Renal disease inpregnancy Presented by Ahmed Mukhtar Ali Mohammed M.B.B.Ch., M.Sc Obstetrics and GynecologyAssistante lecturer of Obstetrics and Gynecology Faculty of Medicine, Zagazig University

1. Abdominal Pain During PregnancyAbdominal Pain During Pregnancy
Dr. Ahmad mukhtarDr. Ahmad mukhtar
M.B.B.Ch., M.Sc Obstetrics and GynecologyM.B.B.Ch., M.Sc Obstetrics and Gynecology
Assistante lecturer of Obstetrics and GynecologyAssistante lecturer of Obstetrics and Gynecology
Faculty of Medicine, Zagazig UniversityFaculty of Medicine, Zagazig University

2.  Introduction
Abdominal pain in pregnancy is a common
complaint. It’s management represents
a challenge
to the clinician because the causes may
be due to pregnancy or may be related
to pregnancy but not directly due to it
or may be unrelated to pregnancy at all.

3. CAUSES OF ABDOMINAL PAIN DURING PREGNANCY
 (A) Pregnancy Related
Pain:
• Early pregnancy
o Abortion: Inevitable,
incomplete or septic
abortions
o Vesicular mole: when
expulsion starts.
o Ectopic pregnancy: pain
precedes bleeding.
• Later pregnancy
o Braxton-Hicks Contraction
o Round Ligament Pain
o Pressure symptoms
o Cholestasis of pregnancy
o Placental abruption
o Placenta percreta
o Acute Fatty Liver
o Pre-eclampsia , HELLP
o Spontaneous rupture of
the liver
o Uterine rupture
o Chorioamnionitis
o Acute Polyhydramnios
o Labor ( Term , Preterm )
 (B)Conditions associated
with pregnancy
• Rupture of rectus abdominus
muscle
• Torsion of the pregnant uterus
• Acute urinary retention due to
retroverted gravid uterus
MusculoSkeletal ( Pubic
Symphysis pain-sacroiliac – back
pain )
Red degeneration of myoma
Torsion of pedunculated myoma
Ovarian cyst rupture
Adnexal torsion
• © Non-Pregnancy Related
Pain
• Gastrointestinal
o Acute appendicitis
o Peptic ulcer
o Gastroenteritis
o Hepatitis
o Inflammatory Bowel Complication
(Crohn’s &Ulcerative Colitis )
o Bowel obstruction
o Bowel perforation
o Herniation
o Meckel diverticulitis
o Toxic megacolon
o Pancreatic pseudocyst
HepatoBliary
o Biliary Stones
o Acute Hepatitis
o Acute Cholecystitis
o Acute pancreatitis
• Genitourinary
o Ureteral calculus
o Acute pyelonephritis
o Acute cystitis
o Rupture of renal pelvis
o Ureteral obstruction
• Vascular
o Superior mesenteric artery syndrome
o Thrombosis/infarction - Specifically
mesenteric venous thrombosis
o Ruptured visceral artery aneurysm
• Respiratory
o Pneumonia
• Other
o Intraperitoneal hemorrhage
o Splenic rupture
o Abdominal trauma
o Acute intermittent porphyria
o Diabetic ketoacidosis
o Sickle cell disease

5. The incidence of the different causes
of abdominal pain in pregnancy is
difficult to estimate . The is because
classifying this symptom into
pregnancy & non-pregnancy symptom
related is often not possible until
after delivery.

6.  Pain directly related to pregnancy;-
First trimesterFirst trimester
 Abortion
 Hydatidiform mole
Ectopic pregnancy
The pain is colicky in nature felt in the lower abdomen
or pelvis  commonly associated with commonly
associated with amenorrhoea and vaginal bleeding 
In threatened & missed abortions there may be mild
or no pain  Diagnosis by BHCG,exam & USS

7. .Molar pregnancy  Incidence is 1 in
1200 pregnancies  Pain when present
is due to the uterus trying to expel
the molar tissue (colicky)  When
severe may suggest intra-peritoneal
bleeding  Uterus large for date
,watery blood stained discharge 
USS shows snow – storm appearance .

