Pregnancy is a state of altered hormonal and hemodynamic milieu leading to changes in acid base, electrolyte and renal function. Even a pregnancy with normal renal function can develop urinary tract infection, acute kidney injury or trauma. Our aim as an Obstetrician or pregnancy expert is to have a successful maternal and fetal outcome in women with pre existing kidney disease (chronic renal disease or post renal transplant) with a multidisciplinary approach and close cooperation between a Nephrologist, Urologist, Physician and an Anaesthesiologist.
Kidney disease can complicate a normal pregnancy
- Pregnancy is accompanied by physiological increase in dilatation of urinary system, increase in renal blood flow, protein excretion and sodium retention leading to edema.
- Urinary tract problems can manifest as asymptomatic bacteriuria, urinary tract infection (UTI), acute cystitis and acute pyelonephritis. Women with a history of UTI earlier have a 10-fold increased risk of infection in pregnancy. The most common infective organism is E coli..
- Cystitis complicates 1% of all pregnancies: common symptoms are urinary frequency, difficulty in passing urine, passage of blood in urine and suprapubic pain. Plenty of fluids and emptying of the bladder after intercourse are preventive measures.
- Infection can also travel to the kidney (acute pyelonephritis) and can complicate 1-2% of all pregnancies. It manifests as fever, loin and abdominal pain, vomiting, rigors, proteinuria and haematuria. Predisposing factors are renal stones, diabetes, polycystic kidney and congenital abnormalities of the renal tract.
- Pregnancy with chronic renal disease: can be aggravated if there is renal impairment or hypertension. Fetus is at risk of miscarriage, low birth weight and growth restriction, preterm delivery and death. Preconception assessment of renal functions and blood pressure can improve prognosis. The fetus should be monitored with regular ultrasound assessment of growth and Doppler assessment of uterine and umbilical circulation.
- Incidence of acute renal failure is rare in pregnancy <0.005%; main features are reduced or absent urination, and rising urea, creatinine levels. Its common causes are septic abortion, puerperal sepsis, rarely acute pyelonephritis, blood Loss, postpartum hemorrhage and abruption.
Pregnancy after renal transplants:
Pregnancy per se has no adverse long-term effect on kidneys and the chance of successful outcome is >90%, but this is reduced to 70% if complications occur before 28 weeks’ gestation. The complication rate is higher for diabetics.
We can achieve a successful maternal and fetal outcome with preconception care and team approach.