2. Physiological Adaptation
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.
5. Asymptomatic Bacteriuria
Incidence
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
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
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
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
This complicates 1-2% of pregnancies
More common in pregnancy ( physiological dilatation of
the upper renal tract).
Clinical Features
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
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
The presence and degree of renal impairment
The presence and severity of proteinuria
The underlying type of chronic renal disease
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.
21. Management
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.
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.
27. HELLP Syndrome
7% have actual renal failure
Thrombotic thrombocytopenic purura/hemolytic
uraemic syndrome (TTP/HUS)
Management
This depend on underlying cause
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
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
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
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
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
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
