Chronic Kidney Disease in Pregnancy

A Case of
Chronic Kidney Disease

in Pregnancy
Remelou G. Alfelor
OBGYN Resident
Bicol Regional Training and Teaching Hospital
GENERAL DATA
• M.S.E.
• G3P2 (2001) CHIEF COMPLAINT:
• 31 yrs old
Labor Pain
• Single
• Roman Catholic
• Binanuhan East, Legazpi City, Albay
HISTORY OF PRESENT PREGNANCY
• LMP: April 17, 2020
• AOG: 37 2/7 weeks
• EDD: Jan 22, 2021
• 7 prenatal check-up at Binanuhan East BHU
• Takes Ferrous Sulfate, Calcium tablets and Multivitamins
• No history of BP elevations and infections
• No history of edema, vomiting, nausea, and body weakness
HISTORY OF PRESENT ILLNESS
• Few hours PTC

(+) Hypogastric pain  Admission
Obstetric History
• G3P2 (2001)
Term/Preterm/A Place of Status at birth and at
Gravida Year bortion
Mode of Delivery
Delivery present
CS Alive, Died after 3
1 2013 Term
(Cord Prolapse) BRTTH weeks due to Sepsis
2 2016 Term VBAC Home Alive, Living
3 Present
MENSTRUAL HISTORY
M 14 years old
I regular, 28-30 days
D 3-4 days
A 4 pads/day, moderately soaked
S (-) dysmenorrhea
• GYNECOLOGIC HISTORY
– No history of STI’s
– No Pap Smear done
• SEXUAL HISTORY
– Coitarche: 20 years old
– One monogamous partner
• CONTRACEPTIVE HISTORY
– No history of contraceptive use
PAST MEDICAL HISTORY
• (-) Cardiovascular Disease, Asthma, Blood dyscrasia, cancer
• No known allergies to medications and food
• No previous history of surgery
FAMILY HISTORY
• (+) Asthma – Sister
• (+) Hypertension - Mother
• (-) Cardiovascular Disease, Diabetes Mellitus, Blood
Dyscrasia, Cancer, Thyroid Disease, SLE
PERSONAL AND SOCIAL HISTORY
• Non-smoker, non-alcoholic beverage drinker
• Denies illicit drug use
• From Baguio City but moved in Albay with husband
• 2nd year high school graduate
• Housewife
REVIEW OF SYSTEM
(-) weight loss, weakness, fatigue
(-) itching, rashes
(-) headache, dizziness, light headedness
(-) eye pain, eye redness, periorbital edema
(-) tinnitus, vertigo
(-) dyspnea, DOB, cough, hemoptysis
(-) chest pain, palpitations, SOB
(-) genital lesions, erythema, vaginal discharge, urinary frequency, dysuria, hematuria
(-) joint pains, leg cramps, varicosities, edema
(-) change in mood, depression and suicidal attempts
(-) anemia, easy bruising
(-) excessive sweating, heat and cold intolerance
PHYSICAL EXAMINATION
• Conscious, coherent, not in cardiorespiratory distress
• GCS 15 (E4M6V5)
• BP 150/80 mmHg
• HR 103 bpm Ht 148 cm
Wt 48 kg
• RR 16 cpm BMI: 22
• Temp 36.4°C
• O sat 99%
• Anicteric sclerae, pink palpebral conjunctiva,
• (-) Periorbital edema, Malar rash
• Thyroid midline no masses, no lymphadenopathies, no
distended neck veins
• Tachycardic, normal heart rhythm, no heaves, no thrills, no
heart murmurs
• Symmetrical chest expansion, clear breath sounds, no
retractions
• Abdomen globular
• FH 27 cm EFW 2,480 g
• FHT 130’s
• Leopold’s Maneuver
– LM1 Fetal buttocks occupying the fundus
– LM 2 Fetal back at right maternal side
– LM 3 cephalic presentation, engaged
– LM 4 cephalic prominence felt on same side with fetal small parts
• Pelvic Examination
– Normal external genitalia
– Nulliparous vagina
– Cervix fully dilated and effaced, Ruptured membrane, cephalic, St
0
– Uterus enlarged to term
– No palpable adnexal mass and tenderness
SALIENT FEATURES
• 31 years old
• Gravida 3 Para 2 (2001)
• Labor pain
• BP 150/90 mmHg
• GCS 15 (E4M6V5)
• Conscious, coherent, not in cardiorespiratory distress
• (-) Periorbital edema, bipedal edema, Malar rash, skin lesions
• FH 27 cm
• FHT 130’s bpm
– IE: Cervix fully dilated and effaced, Ruptured membrane, cephalic, St 0
ADMITTING DIAGNOSIS
G3P2 (2001)
Pregnancy uterine 37 2/7 weeks AOG, CIL
Gestational Hypertension
s/p LSCS 1 for cord prolapse (2013, BRTTH)
s/p VBAC (2016, NID)
t/c IUGR
COURSE IN THE DR
S/O A P
Conscious, coherent, G3P2 (2001) Problem 1: VBAC Term in labor
NICRD Pregnancy uterine 37 2/7 Prepare for delivery using Assisted
BP 150/90 mmHg weeks AOG, CIL Vaginal Delivery by Vacuum Extraction
HR 85 bpm Gestational Hypertension For CBC, PC
RR 18 cpm s/p LSCS 1 for cord Blood typing
Temp 36.8 °C prolapse (2013, BRTTH) Urinalysis
O2 sat 99% s/p VBAC (2016, NID) HBsAg, RPR
t/c IUGR Secure 1 unit pRBC
FH 27 cm EFW 2,480 g Problem 2: Gestational Hypertension
FHT 130’s > For BUN, Creatinine, SGOT, SGPT,
