Renal and Urinary Disorders

and Pregnancy
NCM 108
A Woman with Urinary Tract Infection
• In a pregnant woman, because the ureters dilate from the effect of progesterone,
stasis of urine can occur. The minimal presence of abnormal amounts of glucose
(glycosuria) that also occurs with pregnancy provides an ideal medium for growth
for any organisms present. Combined, these factors cause asymptomatic UTIs in
as many as 10% to 15% of pregnant women. Asymptomatic infections are
potentially dangerous because they can progress to pyelonephritis (i.e., infection
of the pelvis of the kidney) and are associated with preterm labor and premature
rupture of membranes. Women with known vesicoureteral reflux (i.e., backflow
of urine into the ureters) tend to develop UTIs or pyelonephritis more often than
others. The organism most commonly responsible for UTI is Escherichia coli
from an ascending infection. A UTI can also occur as a descending infection or
can begin in the kidneys from the filtration of organisms present from other body
infections. If the infectious organism is determined to be Streptococcus B, vaginal
cultures should be obtained because streptococcal B infection of the genital tract
is associated with pneumonia in newborns.
• A UTI typically manifests as frequency and pain on urination. With
pyelonephritis, a woman develops pain in the lumbar region (usually
on the right side) that radiates downward. The area feels tender to
palpation. She may have accompanying nausea and vomiting, malaise,
pain, and frequency of urination. Her temperature may be elevated
only slightly or may be as high as 103° to 104°F (39° to 40°C). The
infection usually occurs on the right side because there is greater
compression and urinary stasis on the right ureter from the uterus
being pushed that way by the large bulk of the intestine on the left
side. A urine culture will reveal over 100,000 organisms per milliliter
of urine, a level diagnostic of infection.
• Therapeutic Management for UTI
 Obtain a clean-catch urine sample for culture and sensitivity to assess for asymptomatic bacteriuria
or symptoms of UTI . A sensitivity test will then determine which antibiotic will best combat the
infection. Amoxicillin, ampicillin, and cephalosporins are effective against most organisms
causing UTIs and are safe antibiotics during pregnancy. The sulfonamides can be used early in
pregnancy but not near term because they can interfere with protein binding of bilirubin, which
then leads to hyperbilirubinemia in the newborn. Tetracyclines are contraindicated during
pregnancy as they cause retardation of bone growth and staining of the deciduous teeth.
 The pregnant woman with a UTI needs to take the additional measure of drinking an increased
amount of fluid to flush out the infection from the urinary tract. To be most effective, do not
simply tell her to “push fluids” or “drink lots of water.” Give her a specific amount to drink every
day (up to 3 to 4 L per 24 hours) to make certain she increases her fluid intake sufficiently.
 A woman can promote urine drainage by assuming a knee–chest position for 15 minutes morning
and evening. In this position, the weight of the uterus is shifted forward, releasing the pressure on
the ureters and allowing urine to drain more freely.
A Woman with a Hyperactive Bladder
• A hyperactive bladder refers to a bladder that contracts more
frequently than usual, causing symptoms of frequency, urgency, and
incontinence. During pregnancy, these symptoms can increase greatly
because of the additional pressure from the uterus on the bladder.
Fesoterodine, an antispasmodic drug frequently prescribed for the
disorder should be used during pregnancy and breastfeeding only if
the risk outweighs the benefit until it is proven not to be teratogenic.
A Woman with a Chronic Renal Disease
• Women with chronic renal disease need to be monitored carefully during pregnancy because their
diseased kidneys may not produce erythropoietin, a glycoprotein necessary for red cell formation
and so they may develop a severe anemia . Synthetic erythropoietin is available and is safe to take
during pregnancy.
• Because the glomerular filtration rate normally increases during pregnancy, a woman’s serum
creatinine level (a measure of kidney function that elevates when kidneys are under stress) may be
actually slightly below normal during pregnancy or may fall from a usual level of 0.7 mg/100 ml
to about 0.5 mg/100 ml. Women with kidney disease who normally have a serum creatinine level
greater than 2.0 mg/dl may be advised not to undertake a pregnancy in case the increased strain on
already damaged kidneys leads to kidney failure.
• Women with severe renal disease may require dialysis to aid kidney function during pregnancy.
With dialysis, there is a risk of preterm labor, perhaps because progesterone is removed with the
dialysis. To prevent this complication, progesterone may be administered intramuscularly before
the procedure. If hemodialysis is used, it should be scheduled frequently and for short durations to
avoid acute fluid shifts. The heparin administered in connection with hemodialysis is safe during
pregnancy because it does not cross the placenta. Even in light of the expanding uterine size,
peritoneal dialysis is actually preferred over hemodialysis because it normally causes less drastic
fluid shifts.
