Pregnancy and renal disease docx - D. Wsn

PREGNANCY AND RENAL DISEASE

Physiological renal changes in pregnancy

Increase renal blood flow and GFR

. decrease serum urea and creatinine level

. kidney length increase by approximately 1 cm and volume increases 30 %

. the entire collecting system is dilated, which may have confused with an obstructive uropathy

URINARY TRACT INFECTION

This may be divided into the following:

. asymptomatic bacteriuria

. acute cystitis

. acute pyelonephritis

Asymptomatic bacteriuria

.this affects 4 – 7 % of pregnant woman of whom up to 40 % will develop symptomatic UTI and 30 % acute pyelonephritis if untreated in pregnancy

. 75 – 90 % due to E.coli

. Bacteriuria is only considered significant if the colony count exceeds 100,000 \ mL on mid-stream urine

Acute cystitis

. complicates about 1% of pregnancies

. most common infection E. coli and usually preceded by asymptomatic bacteriuria

. usually symptomatic: frequency, urgency. dysuria, hematuria, proteinuria and suprapubic pain

. common in DM ,on steroid , on immunosuppression and in those patient with history of recurrent UTI

Acute pyelonephritis

. complicate 1 – 2 % 0f pregnancies

. more common in pregnancy because of the physiological dilatation of the upper renal tract

.symptomatic :fever ,loin and or abdominal pain ,vomiting ,rigors as well as proteinuria ,hematuria and concomitant features of cystitis

.risk factors : immunosuppression and steroid ,DM ,polycystic kidney ,congenital anomalies of renal tract ,urinary tract calculi , neuropathic bladder

INVESTIGATIONS

. urinalysis: useful marker nitrites and leukocytes

.MSU: positive result is confirmed with culture of more than 100,000 l ml mixed growth or non-significant culture –repeat MSU

. blood: blood culture, FBS ,U&C in pyrexia patient

.Renal US after single episode of pyelonephritis or two or more UTI to exclude hydronephrosis ,congenital abnormalities and calculi

.monthly MSU should be send in woman with culture proven UTI to prove eradication

TREATMENT

.oral antibiotics are recommended in asymptomatic bacteriuria and cystitis to prevent pyelonephritis and preterm labor

. pyelonephritis should be treatment with IV antibiotics until the pyrexia settles and vomiting stop

IV fluids and antipyretics should also be given (in patient management)

Duration of treatment

. asymptomatic bacteriuria three days

. cystitis 7 days

. pyelonephritis 10 – 14 days

Prevention

. increase fluid intake

. double voiding and emptying bladder after sexual intercourse

. cranberry juice to reduce bacteriuria

. prophylactic antibiotics if two or more infections in patient with risk factors

Antibiotic options

Depends on antibiotic sensitivities:

. penicillin amoxicillin

. cephalosporin

. Nitrofurantoin: avoid in third trimester because risk of hemolytic anemia in neonate with G6PD deficiency

.Gentamycin limited by the risk of ototoxicity

CHRONIC RENAL DISEASE

.the frequency of complications is directly proportional with initial creatinine level .

. 10 % of woman with creatinine equal or more than 1.4 mg \dl will have progressive renal deterioration

.creatinine more than 2.3 mg\dl may be regarded as contra indication to pregnancy.

.women with end stage renal disease and dialysis should be counselled about renal transplant before pregnancy

.after successful transplant :better to wait 2 year before pregnancy

.there are increased fetal and maternal risk with renal disease .this depend upon :

*the underlying cause (DM ,SLE….)

*the degree of renal impairment

*the presence and control of hypertension

*the amount of proteinuria

RISK FACTOR

1.maternal :

.acceleration and possible permanent deterioration in renal function

.hypertension

.proteinuria

.pre eclampsia

.venous thromboembolism

2.fetal risk:

.abortion

.IUGR

.spontaneous and iatrogenic preterm labor

.fetal death

MANGEMENT

.baseline investigation for assessment of renal function and underlying pathology

.early and regular antenatal care is advice with the fallowing aims :

*control BP –tight control lessens chance of renal function declining

*monitor renal function and protein urea

*assess fetal size and well being with serial growth scans and Doppler

*early detection of complication –anemia ,UTI , Pre-eclampsia,IUGR

.medication should be reviewed and may be altered eg ACEIs

. prophylactic low dose aspirin may reduce the risk of pre-eclampsia

.erythropoetin may be required with significant renal impairment

.hospital admission : increase protein urea ,hypertension ,deteriorating renal function or symptoms of Pre-eclampsia

ACUTE RENAL FAILURE

Causes of renal failure in pregnancy

*pre-renal (hyovolaemic)

.antepartum(abruption , placenta praevia…)

.hyper emesis

.septic shock

.acute fatty liver of pregnancy

*intrinsic

Pre –eclampsia

HELLP syndrome

Sepsis

Drug reaction

Amniotic fluid embolus

*post –renal

Obstruction like ureteric damage or pelvic or broad ligament hematoma

Presentation :characterize by oliguria ,increase urea and creatinine ,hyperkalemia and metabolic acidosis

There are three phases

1.oliguria

2.polyurea

3.recovery with normal urine

Treatment

.seek the advice of nephrologist

.usually reversible with appropriate management

.intervention include catheterization ,CVL and renal biopsy if improvement is delayed ,only in minority require dialysis

.adequate fluid balance ( input and output )adequate replacement and avoid overload

.maintain blood pressure for adequate renal perfusion

.review medication and stop nephrotoxic drug

.correct hyperkalemia ,coagulopathy ,and give antibiotic if infection is suspected

Pregnancy and renal disease