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OBSTETRICS 2 RENAL AND URINARY TRACT DISORDERS IN PREGNANCY (Dr. Tan)

URINARY TRACT INFECTIONS AND RENAL DISEASE IN

PREGNANCY

Renal Changes in Normal Pregnancy*

INCREASE
DECREASE
Renal blood flow up to 40%
Plasma concentration of urea and
Glomerular Filtration Rate (GFR)
creatinine
Maximum of 65%
Plasma osmolality
12 weeks AOG: increased
25%: Serum uric acid concentration
by 20%
1st and 2nd trimester
Total body water that exceeds the
Returns to pre-pregnant
increased in total body sodium
levels in 3rd trimester
Ureters are dilated and kinked
o More on right because of dextrorotation
o Increased Progesterone levels Relaxes smooth muscle
o Mild obstruction of lower ureters in 3rd trimester

Encourages:

Stasis of urine

Reflux of infected urine to the kidney that

may lead to pyelonephritis
Pregnancy Induced Urinary Tract Changes
Kidney becomes larger
Dilatation of renal calyces, ureters
Vesicoureteral reflux
Functional hypertrophy
o Larger glomeruli
o Increased renal plasma flow: 40%
o Increased glomerular filtration: 65%
Decreased serum creatinine and urea
Other alterations:
o Maintenance of acid-base homeostasis
o Fluid and electrolyte retention
Renal Function Assessment During Pregnancy
Urinalysis: most common diagnostic test at prenatal check-up*
o Unchanged at pregnancy, except occassional glucosuria

> 1/6 of cases: spillage of glucose in urine

o Protein excretion increased but seldom reaches levels
detected by usual screening methods

> 300 mg/day: abnormal

500 mg/day: when associated with Gestational

HPN

Idiopathic hematuria

Urinary dipstick test is +1 or more

Presence of blood in urine

Usually associated with 2-fold increase for preeclampsia

o Serum creatinine

Persistently > 0.9 mg/dl (75 umol/L)

Suspect intrinsic renal disease

Sonography
o Provides imaging of renal size, consistency & elements of
obstruction
Intravenous pyelography
Renal biopsy
o Relatively safe during pregnancy but usually postponed
unless absolutely indicated
o

Dr. Tan
October 7, 2014

Urinary Tract Infections

Most common bacterial infections during pregnancy*
Asymptomatic bacteriuria: most common*
If symptomatic:
o Cystitis
o Pyelonephritis
Organisms
o Normal perineal flora (E.coli): most common (90% of
cases)*

Presence of adhesins for the virulence

14x more common in females than males
o Reasons:

Shorter urethra in females

Continuous contamination of urethra from vagina

and rectum

Possible incomplete emptying

Entry of bacteria during sexual intercourse

Changes in Pregnancy: Hydronephrosis and hydroureter

(compression)

Risk Factors in Puerperium

Decreased bladder sensitivity
o Labor and conduction analgesia
o Episiotomy

Monitor first voided urine

Afraid to urinate because of discomfort by the

episiotomy
o Periurethral laceration
o Vaginal wall hematomas
Catheterizations
o If patient cannot spontaneously void

OBSTETRICS 2 RENAL AND URINARY TRACT DISORDERS IN PREGNANCY (Dr. Tan)

Insertion can cause trauma and pain

Asymptomatic Bacteriuria
Persistent, actively multiplying bacteria in urinary tract
Incidence: 2-7%
100,000 organisms/ml: Diagnostic*
Pyelonephritis develops in some women with colony counts of
20,000 to 50,000 organisms/ml
Significance
Associated with a risk of acute pyelonephritis in pregnancy
25% symptomatic if not treated
Treatment
Single dose treatment:
o Amoxicillin 3g
o Ampicillin 2g
o Cephalosporin 2g
o Nitrofurantoin 200 mg
3 day course treatment:
o Amoxcillin 500 mg TID
o Ampicillin 250 mg QID
o Cephalosporin 250 mg QID
o Nitrofurantoin 50-100 mg QID or 100 mg BID
For treatment failures:
o Nitrofurantoin 100 mg QID for 21 days
Suppression for bacterial persistence or recurrence
o Nitrofurantoin 100 mg at bedtime for remainder of
pregnancy
Cystitis and Urethritis
Signs and Symptoms:
Dysuria, urgency and frequency
Pyuria and bacteriuria
Microscopic hematuria, gross hematuria from hemorrhagic cystitis
Treatment
Same as 3 day treatment for asymptomatic bacteriuria (90%
effectivity)
Single dose treatment is less effective
o Chlamydia (lower renal tract symptoms)

