Renal diseases in pregnancy DR PRAYTHIESH BRUCE MBBS
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Transcript of Renal diseases in pregnancy DR PRAYTHIESH BRUCE MBBS
THE RENAL DISEASES IN THE KIDNEY
BY
PRAYTHIESH BRUCE(CRRI)
DEPT OF OBG,SMIMS
KULASEKHARAM
OVER VIEW
Introduction Urinary tract infection Acute pyelonephritis Chronic pyelonephritis Acute renal failure Pregnancy in renal transplant patient Hypertension and renal disease
INTRODUCTION
Diseases of urinary tract is common in pregnancy-structural and functional changes are normally seen in pregnancy
STRUCTURAL CHANGES: Dilatation of urinary tract-iii trimester
Stasis,hydronephrosis occur- due to gravid uterus and dilatation of right side ureter occur-due to dextrorotation uterus
Progesterone-relaxant-smooth muscle
FUNCTIONAL CHANGES IN PREGNANCY
Renal blood flow-increases by 80% Gfr,creatinine,creatinine clearance-increases
by 50% >0.9%mg/dl s.creatinine suggest renal
disease Glycosuria-lowering of renal threshold Sodium and water retention Fall in osmolality
URINARY TRACT INFECTION
Commonest infection Causative organism; Ecoli Klebsiella Pseudomonas aeroginosa TYPES A)asymptomatic bacteruria B)cystitis C)acute pyelonephritis
ASYMPTOMATIC BACTERURIA Occur in 5%pregnancy Must be treated as 30%can cause
symptomatic infection Diagnosis: First visit:screening by urine culture and
microscopy Routine mid stream urine culture of
>1,00,000organisms per 1 ml (Len)leucocyte esterase nitrate dip stick test
can be used if prevalence is low in the population
TREATMENT OF ASYMPTOMATIC BACTERURIA
Treatment required to prevent pyelonephritis/preterm delivery
It is associated with risk of hypertension,preeclampsia,anaemia in mother and lbw in children
Treatment depend on culture sensitivity report
TREATMENT OF ASYMPTOMATIC BACTERURIA(3-5)DAYS
Oral antibiotics: Ampicillin 500mg qid Amoxycillin 5oomg tds Cephalexin 250mg tds Nitrofurantoin 100mg qid Iv antibiotics: Cefuroxime 750 mg tds Coamoxyclav 1.2g tds
CYSTITIS Infection of lower urinary tract Characterised by burning micturition( dysuria) Frequency Urgency Complicate in 1% pregnancy
CYSTITIS CAUSATIVE ORGANISM
Ecoli Klebsiella Pseudomonas aeroginosa DIAGNOSIS: Urine analysis shows Bacteriuria,pyuria,hematuria Urine culture and sensitivity
TREATMENT FOR CYSTITIS
Depend on culture sensitivity report Oral antibiotics: Nitrofurantoin 100mg qid Ampicillin 500mg qid Amoxycillin 500mg tds Cephalexin 250mg tds
Infection of upper urinary tract involving both renal pelvis and parenchyma
Incidence- 1-2% Causative organism; Ecoli Klebsiella Pseudomonas aeroginosa
ACUTE PYELONEPHRITIS
CLINICAL FEATURES OF ACUTE PYELONEPHRITIS
Onset is acute, 2nd &3rd trimester of pregnancy Symptoms: Anorexia, back pain , chills & rigor with fever,
dysuria, nausea & vomiting Signs: Increased temprature(101of) Urine turbid Tachycardia
INVESTIGATIONS FOR ACUTE PYELONEPHRITIS
Urine examination: High specific gravity, acid reaction,
proteinuria, leucocytes, red cells, white cell cast,bacteria
Urine culture & sensitivity test: Blood examination: sign of renal dysfunction,
elevated bun, creatinine & creatinine clearance
COMPLICATIONS OF ACUTE PYELONEPHRITIS
Septic shock due to endo-toxins Pulmonary injury Chronic renal infections Adult respiratory distress syndrome Abortion, fetal growth restriction,intra-uterine
fetal death Premature labour
TREATMENT OF ACUTE PYELONEPHRITIS
Hospitalisation, bed rest, plenty of fluids, easily digestable diet, pulse oximetry
4th hrly TPR & B.P monitoring Uterine contractions, fetal monitoring, I.V.F for dehydrated & oliguric patients
(crystalloids,dextrose, D.saline) I/V antibiotics Ampicillin 500mg iv 6th hrly Co amoxyclav 1.2g iv 12 hrly after patient is afebrile
for 24-48 hrs oral antibiotics started
CHRONIC PYELONEPHRITIS
Chronic diseases charecterised by severe scarring of the kidneys resulting from persistent/ recurrent infections in patients with vesico-urethral reflux
Complications : Chronic hypertension Acute pyelonephritis Chronic microcytic anaemia Pre-eclampsia, hyponatraemia, glycosuria
TREATMENT OF CHRONIC PYELONEPHRITIS
