renal disease in preg

Dr OmoregieDr Omoregie 11

Renal disease in pregnancyRenal disease in pregnancy


synopsissynopsisIntroduction.Introduction.Renal system changes in normal pregnancy.Renal system changes in normal pregnancy.Pregnancy in women with pre-existing renal Pregnancy in women with pre-existing renal disease.disease.Specific renal diseases in pregnancy.Specific renal diseases in pregnancy.Counselling patient with chronic renal disease.Counselling patient with chronic renal disease.Management guidelinesManagement guidelinesDelivery Delivery Pregnancy in dialysis patientsPregnancy in dialysis patientsPregnancy in renal transplant recipientsPregnancy in renal transplant recipientsConclusions.Conclusions.


introductionintroduction

The attitude of clinicians towards pregnancy in The attitude of clinicians towards pregnancy in women with CRD has changed tremendously in women with CRD has changed tremendously in the last 3 decades.the last 3 decades.Previously the advise was therapeutic abortion Previously the advise was therapeutic abortion followed by sterilisation – this pessimism was followed by sterilisation – this pessimism was succinctly stated in a Lancet editorial of 1975 succinctly stated in a Lancet editorial of 1975 which stated that…’Children of women with renal which stated that…’Children of women with renal dz used to be born dangerously or not at all – dz used to be born dangerously or not at all – not at all if their doctors had their way.” not at all if their doctors had their way.” The current practice, based on clinical evidence The current practice, based on clinical evidence is one of cautious optimism. Most pregnancies is one of cautious optimism. Most pregnancies succeeds provided renal impairment and/or succeeds provided renal impairment and/or hypertension are minimal. hypertension are minimal.


Renal system changes in pregRenal system changes in preg

GFR and renal plasma flow increases by 50-GFR and renal plasma flow increases by 50-70% above the non-pregnant value.70% above the non-pregnant value.

24-hr creatinine clearance increases 24-hr creatinine clearance increases immediately after conception.immediately after conception.

Plasma levels of creatinine and urea which Plasma levels of creatinine and urea which average 73average 73µµmol/l and 4.3mmol/l in the non- mol/l and 4.3mmol/l in the non- pregnant state decrease to mean values of pregnant state decrease to mean values of 5151µµmol/l and 3.1mmol/l in pregnancy.mol/l and 3.1mmol/l in pregnancy.

The kidneys enlarges in pregnancy – its length The kidneys enlarges in pregnancy – its length on x-ray increasing by approximately 1cm. on x-ray increasing by approximately 1cm.


The calyces, renal pelves and ureter dilate The calyces, renal pelves and ureter dilate markedly – all these occurring very early in markedly – all these occurring very early in pregnancy.pregnancy.

Clinical implicationsClinical implicationsIt should not be mistaken for obstructive It should not be mistaken for obstructive uropathy.uropathy.Stasis of urine within the ureters may increase Stasis of urine within the ureters may increase the incidence of acute pyelonephritis in pregnant the incidence of acute pyelonephritis in pregnant women with asymptomatic bacteriuria.women with asymptomatic bacteriuria.There may be errors in test based on timed urine There may be errors in test based on timed urine collections.collections.Post-partum x-ray examination of the urinary Post-partum x-ray examination of the urinary tract should be delayed until at least 12-16wks tract should be delayed until at least 12-16wks after delivery to allow the changes to resolve.after delivery to allow the changes to resolve.


Urinary protein levels are slightly higher in Urinary protein levels are slightly higher in pregnancy – may be due to changes in the pregnancy – may be due to changes in the tubular function.tubular function.

A normal urine in the non-pregnant may A normal urine in the non-pregnant may contain up to 200mg/l of protein; whereas contain up to 200mg/l of protein; whereas up to 300mg/l is considered normal in preg up to 300mg/l is considered normal in preg and occasionally it may be up to 500mg/l and occasionally it may be up to 500mg/l without significant renal disease.without significant renal disease.

The dipstick testing of urine often shows The dipstick testing of urine often shows trace of protein during pregnancy: the trace of protein during pregnancy: the sensitivity of the kit is set for the non-sensitivity of the kit is set for the non-pregnant state. pregnant state.


