Renal Disorders in Renal Disorders in PregnancyPregnancy

DR. Shamsa TariqDR. Shamsa Tariq

Associate Professor RMCAssociate Professor RMC

Physiological AdaptationPhysiological Adaptation Dramatic dilatation of the urinary collecting system Dramatic dilatation of the urinary collecting system

during pregnancy.during pregnancy. Renal plasma flow rises by 60-80% by the second Renal plasma flow rises by 60-80% by the second

trimester.trimester. RPF falls throughout the third trimester but maintained at RPF falls throughout the third trimester but maintained at

50% greater than prepregnancy levels.50% greater than prepregnancy levels. GFR increases significantly and creatinine clearance GFR increases significantly and creatinine clearance

rises by 50%.rises by 50%. Fall in Urea and Creatinine levelFall in Urea and Creatinine level Pretein excretion is increased up to 300 mg per 24 Pretein excretion is increased up to 300 mg per 24

hours.hours. 80% of women develop edema due to physiological 80% of women develop edema due to physiological

increase in sodium retention.increase in sodium retention.

Renal DisordersRenal Disorders

Urinary tract infectionUrinary tract infection

Chronic renal diseaseChronic renal disease

Acute renal failureAcute renal failure

Pregnancy in renal transplant recipient Pregnancy in renal transplant recipient

Urinary Tract InfectionUrinary Tract Infection

Asymptomatic bacteriuriaAsymptomatic bacteriuria

Acute cystitisAcute cystitis

Acute pyelonephritisAcute pyelonephritis

Asymptomatic BacteriuriaAsymptomatic Bacteriuria

IncidenceIncidence This ranges from 2 to 10%This ranges from 2 to 10% 40% will develop symptomatic urinary-tract infection in 40% will develop symptomatic urinary-tract infection in

pregnancy.pregnancy. Women with history of previous urinary-tract infection Women with history of previous urinary-tract infection

have a 10-fold increased risk of developing cystitis or have a 10-fold increased risk of developing cystitis or acute pyelonephritis in pregnancy.acute pyelonephritis in pregnancy.

PathogenesisPathogenesis 75-90% due to E coli, probably derived from large bowel75-90% due to E coli, probably derived from large bowel Colonization of urinary tract results from ascending Colonization of urinary tract results from ascending

infection from the perineum and is related to sexual infection from the perineum and is related to sexual intercourseintercourse..

Diagnosis Diagnosis Most women with asymptomatic bacteriuria are found to Most women with asymptomatic bacteriuria are found to

be infected during early pregnancy and very few be infected during early pregnancy and very few subsequently acquire asymptomatic bacteriuriasubsequently acquire asymptomatic bacteriuria

Bacteriuria is only considered significant if the colony Bacteriuria is only considered significant if the colony count exceeds 100,000/ml on a MSUcount exceeds 100,000/ml on a MSU

Management Management

The choice of antibiotic depends on culture/sensitivityThe choice of antibiotic depends on culture/sensitivity Ampicillin, amoxicillin, Augmentin and the cephalosporin Ampicillin, amoxicillin, Augmentin and the cephalosporin

are safe and appropriate antibiotics in pregnancy.are safe and appropriate antibiotics in pregnancy. Treatment should be continued for 2 weeks in the first Treatment should be continued for 2 weeks in the first

instance and regular urinary culture required.instance and regular urinary culture required.

Acute CystitisAcute Cystitis

IncidenceIncidenceCystitis complicates 1% of pregnanciesCystitis complicates 1% of pregnancies

Clinical featuresClinical featuresUrinary frequency, dysuria, haemeturia and Urinary frequency, dysuria, haemeturia and suprapubic painsuprapubic pain

DiagnosisDiagnosisSignificant bacteriuria on MSUSignificant bacteriuria on MSU

ManagementManagement

Same as asymptomatic bacteriuriaSame as asymptomatic bacteriuria

Several non-pharmacological maneuvers may help to Several non-pharmacological maneuvers may help to prevent recurrent infection in women with recurrent prevent recurrent infection in women with recurrent urinary-tract infections in pregnancy. urinary-tract infections in pregnancy.

These include:These include: Increase fluid intakeIncrease fluid intake Emptying the bladder following sexual intercourseEmptying the bladder following sexual intercourse

Acute PyelonephritisAcute PyelonephritisIncidenceIncidence This complicates 1-2% of pregnanciesThis complicates 1-2% of pregnancies More common in pregnancy ( physiological dilatation of the More common in pregnancy ( physiological dilatation of the

upper renal tract).upper renal tract).

