Renal Diseases In Pregnancy
Embed Size (px)
Transcript of Renal Diseases In Pregnancy
Renal Diseases In Pregnancy
Renal Diseases In Pregnancy Professor Hassan NasratFaculty of Medicine King Abdul-Aziz University Physiological changes in renal system and its clinical implications.Common urinary tract diseases in pregnancy.Pregnancy in women with chronic kidney disease.Acute renal injury (failure) in pregnancy.Anatomic ChangesFunctional Changes:Imaging studies Increases in size and weight due to increased renal vasculature. Also physiological hydro-ureter and hydronephorosis.Stasis and vesico-eretric reflux increase risk of urinary tract infection in pregnancy.The Effective Renal plasma flow (ERPF):The Glomerular filtration rate (GFR):The filtration fraction:The kidneys: The ureters: The Bladder: Glucose: In pregnancy glucosuria does not necessary indicate hyperglycemia i.e. it is not correlated with the blood glucose level.Proteinuria: Increased protein loss. Loss of more that 300 mg of protein/24hours is abnormalReduction in maternal plasma levels of creatinine, blood urea nitrogen (BUN) and uric acid.Serum Creatinie: falls by an average of 0.4 mg/dL (35 micromol/L) to a normal range of 0.4 to 0.8 mg/dL (35 to 70 micromol/L) Blood urea nitrogen (BUN) levels fall to approximately 8 to 10 mg/dL (2.9 to 3.9 mmol/L)
Proteinuria in pregnancy, Causes and DDQualitative testing Dip stick test: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+: - more than 1000 mg/dlFalse positive: due to differences in the osmolality ( concentration) of urine (high urine concentration can give false positive results), contamination with with blood or semen. False negatives: can occur with low specific gravity ( 100,000 colonies/ml of a single bacterial organism in culture from a clean catch voided sample of urine. Asymptomatic BacteriuriaDefinition: Acute bacterial cystitis presents with clinical signs and symptoms of urgency, frequency, dysuria, pyuria, and hematuria without evidence of systemic illness. It affectFrequency:1% to 4% of all pregnancies. The treatment: regiment is the same as in ASB. Follow-up surveillance, including monthly urine cultures for the duration of the pregnancy, is recommended.Uretheral Syndrome often due to Chlamydia infection is suspected in women symptoms consistent with cystitis but with a negative urine culture. CystitisIncidence: 1-2 %. Rt > Lt. The risk factors: ASB, previous history of pyelonephritis, urinary tracts malformations and calculi.Complications: Maternal: bacterial endotoxemia, can lead to endotoxic shock, adult Respiratory Distress Syndrome (ARDS), hemolytic anemia and permanent damage to of renal tissues.Fetal: preterm labor, premature rupture of membranes (PROM) and fetal growth restriction (IUGR).
Acute PyelonephritisThe diagnosis Systemic signs and symptoms: fever; dysuria, costovertebral angle tenderness (CVAT); shaking chills; nausea and vomiting. midstream urine (MSU) culture: Positive culture, in addition to of pyuria or leukocyte casts.The treatment: Hospitalization.Parenteral antimicrobial therapy (to be changed to oral route once the patient is a-febrile).Adequate intravenous hydration and close monitoring of urine output.Antipyretics and analgesics.Investigations: Sonosgraphy: If there is no clinical improvement by 48 to 72 hrs. blood and urine samples: for culture and sensitivity. Complete blood count and serum chemistry. Acute PyelonephritisDefinition: Acute Renal Failure (ARF) is a sudden decrease in renal function Diagnosis: Rapid increase in serum creatinine levels (of at least 0.5 mg/dL/day (44 mol/L/day).And oliguria with urine output of less than 400 mL in 24 hours (20% of the patients maintain normal urine volumes).Incidence: Rare he incidence of ARF that require dialysis is less than 1 in 10,000 - 15,000 pregnancies.Acute Renal Failure (ARF) in pregnancy
Preeclampsia and Eclampsia: Although rare event, but contributes significantly to obstetric causes of ARF. The picture is similar to acute tubular necrosis and recovery of renal function is the rule.
Severe Hemorrhage: Abruptio placenta, amniotic fluid embolism, and retained dead fetus:Hemolytic-Uremic Syndrome (HUS): This unusual cause of ARF can develop following several precipitating events including infections, pregnancy, and certain drugs. It occurs 7-10 days after a seemingly normal pregnancy. There is microangiopathic hemolytic anaemia, thrombocytopenia, with variable degree of neurologic symptoms.The prognosis of this disease is generally poor (61% mortality rate for cases reported prior to 1979). Recently it has markedly been improved with plasma exchange using plasmapheresis.Acute Fatty liver of Pregnancy:
High mortality rate: that ranges from 20% to 60%, mostly from the underlying cause e.g. sepsis and hemorrhage.Development of chronic renal failure: bilateral renal cortical necrosis (BRCN). This complication is particularly common with abruptio placenta. Some patients might have slow recovery of the renal function for up to 3 years after the onset and can achieve a satisfactory lifestyle without dialysis.Complications of ARF
The effect of the pregnancy on the kidneys function: The effect of the kidney disease on the pregnancy:
This depends on:The cause of renal disease (e.g. diabetes, SLE ...etc.) The renal function at the time of conception. Pregnancy with chronic Renal Disease (Failure)
1. Does pregnancy jeopardize the graft?2. What are the criteria that must be fulfilled before a transplanted patient is allowed to get pregnant?3. What is the effect of medication i.e. immunosuppressive therapy on the fetus?Pregnancy after Renal TransplantThe general advice are:pregnancy should be deferred for 1 - 2 years after transplantation with General good health.No proteinuria.No significant hypertension.No evidence of graft rejection.Serum creatinine < 2 mg/dl.Drug therapy