LDH
IE: Cervix fully dilated and
effaced, St 0
COURSE IN THE DR: Post Delivery
S/O A P
Conscious, coherent, G3P3 (2102) Postpartum Care
NICRD Pregnancy uterine delivered 10 units oxytocin IM
BP 140/90 mmHg preterm live baby boy AS 8,9 IVF: D5LR 1l + 10 units oxytocin to run
BW 1,770g BL 45 cm BS 35
HR 90 bpm weeks by VBAC at 30 gtts/min
RR 18 cpm s/p LSCS 1 for cord prolapse Oral Meds:
Temp 36.8 °C (2013, BRTTH) 1. Amoxicillin 500 mg/tab 1tab TID
O2 sat 99% s/p VBAC (2016, NID) 2. Ferrous sulfate tab 3 tabs ODHS
Gestational Hypertension 3. Celecoxib 200 mg/tab 1tab BID prn
Uterus well contracted, no t/c CKD WOF: Uterine atony, profuse vaginal
OS packed, no hematoma bleeding
Intact previous CS scar
Minimal vaginal bleeding
S/O A P
Conscious, coherent, G3P3 (2102) Problem 1: Elevated Creatinine +
NICRD Pregnancy uterine delivered Anemia (t/c CKD)
BP 140/90 mmHg preterm live baby boy AS 8,9 Refer to IM-Nephro for evaluation of
BW 1,770g BL 45 cm BS 35
HR 90 bpm weeks by VBAC elevated Creatinine and BUN with
RR 18 cpm s/p LSCS 1 for cord prolapse Anemia
Temp 36.8 °C (2013, BRTTH)
O2 sat 99% s/p VBAC (2016, NID)
Hbg 89 t/c CKD
BUN 18.30
Creatinine 477.81
S/O A P
Conscious, coherent, G3P3 (2102) Problem 2: Gestational Hypertension
NICRD Pregnancy uterine delivered For BUN, Creatinine, SGOT, SGPT,
BP 140/90 mmHg preterm live baby boy AS 8,9 LDH
BW 1,770g BL 45 cm BS 35
HR 90 bpm weeks by VBAC Methyldopa 250 mg/tab 1tab BID
RR 18 cpm s/p LSCS 1 for cord prolapse
Temp 36.8 °C (2013, BRTTH)
O2 sat 99% s/p VBAC (2016, NID)
t/c CKD
COURSE IN THE ER
COMPLETE BLOOD COUNT
WBC 10.94 NEUTROPHILS 71 High
RBC 2.66 Low LYMPHOCYTES 20
HBG 89 Low MONOCYTES 5
HCT 0.27 Low EOSINOPHILS 3
MCV 100.1 High BASOPHILS 1
MCH 34 High RDW 13.0
MCHC 34 MPV 7.20
PLATELET 353 BLOOD TYPE A+
COUNT
COURSE IN THE ER
HBsAg
Non-reactive
RPR
URINALYSIS
Color Yellow Epithelial Cells Few
Transparency Turbid Bacteria Few
pH 6 Amorphous Urates Few
Specific Gravity 1.015
Glucose Negative
Protein +2
Pus Cells 15-18/hpf
RBCs TNTC/hpf
BLOOD CHEMISTRY AND SERUM ELECTROLYTES
BUN 18.30
Creatinine 477.81
SGOT 18
SGPT 15.80
LDH 173
Cl 105
K 5.50
Mg 0.85 mg/dl
POSTPARTUM DIAGNOSIS
G3P3 (2102)
Pregnancy uterine delivered preterm live baby boy
AS 8,9 BW 1,770g BL 45 cm BS 35 weeks by VBAC
t/c CKD
COURSE IN THE WARD
Postpartum Day 2
S/O A P
Conscious, coherent, G3P3 (2102) Postpartum Care
NICRD Pregnancy uterine delivered Oral Meds:
BP 140/90 mmHg preterm live baby boy AS 8,9 1. Amoxicillin 500 mg/tab 1tab TID
BW 1,770g BL 45 cm BS 35
HR 85 bpm weeks by VBAC 2. Ferrous sulfate tab 3 tabs ODHS
RR 19 cpm s/p LSCS 1 for cord prolapse 3. Paracetamol 500 mg/tab 1tab QID prn
Temp 36.5 °C (2013, BRTTH) WOF: Uterine atony, profuse vaginal
O2 sat 99% s/p VBAC (2016, NID) bleeding
Uterus well contracted, no CKD
OS packed, no hematoma
Intact previous CS scar
Minimal vaginal bleeding
COURSE IN THE WARD
Postpartum Day 2
S/O A P
Conscious, coherent, NICRD G3P3 (2102) Problem 1: CKD
BP 140/90 mmHg Pregnancy uterine delivered IM Nephro Notes: CKD V probably secondary
HR 85 bpm preterm live baby boy AS 8,9 to CGN vs HUS/TTP
RR 19 cpm BW 1,770g BL 45 cm BS 35 IVF: PNSS 1L x 40cc/hr
Temp 36.5 °C weeks by VBAC Start NAC 600 mg BID for 2 days
O2 sat 99% s/p LSCS 1 for cord prolapse Repeat CBC, BUN and Creatinine after 2 days
(2013, BRTTH) For WAB UTZ
No edema extremities s/p VBAC (2016, NID) For possible HD
Uterus well contracted, no OS Gestational Hypertension For CBG monitoring
packed, no hematoma CKD Stage V, not in Uremia For FBS, HBa1c, ANA and C3
For HCV
Urine Output = 70 cc/hr d/c Celecoxib, start Paracetamol 500 mg/tab
1tab QID prn pain
COURSE IN THE WARD
Postpartum Day 3
S/O A P
Conscious, coherent, NICRD G3P3 (2102) Postpartum Care
BP 130-140/80-90 mmHg Pregnancy uterine delivered Oral Meds:
HR 90 bpm preterm live baby boy AS 8,9 1. Amoxicillin 500 mg/tab 1tab TID
RR 18 cpm BW 1,770g BL 45 cm BS 35 2. Ferrous sulfate tab 3 tabs ODHS
Temp 36.8 °C weeks by VBAC 3. Paracetamol 500 mg/tab 1tab QID prn
O2 sat 99% s/p LSCS 1 for cord prolapse WOF: Uterine atony, profuse vaginal bleeding
(2013, BRTTH)
No edema extremities s/p VBAC (2016, NID)
Uterus well contracted, no OS Gestational Hypertension
packed, no hematoma CKD Stage V, not in Uremia
CBG = 104 mg/dL

