Includes all kidney related conditions with pregnancy

1. RENAL DISORDERS IN
PREGNANCY
DR SEEMA NISHAD
DNB
OBS AND GYNAE

2. • Normal changes during pregnancy
• Urinary tract infections- Asymptomatic bacteriuria
- Acute pyelonephritis
• Acute nephrolithiasis
• Acute renal failure
• Chronic renal failure
• Hemolytic-Uremic syndrome
• Renal cortical necrosis
• Nephrotic syndrome
• Renal transplant and pregnancy

3. NORMAL CHANGES DURING PREGNANCY
Anatomic
- 1 cm increase in length of kidneys due to
hypertrophy of glomeruli.
- Dilatation of the collecting system (calyces, renal
pelvis, ureters)
Physiologic
- Renal plasma flow - increase by 40-50%,
maximum at 16 wks, maintained until 34 wks,
then falls by 25%.
- 50% increase in GFR
- Increase clearance of creatinine, blood urea
nitrogen and uric acid from maternal blood.

4. - Decreased Tubular reabsorption of glucose, uric
acid, amino-acids and water soluble vitamins.
- Decreased afferent and efferent arteriolar
resistance
- Ureters – dilated due to pressure of gravid uterus
- Frequency of micturition in 1st and 3rd trimester
of pregnancy
- Creatinine clearance rises to 150-200ml/min and
average serum creatinine decreases to 0.5-0.6
mg/dl.

5. URINARY TRACT INFECTIONS
• Infections during gestation occur frequently.
• The bacteria, originally reside in the rectal or
anal area and from there colonize the
perineum, vaginal introitus, urethra, bladder
and eventually the pelvi-caliceal area and
kidney itself.
• Ascending bacterial infection affects only the
lower urinary tract (asymptomatic bacteriuria,
acute cystitis) but during pregnancy, 25-40%
may ascend to upper tract and may cause
acute pyelonephritis.

6. ASYMPTOMATIC BACTERIURIA
1. Incidence- 4 -10% of all pregnant women
2. Criteria for diagnosis-
• Urine analysis- > 10 leucocytes/ml,
• Dipstick test – reveals leucocyte esterase or nitrates.
High false positive and false negative results.
• > 105 colony forming units in single midstream catch
technique of sample collection
• >205 colony forming units/ml- diagnostic if sample by
catheterization
3. Complications- If untreated, 25-40% develop acute
pyelonephritis, preterm labor, low birth weight and
perinatal mortality.

7. 3. Treatment- First episode by appropriate antibiotics
depending on prevalent resistance. 3 day course of
antibiotics is usually effective.
• Most effective oral regimen - Nitrofurantoin 100 mg
twice daily for 3-7 days (according to WHO)
• Amoxicilline 500 mg orally thrice daily x 3-7 days
• Amoxicilline-clavulanate 500 mg orally twice daily
3-7 days.
• Cephalexin 500 mg orally twice daily 3-7 days.

8. 4. Success of treatment is confirmed by- urine
culture after 2 week of completion of
treatment.
5. If not cured or re-infection occurs, drugs
according to antibiotic sensitivity is used for
10 days.
6. In case of repeated infections, low daily dose
at night is continued till 4 weeks post-partum.
Nitrofurantoin 100 mg orally or Cephalexin
250 mg is given.

9. ACUTE PYELONEPHRITIS
• Incidence- 1-2% , > 50% cases occur in second
trimester.
• Symptoms- malaise ,fatigue, chills, fever ,
headache and back pain
• Signs- Fever, dehydration, costovertebral angle
tenderness (more on right side)
• Urinalysis - urine turbid or bloody, presence of
RBCs, WBCs, WBC cast, bacteria.
• RFT- elevated levels of S. Creatinine and BUN