8. . Ectopic pregnancy  Incidence is 1 in
100 pregnancies in UK Presents with
pain & amenorrhoea  The pain is
commonly in one of the iliac fossa and
may be referred to the tip of the shoulder
 Most of cases are diagnosed by
BHCG,TVS and/or laparoscopy.

9. . Second trimester * Abortion* * Acute
urinary retention in association with
incarcerated* retroverted gravid uterus
typically at 12-14 weeks *
Chorioamnionitis following PROM* *
Retroplacental haemorrhage following
amniocentesis* * Round ligament pain due
to stretch classically at 18-22 wks * Red
degeneration of the fibroid

10. Incarcerated retroverted graved uterus 
Commonly occurs between 12-14wks 
Causes urethral obstruction with acute
urinary retention & pain  Indwelling urine
cathter helps allow the uterus to become
abdominal

11. . Retroplacental haemorrhage following
amniocentesis Can complicate both
diagnostic & therapeutic amniocentesis
especially when the needle inserted
transplacentally  Pain is felt a few hours
after after the procedure  Constant &
localised to the puncture site

12. Round ligament pain  Occurs secondary
to stretching of the ligament as the uterus
enlarges into the abdomen (10-30% of
pregnancy)  Commonly occurs in the
late 1stst and early 2and trimester  Felt
as dragging, stabbing or cramp-like pain in
the outer lower abdomen radiating to
groin  Diagnosis is made by excluding
other other causes .

13.  . Red degeneration of fibroid  Occurs due to
infarction of the centre of the fibroid during mid –
pregnancy  The fibroid suddenly enlarges & is
painful and tender  The pain is ischaemic
,constant, and localised to one side of the uterus
but sometimes diffuse. Mild pyrexia leucocytosis.
USS may be helpful  Treatment is
conservative
 Third Trimester

14. 17. Fetal movements & Braxton-Hicks
contractions  These are spontaneous
uterine contractions becoming more
frequent as pregnanc. advances.

15. Initially painless but then perceived as
vague backache which is minimally
uncomfortable but does not need
analgesia, however can be sever requiring
hospital admission commonly in
primigravida.

16. Placental abruption  Presents with
abdominal pain or vaginal bleeding or
without vaginal bleeding  Complicates up
to 1% of pregnancies  Abdominal pain
could be mild constant or intermittent (like
labour pains)
 When no vaginal bleeding, can be
confused with other causes of abdominal
pain.

17.  Sever Pre-eclampsia & eclampsia
  Incidence about 6% among primigravida
about 6% among primigravidae  Pain is mainly
at the epigastrium & Rt upper quadrantquadrant
 It’s due to stretching of the liver capsuleIt’s
secondary to subcapsular haemorrhage  Other
symptoms & signs are often present 
Treatment involves control & delivery.

18.  20. Uterine rupture Unlikely to occur silently
during pregnancy but it can occur in women
with previous classical C/S usually from early
3rdrd trimester. Others occur in labour in women
who had Others c/s or perforated uterus during
D/C  The abdominal pain typically acute,
 , associated with shock & shoulder tip pain 
Laparotomy is required after resuscitblock.

19.  Pain not directly related to pregnancy
 22. Gastrointestinal TractGastrointestinal Tract
 23. Gastro-esophagealGastro-esophageal refluxreflux 
A common cause of upper abdominalA common cause
of upper abdominal pain in pregnancy. Incidence 60-
70%pain in pregnancy. Incidence 60-70%  More
common in late pregnancyMore common in late
pregnancy multiple pregnancy & polyhydramniosmultiple
pregnancy & polyhydramnios  Felt as burning
sensation inFelt as burning sensation in epigastrium &
behind the sternumepigastrium & behind the sternum 
Caused by relaxation of gastro-Caused by relaxation of
gastro- esophageal sphincteresophageal sphincter

