FAILURE DURING

PREGNANCY
 DEFINITION

CRF is by definition distinguished from

ARF by the fact that the patient has had
loss of kidney function over a more
prolonged period of time( more than 3
months and often a process that has been
going on for years.

Stephan Eisenschenk, MD
Department of Neurology
 STAGES

 Mild: 60 - 80% of normal function, serum

creatinine of 1.4mg/ dl or less
 Moderate: 30 - 60% of normal function, serum
creatinine of 1.5-2.4 mg/ dl
 Severe: 15 - 29%, serum creatinine of 2.5 mg/ dl
or greater
 End stage Renal Disease: < 15 % (these patients
require renal replacement therapy: Hemodialysis;
Peritoneal Dialysis or Kidney Transplantation)
Anatomic changes in the kidney during
pregnancy
• Dilatation of the ureters and
pelvis occurs secondary to the
smooth muscle–relaxing effect of
progesterone.
• An increase in overall kidney
size by about 1-1.5 cm due to
increase in the renal vascular
volume
 Physiological changes
• Renal plasma flow increases by 50-70% in
pregnancy
• The GFR peaks around the 13th week of
pregnancy and can reach levels up to 150%
of normal. Therefore, both BUN and
creatinine levels, the plasma markers of GFR,
are decreased.
• Clinically, the plasma creatinine falls
significantly and should not be greater than
0.8 mg/dL during pregnancy.
• B P falls shortly after conception due to peripheral
vasodilation, mediated by nitric oxide synthesis and
relaxin, and is resistance to the action of angiotensin
II.
• There is a compensatory increase in heart rate and
activation of the renin-angiotensin-aldosterone axis.
Blood volume increases by 20%, and sodium
retention of up to 900 mEq occurs.
• A change in tubular function with increased
glucosuria also occurs.
• In addition, a reset in the osmostat occurs, resulting
in increased thirst and decreased serum sodium
levels (by approximately 5 mEq/L)
 EPIDEMIOLOGY
• Fertility is substantially decreased in women with
GFR’s < 50%
• 85% of women with mild renal disease will have a
surviving infant
• 1/3 of women with pre-existing moderate to severe
renal insufficiency will develop end stage renal
disease within an year of delivery
• Uncontrolled hypertension is the single most
important indicator of poor pregnancy outcome
• Of woman with renal disease requiring dialysis, 2%
with hemodialysis will conceive over a four year
period versus 1% of woman treated with peritoneal
 ETIOLOGY
• Diabetes mellitus 33%

• Hypertension-24%

• Glomerulonephritis -17%

• Polycystic kidney disease- 5%: Autosomal

dominant polycystic kidney disease - Women
with this disorder who are hypertensive have a
high risk for fetal and maternal complications
• Specific kidney diseases
–Glomerular diseases
–Membranoproliferative
glomerulonephritis
–Focal glomerulosclerosis
–Reflux nephropathy
– Immunoglobulin A nephropathy
 Systemic lupus erythematosus (SLE) is a
multiorgan system autoimmune disease
with numerous immunological and clinical
manifestations. It is characterized by an
autoantibody response to nuclear and
cytoplasmic antigens. The disease mainly
involves the skin, joints, kidneys, blood
cells, and nervous system.
• Approximately half of patients experience an
exacerbation of lupus during pregnancy, although it is
much less common in patients who have been in
remission for more than 6 months. Fetal loss occurs in up
to 50% of patients.
• Screen all lupus patients for the presence of lupus
anticoagulant and the anticardiolipin antibody.
• Treatment for lupus flares includes prednisone or
azathioprine. Cyclophosphamide is avoided because it is
teratogenic in the first trimester, and it may cause bone
marrow suppression in the child
 PATHOPHYSIOLOGY
• Impairment of the acid base regulation
predisposes the fetus to acedemia
• Inadequate BP control is associated with
a dismal obstetric prognosis
• Hypertension secondary to renal disease
places the fetus at risk due to
Uteroplacental insufficiency
Decreased perfusion
Decreased oxygen availability
 Signs and smptoms

High blood Loss of appetite

pressure Nausea
Swelling or Back, side or
numbness of abdominal pain
hands and feet Fatigue
Haemeturia Muscle cramps
Proteinurea
 Pregnancy Risk Factors

