CARDIOVASCULAR

COMPLICATIONS IN
PREGNANCY
O B C C PA N E S
PHYSICAL CONSIDERATIONS IN
PREGNANCY
• Increased cardiac output by 50%
– Takes place within 8 weeks and is maximized in midpregnancy
– This is due to augmented stroke volume that results from decreased vascular
resistance
• Increase resting pulse and stroke volume later in pregnancy
– Due toincreased diastolic filling from pregnancy hypervolemia
• Women with underlying cardiac disease may not accommodate these
changes
DIAGNOSIS OF HEART DISEASE

• ECG
• Echocardiogram
• Chest radiograph
• CT angiography- pulmonary embolism
CLINICAL CLASSIFICATION OF HEART
DISEASE
Class I Uncompromised—no limitation of
physical activity: These women do not
have symptoms of cardiac insufficiency
or experience anginal pain.
Class II Slight limitation of physical activity: These
women are comfortable at rest, but if
ordinary physical activity is undertaken,
discomfort in the form of excessive fatigue,
palpitation, dyspnea, or anginal pain results.
Class III. Marked limitation of physical activity: These
women are comfortable at rest, but less
than ordinary activity causes excessive
fatigue, palpitation, dyspnea, or anginal
pain.
Class IV Severely compromised—inability to perform
any physical activity without discomfort:
Symptoms of cardiac insufficiency or angina
may develop even at rest. If any physical
activity is undertaken, discomfort is
increased.
PREDICTORS OF CARDIAC
COMPLICATIONS INCLUDED THE
FOLLOWING:
• Prior heart failure, transient ischemic attack, arrhythmia, or stroke.
• Baseline NYHA class III or IV or cyanosis.
• Left-sided obstruction defined as mitral valve area less than 2 cm2, aortic
valve area less than 1.5 cm2, or peak left ventricular outflow tract gradient
above 30 mm Hg by echocardiography.
• Ejection fraction less than 40 percent.
PRECONCEPTUAL COUNSELING

• important especially on women with severe heart disease

CONGENITAL DISEASE IN OFFSPRING

• Many congenital heart lesions appear to be inherited as poly-genic

characteristics
MANAGEMENT
NYHA CLASS 1 & II DISEASE
• prevention and early correction of heart failure
– the onset of congestive heart failure is generally gradual
• First sign: persistent basilar rales, frequently accompanied by a nocturnal cough.
• Serious heart failure: sudden diminution in ability to carry out usual duties,
increasing dyspnea on exertion, or attacks of smothering with cough
– Hemoptysis, progressive edema, tachycardia
• Avoiding contact in persona with respiratory infections, including common cold
– bacterial endocarditis is a deadly complication of valvular heart disease
• Prohibition of cigarette smoking, illicit drug use
MANAGEMENT
NYHA CLASS 1 & II DISEASE (..CONTD)
Labor and Delivery
• Vaginal delivery is preferred unless there are obstetrical indications for cesarean
delivery
• Pulmonary catheterization- may be indicated for hemodynamic monitoring
• During labor:
– semirecumbent position with lateral tilt
– vital signs monitoring
– Inpending ventricular failure: >100bpm or >24cpm with dyspnea
– intensive medical management immediately
• Delivery itself DOES NOT necessarily improve the maternal condition
MANAGEMENT
NYHA CLASS 1 & II DISEASE (..CONTD)
Analgesia and Anesthesia
• If using conduction analgesia- watch out for HYPOTENSION
– dangerous in women with intracardiac shunts in which flow nmay be reversed
because blood flows right to left within the heart or aorta and bypasses the
lungs
– Also dangerous if accompanied with aortic stenosis or pulmonary hypertension
because ventricular output is dependent on adequate preload
• narcotic or general anesthesia is the preferred method of choice for these
types of patients
MANAGEMENT
NYHA CLASS 1 & II DISEASE (..CONTD)
• - For vaginal delivery in Women with mild cardiovascular compromise
– epidural anesthesia with IV sedation
• Subarachnoid blockade is NOT generally recommended in women with
significant heart disease
• Cesarean delivery
– epidural anesthesia
• General endotracheal anesthesia with thiopental, succinylcholine, nitrous
oxide, and at least 30percent oxygen can also be used
MANAGEMENT
NYHA CLASS 1 & II DISEASE (..CONTD)
Intrapartum heart failure
• Cardiovascular decompensation during labor— manifest as pulmonary
edema with hypoxia or as hypotension, or both
• decompensated mitral stenosis with pulmonary edema due to fluid overload
— manage with agressive diuresis
• Tachycardia— manage heart rate control with B-blocking agents
MANAGEMENT
NYHA CLASS 1 & II DISEASE (..CONTD)
Puerperium
• watch out for serious complications such as Postpartum hemorrhage,
anemia, infection, and thromboembolism
Sterilization and Contraception
• If tubal sterilization is to be performed after vaginal delivery, it is best to
DELAY the procedure until the mother has become hemodynamically near
normal, and when she is afebrile, not anemic, and ambulates normally
MANAGEMENT OF CLASS III AND IV DISEASE

• Question: should pregnancy be undertaken?

