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Maternal Medicine > Renal Disease > Flashcards

Renal Disease Flashcards

1
Q

What causes the dilatation of the urinary collecting system during pregnancy?

A
  1. Progesterone inducing Ureteral smooth muscle relaxation
  2. Enlarging uterus or iliac vessels compressing the ureters

Dilatation more pronounced on the right

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2
Q

Up to what measurement, can the pelvicaliceal diameter be normal in pregnancy?

A

2cm

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3
Q

What happens to renal plasma flow and glomerular filtration rate in pregnancy?

A

They both increase

Creatinine clearance rises by 50%
Results in a fall in the serum urea and creatinine levels

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4
Q

What happens to protein excretion in pregnancy?

A

Increases

Hence why the upper limit of normal in pregnancy is 30mg / mmol

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5
Q

What % of women develop some oedema in pregnancy?

A

80%

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6
Q

What % women have asymptomatic bacteruria in pregnancy?

Of these, how many will develop
A) Symptomatic UTI
B) Acute pyelonephritis

A

4-7%

A) 40%
B) 30%

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7
Q

What is the course of treatment for asymptomatic bacteruria in pregnancy?

A

3 days

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8
Q

What non-pharmacological measures may help prevent recurrent UTIs

A
  1. Increasing fluid intake
  2. Emptying the bladder following sexual intercourse
  3. Double voiding
  4. Front to back cleaning of perineum
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9
Q

What are risk factors for acute pyelonephritis?

A

Polycystic kidneys
Congenital abnormalities of the renal tract
Neuropathic bladder
Urinary tract calculi

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10
Q

What is the effect of pregnancy on CKD?

A

Possible accelerated decline in renal function
Escalating HTN
Worsening proteinuria
Flare / relapse of glomeurlonephritis

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11
Q

What is the effect of CKD on pregnancy?

A 
HTN / PET
FGR
PTB
Polyhydramnios (due to uraemia)
Miscarriage
Fetal death
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12
Q

What should women with CKD Stage 5 be advised?

A

Against conceiving

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13
Q

What is the pathogenesis of polyhydramnios in CKD?

A

High maternal urea
Osmotic load
Fetal polyuria

Polyhydramnios

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14
Q

What % women with reflux nephropathy develop PET?

A

25%

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15
Q

How is reflux nephropathy inherited?

A

AD

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16
Q

What are the adverse outcomes in pregnancy with
- diabetes with nephropathy
Compared to
- diabetes without nephropathy

17
Q

What are the risks of nephrotic syndrome in pregnancy?

A

Hypoalbuminaemia

Therefore,
Pulmonary oedema
Thrombosis

18
Q

How is polycystic kidney disease inherited?

A

Autosomal Dominant

19
Q

What are complications / associations with polycystic kidney disease?

A

Polycystic liver disease
Subarachnoid haemorrhage from intracranial aneurysm
Ruptured renal cyst
CKD

20
Q

What vitamin supplementation is required in CKD?

21
Q

What is the effect of pregnancy on dialysis?

A
  • Increased requirements for dialysis
    up to 20h / week or 5-6 times per week - aim to keep urea <15-10mmol/L
  • Exacerbate anaemia - increased Epo and iron transfusions in pregnancy
  • Heparin requirement increases
  • Pregnancy causes fluctuations in fluid balance and BP
  • Chronic ambulatory peritoneal dialysis (CAPD) - increased risk of peritonitis and lower volume exchange as pregnancy advances
22
Q

What is the effect of pregnancy on women with renal transplants?

A

If Creat < 100, no adverse effect

If Creat > 130, renal graft survival is only 65% at 3 years

23
Q

What immunosuppressive drugs are safe in pregnancy?

Renal transplant

A

Prednisolone
Azathioprine
Ciclosporin
Tacrolimus

24
Q

What immuunosuppressive drugs are not safe in pregnancy?

A

Mycophenolate

Sirolimus

25
Q

How would you manage pyelonephritis?

A
  • Hospital admission
  • Collect MSU
  • IV antibiotics for at least 24 hours; orals for 2 weeks.
  • Check renal function regularly; associated with AKI.
  • IV fluids if volume depleted from inadequate intake, vomiting etc.
  • Renal USS: exclude hydronephrosis, congenital abnormalities, renal calculi.
  • Consider abs prophylaxis in pregnancy: 250mg cefalexin od or 50mg nitrofurantoin od
26
Q

What factors predict adverse outcome in pregnancy due to CKD?

A
  • Presence and degree of HTN
  • Presence and degree of renal impairment
  • Presence and degree of proteinuria
  • underlying cause of CKD

Women without HTN or renal impairment prior to pregnancy tend to have uncomplicated pregnancies’ and experience no worsening in CKD during pregnancy

27
Q

What are potential causes of CKD?

A
  • Glomerulonephritis
  • Diabetic nephropathy
  • PKD
  • Reflux nephropathy
  • Lupus nephropathy
28
Q

How does maternal urea level affect pregnancy risk?

A

Urea ≥10mmol/L - causes polyhydramnios

Urea ≥20mmol/L - risk of fetal death

29
Q

Management of pregnancy with CKD.

A
  • Pre-pregnancy assessment and counselling - check creatinine, urea, proteinuria, BP
  • MDT ANC
  • LDA from 1st trimester
  • Close monitoring BP
  • Commence antihypertensives at lower threshold 130/80 and tighter control
  • Regular assessment creatinine and proteinuria; also Hb, plt, albumin, bicarbonate
  • Vitamin D supplementation
  • Uterine artery doppler at 20-24 wks
  • Growth scans from 28 wks
30
Q

Effect of dialysis on pregnancy.

A
  • Significantly reduces fertility and live birth rate
  • Miscarriage
  • Stillbirth
  • FGR
  • PET
  • Polyhdramnios
  • PTB/PPROM
  • placental abruption
  • increased bleeding risk due to heparinisation to prevent dialysis lines clotting
31
Q

Pre-pregnancy counselling for women with renal transplant.

A
  • Rapid return of ovulation and fertility
  • Use contraception for at least first year to allow graft function to stabilise and dose of anti-rejection drugs reduces to maintenance dose
  • Drugs should be reviewed- change to prednisolone, azothioprine, tacrolimus, ciclosporin - safe in pregnancy. Doses same as pre-pregnancy.Ensure stable for ≥3 months prior to conception.
  • Outcomes proportional to graft function, degree of hypertension, diabetes
  • For many women with good graft function - after 12 weeks >95% liver birth rate
  • Risks: PET, FGR, PTB, deterioration in graft function or graft rejection, maternal hypo and hypercalcemia, infection
  • Delivery by NVD - CS only for obstetric indications
  • Will need prophylactic Abs if any surgical intervention (even episiotomy)

Maternal Medicine (18 decks)

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