Renal And Urinary Tract

Question 1

Significant changes

Answer 1

Kidneys become larger
Inc plasma flow and GFR 40-65%
R Dilatation of renal calyces and ureters - progesterone and mechanical obstruction
Vesicoureteral reflux - incompetence due to bladder flaccidity

Question 2

UA

Answer 2

Occasional glucosuria

Unchanged in normal pregnancy

Question 3

Abnormal proteinure

Answer 3

> 300mg/day

Question 4

Albumin protein excretion

Answer 4

5-30 mg/day

Question 5

+1 or greater blood on urine dipstick when screened before 20 weeks

Risk for developing preeclampsia

Answer 5

Idiopathic hematuria

2 fold

Question 6

Serum creatinine threshold

Answer 6

> 0.9 mg/dl (75 umol/L)

If persistent, consider intrinsic disease

Question 7

Done for recurrent UTI, hematuria, polyps, stones, tumors or cancer in urinary tract

Answer 7

Cystoscopy

Question 8

Done for stone removal during pregnancy

Answer 8

Ureteroscopy

Question 9

Renal biopsy

Answer 9

Postponed until postpartum 7% chance of complication

Question 10

Most common bacterial infection during pregnancy

Answer 10

Asymptomatic bacteriuria

Question 11

Asymptomatic bacteriuria risk is inc because

Answer 11

Mechanical and hormonal changes promoting urinary stasis and vesicoureteral reflux
Short urethra
Improper perineal hygiene

Question 12

90% of non-obstructive pyelonephritis is caused by

Answer 12

E coli

Question 13

Present in E coli that enhance bacterial adherence and inc their virulence

Answer 13

P fimbriae
S fimbriae
adhesins
surface proteins

Question 14

Risk factors that predispose woman to UTI in puerperium

Answer 14

Dec bladder sensitivity to intravesical fluid tension
Dec bladder sensation to distention

Do IE before discharge!!

Question 15

If patient cannot walk postpartum, it is due to

Answer 15

Hematoma

Urinary retention

Question 16

Risk factors that increase likelihood of retention

Answer 16

Primiparity
Perineal laceration
Oxytocin-induced or augmented labor
Operative vaginal delivery
Cathteterization during labor
Labor >10 hours

Question 17

Asymptomatic bacteriuria Dx

Answer 17

Urine culture >100,000

Treat bec of high chance of developing symptomatic infection (20,00-50,000)
Dec incidence pyelonepritis

Screening for bacteruiria on first visit recommended

Question 18

Asymptomatic bacteriuria Tx

Answer 18

Single dose
Amoxicillin 3g
Ampicillin 2g 
Cephalosporin 2g
Nitrofurantoin 200mg
TMP-SMZ 320/1600 

3 day course
Same as above
Ciprofloxacin 250
Levofloxacin 250

Question 19

When dispensed during later course 30 days before delivery, has been linked to inc risk of neonatal jaundice but overall teratogenic potential is LOW

Answer 19

Nitrofurantoin

Question 20

Cystitis and Urethritis Tx

Answer 20

3 day course
Amoxicillin 500mg
Ampicillin 250mg
Cephalosporin 250mg
Ciprofloxacin 250mg
Levofloxacin 250mg 
Nitrofurantoin 50-100mg
TMP-SMZ 160/800mg

Question 21

Lower urinary tract symptoms
Pyuria
Sterile urine culture

Answer 21

Urethritis from Chlamydia trachomatis

Question 22

Chlamydia trachomatis Tx

Answer 22

Azithromycin

Question 23

Most common serious medical complication of pregnancy

Leading cause of septic shock
Fever, chills and flank pain
Leukocytes in clumps
Numerous bacteria

Most occur in 2nd trimester

Unilateral, right sided

Answer 23

Renal infection

Rf:
Nulliparity
Young age

Question 24

70-80% of infections

Most common organism

Answer 24

E coli

Kleb 3-5%
Enterobacter or proteus 3-5%
Gram + (Group B strep and staph)

Question 25

Should be monitored in pyelonephritis because 20% of women develop renal dysfunction reduced to 5% if aggressive fluid management done early