– If yes, mother should be educated about the risks
– If feasible, women should consider pregnancy interruption
• If pregnancy is to be continued— prolonged bed rest
Management
• anesthesia: epidural
• delivery: vaginal
• Cesarean delivery is usually limited to obstetrical indications
SURGICALLY CORRECTED HEART
DISEASE
VALVE REPLACEMENT BEFORE PREGNANCY

Effects:
• women with mechanical valve prosthesis should be anticoagulated, and
when not pregnant, warfarin is recommended
• Overall, the maternal mortality rate is 3 to 4 percent with mechanical
valves, and fetal loss is common.
• Porcine tissue valves
– safe in pregnancy
– anticoagulation is not required
– thrombosis is rare
VALVE REPLACEMENT BEFORE
PREGNANCY (..CONTD)
Management
1. Warfarin
• teratogenic and can cause miscarriage, stillbirths and fetal malformation
2. Low-dose heparin
• inadequate
3. Heparin
• unfractionated heparin
• LMWH
VALVE REPLACEMENT BEFORE
PREGNANCY (..CONTD)
Recommendations for Anticoagulation
• Unfractionated heparin
• from 6-12 weeks and then at 36 weeks
• Discontinued just before delivery
• if bleeding is still present before delivery, PROTAMINE SULFATE can be given
VALVE REPLACEMENT BEFORE
PREGNANCY (..CONTD)
Warfarin
• throughout the rest of pregnancy to achieve an INR of 2.0-3.0
• Anticoagulant therapy may be restarted 6 hours following vaginal delivery.
• Anticoagulant therapy may be restarted 24 hours following major procedure
(ex. CS)
• Warfarin derivatives are safe for breastfeeding women because of minimal
transfer to milk
VALVE REPLACEMENT BEFORE
PREGNANCY (..CONTD)
Contraception
• CONTRAINDICATED in women with prosthetic valves due to high risk of
developing thrombosis
VALVE REPLACEMENT DURING
PREGNANCY
• usually postponed until after delivert except in some life saving cases
• surgery is done electively when possible, pump flow rate is maintained 2.5
L/min/m2, normothermic perfusion pressure is 70 mm Hg, pulsatile flow is
used, and hematocrit is 28 percent
PREGNANCY AFTER HEART
TRANSPLANT
According to Key (1989) and Kim (1996):
• transplanted heart responds normally to pregnancy-induced changes
Complications:
• 50%- hypertension
• 20%- rejection episode
• Delivered via CS at 37-38 weeks
• 75% of infanrs were liveborn
VALVULAR HEART DISEASE
MITRAL STENOSIS

• 75% caused by rheumatix endocarditis

• normal mitral valve surface area is 4.0 cm
• impeded blood flow from left atrium to the left ventricle
• Most common complaint: dyspnea
• Fatigue, palpitations, cough, and hemoptysis
• Pulmonary hypertension and edema
• Increased chances of ventricular failure in pregnancy due to increased preload
• Significant stenosis: tachycardia— shortens ventricular diastolic filling time and
increases the mitral gradient—> incrwase in left strial and pulmonary capillary
pressure—> pulmonary edema
MITRAL STENOSIS (…CONTD)

Pregnancy Outcomes
• complications in women with a mitral-valve area 2cm
• Fetal growth restriction- mitral valve area less than 1.0 cm
Management
• limited physical activity
• Na restriction
• Diuretic therapy
• New onset atrial fibrillation: intravenous verapamil, 5 to 10 mg
• Chronic atrial fibrillation: digoxin, a -blocker,or a calcium-channel blocker
• Vaginal delivery with strict attention to fluid overload
MITRAL INSUFFICIENCY

• chronic mitral regurgitation

• Libman-Sacks endocarditis- associated in women with high antiphospholipid
antibodies
• Acute Mitral Inufficiency- due to rupture of a chorda tendineae, infarction of
papillary muscle, or leaflet perforation from infective endocarditis
• Likewise, mitral regurgitation is well tolerated during pregnancy, probably
because decreased systemic vascular resistance results in less
regurgitation.
AORTIC STENOSIS

• most likely due to congenital lesion

• Most common congenital lesion: bicuspid valve
• NV of aortic orifice: 2-3cm
• Reduction in the valve area to a fourth its normal size severe obstruction to flow and a
progressive pressure overload on the left ventricle concentric left ventricular hypertrophy
elevated end diastolic pressure decline of ejection fraction reduced cardiac output
• S/Sx: develop late; includes chest pain, syncope, heart failure, sudden death from arrythmias
• Uncommonly encountered in pregnancy
• principal underlying hemodynamic problem is the fixed cardiac output associated with severe
stenosis
AORTIC STENOSIS (…CONTD)

