Renal disease in pregnancy

Dr Omoregie 1
 synopsis
Introduction.
Renal system changes in normal pregnancy.
Pregnancy in women with pre-existing renal
disease.
Specific renal diseases in pregnancy.
Counselling patient with chronic renal disease.
Management guidelines
Delivery
Pregnancy in dialysis patients
Pregnancy in renal transplant recipients
Conclusions.
Dr Omoregie 2
 introduction
The attitude of clinicians towards pregnancy in
women with CRD has changed tremendously in
the last 3 decades.
Previously the advise was therapeutic abortion
followed by sterilisation – this pessimism was
succinctly stated in a Lancet editorial of 1975
which stated that…’Children of women with renal
dz used to be born dangerously or not at all –
not at all if their doctors had their way.”
The current practice, based on clinical evidence
is one of cautious optimism. Most pregnancies
succeeds provided renal impairment and/or
hypertension are minimal.
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Renal system changes in preg
GFR and renal plasma flow increases by 50-
70% above the non-pregnant value.
24-hr creatinine clearance increases
immediately after conception.
Plasma levels of creatinine and urea which
average 73µmol/l and 4.3mmol/l in the non-
pregnant state decrease to mean values of
51µmol/l and 3.1mmol/l in pregnancy.
The kidneys enlarges in pregnancy – its length
on x-ray increasing by approximately 1cm.
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 The calyces, renal pelves and ureter dilate
markedly – all these occurring very early in
pregnancy.
Clinical implications
It should not be mistaken for obstructive
uropathy.
Stasis of urine within the ureters may increase
the incidence of acute pyelonephritis in pregnant
women with asymptomatic bacteriuria.
There may be errors in test based on timed urine
collections.
Post-partum x-ray examination of the urinary
tract should be delayed until at least 12-16wks
after delivery to allow the changes to resolve.
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Urinary protein levels are slightly higher in
pregnancy – may be due to changes in
the tubular function.
A normal urine in the non-pregnant may
contain up to 200mg/l of protein; whereas
up to 300mg/l is considered normal in
preg and occasionally it may be up to
500mg/l without significant renal disease.
The dipstick testing of urine often shows
trace of protein during pregnancy: the
sensitivity of the kit is set for the non-
pregnant state.
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Preg in women with pre-existing
renal disease
The frequency of acute pyelonephritis
increases.
Pregnancy has no adverse effect on the
natural history of established renal
parenchymal disease, provided the renal
function is minimally compromised and
hypertension is absent – mild to moderate
renal dysfxn (e.g. plasma creatinine
<125µmol/l, creatinine clearance >60ml/h)
usually have successful pregnancy with
normal fetal outcome.
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Specific renal diseases in preg
Acute glomerulonephritis complicating preg is
rare – when it occurs it is mistaken for pre-
eclampsia.
Chronic glomerulonephritis – the course of preg
should not be complicated, if the patient is
normotensive. Unfortunately hypertension often
supervenes early in the course of such a
pregnancy. UTI may occur more frequently.
Lupus nephropathy – due to SLE, view is
controversial. Prognosis most favourable if dz
was in remission >6 months prior to conception,
steroid dosage should be increases postpartum.
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Renal disease due to scleroderma and
periarteritis nodosa results in dismal preg
outcome with many cases ending in maternal
death.
Diabetic nephropathy – pregnancy has no
adverse effect on renal lesion, but the frequency
of UTI, oedema and/or pre-eclampsia is
increased.
Urolithiasis during pregnancy has a prevalence
of 0.03-0.35%, most of the renal stones contain
calcium. The course of the disease is not
affected by pregnancy. Note – it is a major
cause of non-obstetrically related abdominal
pain during pregnancy. UTI can be more
frequent.
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Polycystic kidney dz – preg well tolerated,
provided renal function is preserved and
hypertension is absent.
Pregnancy is well tolerated by women with
single and normally situated kidney.
Pelvic kidneys – pregnancy is well
tolerated, dystocia rarely occurs with a
pelvic kidney. Decreased fetal salvage is
due to other malformations of the
urogenital tract.

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

Pregnancy in women with CRD is possible

depending on the degree of renal impairment
and the absence of hypertension, rather than
the underlying parenchymal renal lesion.
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Therefore, pregnancy is restricted to those
whose plasma creatinine levels are 250µmol/l or
less and who have a DBP of 90mmHg or lower
(preferably below 80mmHg)
The prospective mother should be counselled on
the need for close monitoring during pregnancy,
the increased risk of hypertension complicating
the pregnancy and the likelihood of terminating
the pregnancy as a result of this complication.
Women with proteinuric disease should be
advised that oedema will most likely appear – or
if present worsen: but that these signs are
mainly cosmetic and usually do not jeopardise
the pregnancy.
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The chances of producing a healthy child
is good for those with minimal renal
dysfunction.

