Renal Disease and Pregnancy (2) Flashcards
What woman with renal impairment should receive pre-pregnancy?
Pre-pregnancy counselling
(multi-disciplinary care: clinicians experienced in Rx high risk pregnancies)
What should be documented in a pregnant woman with renal impairment?
Document baseline (pre and early pregnancy) :
- Creatinine
- urate
- albumin
- protein excretion
Does pre-pregnancy counselling happen often?
No, as most of the pregnancies are unplanned
What should we consider in a pregnant women with renal impairment and mild hypertension?
- tight control of HTN (even if mild) -> to minimise risk of deterioration in renal function
What meds to stop in re to HTN in pregnant women?
- stop ACE inhibitors -> teratogenic
- stop Angiotensin Receptor Blocker -> teratogenic
- diuretics -> usually stop unless severe hypoalbuminaemia or pulmonary oedema
What to Rx hypertension with in pregnancy?
- B blockers
- CCB
e.g. Nifedipine, Labetolol - safe and non-teratogenic
Why is it difficult to diagnose pre-eclampsia in a pregnant woman with renal impairment?
This is due to pre-existing proteinuria and hypertension
- When to admit a pregnant woman with renal impairment?
Admit if: worsening hypertension, increasing creatinine, large increases in proteinuria. (IUGR, thrombocytopenia and abnormal LFTs
What Ix to do if a renal impairment in a woman is discovered during pregnancy?
- blood glucose -> diabetes
- ANA -> SLE
- renal USS -> polycystic kidneys or small kidneys - suggestive of chronic failure
Are ACE-inhibitors safe in breastfeeding?
Yes
Considerations for women with renal transplant and pregnancy
Is it ok to breast-feed if a woman is on cyclosporin and tacrolimus?
*these are drugs to prevent rejection in organ transplant
Advice not to breastfeed
Is Mycophenolate mofetil safe in pregnancy?
- Mycophenolate mofetil* = immunosuppressant drug used in Rx of many autoimmune diseases
- It is contraindicated (as toxic in animal studies)
How is the fertility in woman on dialysis (end stage renal failure)?
Markedly reduced fertility
- evolutionary mechanism to protect a mother and prevent unsuccessful/unhealthy baby
- woman would not be usually menstruating in end-stage renal failure
What are the common complications if a woman on dialysis gets pregnant?
- anaemia and haemorrhage
- miscarriage
- fetal death
- Pre - Eclampsia
- preterm labour
- preterm rupture of the membranes
- polyhydramnios
- abruption
What is required in women on dialysis who decide to continue pregnancy?
increasing dialysis in order to maintain the pre-dialysis urea <15-20 mmol/l
*when urea gets more than these levels - cardiogenic to the foetus -> spontaneous dialysis
What is the commonest cause of AKI in pregnancy?
Commonest causes: pre-eclampsia, haemorrhage, infections, drugs (NSAID), and obstruction due to ureteric damage or stones
What is the cause of an isolated rise in urea (without rise in creatinine)? (in the picture of pregnancy)
Following antenatal corticosteroid administration
What are the signs of acute renal failure?
- oliguria
- rising creatinine and urea
- metabolic acidosis
- hyperkalaemia (associated coagulopathy)
What do we sort out first: pre-eclampsia or renal failure?
Pre-eclampsia -> first sort out this and then worry about kidneys
*so we tend to deplete women of fluids (to prevent pulmonary oedema and respiratory failure)
What is the commonest cause of acute renal failure in the context of pre-eclampsia?
HELLP
Is it safe for a woman on a kidney transplant to become pregnant?
- Yes, chances of a successful pregnancy are high if no graft rejection
- Advice to wait 2 years post-transplant
