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RANZCOG 2024 - maternal medical conditions > Renal > Flashcards

Renal Flashcards

1
Q

What is the definition of AKI in pregnancy

A
  1. Cr >80
  2. Cr increase >50% of baseline
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2
Q

Discuss chronic kidney disease in pregnancy
-Causes
-Stages
-Two main indicators of impact of CKD to fertility and pregnancy

A
  1. Causes of CKD
    -CKD can be caused by many conditions which lead to varying degrees of renal impairment
    -reflux nephropathy, diabetic nephropathy, chronic glomerular nephritis, SLE, polycystic kidney disease, IgA nephropathy, sleroderma
  2. Stages of CKD
    -5 stages
    -Based on eGFR
  3. Two main indicators for pregnancy outcomes irrespective of cause of CKD
    - Degree of renal impairment
    -Presence of absence of HTN
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3
Q

Discuss the impact of pregnancy on CKD in terms of renal function
-Mild renal impairment
-Moderate renal impairment
-Severe renal impairment

A
  1. Mild renal impairment Cr <125
    -2% risk of loss of renal function in pregnancy
    -Always reversible
  2. Moderate impairment Cr 125-180
    -40% loss of function in pregnancy
    -2% risk of ESRF
  3. Severe impairment Cr>180
    -70% loss of renal function in pregnancy
    -35% risk of ESRF
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4
Q

Discus the impact to CKD from pregnancy (4)

A
  1. Escalation in hypertension
  2. Worsening proteinuria
  3. Increased risk of flare / relapse of glomerulonephritis
  4. Deterioration in anaemia
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5
Q

Discuss the effect of CKD on pregnancy
-Maternal (5)
-Fetal (4)

A
  1. Maternal
    -Miscarriage
    -PET (RR 10)
    -VTE in nephrotic syndrome
    -Placental abruption
    -Increased risk of CS
  2. Fetal
    -FGR (RR 5)
    -Preterm delivery - CKD 3-5 = 60-90% risk
    -Perinatal mortality
    -IUFD - associated with maternal urea levels >20-25 and polyhydramnios
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6
Q

Discuss fetal outcomes for women with CKD for different levels of renal impairment
-Mild impairment Cr <125
-Moderate impairment Cr 125-180
-Severe impairment Cr >180
-On dialysis

A
  1. Mild impairment
    - PET 22%
    -FGR 25%
    -PTB 30%
    -Perinatal mortality 1%
  2. Moderate impairment
    -PET 40%
    -FGR 40%
    -PTB - 60%
    -Perinatal mortality 5%
  3. Severe impairment
    -PET 60%
    -FGR 65%
    -PTB 90%
    -Perinatal mortality 10%
  4. On dialysis
    -PET 75%
    -FGR >90%
    -PTB >90%
    -Perinatal mortality 50%
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7
Q

Discuss preconception management of CKD

A
  1. Counsel regarding risks
    -To renal function
    -For poor fetal outcomes
    -Avoid pregnancy if CKD 4-5 or on dialysis, severe HTN, nephrotic syndrome, active lupus, diabetic nephropathy with Cr >125
    -Assess baseline Cr, LFTs, Renal function, PCR
    -Optimise BP control. If long standing HTN consider echo
    -If on cytotoxic drugs for lupus - stop 3 months before pregnancy
    -Stop ACEi and statins
    -High dose folic acid
    -Low dose aspirin + calcium supplements
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8
Q

Discuss antenatal management for women with CKD (13)

A
  1. MDT management
  2. Low dose aspirin, calcium, vit D, high dose folic acid
  3. LMWH if proteinuria >3g/day
  4. Baseline BP, Renal function
  5. Monitor BP, renal function, albumin, Hb, platelets, proteinuria, urea
  6. Consider baseline renal USS
  7. Maternal review fortnightly till 28/40 then weekly
  8. BP and urinalysis at every visit
  9. Consider dialysis if urea >17. Linked to IUFD
  10. Fetal uterine artery dopplers at 24/40
  11. Fetal growth scans - growth, polyhydramnios
  12. Manage anaemia - Fe or EPO
  13. If nephrotic syndrome with oedema consider loop diuretics
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9
Q

