Renal disorders in pregnancy can range from asymptomatic bacteriuria to end-stage renal disease requiring dialysis, all being influenced by the physiologic changes of pregnancy. Women who have mild to moderate renal disease or a renal transplant are now challenging obstetricians and nephrologists with pregnancy.

1. RENAL DISORDERS IN
PREGNANCY
Dr Niranjan Chavan
Professor & Head Of Unit
Dept. of OBGYN,
Lokmanya Tilak Medical College & General Hospital,
Sion, Mumbai -22

3. 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 pre pregnancy levels.
• GFR increases significantly and creatinine clearance rises by
50%.

4. • Fall in Urea and Creatinine level
• Protein excretion is increased up to 300 mg per 24 hours.
• 80% of women develop oedema due to physiological increase
in sodium retention.

5. RENAL DISORDERS
• Urinary tract infection
• Chronic renal disease
• Acute renal failure
• Pregnancy in renal transplant
recipient

6. URINARY TRACT INFECTION
• Asymptomatic bacteriuria
• Acute cystitis
• Acute pyelonephritis

7. 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

8. 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.

9. 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

10. 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.

11. ACUTE CYSTITIS
Incidence
• Cystitis complicates 1% of
pregnancies
Clinical features
• Urinary frequency, dysuria,
haemeturia and suprapubic
pain
Diagnosis
• Significant bacteriuria on MSU

12. 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

13. 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

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

15. 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

16. MANAGEMENT
• Should be after hospitalization
• I/V Antibiotic Penicillin and cephalosporin are the Ist choice.

17. CHRONIC RENAL DISEASE

18. PREGNANCY WITH
CHRONIC RENAL DISEASE
Effects of Pregnancy
The risks include:
• Accelerated decline in renal
function
• Rising hypertension
• Worsening proteinuria

19. Effects of chronic renal disease on pregnancy
The risks includes:
• Miscarriage
• Pre -eclampsia
• Intrauterine growth retardation
• Preterm delivery
• Foetal death

20. FACTORS INFLUENCING OUTCOME
• The presence and degree of renal impairment
• The presence and severity of proteinuria
• The underlying type of chronic renal disease

21. 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)

22. • 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.

23. SPECIFIC TYPES OF RENAL DISEASE
• Glomerulonephritis
• Reflux nephropathy
• Diabetic nephropathy
• SLE nephritis
• Polycystic kidney disease (PKD)

24. MANAGEMENT
• Women with chronic renal disease should be managed jointly
by obstetricians and physicians
• Preconceptional assessment of renal functions and blood
pressure should be made.

25. MANAGEMENT
• 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 pre
pregnancy and antenatally is important.

26. • The foetus 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.

27. ACUTE RENAL FAILURE

28. Incidence
• Rare in pregnancy <0.005%
Clinical Features
• Anuria/ oliguria
• Urea, Creatinine rises
• Decreased GFR

29. CAUSES
Infection
• Septic abortion
• Puerperal sepsis
• Rarely acute
pyelonephritis
Blood Loss
• Postpartum
haemorrhage
• Abruption

30. Volume Contraction
• Pre -eclampsia
• Eclampsia (6%)
• Hypermesis gravidarum
Post-renal Failure
• Ureteric damage or obstruction
Pre- eclampsia

31. HELLP Syndrome
• 7% have actual renal failure
• Thrombotic thrombocytopenic purura/ haemolytic uremic
syndrome (TTP/HUS)
Management
• This depend on underlying cause

32. PREGNANCY IN RENAL
TRANSPLANT RECIPIENTS

33. • 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.

34. 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

35. 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

36. 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.

37. • A FBC and LFTs should also be checked regularly.
• Anaemia is common and haematinics should be prescribed.
• The foetus should be monitored with regular ultrasound
assessment of growth and Doppler assessment of uterine and
umbilical circulation.

38. IMMUNOSUPPRESSIVE THERAPY
The doses of immunosuppressive drugs are maintained at pre
pregnancy levels which should preferably be:
• Prednisolone, <15 mg/day plus either
• Azathioprine, <2 mg/kg/day
• Cyclosporin A, 2-4 mg/kg/day

39. 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.

40. NEONATAL PROBLEMS
These are largely related to prematurely but also include the
following:
• Thymic atrophy
• Transient leukopenia or thrombocytopenia
• Depressed haemopoiesis

41. TAKE HOME MESSAGE
• Exacerbations of pre existing kidney disease or an incident
diagnosis of nephropathy during pregnancy are relatively
common.
• It is important to be familiar with the diagnoses and
management of kidney disorders during pregnancy.
• Close monitoring and awareness of possible complications
will allow for earlier intervention with the aim of improving
maternal and foetal outcomes.

42. THANK YOU