PATHOLOGIC OBSTETRICS

Topic: Renal and Urinary Tract Disorders

Lecturer: Dr. Brillantes (RCB)

PREGNANCY INDUCED URINARY TRACT CHANGES URINARY TRACT INFECTIONS

 Early in pregnancy  there is already hypertrophy of the kidneys and  Most common bacterial infection in pregnancy Causative organism
dilatation of the calyxes and ureters. Initially, the dilatation of the from normal perineal flora
calyxes is brought about by progesterone  2 Types of UTI:
Progesterone-induced relaxation of the muscularis Ureteral 1. Asymptomatic Bacteriuria
compression 2. Symptomatic:
 Cystitis – lower tract
 As pregnancy advances, the uterus  it will exert out a compressive  Pyelonephritis – upper tract
effects on the surrounding structures (particularly the ureter) which will
give an additional dilatation of the calyxes Asymptomatic Bacteriuria
 Persistent, actively multiplying bacteria within the urinary tract in
asymptomatic women.
What’s the point of treating bacteriuria even if it’s asymptomatic?
In nonpregnant  you really don’t need to treat but in pregnant
patients you have to treat because eventually it can become a
symptomatic also you want to prevent pyelonephritis  more
difficult to handle in a pregnant patient

 More than 100,000 organisms/mL in a clean voided urine is diagnostic

 Recommended screening at the first prenatal visit
 Benefits of treatment are limited to the reduction of the incidence of
pyelonephritis
 More common in diabetics

Treatment of Asymptomatic Bacteriuria

Picture Above:
One of the physiologic changes during pregnancy in the bladder involves the
vesicoureteral valve. For some reasons, the vesicoureteral valve becomes
inefficient  it allows backflow of the urine from the bladder to the ureters
making the pregnant patient prone to UTI (infection starting at the bladder
going up)

ASSESSMENT OF RENAL FUNCTION DURING PREGNANCY

 Urinalysis – unchanged
o Glucosuria
o Proteinuria - >300 mg/day
If it exceeds >300 mg/d = a pathologic level and we see this
in patients with complications like hypertension,
preeclampsia, eclampsia, etc.

 Serum creatinine level - <0.9 mg/dl (75 umol/L)

As part of the physiologic changes in pregnancy, all the blood vessels
become dilated = the goal is to increase perfusion to the uterus to
provide blood flwo to the fetus. As a consequence, the blood flow
to the kidneys will also improve, therefore filtering more plasma (↑
GFR) = more effective in taking out toxins in the blood so that you
will expect a lower serum creatinine level. A value of >0.9 mg/dl of
serum creatinine = pathologic in pregnant women because you Cystitis & Urethritis
expect the kidneys to be more efficient in taking out the metabolic  If your UTI is symptomatic, you either have cystitis or urethritis
wastes. You expect pregnant women to have <0.9 mg/dl of serum  Cystitis – inflammation of the bladder
creatinine  Urethritis – inflammation of the urethra
 Not all bacteria are capable of causing symptomatic UTI but most
 Sonography - #1 modality symptomatic UTI are cause by E. coli  due to its virulence factor
 IVP – not routinely Pili  virulence factor of E. coli. Hair-like appendage that allows it
 Cystoscopy – usual indication to be able to adhere to the mucosa (of bladder, urethra) and allow
Inserting a camera so you could directly view the inside of the it to go up that even if you void urine, it will be able to stay there
bladder. It can be done to pregnant woman under usual indication
 Due to the proximity of the anus to the urethral opening  easily cause
 Uteroscopy – similar to cystoscopy E. coli to invade and cause UTI
 MRI
 Renal biopsy
Do it only if there is a need

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 PATHOLOGIC OBSTETRICS
Topic: Renal and Urinary Tract Disorders
Lecturer: Dr. Brillantes (RCB)

Cystitis & Urethritis continued….. Clinical Findings of Acute Pyelonephritis:

