Renal Disease and Pregnancy (2)

Question 1

What woman with renal impairment should receive pre-pregnancy?

Answer 1

Pre-pregnancy counselling

(multi-disciplinary care: clinicians experienced in Rx high risk pregnancies)

Question 2

What should be documented in a pregnant woman with renal impairment?

Answer 2

Document baseline (pre and early pregnancy) :

• Creatinine
• urate
• albumin
• protein excretion

Question 3

Does pre-pregnancy counselling happen often?

Answer 3

No, as most of the pregnancies are unplanned

Question 4

What should we consider in a pregnant women with renal impairment and mild hypertension?

Answer 4

• tight control of HTN (even if mild) -> to minimise risk of deterioration in renal function

Question 5

What meds to stop in re to HTN in pregnant women?

Answer 5

• stop ACE inhibitors -> teratogenic
• stop Angiotensin Receptor Blocker -> teratogenic
• diuretics -> usually stop unless severe hypoalbuminaemia or pulmonary oedema

Question 6

What to Rx hypertension with in pregnancy?

Answer 6

• B blockers
• CCB

e.g. Nifedipine, Labetolol - safe and non-teratogenic

Question 7

Why is it difficult to diagnose pre-eclampsia in a pregnant woman with renal impairment?

Answer 7

This is due to pre-existing proteinuria and hypertension

Question 8

• When to admit a pregnant woman with renal impairment?

Answer 8

Admit if: worsening hypertension, increasing creatinine, large increases in proteinuria. (IUGR, thrombocytopenia and abnormal LFTs

Question 9

What Ix to do if a renal impairment in a woman is discovered during pregnancy?

Answer 9

• blood glucose -> diabetes
• ANA -> SLE
• renal USS -> polycystic kidneys or small kidneys - suggestive of chronic failure

Question 10

Are ACE-inhibitors safe in breastfeeding?

Answer 10

Yes

Question 11

Considerations for women with renal transplant and pregnancy

Answer 11

Question 12

Is it ok to breast-feed if a woman is on cyclosporin and tacrolimus?

Answer 12

*these are drugs to prevent rejection in organ transplant

Advice not to breastfeed

Question 13

Is Mycophenolate mofetil safe in pregnancy?

Answer 13

• Mycophenolate mofetil* = immunosuppressant drug used in Rx of many autoimmune diseases
• It is contraindicated (as toxic in animal studies)

Question 14

How is the fertility in woman on dialysis (end stage renal failure)?

Answer 14

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

Question 15

What are the common complications if a woman on dialysis gets pregnant?

Answer 15

• anaemia and haemorrhage
• miscarriage
• fetal death
• Pre - Eclampsia
• preterm labour
• preterm rupture of the membranes
• polyhydramnios
• abruption

Question 16

What is required in women on dialysis who decide to continue pregnancy?

Answer 16

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

Question 17

What is the commonest cause of AKI in pregnancy?

Answer 17

Commonest causes: pre-eclampsia, haemorrhage, infections, drugs (NSAID), and obstruction due to ureteric damage or stones

Question 18

What is the cause of an isolated rise in urea (without rise in creatinine)? (in the picture of pregnancy)

Answer 18

Following antenatal corticosteroid administration

Question 19

What are the signs of acute renal failure?

Answer 19

• oliguria
• rising creatinine and urea
• metabolic acidosis
• hyperkalaemia (associated coagulopathy)

Question 20

What do we sort out first: pre-eclampsia or renal failure?

Answer 20

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)

Question 21

What is the commonest cause of acute renal failure in the context of pre-eclampsia?

Answer 21

HELLP

Question 22

Is it safe for a woman on a kidney transplant to become pregnant?

Answer 22

• Yes, chances of a successful pregnancy are high if no graft rejection
• Advice to wait 2 years post-transplant