10. • Investigations- Hemogram, renal function test,
serum electrolytes, urine culture and
sensitivity
• Histopathology- Infiltration of renal
interstitium and tubules with neutrophils
(formation of WBC cast)
• Cause – Ascending infections by bacteria
present in vagina or on perineum. Usually
caused by single species of bacteria. Most
common organism- Uropathogenic
Escherichia coli ( 70-95% of cases)

11. • Other causative organisms- Gram negative bacilli (as
Klebsiella pneumoniae, Proteus mirabilis),
enterococci, Staphylococcus saprophyticus.
• Treatment- Admission in hospital, hydration,
injectable antibiotics and careful monitoring of vitals
(Tachycardia and hypotension may indicate early
endotoxic shock), Pulse oxymetry, chest x-ray(to rule
out possibility of ARDS), uterine contraction and fetal
monitoring ( for preterm labor).
o Antibiotic of choice – Ampicillin 2 gms IV 4-6 hrly
o For Gram negative bacteria- best option- Cephazolin
2 gm IVPB 8 hrly
o Ceftrixone 1 gm IV 8 hrly
• When patient is afebrile for 24-48 hrs, switch to oral
drugs for 14 days.

12. • If patient do not respond within 72 hrs, or
relapse after discontinuation of therapy,
possibility of obstruction should be ruled out.
• Ureteral stents and percutaneous
nephrostomy may be needed in urinary
obstruction.
• Follow-up with urine culture is necessary.
• Complications – Hemolytic anemia,
Thrombocytopenia, ARDS, Preterm labor,
endotoxic shock, hypothalemic instability

13. ACUTE NEPHROLITHIASIS
• Incidence- 1 in 1500 deliveries, usually during second and
third trimester.
• Symptoms- severe flank pain which starts abruptly. (Site of
pain depends on site of stone), nausea, vomiting, dysuria.
• Urinalysis- presence of macroscopic or microscopic
hematuria, crystals (specific shape according to material of
stone)
• Renal ultrasound is test of choice. Transvaginal ultrasound
may detect distal ureteric stones. Limited IVP is a single flat
plate of abdomen, taken approximately 5 min after contrast
administration. This test has high sensitivity and minimal fetal
radiation exposure.
• 4 types of urinary stones- Calcium oxalate (80%), Magnesium
ammonium sulphate (15%), Uric acid stone(6%), cystein stone
(2%)

14. • When stone at renal
pelvis – pain occurs at
flank of respective side.
• When stone in ureter –
pain occur in lower
abdomen radiating to
groin and external
genitalia.

15. PHYSIOLOGICAL
HYDRONEPHROSIS
• Unilateral/ bilateral
• More marked on
right side
• Patient not severely
symptomatic
HYDRONEPHROSIS DUE
TO OBSTRUCTION
• Usually unilateral
• On side of patient’s
symptom
• Pain is relentless and
severe

16. • Treatment –
- 80% of pregnant women pass the stone
spontaneously and can be managed expectantly
with hydration and medication to relieve pain.
- High fluid intake to obtain minimum urinary
volume of 2 L/day.
- If no improvement after a reasonable period,
cystoscopic extraction can be done.
- In case of acute hydronephrosis due to
obstruction, cystoscopic passage of ureteral stent
and stone manipulation using retrograde ureteral
catheterization.
- If ureteral stent fails, per-cutaneous
nephrostomy should be done.

17. - Minimally invasive surgical procedures used
in post-partum period as shock wave
lithotripsy, percutaneous nephrolithotomy
and flexible ureteroscopy.
- Low calcium diet and thiazide diuretics –
beneficial for idiopathic hypercalciuria.
- Low purine diet for patient with uricosuria
and uric acid stone.
- Intensive treatment of chronic urinary tract
infections to prevent struvite stone.

