Obstetrics 4th class Dr.Hanaa H.

Al-
Heidery
Renal Tract Infections

More common in pregnancy because of dilatation ‫ بسبب التوسع‬of upper

renal tract and urinary stasis. Asymptomatic bacteriuria affects 5–10% of
pregnant women; untreated it can lead to symptomatic infection in 40% of
cases.
• Cystitis complicates 1% of pregnancies.
• Pyelonephritis occurs in 1–2% of pregnant women and is associated with
preterm labour.
Women should be screened for asymptomatic bacteriuria with MSU sample
‫ تحلي ل الب ول‬at booking. If this is –ve, the chance of developing a urinary
infection in pregnancy is <2%.
Symptoms
• Cystitis: ‫ التهاب مثانة‬urinary frequency, urgency, dysuria, haematuria,
proteinuria, and suprapubic pain.
• Pyelonephritis: fever, rigors, vomiting, loin and abdominal pain.
Tenderness
Consider the diagnosis of pyelonephritis in women presenting with
hyperemesis (severe or prolonged vomiting.) or threatened preterm labour.
Emergency + IV antibiotic for 2 day --- oral 10-14 day +

Investigations
• Urinalysis: the most useful markers are nitrites and leukocytes(pus) but
they `may be poor predictors of positive culture in asymptomatic ‫مايفيد اذا‬
bacteriuria.
• MSU: a positive result is confirmed with a culture of >100000
organisms/mL. Mixed growth or non-significant culture—repeat MSU.
• Bloods: blood cultures, FBC, U&E, and CRP in a pyrexial patient.
• Renal USS: after a single episode of pyelonephritis or ≥ 2UTI, to exclude
hydronephrosis, congenital abnormality, and calculi.
_ 20% of pregnant women with pyelonephritis have an abnormal renal tract.
Monthly MSU should be sent in women with culture-proven urinary
infection to prove eradication. 15% develop recurrent bacteriuria and
require further treatment.

Treatment
Oral antibiotics are recommended in asymptomatic bacteriuria and cystitis
to prevent pyelonephritis and preterm labour.

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Obstetrics 4th class Dr.Hanaa H. Al-
Heidery
• Pyelonephritis should be treated with IV antibiotics until the pyrexia
settles and vomiting stop. IV fluids and antipyretics should also be given
(manage in hospital because of risk of preterm labour).

Duration of treatment
• Asymptomatic bacteriuria: 3 days.
• Cystitis: 7 days.
• Pyelonephritis: 10–14 days.

Prevention
•Increase fluid intake.
• Double voiding and emptying bladder after sexual intercourse.
• Cranberry juice: proven in non-pregnant population to d bacteriuria.
• Prophylactic antibiotics: if ≥ 2 culture +ve urine infections + 1 risk factor.

Risk factors for urinary tract infection

Antenatal
• Previous infection (in previous pregnancy or outside pregnancy).
• Renal stones.
• Diabetes mellitus.
• Immunosuppression.
• Polycystic kidneys.
• Congenital anomalies of renal tract (e.g. Duplex system).
• Neuropathic bladder.

Post-partum (risk mainly associated with catheterization)

• Prolonged labour.
• Prolonged 2nd stage.
• CS.
• Pre-eclampsia.

Antibiotic options for renal tract infections Drug of choice Depends on

antibiotic sensitivities. Options include:
• Penicillin amoxicillin.
• Cephalosporin.
• Gentamicin: monitor levels to minimize risk of ototoxicity.
• Trimethoprim: avoid in 1st trimester as it is a folate antagonist. ‫تراي‬
‫حديد‬
‫سيت واحد‬

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Obstetrics 4th class Dr.Hanaa H. Al-
Heidery
• Nitrofurantoin: avoid in 3rd trimester as risk of haemolytic anaemia in
neonate with glucose-6-phosphate dehydrogenase deficiency. + lacting
weman
• Sulfonamides: avoid in 3rd trimester as risk of kernicterus in neonate
due to displacement of protein binding of bilirubin.

Contraindicated antibiotics
• Tetracyclines: cause permanent staining of teeth and problems with
skeletal development.
• Ciprofloxacin: causes skeletal problems.

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Obstetrics 4th class Dr.Hanaa H. Al-
Heidery
Chronic renal disease
There are increased maternal and fetal risks to pregnancy with renal disease.
This is dependent upon:
• The underlying cause.
• The degree of renal impairment.
• The presence and control of hypertension.
• The amount of proteinuria.
• As renal function deteriorates‫ت^دهو‬, so does the ability to conceive and
sustain a pregnancy.Successful pregnancies are rare with a serum
creatinine >275μmol/L.