Discuss intrapartum and postpartum management in women with CKD
-Intrapartum (3)
-Postpartum (5)

A
  1. Intrapartum
    -Fluid balance and BP monitoring
    -Timing of delivery should be individualised. Increased risk of CS and PTD
    -Continuous fetal monitoring
  2. Postpartum
    -Monitor BP and fluid balance
    -LMWH as increased VTE risk, consider if required for 6/52
    -Avoid NSAID
    -Reassess renal function
    -Resume pre-pregnancy meds. ACEi OK in breastfeeding
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10
Q

Discuss differentiation of PET and deteriorating renal disease
-Shared features (4)
-Features for a renal flare
-Features for PET (3)

A
  1. Shared features
    -HTN, proteinuria, thrombocytopenia, renal impairment
  2. Features for renal flare
    -Development of proteinuria before third trimester
    -Presence of haematuria or renal casts
    -Active disease within 6 months of concepion
    -Raised dsDNA or reduced compliment levels
    -Other SLE sx - discoid rash, fatigue, arthralgia
  3. PET features
    -No baseline proteinuria
    -Elevated or deranged LFTs
    -Antithrombin deficiency
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11
Q

Discuss renal biopsy in pregnancy for renal impairment
-Why should it be done (3)
-When should it be done (3)

A
  1. Why should it be done
    -Only definitive investigation to distinguish between renal flare and PET
    -Allows for initiation of immunosuppression if <24weeks
    -Allows for knowledge of whether delivery will improve outcomes if >24 weeks
  2. When should it be done
    -Non intra-renal causes excluded (PET, obstruction, Infection)
    -Pre-existing undiagnosed nephrotic syndrome
    -New onset nephrotic syndrome 16-20 weeks
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12
Q

Discuss glomerulonephritis in pregnancy
-Causes
-Impact on pregnancy
-Impact of pregnancy to renal function
-Impact of pregnancy to BP

A
  1. Causes of glomerulonephritis
    -Post infection (post strep)
    -Autoimmune - lupus, Goodpastures, IgA nephropathy
    -Vasculitis - polyarteritis
  2. Impact on pregnancy
    -Depends on level of renal function and BP control
  3. Impact of pregnancy on renal function
    -If renal function normal at conception then little impact
    -10% reversible worsening of renal function
    -3% progressive worsening of renal function
  4. Impact of pregnancy on BP
    -25% reversible worsening of BP
    ->10% permanent worsening of BP
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13
Q

Discuss reflux nephropathy
-Pathophysiology (4)
-Complications in pregnancy (4)
-Management in pregnancy (3)

A
  1. Pathophysiology
    -Distinct familial component
    -Caused by scarring due to veiscoureteric reflux.
    -Leads to progressive renal impairment and ESRD
    -Often seen in those with recurrent UTIs, proteinuria, HTN
  2. Complications in pregnancy
    -Associated with degree of HTN and baseline renal impairment
    -Particularly associated with FGR
    -Fetal loss of 18% with Cr >110
    -Increased risk of fetal hydroureter and hydronephrosis as genetic
  3. Management in pregnancy
    -Consider low dose UTI suppression meds
    -Screen for UTI regularly
    -Post natal screening of infant
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14
Q

Discuss management of diabetic nephropathy in pregnancy
-Diagnostic criteria (1)
-Impact on pregnancy (8)
-Impact of pregnancy on nephropathy (1)

A
  1. Diagnostic criteria
    ->500mg/day proteinuria where infection has been ruled out
  2. Impact on pregnancy
    -Adverse outcomes are doubled in diabetic women with nephropathy compared to those diabetic women without nephropathy
    -PET, IUGR, Fetal loss, abruption, PTB
    -Increased anaemia
    -Increased risk of pulmonary oedema and thrombosis given high risk of nephrotic syndrome
  3. Impact of pregnancy on nephropathy
    -Difficult to tell but overall probably no impact
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15
Q

Discuss lupus nephritis in pregnancy
-Pathophysiology (1)
-Diagnosis (2)
-Effect of lupus nephritis on pregnancy (3)
-Effect of pregnancy on lupus nephritis (4)

