3. Anatomic changes during pregnancy
Kidney increase in size (can increase up to 2 cm in
length).
Increase in vascular volume.
Increase in interstitial space and glomerular size.
The greatest changes are seen in the collecting system,
where the calyces, renal pelvis and ureters dilate.
4. Anatomic changes during pregnancy
The changes evident by the 3rd month of gestation and
persist until 12 week post partum.
Stasis of at least 200 ml of urine occurs in collecting system.
The increased susceptibility of pregnant women to
asymptomatic bacterurea to acute pyelonephritis is
attributed to urinary stasis.
5. Anatomic changes during pregnancy
Pregnancy induces increase in synthesis of prostaglandin
E2 (PGE2) which inhibits ureteral peristalsis and may be
responsible for the hypomotility .
Increase estrogen and progesterone causes hypertrophic
changes in urinary tract resulting in hypomotility of the
urinary tract.
Mechanical obstruction by enlarged uterus can contribute
to ureteral distension.
6. Functional renal changes during pregnancy
Increase CO and renal VD(40 %) → increase RBF .
The increase in RBF →↑ in GFR.
This changes begins during 1st few weeks after
conception ,it is great at the beginning of 2nd trimester
and remains until after delivery.
Systemic VD → decrease vascular resistance →
decrease in systemic blood pressure.
7. Functional renal changes during pregnancy
Creatinine, urea and uric acid clearance increase
therefore serum levels decrease during pregnancy.
Glucosoria irrespective of blood glucose level.
Amino acids, proteins, water soluble vitamins are
excreted during normal pregnancy due to increase in
GFR.
Increase body water by 6-8 litters.
Na decrease by 4-5 meq/l due to increase plasma volume.
8. Functional renal changes during pregnancy
Plasma osmolarity level decrease by 10 mosm/l.
These may suppress ADH so leads to diuresis.
Osmoreceptors reset at lower level to avoid
continuous diuresis.
Plasma renin concentration 5-10 times greater in
pregnancy .
9. Functional renal changes during pregnancy
However the pregnant lady is extremely resistant to
vasopressor effect of angiotensin II.
May be due to increase level of aminopeptidase which
destroy angiotensine II.
Placenta converts some 25-hydroxyvitamin D3 to 1,25-
dihydroxyvitamin D3.
10. Relationship between pregnancy and kidney disease
Effect of pregnancy on kidney
disease
Effect of kidney disease on
pregnancy
- Worsening proteinuria.
- Deterioration of renal
function.
- Hypertension and
preeclampsia.
- Infertility.
- Abortion
- Preterm delivery.
- IUGR.
- Preeclampsia.
- Polyhydramnios.
11. Pregnancy in CKD is it possible???
Decrease fertility:
- Hyper-prolactenemia.
- luteinizing hormone (LH) levels are elevated.
- Hypothalamic pituitary dysfunction.
- Women with ESRD may undergo menopause earlier
(median age 47)
- Anemia.
- Medications.
12. Pregnancy in CKD is it possible???
Depression and decrease sex drive:
- Eighty four percent reported sexual dysfunction and
only 35% of women reported being sexually active
- Negative body image (potentially related to the
presence of catheters and fistulas) contribute to low
libido.
13. Why it can happen???
Due to improvement of the efficacy of dialysis.
Improve treatment of anemia.
Change in counseling practices.
Improve in sex drive of the patient and in general
condition.
14. Pregnancy Incidence
• Hemodialysis
• Prior to 1976, there were no reported pregnancies in the registry,
with rates increasing to 0.67 pregnancies per 1,000 person-years
from 1986 to 1995.
• 1996–2008. 3.3 pregnancies per 1,000 person-years.
• A recent metaanalysis noted a large increase in number of
reported cases of pregnancy in women on hemodialysis (616
pregnancies from 2000 to 2014) .
• where 7 out of 45 women receiving intensive dialysis became
pregnant.
Nephrol DialTransplant 2016;31:1915–1934
15. Pregnancy Incidence
• Peritoneal dialysis:
• Pregnancy rates in women on PD are lower than on hemodialysis.
• United States, 1.1% of reproductive age women on PD conceived
versus 2.4% on hemodialysis.
• A hypothesis is that hypertonic dextrose solutions and the fluid
filled peritoneum interfere with ovum transit to the uterus.
16. Diagnosis of pregnancy in dialysis patients??
Pregnancy usually unexpected.
Symptoms in the early phase may mimic different diseases and
complications of dialysis.
- Irregular cycles & an anovulatory.
- Abdominal pain, nausea, vomiting and fatigue.