Hypertension
Preeclampsia
Premature labor
Miscarriage
Decreased kidney function
Greater risk of urinary tract infections
Acute renal failure
 Effect of renal insufficiency on
pregnancy
 Fetal survival rates are good, approaching 95% in
most studies.
 Complications, including SGA infants, preterm
labor, and stillbirth, are increased even in mild renal
insufficiency.
 Factors associated with increased perinatal mortality
and preterm labor were impaired renal function,
early or severe hypertension, and nephrotic-range
proteinuria.
PREGNANCY IN PATIENTS RECEIVING
DIALYSIS
 Only 23-55% of pregnancies result in
surviving infants, and a large number of
second-trimester spontaneous abortions
occur.
 Approximately 85% of surviving infants
are born premature, and 28% are born
SGA. Hypertension worsens in more
than 80% of pregnant females
 Diagnosis of pregnancy is difficult
because levels of beta-hCG are normally
elevated in patients receiving dialysis.
 General recommendations
• Place the patient on a transplant list because
outcomes with allograft transplant patients are
markedly better.
• During hemodialysis, pursue uterine and fetal
monitoring and make every attempt to avoid
dialysis-induced hypotension.
• Erythropoietin can also increase hypertension
and must be used cautiously.
• Aggressive dialysis to keep BUN levels <50
mg/dL may be pursued with daily dialysis.
 PREGNANCY IN PATIENTS AFTER
TRANSPLANTATION
• Poor pre pregnancy renal function are
important prognostic indicators for the risk
of renal function deterioration.
• An elevated pre pregnancy creatinine level
(ie, >1.4 mg/dL) is not only associated with
a higher risk of renal decline but also with
a decreased fetal survival rate.
• The fetal survival rate is approximately
74% in patients with a creatinine level of
more than 1.4 mg/dL, while it increases to
about 96% in patients with a creatinine
level of less than 1.4 mg/dL.
 Diagnostic tests
• History and Physical Exam
• Urine Total Protein
• Creatinine Clearance Test
• Blood Urea Nitrogen
• Serum Potassium Test
• Serum Creatinine Test
• Serum Chloride Test
• Serum Bicarbonate Test
• Electrolyte Panel
• Erythropoietin Test
• Glucose Measurement
• Serum Total Calcium Test
• Serum Magnesium Test
• Abdominal Ultrasound
• Abdominal CT Scan
• Kidney Scan
• Serum Parathyroid
Hormone (PTH) Level Test
• Urinalysis
• Biopsy
 MANAGEMENT

• General management
• A multidisciplinary approach
• Prenatal visits every 2 weeks until 28 weeks'
gestation and then weekly.
• Check blood pressure. Measure protein excretion,
usually by dipstick. If any worsening proteinuria is
discovered, obtain a 24-urine collection
• Patients who have had a transplant
to wait a year after a living relative
donor transplant and 2 years after a
cadaveric renal transplant before
attempting pregnancy
• Stable Renal function, with a serum
creatinine level of <2.0 mg/dL.
• Discontinue ACE inhibitors, and
make every attempt to decrease
prednisone to 15 mg/d or less,
azathioprine to 2 mg/kg/d or less,
and cyclosporine to 5 mg/kg/d or
less.
• Check of immune status for hepatitis B virus,
herpes simplex virus (HSV), cytomegalovirus
(CMV), and Toxoplasma species
• If rubella titers are low, administer the vaccine
before transplant
• Laboratory work consist of CBC counts,
electrolytes, BUN and creatinine levels, and (if
indicated) a cyclosporin level.
• Perform monthly ultrasounds and urine
cultures.
• Biweekly fetal surveillance with a biophysical
profile is indicated in the third trimester.
 OBSTETRIC MANAGEMENT
• Preterm labor. Magnesium can be
cautiously used to avoid toxicity and
respiratory depression.
• The literature reflects a debate about
elective early delivery (34-36 wk) in
patients with chronic renal insufficiency
or those receiving dialysis, especially
when fetal lung maturity is present.
• In patients who have had a transplant,
delaying delivery until the onset of labor
provided, of course, that the mother and
fetus show no signs of distress.
 Fetal Surveillance and Timing of
delivery:
• Cesarean section should be
necessary only for purely
obstetric reasons.
• In fact, preterm labor is generally
the rule and may commence
during hemodialysis. The role of
cesarean section in this situation
needs to be carefully considered
• Anemia management
DIALYSIS
• Early dialysis is
necessary in pregnant
women and should be
considered when the
serum creatinine reaches
3.5 mg/dL or the GFR is
less than 20 mL/min.
• Conti
– Longer, more frequent dialysis (20 hrs/week)
is associated with the best fetal outcome.
Hemodialysis may therefore be necessary at
least 5 days per week
– Careful avoidance of hypotension is
important.
– Peritoneal dialysis with smaller volumes and
frequent exchanges is another option.
– Premature labor and fetal size that is small
for the fetus' gestational age are typical in
women who deliver on dialysis.
• Nutritional support that allows weight gains of 0.3
to 0.5 kg/wk should be maintained in the second
and third trimesters.
• A daily oral intake of 70 gm protein, 1,500 mg
calcium, 50 mM potassium and 80 mM sodium is
advised, with supplements of dialyzable vitamins.
• Vitamin D supplements can be difficult to judge in
patients who have had parathroidectomy. In
addition, the placenta produces hydroxyvitamin D,
one reason why oral supplementation may have to
be curtailed.
 Renal Transplantation
Guidelines for pregnancy in kidney
transplant recipient
Two years posttransplant, with
good general health and serum
creatinine less than 2.0 mg/dL
(preferably <1.5 mg/dL)
No recent or ongoing rejection
Normotension, or minimal
antihypertensives
Absent or minimal proteinuria
No evidence of pelvicalyceal
dilation on renal ultrasonogram
Immunosuppression
 Prednisone - Less than 15 mg per day