Preg in women with pre-existing Preg in women with pre-existing renal diseaserenal disease

The frequency of acute pyelonephritis The frequency of acute pyelonephritis increases.increases.Pregnancy has no adverse effect on the Pregnancy has no adverse effect on the natural history of established renal natural history of established renal parenchymal disease, provided the renal parenchymal disease, provided the renal function is minimally compromised and function is minimally compromised and hypertension is absent – mild to moderate hypertension is absent – mild to moderate renal dysfxn (e.g. plasma creatinine renal dysfxn (e.g. plasma creatinine <125<125µµmol/l, creatinine clearance >60ml/h) mol/l, creatinine clearance >60ml/h) usually have successful pregnancy with usually have successful pregnancy with normal fetal outcome. normal fetal outcome.


Specific renal diseases in pregSpecific renal diseases in preg

Acute glomerulonephritis complicating preg is Acute glomerulonephritis complicating preg is rare – when it occurs it is mistaken for pre-rare – when it occurs it is mistaken for pre-eclampsia.eclampsia.Chronic glomerulonephritis – the course of preg Chronic glomerulonephritis – the course of preg should not be complicated, if the patient is should not be complicated, if the patient is normotensive. Unfortunately hypertension often normotensive. Unfortunately hypertension often supervenes early in the course of such a supervenes early in the course of such a pregnancy. UTI may occur more frequently.pregnancy. UTI may occur more frequently.Lupus nephropathy – due to SLE, view is Lupus nephropathy – due to SLE, view is controversial. Prognosis most favourable if dz controversial. Prognosis most favourable if dz was in remission >6 months prior to conception, was in remission >6 months prior to conception, steroid dosage should be increases postpartum.steroid dosage should be increases postpartum.


Renal disease due to scleroderma and Renal disease due to scleroderma and periarteritis nodosa results in dismal preg periarteritis nodosa results in dismal preg outcome with many cases ending in maternal outcome with many cases ending in maternal death.death.Diabetic nephropathy – pregnancy has no Diabetic nephropathy – pregnancy has no adverse effect on renal lesion, but the frequency adverse effect on renal lesion, but the frequency of UTI, oedema and/or pre-eclampsia is of UTI, oedema and/or pre-eclampsia is increased.increased.Urolithiasis during pregnancy has a prevalence Urolithiasis during pregnancy has a prevalence of 0.03-0.35%, most of the renal stones contain of 0.03-0.35%, most of the renal stones contain calcium. The course of the disease is not calcium. The course of the disease is not affected by pregnancy. Note – it is a major affected by pregnancy. Note – it is a major cause of non-obstetrically related abdominal cause of non-obstetrically related abdominal pain during pregnancy. UTI can be more pain during pregnancy. UTI can be more frequent. frequent.


Polycystic kidney dz – preg well tolerated, Polycystic kidney dz – preg well tolerated, provided renal function is preserved and provided renal function is preserved and hypertension is absent.hypertension is absent.

Pregnancy is well tolerated by women with Pregnancy is well tolerated by women with single and normally situated kidney.single and normally situated kidney.

Pelvic kidneys – pregnancy is well Pelvic kidneys – pregnancy is well tolerated, dystocia rarely occurs with a tolerated, dystocia rarely occurs with a pelvic kidney. Decreased fetal salvage is pelvic kidney. Decreased fetal salvage is due to other malformations of the due to other malformations of the urogenital tract. urogenital tract.


Counselling patient with CRDCounselling patient with CRD

Is pregnancy possible?Is pregnancy possible?Will pregnancy be complicated?Will pregnancy be complicated?Will the pregnancy result in a healthy baby?Will the pregnancy result in a healthy baby?Will the pregnancy cause any long-term Will the pregnancy cause any long-term harm?harm?

Pregnancy in women with CRD is possible Pregnancy in women with CRD is possible depending on the degree of renal impairment depending on the degree of renal impairment and the absence of hypertension, rather than and the absence of hypertension, rather than the underlying parenchymal renal lesion.the underlying parenchymal renal lesion.


Therefore, pregnancy is restricted to those Therefore, pregnancy is restricted to those whose plasma creatinine levels are 250whose plasma creatinine levels are 250µµmol/l or mol/l or less and who have a DBP of 90mmHg or lower less and who have a DBP of 90mmHg or lower (preferably below 80mmHg)(preferably below 80mmHg)

The prospective mother should be counselled on The prospective mother should be counselled on the need for close monitoring during pregnancy, the need for close monitoring during pregnancy, the increased risk of hypertension complicating the increased risk of hypertension complicating the pregnancy and the likelihood of terminating the pregnancy and the likelihood of terminating the pregnancy as a result of this complication. the pregnancy as a result of this complication.

