OBSTETRIC MEDICINE

RENAL DISORDERS
IN PREGNANCY

DR.MAHA ABDULAZIZ
OBJECTIVES
BY THE END OF THIS TOPIC THE STUDENT SHOULD BE ABL TO:
 Appreciate the importance of preconception counselling
and its impact on improving pregnancy outcomes.
 Understand the impact of kidney disease on maternal and
infant health.
 Diagnose common pathological conditions in the renal
system during pregnancy
 Know the principles in management of those common
renal diseases during pregnancy

DR.MAHA ABDULAZIZ
What the pregnant woman wants
to know: Questions

 Is there a risk of my children inheriting

my condition?
 Will I have a normal healthy baby?
 Will pregnancy make my disease worse
& Will my disease be worse after
pregnancy?
 What treatment is safe during
pregnancy?
 Should I be delivered by Caesarean
section?
 Is breastfeeding advisable?

DR.MAHA ABDULAZIZ
 What are the anatomical
and physiological changes
in the renal system during
pregnancy???

DR.MAHA ABDULAZIZ
 kidney size increase
Anatomical Renal pelvis increase
changes Ureteral size increase
Renal plasma flow increase
GFR increase
Physiological Creatinine clearance increase
changes Blood Urea Nitrogen(BUN) Decrease
Serum Creatinine Decrease
Serum Uric Acid Decrease
THE PRESENCE OF GLUCOSUREA IS NOT NECESSORY ABNORMAL finding
??

DR.MAHA ABDULAZIZ
Changes in indices of renal function during pregnancy (mean
values); data from de Swiet, Medical disorders in
obstetric practice, 2002

DR.MAHA ABDULAZIZ
Urinary Tract Infections in Pregnancy
 The most common serious medical complication pf
pregnancy(2%).
 The incidence varies depends on the presence of
asymptomatic bacteriurea.
1-Asymptomatic bacteriuria:
Should be treated in pregnancy because of the high risk of
ascending infection(20-30 fold increased risk
ofpyelonephritis)
Management:
Amoxicillin
Cephalosporin
Nitrofurantoin
DR.MAHA ABDULAZIZ
Causative agents of UTIs

 Most common
Escherichia coli
 Others:
Enterococci
Staphylococcus saprophyticus and
Klebsiellas
 Rare
various types of pseudomonas and proteus

DR.MAHA ABDULAZIZ
 2-Cystitis:
 Clinical .
 Management:

Pyelonephritis:
 Clinical presentation:
 D.Diagnosis
 MANAGEMENT

DR.MAHA ABDULAZIZ
 MANAGEMENT
 Pyelonephritis in pregnancy should always be
treated as an inpatient.
 Urine &blood culture.
 Hemogram,serum creatinine and electrolytes
 Monitor vital signs and urinary output
 Intravenous hyderation.
 Intravenous antibiotic, changes to oral when the
patient afebrile and discharge with antimicrobial
for 7-10 days.
.

DR.MAHA ABDULAZIZ
 Cephalosporins and penicillins are recommended in
pregnancy because of their long term safety record

 Nitrofurantoin is also likely to be safe during pregnancy.

 Urine culture 1-2 weeks after antimicrobial therapy

completed.

The recurrence rate of pyelonephritis in pregnancy is

high.(30-40), so, All women who develop
pyelonephritis in pregnancy should receive prophylactic
antibiotics(Nitrofurantoin,100mg at bed time) for the
remainder of the pregnancy.
Complications

DR.MAHA ABDULAZIZ
 Acute Renal Failure
The approach to acute renal failure in pregnancy is the same as in the non-
pregnant state.
Causes :
Septic abortion.
Dehydration( hyperemesis gravidarum)
Obstetrical hemorrhage(Abruptio placenta+placenta previa)
Preeclampsia-eclampsia
 Puerperal sepsis & Septicaemia
Intrauterine fatal death(IUFD)
Acute pyelonphritis.
Urinary obstruction from stone

DR.MAHA ABDULAZIZ
Treatment
Prevention:
Careful treatment of shock
Proper treatment of high obstetric conditions
Avoid nephrotoxic antibiotics
Hydrocortisone 200mg/twice daily
DELIVERY AS EARLY AS POSSIBLE

DR.MAHA ABDULAZIZ
Pregnancy in Women with Chronic Renal
Disease

The prognosis for pregnancy in women with chronic renal disease is

dependent more on the degree of renal impairment than the
underlying disorder.
The presence of hypertension increases the risk of morbidity with
pregnancy
 Chronic kidney disease (CKD) is classified into five stages based
on the level of renal function (Table 12.3 ten teacher- 19th edit.).