Clinical FeaturesClinical Features FeverFever Loin and abdominal painLoin and abdominal pain VomitingVomiting RigorsRigors ProteinuriaProteinuria HaematuriaHaematuria

Risk increases in womenRisk increases in women On steroid therapyOn steroid therapy With polycystic kidneysWith polycystic kidneys Congenital abnormalities of renal tract Congenital abnormalities of renal tract Urinary-tract calculiUrinary-tract calculi DiabetesDiabetes

Diagnosis Diagnosis

Significant bacteriuria on MSU specimen.Significant bacteriuria on MSU specimen.

Differential diagnosis Differential diagnosis PneumoniaPneumonia Viral infectionsViral infections Cholecystitis , biliary colicCholecystitis , biliary colic Acute appendicitisAcute appendicitis Gastroenteritis,Gastroenteritis, Placental abruptionPlacental abruption Degenerating uterine fibroid.Degenerating uterine fibroid.

Blood cultures and a full blood count is Blood cultures and a full blood count is recommendedrecommended

ManagementManagement

Should be after hospitalizationShould be after hospitalization

I/V Antibiotic Penicillin and cephalosporin are the Ist I/V Antibiotic Penicillin and cephalosporin are the Ist choice.choice.

Chronic Renal DiseaseChronic Renal Disease

Pregnancy with Chronic Renal Pregnancy with Chronic Renal Disease Disease

Effects of PregnancyEffects of PregnancyThe risks include:The risks include: Accelerated decline in renal functionAccelerated decline in renal function Rising hypertension Rising hypertension Worsening proteinuria Worsening proteinuria

Effects of chronic renal disease on pregnancyEffects of chronic renal disease on pregnancyThe risks includes:The risks includes: MiscarriageMiscarriage Pre-eclampsiaPre-eclampsia Intrauterine growth retardation Intrauterine growth retardation Preterm delivery Preterm delivery Fetal deathFetal death

Factors Influencing OutcomeFactors Influencing Outcome

The presence and degree of renal impairmentThe presence and degree of renal impairment

The presence and severity of proteinuriaThe presence and severity of proteinuria

The underlying type of chronic renal diseaseThe underlying type of chronic renal disease

Degree of Renal ImpairmentDegree of Renal Impairment

Mild renal impairment (plasma creatinine <125 umol/I)Mild renal impairment (plasma creatinine <125 umol/I)

Moderate renal impairment (plasma creatinine 125-250 Moderate renal impairment (plasma creatinine 125-250 umol/I)umol/I)

Severe renal impairment (plasma creatinine >250 umol/I)Severe renal impairment (plasma creatinine >250 umol/I)

In general, women without hypertension or renal In general, women without hypertension or renal impairment prior to conception have successful impairment prior to conception have successful pregnancies, and pregnancy does not adversely pregnancies, and pregnancy does not adversely influence the progression of the renal disease.influence the progression of the renal disease.

Specific Types of Renal DiseaseSpecific Types of Renal Disease

GlomerulonephritisGlomerulonephritis

Reflux nephropathyReflux nephropathy

Diabetic nephropathyDiabetic nephropathy

SLE nephritisSLE nephritis

Polycystic kidney disease (PKD)Polycystic kidney disease (PKD)

ManagementManagement

Women with chronic renal disease should be managed Women with chronic renal disease should be managed jointly by obstetricians and physiciansjointly by obstetricians and physicians

Preconceptual assessment of renal functions and blood Preconceptual assessment of renal functions and blood pressure should be made.pressure should be made.

In view of the increased risk of pre-eclampsia, treatment In view of the increased risk of pre-eclampsia, treatment with low dose aspirin should be considered especially in with low dose aspirin should be considered especially in those with hypertension, renal impairment or a previous those with hypertension, renal impairment or a previous poor obstetric history.poor obstetric history.

Careful monitoring and control of blood pressure both Careful monitoring and control of blood pressure both prepregnancy and antenatally is important.prepregnancy and antenatally is important.

The fetus should be monitored with regular ultrasound The fetus should be monitored with regular ultrasound assessment of growth and Doppler assessment of assessment of growth and Doppler assessment of uterine and umbilical circulation.uterine and umbilical circulation.

Admission should be considered if the woman develops Admission should be considered if the woman develops worsening hypertension, deteriorating renal function or worsening hypertension, deteriorating renal function or proteinuria, or superimposed eclampsia. proteinuria, or superimposed eclampsia.

