renal disease in pregnancy Flashcards
Organisms that cause urinary infections are
90 percent of Escherichia coli strains that
cause nonobstructive pyelonephritis have adhesins such as P- and S-fimbriae. These are cell-surface protein structures that enhance bacterial adherence and, thereby, virulence.
Asymptomatic Bacteriuria
A clean-voided specimen containing more than 100,000 organisms/mL is diagnostic. It may be prudent to treat when lower concentrations are identified,
because pyelonephritis develops in some women despite colony counts of only 20,000 to 50,000 organisms/mL.
urinary tract infection to be associated with greater risks for
low-birthweight infants, preterm delivery, pregnancy-associated hypertension, and anemia.
Asymptomatic Bacteriuria Treatment
empirical oral treatment for 10 days with nitrofurantoin macrocrystals, 100 mg at bedtime.
Satisfactory results are also achieved with a 7-day oral course of nitrofurantoin,100 mg given twice daily.
For recurrent bacteriuria, success achieved with nitrofurantoin, 100 mg orally at bedtime for 21 days.
Lower urinary tract symptoms with pyuria accompanied by a sterile urine culture may stem from urethritis caused by
Chlamydia trachomatis. Mucopurulent
cervicitis usually coexists, and azithromycin therapy is effective
The differential diagnosis of acute pyelonephritis includes
labor, chorioamnionitis, adnexal torsion, appendicitis, placental abruption, or infarcted leiomyoma.
Acute pyelonephritis most common isolated organisms:
Bacteremia is demonstrated in 15 to 20 percent of these women. E coli is isolated from urine or blood in 70 to 80 percent of infections, K.pneumoniae in 3 to 5 percent, Enterobacter or Proteus species in 3 to 5 percent, and gram-positive organisms, including GBS and Staphylococcus aureus, in up to 10 percent of cases
management of acute pyelonephritis:
Hospitalize patient
Obtain urine and possibly blood cultures
Evaluate hemogram, serum creatinine, and electrolytes
Monitor vital signs frequently, including urinary output—consider indwelling catheter
Establish urinary output ≥50 mL/hr with intravenous crystalloid solution
(Intravenous hydration to ensure adequate urinary output is the cornerstone of treatment)
Administer intravenous antimicrobial therapy empirical, and ampicillin plus gentamicin; cefazolin or ceftriaxone; or an extended-spectrum antibiotic are all 95-percent effective in randomized trials
Obtain chest x-ray if there is dyspnea or tachypnea
Repeat hematology and chemistry studies in 48 hours
Change to oral antimicrobials when afebrile
Discharge when afebrile 24 hours, consider antimicrobial therapy for 7 to 10 days
Repeat urine culture 1 to 2 weeks after antimicrobial therapy completed
most stones in pregnancy—65 to 75 percent—are (The type)
Calcium salts make up approximately 90 percent of stones, and hyperparathyroidism should be excluded. Although calcium oxalate stones in young nonpregnant women are most common, most stones in pregnancy—65 to 75 percent—are calcium phosphate or hydroxyapatite
When Hydronephrosis and hydroureter return to normal after pregnancy?
3-4 months after delivery
What are the renal filtration physiological changes?
Renal plasma flow increase by 50-80%. GFR increase by 40-50%.
Creatinine clearance increase.
Lower mean BUN and creatinine.
What is the abnormal level of protein in urine?
Protein /creatinine ration more or equal to 0.3 mg/dL. Protienurea more than 300 mg/dL.
When you should consider prophylaxis antibiotics in cases of UTI?
If recurrent UTI 2 or more.
Does women with sickle cell trait have increased risk of asymptomatic bacteriuria (ASB)?
Yes , 2 folds , should. Be screened every trimester.
What are the first line antibiotics?
Nitrofunitoin and Slufonamides. Starting from the 2nd trimester.
Whats the causative organisms for urethritis?
Chlamydia trichromatis.
If the patient has symptoms of acute cystitis with negative urine culture what will you suspect?
Urethritis
Q: Whats the treatment of urethritis?
Single dose of aZithromycin in for the patient and her partner.
Q: Whats the leading cause of septic shock in pregnancy?
Pyelponephritis
What is the antibiotics of choice in pyelonephritis?
Ceftriaxone.
Gentamicin and ampicillin.
If the patient is penicllin allergy:
Clindamycin and gentamicin.
What are the complications of poly cystic kidney disease?
Hypertensive crisis
pre eclampsia.
Recurrent UTI Flank pain Nephrolithiasis Hematuria.
Whats the definitive diagnosis for glomerular disease?
Renal biopsy
How does nephritis syndrome presents?
Hypertension Hematuria Urinary red cell casts Pyuria. Protienurea.
What are the causes of nephritic syndrome?
