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صفحه 21:
IN THE NAME OF
GOD
THE NORMAL AND
DISEASED KIDNEY
IN PREGNANCY
PREGNANCY-INDUCED
CHANGES IN ANATOMY
Length of kidney
Length of PT
Kidney volume
Capacity of the dilated renal collecting system
Pregnancy
inhibits ureteral peristalsis
distention of ureter
mechanical obstruction
ureteral
hypomotility
Pregnancy
ureteral
distention
Pregnancy
smooth muscle relaxation VUR
Etiology of the UT dilatation in pregnancy
Clinical relevance
CARDIOVASCULAR AND
RENAL PHYSIOLOGY IN
PREGNANCY
PREGNANCY
COP/ PVR / RVR /
PREGNANCY
RBF / RPF/ RVR
BP
Blood volume /Na retention /Edema
Clinical relevance
R-A-A-S in pregnancy
Pregnancy
R/ A/ PRA /Pro-R
Etiology : PGI2
Renin secretion
Resistance to A2
Nepi/Avp
Renal tubular function
GTB in pregnancy (PT/DT)
Normal Na balance
Normal water balance(ability to produce a maximally
concentrated&maximally dilute urine
24h urine volume
Plasma Na level(5 meq/l )
Plasma osmolality (10 mosmol/kg h2o)
Osmotic threshold for AVP release (285
276)
Osmotic thirst threshold (290
280 )
Evaluation of renal function in pregnancy
Examination of the urine :Pro/Alb/RBC
Creatinin clearance
Pro/ Cr
Cockroft-Gault formula
RENAL BIOPSY
Sudden deterioration of renal function with no
apparent cause
Symptomatic NS
Theclinical spectrum&management of
renal disorders in gestation
Pregnancy associated ARF
pattern
Pre-renal
Bimodal
Hyperemesis gravidarum
Bleeding
Post-renal Stone/ Tumor
Renal
ATN/ ACN
Preeclampsia
ATN
HELLP SYN.
ARF
MANAGEMENT OF
ARF IN
PREGNANCY
NEPHROLITHIASIS IN
PREGNANCY
Frequency
Type of stone
DX
Treatment
UTI IN PREGNANCY
Prevalence (2-10% )
Asymptomatic bacteriuria (6-7%)
Acute pyelonephritis (20- 30%)
Screening (16 W )
Baceriuria post delivery (17%)
Symptomatic infection(3%)
Cystitis (./3 -1/3 %)
Pyelonephritis (1-3%)
Secound trimester
10% in early pregnancy
Management of UTI in pregnancy
RF for bacteriuria in pregnancy
Previous history of UTI
Multiparity
Presence of HbS
Lower socioeconomic status
Sexual activity
DM
Advanced maternal age
PRE-EXISTING RENAL
DISEASE
Normotensive women with intact or only mildly
decrease and stable renal function(Cr<1/4mg/dl
)
Live birth :95%
Frequeency of preeclampsia
/HTN /Proteinuria in late pregnancy
Exception :LN/ MPGN /SS / PAN
Moderate impairment
:1/5mg/dl<Cr<3mg/dl
Live birth :90%
Fetal GR &Preterm delivery>50%
Renal function deterioration >1/3
PREGNANCY IS NOT
ADVISABLE
Severe impairement :
Cr >3mg/dl
Incidence of IP hemorrhage /severe HTN
SPECEFIC DISEASE
DM
Chronic
CTD
Reflux
GN
nephropathy
GUIDELINE ON MANAGING
WOMAN WITH PREEXISTING RENAL DISEASE
Counseling
Cr<1/4mg/dl
Normotensive:DBP=90mmhg
Follow up
Diuretic &NS
Pro- restriction
Obstetrical management of women with
underlying renal disease
Frequency of prenatal visit (every two weeks until the
third trimester and then weekly )
Early detection &treatment of asymptomatic bacteriuria
Serial monitoring (at least monthly ) of maternal renal
function
Close monitoring for the development of the
preeclampsia
Fetal surveillance with US&FHR monitoring to
assess FG &well-being
Treatment of maternal HTN
HTN &PREGNANCY
Physiologic changes in BP during normal pregnancy
Hypertensive level of BP for development of preeclampsia :
SBP>140 mmhg
Risk of HTN
DBP>90mmhg
Fetal risk : IUGR / perinatal death /
Preterm delivery
Maternal risk : preeclampsia / proteinuria
Treatment of HTN
Acute HTN: DBP>100 mmhg
DBP>90mmhg
Chronic HTN with end organ damage : Goal: BP<140/90
Chronic HTN without end organ damage :Goal:SBP:140-150
DBP:90-100mmhg