Management
• Asymptomatic- close observation
• Symptomatic- strict limitation of activity; prompt treatment of infections
– If symptoms still persist despite bed rest valvotomy using cardiopulmonary bypass
– Balloon valvotomy is AVOIDED due to risk of complications of stroke, aortic rupture, aortic valve insufficiency and
death
• Critical aortic stenosis
– Intensive monitoring during labor
– Pulmonary artery catheterization
• Key to management: decreased ventricular preload and maintenance of cardiac output
• narcotic epidural analgesia can be ideal during delivery to avoid potentially hazardous hypotension
• forceps or vacuum delivery can be used in hemodynamically stable women
AORTIC INSUFFICIENCY

• aka aortic regurgitation

• diastolic flow of blood from the aorta into the left ventricle
• common causes: rheumatic fever, connective-tissue abnormalities
• left ventricular hypertrophy and dilatation
• well tolerated in pregnancy
PULMONIC STENOSIS

• congenital
• associated with Noonan syndrome
• systolic ejection murmur over the pulmonary area that is louder during
inspiration
• Increased hemodynamic burdens of pregnancy can precipitate right-sided
heart failure or atrial arrhythmias in women with severe stenosis
• Management: surgical correction before or during pregnancy
CONGENITAL HEART DISEASE
SEPTAL DEFECTS

1. ATRIAL SEPTAL DEFECT

• most commonly encountered adult congenital cardiac lesion after bicuspid aortic valve
• 70%
– Secundum type
– associated mitral valve myxomatous abnormalities with prolapse
• “Paradoxical embolism”
– Due to shunting of blood from right to left
– entry of a venous thrombus through the septal defect and into the systemic circulation
• recommended repair if discovered in adulthood
• Pregnancy is well tolerated unless pulmonary hypertension has developed
• Management:
– Treatment is given if there is development of heart failure or arrythmia
– Bacterial endocarditis prophylaxis
SEPTAL DEFECTS

2. VENTRICULAR SEPTAL DEFECT

• 90% cases in childhood

• Most defects are paramembranous
• When the effective size of the defect exceeds that of the aortic valve orifice,
symptoms rapidly develop
• Pregnancy is well tolerated with small to moderate left-toright shunts
• Eisenmenger syndrome
– Reversal or bidirectional flow
– Mortality rate of 30-50%
– Pregnancy is not advisable
SEPTAL DEFECTS

3. ATRIOVENTRICULAR SEPTAL DEFECT

• 3% of cardiac malformations
• characterized by a common, ovoid-shaped AV junction
• associated with aneuploidy
• complications are more frequent in pregnancy in contrast to other septal
defects
SEPTAL DEFECTS

4. PERSISTENT DUCTUS ARTERIOSUS

• More likely to develop pulmonary hypertension, heart failure, or cyanosis if

systemic blood pressure falls with reversal of blood flow from the pulmonary
artery into the aorta
• A sudden blood pressure decrease at delivery—such as with conduction
analgesia or hemorrhage—may lead to fatal collapse
CYANOTIC HEART DISEASE

• Tetralogy of fallot
– Large VSD
– Pulmonary stenosis
– Right ventricular hypertrophy
– Overriding of aorta
• Women who have undergone repair, and in whom cyanosis did not reappear,
do well in pregnancy
Effects on Pregnancy
• Do poorly during pregnancy
CYANOTIC HEART DISEASE (…CONTD)

Pregnancy after Surgical Repair

• Improved maternal and fetal outcomes; pregnancy is well tolerated
• Few instances that the mother may develop arrythmia or heart failure
Labor and Delivery
• Vaginal delivery is preferred
EISENMENGER SYNDROME

• secondary pulmonary hypertension that develops from any cardiac lesion

• develops when pulmonary vascular resistance exceeds systemic resistance,
with concomitant right-to-left shunting
• prognosis depends on the severity
PULMONARY HYPERTENSION
PULMONARY HYPERTENSION

• normal resting mean pulmonary artery pressure: 12-16mm

• there is 34% decrease pulmonary resistance in late pregnancy
• a hemodynamic observation and NOT a diagnosis
• defined in nonpregnant individuals as a mean pulmonary pressure
>25mmHg
• Class I- specific disease that affects
pulmonary arterioles
• Class II- more commonly encountered in
pregnant women; secondary to
pulmonary venous hypertension caused
by left-sided atrial, ventricular, or
valvular disorders
PULMONARY HYPERTENSION (…
CONTD)
Diagnosis
• Dyspnea with exertion- most common
• Class II- orthopnea and nocturnal dyspnea
• Chest radiography- enlarged pulmonary hilar arteries and attenuated
peripheral markings
• Diagnosis is by echocardiography and is confirmed by right-sided
catheterization
Prognosis
• Depends on the severity
• Pulmonary Hypertension and Pregnancy
Increased maternal mortality especially in idiopathic pulmonary hypertension
– 65% mortality in those with primary disease
• Pregnancy is contraindicated in those with severe disease especially in
those with pulmonary arterial changes (Class I)
• Treatment:
– Limitation of activity, avoidance of supine position in late pregnancy
– During labor and delivery, careful attention is given to epidural analgesia
induction to avoid hypotension and prevent blood loss during delivery
OTHER CARDIOVASCULAR
CONDITIONS
MITRAL VALVE PROLAPSE

