RENAL DISEASES IN PREGNANCY - Dr.

Harrison Tamooh o recurrent UTI

OVERVIEW
• Physiological changes in pregnancy • Investigations
• Assessment of renal disease in pregnancy 1. Sonography - pregnancy induced hydronephrosis may
• Urolithiasis obscure the findings
• Acute Renal Failure 2. IVU – preferably a one shot pyelogram
• Chronic Renal Disease
• Urinary Tract Infections Treatment
Depends on symptoms and duration of disease:
PHYSIOLOGICAL CHANGES IN PREGNANCY 1. Intravenous hydration
• Kidneys increase in length and weight 2. Analgesics
3. Antibiotics – almost half have associated infection
• Dilatation of the ureters and the renal calyses
In 75% of cases there is improvement with conservative
• Increase in renal plasma flow/renal perfusion
therapy and the stone usually pass spontaneously.
• Increase in glomerular filtration rate The rest 25% will require an invasive procedure such as:
• Decrease in serum creatinine and BUN • Ureteral stenting
• Saturation of tubular re-absorption of glucose may result • Percutaneous nephrostomy
in gycosuria • Laser lithotripsy
• Increased urinary frequency • Basket extraction or
• Increased vesico-ureteric reflux • Surgical exploration

ASSESSMENT OF RENAL DISEASE IN PREGNANCY ACUTE RENAL FAILURE

• Urinalysis • Defined as urine output < 400 mls/24 hrs
o Spot urinalysis
• Rapid onset of impaired renal function characterized by
o 24hr urine sample azotemia (inability to excrete creatinine and other
o Urine MCS products of daily metabolism)
• Infrequent in pregnancy
 A clean catch specimen must be taken • High mortality rate
 interpretation unchanged except for occasional • Must be prevented where possible and treated
glycosuria aggressively
 Proteinuria must exceed 300mg/24hrs to be • BUN and serum creatinine raised
considered abnormal in pregnancy
• Serum creatinine Classification
o if persistently >0.9mg/dl (75μmol/l) then Based on the cause:
intrinsic renal disease should be suspected • Pre-renal ARF - Due to renal hypoperfusion 20 to:
• Ultrasonography- renal size and relative consistency and
o Maternal hypovolemia
elements of obstruction
 Haemorrhage
• Intravenous urography – not routinely done in pregnancy
 Dehydration
• Cystoscopy - usual clinical indications followed
 Septicaemia
• Renal biopsy - can usually be postponed until after o Circulating nephrotoxins
pregnancy o Mismatched blood transfusion
o DIC
UROLITHIASIS o Hypoxaemia
• Relatively uncommon complication of pregnancy
• Renal ARF - Intrinsic renal diseases
• Incidence 1:2000 to 1:3000 pregnancies
o Acute glomerulonephritis
• Pregnancy does not predispose to stone formation
o Acute pyelonephritis
• No adverse outcome on pregnancy
o Amyloidosis
• Increases frequency of UTIs
• Post-renal ARF - Urinary obstruction:
• Calcium salts make up 80% of renal stones
o Ureteric stones
• Hyperparathyroidism should be excluded
o Retroperitoneal tumours
Diagnosis
• Symptoms: Clinical Course
1. Oliguric phase- urine output <30ml/hr with raised BUN
o Flank pain,
and creatinine
o Haematuria,
2. Diuretic phase- large volumes of dilute urine • Patients with moderate to severe renal insufficiency are
3. Recovery phase- volume and composition of urine at great risk for worsening of their renal function.
normalize
Associated Complications:
• Abortions
• Preterm delivery
• IUGR
Treatment
• Hypertension
• Prevention
• Superimposed pre-eclampsia
o Appropriate volume replacement to maintain
adequate urine output • Abruptio placentae
o Proper management of high risk obstetric
conditions
o Ready availability of blood Management
o Avoidance of nephrotoxic antibiotics • Pre-pregnancy counselling
• Early pregnancy diagnosis and accurate dating
• Specific treatment
• Baseline laboratory studies (BP, serum creatinine, BUN,
o Emergency - Treat underlying cause (e.g.
electrolytes, 24hr urine protein, creatinine clearance,
haemorrhagic shock)
urinalysis and urine culture)
o Surgical - manage obstructive uropathy or
• Frequent prenatal visits – every 2 wks until 28 wks then
evacuate retained product of conception
weekly until delivery
• Routine measures • Laboratory studies repeated each trimester and when
o Achieve fluid and electrolyte balance clinically indicated
o Input/output chart • Screen and treat for bacteriuria
o Correct hyperkalemia (insulin + glucose) • Protein restricted diets not recommended in pregnancy