18. ACUTE RENAL FAILURE
• Defined as –
 urine output < 400 ml in 24 hrs or <20 ml/ hr.
 Urine output < 0.5 ml/kg/hr for 6 hrs
 Increase of S Creatinine >0.3 mg/dL from base-line
 Increase of S. Creatinine > 1.5 times of the normal
• Incidence – decreased during recent years
significantly due to-
1. Diminished number of septic abortions
2. Judicious and early termination of severe pre-
eclampsia
3. Better management of shock
4. Appropriate management of abruptio placenta
5. Facilities of blood transfusion

20. CAUSES OF ARF IN PREGNANCY
PRE-RENAL CAUSES- due to renal hypoperfusion. Most
common form.
(A) Early pregnancy-
1) Acute and massive hemorrhage ( abortion, ectopic
pregnancy, hydatidiform mole)
2) Severe dehydration ( hyperemesis gravidarum)
3) Septic abortion (endotoxic shock, hypotension)
(B) Late pregnancy and labor-
1) Acute and massive hemorrhage ( PPH, Placenta
previa)
2) Abruptio placenta ( hypovolumia and DIC)
3) Severe pre-eclampsia and eclampsia, HELLP
syndrome
4) Acute fatty liver of pregnancy
5) severe infection ( chorioamnionitis, pyelonephritis)

21. (C)Other causes-
1. Mismatched blood transfusion
2. Thrombotic micro-angiopathy
3. Hemolytic uremic syndrome
RENAL CAUSES- Pre-existing renal disease- interstitial
nephritis, SLE, toxins, drugs ( NSAIDs,
aminoglycosides), obstetric pathology
superimposed on pre-existing renal pathology.
POST-RENAL CAUSES- Obstructive- accidental ligature
of ureters during caesarean section or
hysterectomy for rupture uterus.

22. ACUTE TUBULAR
NECROSIS
• Most common pathology in
obstetrics
• Less serious
• Reversible ( recovery in 1-2
weeks time)
• Associated with sepsis &
hypertension
• Kidney lesion- focal,
ischemic degeneration and
necrosis of renal tubules,
pigment and cast in lower
part of nephrons
RENAL CORTICAL
NECROSIS
• Relatively uncommon
• serious
• Irreversible
• Associated with obstetric
causes as abruptio
placentae and endotoxic
shock following Gram -
negative septicemia.
• Kidney lesion - focal, Patchy
/gross ischemic necrosis of
renal cortex resulting from
thrombosis of renal vascular
system

23. CLINICAL FEATURES- 4 phases-
1) Incipient phase - Marked diminution of urinary output.
2) Phase of anuria – Urinary output <100 ml in 24 hrs. Initially
patient looks well but gradually deteriorates if not treated
timely.
• Leucocytosis
• Scanty urine, protein in varying amount, presence of red cell
cast (s/o glomerular pathology)
URINALYSIS PRE-RENAL RENAL
URINARY Na < 20 mEq/L > 40 mEq/L
URINE OSMOLALITY >500 <350
FRACTIONAL
EXCRETION OF Na
< 1% >2%

24. • ECG- peak T wave, Absent P wave, prolonged QRS complex
( due to raised levels of potassium and magnesium)
3) (a) Phase of early diuresis - Favourable for recovery but S.
Creatinine, sodium, potassium, BUN, chloride levels are raised
continueously.
(b) Phase of late diuresis – Causes are-
• Osmotic diuresis due to high blood urea
• Functional inadequecy of tubular reabsorption
• Release of surplus fluid and electrolytes, mainly sodium and
potassium
4) Phase of recovery – Tubular epithelium regenerates, functions
re-established. May take about 1 yr for full recovery.

