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Values considered normal when not pregnant may reflect decreased renal function in pregnancy. Creatinine above 75 mol/L and urea above 4.5 mmol/L are indications for further investigation.1 The use of estimated glomerular filtration rate (eGFR) is not recommended in pregnancy.2 Glycosuria is common and does not usually indicate diabetes or impaired glucose tolerance. Urinary protein excretion increases during pregnancy, but never to more than 300 mg/day and, therefore, overt proteinuria is abnormal. Women are at increased risk of urinary tract infection (UTI) because of renal tract dilatation leading to urinary stasis.
Women with +1 (or more) dipstick positive proteinuria in the absence of infection should have the level of proteinuria quantified. Baseline quantification of proteinuria should be by 24-hour collection for urine protein and by protein/creatinine ratio (PCR). PCR alone may be used for follow-up. Pregnant women with persistent proteinuria above 500 mg/day diagnosed before 20 weeks' gestation should be referred promptly to a nephrologist. Women with nephrotic syndrome should be given thromboprophylaxis with heparin in pregnancy and the puerperium. Lower levels of proteinuria may increase the risk for venous thromboembolism and may also warrant thromboprophylaxis in pregnancy. Isolated microscopic haematuria with structurally normal kidneys does not need to be investigated during pregnancy but should be evaluated if persistent following delivery.2 Asymptomatic bacteriuria is found in 2% of sexually active women, and is more common (up to 7%) during pregnancy. Because of the dilatation of the calyces and ureters that occurs in pregnancy, 25% will go on to develop pyelonephritis, which can cause fetal growth restriction, fetal death, and premature labour. Pyelonephritis is common at around 20 weeks and in the puerperium.
Asymptomatic bacteriuria and urinary tract infections (UTIs) in pregnancy should be treated with antibiotics. Antibiotic prophylaxis should be given to women with recurrent bacteriuria or UTIs and kidney disease.2 20% of women having pyelonephritis in pregnancy have underlying renal tract abnormalities and an intravenous urogram (IVU) or ultrasound at 12 weeks postpartum should be considered.
Reflux nephropathy: o Prophylactic antibiotics are required. o Potential for inheritance. Systemic lupus erythematosus: o High risk of spontaneous abortion. o May need immunosuppressant therapy. o Problems for the fetus (e.g. neonatal lupus, heart block). Diabetic nephropathy: o Deterioration of hypertension. o Increased risk of pre-eclampsia. o Accelerated decline in renal function Kidney transplant recipient: o Increased risk of miscarriage in the first trimester. o Risk from some immunosuppressants (e.g. mycophenolate mofetil). o Increased risk of hypertension. o Premature delivery.