 Azathioprine - Less than or equal to 2

mg/kg/d
 Calcineurin inhibitor–based therapy -

Therapeutic levels
 Mycophenolate mofetil and sirolimus

- Discontinue 6 weeks prior to

conception
 Methylprednisolone - The preferred

agent for treatment of rejection

during pregnancy
 Immunosuppressive drugs in pregnancy
 Prednisone crosses the placenta with a
maternal-to-cord ration of 1:10. Fetal
complications include neonatal adrenal
insufficiency and thymic hypoplasia. These
are unlikely to occur if the dose is less than
15 mg/d. If acute rejection of the kidney
occurs during pregnancy, there is generally
no hesitation in the use of high-dose
steroids.
 Azathioprine apparently crosses the
placenta, the immature fetal liver cannot
convert it to its active form, 6-
mercaptopurine. Use of azathioprine is
associated with SGA babies and dose-
related myelosuppression in the fetus.

 Cyclosporine has not been associated with

an increase in congenital anomalies but has
been associated with SGA babies.
Complication Risks
 Immunosuppressive agents increase the

risk of hypertension during pregnancy.

 Preeclampsia occurs in approximately one-

third of transplant recipients.

 Almost 50% of pregnancies in these

women end in preterm delivery due to

hypertension.
 There is an increased risk of

cytomegalovirus, toxoplasmosis, and

herpes infections, which arouse concern for
the fetus.
 COUNSELING AND EARLY
PREGNANCY ASSESSMENT

 PRECONCEPTION GUIDELINES
A wait of 18 months to 2 years post-
transplant is advised before conception.
Also, if function is well maintained at 24
months, there is a high probability of
allograft survival at 5 years
 Good general health about 2 years since transplantation
 Stature compatible with good obstetric outcome
 No or minimal proteinurea
 Absence of hypertension
 No evidence of graft rejection
 Stable renal function with plasma creatinine of 2
mg/100 ml or less (preferably less than 1.5 mg/100 ml)
 Drug therapy reduced to maintenance levels:
prednisone 15 mg/day or less, and azathioprine 2
mg/kg body weight/day or less. Safe doses of
cyclosporine-A, have not yet been established because
of limited clinical experience, but 5 mg/kg body weight
per day or less is quoted anecdotally
NURSING MANAGEMENT
• Assess for risk for fluid overload
• Fluid intake should be carefully
monitored & intake should equal
output
• Evaluate the degree of edema.
• Discuss the importance of
nutritional modifications and
refer to dietician
• Teach family on home BP
monitoring
• Instruct the patient & family on about
importance of recognizing & reporting
signs of fluid & electrolyte imbalance,
HELLP syndrome, medicine induced
side effects etc
• Modify home activities to reduce onset
of dangerous hypertension & avoid
added fatigue factors
• Teach patient to avoid infection
• Teach the patient the signs &
symptoms of preterm labour & report
it( 4 painless contractions per hour
unrelieved by rest of 1 hour)
• Avoid using urinary catheters
• Always run a clean catch urine
specimen
• Start fetal surveillance with electronic
fetal monitoring , BPP, NST
• After 24 weeks of gestation evaluate
for fetal IUGR
• Assess for hypertensive disorders of
pregnancy & or DIC
• Assess for signs of fluid, electrolyte,
acid base imbalance
• Perform dialysis as ordered.
• Weight the patient at each dialysis
exchange
NURSING DIAGNOSIS
• Imbalanced nutrition less than body
requirement related to dietary restriction.
• Fluid volume excess related to compromised
regulatory mechanism
• High risk for decreased cardiac output
related to fluid volume overload,
accumulated toxins
• High risk for injury ( hypocalcemia)related
to increased phosphorus level, renal failure
• High risk for injury related to bone
marrow suppression secondary to
insufficient renal production of
erythropoietic factor
• High risk for impaired skin integrity
related to edema
• High risk for self esteem disturbance
related to loss of body function,
prolonged dialysis
• High risk for noncompliance related to
lack of resources, knowledge deficit.
BIBLIOGRAPHY
• Blackburn ST. Maternal, Fetal & neonatal physiology.3rd edition. Missouri:
Elsevier; 2007
• Arias F, Daftary SN, Bhide AG. High risk pregnancy & delivery. 3 rd edition.
Noida: Elsevier; 2008
• Mudaliar AL, Menon MK. Clinical obstetrics.10th edition. Chennai: Orient
Longman; 2005.
• Evans AT. Manual of Obstetrics. 7th edition. New Delhi: Wolter Kluwer Pvt
Ltd; 2007
• Ladewig PW, London ML, Olds SB. Maternal newborn nursing. California:
Addison Wesley nursing; 2007
• Gilbert ES. High risk pregnancy & delivery. 4th edition. Missouri: Mosby;
2007
• http://www.womenshealthsection.com/content/obsmd/obsm004.php3
• http://www.ackdjournal.org/article/S1548-5595(07)00005-5/abstract
• http://emedicine.medscape.com/article/246123-overview
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