Professional Documents
Culture Documents
Problems
during
pregnancy (%)
26
47
86
Successful
obstetric
outcome (%)
96 (85)
90 (69)
75 (61)
Long-term
renal
problems (%)
< 3 (8)
25 (70)
53 (92)
MEDICINE
110
PREGNANCY
MEDICINE
Serum creatinine
73 mol/litre
(0.82 mg/dl)
Serum urea
4.3 mmol/litre
(25 mg/dl)
51 mol/litre
(0.5 mg/dl)
3.3 mmol/litre
(20 mg/dl)
111
PREGNANCY
Secondary to
Hyperemesis
Sepsis
Haemorrhage
Pre-eclamptic toxaemia/HELLP syndrome/ acute fatty liver of
pregnancy/haemolytic uraemic syndrome
Obstruction
MEDICINE
112
PREGNANCY
then undergoes diuresis and is at risk of dehydration and electrolyte disturbances. Close post-natal monitoring is required. The high
serum urea may improve the immature kidneys concentrating
ability earlier than normal; thus, abnormalities may be corrected
quickly.
Prednisolone is largely metabolized by the placenta, but fetal
hypo-adrenalism is possible and should be considered.
Advice about breast-feeding is changing. The author advises
that the benefits of breast-feeding probably outweigh any risks with
ciclosporin or azathioprine. Tacrolimus is present in higher levels
in breast milk and therefore breast-feeding is contraindicated. In
the UK, advice about specific drug effects can be obtained from the
national breast-feeding drug information centre in Leicester.
Further information
In the UK, practical advice about the risks of drugs in pregnancy can
be obtained from:
National Teratology Information Service
NHS Northern and Yorkshire Regional Drug and Therapeutics Centre
Wolfson Unit
Claremont Place
Newcastle upon Tyne, NE2 4HI
Fax: 0191 261 5733
susceptible to life-threatening pulmonary oedema caused by leakage via damaged pulmonary capillary endothelium.
Hypertension should be controlled vigorously and magnesium
sulphate should be given as prophylaxis against eclampsia.
Blood loss is replaced and clotting abnormalities are corrected
(disseminated intravascular coagulation is common in preeclampsia and rare in pure HUS).
Renal function often deteriorates post-partum; dialysis may be
required. Eclampsia can also occur post-partum.
There is little evidence that delivery alters the outcome of pure
HUS (i.e. not associated with pre-eclampsia), but this is seldom an
antenatal problem. It should be treated conventionally with plasma
exchange and fresh frozen plasma or cryo-poor supernatant.
Proteinuria may take months to resolve after pre-eclampsia.
Patients should be re-evaluated at 6 weeks. If significant proteinuria or renal impairment remains, renal biopsy should be
considered.
The prognosis is good in women with pure pre-eclampsia
who wish to contemplate another pregnancy. In those with
impaired renal function and/or hypertension, there is a high
risk of recurrence and worsening renal function; 20% of women
with HELLP syndrome in one pregnancy develop pre-eclampsia
(but seldom HELLP syndrome) in subsequent pregnancies.
FURTHER READING
Hou S, ed. Pregnancy in Endstage Renal Disease. Adv Renal Replace Ther
1998; 5(1).
(Covers all aspects of pregnancy in women on dialysis and with
transplants; includes an overview of medical management of
pregnant transplant recipients and a guide to the effects of
immunosuppressive drugs in pregnancy.)
Nelson-Piercy C. Renal Disease. In: Nelson-Piercy C. Obstetric Medicine.
2nd ed. Oxford: Isis Medical Media, 2002.
(Clear and concise, with good management guidelines.)
Sibai B M, Kustermann L, Velasco J. Current Understanding of Severe
Pre-eclampsia, Pregnancy-associated Hemolytic Uremic Syndrome,
Thrombotic Thrombocytopenic Purpura, Hemolysis, Elevated Liver
Enzymes, and Low Platelet Syndrome, and Post-partum Acute Renal
Failure: Different Clinical Syndromes or Just Different Names? Curr
Opin Nephrol Hypertens 1994; 3: 43645.
(A thorough and interesting review of the similarities and differences
between all these syndromes from the group that has undertaken the
most detailed analyses of patients with HELLP.)
Williams D J, de Swiet M. The Pathophysiology of Preeclampsia. Intensive
Care Med 1997; 23: 6209.
(A clear overview of current understanding of the mechanisms
underlying predisposition to and the clinical features of
pre-eclampsia.)
MEDICINE
Practice points
The normal range for creatinine in pregnant women is
significantly lower than in non-pregnant women beware
creatinine > 75 mol/litre
Do not overlook the fact that a patient is a woman of
child-bearing age discuss issues of fertility and pregnancy
early in the course of her disease and modify treatment if she is
planning a pregnancy
In pre-existing renal disease, the outlook for mother and baby
is better in the presence of normal renal function and blood
pressure; therefore, in chronic diseases recommend the patient
becomes pregnant sooner rather than later
Renal disease caused by pregnancy may mimic underlying
renal disease, may lead to irreversible renal decline and is
more common in women with pre-existing renal disease and
hypertension, in whom it has a worse prognosis
113