Renal disorders in pregnancy


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Renal disorders in pregnancy

  1. 1. Renal Disorders in Pregnancy DR. Shamsa Tariq Associate Professor RMC
  2. 2. Physiological Adaptation        Dramatic dilatation of the urinary collecting system during pregnancy. Renal plasma flow rises by 60-80% by the second trimester. RPF falls throughout the third trimester but maintained at 50% greater than prepregnancy levels. GFR increases significantly and creatinine clearance rises by 50%. Fall in Urea and Creatinine level Pretein excretion is increased up to 300 mg per 24 hours. 80% of women develop edema due to physiological increase in sodium retention.
  3. 3. Renal Disorders  Urinary tract infection  Chronic renal disease  Acute renal failure  Pregnancy in renal transplant recipient
  4. 4. Urinary Tract Infection  Asymptomatic bacteriuria  Acute cystitis  Acute pyelonephritis
  5. 5. Asymptomatic Bacteriuria Incidence    This ranges from 2 to 10% 40% will develop symptomatic urinary-tract infection in pregnancy. Women with history of previous urinary-tract infection have a 10-fold increased risk of developing cystitis or acute pyelonephritis in pregnancy.
  6. 6. Pathogenesis   75-90% due to E coli, probably derived from large bowel Colonization of urinary tract results from ascending infection from the perineum and is related to sexual intercourse. Diagnosis   Most women with asymptomatic bacteriuria are found to be infected during early pregnancy and very few subsequently acquire asymptomatic bacteriuria Bacteriuria is only considered significant if the colony count exceeds 100,000/ml on a MSU
  7. 7. Management    The choice of antibiotic depends on culture/sensitivity Ampicillin, amoxicillin, Augmentin and the cephalosporin are safe and appropriate antibiotics in pregnancy. Treatment should be continued for 2 weeks in the first instance and regular urinary culture required.
  8. 8. Acute Cystitis Incidence Cystitis complicates 1% of pregnancies Clinical features Urinary frequency, dysuria, haemeturia and suprapubic pain Diagnosis Significant bacteriuria on MSU
  9. 9. Management  Same as asymptomatic bacteriuria Several non-pharmacological maneuvers may help to prevent recurrent infection in women with recurrent urinary-tract infections in pregnancy. These include:  Increase fluid intake  Emptying the bladder following sexual intercourse
  10. 10. Acute Pyelonephritis Incidence   This complicates 1-2% of pregnancies More common in pregnancy ( physiological dilatation of the upper renal tract). Clinical Features       Fever Loin and abdominal pain Vomiting Rigors Proteinuria Haematuria
  11. 11. Risk increases in women  On steroid therapy  With polycystic kidneys  Congenital abnormalities of renal tract  Urinary-tract calculi  Diabetes
  12. 12. Diagnosis Significant bacteriuria on MSU specimen. Differential diagnosis  Pneumonia  Viral infections  Cholecystitis , biliary colic  Acute appendicitis  Gastroenteritis,  Placental abruption  Degenerating uterine fibroid. Blood cultures and a full blood count is recommended
  13. 13. Management  Should be after hospitalization  I/V Antibiotic Penicillin and cephalosporin are the Ist choice.
  14. 14. Chronic Renal Disease
  15. 15. Pregnancy with Chronic Renal Disease Effects of Pregnancy The risks include:  Accelerated decline in renal function  Rising hypertension  Worsening proteinuria
  16. 16. Effects of chronic renal disease on pregnancy The risks includes:  Miscarriage  Pre-eclampsia  Intrauterine growth retardation  Preterm delivery  Fetal death
  17. 17. Factors Influencing Outcome  The presence and degree of renal impairment  The presence and severity of proteinuria  The underlying type of chronic renal disease
  18. 18. Degree of Renal Impairment  Mild renal impairment (plasma creatinine <125 umol/I)  Moderate renal impairment (plasma creatinine 125-250 umol/I)  Severe renal impairment (plasma creatinine >250 umol/I)
  19. 19. In general, women without hypertension or renal impairment prior to conception have successful pregnancies, and pregnancy does not adversely influence the progression of the renal disease.
  20. 20. Specific Types of Renal Disease  Glomerulonephritis  Reflux nephropathy  Diabetic nephropathy  SLE nephritis  Polycystic kidney disease (PKD)
  21. 21. Management     Women with chronic renal disease should be managed jointly by obstetricians and physicians Preconceptual assessment of renal functions and blood pressure should be made. In view of the increased risk of pre-eclampsia, treatment with low dose aspirin should be considered especially in those with hypertension, renal impairment or a previous poor obstetric history. Careful monitoring and control of blood pressure both prepregnancy and antenatally is important.
  22. 22.   The fetus should be monitored with regular ultrasound assessment of growth and Doppler assessment of uterine and umbilical circulation. Admission should be considered if the woman develops worsening hypertension, deteriorating renal function or proteinuria, or superimposed eclampsia.
  23. 23. Acute Renal Failure
  24. 24. Incidence  Rare in pregnancy <0.005% Clinical Features    Anuria/oliguria urea, creatinine rises Decreased GFR
  25. 25. Causes Infection    Septic abortion Puerperal sepsis Rarely acute pyelonephritis Blood Loss   Postpartum hemorrhage Abruption
  26. 26. Volume Contraction    Pre-eclampsia Eclampsia (6%) Hypermesis gravidarum Post-renal Failure  Ureteric damage or obstruction Pre-eclampsia
  27. 27. HELLP Syndrome   7% have actual renal failure Thrombotic thrombocytopenic purura/hemolytic uraemic syndrome (TTP/HUS) Management  This depend on underlying cause
  28. 28. Pregnancy in Renal Transplant Recipients
  29. 29.  Women receiving renal transplants should be warned that as renal function returns to normal, ovulation, menstruation and fertility also resume.  Women desiring pregnancy are usually advised to wait about 1-2 years after transplantation.
  30. 30. Effects of pregnancy on renal transplants     Pregnancy probably has no adverse long-term effect Renal allograft adapt to pregnancy About 15% of women develop significant impairment About 40% develop proteinuria towards term
  31. 31. Effect of renal transplants on pregnancy   The chance of successful outcome is >90%, but this is reduced to 70% if complications occur before 28 weeks’ gestation. The complication rate is higher for diabetics.
  32. 32. Antenatal Management      Women should be managed jointly by nephrologists and obstetricians with expertise in the care of pregnant renal transplant recipients. Careful monitoring and control of blood pressure is important. Regular assessment of RFTs by creatinine clearance and 24 hour protein excretion, as well as serum creatinine and urea is essential. A FBC and LFTs should also be checked regularly. Anemia is common and haematinics should be prescribed. The fetus should be monitored with regular ultrasound assessment of growth and Doppler assessment of uterine Sand umbilical circulation.
  33. 33. Immunosuppressive Therapy   The doses of immunosuppressive drugs are maintained at prepregnancy Levels which should preferably be: Prednisolone, <15 mg/day plus either Azathioprine, <2 mg/kg/day Cyclosporin A, 2-4 mg/kg/day
  34. 34. Delivery    Caesarean section is only required for obstetric indications. Prophylactic antibiotics should be given to cover any surgical procedure including episiotomy. Parental steroids are necessary to cover labour, as with any woman on maintenance steroids.
  35. 35. Neonatal Problems These are largely related to prematurely but also include the following:  Thymic atrophy  Transient leukopenia or thrombocytopenia  Depressed haemopoiesis