Acute Renal Failure Acute Renal Failure

Incidence Incidence Rare in pregnancy <0.005%Rare in pregnancy <0.005%

Clinical FeaturesClinical Features Anuria/oliguriaAnuria/oliguria urea, creatinine risesurea, creatinine rises Decreased GFRDecreased GFR

Causes Causes

Infection Infection Septic abortionSeptic abortion Puerperal sepsisPuerperal sepsis Rarely acute pyelonephritisRarely acute pyelonephritis

Blood LossBlood Loss Postpartum hemorrhagePostpartum hemorrhage Abruption Abruption

Volume ContractionVolume Contraction Pre-eclampsiaPre-eclampsia Eclampsia (6%)Eclampsia (6%) Hypermesis gravidarumHypermesis gravidarum

Post-renal FailurePost-renal Failure Ureteric damage or obstructionUreteric damage or obstruction

Pre-eclampsiaPre-eclampsia

HELLP SyndromeHELLP Syndrome 7% have actual renal failure7% have actual renal failure Thrombotic thrombocytopenic Thrombotic thrombocytopenic purura/hemolytic purura/hemolytic

uraemic syndrome (TTP/HUS)uraemic syndrome (TTP/HUS)

ManagementManagement This depend on underlying causeThis depend on underlying cause

Pregnancy in Renal Pregnancy in Renal Transplant Transplant RecipientsRecipients

Women receiving renal transplants should be warned Women receiving renal transplants should be warned that as renal function returns to normal, ovulation, that as renal function returns to normal, ovulation, menstruation and fertility also resume.menstruation and fertility also resume.

Women desiring pregnancy are usually advised to wait Women desiring pregnancy are usually advised to wait about 1-2 years after transplantation.about 1-2 years after transplantation.

Effects of pregnancy on renal transplantsEffects of pregnancy on renal transplants Pregnancy probably has no adverse long-term effectPregnancy probably has no adverse long-term effect Renal allograft adapt to pregnancyRenal allograft adapt to pregnancy About 15% of women develop significant impairmentAbout 15% of women develop significant impairment About 40% develop proteinuria towards termAbout 40% develop proteinuria towards term

Effect of renal transplants on pregnancyEffect of renal transplants on pregnancy The chance of successful outcome is >90%, but this is The chance of successful outcome is >90%, but this is

reduced to 70% if complications occur before 28 weeks’ reduced to 70% if complications occur before 28 weeks’ gestation.gestation.

The complication rate is higher for diabetics.The complication rate is higher for diabetics.

Antenatal ManagementAntenatal Management Women should be managed jointly by nephrologists and Women should be managed jointly by nephrologists and

obstetricians with expertise in the care of pregnant renal obstetricians with expertise in the care of pregnant renal transplant recipients.transplant recipients.

Careful monitoring and control of blood pressure is Careful monitoring and control of blood pressure is important.important.

Regular assessment of RFTs by creatinine clearance Regular assessment of RFTs by creatinine clearance and 24 hour protein excretion, as well as serum and 24 hour protein excretion, as well as serum creatinine and urea is essential.creatinine and urea is essential.

A FBC and LFTs should also be checked regularly. A FBC and LFTs should also be checked regularly. Anemia is common and haematinics should be Anemia is common and haematinics should be prescribed.prescribed.

The fetus should be monitored with regular ultrasound The fetus should be monitored with regular ultrasound assessment of growth and Doppler assessment of assessment of growth and Doppler assessment of uterine Sand umbilical circulation.uterine Sand umbilical circulation.

Immunosuppressive TherapyImmunosuppressive Therapy

The doses of immunosuppressive drugs are maintained The doses of immunosuppressive drugs are maintained at prepregnancyat prepregnancy

Levels which should preferably be:Levels which should preferably be:

Prednisolone, <15 mg/day plus eitherPrednisolone, <15 mg/day plus either

Azathioprine, <2 mg/kg/dayAzathioprine, <2 mg/kg/day

Cyclosporin A, 2-4 mg/kg/dayCyclosporin A, 2-4 mg/kg/day

Delivery Delivery

Caesarean section is only required for obstetric Caesarean section is only required for obstetric indications.indications.

Prophylactic antibiotics should be given to cover any Prophylactic antibiotics should be given to cover any surgical procedure including episiotomy.surgical procedure including episiotomy.

Parental steroids are necessary to cover labour, as with Parental steroids are necessary to cover labour, as with any woman on maintenance steroids.any woman on maintenance steroids.

Neonatal Problems Neonatal Problems

These are largely related to prematurely but also include These are largely related to prematurely but also include the following:the following:

Thymic atrophyThymic atrophy Transient leukopenia or thrombocytopeniaTransient leukopenia or thrombocytopenia Depressed haemopoiesisDepressed haemopoiesis