Poststreptocoocal golmerluonephritis . Lupus nephritis. Immunoglobulin A nephropathy. Membrane proliferation glomerulonephritis Endocarditis associated glomerulonephrtisi Antiglomerular basemenet memebrance disease Goodpasture syndrome Wagner syndrome Chug-strausss syndrome.
What does nephrotic syndrome presents as?
Protienurea > 3.5 g/dL. Hypertension
Edema
Hyperlinked is
Minimal hematuria. Minimal cells or casts.
What are the causes of nephrotic syndrome?
Minimal change disease Focal segmental gllyomloscelerosis secondary to HIV Membranous glumorluonephririts Diabetic nephropathy Hep B SLE Amylodosis.
What are the complications of nephrotic syndrome on pregnancy ?
Preterm labor IUGR Still birth Maternal hypertension Pet Impaired renal function
What are the criteria to diagnose Acute kidney injury?
Increase in serum creatinine by > or equal to 0.3 mg/dL ( 27 micromol/L) in 48 hours. Or Increase more than or equal to 1.5 times baseline within 7 days.
Or decrease in urine volume to < than 3 ml/kg over 6 hours.
What are the causes of acute kidney injury ?
In early pregnancy»_space; hyperemesis gravidarum , septic abortion
Later in pregnancy or postpartum»_space; viral or bacterial infection , severe PET , Hemolytic uremic syndrome ( HUS ) , TTP , AFLP , pyelonephroitis , ureteral compression or injury , obstetrical hemorraghe .
Whats the management of AKI?
Fluid resussutiation
Avoid nephrotoxic medications
Manage complications such as hyperkalemia Timely initiation of renal replacement therapy.
What are the indications for dialysis?
BUN > 50 because BUN is fetotoxic.
How to differentiate between HUS/TTP from pre-eclampsia?
Presence of shicstocytes on peripheral blood smear .
Whats the mainstay of treatment of HUS?
Plasmapharesis and eculizumab.
How to diagnose CKD?
Impaired renal function or damage for more than 3 months.
What are the categories of CKD?
Mild ( serum creative less than 1.5 mg/dL)
Moderate ( 1.5-3.0 mg/dL )
Severe ( > 3.0 mg/dL)
what is the antepartum management in cases of CKD?
- Early pregnancy diagnosis and dating
- Preconception planning and counseling are encouraged.
- Baseline laboratory studies including serum creatinine, electrolytes, BUN, 24-hour urine protein and creatinine clearance, urinalysis, and urine culture; serial monitoring of maternal renal function, as clinically indicated
- Increased frequency of prenatal visits, depending on disease severity
- Serial ultrasonographic fetal growth examinations.
- Antepartum fetal testing in the third trimester.
What is the conception rate of patient on dialysis ?
1%.
whats the percentage of surviving infants as outcome ?
40-75%.
fertility rate after renal transplant?
5-10%.
Q: When can a women get pregnancy after transplant ?
1 year if transplant from a living related donor. 2 years after deceased donor transplant.
What are the factors associate with favorable outcomes of pregnancy of mother with renal transplant?
Creatinine less than 1.5 mg/dL. Well controlled blood pressure. Protienurea less than 500 mg/day. No recent episode of acute rejection. Maintenance level of immunisuppresion. Normal apppearing of transplanted kidney on ultrasound.
What are the commonly used immunosuppressive used in pregnancy ?
Cyclosporine
Tacrolimus
both needs to be monitored and follow up of renal function.
Q: If patient wants to get pregnant and she’s on mycophenolate mofetil and Sirolimus?
Needs to be stopped 6 months pre pregnancy
And switched to other immunosuppressive that are safer in pregnancy .
The following summarizes the criteria for renal transplant recipients contemplating pregnancy (ensure good outcome of pregnancy)
At least 6 months after transplantation
Stable allograft function and creatinine < 1.4 mg/dL
No recent episodes of acute rejection
Blood pressure ≤ 140/90 mmHg
No or minimal proteinuria ≤ 500 mg/24 hours
Prednisone ≤ 15 mg/day
Azathioprine ≤ 2 mg/kg/day
Stopping mycophenolate mofetil and sirolimus 6 weeks prior to conception
How to counsel pregnant with Effect of pregnancy on kidney disease
• When initial renal function is normal or near normal ( S cr < 1.5mg) , 0 – 10 % of women will have permanent decline in renal function.
• Women with mod renal insuffiency ( S cr 1.5 – 2.9mg) : Large no. will have irreversible decline in GFR.
• Women with severe renal failure ( S cr > 3.0 mg) : Frequently have amenorrhea & no conception.
(Junger P et al . Lancet 1995:346)
( Imbasciati, et al . AMJK 2007;49:753)
acute kidney injury (AKI) definitions
Current definitions include a rise in a serum creatinine level of at least 0.3 mg/dL within 48 hours, or ≥50 percent increase from baseline within a week, or urine output reduced to <0.5 mL/kg per hour for >6 hours.
