Transcript الشريحة 1

Renal disease
Urinary tract infection
-definition:
-Urinary tract infection (UTI) is the
presence of significant bacteria in a
clean-catch or catheter specimen of urine
- most commonly described as a colony of
at least 100 000 bacteria/mL of urine. Infection in the lower urinary tract may
originate in the urethra (urethritis) or
bladder (cystitis) and if untreated ascend
into the upper urinary tract and affect
the kidneys (pyelonephritis).
Symptoms of a lower urinary tract
infection include :
-burning or pain on urination (dysuria)
- frequent passing of small amounts of
urine (frequency)
- a change in the smell of the urine
- the presence of blood in the urine
(haematuria)
-discomfort in the suprapubic area
fever (pyrexia >38 °C)
Rigors
Tachycardia
nausea and vomiting leading to
dehydration
pain and tenderness over the kidney area
is indicative of pyelonephritis.
Acute pyelonephritis occurs in 1–2 % of
pregnant women
it most commonly occurs: in nulliparous
women; the younger age group (20–29
years) and at the end of the
second/beginning of the third trimester
and the puerperium.
-diagnosis:
1-presenting symptoms
2-Examination of the urine shows it to be
cloudy with the presence of white blood
cells (leucocytes) and the infecting
organism is often Escherichia coli by
Vaginal infections and sexually
transmitted diseases such as Chlamydia
trachomatis may mimic symptoms of UTI
and should be excluded urine microscopy
and culture.
-UTIs in pregnancy need to be treated
promptly to prevent the development of
maternal morbidity include;
-chronic renal insufficiency
- transient renal failure
-acute respiratory distress syndrome
(ARDS)
- sepsis and shock)
fetal morbidity and mortality include:
pre-labor rupture of membranes
chorioamnionitis
preterm labour and birth
Management
-pyelonephritis need admission to hospital
, intravenous antibiotics can be
administered.
- During the early stages of the illness the
woman will feel quite ill.
-Severe nausea and vomiting will lead to
dehydration and intravenous fluids may
be required.
-A record of fluid balance is maintained to
assess renal function
The midwifery care; :
-regular observation of temperature, pulse,
blood pressure and respiratory rate.
-Cold compressor & antipyretic
-Uterine activity should be monitored to
detect the onset of pre-term labour.
- the use of antithrombotic stockings to
avoid deep vein thrombosis.
- the doctor may prescribe low dose
heparin therapy.
Antibiotic therapy is effective in curing
urinary tract infections
- Many different drugs may be used, given
by oral or i.v. route with the course of
treatment dependent on the drug used.
- Repeat cultures should be done 2 weeks
after completion of the course of
treatment and monthly until birth in
order to ensure there is no recurrence
Women who develop recurrent UTI may
require prophylactic antibiotic treatment
throughout pregnancy.
- Follow-up examination of the renal
system (excretion urography) is often
undertaken 3 months postnatally as
persistent or recurrent infection, with or
without symptoms, may be associated
with an abnormality of the renal tract.
Asymptomatic bacteriuria
-All pregnant women should be screened
for bacteriuria using a clean voided
specimen of urine at their first antenatal
visit.
-A diagnosis of asymptomatic bacteriuria
(ASB) (significant bacteriuria without
symptoms of UTI) is made when there
are >100 000 bacteria/mL of urine.
-.
ASB occurs in 2–10% of pregnant women
as a result of the physiological changes in
the urinary tract during pregnancy.
-If ASB is not identified and treated, 20–
30% of these women will develop a
symptomatic urinary tract infection such
as cystitis or pyelonephritis
Treatment with antibiotics is recommended
to reduce the incidence of symptomatic
kidney infection and pregnancy
complications
Chronic renal disease
-it depend on various issues as
• general health status of the woman
• presence or absence of hypertension
• presence or absence of proteinuria
• type of kidney disease and current renal
function
• pre-pregnancy drug therapy.
*If the renal disease is under control
maternal and fetal outcome is usually
good.