Urine Output = 80 cc/hr
COURSE IN THE WARD
Postpartum Day 3
S/O A P
BP 130-140/80-90 mmHg Pregnancy uterine delivered IM Nephro Notes: CKD V probably secondary
Temp 36.8 °C weeks by VBAC NAC 600 mg BID (Day 2)
O2 sat 99% s/p LSCS 1 for cord prolapse Awaiting for repeat CBC, BUN and Creatinine
(2013, BRTTH) results
No edema extremities s/p VBAC (2016, NID) For WAB UTZ – not done
Uterus well contracted, no OS Gestational Hypertension For possible HD
packed, no hematoma CKD Stage V, not in Uremia CBG monitoring premeals
For awaiting FBS, HBa1c, HCV results
CBG = 105 mg/dL ANA and C3 – not done due to financial
Urine Output = 90 cc/hr contraints
For HCV
For Total Bilirubin, Indirect Bilirubin, Direct
Bilirubin, BUA
For serum elctrolytes – NA, K, Cl, Ca
COURSE IN THE WARD
Postpartum Day 3
COMPLETE BLOOD COUNT
WBC 8.92 NEUTROPHILS 67 High
RBC 2.27 Low LYMPHOCYTES 25
HBG 75 Low MONOCYTES 3
HCT 0.23 Low EOSINOPHILS 5
MCV 100.1 BASOPHILS 0
MCH 33 RDW 12.0
MCHC 33 MPV 6.80
PLATELET 331
COUNT
URINALYSIS
Color Yellow Epithelial Cells Few
Transparency Slightly Turbid Bacteria Few
pH 6 Amorphous Urates Few
Specific Gravity 1.020
Glucose Negative
Protein +2
Pus Cells 2-3/hpf
RBCs TNTC/hpf
COURSE IN THE WARD
Postpartum Day 4
S/O A P
(2013, BRTTH)
No edema extremities s/p VBAC (2016, NID)
Uterus well contracted, no OS Gestational Hypertension
packed, no hematoma CKD Stage V, not in Uremia
CBG = 110 mg/dL