Pyuria, mucopurulent cervicitis

Erythromycin

For pregnant women

Azithromycin

For non-pregnant women

Acute Pyelonephritis
More frequent in 2nd trimester
Unilateral & right sided
o > 50% of cases
Bilateral
o
of cases
Signs and symptoms
Dysuria (due to urethritis)
Increased frequency (due to trigonitis)
Backache, night sweats and rogors (due to pyelonephritis)
Headache, vomiting and muscle aches (due to pyrexia)
Diagnostic procedures
Midstream urine specimen sent for:
o Dipstick for nitrites and leukocytes
o Microscopy for white cells
o Culture to determine the organism present (100,000
org/ml)
o Sensitivity to antibiotics
Management
Admit the patient
Urine and blood cultures
CBC, serum creatinine and electrolytes
Monitor vital signs, urinary output
o Consider IFC (Indwelling Foley Catheter)
IV hydration to ensure adequate urine output
o Cornerstone of treatment (Crystalloids)*
IV antimicrobial therapy
Chest Xray and Arterial Blood Gases (ABG)
o For tachypnea and dyspnea
Reflux Nephropathy
Chronic interstitial nephritis
Radiologically identified scarring accompanied by ureteral reflux
with voiding
Hypertension
o Long term complication*
Maternal and fetal prognosis depends on extent of renal
destruction
Impaired renal function and bilateral renal scarring
o Increased maternal complications

Nephrolithiasis

OBSTETRICS 2 RENAL AND URINARY TRACT DISORDERS IN PREGNANCY (Dr. Tan)

Types
1.
2.
3.
-

of stones:
Calcium salts: 80%, most common*
Struvite stones
Uric acid
In pregnancy: 75% calcium phosphate (hydroxyapatite)*
Patients who have stones typically form another stone every 2-3
years

Signs
-

and symptoms:
Flank pain: 90%
CVA tenderness
Abdominal pain
Urgency
Dysuria
Frequency
Vomiting
Hematuria: 23%

Nephrolithiasis and Pregnancy

Pregnancy does NOT increase the risk of stone formation
Pregnancy increases passage of stones
o Due to urinary tract dilatation in pregnancy
Increased frequency of UTI with stones
Urinary stones seldom cause severe symptomatic obstruction
during pregnancy
No adverse effect except infection and preterm delivery
Fewer symptoms with stone passage among pregnant patients due
to urinary tract dilatation
Persistent pyelonephritis despite adequate antimicrobial therapy
o Warrants search for obstruction
Diagnosis
Ultrasound
Xray (one shot pyelogram)
Transabdominal color doppler ultrasound
Indications for stone removal:*
Obstruction
Intractable pain
Infection
Heavy bleeding

Chronic Renal Disease

Results in End Stage Renal Disease (ESRD) through progressive
loss of nephron number and function
At least 3 months duration
Most common causes of ESRD:
Diabetes: 33%
Hypertension: 24%,
Glomerulonephritis: 17%
Polycystic kidney disease: 15%
Categories of Renal Function
CATEGORY
SERUM
CREATININE
Normal/Mild
< 1.5 mg/dl
Impairment
Moderate Impairment
1.5-3 mg/dl
Severe Renal
> 3 mg/dl
Insufficiency
Complications during Pregnancy:
Chronic or Gestational Hypertension
Worsening renal function
Permanent dysfunction
Preterm delivery
IUGR (Intrauterine Growth Restriction)
Increased perinatal mortality
Prognosis
Outcome of the pregnancy is worse if there is:
o Hypertension before pregnancy
o Proteinuria before pregnancy
o Active progression of renal disease
-

