Renal disease in pregnancy

Published on 09/03/2015 by admin

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Last modified 09/03/2015

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Chapter 54 Renal disease in pregnancy

Michael Flynn

Physiology

In pregnancy there is a rise in renal blood flow and a subsequent rise in glomerular filtration rate (GFR) by up to 50%, which is present from the first trimester. There is a slight fall in GFR in the last 3 weeks of pregnancy. This increase in GFR causes a fall in serum creatinine and urea levels to lower than non-pregnant levels.

Changes in renal tubular function result in a fall in serum urate levels in early and mid-pregnancy, with levels rising again in the third trimester. Similarly, up to 50% of normal women will have glycosuria at some point in pregnancy, as the rise in GFR exceeds the tubular capacity to reabsorb glucose.

Anatomically, in pregnancy the kidney enlarges and the renal pelves and ureters dilate. The right side enlarges more than the left due to the dextrorotation of the uterus.

Urinary tract infections

Acute pyelonephritis occurs in 1%–2% of all pregnancies (seeCh 30).

Chronic renal disease

Pregnancy outcome in chronic renal disease is dependent on renal function and blood pressure before pregnancy.

Mild renal disease is defined as serum creatinine <125 μmol/L preconception. There is usually a successful outcome. Pregnancy usually does not affect the long-term progress of the disease, although proteinuria is common. Hypertension is usually not a feature.

Moderate renal disease is preconception serum creatinine between 125 and 250 μmol/L. Most pregnancies are complicated by intrauterine growth restriction (IUGR) and hypertension. Close monitoring is required. A definite group will have irreversible decline in renal function. The risk is especially in uncontrolled hypertension. The major predictor of permanent decrease in renal function from pregnancy is hypertension and prepregnancy serum creatinine, rather than underlying aetiology. Fetal demise due to uncontrolled hypertension, and prematurity, is higher. Prematurity is secondary to severe pre-eclampsia and IUGR. Women with underlying renal disease have a risk of earlier and more severe pre-eclampsia.

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