COURSE IN THE WARD
Postpartum Day 4
S/O A P
Temp 36.5 °C weeks by VBAC NAC 600 mg BID
O2 sat 99% s/p LSCS 1 for cord prolapse Awaiting for repeat CBC, BUN and Creatinine
(2013, BRTTH) results
No edema extremities s/p VBAC (2016, NID) For WAB UTZ – not done
Uterus well contracted, no OS Gestational Hypertension For possible HD
packed, no hematoma CKD Stage V, not in Uremia CBG monitoring premeals
For awaiting FBS, HBa1c, HCV results
CBG = 110 mg/dL ANA and C3 – not done due to financial
Urine Output = 70 cc/hr contraints
For HCV
For Total Bilirubin, Indirect Bilirubin, Direct
Bilirubin, BUA , Albumin
For serum electrolytes – NA, K, Cl, Ca
Laboratories
FBS 4.4
HBA1c 5.2
Direct Bilirubin 1.71
Indirect Bilirubin 0.9
Total Bilirubin 2.6 (low)
BUN 18 (high)
Creatinine 482.13 (high)
BUA 449.24
COURSE IN THE WARD
Postpartum Day 5
S/O A P
(2013, BRTTH) Patient decided to do HAMA
No edema extremities s/p VBAC (2016, NID) Refused HD
Uterus well contracted, no OS Gestational Hypertension Home meds:
packed, no hematoma CKD Stage V, not in Uremia 4. Amoxicillin 500 mg/tab 1tab TID
5. Ferrous sulfate tab 3 tabs ODHS
CBG = 107 mg/dL 6. Paracetamol 500 mg/tab 1tab QID prn
Urine Output = 90 cc/hr 7. NAC 600 mg BID
COURSE IN THE WARD
Postpartum Day 5
S/O A P
Temp 36.8 °C weeks by VBAC NAC 600 mg BID
O2 sat 99% s/p LSCS 1 for cord prolapse For WAB UTZ – not done
(2013, BRTTH) For HD – patient refused
No edema extremities s/p VBAC (2016, NID) CBG monitoring premeals
Uterus well contracted, no OS Gestational Hypertension F ANA and C3 – not done due to financial
packed, no hematoma CKD Stage V, not in Uremia constraints
Awaiting serum electrolytes – NA, K, Cl, Ca
CBG = 107 mg/dL
POSTPARTUM DIAGNOSIS
G3P3 (2102)
Pregnancy uterine delivered preterm live baby boy
AS 8,9 BW 1,770g BL 45 cm BS 35 weeks by VBAC
Chronic Kidney Disease Stage V, not in Uremia
Definition
• CHRONIC RENAL INSUFFICEINCY
– CHRONIC RENAL FAILURE
– Irreversible progressive impaired kidney function ultimately leading to
End-Stage Renal Insufficiency
• END-STAGE RENAL DISEASE
– Kidney no longer have function adequate to sustain life
– Require dialysis or kidney transplant
Source: V. Beghella. Maternal-Fetal Evidence Based Guidelines 3 rd Ed. 2017.