20.  Peptic ulcerPeptic ulcer  Uncommon during
pregnancyUncommon during pregnancy  Usually there
is a pre-existing historyUsually there is a pre-existing
history  Pain typically in the epigasric & RtPain typically
in the epigasric & Rt hypochodrium worse with hunger &
spicyhypochodrium worse with hunger & spicy foodfood
 Perforation is rare but may occur especiallyPerforation
is rare but may occur especially after delivery. Presents
with acute painafter delivery. Presents with acute pain
,collapse & peritonitis,collapse & peritonitis  Gas under
diaphragm on erect x-ray abdomGas under diaphragm
on erect x-ray abdom

21.  . Hiatus herniaHiatus hernia  Incidence 7-22% of all
pregnanciesIncidence 7-22% of all pregnancies  Present in 62% of
cases of severPresent in 62% of cases of sever heartburn in the
3heartburn in the 3rdrd trimestertrimester  Very severe cases
present with severVery severe cases present with sever vomiting &
haematemesisvomiting & haematemesis  Treatment as for reflux
esophagitisTreatment as for reflux esophagitis
 26. constipationconstipation  May present as sever or chronicMay
present as sever or chronic abdominal painabdominal pain 
Caused by slow peristalsisCaused by slow peristalsis (progeterone
effect)(progeterone effect)  Felt as dull, constant & sometimesFelt
as dull, constant & sometimes colicky pain in the iliac fossae
(Ltcolicky pain in the iliac fossae (Lt  Treatment with high fibre diet
&Treatment with high fibre diet & laxativeslaxatives

22.  27. Acute appendicitisAcute appendicitis 
Complicates 1 in 1500-2500Complicates 1 in
1500-2500 pregnancies (as in non-
pregnants)pregnancies (as in non-pregnants) 
Symptoms & signs may be atypical.Symptoms &
signs may be atypical.  Pain may be in the Rt
lumber region inPain may be in the Rt lumber
region in early gestation or in the Rtearly
gestation or in the Rt hypochondrium in late
pregnancy duehypochondrium in late pregnancy
due to displacement of caecum & appedixto
displacement of caecum & appedix by the gravid
uterusby the gravid uterus

23.  The pain in early pregnancy startsThe pain in early pregnancy starts around the umbilicus then
settles inaround the umbilicus then settles in the RIFthe RIF  Accompanied by nausea,
vomitingAccompanied by nausea, vomiting anorexia & fever however, theseanorexia & fever
however, these symptoms may be absent in latesymptoms may be absent in late
pregnancypregnancy
 29.  Leucocytosis is an important sign butLeucocytosis is an important sign but due to
physiological leucocytosis indue to physiological leucocytosis in pregnancy, serial count is more
usefulpregnancy, serial count is more useful  Pyrexia, tenderness & guarding overPyrexia,
tenderness & guarding over the Rt abdomen may be the only signsthe Rt abdomen may be the
only signs presentpresent  The inflammed appendix may induceThe inflammed appendix may
induce preterm labourpreterm labour
 30. Treatment of acute appendicitisTreatment of acute appendicitis  In early pregnancy
laparoscopicIn early pregnancy laparoscopic appendectomy can be done or
throughappendectomy can be done or through the classical McBurney incisionthe classical
McBurney incision  If laparotomy is necessary, a para-If laparotomy is necessary, a para-
median incision over the area of maxmedian incision over the area of max tenderness allows the
best access iftenderness allows the best access if extension is neededextension is needed
 31. Complications of appendicitis inComplications of appendicitis in pregnancypregnancy 
RuptureRupture  Peritonitis: organ displacementPeritonitis: organ displacement prevents
walling- off of the inflammedprevents walling- off of the inflammed appendixappendix  PROM &
preterm labourPROM & preterm labour