Maternal & fetal prognosis depends on the extent of the renal damage
Cap. Ampicillin 500mg/tab.nitrofurantoin 100mg/cap. Cephalexin 500mg -1cap. Every night for the duration of pregnancy
ACUTE RENAL FAILURE
Rare complication in pregnancy in which sudden decrease in renal function with oliguria over a period of hours or days
Diagnosis: Oliguria, hyperkalemia, metabolic
acidosis,rising blood urea &creatinine
CAUSES OF ACUTE RENAL FAILURE
Obstetric haemorrhage Infection Septic abortion Pre eclampsia Drugs-nsaids Renal diseases Post renal(obstructive uropathy)
TYPES OF ACUTE RENAL FAILURE
ACUTE TUBULAR NECROSIS
RENAL CORTICAL NECROSIS
Less serious serious
Reversible Irreversible
a/w sepsis & htn a/w obstetric causes& pre-eclampsia
Kidney lesion- focal, dilatation & flattening of epethelium of DCT,pigmented cast in lower part of nephrons
Kidney lesion- focal,patchy confluent/gross resulting from thrombosis of renal vascular system
TYPES OF ACUTE RENAL FAILURE
ACUTE TUBULAR NECROSIS
RENAL CORTICAL NECROSIS
Patint have high grade temperature, vomiting, diarhoea
Oliguria which can lead to anuria, azotoemia &consumptive coagulopathy
Shock occurs rapidly & may have mild jaundice, pallor& cyanosis
Extra-renal manifestations like cardic dilatation, CHF, lethargy, convulsions
Most patient respond to volume resuscitation &vigorous antibiotics in ICU
_
CLINICAL FEATURES OF ACUTE RENAL FAILURE
Oliguria- sign of acute impaired renal function Input /output chart Patient is warm to touch, thirsty, irritable,
lethargic Rise in blood urea &serum potassium level
which causes muscular & ECG changes In diuretic phase there is excess of passage
of urine, but blood urea remains high
MANAGEMENT OF ACUTE RENAL FAILURE Early diagnosis is important Blood volume replacement is required for hemorrhage,
control of B.P& delivery for pre- eclampsia, stoppage of nephro-toxic drugs
Patient needs intensive care with hydration Assessment of fluid balance by C.V.P line is important Liberal fluids given in hemorrhagic shock Infection should be controlled by antibiotics in septic
abortion & puerperal sepsis Blood levels of electrolytes, urea, creatinine should be
checked daily Help of nephrologist is sought Peritoneal/hemodialysis is performed to keep BUN to
50mg/dl If not already delivered, delivery should be expedited after
stabilising her general condition
PREGNANCY IN RENAL TRANSPLANT PATIENT
More women are expected to come for pregnancy with more liberal use of renal transplant
They should delay pregnancy for 1-2 years after transplantation to allow the graft function to stabilise &immunosupperession reach maintenance level
Cyclosporine, azathioprine, prednisolone are considered safe in pregnancy
Women on Cyclosporine should not breast feed
CHRONIC RENAL DISEASE IN PREGNANCY
Incidence: 0.2% Effect of pregnancy on kidney disease:Effect of pregnancy on kidney disease:
Mild Moderate Severe
Risk of renal failure is low (<5%)
Risk of renal failure is 10%
Risk of renal failure is 50%
Serum creatinine <125 micromol/lit
Serum creatinine 125-250 micromol/lit
Serum creatinine >250 micromol/lit
Super-imposed pre-eclampsia prognosis is worse
Primary glomerulo-nephritis has better prognosis
Focal glomerulo sclerosis, immune nephropathy, membrano-proliferative glomerulo-nephritis has poor prognosis
Effect of kidney disease on Effect of kidney disease on pregnancypregnancy
Effect of pregnancy depends upon the severity of Effect of pregnancy depends upon the severity of renal diseases, serum creatinine levels, renal diseases, serum creatinine levels, hypertension & proteinuriahypertension & proteinuria
Super-imposed pre-eclampsia- perinatal mortality is 50%
In severe kidney disease risk of abortion, IUGR, pre-term labour
Careful pregnancy surveillance, proper treatment, improved neonatal care& colaboration with nephrologist has improved prognosis of mother & newborn
TREATMENT OF CHRONIC RENAL DISEASE IN PREGNANCY
Pre-conceptional counselling Mild to moderate kidney disease- regular
assessment of kidney function Women with severe kidney disease adviced against