Women with proteinuric disease should be Women with proteinuric disease should be advised that oedema will most likely appear – or advised that oedema will most likely appear – or if present worsen: but that these signs are if present worsen: but that these signs are mainly cosmetic and usually do not jeopardise mainly cosmetic and usually do not jeopardise the pregnancy. the pregnancy.


The chances of producing a healthy child The chances of producing a healthy child is good for those with minimal renal is good for those with minimal renal dysfunction.dysfunction.


Guidelines for managementGuidelines for management

Pre-conception care – planned pregnancyPre-conception care – planned pregnancy - Good diet, no smoking, no alcohol- Good diet, no smoking, no alcohol

Uncomplicated antenatal courseUncomplicated antenatal course- ANC visitANC visit- 2 weekly until 32 wk gestation and thereafter weekly until 2 weekly until 32 wk gestation and thereafter weekly until

deliverydelivery- Assessment in the ANCAssessment in the ANC- Booking clinic – Hx, physical exam – wt, Ht, BP, FH, lie, Booking clinic – Hx, physical exam – wt, Ht, BP, FH, lie,

presentation, FHRpresentation, FHR- Investigations – PCV, blood group, genotype, VDRL, Investigations – PCV, blood group, genotype, VDRL,

urinalysis&m/c/s, ? USS etc.urinalysis&m/c/s, ? USS etc.- Drugs - Malarial chemoprophylaxis + haematinicsDrugs - Malarial chemoprophylaxis + haematinics


Subsequent visits – Hx, P.E, wt, FH, lie, Subsequent visits – Hx, P.E, wt, FH, lie, presentation, FHR, urinalysis, PCV.presentation, FHR, urinalysis, PCV.

Supplementary investigationsSupplementary investigations- Assessment of renal function: 24hr Assessment of renal function: 24hr

creatinine clearance and 24hr protein creatinine clearance and 24hr protein excretion.excretion.

- Urine m/c/s (early detection of asympt Urine m/c/s (early detection of asympt bacteriuria).bacteriuria).

- Early detection of pre-eclampsiaEarly detection of pre-eclampsia- Assessment of fetal size, development & Assessment of fetal size, development &

well being.well being.


Further MxFurther Mx- If renal fxn deteriorates – seek for causeIf renal fxn deteriorates – seek for cause- If reversible (UTI, dehydration or electrolyte If reversible (UTI, dehydration or electrolyte

imbalance) treat and allow pregnancy to continue.imbalance) treat and allow pregnancy to continue.- When proteinuria occurs and persist, but BP is When proteinuria occurs and persist, but BP is

normal and renal function is preserved, the normal and renal function is preserved, the pregnancy should be allowed to continue.pregnancy should be allowed to continue.

- BP – moderate hyptension (DBPBP – moderate hyptension (DBP<<110mmHg) need 110mmHg) need not be treated, treatment of severe Ht not be treated, treatment of severe Ht (DBP>110mmHg) is necessary for maternal well (DBP>110mmHg) is necessary for maternal well being and also allows the preg to continue, so has being and also allows the preg to continue, so has to achieve a further fetal maturation prior to to achieve a further fetal maturation prior to delivery. delivery.


Fetal surveillance – necessary since IUGR is Fetal surveillance – necessary since IUGR is associated with renal dz in pregnancy. USS, associated with renal dz in pregnancy. USS, antenatal cardiotocography, fetal pulm maturity antenatal cardiotocography, fetal pulm maturity (L/S ratio).(L/S ratio).

DeliveryDelivery- Induce labour at 38wk – to prevent IUFD due to Induce labour at 38wk – to prevent IUFD due to

placental failure.placental failure.Reasons for early delivery prior to 38wksReasons for early delivery prior to 38wks- Evident renal fxn deteriorationEvident renal fxn deterioration- Signs of imminent IUFDSigns of imminent IUFD- Uncontrollable hypertensionUncontrollable hypertension- EclampsiaEclampsiaNote: Delivery should only occur in centres with good fetal monitoring Note: Delivery should only occur in centres with good fetal monitoring

devices, operative delivery and neonatal resuscitation servicesdevices, operative delivery and neonatal resuscitation services


Diagnosis of renal dz during pregnancyDiagnosis of renal dz during pregnancyOccasionally noted for the 1Occasionally noted for the 1stst time during preg time during preg

It is essential to try and establish a diagnosisIt is essential to try and establish a diagnosis

If a patient presents with HT, proteinuria and/or If a patient presents with HT, proteinuria and/or abnormal renal fxn, it is difficult to distinguish renal abnormal renal fxn, it is difficult to distinguish renal parenchymal dz from pre-eclampsia.parenchymal dz from pre-eclampsia.

