1.

Kidneys enlarge by as much as 30%

2. Collecting system dilates; hydronephrosis is very common
3. Creatinine clearance increases and BUN decreases due to an increase in GFR
and renal plasma flow during pregnancy
(a) Normal Cr level during pregnancy is 0.5–0.6 mg/dL
(b) Normal BUN level during pregnancy is 8–9 mg/dL
4. Urinary protein, albumin, and glucose excretion are increased during pregnancy

-Hal 9- Absolute Obstetric Anaesthesia Review

1. Renal parenchymal disease

(a) Glomerulopathies
(i) Nephritic syndromes: inflammatory or necrotizing lesions
(ii) Nephrotic syndromes: abnormal permeability to protein and other
macromolecules
(b) Tubulointerstitial disease: abnormal tubular function (i.e., interstitial nephritis,
renal cystic disease, renal neoplasia, and functional tubular defects)
(c) Pregnancy does not alter the natural course of renal disease in women with
mild antenatal renal insufficiency, but it often causes deterioration of renal
function in parturients with moderate or severe antenatal renal insufficiency
(d) Obstetric complications from chronic renal disease include IUGR, preterm
delivery, HTN, preeclampsia, an increased cesarean delivery rate, and higher
risk of neonatal mortality
(e) Recombinant human erythropoietin improves maternal anemia during
pregnancy
(f) Abnormalities that may affect anesthetic management in chronic renal
failure:
(i) Cardiovascular: HTN, fluid overload, ventricular hypertrophy, accelerated
atherosclerosis, uremic pericarditis, and uremic cardiomyopathy
(ii) Gastrointestinal: delayed gastric emptying, increased gastric acidity,
hepatic venous congestion, hepatitis (viral or drug-induced),
malnutrition
1. Chronic uremia causes delayed gastric emptying and hyperacidity
(iii) Pulmonary: increased risk of difficult airway and recurrent pulmonary
infections
1. Increased risk of aspiration pneumonitis due to delayed gastric emptying
and hyperacidity

(iv) Metabolic and endocrine: hyperkalemia, metabolic acidosis, hyponatremia,

hypocalcemia, hypermagnesemia, hypoglycemia, decreased
protein binding of drugs
(v) Hematologic: anemia, platelet dysfunction, decreased coagulation factors,
leukocyte dysfunction
1. Uremia causes functional platelet defects and a prolonged bleeding
time that dialysis reverses
(vi) Neurologic: autonomic neuropathy, mental status changes, peripheral
neuropathy, restless leg syndrome, seizure disorder
(g) Hypovolemia and autonomic neuropathy may cause profound hypotension
during sympathetic blockade. Minimize the risk with prehydration and slow
induction of epidural

2. Acute renal failure (ARF)

(a) Defined by a sharp increase in plasma creatinine (>0.8 mg/dL) and BUN
(>13 mg/dL) concentrations.
(b) Subdivided by etiology (i.e., prerenal, postrenal, intrarenal)
(i) Prerenal urinary indices show Uosm > 500 mOsm/kg H2O,
UNa < 20 mEq/L, FENA < 1%, and a urinary-to-plasma creatinine ratio
>40
1. Due to hyperemesis gravidarum, uterine hemorrhage, or heart
failure
(ii) Intrarenal urinary indices show Uosm < 350 mOsm/kg H2O,
UNa > 40 mEq/L, FENA > 1%, and a urinary-to-plasma creatinine ratio
<20
1. Due to acute tubular necrosis (ATN), septic abortion, AFE, druginduced
acute interstitial nephritis, acute glomerulonephritis, bilateral
renal cortical necrosis, acute pyelonephritis, preeclampsia/
eclampsia, HELLP syndrome, acute fatty liver of pregnancy, and
idiopathic postpartum renal failure
(iii) Postrenal due to urolithiasis or ureteral obstruction by the gravid uterus
(c) Leading cause of pregnancy-related ARF in developing countries is septic
abortion
(d) Most common cause in developed countries is severe preeclampsia/eclampsia,
acute pyelonephritis of pregnancy, and bilateral renal cortical necrosis
(e) ATN is due to nephrotoxic drugs, AFE, rhabdomyolysis, IUFD, and prolonged
renal ischemia from hemorrhagic or septic shock
(i) UA shows brown epithelial cell casts and coarse granular casts
(f) Acute interstitial nephritis is caused by NSAIDs and some antibiotics.
Eosinophilia and urine eosinophils are seen
(g) Bilateral renal cortical necrosis is most commonly caused by placental
abruption. Pathogenesis is unclear.
(h) Neuraxial anesthesia may be administered in the absence of coagulopathy,
thrombocytopenia, and hypovolemia
(i) Epidural may be preferred over spinal when intravascular volume status
is questionable

3. Renal transplantation

(a) Increased pregnancy complications: IUGR, IUFD, preterm delivery, spontaneous

abortion, and HTN
(b) Pregnancy does not affect long-term outcome of renal allograft
(c) Fetus will be exposed to immunosuppressant drugs and may be adversely
affected
(d) Stress-dose corticosteroid is indicated in cesarean deliveries
(e) No contraindications to neuraxial anesthesia, but strict aseptic technique
must be maintained

4. Urolithiasis

(a) Most stones are calcium oxalate

(b) Must consider in patients with pyelonephritis who remain febrile or have
continued bacteriuria despite 48 h of antibiotics
(c) Diagnose with US or MRI to limit radiation exposure to fetus in utero
(d) Women with nephrolithiasis have a higher rate of preterm delivery
(e) Most stones (70%) pass spontaneously. Others may need urologic intervention
(i.e., ureteroscopy and stent placement)
(i) YAG laser lithotripsy may be used in pregnancy; extracorporeal lithotripsy
is not approved for use during pregnancy
(f) Epidural may be used during conservative management of urolithiasis for
pain relief (ureter sensory innervation is T11-L1)
(i) Allows analgesia without systemic opioids, which impair normal ureteral peristalsis
-Hal 137-139- Absolute Obstetric Anaesthesia Review