25. MANAGEMENT OF ARF –
1. To exclude post-renal cause (obstruction in ureters)
by USG.
2. Restore intravascular volume by appropriate fluid-
as by blood transfusion or PRBC transfusion in case
of massive haemorrhage, crystalloids and colloids
for mild and moderate haemorrhage.
3. Forced diuresis with use of Inj. Frusemide ( 80-120
mg) intravenously.
4. During phase of anuria, fluid balance is the goal.
Patient should not be overhydrated. Amount of fluid
to be transfused in calculated by-
Amount in vomitus + Gastric aspiration + Loss in
diarrhoea + Loss in sweating + 500 ml ( + 200 ml for
each degree of rise of temp. )

26. 5. Protein and salt restricted diet, carbohydrate rich
diet. Glucose prevents protein catabolism and
production of urea and potassium is minimized.
( Prevention of complications)
6. Treatment of Hyperkalemia –
• Administration of insulin with infusion of 50%
Dextrose.
• Oral carbohydrate intake. Fruit juices must not be
given due to high content of potassium.
• Inj. Calcium gluconate 10 ml of 10% solution (
Reduces cardiotoxic effect of high potassium levels)
7. Treatment of Hyperphosphatemia – Restriction of
dietary intake of phosphate, phosphate binding
agents ( calcium carbonate, calcium oxalate)

27. 8. Dialysis – Indication-
• Electrolyte abnormalities refractory to medical
treatment
• Volume overload with congestive heart failure and
pulmonary oedema refractory to standard therapy.
( Most common indication)
• Severe metabolic acidosis
• Uremia( BUN > 39 mg/dL or S. Creatinine > 5.65
mg/dl)
Continuous electronic fetal monitoring should be done
during dialysis. Hematocrit should be above 25%.
Risk of preterm labor is high, so parenteral
progesterone to be given. Placental abruption, sepsis
and heart failure can also occur.

28. 9. Supportive therapy –
• Control of infections – Avoid nephrotoxic antibiotics.
• Intra-vascular volume overload – to be kept in check.
• Hemoglobin level to be maintained above 7 gm%, if
less, transfusion of PRBC should be done.
10. During phase of Diuresis – Fluid and electrolyte
balance to be maintained.
PROGNOSIS – Majority of patients recover without
sequelae. Prognosis of fetus is unfavourable, about
50% mortality.

29. CHRONIC RENAL FAILURE
• A linear relationship exists between the pre-
conceptional creatinine levels and risk of further
renal damage during pregnancy.
• Creatinine clearance is more accurate marker than
serum creatinine levels.
• Hypertension present at conception increases
perinatal mortality rates.
• Low sodium diet ( containing 1.5 gms), bed rest in
lateral position to improve GFR and small dose of
loop diuretics with caution should be given.
• Dialysis can be done as and when required during
expectant management.

30. • Antenatal visits at every 2 weeks and weekly after 32
weeks.
• Fetal growth assessed by USG and umbilical artery
Doppler studies. Bio-physical profile to be performed
weekly from 28 weeks onwards specially with
worsening renal failure, hypertension, proteinuria
and placental insufficiency.
• Delivery at term, if no deterioration. Caesarean
delivery only for obstetric indication.
• If deterioration in creatinine levels or creatinine
clearance of 25%, termination of pregnancy is
justified. Expectant management can be done if GA
between 24-31 weeks, normal well grown fetus and
blood pressure well controlled.

31. HEMOLYTIC UREMIC SYNDROME (HUS)
• HUS is a disease independent of pregnancy and closely
related to Thrombotic thrombocytopenic purpura.
• Thrombotic microangiopathy secondary to expoure to
enteropathic organisms, particularly E. Coli serotype
0157-H7.
• Characterized by sudden onset and rapid progression of
hemolytic anemia, thrombocytopenia and renal failure
usually in postpartum period, at any time from day 1 and
10 weeks after delivery.
• Pathophysiology – Damage to glomerular capillaries by
subendothelial deposits of fibrin, that separates the
endothelial cells from the basement membranes, leading
to reduced vascular lumen. Formation of microthrombi,
especially in afferent arterioles leads to renal ischemia.