Manifestation:  Abrupt onset
 Dysuria  Fever
 Urgency  Shaking chills
 Frequency  Aching pain in one or both lumbar regions
 Few associated systemic findings  Anorexia, nausea, and vomiting
 Pyuria  Tenderness elicited by percussion in one or both costovertebral angles
 Bacteriuria o Kidney punch – to elicit costovertebral angle tenderness
 Microscopic / gross hematuria  Urinary sediment: many leukocytes, frequently in clumps, and
numerous bacteria.
Management:  Bacteremia
 The choice of antibiotics is the same as the ones used in asymptomatic  Isolated from urine or blood:
bacteriuria (3 day regimen) o E coli , Klebsiella pneumonia
o Enterobacter or Proteus sp
 Chlamydia trachomatis – lower urinary tract symptoms with pyuria o Gm (+) organisms, including group B
accompanied by a sterile urine culture o Streptococcus & S aureus
o Mucopurulent cervicitis usually coexists
o Azithromycin therapy It is important to Rule out Renal Dysfunction. You have to make sure that
the kidney is still functioning despite it being infected
PUERPERIUM
Risk factors that predispose to urinary infection  Respiratory insufficiency - pulmonary edema - ARDS Can be
attributed to
 Decreased bladder sensitivity to intravesical fluid tension as a  Uterine activity
the Endotoxin
consequence of labor trauma or conduction analgesia  Anemia due to hemolysis of the E. coli
This means the bladder is distended = woman is not capable of
voiding spontaneously, may be due to anesthesia used during Differential Diagnosis of Acute Pyelonephritis:
delivery or because there was trauma to the bladder during the  Labor
descent of the fetus along the pelvic canal  Chorioamnionitis
Decreased bladder sensitivity  favors stasis putting her at risk of
 Appendicitis
infection
Why is this a differential diagnosis? As the uterus enlarges, it’s going
to push all the surrounding structures superiorly and laterally. So the
 Diminished bladder sensation of distention due to discomfort caused by
appendix is going superiorly and laterally  pain may be on the
an episiotomy, periurethral lacerations, or vaginal wall hematomas lumbar area (mimic the costovertebral angle tenderness of acute
 Normal postpartum diuresis may worsen bladder overdistention pyelonephritis)
 Catheterization to relieve retention
Also a risk factor and contributes also to UTI due to possible trauma  Placental abruption
to urethra  Infarcted leiomyoma

It is important to Rule out Sepsis Syndrome

UPPER UTI
Risk Factors: Management:
 Urinary stasis  Intravenous hydration to ensure adequate urinary output is the
 Vesicoureteral reflux cornerstone of treatment.
 Diabetes How do you know if there is adequate urine output? 30 cc/hour

Lecture Discussion:  Antimicrobials are begun promptly

Obstruction by the heavy uterus of the pregnant  can compress on the  Surveillance for worsening of sepsis syndrome by serial determinations
bladder and ureter causing stasis = possible UTI of :
o Urinary output
Acute Pyelonephritis o Blood pressure
 Renal infection o Pulse
 The most common serious medical complication of pregnancy o Temperature
Also it is the most common cause of sepsis in pregnancy o Oxygen saturation
 High fever should be lowered with a cooling blanket or acetaminophen.
 Develops more frequently in the second trimester High fever during the 1st trimester is teratogenic  so our goal is to
 Nulliparity and young age are associated risk factors lower the fever
 Often unilateral & R-sided
By the 2nd trimester, the heavy uterus starts to put a compressive
effect on the bladder and ureter.
The left side of the pelvic cavity is occupied by the sigmoid colon and
because the sigmoid colon is on the left, the enlarging uterus now
seeks out a “roomier space” which is the right  dextrorotation
happens = uterus turns (twists) to the right and now may compress
the right ureter  obstruction (stasis)  UTI on the right

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 PATHOLOGIC OBSTETRICS
Topic: Renal and Urinary Tract Disorders
Lecturer: Dr. Brillantes (RCB)

Management of Acute Pyelonephritis Management of Urinary Obstruction (Obstruction Relief):

 Double-J ureteral stent placement
 Percutaneous nephrostomy
 Surgical removal of stones

Surveillance:
 Recurrent infection—either covert or symptomatic—is common
 Nitrofurantoin 100 mg orally at bedtime given for the remainder of the
pregnancy to reduce recurrence