• diagnosis implies the presence of a pathological connective tissue disorder

—often termed myxomatous degeneration—which may involve the valve
leaflets themselves, the annulus, or the chordae tendineae
• most women are asymptomatic and diagnosed during routine examination
or while undergoing echocardiography
• small percentage in women develop anxiety, palpitations, atypical chest
pain, and syncope
• increased risk for sudden death, infective endocarditis, or cerebral
embolism
MITRAL VALVE PROLAPSE (…CONTD)

Effects on Pregnancy
• rarely have cardiac complications
• pregnancy-induced hypervolemia may improve alignment of the mitral
valve
• Symptomatic women: B blockers to decrease sympathetic tone, relieve
chest pain and palpitations, and reduce the risk of life-threatening
arrhythmias
PERIPARTUM CARDIOMYOPATHY

• a diagnosis of exclusion following a contemporaneous cardiac evaluation of

peripartum heart failure
• Diagnostic Criteria for Peripartum Cardiomyopathy
– 1. Development of cardiac failure in the last month of pregnancy or within 5
months after delivery
– 2. Absence of an identifiable cause for the cardiac failure,
– 3. Absence of recognizable heart disease prior to the last month of pregnancy,
and
– 4. Left ventricular systolic dysfunction demonstrated by classic
echocardiographic criteria such as depressed shortening fraction or ejection
fraction
PERIPARTUM CARDIOMYOPATHY (…
CONTD)
• Most common cause: myocarditis
– 50% associated with parvovirus B19, human herpesvirus 6, Epstein-Barr virus,
and human cytomegalovirus
• women who develop peripartum heart failure often have obstetrical
complications that either contribute to or precipitate heart failure
IDIOPATHIC CARDIOMYOPATHY IN PREGNANCY

• women present signs and symptoms of congestive heart failure

• orthopnea, cough, palpations and chest pain
• hallmark finding: impressive cardiomegaly
• Echocardiographic findings
– Ejection fraction <45%
– Fractional shortening <30%
– End diastolic dimension >2.7cm /m2
Management:
• Diuretics- to reduce preload
• Hydralazine or another vasodilator to reduce afterload
• ACE inhibitors are PROHIBITED during the course of pregnancy due to fetal
effects
• Prophylactic heparin due to high incidence of thromboembolism
HYPERTROPHIC CARDIOMYOPATHY

• Can either be:

– Concentric left ventricular hypertrophy- familial (autosomal dominant)
– idiopathic hypertrophic subaortic stenosis- sporadic form not related to hypertension
• common disorder
• characterized by cardiac hypertrophy, myocyte disarray, and interstitial fibrosis
• caused by mutations in any one of more than a dozen genes that encode proteins of the cardiac
sarcomere
• abnormality in cardiac muscle
• characterized by left ventricular myocardial hypertrophy with a pressure gradient to left
ventricular outflow
• most affected women are asymptomatic; dyspnea, angina and arrythmias may develop
HYPERTROPHIC CARDIOMYOPATHY
(…CONTD)
Pregnancy
• congestive heart failure is common
• no maternal deaths recorded
• 25% experienced one adverse cardiac symptom, including dyspnea, chest pain, or
palpitations
Management:
• Prohibition of strenuous exercise
• B adrenergic and calcium channel blockers
• Route of delivery is determined by obstetrical indications
• Spinal analgesia is contraindicated
INFECTIVE ENDOCARDITIS

• involves cardiac endothelium and produces vegetationsthat usually deposit on a

valve
• associated with IV drug abuse
• Subacute bacterial endocarditis
– due to a low-virulence bacterial infection superimposed on an underlying structural lesion
– Most common: viridans group Streptococci; Enterococcus
– S.aureus- common in IV drug abuse
– S. epidermidis- common in prosthetic valve infection
– Streptococcus pneumoniae and Neisseria gonorrhoeae- cause acute fulminating disease
– Neisseria sicca and Neiserria mucosa- causes antepartum endocarditis
INFECTIVE ENDOCARDITIS (…CONTD)

• Diagnosis
Management:
• Primarily medical with appropriate timing of surgical intervention
• Penicillin G IV with gentamicin for 2 weeks
• Complicated infections- IV ceftriaxone or vancomycin for 4 weeks
Endocarditis in Pregnancy
• Uncommon
• Antimicrobial prophylaxis is still questionable
ARRYTHMIAS