Treatment
Depends on symptoms and AOG
Hydration
Analgesia
Antimicrobial therapy
2/3 of cases: pass spontaneously

1/3 cases require procedures

o Ureteral stents
o Ureteroscopy
o Nephrostomy
o Transurethral laser lithotripsy
o Basket extraction via cytoscopy

Fetal prognosis
o Risk of fetal death is directly related to AOG
o Women with severe renal disease have a high incidence of
both toxemia and impaired fetal growth

Cause of death is from preterm delivery and

complications associated with SGA

OBSTETRICS 2 RENAL AND URINARY TRACT DISORDERS IN PREGNANCY (Dr. Tan)

Management
Frequent prenatal visits
Monitor:
o Blood pressure
o Renal function
o Protein excretion
o Bacteriuria
o Anemia
Treat bacteriuria, anemia and hypertension
Close fetal surveillance
Dialysis during Pregnancy
For significantly impaired renal function
Hemodialysis or peritoneal dialysis
Serum creatinine levels: 5-7 mg/dl
Dialysis frequency: 5-6 times/week
o Abrupt volume changes may cause complications
Initiated at a GFR of 20 ml/min
Maternal complications:*
o Severe Hypertension
o Sepsis
o Heart failure
o Placental abruption
Pregnancy after Renal Transplantation
Management
Careful monitoring of mother and fetus
Multidisciplinary approach: OB, perinatologist, nephrologist,
urologist
Delivery: CS for OB indications (transplanted kidney may obstruct
labor)
o CS rate: 50%
Criteria before recommending pregnancy:
In good general health for at least 2 years after transplantation
Stable renal function without severe renal insufficiwncy
o Serum creatinine < 2mg/dl, preferably < 1.5 mg/dl
o None to minimal proteinuria
o No evidence of graft rejection
o Absence of pyelocalyceal distention by urography
Absent or easily controlled hypertension
Drug therapy
o Prednisone, Azathioprine, Cyclosporine
Polycystic Kidney Disease
Autosomal dominant systemic disease
1/800 live births
Least common cause of chronic renal disease*
Findings:

o Flank pain
o Hematuria
o Nocturia
o Proteinuria
o Calculi
Hypertension in 75% of cases
Progression to renal failure: major problem*
Superimposed acute renal failure may develop from infection or
obstruction from ureteral angulation by cyst displacement
Pregnancy outcome depends on degree of associated:
o Hypertension
o Renal insufficiency
o Urinary tract infections (common)*
Pregnancy does not accelerate natural course of disease

Glomerulopathies (6)
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Acute Nephritic Syndrome
Symptoms:
Hypertension
Red cell mass
Hematuria
Proteinuria
Pyuria
Salt and water retention
* These symptoms are clinically indistinguishable from pre-eclampsia
especially if onset is at 2nd half of pregnancy
Causes:
Post streptococcal infection
Subacute bacterial endocarditis
Systemic Lupus Erythematosus
Anti-glomerular basement membrane disease
IgA nephropathy (Berger disease)
ANCA small vessel vasculitis
Henoch-Schonlein purpura
Cryoglobulinemia
Membranoproliferative glomerulonephritis
Mesangioproliferative glomerulonephritis
Diagnosis: Renal biopsy: help determine etiology
Management and Prognosis
Depends on etiology
May heal spontaneously in subsequent uncomplicated pregnancies
May develop RPGN: may occur within weeks to months of AGN
End stage renal failure
Chronic Glomerulonephritis
Develops with slowly progressive renal disease

OBSTETRICS 2 RENAL AND URINARY TRACT DISORDERS IN PREGNANCY (Dr. Tan)

