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Encourages:
Stasis of urine
Idiopathic hematuria
Dr. Tan
October 7, 2014
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)
Erythromycin
Azithromycin
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
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%
Treatment
Depends on symptoms and AOG
Hydration
Analgesia
Antimicrobial therapy
2/3 of cases: pass spontaneously
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
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)
1
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
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
-
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
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
Vesicovaginal Fistulas
Following a McDonald cerclage
Form from prolonged obstructed labor
After prior CS delivery
Risk factors:
Twins
Hydramnios
End
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