A
  1. Pathophysiology
    -50% of patients with Lupus develop lupus nephritis secondary to deposition of immune complexes and complement activation
  2. Diagnosis
    -Casts in urine, haematuria, proteinuria
    -Definitive dx by renal biopsy
  3. Effect of lupus nephritis on pregnancy
    -Acute renal failure and maternal mortality
    -PET - increased risk if HTN and presence of antiphospholid antibodies
    -Risk of neonatal lupus
  4. Effect of pregnancy on lupus nephritis
    -33% have renal flares
    -Flares increased in risk if conception at time of active flare (60%)
    -21% renal deterioration.
    -7% permanent renal deterioration
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16
Q

Discuss management of lupus nephritis in pregnancy
-Pre conception
-In pregnancy

A
  1. Pre conception
    -At least 6 months of remission before conception to decrease risk of flare
    -Optimus lupus management
    -Continue immune suppression
    -Check anti-Ro and Anti-La status
    -Check APLS status
  2. In pregnancy
    -Monitor for disease flares every 4 weeks
    -Monitor for PET risks
    -Review immunosupression meds
    -Monitor fetal growth
17
Q

Discuss nephrotic syndrome in pregnancy
-Causes (5)
-Definition
-Impact on pregnancy

A
  1. Causes of nephrotic syndrome
    -Diabetic nephropathy
    -PET (Most common)
    -Lupus nephritis
    -Reflux nephropathy
    -IgA nephropathy
    -Plus more
  2. Definition
    ->3g/24hrs of proteinuria
  3. Impact on pregnancy
    -Proteinuria alone doesn’t affect fetal or maternal outcomes in the absence of HTN or renal impairment
18
Q

Discuss renal dialysis
-Chance of successful outcome in pregnancy
-Effect of pregnancy on dialysis (4)
-Effect of dialysis on pregnancy (9)

A
  1. Chance of a successful pregnancy outcome
    -50%
  2. Effect of pregnancy on dialysis
    -Increased dialysis requirements
    -Increased EPO, Fe requirements
    -Increased heparin requirement
    -Reduced doses of vit D and calcium
  3. Effect of dialysis on pregnancy
    -Reduced fertility
    -Miscarriage
    -IUFD
    -HTN, PET
    -PTL
    -PPROM
    -Polyhydramnios related to uraemia
    -Placental abruption
    -Increased bleeding risk due to heparin requirement
19
Q

Discuss management of women on dialysis in pregnancy
-Pre-conception
-Antenatally
-Intrapartum
-Postnatally

A
  1. Pre-conception
    -Pregnancy is contra-indicated while on dialysis
    -Pregnancy outcome improved post renal transplant
    -Fertility improved with haemodialysis cf peritoneal
  2. Antenatal
    -Ensure patient is on transplant list
    -Aspirin, folic acid, EPO, Fe, Consider vit K supplements
    -Increase haemodialysis. Aim to maintain urea below 20
    -Fetal monitoring after 24 weeks
    -Good BP control
    -Monitor for infection esp with peritoneal dialysis
  3. Intrapartum
    -50% risk of CS delivery
    -Close fetal and maternal monitoring
  4. Postpartum
    -Monitor fluid balance
    -VTE prophylaxis
    -Avoid NSAIDS
    -Resume pre-pregnancy medications
20
Q

Discuss renal calculi in pregnancy
-Pregnancy related risk factors
-Incidence
-Diagnosis
-Management

A
  1. Pregnancy related risk factors
    -Increased calcium excretion in the urine
    -Reduced urine citrate and magnesium
    -Urinary stasis
  2. Incidence
    -1:1000 pregnancies
    -20% in first trimester
    -80% in second and third trimester when stones harder to pass
  3. Diagnosis
    -Present with flank pain with radiation to groin, haematuria or pyuria
    -USS as first line. Sensitivity 35%. Specificity 86%
  4. Management
    -Conservative management - hydration, analgesia, smooth muscle relaxants
    -Percutaneous nephrostomy
    -JJ stents
    -Lithotripsy is contra-indicated. Associated with abnormalities and death in animal studies
21
Q

Discuss renal transplants in pregnancy
-Effect of pregnancy on renal transplants (5)
-Effect of renal transplants on pregnancy (8)