contraception Therapeutic abortion justified in early pregnancy Anti-hypertensive drugs given for hypertension Fetal monitoring performed each visit Management of labour is like pre-eclampsia with the
aim of vaginal delivery
RENAL DISEASE AND HYPERENSION
DEFINITION-blood pressure of more than140/90mmhg or greater or an increase of 30 mm hg sysolic or 15 mm hg diastolic over the baseline value on atleast two occations
TYPES OF HYPERTENSIVE DISEASE IN PREGNANCY
1-Gestational hypertension/pregnancy induced hypertension
2-pre eclampsia 3-Eclampsia 4-preclampsia superimposed on chronic
hypertension 5-chronic hypetension
** INCIDENCE: 5-10% 0f all pregnancies . 20% recurrence
This is the third most important cause of maternal mortality worldwide
** DEFINITION OF HYPERTENSION:
D.B.P. > 90 mmHg or
S.B.P. > 140 mmHg along with
** PROTIENUREA: Proteinurea is defined as urinary excretion
0.3 g protein or greater in a 24-hour 30 mg/dl (+1 or greater on urine dip specimen)
** OEDEMA: 90% pregnancy. progressive
+/-
INCIDENCE & RISK FACTORSPre eclampsia occurs in 6-8% of all
live birth
RISK FACTORS Extremes of reproductive age
15 < & >35 Y Nulliparity Black race Hx of PET in a 1st degree
female relative Hx of PET in prior pregnancy DM Chronic renal disease Ch HPT
Multiple pregnancy twins 13 vs 6%
Hydatidiform mole Nonimmune hydrops fetalis Obesity 4.3% BMI < 19.8
kg/m²
13.3% BMI ≥ 35 kg/m²
Smoking ↓ risk of HPT
•Abnormal trophoblast invasion…
first 12 weeks, the decidual segments of the spiral arteries are invaded… elastic and muscular wall replaced by fibinoid walls
… by 20 weeks trophoblast invades intramyometrial segment of spiral arteries(high resistance low flow-low resistanc high flow) increase in utero placental flow
In pre eclampsia- trophoblast invasion is patchy & spiral arteries retain their muscular walls….
PATHOGENESIS Endothelial cell injury ↓ ↓ prostacyclin & ↑ thromboxaneA2 Vasospasm and endothelial cell dysfunction>>> platelet
activation and micro aggregate formation Rejection phenomenon (inadequate matenal Ab response)
Compromised placental perfusion Altered vascular reactivity ↑sensitivity to vasopressin EPN,
NEPN & angiotensin ↓ GFR with retention of salt & water ↓ intravascular volume ↑ CNS irritability DIC Uterine muscle stretch & ischemia Dietary factors Genetic factors
PATHOGENESISSummary of current hypothesis:
Immunological disturbance abnormal placental
implantation ↓ placental perfusion production of
substances that activate or injure endothelial cells of the
blood vessels multiple organ system involvement
SYMPTOMS & SIGNS ↑ BP Proteinuria Edema of the face & hands ( but it has been
dropped of the definition due to poor predictive value)
Headache Visual disturbance Epigastric pain Exaggerated reflexes
CLASSIFICATION OF PE ECLAMPSIASEVERE PRE ECLAMPSIA-Systolic BP >160 mmHg or
diastolic >110 mmHg on two occasions at least 6 hrs apart Proteinuria ≥ 5 g/24 hrs Oliguria < 500 cc /24 hrs Cerebral or visual symptoms Epigastric or Rt upper quadrant pain
Pulmonary edema or cyanosis Low PLt IUGR MILD PRE ECLAMPSIA any pre eclampsia that is not
considered severe
•Why screening
•Accuracy. Uterine artery doppler at 24 weeks, notching on both uterine arteries identifies 80% who will develop pre clampsia,,, 5% false positive
Management of pre eclampsia
OBJECTIVES Birth of an infant who subsequently thrives Complete restoration of health to the mother terminaton of pregnancy with the least possible trauma to
the mother & fetus
1- Hospitalization Women with new onset BP ≥ 140/90 Worsening BP Development of proteinuria in addition to existing BP
INITIAL HOSPITAL MANAGEMENT
Observe for headache , visual disturbance, epigastric pain & rapid wt gain
Wt daily Analysis for proteinuria every 2 days / daily BP in sitting position every 4 hrs except during sleep Blood investigations Hct, Plt, S creatinine, liver
enzymes Frequent evaluation of fetal size & AF Reduced physical activity but not absolute bed rest N diet & fluid intake
FURTHER MANAGEMENT Depends on: Severity of pre eclampsia Duration of gestation Condition of the Cervix Complete resolution of the signs & symptoms does not