32. • Microangiopathic hemolytic anemia and
thrombocytopenia occurs due to fragmentation of
RBCs and platelets during passage through affected
vessels.
• Most important D/D is HELLP syndrome.
• Persistence of symptoms and sign of HELLP
syndrome beyond postpartum day 3, raises the
probability of HUS. Diagnosis of HUS is more likely if
there is a symptom free period of several days after
delivery.
• Maternal mortality with HUS is 8 – 44%. Perinatal
mortality is also high, 30 -80 %.

33. CLINICAL
FINDINGS
HELLP
SYNDROME
TTP HUS
Onset After 28 weeks Median
23 weeks
Postpartum
Primary
menifestation
Hypertension,
Proteinuria
Neurologic
symptoms
Renal
failure
Fever Absent PRESENT Absent
Purpura Absent PRESENT Absent
VWF
multimers
Absent PRESENT PRESENT

34. RENAL CORTICAL NECROSIS
• This severe form of ARF is usually associated with
catastrophic obstetric complications such as
severe hypovolumia secondary to abruptio
placenta or placenta previa or amniotic fluid
embolism.
• Histology – Necrosis of all the elements of renal
cortex including extensive necrosis and
thrombosis of the renal vessels.
• Characterized by sudden onset of severe oliguria
or anuria with life threatening complications of
pregnancy.
• Prolonged oliguria and anuria with little or no
improvement of renal function is characterstic.

35. • Urine is frankly hematuric and urinary red cells are
dysmorphic and hypochromic with appearance of
collapsed empty sacs.
• Hematologic abnormalities characterstic of DIC.
• BUN and plasma Creatinine increase rapidly.
• Renal ultrasound demonstrates hypoechoic areas in
the renal cortex.
• Dialysis is required usually. Plasma exchange and
prednisolone to be continued even postpartum for 1
month. Delivery is advisable once diagnosis is
confirmed, as risk of maternal complication is high.
• Prognosis – poor, majority do not recover and
require chronic dialysis. Only 20 – 40% with partial
recovery and can live without dialysis.

36. NEPHROTIC SYNDROME
• Characterized by –
 Presence of proteinuria > 3 gms/24 hr
 S. Albumin < 3 gm/dL
 Edema
 Hypercholesterolemia
• Etiology –
1) pre-eclampsia
2) Diabetic nephropathy
3) Lupus nephritis
4) Primary glomerular disease
Etiology is strongly suggested by clinical history

37. DIFFERENTIAL DIAGNOSIS OF CAUSES OF NEPHROTIC
SYNDROME DURING PREGNANCY
HYPERTENSION
NO YES PRE-ECLAMPSIA
COMPLIMENTS
NORMAL LOW LUPUS NEPHRITIS
SELECTIVITY OF PROTEINURIA
LACK OF
SELECTIVITY
HIGHLY SELECTIVE MINIMAL CHANGE
URINE
SEDIMENT
NEPHROTIC
NEPHRITIC
DIABETES
IgA GLOMERULONEPHRITIS

38. • Complications – Hypertension, fetal growth
restriction, preterm birth, fetal distress.
• Management –
1) General measures –
o Moderate physical activity, avoid prolonged
periods of standing up or sitting.
o Increased periods of bed rest in left lateral
position,
o diet rich in high quality protein,
o Sodium intake adjustment if patient is
hypertensive or excessive accumulation of
sodium and water.

39. 2) Antihypertensive treatment
3) Monitoring of renal function –
o S. Creatinine every 4-6 weeks
o Daily qualitative determination of urine
protein
o If significant change in urine protein with
albustix strips, quantitative protein
determination of 24 hr urine is done.
o Renal function tests at least twice every week
by measuring BUN, S. Creatinine, uric acid and
electrolytes. Urine protein creatinine ratio
(normal < 0.15) becomes > 3.5.

