Urinary tract disorders in
pregnancy
Upper urinary tract:-
Anatomical changes:-
1. Kidney enlarges during pregnancy.
2.increase circulating hormones (progesterone) &
mechanical (pressure of pregnant uterus on
bladder ) will lead to dilatation of ureters & pelvi
– calcyeal system (97% had hydronephrosis ).This
occur from the first trimester , more on right side
- stasis – increase UTI (asym.&symptomatic
bacteruria ) .
3. Vesico- ureteric reflux occurs in 3% will lead to
increase incidence of pyelonephritis in pregnancy.
Physiological changes:-
• 50% increase in R.P.F & G.F.R from the first
trimester.
• Increase G.F.R will lead to glycosuria 10 times
more than non pregnant .2/3 had glycosuria.
• Increase GFR will lead to decrease blood urea
& uric acid due to increase renal clearance.
•
Chronic renal disease:-
Risk of pregnancy will depend on:-
1. Rate of disease progress.
2. Amount of renal damage.
3. Hypertension is a major risk factor.
Antenatal management:-
1. Frequent ANC check B.P to detect H.T or
superimposed P.E.T.
2. MSG to detect UTI should be treated.
3. U/S to detect IUGR (common sequale).
Deterioration of renal function, if more than 15-
20% needs immediate delivery.
Urinary calculi:-
• 0.3 /1000 pregnant.
• Single x-ray for the purpose of diagnosis is not
contraindicated at any stage of pregnancy.
• Treatment is conservative: - I.V fluid, AB &
systemic analgesia.
• Usually non- obstructive stone:-AB until after
delivery.
• Obstructive stone: - need surgery.
•
Haematuria:-
• Commonest cause in pregnancy is UTI.
• Other causes: - stone, tumors must be
excluded by renal U/S or cystoscopy.
Pregnancy after renal transplantation:-
1. Important the transplanted kidney should be
stable, so wait 18 months after transplantation
prior to pregnancy.
2. Women should be normotensive prior to
pregnancy even by therapy.
3. Immunosuppressive treatment should be at
maintenance dose.
4. Most important that renal function should be
adequate to allow increase demand of pregnancy.
5. Risk associated with pregnancy:-
a.H.T, renal failure,& infection (CMV& herpes
due to immunpsuppresion).
B.preterm delivery 50%.
C.IUGR 20%.
Acute renal failure:-
• U/o less than 400 ml /day.
• The common obstetrical causes: - septic
abortion, severe PET, abruption, placenta
previa & PPH.
• Treatment: - I.V fluid monitored by CVP, AB,
corticosteroid & renal dialysis.
•
UTI:-
• Common in pregnancy .8% of Pregnant
women had asymptomatic, (100000
organism/ml of urine).If untreated, half (50%)
will develop pyelonephritis.
• So asymptomatic bacteruria should be treated
with AB for 7-10 days course of ampicilline or
cephalosporin, or 3 days course of
nitrofurantoin.
•
Acute pyelonephritis:
1-2% of pregnancy .Fever, loin pain, vomiting
.Increase preterm labour, & IUGR.
Treatment: hospital Admission, MSG:
microscopy & culture, but AB starts
immediately (usually start I.V
1. AB: ampicilline or cephalosporin, sometime
amino glycoside may be needed.
2. I.V fluid 1.5-2 litters /day.
3. Systemic analgesia.
Lower urinary tract:-
(Bladder & urethra).
Increase frequency of micturition (7 times/day).
Increase nocturia (2 night voids).
Causes (combination)I
1. Pressure effect of pregnant uterus on the
bladder.
2. Increase bladder capacity from 12-32 weeks up
to 1300ml.
3. ↑ Urine production especially in 1
st
& 2
nd
trimesters
Incontinence:-
• 67% of pregnant get stress incontinence.
• More common in multiparous.
• In most cases reversible & resolve
postpartum.
• During pregnancy the cause is detrusor
instability, & in postpartum period the cause is
genuine stress incontinence because of pelvic
floor denervation (stretching of the
supporting structures as a result of labour may
lead to damage & weakening of the sphincter
mechanism).
•
Voiding difficulties:-
• During pregnancy:-
• Urinary retention at 14-16 weeks by
retroverted uterus incancerated in the pelvis.
• Treatment by catheter drainage, patient lie
prone, occasionally uterus manipulated under
anesthesia.
•
• During labour:-
• Causes of retention are epidural, prolonged
traumatic delivery, forceps.
• Treatment by catheterization.
•
Urinary fistula:-
• Obstructed prolonged labour lead to tissue
necrosis.
• Small fistula may heal spontaneously by
continuous catheter drainage & AB.
• Large fistula: need surgical repair after 10-
12weeks so that edema & infection resolved.
• Low fistula: repair vaginally.
• High fistula or complex fistula: need abdominal
operation.
•