH, Grimes DA. Outpatient
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Reprints are not available. Address correspondence to: Jeanne S.
Sheffield, MD, Department of Obstetrics & Gynecology, Univer-
sity of Texas Southwestern Medical Center at Dallas, 5323 Harry
Hines Boulevard, Dallas, TX 75390 –9032; e-mail: Jeanne.
Sheffield@utsouthwestern.edu.
Received July 11, 2004. Received in revised form October 1, 2004.
Accepted October 7, 2004.
Hill et al Pyelonephritis in Pregnancy 23