effect of pregnancy on the kidney increased plasma volume increased intravascular volume ...
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Effect of pregnancy on the kidney
Increased plasma volume Increased intravascular volume Increased GFR Increased intraglomerular pressure Hyponatremia is frequently seen Hypokalemia can be seen
Pregnancy and renal disease Hormonal changes contribute to these
changes Pregnant ladies gain 12 to 16 kilograms of
weight mostly fluids Serum creatinine and BUN decreases in
pregnancy Normal serum creatinine can be a sign of a
significant renal disease Pregnancy affect renal disease and renal
disease affect the outcome of pregnancy
Pregnancy and renal disease
Pregnancy is associated in a decline in renal function in 1 -- 10% of cases when GFR is mildly reduced at the beginning of pregnancy Cr less than 1.5 mg/dl
The rise in Cr is seen at the third trimester Transient decline in renal function may be seen
Moderate renal impairment
Women with moderate renal insufficiency ( Cr between 1.5 and 2.9 mg/dl )
In these patients there is a decline of Cr in the first trimester but rise above base line level as the pregnancy progress
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76 women with pregnancy and moderate renal impairment
First trimester 3rd trimester
Jones etal New Eng J 1996 335 : 226
Some patients may have permanent decline in renal function
In the previous study 10% of the women progressed to end stage renal disease
The risk was highest in patients with a serum Cr above 2 mg/dl
The risk of permanent decline in renal function is highest in the presence of uncontrolled hypertension
Once serum creatinine exceed 3 mg /dl most women have amenorrhea or anovulatory cycles making the likelihood of pregnancy very small
Some studies showed some link between the type of renal disease and outcome being worse in MPGN and reflux nephropathy
Effect of kidney disease on pregnancy Fetal survival is lowest with
uncontrolled hypertension The relative risk of fetal death tenfold
higher in women with a mean blood pressure greater than 105 mmHg
The risk of prematurity is increased when serum creatinine exceed 1.4 mg/dl
Preterm delivery is not uncommon
There is an increased risk of pre-eclampsia with increased fetal and maternal morbidity
Pre-eclampsia might be more difficult to diagnose in the presence of baseline proteinuria and hypertension
In this situation worsening of proteinuria and hypertension might be a clue to the diagnosis
Pregnancy in the dialysis patient
The frequency of conception in this group is .3 to 1.5 % per year
There is increase fetal wastage in this group
Blood pressure and anemia may become more difficult to control in this group
Hou an his group surveyed 1281 women of childbearing age on dialysis
1.5% became pregnant over tow years time
52% had surviving infants
02468
101214161820
total no
surviving infants
Hou,SH pregnancy in women on dialysis AM J Kid Dis 1994 23 60
Survivng infants
Total no
Pregnancy and dialysis
Bogan in Belgium surveyed 1472 women of child bearing age on dialysis
1.5% became pregnant over tow years time
50% had successful out come of pregnancy
Bagon etal pregnancy and dialysis Am J of Kid disease 1998 , 31 ; 766
Dialysis and pregnancy There is improvement in the survival
compared to old reports because of More intense dialysis with BUN below
17 mmol/l 50 mg/dl ( almost daily dialysis )
Higher dose of EPO is required to provide adequate red cell mass
Metabolic acidosis and hypocalcaemia should be corrected
Pregnancy and dialysis Careful uterine and fetal monitoring during
dialysis and through out the whole pregnancy
Avoid hypotension during dialysis since this may provoke uterine contraction and fetal loss
Nutritional status and dry weight should be assessed on frequent bases since intradialytic weight gain can be confused with the usual weight gain in pregnancy
Dialysis and fetal size
In spite of optimal therapy mothers are at increased risk of sever hypertension and premature delivery with a mean gestational age of 30 weeks
If the patient is a good potential candidate for transplant it is better to delay pregnancy tell she is transplanted
Case presentation
A 24 year old saudi lady found to have raised creatinine when she was evaluated for primary infertility and a diagnosis of ESRD was made
Her renal function continued to deteriorate and she was put on regular hemodialysis
A cadaver transplant was done
Case presentation The transplant was successful and her
serum Cr was around 1.2 mg/dl She was maintained on azathioprine
steroids and cyclosporine She became pregnant 18 months post
transplant with a full term twins Serum Cr post delivery was 1.3 mg One year later her serum Cr was 1.4 She became pregnant
Case presentation
Hb before gestation was 9.4 gm Hb decreased to 7.8 gm with more
symptoms EPO was added and her anemia
improved with Hb of 11 at the time of delivery
The outcome of the pregnancy was successful
Erythropoietin Therapy in a Pregnant Post-Renal Transplant PatientSaad Al Shohaib
