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Chapter-21 Renal Disease in Pregnancy

BOOK TITLE: Management of High-Risk Pregnancy—A Practical Approach

Author
1. Mittal Suneeta
2. Aggarwal Pakhee
ISBN
9789380704739
DOI
10.5005/jp/books/11228_21
Edition
1/e
Publishing Year
2010
Pages
15
Author Affiliations
1. WHO-CCR in Human Reproduction, All India Institute of Medical Sciences, New Delhi, India, Fortis Memorial Research Institute, Gurugram, Haryana, Fortis Memorial Research Institute, Gurugram, Haryana, India; All India Institute of Medical Sciences (AIIMS), New Delhi, India, Fortis Memorial Research Institute, Gurgaon, Haryana, India, Fortis Memorial Research Institute Gurgaon, Haryana, India; WHO-CCR in Human Reproduction; ART Centre and IVF Facility, All India Institute of Medical Sciences, New Delhi, India, All India Institute of Medical Sciences (AIIMS), New Delhi, India, WHO-CCR in Human Reproduction, All India Institute of Medical Sciences, New Delhi, Center for Research in Human Reproduction Vice President Elect (FOGSI)-2007, AIIMS, New Delhi, India, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India, ART Centre and IVF Facility, All India Institute of Medical Sciences, New Delhi, India, AIIMS, New Delhi, All India Institute of Medical Sciences, New Delhi, Director Incharge WHO-CCR i
2. Fortis Aashlok Hospital, New Delhi, India, Lady Hardinge College and Smt SK Hospital, New Delhi, India, Maulana Azad Medical College, New Delhi, India, Maulana Azad Medical College, Lok Nayak Hospital, New Delhi, Maulana Azad Medical College and Lok Nayak Hospital, New Delhi, Maulana Azad Medical College, New Delhi, LN Hospital, New Delhi, Postgraduate student, Maulana Azad Medical College, New Delhi, Senior Resident, Department of Obstetrics and Gynecology, All India Institute of Medical Sciences (AIIMS) New Delhi, India, All India Institute of Medical Sciences, New Delhi, India
Chapter keywords

Abstract

Gestational changes in renal physiology can both mimic and mask renal disease. Renal disease with preserved renal function carries a good prognosis for the mother and baby. In general, the worse the baseline renal function and more the associated complications (proteinuria, hypertension, UTI, poor glycemic control), the more likely is an adverse pregnancy outcome for the mother and fetus. Women with a baseline serum creatinine > 0.18 mmol/l (2 mg/dl) have a one in three chance of an accelerated decline in renal function that is unlikely to recover postpartum. In terms of fetal prognosis, there is increased incidence of spontaneous abortions, preterm labor—both spontaneous and iatrogenic, low birth weight and growth restricted infants (secondary to hypertension and uremia), dehydration (due to osmotic diuresis caused by high blood urea levels), osteomalacia (due to maternal disturbance of calcium metabolism) and a higher perinatal mortality. Blood pressure (diastolic) less than 90 mm Hg is a reasonable target. Calcium channel blockers, beta-blockers, and alphamethyldopa are safe and can be continued if the patient is taking them pre-pregnancy. Thiazide diuretics, ACE inhibitors and angiotensin receptor blockers (ARB) are better avoided. Pregnant women with proteinuria (>1 gm/24 hours), whether due to nephrotic syndrome or preeclampsia, are at increased risk of venous thrombosis and should receive thromboprophylaxis with low-molecular weight heparin (LMWH) until 6 weeks postpartum. Twice the non-pregnant thromboprophylaxis dose is required due to increased renal clearance of heparin in pregnancy. Assessment of intravascular volume is a critical part of peripartum management of women with renal disease, especially if complicated by pre eclampsia. Invasive monitoring with a central venous pressure line or pulmonary artery catheter is necessary if there is more than mild renal impairment, pulmonary oedema or severe preeclampsia.

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