24.  . Bowel obstructionBowel obstruction  Is a rare cause of acute abdominalIs
a rare cause of acute abdominal pain in pregnancy (1 in 2500-3500 )pain in
pregnancy (1 in 2500-3500 )  Incidence appears to be increasingIncidence
appears to be increasing due to increased abdomino –pelvicdue to
increased abdomino –pelvic surgery causing adhesion bandssurgery
causing adhesion bands  Rarely caused by strangulated femoralRarely
caused by strangulated femoral or inguinal herniae & volvulus.or inguinal
herniae & volvulus.
 33. Bowel obstruction ..contBowel obstruction ..cont  The pain is colicky
with exaggerated bowelThe pain is colicky with exaggerated bowel sounds
& constipation. Abdominalsounds & constipation. Abdominal distension may
be difficult to detect indistension may be difficult to detect in advanced
pregnancyadvanced pregnancy  Treatment is conservative with N/S
tubing,Treatment is conservative with N/S tubing, fluid & electrolyte
replacementfluid & electrolyte replacement it usually settle within few hours
otherwiseit usually settle within few hours otherwise laparotomy is required
to divide adhesionslaparotomy is required to divide adhesions

25.  . Gallstones &Gallstones & cholecystitischolecystitis  Pregnancy predisposes to gallstonesPregnancy predisposes to gallstones due to
biliary stasis and raiseddue to biliary stasis and raised cholesterol in pregnancycholesterol in pregnancy  Incidence about 3.5%Incidence
about 3.5%  Most women are asymptomaticMost women are asymptomatic  Symptomatic Pt’s present with suddenSymptomatic Pt’s
present with sudden onset of colicky abdominal painonset of colicky abdominal pain radiating to the back in Rt hypochodriuradiating to the
back in Rt hypochodriu
 35. Gallbladder ..contGallbladder ..cont  Nausea, vomiting & vasovagal attacksNausea, vomiting & vasovagal attacks  Tenderness &
positive murphy’s signTenderness & positive murphy’s sign may be the only positive clinical signsmay be the only positive clinical signs 
Diagnosis can be made by ultrasoundDiagnosis can be made by ultrasound  Treatment is coservativeTreatment is coservative 
Surgery can be performed in earlySurgery can be performed in early pregnancy laparoscopicallypregnancy laparoscopically
 36. Gallbladder..contGallbladder..cont  Open surgery can be done inOpen surgery can be done in advanced pregnancy but risks
areadvanced pregnancy but risks are ascending cholangitis which may leadascending cholangitis which may lead to septicaemia &
preterm labourto septicaemia & preterm labour
 37. Gallbladder..contGallbladder..cont  Acute cholecystitis is uncommon inAcute cholecystitis is uncommon in pregnancypregnancy 
Presents with acute Rt hypochonderialPresents with acute Rt hypochonderial pain, nausea, vomiting & pyrexiapain, nausea, vomiting &
pyrexia  Pyrexia differentiating it from gallstonePyrexia differentiating it from gallstone  Incidence 1 in 1000 pregnanciesIncidence 1 in
1000 pregnancies  Treatment with antibiotics & analgesiaTreatment with antibiotics & analgesia
 38. pancreatitispancreatitis  Uncommon in pregnancy (1 in 5000)Uncommon in pregnancy (1 in 5000)  More common in pregnants
than nonMore common in pregnants than non  High mortality rate (>10%)High mortality rate (>10%)  Presents with central or
upperPresents with central or upper abdominal pain radiating to the backabdominal pain radiating to the back  There may be nausea,
vomiting &There may be nausea, vomiting & shock. Few with juandice when thereshock. Few with juandice when there is obstructed
biliary systemis obstructed biliary system
 39. Pancreatitis.. contPancreatitis.. cont  Diagnosis confirmed by raised serumDiagnosis confirmed by raised serum amylaseamylase 
Ultrasound shows gallstones in 50% ofUltrasound shows gallstones in 50% of casescases  Treatment is conservative with iv
fluidTreatment is conservative with iv fluid & electrolyte replacement, pethidine,& electrolyte replacement, pethidine, steroids, antibiotics
cimitidine &steroids, antibiotics cimitidine & glucgoneglucgone
 40. Renal tractRenal tract
 41. Acute pyelonephritisAcute pyelonephritis  Is the most common renal cause ofIs the most common renal cause of abdominal pain in
pregnancy (1-2%)abdominal pain in pregnancy (1-2%)  Most cases present in the 2Most cases present in the 2ndnd & 3& 3rdrd
trimesters with sever abdominal paintrimesters with sever abdominal pain in the lumbar region radiating to thein the lumbar region
radiating to the iliac fossa or vulvailiac fossa or vulva  Nausea, vomiting, pyrexia, rigors &Nausea, vomiting, pyrexia, rigors & tachycardia
with loin tendernesstachycardia with loin tenderness