-In some instances renal function may
deteriorate and the chance of pregnancy
complications subsequently rises.
- Renal disease combined with hypertension is
associated with :
-fetal growth restriction
-pre-term birth
- increased perinatal mortality.
-Pregnant women with mild renal insufficiency
(serum creatinine [Scr] <125 μmol/L or 1.4
mg/dL) have relatively few complications of
pregnancy.
-Moderate or severe renal insufficiency (Scr 125–
250 μmol/L or 1.4–2.6 mg/dL). Complications are
frequent and include
1- a rise in hypertension
2-high grade proteinuria (urinary excretion >3 g in
24 hrs)
3- loss of renal function, which may persist up to 1
year following birth.
Around 10% of cases will progress to endstage renal failure necessitating dialysis
during or shortly after pregnancy;
this is most likely to occur when the Scr is
>250 μmol/L or 2.8 mg/dL at the
beginning of pregnancy
Care and management
-Assessment of renal function prior to
conception is important
-more frequent attendance for antenatal
care ,between the midwife, obstetrician
and nephrologist.
Renal function can be assessed on a regular
basis by measuring :
-serum urate levels
- serum electrolyte
- urea, 24 hrs creatinine
-clearance and serum creatinine.
- Urinalysis is undertaken for glycosuria,
proteinuria and haematuria.
-Regular urine cultures will detect infection
and advice should be given regarding the
signs and symptoms so that women can
seek treatment early
-The emergence and severity of
hypertension and pre-eclampsia are
monitored by recording blood pressure,
- undertaking urinalysis and utilizing preeclampsia blood screening tests.
- A full blood count will detect anemia as
the production of erythropoietin is
suppressed in chronic renal disease.
- Fetal surveillance includes :
-fortnightly ultrasound scans from 24
weeks,
- Doppler blood flow studies and
monitoring fetal activity.
-Admission to hospital is advised when
there is evidence of fetal compromise
if renal function deteriorates and
proteinuria increases or the blood
pressure rises.
-If the maternal condition becomes lifethreatening, the risks and benefits of
continuing with the pregnancy need to be
discussed with the woman and her
family.
Women on haemodialysis/peritoneal
dialysis:
-Women who develop end-stage renal
failure prior to or during pregnancy may
require dialysis.
- End-stage renal failure results in
hypothalamic-gonadal dysfunction
causing infertility.
- however, dialysis lessens the hormonal
dysfunction and those who conceive and
continue a pregnancy are at significant
risk for adverse maternal and fetal
outcomes
Pregnancy will increase the length and
frequency of dialysis required in order to
achieve a serum urea below 20 mmol/L,
Higher levels are associated with an
increased risk of fetal demise During
dialysis
- it is important to prevent fluid overload
and the development of hypertension
-may require erythropoietin (Epo) therapy
and blood transfusions to resolve anemia
because of dialysis.
- Hypertension and superimposed preeclampsia are common maternal
complications.
- Many pregnancies in dialyzed patients end
in early spontaneous abortion,
therapeutic abortion and pre-term birth
with only 40–50% of pregnancies
resulting in a successful outcome
Renal transplant with pregnancy:
-Preconception advice is important
-It is advisable for her to wait a minimum
of 2 years before attempting pregnancy
as this allows time for the success of the
graft.
-During pregnancy women are monitored
closely by the multidisciplinary team.
-frequent renal function including
urinalysis, blood pressure, hemoglobin
levels and the status of the graft are
assessed.
- Close monitoring of the fetus is also
required to detect fetal growth
restriction.
- Immunosuppressive therapy is usually
continued during pregnancy although the
effect on the pregnancy and the fetus is
unknown.
- this drug make the woman more
vulnerable to infection.
- The newborn baby will also be more prone
to infection as immunosuppressive
therapy reduces the transmission of
maternal antibodies to the fetus.
-factors that is related to maternal & fetal
complications :
1-transplant–pregnancy interval <2 years
2- maternal hypertension
3-elevated serum creatinine levels
4-asymptomatic bacteriuria.
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