The document discusses physiological adaptations and renal disorders that can occur during pregnancy. The kidneys undergo dramatic changes during pregnancy with increases in renal plasma flow, GFR, and creatinine clearance. Asymptomatic bacteriuria occurs in 2-10% of pregnancies and can lead to urinary tract infections. Acute cystitis and pyelonephritis are also discussed. Chronic renal disease can impact both mother and fetus, with risks including preeclampsia and growth restriction. Management involves treatment of infections, blood pressure control, and dialysis if needed to preserve renal function and optimize outcomes.

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. Renal Disorders
 Urinary tract infection:
 1.Asymptomatic Bacteriuria
2. Acute cystitis.
3.Acute pyelonephritis
 Chronic renal disease

4. 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.

5. 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

6. 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.

7. Acute Cystitis:-
Incidence
Cystitis complicates 1% of pregnancies
Clinical features
Urinary frequency, dysuria, haemeturia and
suprapubic pain
Diagnosis
Significant bacteriuria on MSU

8. 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

9. 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

10. Risk increases in women
 On steroid therapy
 With polycystic kidneys
 Congenital abnormalities of renal tract
 Urinary-tract calculi
 Diabetes

11. .
Differential diagnosis:-
 Pneumonia
 Viral infections
 Cholecystitis , biliary colic
 Acute appendicitis
 Gastroenteritis

12. Management:-
Intravenous fluid for adequate hydration
(crystalloids).
 I/V Antibiotic Penicillin and cephalosporin are the Ist
choice.
 Evaluate hemogram, serum electrolytes, creatinine
 Antimicrobial supression therapy is continued till the
end of pregnancy to prevent recurrence.
Nitrofurantoin 100 mg daily at bed time is effective.

13. Chronic Renal Disease

14. Pregnancy with Chronic Renal Disease :-
Effects of Pregnancy
The risks include:
 Accelerated decline in renal function
 Rising hypertension
 Worsening proteinuria

15. Effects of chronic renal disease on pregnancy
The risks includes:
 Miscarriage
 Pre-eclampsia
 Intrauterine growth retardation
 Preterm delivery
 Fetal death

16. Factors Influencing Outcome:-
 The presence and degree of renal impairment
 The presence and severity of proteinuria
 The underlying type of chronic renal disease

17. 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)

18. Specific Types of Renal Disease:-
 Glomerulonephritis
 Reflux nephropathy
 Diabetic nephropathy
 SLE nephritis
 Polycystic kidney disease (PKD)

19. Management :-
 24 hours urine collection is done for creatinine clearance
and total proteinuria.
 Antihypertensive drugs is started
early(Nifedipine,hydralzine) to preserve renal function.
 Diuretics may be used in cases of severe edema.
 Regular hemodialysis during pregnancy in patient with
moderate renal compromise may improve the outcome.