26.  . Pyelonephritis..contPyelonephritis..cont  Associated with increased risk ofAssociated with increased risk of preterm labourpreterm labour  Diagnosis by MSU for R/E
& C/SDiagnosis by MSU for R/E & C/S  E. Coli is the most common causeE. Coli is the most common cause  If recurrent exclude renal anomaliesIf recurrent exclude
renal anomalies USS during preg. Or IVP 3-4 monthsUSS during preg. Or IVP 3-4 months after delivery.after delivery.
 43. Renal stonesRenal stones  Affects 0.03-0.05% of pregnant women (asAffects 0.03-0.05% of pregnant women (as in non-pregnants)in non-pregnants)  Pregnancy
does not predispose to stonePregnancy does not predispose to stone formation . In fact small stones may passedformation . In fact small stones may passed unnoticed
due to ureteric dilatationunnoticed due to ureteric dilatation  Presents with loin pain radiating to thePresents with loin pain radiating to the suprapubic region the pain may
besuprapubic region the pain may be excruciating & associated with shockexcruciating & associated with shock
 44. Renal stones...contRenal stones...cont  Renal tenderness may be the only clinicalRenal tenderness may be the only clinical sign USS may show dilated renal tract or
asign USS may show dilated renal tract or a stonestone  Treatment mostly conservative with potentTreatment mostly conservative with potent analgesic & liberal fluid
intakeanalgesic & liberal fluid intake  If obstruction persist surgery is indicatedIf obstruction persist surgery is indicated  There is a risk of precipitating pretermThere is
a risk of precipitating preterm labourlabour
 45. Acute retention of urineAcute retention of urine  More likely to occur in the 1More likely to occur in the 1stst trimestertrimester and in the puerperium.and in the
puerperium.  Causes include:Causes include: - incarcerated R/v gravid uterus- incarcerated R/v gravid uterus - pelvic mass (ovarian or fibroid)- pelvic mass (ovarian or
fibroid) - acute herpes infection- acute herpes infection - vulval haematoma- vulval haematoma
 46. Urine retention..contUrine retention..cont  Presents with sudden onset of severPresents with sudden onset of sever pain with distended bladder on exampain with
distended bladder on exam  Catherterization for 24-48hrs &Catherterization for 24-48hrs & analgesia are very helpful and allowanalgesia are very helpful and allow the
gravid uterus to becomethe gravid uterus to become abdominalabdominal
 47. Adenxal accidentsAdenxal accidents  Corpus luteum cyst in early pregnancy mayCorpus luteum cyst in early pregnancy may bleed causing pain or rupture causing
shockbleed causing pain or rupture causing shock  Mostly diagnosed by USS or bimanually ifMostly diagnosed by USS or bimanually if they are largethey are large 
Managed mostly conservatively but if theyManaged mostly conservatively but if they are large or showing abnormal pathologyare large or showing abnormal pathology
they should be removed after 14 wksthey should be removed after 14 wks
 48. Adenxal accidents..contAdenxal accidents..cont  Torsion of a pre-existing ovarian cystTorsion of a pre-existing ovarian cyst (benign or malignant) presents
with(benign or malignant) presents with intermittent abdominal pain which laterintermittent abdominal pain which later becomes constant (indicatingbecomes constant
(indicating ischaemia). There may be nausea,ischaemia). There may be nausea, vomiting, low grade fever andvomiting, low grade fever and leucocytosis .If ignored the
ovary mayleucocytosis .If ignored the ovary may become gangrenousbecome gangrenous
 49. Adnexal accidents..contAdnexal accidents..cont  Laparotomy with oophorectomy orLaparotomy with oophorectomy or fixing the ovary if viablefixing the ovary if viable
 Torsion of a pedunculated fibroid mayTorsion of a pedunculated fibroid may present in a similar way to tortedpresent in a similar way to torted ovarian cyst. They need to
beovarian cyst. They need to be removed at laparotomy. Don’t try toremoved at laparotomy. Don’t try to remove subserous, intramural fibroidremove subserous, intramural
fibroid as it may end by hysterectomyas it may end by hysterectomy
 50. Miscellaneous causeMiscellaneous cause  Musculoskeletal :Musculoskeletal : - exaggerated lumbar lordosis- exaggerated lumbar lordosis - sumphyseal diasthesis-
sumphyseal diasthesis * sickle cell crisis* sickle cell crisis * rectus sheath haematoma* rectus sheath haematoma * porphyria* porphyria * Aortic aneurysm* Aortic
aneurysm
 Recommended
 Strategic Planning Fundamentals