A. Bradyarrythmias
• Successful pregnancy outcome
• Some with complete heart block have syncope during labor and delivery
• women with permanent artificial pacemakers usually tolerate pregnancy
well
B. Tachyarrythmias
• Common and should prompt consideration of underlying cardiac disease
• Paroxysmal supraventricular tachycardia is most frequent
• Management: calcium channel blockers or beta blockers
ARRYTHMIAS (…CONTD)

C. Atrial flutter and atrial fibrillation

• More associated with thyrotoxicosis or mitral stenosis
• Management: heparin
D. Ventricular tachycardia
• - uncommon
E. QT-interval prolongation
• - may predispose to torsades de pointes
DISEASES OF AORTA
AORTIC DISSECTION

• Associated with Marfan’s syndrome and coarctation of aorta

• Other associations: Ehler’s Danlos Syndrome
• Initiating event: aortic intimal tear, and rupture
• S/Sx: Severe chest pain: ripping, tearing, or stabbing in nature; Diminution
or loss of peripheral pulses in conjunction with a recently acquired murmur
of aortic insufficiency
• Definitive diagnosis: Aortic angiography
• Management:
– Initial: lower blood pressure
MARFAN’S SYNDROME

• autosomal dominant trait with a high degree of penetrance

• Prenatal diagnosis is usually possible using linkage analysis
• Connective tissue disorder caused by abnormal fibrillin—a constituent of
elastin—caused by any of dozens of mutations in the FBN1 gene located on
chromosome 15q21
• Joint laxity and scoliosis Progressive aortic dilatation causes aortic valve
insufficiency, and there may be infective endocarditis and mitral valve
prolapse with insufficiency
• Aortic dilatation and dissecting aneurysm
• Management: long term B blockers
Effect on Pregnancy
• Both aortic dissection and Marfan’s syndrome are high risk factors for life-
threatening cardiovascular complications during pregnancy
AORTIC COARCTATION

• relatively rare lesion often accompanied by abnormalities of other large arteries

• associated with persistent ductus arteriosus, septal defects, and Turner syndrome
Effects on Pregnancy
• more likely in late pregnancy or postpartum
• major complications: congestive heart failure after long standing severe hypertension
• Management
– resection of the coarctation be undertaken during pregnancy to protect against the
possibility of a dissecting aneurysm and aortic rupture
– cesarean delivery to prevent transient blood pressure elevations that might lead to rupture
of the aorta or coexisting cerebral aneurysms
ISCHEMIC HEART DISEASE

• rare complication of pregnancy

• Risk factors: diabetes, smoking, hypertension, hyperlipidemia, and obesity
• Diagnosis during pregnancy is not different from the nonpregnant patient
– Measurement of troponin I
• Pregancy with Prior Ischemic Heart Disease
• Pregnancy is unadvised
• For those who become pregnant, echocardiography should be done
RENAL AND URINARY
TRACT
COMPLICATIONS IN
PREGNANCY
O B C C PA N E S
PREGNANCY INDUCED URINARY
CHANGES
• - kidneys become larger - dilatation of the renal calyces and ureters can be striking
– some dilatation develops before 14 weeks due to progesterone-induced relaxation of the muscular layers
– more apparent dilatation on mid pregnancy due to ureteral compression especially on the right side
• Vesicoureteral reflux
• Increased risk of upper urinary tract infection
• Functional hypertrophy
– glomerulus becomes larger but does not increase in number
• Intrarenal vasodilation—> increase effective renal plasma flow and glomerular filtration
– 12 weeks AOG- increase glomerular filtration by 20% above nonpregnant values—> ultimately up to 65%
• - Plasma flow increases up to 40%
ASSESMENT OF RENAL FUNCTION
DURING PREGNANCY
Urinalysis
• unchanged in pregnancy except for occasional glucosuria
• protein excretion is increased but seldom it does not reach on detectable levels
• 24hr protein in all trimesters: 260mg/day
• Albumin: 5-30mg/day
• -proteinuria: >400mg/day; >500mg/day- associated with gestational hypertension
• nulliparas: idiopathic hematuria (>1+ before 20 weeks
– they are also at twofold risk of having preeclampsia
• suspect intrarenal disease if serum creatinine >0.9mg/dL
ASSESMENT OF RENAL FUNCTION
DURING PREGNANCY (…CONTD)
• Sonography- determine renal size and consistency
• -intravenous pyelography, cystoscopy, renal biopsy- safely performed in
pregnancy
PREGNANCY AFTER UNILATERAL
NEPHRECTOMY
• surviving kidney undergoes pregnancy-induced hypertrophy of function
• Therefore a woman with one kidney have no difficulty in pregnancy
ORTHOSTATIC PROTEINURIA