NEPHROLITHIASIS
 Since the calyxes and ureters of the pregnant women is dilated  they
can easily pass out stones
 Pregnant women rarely complains of pain or symptoms secondary to
nephrolithiasis because they can just spontaneously pass it out
 So if you have an incidental finding of nephrolithiasis  management is
Lecture Discussion:
conservative (supportive) because we expect them to just pass it out
CBC (hemogram)  we want to see here the level of infection that she has spontaneously
(is she septic?) another is the hematocrit, hemoglobin and RBC for us to check
for anemia (caused by the endotoxin) Indications for stone removal:
Serum creatinine  we want to rule out kidney dysfunction  Infection
Chest x-ray  to check for evidence of pulmonary edema (if the patient is  Obstruction
dyspneic and tachypneic) ~ also due to the endotoxin  Intractable pain
 Bleeding
Repeat hematology in 48 hrs  we expect the fever to lyse after giving
medications (IV antibiotics)
 Once the patient goes afebrile for 24 hrs.  you can now shift to  Normally, Calcium Oxalate are usually the stones formed but for
oral antibiotics (since IV antibiotic is expensive) pregnant women, Calcium Phosphate is the most common type of
 Follow up after 1-2 weeks and do urine culture to make sure that urinary stone
the infection is eradicated Low-calcium diet  promotes stone formation (because if you
have no calcium, you form more oxalate = ↑ stone formation)
 Antimicrobial therapy usually is empirical:
o Ampicillin + Gentamicin  Prevention:
o Cefazolin o Low sodium and low protein diet
o Ceftriaxone o Hydration
o Extended-spectrum antibiotic o Thiazide diuretics

After discharge, recommend oral therapy for a total of 7 to 14 days It is important to Rule out Hyperparathyroidism
Parathyroid gland is responsible for the metabolism of calcium  if there is
Persistent Infection: too much calcium in the urine (the PTH is mobilizing its effects on increasing
 Spiking fever or lack of clinical improvement by 48 to 72 hours calcium to the blood stream)
 Urinary tract obstruction or another complication or both are
considered Diagnosis:
 Tests for looking for urinary obstruction:  Fewer symptoms with stone passage
o Renal sonography to search for obstruction  Pain
 Gross hematuria - less common
 Sonography
 One shot IVP - dilated calices with no stones
 Transabdominal color doppler US
 Unenhanced Helical CT scan
 MRI - second line test

Management:
 Intravenous hydration
It just tells you that there is hydronephrosis but it does not
 Analgesics Because we expect the
tell you where the obstruction is. So to confirm it you use patient to just pass the
the other modalities  Antibiotics
stones out
 Conservative
o Plain ab  Ureteral stenting, ureteroscopy, percutaneous nephrostomy,
o One shot IVP transurethral laser lithotripsy, or basket extraction
o MRI  YAG laser lithotripsy
 Ureteroscopic removal
 Extracorporeal shock wave lithotripsy is contraindicated

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 PATHOLOGIC OBSTETRICS
Topic: Renal and Urinary Tract Disorders
Lecturer: Dr. Brillantes (RCB)

POLYCYSTIC KIDNEY DISEASE Acute Nephritic Syndrome:

Signs & Symptoms:  Hypertension – hallmark of nephritic syndrome
 Hematuria Although there is also hypertension in nephrotic syndrome, this is
 Proteinuria more prominent in nephritic
 Abdominal masses
 Calculi  Hematuria
 Infection  Red-cell casts
 Hypertension Clumping of RBCs  indicates a more severe tubular damage
 Progression to renal failure
 Other organs involved  Pyuria
 Proteinuria.
Pregnancy Outcome:  Varying degrees of renal insufficiency
 Prognosis for pregnancy depends on the degree of associated  Salt and water retention result in edema, hypertension, and circulatory
hypertension and renal insufficiency congestion
 UTI are common
 Pregnancy does not seem to accelerate the natural disease course Lecture Discussion:

GLOMERULAR DISEASES
Causes:
 Toxins or infections
 Hypertension
 Diabetes
 Idiopathic

Glomerulonephritis: In a patient with nephritic syndrome, their urine is “coca cola-like” in color
due to hematuria
 Capillary inflammation
 Autoimmune process may be involved
Acute Poststreptococcal Glomerulonephritis
 May result following streptococcal infection
 Prototype; Since you have a pronounced hypertension in acute
There could be deposition of immune complexes in the glomerulus.
poststreptococcal glomerulonephritis, it can be confused with
So for example the patient has sore throat due to strep infection 
glomerulonephritis is possible eclampsia