IgA Nephropathy
Berger disease
Most common form of AGN worldwide*
Primary form: Immune complex disease
Systemic form: Henich-Schonlein purpura
Pregnancy outcome depends on renal insufficiency and
hypertension
Good Pasture Syndrome
o Involve lungs and may manifest as bleeding that may lead
to permanent lung and kidney damage

Chronic Glomerulonephritis
Pre-eclampsia/eclampsia without resolution postpartum
Progressive renal destruction over time
o Eventually producing ESRD (10-20 years before ESRD)

Diagnosis
Proteinuria/abnormal urinary sediment
Anemia
Elevated creatinine
Bilaterally small kidneys
Microscopic renal lesions
o Proliferative sclerosing or membranous
Effect of Glomerulonephritis on Pregnancy
Most common lesions on biopsy:
o Membranous glomerulonephritis
o IgA glomerulonephritis
o Diffuse mesangial glomerulonephritis
-

Worst perinatal outcomes in women

o Impaired renal function
o Early or severe hypertension
o Nephrotic-range proteinuria

Nephrotic Syndrome
Clinical findings:
Proteinuria: hallmark*
o > 3g/day
o Hypoalbuminemia
o Hyperlipidemia
o Edema
o Renal dysfunction
Salt restriction should be started at the beginning of pregnancy
4

Causes:
Minimal Change Disease (MCD): 10-15%
o Primary idiopathic (most cases)
o Drug induced (NSAIDs)

o Allergies
o Viral infections
Focal Segmental Glomerulosclerosis (FSGS): 33%
o Viruses
o Hypertension
o Reflux nephropathy
o Sickle cell disease
Membranous glomerulonephritis: 30%
o Idiopathic (majority)*
o Malignancy
o Infection
o Connective tissue disease
Diabetic nephropathy: most common cause of ESRD*
Amyloidosis

Complications in Pregnancy:
Massive vulvar edema
Thromboembolism (arterial and venous)
o Renal vein thrombosis
Hypertension/Pre-eclampsia
Renal insufficiency
Anemia
Fetal complications:
Abortions and preterm deliveries
Prognosis
ESRD requiring dialysis or transplant
Depends on underlying cause and extent of renal insufficiency
Acute
-

Renal Failure
Rapid decrease in GFR over minutes to days
Acute kidney injury
Sudden kidney function impairment with retention of nitrogenous
waste products normally excreted by kidneys

Etiology in Pregnancy
Pre-eclampsia/eclampsia (HELLP)
Drug abuse
HIV
SLE
Abortion
Sepsis
Nephrotic syndrome
Postparum hemorrhage
Sickle cell disease
Abruptio placenta
Obstructive uropathy
Management
Identify and treat cause

OBSTETRICS 2 RENAL AND URINARY TRACT DISORDERS IN PREGNANCY (Dr. Tan)

Hemodialysis
o When done early, reduce mortality and enhances recovery
of renal function

Prevention
Prompt replacement of blood
Termination of pregnancy complicated by pre-eclampsia/eclampsia
Observe for early signs of sepsis and shock in women with
pyelonephritis, septic abortion, chorioamnionitis or sepsis from
other pelvic infections
Avoid potent diuretics to treat oliguria
o Assure good cardiac output for renal perfusion
Avoid vasoconstrictors to treat hypotension

Previous urinary tract surgery

Treatment: Relieve obstruction

Lower Genital Tract Lesions (3)
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Urethral Diverticulum
Originate from enlarging paraurethral gland abscess that ruptures
into urethral lumen
Findings: urine collecting within and dribbling from the sac, pain,
palpable mass an recurrent UTI
Managed expectantly during pregnancy
Drainage/Surgery
Additional antepartum evaluation: MRI (superior soft tissue
resolution)
Genital Tract Fistulas
May exist prior to pregnancy or rarely form during pregnancy

Vesicovaginal Fistulas
Following a McDonald cerclage
Form from prolonged obstructed labor
After prior CS delivery

Obstructive Renal Failure

Rare
Bilateral ureteral compression, severe oliguria and azotemia

Risk factors:
Twins
Hydramnios

End

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