• pregnant woman with orthostatic proteinuria should be evaluates for

bacteruria, abnormal urinary sediment, reduced glomerular filtration, and
hypertension
URINARY TRACT INFECTIONS
URINARY TRACT INFECTIONS

• most common bacterial infections in pregnancy

– asymptomatic bacteruria- most common
– pyelonephritis
– cystitis
Organisms
• from perineal flora
• Escherichia coli- 90%- cause nonobstructive pyelonephritis
• Puerperium risk factors
– decreased bladder sensitivity to intravesical fluid tension, episiotomy, periurethral
lacerations, or vaginal wall hematomas
URINARY TRACT INFECTIONS (…
CONTD)
Asymptomatic bacteruria
• persistent, actively multiplying bacteria within the urinary tract in
asymptomatic women
• 2-7% incidence rate in pregnant women
• Highest incidence in African-American and lowest incidence in Whites
• Typically present on first prenatal visit— identified on initial positive urine
culture
URINARY TRACT INFECTIONS (…
CONTD)
Significance
• if not treated, 25% chance to develop symptomatic infection during
pregnancy
• screening recommendation for bacteruria is during first prenatal visit via
dipstick culture technique
• In some studies, covert bacteruria is associated with preterm or low
birthweight infants
• Bacteria that persists or recurs after delivery is associated with
pyelographic evidence of chronic infection, obstructive lesions, and
congenital abnormalities
CYSTITIS AND URETHRITIS

• lower urinary tract infection

• May develop without antecedent covert bacteruria
• Cystitis
– dysuria, urgency, frequency, pyuris, bacteruria
– occasional gross hematuria
• 40% of pregnant women with acute pyelonephritis have preceding symptoms of lower tract infection
Treatment
• 3 day regimens on Table 48-1 (pp1036)
• Lower urinary tract symptoms with pyuria may be from urethritis caused by Chlamydia trachomatis
– erythromycin
ACUTE PYELONEPHRITIS

• most common serious medical complication of pregnancy

• Leading cause of septic shock in pregnancy
• Associated with sepsis syndrome
Clinical Findings
• develops more frequently on 2nd trimester
• Associated risk factors: nulliparity, young age
• 1/2 cases: unilateral
• 1/4 cases: bilateral
• abrupt onset with fever, shaking chills, and aching pain in one or both lumbar regions
• Anorexia, nausea, and vomiting—> may lead to dehydration
• Tenderness on one or both costovertebral angles
ACUTE PYELONEPHRITIS (…CONTD)

• Urinary sediment: WBC, bacteria

• 70-80%: E. Coli
• 10%: Streptococcus
• 3-5%: Klebsiella pneumoniae
• 3-5%: Enterobacter, Proteus
• Differential diagnoses: labor, chorioamnionitis, appendicitis, placental
abruption, or infarcted leiomyoma
ACUTE PYELONEPHRITIS (…CONTD)

• 20% of pregnant women develop renal dysfunction; reversible

• 10% of pregnant women: respiratory insufficiency from endotoxin-induced
alveolar injury and may cause acute pulmonary distress syndrome
• Incidence of pulmonary edema 8%
• Uterine activity from endotoxin is common
– 5 contractions per hour
• Endotoxin induced hemolysis
ACUTE PYELONEPHRITIS (…CONTD)
ACUTE PYELONEPHRITIS (…CONTD)

• - Cornerstone of treatment: “Intravenous hydration”

– to ensure adequate urinary output
• High fever: cooling blanket or acetaminophen
• Empiric antimicrobial therapy
– ampicillin + gentamicin
– cefazolin or ceftriaxone
– extended spectrum antibiotic
Outpatient Management
• - IM ceftriaxone, two 1g doses, 24h apart
ACUTE PYELONEPHRITIS (…CONTD)

Management of Nonresponders
• no clinical improvement within 48-72h
• Do sonography
• Plain abdominal radiograph if stones are to be suspected
• Intravenous pyelography
Followup
• recurrent infection in 30-40% cases
REFLUX NEPHROPATHY

• chronic interstitial nephritis that classically was thought to be due to

infection (chrinic pyelonephritis)
• Long term complications: renal damage, hypertension
• Maternal complications: impaired renal function and bilateral renal scarring
NEPHROLITHIASIS
NEPHROLITHIASIS

• 80% of stones are calcium salts

• Half of affected women have familial idiopathic hypocalciuria
• Stone disease During Pregnancy is common
Diagnosis
• Pain, gross hematuria
• Sonography
NEPHROLITHIASIS (…CONTD)

Management
• Intravenous hydration and analgesics
• A persistent pyelonephritis should prompt a search for obstruction dueto
nephrolithiasis
• 2/3 of cases- usually resolve spontaneously by conservative therapy
• Severe cases: ureteral stenting, ureteroscopy, percutaneous nephrostomy,
transurethral laser lithotripsy, or basket extraction
CHRONIC RENAL DISEASE
CHRONIC RENAL DISEASE