Department of Medicine, King Khalid National Guard Hospital, Jeddah, Kingdom of Saudi Arabia
Address of Corresponding AuthorNephron 1999;81:81-83 (DOI: 10.1159/000045251)
Renal transplant Fertility return after transplant with a
pregnancy success rate of more than 90% after the first trimester
There is slight increase in spontaneous abortion and intrauterine growth retardation
Pregnancy has no important early effect on renal function and affected by the same factors in pregnancy in patients with renal impairment
Renal transplant Women are advised to wait one year after
living related transplant and tow years post cadaver transplant to avoid complications arising from rejection
Neither low dose prednisolone or azathioprine appear to have adverse effect on the fetus
The obstetrician should review the operative notes to confirm the location of the graft
cyclosporine Cyclosporine may aggravate or induce
hypertension during pregnancy Cyclosporine does not appear to be a
major teratogen Cyclosporine metabolism is increased
during pregnancy and higher doses may be required to achieve adequate levels however there is controversy regarding adjusting the dose
Mycophenolate mofetil
MMF should not be used in pregnancy as animal studies showed adverse effect on the fetus
Patient that are welling to get pregnant should be converted to azathioprine
Sirolimus (Rapamycin )
Sirolimus is contraindicated in pregnancy and should discontinued at least 12 weeks prior to pregnancy
Cyclosporine should be used during gestation but once delivered sirolimus can be restarted
Tacrolimus (prograf )
Kains reviewed 100 pregnancies in 84 women treated on prograf
27% were renal transplant recipients 68% progressed to alive birth Four babies had malformations
Obstetrical mangement
Increase frequency of prenatal visit Early treatment of a symptomatic
bacteriuria Monthly renal function Close monitoring for the development
of pre eclampsia
SLE
SLE occur frequently in women in child bearing age
SLE patients are usually as fertile as other patients but their pregnancy is associated with more complication
The prognosis is best for both the mother and fetus if SLE is quiescent for at least 6 months
Exacerbation of the disease
50% of patients will exacerbate their disease during pregnancy
Flares occur in all three trimester and in the immediate postpartum period
Ruiz prospectively evaluated 40 pregnancies in 37 patients with SLE
Flare up occurred in 24 cases 60%
Compared to the rates of flare up post delivery the rate is higher
Flare up mainly as nephritis and arthritis
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sle
Ruiz etal increased rate of lupus flare up during pregnancy Br J Rheum 1996 35:133
Lupus nephritis There is increased risk of fetal loss Increased risk of worsening renal
function as well as other manifestations of the disease
Sever renal impairment requiring dialysis may occur
Pre existing hypertension and azotemia are associated with worse prognosis
Comparison between SLE and Non SLE post renal transplant pregnancy outcome
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SLE 60
non LSE376
Live birth
abortion
Therapeutic termination
Mccy Groy etal pregnancy outcome Am J Transp 2003 3:35
pre eclampsia and SLE
Preeclampsia is a frequent complication of SLE 13%
It might be difficult to distinguish between preeclamsia and lupus nephritis
Active urinary sediment is suggestive of lupus nephritis
P
Pre eclampsia and SLE
Complement C3 C4 are low in lupus nephritis but normal in preeclamsia
Anti DNA titer is increased in lupus nephritis
Thrombocytopenia and raised liver enzymes are suggestive of preecalmpsia
Fetal loss and SLE risk factors
Hypertension Lupus nephritis Low C3 high DNA Antiphospholipid antibody
Fetal loss and SLE
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SLE control control
fetal loss
Petri etal fetal outcome of lupus pregnancy J Rheum 1993 20 650
Hypertension and pregnancy
Preeclamsia eclampsia Chronic hypertension (present before
20 weeks of pregnancy Preeclampsia superimposed on
underlying hypertension Gestational hypertension
(hypertension in after 20 weeks without prteinuria
Hypertension preeclampsia
Labetalol is the is the preferred therapy for sever hypertension
Hydralazine is an acceptable alternative
Methyldopa and labetalol the first line oral therapy
Atenolol should be avoided in early pregnancy
Hypertension and pregnancy
ACE inhibitors and ARBs are contraindicated during pregnancy since uterine and placental ischemia may occur
Nitroprusside should be avoided (fetal cyanide poisinig)
Breast feeding
Beta blockers and calcium channel blockers enter breast milk but are safe during lactation
ACE inhibitors and ARBs should be avoided
Diuretics reduce milk volume and should be avoided
Preexisting hypertension
Has a strong on fetal and maternal outcome
Preeclampsia 10– 20% Preterm birth 12—34% Growth retardation 8—16% The higher the blood pressure the
worse the outcome
ARF in pregnancy
HUS TTP HELLP syndrome Renal cortical necrosis Acute pyelonephritis Acute fatty liver of pregnancy
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