A
  1. Effect of pregnancy on renal transplants
    -Pregnancy doesn’t adversely impact transplant as long as baseline Cr <120
    -If Cr >125 at conception risk of graft survival at 3yrs is 65%
    -Renal allografts adapt to pregnancy in the same way normal kidneys do
    -Risk of renal impairment higher in those with baseline impairment or HTN
    -Risk of graft rejection 2%
  2. Effect of renal transplant on pregnancy
    -Risk of complications is 50%
    -Restores fertility to normal levels
    -Outcomes for pregnancy optimal with normal renal function, no HTN, no proteinuria
    -PET/HTN 30%
    -FGR 20-30%
    -PTB 50%
    -Impact of medications
    -Live birth rate >90%
22
Q

Discuss management in pregnancy for post renal transplant women.
-Preconception (6)
-Antenatally (10)
-Intrapartum (5)
-Postnatally (3)

A
  1. Preconception
    -Delay pregnancy until Cr <125, total 24hr proteinuria <500mg, not on fetotoxic meds, stable on immunosuppressants
    -Ideally wait 12-18 months prior to attempting pregnancy
    -Assess renal function and BP at baseline
    -Review risk of infection - immunity to HepB, CMV, toxo, rubella
    -Advise to continue immunosuppression if prednisone, azathioprine, ciclosporin, tacrolimus.
    -Advise to change from mycophenalate, sirolimus
  2. Antenatally
    -MDT approach
    -Monitor BP and aim for tight control <140/90. Monitor daily
    -Low dose aspirin
    -Regular frequent ANC
    -Regular MSU checks for UTI (Occur in 40% of patients)
    -FBC and calcium checks every months
    -Regular renal function checks
    -Serial growth scans
    -Vigalence for PET
    -If CMV negative at baseline CVM titres every trimester
    -OGTT as usually on steroids
    -Consider LMWH if dense proteinuria
  3. Intrapartum
    -Proteinuria alone is not a reason to deliver
    -Prophylactic antibiotics for any intervention
    -Avoid fluid overload. Judicious use of oxytocin
    -CS rate high but can aim vaginal birth. Graft doesn’t obstruct labour
    -Will likely need hydrocortisone in labour
  4. Postnatally
    -Avoid breastfeeding if on cyclosporin
    -Avoid NSAIDS
    -Consider LMWH for 6 weeks if dense proteinuria
23
Q

Discuss asymptomatic bacteriuria in pregnancy
-Incidence
-Progression without treatment
-Pathogens
-Diagnosis
-Treatment

A
  1. Incidence
    -5-10%
  2. Progression without treatment
    -40% will have symptomatic cystitis
    -30% will develop pyelopnephritis
  3. Pathogens
    -90% are E. coli.
    -Klebsiella proteus
    -Enterobacter
  4. Diagnosis
    -Colony count >100,000mL on MSU
  5. Treatment
    -Always treat
    -Cephalexin 500mg PO BD 7/7
    -Nitrofurantoin 100mg TDS 7/7 Avoid after 36 weeks - causes neonatal haemolytic anemia
    -Trimethoprim 300mg PO OD 7/7. Avoid in first trimester as increases risk of NTD (Folate antagonist)
24
Q

Discus management of pyelonephritis in pregnancy
-Incidence
-Investigations
-Management

A
  1. Incidence
    -1-2%
    -15-20% develop bacteremia
  2. Investigations
    -MSU (>100,000/mL)
    -FBC, U&E, Cr
    -Consider renal tract USS to exclude congenital abnormalities, stone
  3. Management
    -IV Abx ceftriaxone 2g IV OD +/- Gent
    -Monitor renal function
    -VTE prophylaxis
    -IVF and analgesia
    -Follow-up MSU to check resolution
    -MSU monthly thereafter
25
Q

Discuss recurrent UTI or pyelonephritis in pregnancy
-Prophylactic management

A
  1. Recurrent UTI in pregnancy =2 or more episodes
  2. Image renal tract
  3. Prophylaxis
    - cephalexin 250mg PO OD
    -nitrofurantoin 50mg PO OD

RANZCOG 2024 - maternal medical conditions (14 decks)

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