1. Renal Disorders in
Pregnancy
DR. Shamsa Tariq
Associate Professor RMC

2. Physiological Adaptation
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Dramatic dilatation of the urinary collecting system
during pregnancy.
Renal plasma flow rises by 60-80% by the second
trimester.
RPF falls throughout the third trimester but maintained at
50% greater than prepregnancy levels.
GFR increases significantly and creatinine clearance
rises by 50%.
Fall in Urea and Creatinine level
Pretein excretion is increased up to 300 mg per 24
hours.
80% of women develop edema due to physiological
increase in sodium retention.

3. Renal Disorders

Urinary tract infection

Chronic renal disease

Acute renal failure

Pregnancy in renal transplant recipient

4. Urinary Tract Infection

Asymptomatic bacteriuria

Acute cystitis
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Acute pyelonephritis

5. Asymptomatic Bacteriuria
Incidence
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This ranges from 2 to 10%
40% will develop symptomatic urinary-tract infection in
pregnancy.
Women with history of previous urinary-tract infection
have a 10-fold increased risk of developing cystitis or
acute pyelonephritis in pregnancy.

6. Pathogenesis
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75-90% due to E coli, probably derived from large bowel
Colonization of urinary tract results from ascending
infection from the perineum and is related to sexual
intercourse.
Diagnosis
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Most women with asymptomatic bacteriuria are found to
be infected during early pregnancy and very few
subsequently acquire asymptomatic bacteriuria
Bacteriuria is only considered significant if the colony
count exceeds 100,000/ml on a MSU

7. Management
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The choice of antibiotic depends on culture/sensitivity
Ampicillin, amoxicillin, Augmentin and the cephalosporin
are safe and appropriate antibiotics in pregnancy.
Treatment should be continued for 2 weeks in the first
instance and regular urinary culture required.

8. Acute Cystitis
Incidence
Cystitis complicates 1% of pregnancies
Clinical features
Urinary frequency, dysuria, haemeturia and
suprapubic pain
Diagnosis
Significant bacteriuria on MSU

9. Management

Same as asymptomatic bacteriuria
Several non-pharmacological maneuvers may help to
prevent recurrent infection in women with recurrent
urinary-tract infections in pregnancy.
These include:
 Increase fluid intake
 Emptying the bladder following sexual intercourse

10. Acute Pyelonephritis
Incidence
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This complicates 1-2% of pregnancies
More common in pregnancy ( physiological dilatation of
the upper renal tract).
Clinical Features
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Fever
Loin and abdominal pain
Vomiting
Rigors
Proteinuria
Haematuria

11. Risk increases in women
 On steroid therapy

With polycystic kidneys
 Congenital abnormalities of renal tract
 Urinary-tract calculi
 Diabetes

12. Diagnosis
Significant bacteriuria on MSU specimen.
Differential diagnosis
 Pneumonia
 Viral infections
 Cholecystitis , biliary colic
 Acute appendicitis
 Gastroenteritis,
 Placental abruption
 Degenerating uterine fibroid.
Blood cultures and a full blood count is
recommended

13. Management
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Should be after hospitalization

I/V Antibiotic Penicillin and cephalosporin are the Ist
choice.

14. Chronic Renal Disease

15. Pregnancy with Chronic Renal
Disease
Effects of Pregnancy
The risks include:
 Accelerated decline in renal function
 Rising hypertension
 Worsening proteinuria

16. Effects of chronic renal disease on pregnancy
The risks includes:
 Miscarriage
 Pre-eclampsia
 Intrauterine growth retardation
 Preterm delivery
 Fetal death

17. Factors Influencing Outcome
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The presence and degree of renal impairment
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The presence and severity of proteinuria
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The underlying type of chronic renal disease

18. Degree of Renal Impairment
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Mild renal impairment (plasma creatinine <125 umol/I)
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Moderate renal impairment (plasma creatinine 125-250
umol/I)
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Severe renal impairment (plasma creatinine >250 umol/I)

19. In general, women without hypertension or renal
impairment prior to conception have successful
pregnancies, and pregnancy does not adversely
influence the progression of the renal disease.

20. Specific Types of Renal Disease

Glomerulonephritis
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Reflux nephropathy
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Diabetic nephropathy
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SLE nephritis
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Polycystic kidney disease (PKD)

21. Management
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Women with chronic renal disease should be managed
jointly by obstetricians and physicians
Preconceptual assessment of renal functions and blood
pressure should be made.
In view of the increased risk of pre-eclampsia, treatment
with low dose aspirin should be considered especially in
those with hypertension, renal impairment or a previous
poor obstetric history.
Careful monitoring and control of blood pressure both
prepregnancy and antenatally is important.

22. 
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The fetus should be monitored with regular ultrasound
assessment of growth and Doppler assessment of
uterine and umbilical circulation.
Admission should be considered if the woman develops
worsening hypertension, deteriorating renal function or
proteinuria, or superimposed eclampsia.

23. Acute Renal Failure

24. Incidence

Rare in pregnancy <0.005%
Clinical Features
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Anuria/oliguria
urea, creatinine rises
Decreased GFR

25. Causes
Infection
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Septic abortion
Puerperal sepsis
Rarely acute pyelonephritis
Blood Loss
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Postpartum hemorrhage
Abruption

26. Volume Contraction
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Pre-eclampsia
Eclampsia (6%)
Hypermesis gravidarum
Post-renal Failure
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Ureteric damage or obstruction
Pre-eclampsia

27. HELLP Syndrome
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7% have actual renal failure
Thrombotic thrombocytopenic purura/hemolytic
uraemic syndrome (TTP/HUS)
Management
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This depend on underlying cause

28. Pregnancy in Renal
Transplant
Recipients

29. 
Women receiving renal transplants should be warned
that as renal function returns to normal, ovulation,
menstruation and fertility also resume.

Women desiring pregnancy are usually advised to wait
about 1-2 years after transplantation.

30. Effects of pregnancy on renal transplants
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Pregnancy probably has no adverse long-term effect
Renal allograft adapt to pregnancy
About 15% of women develop significant impairment
About 40% develop proteinuria towards term

31. Effect of renal transplants on pregnancy
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The chance of successful outcome is >90%, but this is
reduced to 70% if complications occur before 28 weeks’
gestation.
The complication rate is higher for diabetics.

32. Antenatal Management
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Women should be managed jointly by nephrologists and
obstetricians with expertise in the care of pregnant renal
transplant recipients.
Careful monitoring and control of blood pressure is
important.
Regular assessment of RFTs by creatinine clearance
and 24 hour protein excretion, as well as serum
creatinine and urea is essential.
A FBC and LFTs should also be checked regularly.
Anemia is common and haematinics should be
prescribed.
The fetus should be monitored with regular ultrasound
assessment of growth and Doppler assessment of
uterine Sand umbilical circulation.

33. Immunosuppressive Therapy

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The doses of immunosuppressive drugs are maintained
at prepregnancy
Levels which should preferably be:
Prednisolone, <15 mg/day plus either
Azathioprine, <2 mg/kg/day
Cyclosporin A, 2-4 mg/kg/day

34. Delivery
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Caesarean section is only required for obstetric
indications.
Prophylactic antibiotics should be given to cover any
surgical procedure including episiotomy.
Parental steroids are necessary to cover labour, as with
any woman on maintenance steroids.

35. Neonatal Problems
These are largely related to prematurely but also include
the following:
 Thymic atrophy
 Transient leukopenia or thrombocytopenia
 Depressed haemopoiesis