40. 4) Prophylactic antibiotics – as there is high risk of
development of infections, particularly UTI.
5) Prophylactic anticoagulants- for risk of thrombo-
embolism.
5) Fetal evaluation – Serial USG at every 3-4 weeks
to follow fetal growth, Doppler study every week.
NST and amniotic fluid evaluation twice weekly.
6) Delivery –
o If patient is stable- delivery at term with
development of spontaneous labor.
o If unstable, delivery as soon as fetal lung maturity
is reached.
o If patient is severely ill, immediate delivery is
indicated even without fetal lung maturity.

41. DIABETIC NEPHROPATHY
• Most common chronic renal disorder in pregnancy.
• History of insulin dependent diabetes of long
duration.
• Pre-eclampsia is present in more than 50% cases.
• Managed by adequate glycemic control and control
of BP < 150/90 mmHg.
• In case of severe renal failure, early delivery is
considered.

42. PREGNANCY IN WOMEN ON CHRONIC
DIALYSIS
• Women having end stage renal disease are less likely
to conceive, but with hemodialysis, there is a
possibility of spontaneous conception.
• Dialysis regimen should mimic physiological changes
in renal system during pregnancy.
• After completion of first trimester, dialysis should be
done daily (20-24 hrs/week).
• Pre-dialysis BUN <50 mg/dL and S. Creatinine < 4.5
mg/dL and fluid removal < 400ml/session should be
maintained.

43. • Follow-up –
1. Hb, serum iron, serum ferritin – assessed monthly
2. If Hb < 8gm/Dl, IV iron or IV/SC Erythropoitin should
be given.
Erythropoitin
• contraindicated with uncontrolled hypertension.
• Does not cross placenta
• Dose should be reduced if Hb rise > 1 gm/Dl in 2
weeks due to increased risk of hypertension.
3. Fetal monitoring after each dialysis session due to
acute fluid shift.
4. Fetal growth scans and doppler – to follow the
growth.

44. • Complications – Preterm labor, IUGR, fetal loss
• Delivery – planned at GA 34 – 36 weeks.
Caesarean section rates- 50%
• Post-partum – Peritoneal dialysis can be
resumed with smaller (1 L) exchange fluid
after 24 hr of Ceasarean. If there is leakage,
hemodialysis is used.
• Perinatal complications –
Osmotic diuresis at birth.
Hypocalcemia and tetany afterwards.
Monitoring and appropriate management of
Electrolyte imbalance is needed.

45. PREGNANCY IN WOMEN WITH RENAL
TRANSPLANT
• Pregnancy can be safely undertaken one year
after renal transplant if –
1) No rejection
2) Allograft function is adequate
3) S. Creatinine < 1.5 mg/dL and urinary protein
excretion <500 mg/ 24 hr.
4) Immunosuppressive medications are
responsive and well tolerated
5) No infection.
• If S. Creatinine >2.3 mg/dL, progression of renal
failure and need of renal replacement therapy
within next 2 yrs of delivery. Hence , pregnancy
should be contraindicated in such patients.

46. • Maternal complication – worsening of renal
function, pre-eclampsia, infectious morbidity,
preterm delivery(50%)
• Fetal survival is good (95%), once the
pregnancy is beyond first trimester.
• Immunosuppression should be maintained
similar to pre-pregnancy levels. Cyclosporin is
well tolerated. Side effects may present as low
birth weight, preterm births and midline facial
defects (with prolonged use of steroids).

47. Follow-up during pregnancy-
1. BUN, S. Creatinine and electrolytes- every 10 days
2. Allograft function assessment – monthly by USG
3. Technetium scan – at least in each trimester
4. Urine culture – monthly ( UTI – most common infection)
5. Fetal USG and doppler- to evaluate interval growth.
During labor - Prophylactic antibiotics and stress dose of
corticosteroids should be given.
Delivery – should be attempted at birth, if no complication.
• Vaginal delivery is route of choice.
• Delivery without delay if PROM.
• Caesarean delivery only for obstetric indications but
preferred in combined pancreas-kidney transplant.
Breast feeding - Not contraindicated.