• pathophysiological process that ultimately results in end-stage renal disease (ESRD)

through a progressive loss of nephron number and function
• multiple etiologies
• at least 3 months
• Most common causes:
– Diabetes- 33%
– Hypertension- 24%
– Glomerulonephritis- 17%
– Polycystic kidney disease- 15%
• There is usually renal insufficiency, proteinuria, or both
Categories of Renal Function in Women

• Mild impairment- serum creatinine of <1.5mg/dL

• Moderate impairment- serum creatinine of 1.5-3.0mg/dL
• Severe renal insufficiency- serum creatinine of >3.0mg/dL
CHRONIC RENAL DISEASE (…CONTD)

Pregnancy and Chronic Renal Disease

• Usually have mild insufficiency
• Renal disease as part of diabetes and connective-tissue disorders— as well
as other co-morbidities portend a worse prognosis
CHRONIC RENAL DISEASE (…CONTD)

Physiological changes
 
• Loss of renal tissue compensatory intrarenal vasodilation and hypertrophy
of the surviving nephrons compensation fails and the surviving nephrons
sclerose worsening renal function greater augmentation of renal plasma
flow and glomerular filtration augmented renal plasma flow becomes
diminished to absent
CHRONIC RENAL DISEASE (…CONTD)

• In pregnancy, some have preexisting glomerulonephritis and minimal renal

insufficiency
– 15%- developed impaired renal function
– 60%- worsening proteinuria
– 12% hypertension antedating pregnancy
– >50%- developed gestational hypertension
– 5%- irreversibly worsened renal function
– Mortality in few percentages
COMPLICATIONS ASSOCIATED WITH CHRONIC RENAL
DISEASE DURING PREGNANCY
CHRONIC RENAL DISEASE (…CONTD)

Management
• Frequent prenatal visits
– To monitor blood pressure
• Serial serum creatinine
• Treatment of bacteruria if present
• Protein restricted diets are NOT recommended
• Anemia from chronic renal insufficiency- ERYTHROPOIETIN
• followup
CHRONIC RENAL DISEASE (…CONTD)

• Dialysis during Pregnancy

• women can still be pregnant even under dialysis
– 80% hypertensive
– 95% anemic
• Pregnancy outcomes
– Early losses- 42%
– Preterm births- 26%
– Stillbirths- 8%
– Infant survival in women who conceived during dialysis- 40%
– Infant survival in women who commenced dialysis after becoming pregnant- 75%
• The type of dialysis did not influence pregnancy outcome
CHRONIC RENAL DISEASE (…CONTD)

Indications for dialysis

• Both hemodialysis and peritoneal dialysis are feasible
• Initiation of dialysis: If serum creatinine is 5-7mg/dL
• Frequency: 5-6x weekly
– To avoid abrupt volume changes that may cause hypotension
PREGNANCY AFTER RENAL
TRANSPLANT
PREGNANCY AFTER RENAL
TRANSPLANTATION
• Pregnancy Outcomes (mostly treated with cyclosporine and tacrolimus)
• 20% incidence of miscarriage and therapeutic abortion
• 76% incidence of live birth pregnancies
• 50% women delivered before 37 weeks
• 50% infants were low birthweight as well as fetal growth restriction
• 30% incidence of preecclampsia
• 3% incidence of rejection episodes
• 22% developed infections
• 10% developed diabetes mellitus
– Infections and diabetes mellitus developed as a result of immunosuppression therapy
PREGNANCY AFTER RENAL
TRANSPLANTATION (…CONTD)
Cyclosporine and tarolimus
• Given routinely to renal transplantation recipients
• Nephrotoxic and may cause renal hypertension
• Contribute to renal disease in 10-20% of patients
• Late effects on offspring: malignancy, germ cell dysfunction, and
malformations in the children of the offspring
– Cyclosporine is secreted in breastmilk
PREGNANCY AFTER RENAL
TRANSPLANTATION (…CONTD)
Recommendation on women who have undergone transplantation satisfy the
following requisites before attempting pregnancy: (based on Lindheimer and
colleagues (2008) and Hou (2003))
• They should be in good general health for at least 2 years after transplantation
• There should be stable renal function without severe renal insufficiency—serum
creatinine <2 mg/dL and preferably <1.5 mg/dL, none to minimal proteinuria, no
evidence of graft rejection, and absence of pyelocalyceal distension by urography
• Absent or easily controlled hypertension
• Drug therapy reduced to maintenance levels
PREGNANCY AFTER RENAL
TRANSPLANTATION (…CONTD)
Management
• Close surveillance
• Treatment of covert bacteruria
• Monitoring of serial hepatic enzyme concentrations and blood counts
• Serum cyclosporine measurement
• Monitoring of renal function
• vigilant fetal surveillance
• cesearean delivery- 50% success rate
POLYCYSTIC KIDNEY DISEASE
POLYCYSTIC KIDNEY DISEASE