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 Guidelines for management
Pre-conception care – planned pregnancy
- Good diet, no smoking, no alcohol
Uncomplicated antenatal course
- ANC visit
- 2 weekly until 32 wk gestation and thereafter weekly until
delivery
- Assessment in the ANC
- Booking clinic – Hx, physical exam – wt, Ht, BP, FH, lie,
presentation, FHR
- Investigations – PCV, blood group, genotype, VDRL,
urinalysis&m/c/s, ? USS etc.
- Drugs - Malarial chemoprophylaxis + haematinics
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 Subsequent visits – Hx, P.E, wt, FH, lie,
presentation, FHR, urinalysis, PCV.
Supplementary investigations
- Assessment of renal function: 24hr
creatinine clearance and 24hr protein
excretion.
- Urine m/c/s (early detection of asympt
bacteriuria).
- Early detection of pre-eclampsia
- Assessment of fetal size, development &
well being.
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Further Mx
If renal fxn deteriorates – seek for cause
If reversible (UTI, dehydration or electrolyte
imbalance) treat and allow pregnancy to continue.
When proteinuria occurs and persist, but BP is
normal and renal function is preserved, the
pregnancy should be allowed to continue.
BP – moderate hyptension (DBP<110mmHg) need
not be treated, treatment of severe Ht
(DBP>110mmHg) is necessary for maternal well
being and also allows the preg to continue, so has
to achieve a further fetal maturation prior to
delivery.
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 Fetal surveillance – necessary since IUGR is
associated with renal dz in pregnancy. USS,
antenatal cardiotocography, fetal pulm maturity
(L/S ratio).

Delivery
- Induce labour at 38wk – to prevent IUFD due to
placental failure.
Reasons for early delivery prior to 38wks
- Evident renal fxn deterioration
- Signs of imminent IUFD
- Uncontrollable hypertension
- Eclampsia
Note: Delivery should only occur in centres with good fetal monitoring
devices, operative delivery and neonatal resuscitation services
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Diagnosis of renal dz during pregnancy
Occasionally noted for the 1st time during preg
It is essential to try and establish a diagnosis
If a patient presents with HT, proteinuria and/or
abnormal renal fxn, it is difficult to distinguish renal
parenchymal dz from pre-eclampsia.
A previous hx of renal dz, abnormal urinalysis, a family
hx of renal disorder or a hx of systemic illness known to
involve the kidneys is very helpful.
Note – renal parenchymal dz may coexist with pre-
eclampsia.
A definitive diagnosis usually defered until further
assessment after delivery.

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Pregnancy in dialysis patients
Patient usually have irregular or absent
menstruation, decreased libido and
impaired fertility – but they can conceive!!
Therefore use contraception (if pregnancy
is undesired).
The outcome of preg is usually very poor
Maternal condition may be compromised

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 Pregnancy in renal transplant recipient
40% of conception end up in spontaneous abortion,
termination of pregnancy or ectopic gestation.
90% of the pregnancy that proceed beyond 1st trimester
results in successful outcome.
Criteria for successful outcome
Good general health for 2yrs after transplant
Stature compatible with good obstetric outcome.
No proteinuria
No significant hypertension
No evidence of graft rejection
No evidence of pelvicalyceal distension on a recent
excretory urogram
Stable GFR: plasma creatinine <180µmol/l
Drug therapy: prednisolone<15mg/day and azathioprine
<2mg/kg/day
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 conclusion
During normal pregnancy the urinary system
undergo major morphologic and functional
changes as exemplified by substantial and
sustained renal haemodynamics which also
occurs in women with pre-existing renal dz. With
the exception of few, pregnancy has no adverse
effect on the underlying renal dz, if the renal fxn
prior to pregnancy is preserved and
hypertension is absent. Although the fetal
prognosis is less favourable than in healthy
women, it does not justify discouraging
pregnancy in women with renal disease.
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Women on haemodialysis should be on
contraception, since there is reduced
likelihood of a successful fetal outcome
and there are many argument against
pregnancy in these women.
Pregnancy in women with renal transplant,
once quite rare, has increased markedly in
the recent past and the key to success is
adequate pre-pregnancy assessment and
meticulous antenatal care with
cooperation between all the relevant
specialities involved in her care.

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