PHYSIOLOGICAL CHANGES IN KIDNEY AND URINARY SYSTEM DURING PREGNANCY
When a woman becomes pregnant, her whole body undergoes physiological changes.
Same is true for the kidney and urinary system also.
Let's look at these changes one by one.
-The size of the kidneys increases by 1 to 1.5 centimeters.
- Part of kidneys like renal calyces,pelvis and ureters too dilate under the effect of pregnancy hormone progesterone and because of compression of gravid uterus.
-Glomerular filtration rate- what does it mean?It means the rate at which the kidney produces urine increases and also blood supply to the kidney increases.
Because of these above changes the serum urea and creatinine levels are lesser than the non pregnant state.
Some proteinuria -that is passage of proteins in urine and glycosuria- that is passage of sugar in urine can occur.
There are more chances of UTI -that is urinary tract infection, because
- The collecting system is dilated
- There is a backflow of urine from bladder to ureter known as the vesicoureteral reflux.
- Gravid uterus because of its weight,prevents complete emptying of the bladder.
PRE-PREGNANCY COUNSELING IN WOMEN WITH CHRONIC KIDNEY DISEASE
Women with chronic renal disease need pre pregnancy counseling.
-Their CBC, kidney function test and BP all should be checked.
- If serum creatinine is more than 2 mg/dl, they should definitely refrain from pregnancy.
- BP should be controlled and anemia should be corrected.
- All adverse effects of pre-eclampsia on mother and fetus should be explained.
- Fetotoxic drugs like ACE inhibitors ( Angiotensin Converting Enzyme Inhibitors) and angiotensin 2 receptor blockers should be stopped if possible and safer drugs should be started
PREGNANCY IN WOMEN AFTER KIDNEY TRANSPLANT-CHALLENGES AND MANAGEMENT
If a woman is in the reproductive age group and she has undergone renal (kidney) transplant and she wishes for child bearing,it poses management challenges for her gynecologist.
Here the most important factor is case selection criteria.
Following criteria must be fulfilled before she can think of conceiving-
-Firstly at least 2 years should have passed since the renal transplant.
-Next, her health and renal function should be stable.
-It means that serum creatinine should be less than 2 mg/dl and proteinuria should be less than 500 mg/day
-Next, her blood pressure should be under control.
-Next, she should be on minimum dose of immunosuppressant drugs
- Among the immunosuppressant drugs that are used prednisolone is relatively safe as very little amount of this drug crosses the placenta.
-One more drug Azathioprine can also be considered as it cannot be converted into its active metabolic by fetal liver
COMPLICATIONS DURING ANTENATAL PERIOD
During antenatal period, the gynecologist needs to be extra cautious as some complications are more common in post kidney transplant patients like
-Pre-eclampsia
-Fetal growth restriction
-Low birth weight
-Pre term labor
-Premature rupture of membranes
-Infections
-Rejection of graft
-Having discussed all of that I still want to say that till date there are a couple of thousands pregnancy that have been reported globally with successful outcomes owing to advanced medical technology
EARLY ONSET PRE-ECLAMPSIA IN PREGNANT WOMAN WITH RENAL DISEASE
If a pregnant woman has developed early onset preeclampsia that is an increase in blood pressure along with passage of protein in urine and swelling of feet before 30 weeks of gestation are complete,the gynecologist should look into kidney or renal function first.
Around 20% of these women have undetected chronic kidney disease and require special attention to manage their pregnancy
SEVERITY OF KIDNEY DISEASE AND OUTCOME OF PREGNANCY
If a woman already has kidney disease and becomes pregnant, then the outcome depends on the degree of dysfunction.
-In mild variety there are mild chances of increase in BP, preterm birth and low birth weight but the outcome is good.
-In moderate variety 40% of women may deteriorate and may even continue to deteriorate in the postpartum period. Above set complications are also much higher.
-In severe variety almost 80% of women will have abo andve fat complications 30 and 32 45% of them will version to and stage renal disease
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