• usually autosomal dominant

• 85%- due to PKD1 gene mutations on chromosome 16
• 15%- due to PKD2 mutations on chromosome 4
• Prenatal diagnosis is available if the mutation has been identified in a family
• Sx: Flank pain, hematuria, nocturia, proteinuria, and associated calculi and
infection
POLYCYSTIC KIDNEY DISEASE (…
CONTD)
• Progression to renal failure
• Other organs may also be involved and may present as
– Hepatic cysts
– Cardiac valvular lesions
– Mitral valve prolapse
– Intracranial berry aneurysm
• Pregnancy does not seem to accelerate the natural disease course
GLOMERULOPATHIES
GLOMERULOPATHIES

1. ACUTE NEPHRITIC SYNDROME

• hypertension, hematuria, red-cell casts, pyuria, and proteinuria

• renal insufficiency and salt and water retention edema, hypertension, and
circulatory congestion
(…CONTD)

1. ACUTE NEPHRITIC SYNDROME

• Acute poststreptococcal glomerulonephritis

– Rarely develops during pregnancy
• Prognosis
– maternal and neonatal morbidity in a woman in whom the diagnosis was
established by renal biopsy performed at 18 weeks
• rapidly progressive glomerulonephritis
– leads to end-stage renal failure
• Chronic glomerulonephritis
– Develops with slowly progressive renal disease
GLOMERULOPATHIES

2. IGA NEPHROPATHY

• Aka Berger disease

• most common form of acute glomerulonephritis worldwide
• immune complex disease
• pregnancy outcome depends on the degree of renal insufficiency and
hypertension
(…CONTD)

2. IGA NEPHROPATHY

Effect of Glomerulonephritis on Pregnancy

• most of women have still normal renal function
• overall fetal loss- 25%
• perinatal mortality rate after 28 weeks- 80 per 1000
• preterm delivery- 25%
• fetal growth restriction- 15%
• Proteinuria worsened in 60%
• Worst perinatal outcomes- impaired renal function, early or severe
hypertension, nephrotic range proteinuria
GLOMERULOPATHIES

3. CHRONIC GLOMERULONEPHRITIS

• Characterized by progressive renal destruction over years or decades

• S/Sx: Persistent proteinuria and hematuria
• Microscopic: proliferative, sclerosing, or membranous
GLOMERULOPATHIES

3. NEPHROTIC SYNDROME

• spectrum of renal disorders in which PROTEINURIA is the hallmark

• Characteristics:
– proteinuria in excess of 3 g/day
– hypoalbuminemia
– hyperlipidemia
– edema
• Diagnosis: renal biopsy
(…CONTD)

3. NEPHROTIC SYNDROME

Management
• Depends on etiology (viral, bacterial, thromboembolism)
• Edema- managed cautiously

Nephrotic Range Proteinuria in Pregnancy

• Protein excretion exceeds 3g/day
• Women with nephrosis without severe hypertension or renal insufficiency-
successful pregnancy outcome

Long Term Follow-up

• Especially indicated in women had progressed to end-stage renal failure
GLOMERULOPATHIES

4. ACUTE RENAL FAILURE

• rapid decrease in the glomerular filtration rate over minutes to days

• aka acute kidney injury
• associated mortality depends on the severity and whether dialysis is
needed
• most often associated with severe preeclampsia-eclampsia
• some women with HELLP syndrome is associated with renal failure
– hemolysis, elevated liver enzymes, and low platelets
• Risk factors:
– Obstetrical hemorrhage, placental abruption, septicemia
(…CONTD)

4. ACUTE RENAL FAILURE

• Management
• In most women, renal failure develops postpartum and management is not
complicated by fetal considerations
• Hemofiltration and dialysis
– For azotemia
• Early dialysis
(…CONTD)

4. ACUTE RENAL FAILURE

Prevention

• 1. Prompt and vigorous replacement of blood in instances of massive hemorrhage, such as in

placental abruption, placental previa, uterine rupture, and postpartum uterine atony
• 2. Termination of pregnancies complicated by severe preeclampsia or eclampsia and careful blood
replacement if loss is excessive
• 3. Close observation for early signs of sepsis syndrome and shock in women with pyelonephritis,
septic abortion, chorioamnionitis, or sepsis from other pelvic infections
• 4. Avoidance of potent diuretics to treat oliguria before initiating appropriate efforts to ensure that
cardiac output is adequate for renal perfusion
• 5. Avoidance of vasoconstrictors to treat hypotension, unless pathological vasodilation is
unequivocally the cause of the hypotension.
OBSTRUCTIVE RENAL FAILURE

• In rare cases, bilateral ureteral compression by a very large pregnant uterus

causes ureteral obstruction and cause severe oliguria and azotemia
THANK YOU.