o Diet high in calories and -CHO, low in proteins • Associated anaemia can be treated with recombinant
and electrolytes erythropoietin
o Parenteral nutrition in case of nausea and
• Manage hypertension
vomiting
• Monitor fetal growth and liquor volume with serial U/S
o Prophylactic antibiotics
scans
o Avoid indwelling urethral catheters if possible
• Postpartum continued monitoring
• Dialysis
• In patients requiring dialysis, increased dialysis time
Indications
may improve outcome
o K+ ≥7meq/l
o Na+ ≤ 130meq/ml POLYCYSTIC KIDNEY DISEASE
o HCO3- ≤ 13meq/ml • Autosomal dominant disease
o BUN > 120mg/dl • 1:500 autopsies, 1:3000 hospital admissions and causes
Types 10% of all end stage renal disease.
o Peritoneal
• Polycystic Kidney Disease
o haemodialysis
• Symptoms usually in 3rd and 4th decade
CHRONIC RENAL DISEASE o flank pain
o Haematuria
• Prognosis for successful pregnancy outcome in general is
o Nocturia
not related to the underlying disorder, but rather on the
degree of associated hypertension and renal o Proteinuria
insufficiency. o Associated calculi and infection
• Categories of functional impairment: o Hypertension in ¾ of patients
1. Normal or mild impairment- serum creatinine • Progression to end stage renal disease a major problem
<1.5mg/dl (125 μmol/l) and minimal hypertension • Superimposed ARF results from infection or obstruction
2. Moderate impairment- serum creatinine 1.5- from ureteral angulation by cyst displacement
3.0mg/dl (125 - 250 μmol/l) • In pregnancy:
3. Severe renal insufficiency- serum creatinine o Outcome depend on the degree of associated
>3.0mg/dl (250 μmol/l) hypertension and renal insufficiency
• Patients with mild renal insufficiency experience little or o Upper urinary tract infections are common
no disease progression during pregnancy o Pregnancy does not seem to accelerate the
natural disease course
 • Urinary sediment contains many leucocytes and
URINARY TRACT INFECTIONS numerous bacteria
Are common disorders in pregnancy • Differential Diagnosis
• Asymptomatic Bacteriuria
• Labour
• Acute Cystitis
• Chorioamnionitis
• Acute pyelonephritis • Appendicitis
• Abruptio-placentae
Asymptomatic Bacteriuria
• Infarcted myoma
• Definition: presence of actively multiplying bacteria in
the urinary tract excluding the distal urethra in a patient • Management
without any obvious symptoms. • Hospitalization
• Incidence: 2-10% • Urine and blood cultures
• Risk factors: sickle cell trait, diabetes mellitus, renal • CBC, urea, creatinine and electrolytes
transplant, high parity, low SES, age and sexual practice • Frequent monitoring of vital signs including urine
• If untreated 40% develop symptomatic UTI, (25-30% acute output
pyelonephritis), with treatment the rate is only 10% • Intravenous fluids
• Associated with preterm labour, foetal loss and pre- • Intravenous antibiotics (empirical)
eclampsia o Ampicillin + gentamicin
• Diagnosis is by isolation of >105 organisms per ml of o Cephalosporins
o Co - amoxoclav
urine in a clean catch specimen
• CXR if there is tachycardia or dyspnoea
• Escherichia coli isolated in 80%,the rest 20% is caused by
• Repeat CBC and renal function in 24 hours
Enterobacter - Serratia group, Staphylococcus aureus,
Enterococcus and group B Streptococcus. • Oral antibiotics when afebrile
• Treatment • Discharge when afebrile for 24 hours.
o Amoxycillin • Continue antibiotics for 10-14 days
o Ampicillin • Urine cultures 1-2 wks after completing antibiotics
o Cephalosporin
o Nitrofurantoin
o Sulphonamide

Cystitis
• Uncommon in pregnancy ( incidence 1%)
• Causative organisms similar to those for asymptomatic
bacteriuria
• Presents with urinary frequency, urgency, dysuria and
suprapubic discomfort
• Urine often cloudy and malodorous
• Diagnosis is by microscopy, culture and sensitivity of
urine
• Treatment is as for asymptomatic bacteriuria

Acute Pyelonephritis
• Most common serious medical complication of pregnancy
• Occurs in 2% of pregnant women
• A leading cause of septic shock in pregnancy
• More common after mid pregnancy
• Unilateral and right sided in over 50% of cases and
bilateral in 25%
• Clinical findings
• Onset abrupt
• Fever, shaking chills, aching pain in one or both
lumbar regions
• Anorexia, nausea and vomiting
• Signs may include fever >400C or hypothermia 340C
and tenderness in one or both costo-vertebral angles