 Time Management Fundamentals

27. Renal DisordersRenal Disorders
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.

28. DiagnosisDiagnosis
 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

29. ManagementManagement
 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.

30. Risks: pyelonephritis, preterm
birth, low birth weight, increased
perinatal mortality

31. Acute CystitisAcute Cystitis
Acute cystitis:-inflammation of the
bladder {bacterial or nonbacterial
causes (eg, radiation or viral
infection)}.
Cystitis complicates 1% of pregnancies
Clinical features:- Urinary frequency,
dysuria, haemeturia and suprapubic
pain
 Diagnosis Significant bacteriuria on
MSU

32. Acute CystitisAcute Cystitis
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

33. Acute PyelonephritisAcute Pyelonephritis
Incidence :-
 This complicates 1-2% of
pregnancies More common in
pregnancy ( physiological dilatation of
the upper renal tract).

34.  Epidemiology:-
 UTIs in women: 14 times more frequent
than in men.
 1. The urethra is shorter
 2. lower 1/3 of the urethra is continually
contaminated with pathogens from the
vagina and the rectum
 3. Women tend not to empty their bladders
as completely as men do
 4. Urogenital system is exposed to bacteria
during intercourse .

35.  Hormonal and mechanical changes:-
 urinary stasis and vesicoureteral reflux urinary
stasis {progesterone-induced ureteral smooth
muscle relaxation}.
 urinary retention {weight of the enlarging uterus}
 Loss of ureteral tone combined with increased
urinary tract volume.
 urinary stasis: dilatation of the ureters, renal
pelvis, and calyces. more common on right side
(86% of cases)
 Glycosuria and aminoaciduria.

36.  Etiology :-
 E coli : most common cause of UTI, 80-
90% originates from fecal flora colonizing
the periurethral area: ascending infection.
 Other pathogens: Klebsiella pneumoniae
(5%) Proteus mirabilis (5%) Enterobacter
species (3%) Staphylococcus saprophyticus
(2%) Group B beta-hemolytic Streptococcus
(GBS; 1%) Proteus species (2%)

37. Acute PyelonephritisAcute Pyelonephritis
Clinical Features :- Fever, Loin and
abdominal pain, Vomiting, Rigors
Proteinuria, Haematuria.
Risk increases in women:-
 On steroid therapy
 With polycystic kidneys
 Congenital abnormalities of renal
tract
 Urinary-tract calculi
 Diabetes

38. Acute PyelonephritisAcute Pyelonephritis
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

39. Complications :-
 IUGR
 Preeclampsia
 preterm delivery.
 acute cystitis
 maternal anemia, and amnionitis.

40. Other complications:
 1. Perinephric cellulitis and abscess, Septic
shock (rare)
 2. Renal dysfunction.
 4. Pulmonary injury: 2% Endotoxins that
alter alveolar-capillary membrane
permeability are produced; subsequently,
pulmonary edema and acute respiratory
distress syndrome develop.