Answer 25

Creatinine

Question 26

Pyelonephritis Tx

Answer 26

Admit Urine and blood culture Hemogram, serum crea and electrolytes Cath (24 h urine collection) UO >/= 50ml/hr with IV crystalloid IV antibiotics - oral, and discharge if afebrile more than 24h Repeat urine culture 1-2 weeks after

Question 27

Cornerstone of pyelonepritis tx

Answer 27

IV hydration

Question 28

Fever should be controlled in pyelo because of possible

Answer 28

Teratogenic effects

Question 29

Do renal UTZ if there is

Answer 29

persistence of fever >3 days Rule out obstruction Last option, MRI

Question 30

Identifies 90% of renal calculi

Answer 30

Plain Ab Modified one-shot IVP Stent to relieve obstruction and left in place until delivery

Question 31

Patchy interstitial scarring Tubular atrophy Loss of nephron mass Chronic pyelonephritis because of vesicoureteral reflux Long term complication: Hypertension

Answer 31

Reflux Nephropathy

Question 32

80% of stones Polygenic familial idiopathic hypercalciuria 65-75% of stones in pregnancy Low calcium diet promotes stone formation

Answer 32

Calcium salts Calcium phosphate Calcium hydroxyapatite

Question 33

Nephrolithiasis Tx

Answer 33

Hydration Diet low in sodium and protein to prevent recurrence Thiazide diuretics

Question 34

Indication for removal of stones

Answer 34

Obstruction (very painful) Infection Intractable pain Heavy bleeding

Question 35

Nephrolithiasis removal in pregnant

Answer 35

Flexible basket via cystoscopy Ureteroscopic removal Ureteral stent Percutaneous nephrostomy

Question 36

Contraindicated for removal of neprolithiasis in pregnant

Answer 36

Lithotripsy Pain increases risk for contraction leading to preterm birth

Question 37

``` Pain in 90% Gross hematuria UTZ One shot pyelogram (to see stones in ureter) CT scan only postpartum ```

Answer 37

Nephrolithiasis

Question 38

This drug should be stopped in renal transplant patients if they want to get pregnant because teratogenic 6 weeks prior to conception

Answer 38

Mycophenolate mofetil

Question 39

Incidence is high in all transplant patients

Answer 39

Preeclampsia | GDM

Question 40

Most frequent viral infection following renal transplant

Answer 40

Polyomavirus hominis 1 | BK

Question 41

Autosomal dominant Ciliopathy Hypertension in 70% Progression to renal failure Involves liver, heart and brain

Answer 41

Polycystic kidney disease

Question 42

``` HTN Hematuria Red cell cast Pyuria Proteinuria ```

Answer 42

Nephritic

Question 43

Most common nephritis syndrome

Answer 43

IgA Nephropathy Berger disease

Question 44

``` Proteinuria Hypoalbuminemia Hypercholesterolemia Edema Hypertension ``` Renal biopsy if etiology to be determined Vulvar edema Chronic HTN PreEclampsia

Answer 44

Nephrotic syndromes

Question 45

Pregnant undergoing dialysis

Answer 45

Multivitamin doses doubled Calcium and iron salts provided Chronic anemia with epo Extra calcium to diasylate with less bicarbonate

Question 46

High morbidity High mortality Sudden impairment of kidney function with retention of nitrogenous waste and other waste products normally excreted by kidneys ``` Severe pre eclampsia and hemorrhage HEELP Septicemia Acute fatty liver in pregnancy Dehydration from hyperemesis gravidarum Thrombotic microangiopathy ```

Answer 46

AKI

Question 47

Most common outcome following AKI

Answer 47

Preeclampsia 70%

Question 48

Important sign of acute impaired renal function

Answer 48

Oliguria

Question 49

Contraindicated in treatment of oliguria

Answer 49

Loop diuretics

Question 50

AKI is most often due to

Answer 50

Acute blood loss associated with preeclampsia

Question 51

Originate from an enlarging paraurethral gland abscess that ruptures into urethral lumen

Answer 51

Urethral diverticulum

Question 52

Urethral diverticulum Tx

Answer 52

Expectant during pregnancy MRI if necessary

Question 53

Caused by McDonald cerclage prolonged obstructed labor

Answer 53

Vesicocervical fistula