Chronic Kidney Disease
• Kidney damage with alteration in morphology, imaging, or function of the
kidney
• eGFR of <60 mL/min/1.73 m2 for at least 3 months
Source: KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease
Physiologic Renal Changes in Pregnancy
• Vasodilation  drop in BP, increase Cardiac Output and increase
GFR and Renal blood flow
• Creatinine and Urea production remain unchanged
• Increase in kidney size and urinary collecting system
– Kidney increase in length 1 cm
– Volume increases 30%
• Collecting system dilated
– Obstructive Uropathy
• Mild hydonephrosis (Right)
Risk Factors
Symptoms
• Frequent need to urinate
• Edema
• Anemia
• Fatigue
• Weakness
• Headaches
• Loss of Appetite
• Nausea, vomiting, bad breath and pruritus

Risk Factors
• Vasculopathy
• Lupus Nephritis
• IgA Nephropathy
• Mild Renal Insufficiency
• Moderate and severe renal insufficiency

Complications

Complications
• Infertility
• Hypertension
• Preeclampsia
• Preterm Labor
• Low Birth Weight
• Perinatal Mortality
Work-up
• Serum creatinine
• BUN
• Electrolytes
• 24 urine collection
– Gold Standard
• Random Protein-Creatinine Ration
– Predict baseline proteinuria in early pregnancy
• Renal Biopsy
– Sudden deterioration of renal function
– Before 32 weeks AOG

Management
• Preconception
– Creatinine ≥ 2.3 mg/dL
• Progressive renal deterioration (10%)
• Contraindication to pregnancy
– ESRD = should have renal transplant then wait for 2-3
years before conception
– Preconception assessment of renal function
• Diabetes Mellitus, CHVD and SLE

Management
• Prenatal Care
– Every 2-4 weeks until 32 weeks then weekly
– Careful monitoring BP and proteinuria
• Early detection Hypertension, Superimposed
Preeclampsia and Eclampsia

Management
• Laboratory Tests
– 24 hours Creatinine Clearance and Protein
excretion
– Frequent urine culture
– Maternal anemia should be corrected
• Higher dose EPO to maintain Hct >35%

Management
• Antenatal Testing
– Frequent Ultrasound for fetal growth monitoring
– Biophysical Assessment (Weekly beginning ≥ 32 weeks)
• Therapy
– Hypertension
• Keep Diastolic Blood Pressure <90 mmHg
• Use of Antihypertensive medications

