01-30 Pregnancy

Question 1

∆ in [Cr], why?

Answer 1

[Cr] falls b/c:
—systemic vasodilation → GFR increases
—so a “normal/high-nl Cr in a pregnant woman is actually high

Question 2

∆s in blood pH and bicarb?

Answer 2

—there is a mild resp alkalosis (higher RR)

—so pH is higher and bicarb falls to comp

Question 3

∆ in Hb, why?

Answer 3

Hb conc goes down b/c:

a) increased plasma vol
b) decr sensitivity to Epo!

Question 4

URine protein level ∆?

Answer 4

Double normal is found in pregnany

Question 5

∆ in [Na+] serum, why?

Answer 5

Na falls 130-135 (vs. 135-140)

—b/c Increased circulating AVP, and increased water intake

Question 6

∆ in BP, why?

Answer 6

BP falls, decreased vascular tone.
—also perhaps due to lower albumin?
—stay lower for 2-3 mo s/p

Question 7

∆ in cardiac output?

Answer 7

CO increases

Question 8

∆s in kidney anatomy and physiology in pregnancy?

Answer 8

—kidneys enlarge
RBF incr
—SMM fxn → relax the renal pelvis and decr motility of the ureters
—microenvironment of the lower urinary tract is less resistant to bacterial invasion
—physiological changes persist for 2-3 months after delivery.

THIS MEANS
The net result is polyuria and increased susceptibility to urinary tract infections and to reflux of urine to the kidney resulting in pyelonephritis
—Therefore tx non-sx bacturia in pregnancy

Question 9

CKD and HTN cause changes are opposite, in what way?

Answer 9

Pregnancy
—↑ endothelial vascular relaxation: vasodilation and ‪↓‬ decr BP
—↑ venous and arterial compliance
OPPOSITE occurs in preg
—this is key slide for this lecture

Question 10

CKD effect on RBC mass, GFR and blood volume

Answer 10

CKD blunts the normal physiological increase in blood vol, RBC mass and GFR seen in healthy pregnancy
—linear relationship with the stage of CKD and degree of blunting

Question 11

% Successful outcomes of pregnancy in CKD

Answer 11

Even stage 3 is 90%
—Stage 4-5 is 30-50% w/ 80-90% of women having complications
—99% delivered pre-term and/or to mothers w/ pre-eclampsia
—However, many complications are manageable with good antenatal and neonatal care, so that a successful outcome may be possible even in advanced CKD.

Question 12

What do we know about the effects of pregnancy on healthy kidneys?

Answer 12

—despite hyperfiltration and alterations in GFR, pregnancy does not appear to be deleterious to healthy kidneys
—no increase in new onset renal disease in pregnancy…
—…w/ one important exception: SLE may present for the first time or become more severe
—may unmask previously undiagnosed renal disease (failure to increase GFR, the new onset of proteinuria, or new HTN)

Question 13

Take away about CKD in pregnancy

Answer 13

1. successful preg is possible for many CKD pts
2. CKD incr r/o adverse outcome in preg
3. that risk is proportional to degree of renal impairment

Question 14

Adverse effets of HTN on preg

Answer 14

—decr perfusion of the placenta
—incr r/o pre-eclampsia
—prematurity
—intrauterine growth retardation
**Proportional to degree of HTN

Question 15

DDx of HTN in pregnancy

Answer 15

1. pre-existing HTN
2. pregnancy-induced HTN (newly dx’d htn in preg not assoc’d w/ pre-eclampsia)
3. pre-eclampsia

Question 16

Pre-existing HTN and preg

Answer 16

—the better the BP ctrl the better the preg outcome (goal = < 120/80)
—mild HTN often resolves in women w/ nl GFR
—mod or severe HTN, though, usually worsens (Esp w/ kidney dz)

Question 17

Preg-assoc’d HTN

Answer 17

—HTN occuring for first time in preg usu in 1st or 2nd tri
—most remain w/ HTN post-partum or will become so later in life
—suggests underling renal dz
—as above, good ctrl incr outcomes

Question 18

Pre-eclampsia
—Etiology
—How common?
—Presentation
—Dx?

Answer 18

"Toxemia" of pregnancy
—thrombotic microangiopathy d/o similar to HUS/TTP
—4-7% nl pregnancies
PRESENTATION
usu only presents hours-days before delivery (but often early if pre-existing CKD or HTN)
—HTN + rapid edema (almost always)
—proteinuria usually
—AKI
—Encephalopathy (h/a, hyperflexia, szs)
—placentla dysfxn -> fetal distress

Can occur w/ HELLP Syndrome
—Hemolysis
—Elevated...
—...Liver zymes
—Low...
—...Platelets

DX
—proteinuria?
—low platelets
—high serum uric acid (assoc’d w/ Na+ reabs, but not specific or sensitive)

Question 19

Pathogenesis of Pre-Eclampsia and possibilities for better testing.

Answer 19

end result: procoagulant and vasoconstricting pattern
—VEGF is seemingly important to endothelial functioning
—VEGF is inactivated by a surge of sFLT1 (a soluble version of FLT1, a receptor of VEGF)
—May be able to test sFLT1 levels soon?

Question 20

Treatment of pre-eclampsia

Answer 20

Admit!
Give IV fluids and AVOID diuretics
—women are actually HYPOprofusing b/c of microthrombi/constriction
—IV fluids might actually lower BP
IV Mag sulfate for sz mgmt
Deliver (the placenta) ASAP

Question 21

Managing non-preeclamptic HTN in pregnancy

Answer 21

Avoid diuretics
—you want volume expansion
—pt might have as-of-yet silent pre-eclampsia
—especially ACEIs/ARBs → teratogenic

Question 22

Med of choice for pregnancy HTN

Answer 22

α-Methyl-Dopa
—Metabolite stimulates α2-adrenergic receptors →
decr symp tone

Question 23

Pregnancy in kidney transplant

Answer 23

—actually lower risk of rejection during pregnancy (“immunologic privilege”), but will INCREASE 3-6 months post partum
—advise women to wait 1+ yr s/p transplant
—stop azathioprine

Question 24

Pregnancy in women on dialysis

Answer 24

Is possible
—10-50% successful outcome
—keep good nutrition, Hb up, increase dialysis to 5-6X/wk