Renal Disorder in Pregnancy

RENAL DISORDER IN
PREGNANCY
• Renal disease can affect the outcome of
pregnancy, pregnancy can affect the progression
of pre-existing renal disease, and pregnancy can
itself cause renal impairment. The renal system
undergoes significant physiological and
anatomical changes during a normal pregnancy.
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 the prepregnancy levels.
GFR increase significantly and creatinine clearance rises by 50%.
Fall in Urea and Creatinine level.
Protein excretion is increased up to 300 mg per 24 hours.
80% of women edema due to physiological increase in sodium
retention.
Renal Disorders
Urinary Tract Infection
Chronic Renal Disease
Acute Renal Failure
Pregnancy in renal transplant recipient
Urinary Tract Infection
Asymptomatic bacteriuria
Acute cystitis
Acute pyelonepritis
Asymptomatic Bacteriuria
Incidence
This ranges from 2 to 10%
40% will develop symptomatic urinary-tract
infection have a 10-fold increased risk of developing
cystitis or acute pyelonephritis in pregnancy.
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 symptomatic 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 (midstream urine)
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 for2 weeks in the first
instance and regular urinary culture required.
Acute Cystitis
Incidence
Cystitis complicate 1% of pregnancies
Clinical Features
Urinary frequency, dysuria, hematuria, and suprapubic pain
Diagnosis
Significant bacteria on MSU
Management
Same as asymptomatic bacteriuria
Several non-pharmacologic maneuvers may help prevent
recurrent infection in women with recurrent urinary-tract
infections in pregnancy.
These include:
Increase fluid intake
Emptying the bladder following sexual intercourse
Incidence Acute Pyelonephritis
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
Hematuria
Risk increases in women
On steroid therapy
With polycystic kidneys
Congenital abnormalities of renal tract
Urinary-tract calculi
Diabetes
Diagnosis
Significant bacteriuria on MSU specimen.
Differential diagnosis
Pneumonia
Viral infections
Cholecystitis, biliary colic
Acute appendicitis
Gastroenteritis
Placental abruption
Degenerating urine fibroid
Blood culture and a full blood count is recommended
Management
Should after hospitalization

I/V antibiotic Penicillin and cephalosporin are the 1st
choice.
Chronic 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 in pregnancy
The risks includes:
Miscarriage
Pre-eclampasia
Intrauterine growth retardation
Preterm delivery
Fetal death
Factors Influencing Outcome
The presence and degree of renal impairment

The presence and severity of proteinuria
The underlying type of chronic renal disease
Degree of Renal Impairment
Mild renal impairment (plasma creatinine ≤ 125 umol/L)
Moderate renal impairment (plasma creatinine 125-150
umol/L
Severe renal impairment (plasma creatinine ≥ 250 umol/L
In general, women without hypertension or renal
impairment prior to conception have successful
pregnancies, and pregnancy does not adversely
influence the progression of renal disease.
Specific Types of Renal Disease
Glomerulonephritis
Reflux nephropathy
Diabetic nephropathy
SLE nephritis
Polycystic kidney disease (PKD)
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
prepregnancy and antenatally is important.
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.
Acute 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
Volume Contraction
Pre-eclampsia
Eclampsia (6%)
Hyperemesis gravidarum
Post-renal Failure
Ureteric damage or obstruction
HELLP Syndrome
7% have actual renal failure
Thrombotic thrombocytopenic purpura/hemolytic
uremic syndrome (TTP/HUS)
Management
This depend upon the underlying cause
Pregnancy in Renal Transplant Recipients
Women receiving renal transplant should be warned

that as renal function returns to normal, ovulation,
menstruation and fertility also resume.
Women desiring pregnancy usually advised to wait
about 1-2 years after transplantation.
Effects of pregnancy on renal transplants
Pregnancy has probably no adverse long-term effect
Renal allograft adopt 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.
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 RFT’s by creatinine clearance and 24 hour
protein excretion, as well as serum creatinine and urea is essential.
A FBC and LFT’s should also be checked regularly. Anemia is
common and hematinics should be prescribed.
The fetus should be monitored with regular ultrasound assessment of
growth and Doppler assessment of uterine and umbilical circulation.
Immunosuppressive Therapy
The doses of immunosuppressive drugs are maintained at
prepregnancy
Levels which should be preferably be:
Prednisone, ≤ 15 mg/day plus either
Azathioprine, ≤ 2mg/kg/day
Cyclosporine A,
Delivery
Cesarean section should only be required for obstetric indications.
Prophylactic antibiotics should be given to cover any surgical
procedure including episiotomy.
Parenteral steroids is necessary to cover labor as any woman on
maintenance steroids.
Neonatal Problems
These are largely related to prematurity but also include
the following:
Thymic atrophy
Transient leukopenia or thrombocytopenia
Depressed hemopoiesis

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RENAL DISORDER IN

Should after hospitalization

The presence and degree of renal impairment

Women receiving renal transplant should be warned

The chance of successful outcome is ≥90% but this is reduced

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