RENAL DISEASE IN PREGNANCY

Dr K. W OBSGYN Department CWM Hospital

Renal Disease in Pregnancy

This presentation will try and focus on

1. Advice to patient about pregnancy 2. Determinant the pregnancy 3. Management

CASE PRESENTATION

Mrs Z. Z. R
24 yr old Indian primp Married for 2 years She is a twin PMHx (PATIS Info) was admitted to lautoka hosp for bilateral plueral effusion and Nephrotic Syndrome in 2006 Discharge medication
Prednisone 80 mg od Lasix 80mg bd Enalapril 5mg

physical examination was unremarkable She was booked at 20 weeks on the 1st January with a

FH 21 cm Bp 100/70 Weight 57

Zarina Zaheen Rauf

then booked for NV on the 22nd of march ( 7 weeks) on the 2nd of March she presented to a GP with

Bipedal Oedema x 1/52 Bp 100/62 P 86 Dip stick 4+ protein FBC : Hb- 11.5 PCV 38 MCV 84 WC 10430 Plt 291000 Renal : U 2.6 Cr 35 Na 133 K 4.7 Cl 105 Lipid : Chol 22.3 Trig 27 LFT : AST 14 ALT - 9 ALB- 19 24hr Urine Protein 2241.8 mg Polycose 5.2

Zarina Zaheen Rauf

Medical reviewed the case noted that

BP is always
systolic 100 to 90 Diastolic 60 to 50

Diagnosed her as Nephrotic syndrome 2ry to ? Chronic GN Started on Laisx 40mg bd Dialy weighing from 64 to 62 Kg in 3 days Which improved the symptoms Discharged after 5 days of adimsion
With Lasix 40mg BD Rv 21st March with ANA & Ds DNA results

LITERATURES

Literature
literature did not reveal any randomized clinical trials or metaanalyses. The available information is derived from opinion, reviews, retrospective series, and limited observational series.

The Incidence of chronic Renal disease is uncommon in all centres

NORMAL PHYSIOLOGY

Normal Physiology
R e n a l P la sm a F lo w

8 0 % i 2 nd trim n 5 5 % i 3 rd trim n

GFR

Creatinine
25% at 3-4 w 45% at 12 w

clearance
50% ( 2nd trim)

Dec Serum
Normal non pregnant Normal Pregnant Cr (44 to 106) micromol/L Cr (35 to 70) micromol/L

creatinine

Normal Physiology
Protein excretion: increase to aprox 200mg/day due to Incr GFR and Permability Abnormal if >300mg/24hrs Error Varibilty in urine concentration F+ve: 1.gross (macroscopic) blood in the urine 2.Semen 3.pH >7 4.detergents and disinfectants 5.Infection F-ve: 1.high saltconcentration 2.highly acidic urine 3.nonalbumin proteinuria

Screening Dipstick: Negative Trace - between 15 and 30 mg/dL 1+ - between 30 and 100 mg/dL 2+ - between 100 and 300 mg/dL 3+ - between 300 and 1000 mg/dL 4+ - >1000 mg/dL

Normal Physiology
Diagnostic 1.24hr urine collection for protein 2.Protein and creatinine in a spot MSU Protein uria > 3gram/24hr = Nephrotic range proteinuria

When distinguishing proteinuria from renal pathology or preeclampsia is difficult it advisable to assume preeclampsia

Normal Physiology
Anatomical Changes 1.Increase in kidney size of apro1 to 1.5 cm 2.Increase in Kidney volume 3.Ureter dilation due to progesterone and mechanical compression 1.200ml to 300ml 4.