A Woman with Acute Renal Failure
• ARF results from a precipitating insult. The precipitating insult of prerenal
failure is usually severe hypovolemia and decreased perfusion to the kidneys
as the result of severe hemorrhage, dehydration or septic shock. Intrinsic
renal failure, in the form of acute tubular necrosis, is usually secondary to a
severe pregnancy complication that progresses to hemodynamic instability
or severe disseminated intravascular coagulation. Such severe pregnancy
complications are preeclampsia/HELLP, acute fatty liver of pregnancy,
amniotic fluid embolism, pyelonephritis and prolonged intrauterine fetal
demise. Postrenal failure is usually secondary to a renal tract obstruction.
ARF causes the retention of nitrogenous waste products such as blood urea
nitrogen and creatinine and the inability to maintain normal fluid and
electrolyte balance.
A Woman with Urethral and Renal Calculi
• Calculi rarely occur in pregnancy. Calculi may form because pregnancy
induced urinary status, related to increased intraureteral pressure
especially on the right side, or smooth muscle relaxation of the
ureters related to placental hormones. There is also increased calcium
excretion in the urine and urinary excretion rate of calcium stone
inhibitors(citrate and magnesium).Frequent presenting symptoms of
calculi are hematuria, sudden onset severe colicky radiating pain from
the back to the abdomen, nausea, vomiting and fever.
Fetal and Neonatal Effects of Renal Disorders
• Because of the loss of water from the plasma volume, circulation to
the uterus can be diminished. The fetus can suffer nutritionally from
the resultant deficiency. Intrauterine growth restriction is common in
the fetus of a woman with renal disease as well as preterm birth. If
hypertension is also present, arterial resistance to blood flow into the
intervillous space can cause chronic hypoxemia of the fetus.
Depending on the severity and chronicity of hypoxia, the fetus can
suffer central nervous system damage and face potential demise.
Nursing Management
• Prevention
 Prevention of symptomatic UTIs is greatly aided by nursing interventions.
Pregnant women should be educated to practice correct perineal hygiene and
to report any indication of vaginitis or UTI. Routine evaluation of the urine
should be carried out at each office visit. The voided specimen should be
fresh, not saved from home, and should be evaluated for protein, nitrites or
leukocyte esterase, which are produced in increased amounts when bacterial
growth is significant. If the protein level is 1 or more in the absence of
pregnancy-induced hypertension or if nitrites are evident, a clean-catch
specimen should be obtained for urinalysis, culture and sensitivity studies.
The pregnant woman should be encouraged to drink at least 3000ml of fluid
every 24 hours.
 Nursing Interventions for Renal Disease
1. Assess for risk for fluid overload and renal function using the identified diagnostic tests.
2. In the presence of renal failure, fluid intake should be carefully monitored and intake
should equal output unless the patient is febrile. If the patient is febrile, 100 ml of
additional fluid is needed for every degree Celsius of elevation from 38C.
3. Evaluate the degree of edema.
4. When drug therapy is prescribed, teach the patient about the purpose, dosage schedule
and potential side effects.
5. Discuss the importance of nutritional modifications and make referrals to a registered
dietitian when necessary.
6. Teach the patient or family to do home bold pressure monitoring.
7. Modify home activities to reduce onset of dangerous hypertensin and avoid added
fatigue factors.
8. Teach the patients the signs and symptoms of preterm labor and when to report it If it
becomes regular(four painless contractions per hour unrelieved by 1 hour of rest).
9. Avoid using urinary catheters in the presence of renal disorders to prevent
introduction of new bacteria into the urinary tract.
10. Always obtain a clean catch urine specimen to run a 48-hour culture and sensitivity
before beginning the 1st dose of antibiotic.
11. Perform dipstick urine test for protein, nitrites and leukocytes esterase at each
antepartum office visit.
12. Educate the patient about the importance of drinking a variety of fluids(avoid high
acid, carbonated or caffeinated beverages). At least 8 to 10 ounces every waking
hour.
13. Instruct the patient to empty her bladder at least every 2 hours while awake and to
void after intercourse.
14. Tell the patient to perform perineal hygiene front to back.
15. After 24 weeks of gestation, evaluate fro fetal intrauterine growth restriction every 4
-6 weeks by ultrasound.
Drug therapy
• Antimicrobials
• Antihypertensive agents
• Diuretics
That in all things God maybe glorified.