Risk factors
Maternal risks
• Accelerated, and possibly permanent, deterioration in renal function; this
is more likely if there is also hypertension and proteinuria and significant
renal impairment at conception.
• Hypertension.
• Proteinuria.
• Pre-eclampsia.
• Venous thromboembolism (if nephroitic level of proteinuria).
• UTI.

Fetal risks
• Miscarriage.
• I UGR.
• Spontaneous and iatrogenic preterm delivery.
• Fetal death.
.‫االجهاض‬
‫ خاصةً بش^^كل تلق^^ائي أو‬، ‫ طرد الجنين من الرحم قبل أن يتمكن من البقاء بشكل مستقل‬.UGR ‫• أنا‬
.‫نتيجة للحادث‬
‫ موت الجنين‬+ .‫• الوالدة المبكرة التلقائية والولدية‬

Management
• Multidisciplinary care involving a renal physician.
• Baseline investigations, ideally before conception, include FBC, U&E,
urate, 24h protein, and creatinine clearance.
• Pre pregnancy counselling (genetic counselling if a familial disorder).
• Early and regular antenatal care is advised with the following aims;
• control BP— tight control lessens chance of renal function declining
• monitor renal function and proteinuria
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Obstetrics 4th class Dr.Hanaa H. Al-
Heidery
• assess fetal size and well-being with serial growth scans + Doppler early
detection of complication —anaemia, UTI, pre-eclampsia, IUGR.
• Medication should be reviewed and may need altering. ACEIs should be
stopped as soon as pregnancy is confirmed.
• Prophylactic low-dose aspirin may reduce the risk of pre-eclampsia.
• Erythropoetin may be required with signifcant renal impairment.
• Hospital admission should be considered with in proteinuria or
hypertension, deteriorating renal function, or symptoms of preeclampsia.
_
Look for an underlying cause of deterioration in renal function:
UTI, obstruction, dehydration, pre-eclampsia, renal vein thrombosis.

_It can be diffcult to differentiate between pre-eclampsia and deterioration

of renal impairment. Thrombocytopaenia, IUGR, and abnormal LFTs
suggest the former diagnosis. Aim for vaginal delivery, but rates of CS are
increased.

Commonest causes of chronic renal impairment in pregnancy

• Reflux nephropathy.
• Diabetes.
• Lupus nephritis.
• Chronic glomerulonephritides.
• Polycystic kidneys.

Outcomes in pregnancy dependent on renal function

• A successful outcome is achieved in 90% of cases.
Mild renal impairment (creatinine <125μmol/L)
• Increasing proteinuria is common (>50% of pregnancies) and can be in
nephrotic range.
Moderate renal impairment (creatinine 125–250μmol/L)
• 2 5% of women experience an accelerated decline in renal function.
• Preterm delivery rate is up to 50%, and 1/3 have IUGR.
• Asuccessful outcome is achieved in 60–90% of cases.
Severe renal impairment (creatinine >250μmol/L)
• The risk of maternal complications is significantly higher than the chance
of successful pregnancy; advise against pregnancy.
• There is reduced fertility due to amenorrhoea.
• Permanent deterioration in renal function can occur in up to 25%.
• Preterm delivery rate is >70%, and the rate of IUGR is 30%.

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Obstetrics 4th class Dr.Hanaa H. Al-
Heidery
Creatinine level + protein is dependent on muscle mass as well as renal
function so patients may have significantly different creatinine clearance on
24h urine collection, despite similar blood results. The latter is a more
accurate reflection of renal function.
Hypertension is an important predictor of outcome regardless of renal
function.

Pregnancy after renal transplantation

Menstruation, ovulation, and fertility return after transplantation. Women
should be informed of this and contraception discussed. Those who wish to
conceive should be advised to wait at least 1yr after transplantation,
until stabilization of renal function has been achieved and
immunosuppression is at maintenance levels. The best outcomes are seen
with:
• W ell-controlled BP.
• No proteinuria.
• No evidence of graft rejection.
• Plasma creatinine <180, preferably <125μmol/L.