DETERMINANT OF MATERNAL AND FETAL OUTCOME

Outcomes
1. Successful outcome

Live birth without complication

2. Short term complication

Superimposed preeclampsia, aneamia Preterm delivery IUGR Still birth and postpartum death
3. Long term complication

Development of ESRD postnatal Development of handicaps by the child

Factors that contribute

1. Degree of renal impairment by serum creatinine 2. Protein urea 3. Type of renal disease 4. Presences of HTN

Degree of renal impairment

Serum creatinine concerntration Mild (creatinine < 123micromol/L) - Moderate (123 to 212) - Severe (> 212) - ESRD (>530)

Mild renal impairment

That is Cr <123micromol/L With the available data there is a very row risk of adverse pregnancy outcome All the studies reported a success rate of >90% for mothers with this type It also reported a good outcome even when taking into account the type of Renal disease

Moderate to severe impairment

That is >123micromol/L there is clearly a higher risk associated with this type There is a higher rate of PTL, supaPreclmsia, IUGR, SB(3%) .etc They have higher risk of worsening renal function during and after pregnancy The progression to ESRD is greatest with Cr 176

Proteinurea
Study by stelleer and Cunning and jacob associat

Both study found that >93% of women with P.U >500mg/24hr had a Live newborn with short term complication But 50%PT 25% IUGR Insufficient data
No relation has been proven

Type of renal disease

Type of renal disease

Chronic glomerulonephritis and focal glomerular sclerosis (FGS)

Increased incidence of high blood pressure late in gestation but usually no adverse effect if renal function is preserved and hypertension is absent before gestation.
Diabetic nephropathy

No adverse effect on the renal lesion. Increased frequency of infections, edema, or preeclampsia.
Systemic lupus erythematosus

Prognosis is most favorable if disease is in remission 6 or more months before conception. Some authorities increase steroid dosage in immediate postpartum period.

HTN
There is a strong association with adverse effect both M& F Risk of preeclampsia increases from 50% to about 80% - HTN at conception increases rate of fetal loss X 10

Fair to conclude that pregnant women with mild renal impairment and normal Bp have >90% of a successful outcome

MANAGMENT

Management issue
1. Prepregnancy or early antenatal councelling 2. Management during pregnancy 3. Dialysis 4. Renal transplant

5.

councelling

1. Fertility is dependent on the degree of renal impairment ie moderate to severe renal impairment has less chances of conceiving 2. The adverse outcome is directly related to the renal impairment 3. Pregnancy outcome is also related to the presence of HTN or SupaPreclmsia. 4. The teratogenic drugs such as ACE Inhibitor

5.

Management during Pregnancy

1. ANC every 2 weeks till 30 to 32 weeks then weekly visit 2. Growth of the fetus, Renal Function and 24 hr protein with other test should be reviewed every 4 to 6 weeks throughout the pregnancy 3. Anemia is investigated and can be treated with Iron or EPO (recommended if hematocrit <19%) 4. Biophysical Profile at 30 or 32 weeks 5. In the absences of maternal and fetal deterioration consideration should be given to delivery at or near term 6. Drugs
1.prednisone 15mg/day 2.Diuretic ( avoid) no clear evidence for Loop & thiazide 1.With daily weighing

7.

Dialysis
Indication next slide Better outcome for the fetus for 1st dialysis during pregnancy compared to pre pregnant dialysis No difference between HD and PD

Indication for dialysis

1. Pericarditis or pleuritis (urgent indication) 2. Progressive uremic encephalopathy or neuropathy, 3. A clinically significant bleeding diathesis attributable to uremia (urgent indication) 4. Fluid overload refractory to diuretics 5. Hypertension poorly responsive to antihypertensive medications 6. Persistent metabolic disturbances that are refractory to medical therapy;

1.hyperkalemia, 2.metabolic acidosis, 3.Hypercalcemia or hypocalcemia, hyperphosphatemia

7. Persistent nausea and vomiting 8. Evidence of malnutrition

Summary
1. Although chronic renal disease and at incre risk of both maternal & fetal outcome 2. Adverse outcomes are related the degree of renal impairment 3. Screening and antenatal care can be provided by a obstetrician in disguising degree of renal impairment. 4. Counseling and management of complication with timing of the delivery can be addressed with multidisciplinary approach 5. there is still more data needed to provide a better association of risk factors

6. 7.

Case
She is in her 2nd trim Normal Renal Function Normal Bp Not anaemia Good out come for the type renal disease Counsel on the adverse outcome Review her regularly Should have a good out if no adverse effect develop