Serum levels of beta-HCG may be increased even in the absence of
pregnancy.
Urine pregnancy test difficult due to anuria.
18. The pre-pregnancy factors predicting
outcome
Degree of renal impairment rather than the aetiology
of renal disease.
Control of hypertension.
Degree of proteinuria.
21. Management of dialysis pregnant lady
Discontinuation of teratogenic medications with substitution for
pregnancy-safe options.
low-dose aspirin is recommended for the prevention of
preeclampsia (stop between 34 and 36 weeks if on heparin).
Down syndrome screening requires confirmation:
Ultrasound measurement for nuchal translucency.
Cell-free DNA.
Amniocentesis.
22. Role of nutrionist
Protein intake:
Because of 10-15 g of amino acids can be lost daily in the
dialysate, higher intake 1.5–1.8 g/kg/day is recommended
+10- 20 g/day.
Caloric intake of 35 kcal/kg pregnant weight +300 kcl/day
Folic acid and water soluble vitamins should be
supplemented
23. Role of nutrionist
• Phosphate: monitored frequently- may stop phosphate
binders or need supplementation (important to fetal
skeletal development)
• Phosphate supplementation is often necessary orally or
by addition of sodium phosphate to the dialysate.
• Calcium: increase dialysate calcium to 1.75 mmol/l – oral
supplementation (1-2 g/d).
25. Role of obstetrician
• Prevent preterm birth:-
Indomethacin
Corticosteroids
Iv mg
CCB
Umbilical artery Doppler measuring velocity flow / 2
weeks
26. Role of obstetrician
• Monitoring of cervical competency and amniotic fluid levels.
• Cervical incompetence appears to be more common in
women with ESRD compared to the general population.
• Cerclage may be necessary to prevent preterm delivery
among women with ESRD on intensive hemodialysis.
27. Role of obstetrician
• Delivery :-
Target 38 weeks unless complications nessicitating
delivery.
Kidney disease is not an indication for CS, only
indicated like non HD patients.
Newborn should be in high risk units as he usually
have blood urea similar to mother ,so may suffer
osmotic diuresis.
28. Role of nephrologist
• Control of Blood pressure:-
- Diastolic 80-90mmhg.
- Very critical ,need controlling Bl P without compromising
uteroplacental circulation.
- In pregnant lady adjustment of UF is very difficult.
- If the patient have preeclampsia , we have to take care as fluid
extraction exacerbate hypoperfusion to various organs
29. Role of nephrologist
• Antihypertensive drugs:-
Alpha methyl dopa.
Beta Blockers.
Arterial VD.
Calcium channel blockers.
ACEI/ARBS & diuretic are contraindicated during pregnancy
30. Hemodialysis prescription
Duration of HD
- More than 20 hour/week .
- Shift to night dialysis.
- Target BUN <50 mg/dl.
Increase HD duration:
- Increase conception.
- Decrease incidence of preeclampsia
- Decrease incidence of polyhydramnios
37. Hemodialysis prescription
• Heparin :
• Pregnancy is a hypercoagulability state.
• Theoretically there are increased requirements.
• It is safe to use heparin whenever there is no vaginal bleeding
38. Minerals and water soluble vitamins
• Give at increased doses, because they can be partially
removed by intensive dialysis.
• Folic acid at a higher dose of 5 mg daily if on dialysis
39. Hemodialysis prescription
•UF & dry body weight assessment
body weight gain in pregnancy
Body weight gain 1 to 2 kg during the first three months then 0.5 kg a
week during the rest of pregnancy
40. Hemodialysis prescription
• Anemia:
• Target : 10 -11g/dl.
• EPO : Increase dose by 50- 100%.
• Iron : monitored monthly Iron sucrose is the preferred form of
intravenous iron during pregnancy
• CBC weekly.
42. Conception
• All sexually active women who have normal cycles should
advised to use contraception specially if serum creatinine >3
mg/dl as poor outcomes with advanced kidney disease
• Types of contraception
• Oral not contraindicated( Access & lupus).
- Intrauterine device bleeding and infection .
- Barrier method is the best
- .
43. Post partum
•Breast feeding :-
• There are no known contraindications to breastfeeding in
women with ESRD on hemodialysis.
• Significant variations in breast milk composition between pre
and post-HD samples suggest that breast feeding might be
preferably performed after dialysis treatment.
44. Post partum
• ACE inhibitors may be used post-partum for women
who benefit from renin-angiotensin-aldosterone system
blockade for blood pressure management
• ESAs and iron can be continued.
• Emotional support is also essential.