occur till after deliveryLines of management Termination of pregnancy Antihypertensive therapy Anticonvulsant therapy Home health care if BP improved within few days Pt
can be managed as outpatient Home BP & urine protein monitoring . Instruction to come to hospital if she has waning symptoms . Rest at home
Termination of pregnancyIndications Term pregnancy with mild or severe Pre eclampsia Severe Pre eclampsia regardless of the gestational age Warning signs headache , visual disturbance, epigastric pain,
oliguria Eclampsia Pt must be stabilized & delivered immediatelyPreterm with mild Pre eclampsia Assess fetal wellbeing by NST,
BPP, DopplerMethods of termination IOL with prostaglandines to ripen the Cx followed by IV oxytocin Elective CS Severe Pre eclampsia with unfavorable
cervix
Antihypertensive therapy for severe pre eclampsia
Hydralazine
IV infusion or IV 5-10 mg bolus at 15-20 min interval
when diastolic BP ≥100-110 mm Hg or systolic BP ≥ 160 mmHg
Nifedipine 10 mg po repeated in 30 min Labetalol 10 mg IV / 20 mg after 10 min/ 40mg after
10min/80 mg (not to exceed 220 mg) Nitroprusside used only in PT not responding to other
drugs Diuretics not recommended because intravascular
volume depletion already exists in Pre eclampsia
Antihypertensive therapy
Mild pre eclampsia-There is no benefit of antihypertensive therapy
Reduction in the maternal BP with labetalol or nifedipine IUGR
ACI contraindicated IUGR, boney malformations, limb contracture, PDA, pulmonary hypoplasia, RDS, hypotension &death
Severe pre eclampsia-
Antihypertensive therapy is used to control BP untill the Pt delivers or in preterm for 48 48 hrs to allow time for glucocorticoid administration for fetal lung maturity then delivery
Fluid therapy Hyperosmotic agents not recommended
because intravascular influx of fluid subsequent escape of fluid to vital organs pulmonary edema & cerebral edema
LR 60-120 ml/hr Excessive fluid administration pulmonary edema & cerebral edema
Definitions
Chronic hypertension: A sustained BP > 140/90 that can antecedes
pregnancy or persists postpartum (beyond 6 weeks). HTN that is present before the 20th week of pregnancy may also be included as CHTN.
Chronic Hypertension
Often seen in patients who have other medical complications: obesity, diabetes, hyperlipidemia, cigarette smoking. Essential HTN – majority will have normal
pregnancies. Secondary HTN – parenchymal renal disease,
pheochromocytoma, Cushing’s syndrome, hyperthyroidism, etc.
Chronic Hypertension
If end-organ disease is present (renal, cardiac, cerebrovascular), there is an increased risk of morbidity and mortality. Maternal – superimposed preeclampsia, placental
abruption, congestive heart failure Fetal – intrauterine growth restriction, prematurity
and fetal death
Preconception Care of CHTN
Review the medical history: diagnosis and duration of hypertension, ongoing pharmacological treatment, known existence of organ damage or other compounding illnesses.
Review obstetrical history.
Preconception Care of CHTN
Physical exam and laboratory evaluation Urine analysis, urine culture/sensitivity, 24 hour urine
for total protein and creatinine clearance CBC Diabetes screening If the patient has severe hypertension, significant
proteinuria or prior poor obstetric outcome more extensive tests may be offered.
Preconception Care of CHTN
Optimize control with recommended medications. Methyldopa (Aldomet): extensively studied in
pregnant women, treatment of choice if needed. Central adrenergic inhibitor
Hydralazine: potent vasodilator, which acts directly on vascular smooth muscle.
Calcium channel blockers (Nifedipine): inhibits transmembrane calcium ion influx which causes vasodilation.
Antihypertensives
B-Adrenoreceptor blockers (e.g. atenolol, propranolol): possible fetal IUGR, neonatal respiratory depression, bradycardia and hypoglycemia
Angiotensin-converting enzyme inhibitors: not recommended for use in pregnancy
Thiazides diuretics: not recommended for use in pregnancy.
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