41. Acute PyelonephritisAcute Pyelonephritis
Management:-
 Should be after hospitalization
 I/V Antibiotic Penicillin and
cephalosporin are the Ist choice.

42. Chronic Renal DiseaseChronic Renal Disease
 Pregnancy with Chronic Renal Disease
 Effects of Pregnancy The risks include:
  Accelerated decline in renal function
  Rising hypertension
  Worsening proteinuria
 Effects of chronic renal disease on
pregnancy The risks includes:
  Miscarriage
  Pre-eclampsia
  Intrauterine growth retardation
  Preterm delivery  Fetal death

43. Chronic Renal DiseaseChronic Renal Disease
Factors Influencing Outcome
 The presence and degree of renal
impairment
 The presence and severity of
proteinuria
 The underlying type of chronic renal
disease

44. Chronic Renal DiseaseChronic Renal Disease
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)

45. Chronic Renal DiseaseChronic Renal Disease
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.

46. Specific Types of RenalSpecific Types of Renal
DiseaseDisease

 Glomerulonephritis
 Reflux nephropathy
 Diabetic nephropathy
 SLE nephritis
 Polycystic kidney
disease (PKD)

47. Chronic Renal DiseaseChronic Renal Disease
 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.

48. Specific Types of Renal DiseaseSpecific Types of Renal Disease
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.

49. Acute Renal FailureAcute Renal Failure
Incidence :-
Rare in pregnancy <0.005%
Clinical Features    Anuria/oliguria
urea, creatinine rises Decreased GFR
Causes
Infection    Septic abortion Puerperal
sepsis Rarely acute pyelonephritis Blood
Loss   Postpartum hemorrhage
Abruption

50. Acute Renal FailureAcute Renal Failure
 Causes
 Infection :- Septic abortion Puerperal sepsis
Rarely acute pyelonephritis
 Blood Loss:- Postpartum hemorrhage. Abruption
 Volume Contraction
 Pre-eclampsia
 Eclampsia (6%)
 Hypermesis gravidarum
 Post-renal Failure  Ureteric damage or
obstruction
 HELLP Syndrome 7% have actual renal failure
 Thrombotic thrombocytopenic purura/hemolytic
uraemic syndrome (TTP/HUS)

51. Idiopathic postpartum renalIdiopathic postpartum renal
failurefailure
 Associated primarily withAssociated primarily with
microangiopathic processesmicroangiopathic processes
 Postpartum hemolytic-uremic syndrome.Postpartum hemolytic-uremic syndrome.
 These were often irreversible and wereThese were often irreversible and were
associated with substantial mortality.associated with substantial mortality.
 Now improved outcome with plasmaNow improved outcome with plasma
exchange,dialysis,prostacyclin infusion,exchange,dialysis,prostacyclin infusion,
correcting coagulopathycorrecting coagulopathy
5151Dr Mona ShroffDr Mona Shroff

52. DialysisDialysis
 pregnancy on dialysis is unusual: end-stagepregnancy on dialysis is unusual: end-stage
renal failure reduces fertility.renal failure reduces fertility.
 Patients on dialysis should be advised not toPatients on dialysis should be advised not to
get pregnant.get pregnant.
 Common risks: anaemia and haemorrhage.Common risks: anaemia and haemorrhage.
 Increased risks of:Increased risks of:
miscarriage, fetal death, pre-eclampsia, pre-miscarriage, fetal death, pre-eclampsia, pre-
term labour, PROM, polyhydramnios andterm labour, PROM, polyhydramnios and
placental abruption.placental abruption.
 Pregnant women require increasing dialysis toPregnant women require increasing dialysis to
maintain the pre-dialysis urea < 15-20 mmol/l.maintain the pre-dialysis urea < 15-20 mmol/l.
 Poor obstetric outcome is similar with bothPoor obstetric outcome is similar with both
haemodialysis and peritoneal dialysis.haemodialysis and peritoneal dialysis.