Management of pregnancy in a transplant recipient

• Multidisciplinary management with a renal physician.
• Antenatal care should be at fortnightly intervals ‫كل اسبوعين تشوفها‬. The aim
is:
• serial assessment of renal function: deterioration may be caused by
infection, dehydration, pre-eclampsia, drug toxicity, or rejection
• diagnosis and treatment of graft rejection
• BP control (avoid ACEIs and β -blockers)
• prevention, early diagnosis, and treatment of anaemia
• detection and treatment of any infection
• serial assessment of fetus (risk of IUGR).
• All women will be on immunosuppressive therapy, which must be
continued; commonly used are prednisolone, azathioprine, and tacrolimus.
• Aim for vaginal delivery with continuous fetal monitoring (parenteral
steroids are necessary to cover labour, due to adrenal suppression). ‫مهم‬
• Prophylactic antibiotics are recommended for obstetric procedures.

• A transplanted kidney does not obstruct labour; CS should be for

obstetric reasons—the current rate is 40% (patients with pelvic
osteodystrophy may need elective CS).
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Obstetrics 4th class Dr.Hanaa H. Al-
Heidery

_ Mycophenalate mofetil is associated with congenital abnormalities and

should be stopped before conception.
.
Investigations in pregnancy following renal transplantation
At each visit
• F BC, U&E, urate.
• M SU.
• P CR.
Every 2–4wks
• U SS for fetal growth and Doppler studies.
Every 4wks
• Drug levels of ciclosporin and tacrolimus.
Every 6wks
• C alcium, phosphate, albumin, and LFTs .
• 2 4h urine for creatinine clearance and protein.

Graft rejection
Consider the diagnosis if there is deteriorating renal function with:
• Fever.
• Oliguria.
• Renal enlargement and tenderness.
2 It can be difficult to diagnose and a renal biopsy may be required.

_ Blood transfusion should be avoided if possible as it increases

likelihood of sensitization making graft rejection more of a problem.

Acute renal failure

Characterized by oliguria (<400mL/day), i urea and
creatinine,hyperkalaemia,
and metabolic acidosis. Rare in pregnancy, typically complicating the post-
partum period. There are three phases:
• Oliguria: few days to several weeks.
• Polyuria: 2 days to 2wks, dilute urine is produced, and as waste products
are still not excreted, renal function still deteriorates.
• Recovery: urine volume returns to normal with a gradual improvement in
renal function.
Management of acute renal failure
• S eek advice from a physician or nephrologist.

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Obstetrics 4th class Dr.Hanaa H. Al-
Heidery
• M ost cases are reversible with appropriate management (permanent
problems more likely with pre-existing renal disease).
• Assessment should include the following investigations:
• F BC, coagulation, U&E, plasma osmolality, glucose, albumin
• blood cultures, MSU, HVS
• urinalysis and urine osmolality and electrolytes
• E CG (looking for changes due to i K + ) and arterial blood gases
(ABG)
• fetal assessment with CTG and USS
• renal USS if obstruction suspected.
• Interventions should include catheterization, central venous line, and renal
biopsy if improvement is delayed; only a minority require dialysis.
• Replace fluid/blood loss but avoid fluid overload as there is a significant
risk of pulmonary oedema (accurate documentation of input/output, daily
weight, and central venous pressure monitoring).
• Maintain BP at levels that allow adequate renal perfusion.
• Review medication and stop nephrotoxic drugs.
• Correct hyperkalaemia, coagulopathy, and give antibiotics if infection
suspected.
• Dialysis is required for persistent hyperkalaemia, acidosis, pulmonary
oedema, or uraemia.

Some causes of renal failure in pregnancy

Pre-renal (hypovolaemic)
• Haemorrhage:
• antepartum (abruption, placenta praevia, etc.)
• post-partum (uterine atony, genital tract trauma, etc.)
• Hyperemesis.
• Septic shock.
• Acute fatty liver of pregnancy.
Intrinsic
• P re-eclampsia.
• H ELLP syndrome.
• Sepsis (Gram –ve, etc.).
• Drug reaction.
• Amniotic fl uid embolus.

Treatment of hyperkalaemia
• 1 0mL calcium gluconate (10%) IV slowly, for cardioprotection.
• 1 5U soluble insulin with 50g of glucose 50% IV over 20min.
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Obstetrics 4th class Dr.Hanaa H. Al-
Heidery
• Consider use of Calcium Resonium® .
X These are only temporary measures; dialysis may be required.Obstruction
• Ureteric damage.
• Pelvic or broad ligament haematoma.
_ Non-pregnancy-related problems may also be the cause.