Management
– Preeclampsia
• MgSO4 used with extreme precaution at 1-2g /hr given as
bolus
• Evaluation MgSo4 side effects monitored hourly
• Serum Mg monitored 2-4 hours
• Calcium Gluconate should always be readily available
– Phenytoin 1-20 mg/kg IV
• Low dose Aspirin started on first trimester
– Lupus Nephritis
– Moderate t severe CRI

Management
– Preterm Labor
• Magnesium Sulfate and Indomethacin – use with caution

Management: Delivery
– Tertiary Hospital
– Mode of delivery depends on standard obstetrical
indications
– Preterm Birth
• Worsening maternal renal function
• Severe Preeclampsia
• Worsening fetal Status

Management: Post Partum
• Breastfeeding
– Immunosuppressant
• Caution should be used in recommending breast
feeding
• Long Term Prognosis
– Moderate to severe Renal Insufficiency (Serum
Creatinine >1.4 mg/dL) will have 10% progressive
renal deterioration
Prevention
• Goal: Preserve whatever renal function remains
• Screening for DM and Hypertension
• Dose adjustment for medications appropriate to avoid
Acute and Chronic Kidney injury

Dialysis in Pregnancy
• Ultrasound should be used to confirm diagnosis of pregnancy
• Complications
– Still birth
– Neonatal Death
– Preterm delivery
– Severe Preeclampsia
– Polyhydramnios
– FGR
– Hypetension
– Anemia
– Maternal Death
• Hemodialysis should be done 6-7 times weekly
• Predialysis
– Urea <100 mg/dL
– BUN 710 mg/dL
• BP should be maintained 130-150/80-90 mmHg
• Alter Heparin regimen near delivery

• Maintain
– Bicarbonate 22-26 mEq/L
– Hemoglobin 11-12 mg/dL
• EPO should be increased to 50%
• Avoid MgSO4 if possible or use with caution

• Antenatal fetal surveillance due to risk of FGR and FHR
abnormalities
• Delivery at 34-36 weeks
• Asymptomatic bacteriuria: Treated for 2 weeks
Thank you

Chronic Kidney Disease in Pregnancy

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Chronic Kidney Disease in Pregnancy

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A Case of

Chronic Kidney Disease

• Few hours PTC

Specific Gravity 1.015

CBG = 104 mg/dL

Specific Gravity 1.020

CBG = 110 mg/dL

Source: V. Beghella. Maternal-Fetal Evidence Based Guidelines 3 rd Ed. 2017.

Source: V. Beghella. Maternal-Fetal Evidence Based Guidelines 3 rd Ed. 2017.

Source: V. Beghella. Maternal-Fetal Evidence Based Guidelines 3 rd Ed. 2017.

Source: V. Beghella. Maternal-Fetal Evidence Based Guidelines 3 rd Ed. 2017.

Source: V. Beghella. Maternal-Fetal Evidence Based Guidelines 3 rd Ed. 2017.

Source: V. Beghella. Maternal-Fetal Evidence Based Guidelines 3 rd Ed. 2017.

Source: V. Beghella. Maternal-Fetal Evidence Based Guidelines 3 rd Ed. 2017.

Source: V. Beghella. Maternal-Fetal Evidence Based Guidelines 3 rd Ed. 2017.

Source: V. Beghella. Maternal-Fetal Evidence Based Guidelines 3 rd Ed. 2017.

Source: V. Beghella. Maternal-Fetal Evidence Based Guidelines 3 rd Ed. 2017.

Source: V. Beghella. Maternal-Fetal Evidence Based Guidelines 3 rd Ed. 2017.

Source: V. Beghella. Maternal-Fetal Evidence Based Guidelines 3 rd Ed. 2017.

Source: V. Beghella. Maternal-Fetal Evidence Based Guidelines 3 rd Ed. 2017.

Source: V. Beghella. Maternal-Fetal Evidence Based Guidelines 3 rd Ed. 2017.

• Avoid MgSO4 if possible or use with caution

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