53. Indications for KidneyIndications for Kidney
Replacement TherapyReplacement Therapy
 Acidosis unresponsive to medical therapyAcidosis unresponsive to medical therapy
 Acute, severe, refractory electrolyteAcute, severe, refractory electrolyte
changes (e.g., hyperkalemia)changes (e.g., hyperkalemia)
 EncephalopathyEncephalopathy
 Significant azotemia (blood urea nitrogenSignificant azotemia (blood urea nitrogen
level >100 mg per dL [36 mmol per L])level >100 mg per dL [36 mmol per L])
 Significant bleedingSignificant bleeding
 Uremic pericarditisUremic pericarditis
 Volume overloadVolume overload
5353Dr Mona ShroffDr Mona Shroff

54. Hemodialysis Vs PeritonealHemodialysis Vs Peritoneal
dialysisdialysis
 Limited usefulnessLimited usefulness
if hypotensionif hypotension
 C/I in activelyC/I in actively
bleeding pt.bleeding pt.
 ControlledControlled
anticoagulation reqdanticoagulation reqd
 Volume shifts-Volume shifts-
carefulcareful
 Faster correctionFaster correction
 Can be used inCan be used in
preg/PP pt.preg/PP pt.
 Easily availableEasily available
 Simple,inexpensiveSimple,inexpensive
 Lower Cx rateLower Cx rate
 Minimises rapidMinimises rapid
metabolicmetabolic
pertubations & fluidpertubations & fluid
shiftsshifts
 Insert cath highInsert cath high
direct visiondirect vision
5454Dr Mona ShroffDr Mona Shroff

55. Pregnancy in Renal TransplantPregnancy in Renal Transplant
RecipientsRecipients
 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.

56. Guidelines for pregnancy in kidney:-
transplant recipient
 Two years post-transplant, with good
general health and serum creatinine less
than 2.0 mg/dL (preferably <1.5 mg/dL(.
No recent or ongoing rejection .
  Normotension, or minimal
antihypertensives
 Absent or minimal proteinuria.
  No evidence of pelvicalyceal dilation on
renal ultrasonogram

57. Immunosuppression
 Prednisone - Less than 15 mg per day
 Azathioprine - Less than or equal to 2
mg/kg/d
 Calcineurin inhibitor–based therapy -
Therapeutic levels
 Mycophenolate mofetil and sirolimus -
Discontinue 6 weeks prior to conception

58. Pregnancy in Renal TransplantPregnancy in Renal Transplant
RecipientsRecipients
 Complication Risks Immunosuppressive agents
increase the risk of hypertension during pregnancy.
Preeclampsia occurs in approximately one-third of
transplant recipients.
 Almost 50% of pregnancies in these women end in
preterm delivery due to hypertension
 Blood levels of calcineurin inhibitors need to be
frequently monitored due to changes in volumes of
distribution of extracellular volume.
 There is an increased risk of infection included
cytomegalovirus, toxoplasmosis, and herpes
infections, and bacterial infection which arouse
concern for the fetus.

59. Pregnancy in Renal TransplantPregnancy in Renal Transplant
RecipientsRecipients
 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.
 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.

60. Pregnancy in Renal TransplantPregnancy in Renal Transplant
RecipientsRecipients
Recommended :-
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,

61. Pregnancy in Renal TransplantPregnancy in Renal Transplant
RecipientsRecipients
as well as serum creatinine and urea
is essential.
a full blood count, 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.

62. Pregnancy in Renal TransplantPregnancy in Renal Transplant
RecipientsRecipients
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

63. Pregnancy in Renal TransplantPregnancy in Renal Transplant
RecipientsRecipients
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.

64. Pregnancy in Renal TransplantPregnancy in Renal Transplant
RecipientsRecipients
Neonatal Problems These are largely
related to prematurely but also
include the following:
 Thymic atrophy
 Transient leukopenia or
thrombocytopenia
 Depressed haemopoiesis

65. THANKTHANK
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