A previous hx of renal dz, abnormal urinalysis, a family A previous hx of renal dz, abnormal urinalysis, a family hx of renal disorder or a hx of systemic illness known to hx of renal disorder or a hx of systemic illness known to involve the kidneys is very helpful.involve the kidneys is very helpful.

Note – renal parenchymal dz may coexist with pre-Note – renal parenchymal dz may coexist with pre-eclampsia.eclampsia.

A definitive diagnosis usually defered until further A definitive diagnosis usually defered until further assessment after delivery. assessment after delivery.


Pregnancy in dialysis patientsPregnancy in dialysis patients

Patient usually have irregular or absent Patient usually have irregular or absent menstruation, decreased libido and menstruation, decreased libido and impaired fertility – but they can conceive!!impaired fertility – but they can conceive!!

Therefore use contraception (if pregnancy Therefore use contraception (if pregnancy is undesired).is undesired).

The outcome of preg is usually very poorThe outcome of preg is usually very poor

Maternal condition may be compromised Maternal condition may be compromised


Pregnancy in renal transplant recipientPregnancy in renal transplant recipient 40% of conception end up in spontaneous abortion, 40% of conception end up in spontaneous abortion, termination of pregnancy or ectopic gestation.termination of pregnancy or ectopic gestation.90% of the pregnancy that proceed beyond 190% of the pregnancy that proceed beyond 1stst trimester trimester results in successful outcome.results in successful outcome.

Criteria for successful outcomeCriteria for successful outcomeGood general health for 2yrs after transplantGood general health for 2yrs after transplantStature compatible with good obstetric outcome.Stature compatible with good obstetric outcome.No proteinuriaNo proteinuriaNo significant hypertensionNo significant hypertensionNo evidence of graft rejectionNo evidence of graft rejectionNo evidence of pelvicalyceal distension on a recent No evidence of pelvicalyceal distension on a recent excretory urogramexcretory urogramStable GFR: plasma creatinine Stable GFR: plasma creatinine <<180180µµmol/lmol/lDrug therapy: prednisoloneDrug therapy: prednisolone<<15mg/day and azathioprine 15mg/day and azathioprine <<2mg/kg/day2mg/kg/day


conclusionconclusion

During normal pregnancy the urinary system During normal pregnancy the urinary system undergo major morphologic and functional undergo major morphologic and functional changes as exemplified by substantial and changes as exemplified by substantial and sustained renal haemodynamics which also sustained renal haemodynamics which also occurs in women with pre-existing renal dz. With occurs in women with pre-existing renal dz. With the exception of few, pregnancy has no adverse the exception of few, pregnancy has no adverse effect on the underlying renal dz, if the renal fxn effect on the underlying renal dz, if the renal fxn prior to pregnancy is preserved and prior to pregnancy is preserved and hypertension is absent. Although the fetal hypertension is absent. Although the fetal prognosis is less favourable than in healthy prognosis is less favourable than in healthy women, it does not justify discouraging women, it does not justify discouraging pregnancy in women with renal disease. pregnancy in women with renal disease.


Women on haemodialysis should be on Women on haemodialysis should be on contraception, since there is reduced contraception, since there is reduced likelihood of a successful fetal outcome likelihood of a successful fetal outcome and there are many argument against and there are many argument against pregnancy in these women.pregnancy in these women.Pregnancy in women with renal transplant, Pregnancy in women with renal transplant, once quite rare, has increased markedly in once quite rare, has increased markedly in the recent past and the key to success is the recent past and the key to success is adequate pre-pregnancy assessment and adequate pre-pregnancy assessment and meticulous antenatal care with cooperation meticulous antenatal care with cooperation between all the relevant specialities between all the relevant specialities involved in her care. involved in her care.

renal disease in preg

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