 May be a manifestation of multisystem disease i.e. SLE, DM IgA Nephropathy

 If not addressed immediately, eventual renal functional decline  Also known as Berger’s disease
 Is the most common form of acute glomerulonephritis
Nephrotic Syndrome:  Isolated form occurs sporadically, and may be related to Henoch-
 Heavy proteinuria - the hallmark Schonlein purpura as the systemic form
 Hypoalbuminemia
 Hypercholesterolemia CHRONIC RENAL DISEASE
 Pathophysiological process that can progress to end-stage renal disease
 Edema
 Diseases that leads to end-stage disease requiring dialysis and kidney
 Hypertension
transplantation:
 Albumin nephrotoxicity
o Diabetes
 Renal insufficiency
o Hypertension
o Glomerulonephritis
Lecture Discussion:
o Polycystic kidney disease

The prognosis of patients with CKD would depend on the:

Degree of renal function impairment associated with hypertension

In a patient with nephrotic syndrome, their urine is frothy or bubbly

Management:
 Renal biopsy
 Normal amounts of dietary protein of high biological value are
encouraged—
 Prophylactic anticoagulation value is unclear.
 Glucocorticosteroids
 Other immunosuppressants or cytotoxic drug therapy

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 PATHOLOGIC OBSTETRICS
Topic: Renal and Urinary Tract Disorders
Lecturer: Dr. Brillantes (RCB)

Management: OBSTRUCTIVE RENAL FAILURE

 Frequent monitoring of BP is paramount  Usually, this is unilateral (it is rarely bilateral)
 Serum creatinine levels and 24-hour protein excretion quantified  The complaints are usually: oliguria, azotemia (if unilateral)
 Bacteriuria is treated fluid retention, hypertenstion (if bilateral)
 Protein-restricted diets are not recommended
 Recombinant erythropoietin - hypertension is a common side effect LOWER GENITAL TRACT LESIONS
 Serial sonography - to follow fetal growth  Genital
 Angiogenic biomarkers placental growth factor (PlGF) and its soluble  Tract
receptor (sFlt-1) may be useful to separate chronic from gestational  Fistulas
hypertension
 Multivitamin doses are doubled, and calcium and iron salts are provided Lecture Discussion:
along with sufficient dietary protein and calories for those on dialysis
Since you kidney is not functioning as it should be, if one is taking
multivitamins, doses are usually doubled (due to increased spillage
on urine)

ACUTE KIDNEY INJURY

 Previously termed acute renal failure
 Sudden impairment of kidney function with retention of nitrogenous
and other waste
 Products normally excreted by the kidneys
 Less common today

Acute Renal Ischemia is commonly associated with:

During obstructed labor, the head of the baby becomes descended to the
 Severe preeclampsia pelvic canal  it is pressing on the bladder against the symphysis pubis of
 Hemorrhage the mother. Necrosis may ensue at the area where the head of the baby is
 HELLP syndrome impinging. After necrosis  there will be fistula formation. Postpartum, the
 Placental abruption mother will complain of water vaginal discharge
 Septicemia  “Doc palagi po akong basa, hindi naman ako umiihi”  this is
 Acute fatty liver of pregnancy because the urine is coming out of the vagina through a fistula that
was formed during labor = vesicovaginal fistula
 Dehydration due to hyperemesis gravidarum
Hyperemesis gravidarum  normal in pregnant women but it can
sometimes be so severe that can cause kidney injury. We should
take note of the degree of dehydration

Diagnosis:
 Acute increase in serum creatinine - due to renal ischemia
 Oliguria - sign of impaired renal function

Management:
 Renal replacement treatment - hemofiltration, dialysis
 Hemodynamic measurements are normalized
 Medication dose adjustments are imperative- mgSO4
Dose adjustments are made so as to prevent toxicity of medications

You can also have a fistula during cesarean section:

 This is what we called vesicouterine fistula
The patient will complain of menuria  the patient will not have
menstruation after cesarean section
 Doc hindi na po ako nag memens pero every month ang ihi
ko may dugo. Why?  because the menstrual blood from
the uterus is coming out of the bladder through the
vesicouterine fistula

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