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 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 > 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 end- stage 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 pre- eclampsia 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 life- threatening, 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 pre- eclampsia 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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