DR.MAHA ABDULAZIZ
Stages of chronic kidney disease(Ten teacher- 19th edit.chap:12)

Stages 1 and 2 ( around 3 % )of women of childbearing age (20–39).

 Stages 3–5 ( 1 in150) women in this age group, pregnancy in these
women is less common.

DR.MAHA ABDULAZIZ
Effect of pregnancy on CKD

 Women with CKD stages 1–2 have mild renal

dysfunction ( serum creatinine 110μmol/L(< 1.5
mg/dL), minimal proteinuria (1 g/24 hours), and
absent or well-controlled hypertension pre-pregnancy)
= little or no adverse effect on long-term maternal
renal function and have smooth pregnancy(good
maternal and fetal outcome).
DR.MAHA ABDULAZIZ
 Women with moderate to severe disease (stages 3–
5) are at highest risk of complications during
pregnancy and of an accelerated decline in their
renal function. Pre-existing hypertension and
proteinuria greatly increase the risk.
 moderate (creatinine 1.5 mg/dL to 3.0 mg/dL)
 Severe(creatinine > 3mg/dL)

DR.MAHA ABDULAZIZ
 Effect of CKD on pregnancy outcome
 Pregnancies in mothers with CKD have
 increased risks of preterm delivery,
 Delivery by Caesarean section (40 per cent)
 Fetal GR (increased two-fold).
 Fetal death(50%)

The risk of adverse pregnancy outcome correlates with the degree

of renal dysfunction (Table 12.4 ten teacher 19th edition).

DR.MAHA ABDULAZIZ
Estimated effects of renal function on pregnancy
outcome and maternal renal function

DR.MAHA ABDULAZIZ
Monitoring of patients with CKD during
pregnancy
 Blood pressure
 Full blood count
 Renal ultrasound
 • Renal function
 Fetal ultrasound
 • creatinine
 Uterine artery
Doppler 20–24
weeks
DR.MAHA ABDULAZIZ
Dialysis in Pregnancy
 Hemodialysis and peritoneal dialysis can
be successfully carried out during
pregnancy.
 Thefetus tolerates uremia in the mother
poorly, so dialysis may need to be done
more frequently.
 Patientswith severe renal disease may
require the earlier initial of dialysis for
fetal concerns.
DR.MAHA ABDULAZIZ
Nephrolithiasis

 Renal calculi are among the most common

causes of abdominal pain requiring hospitalization

during pregnancy.

DR.MAHA ABDULAZIZ
Pregnancy in women with renal transplant

Women with end-stage kidney disease conception

is rare.
 After renal transplantation about 2–10 % of female
recipients conceive.
 Of pregnancies progressing beyond the third trimester,
the vast majority ( 90 %) result in a successful
pregnancy outcome.
 Most transplantation centers advise that conception is
safe after the second post-transplantation year,
provided the graft is functioning well and no rejection
episodes occur in the year before conception.
DR.MAHA ABDULAZIZ
Pregnancy in women with renal
transplants(cont.)
 All pregnancies in transplant recipients are high risk and
should be managed by a different specialty team.
 Complications
 Pregnancy-induced hypertension (30–50 %),
 Preterm delivery (40–60 %),
 Pre-eclampsia (10–40 %)
 Urinary tract infection (20–40%).
Vaginal delivery is safe, with Caesarean section considered
for the usual obstetric indications.

DR.MAHA ABDULAZIZ
Monitoring of renal transplant patients
during pregnancy
 Renal function
 blood pressure
 creatinine
 proteinuria
 Drug levels
 Fetal growth
 If renal function declines, exclude
 • obstruction
 • infection
 • rejection.
DR.MAHA ABDULAZIZ
 Predictors of fetal outcome

 Pre-pregnancy maternal hypertension,

 Diabetes mellitus
 Maternal drug treatment(immunosuppressive
medications)

Prednisolone, azathioprine, cyclosporin and

tacrolimus are considered safe.

DR.MAHA ABDULAZIZ
DR.MAHA ABDULAZIZ