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32 Cards in this Set
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Renal changes in preg
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hypertrophy, more smooth muscle motility (pelvis/ureter dilation, less bladder emptying, reflex from bladder to ureters which is backwards)
pH changes so more risk of infection |
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Vasc changes in preg
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Endothelial relaxation
Small vessels dilate large vessels have more compliance these changes are early in the pregnancy |
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Physiological changes in preg
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less resistance to vasculature
more CO, less BP, more blood volume (anemic though) renal blood flow and thus GFR increases. |
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after preg to assess renal func
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must wait 3 months till they get back to their baseline.
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What happens to the following in preg
BUN, creat, sodium pH, bicarb, albumin, urine protein, RBC mass |
BUN down, creat down - filtering more
sodium down pH up and bicarb is down (so a respiratory alkalosis with compensation) albumin low urine prot increased (more GFR) RBC mass increases. but remember, plasma volume increases more (Anemia) |
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failure to drop creatinine during pregnancy....
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is an indication of underlying kidney disease.
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Abnormal changes in preg in a pt who has chronic kidney disease and HTN
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they oppose the normal.
less endothelial relaxation (periph vasoconstriction and HTN) Less large vessel compliance. |
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Conclusions of studies of chronic kidney disease and pregnancy
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it is possible, contrary to previous belief.
but more risk of an adverse outcome and the degree of risk is proportional to the degree of renal impairment. |
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GFR and stages of chronic kidney disease
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need to know these...
1 - >90 2 - 60-89 3 - 30-59 4 - 15-29 5 - <15 - NEED DIALYSIS!!!! 6 - on dialysis |
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worse CKD pts are more likely to...
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not increase their blood vol, not increase their GFR, not increase RBC mass, have MORE protein excretion
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risks to fetus and mother
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fetal risks are way way worse.
fetus - prematurity, intrauterine growth retardation, spont abortion, intrauterine death maternal - HTN/pre-eclampsia, worsening kidney function, death (usually HTN or pre-exlampsia) |
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more likely to have preg complic with ___ ckd
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higher stage.
duh includes lower birth weight, preterm deliv and perinatal death. |
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how does preg affect course of chronic kidney disease?
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hyperfiltration of preg may make CKD progress.
<10% chance of GFR decreasing. more likely to have an increase in BP |
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GFR pattern in pts with CKD
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goes up until 2nd trim then back to normal in 3rd trim. similar to normal. but more pts have weird patterns.
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the one disease that presents MORE COMMONLY in preg
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lupus
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pregnancy effects on normal kidneys
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aside from lupus, not more likely to get any renal disease.
but because of new attention, may discover and pre-existing undx kidney disease (more proteinuria, failure to decrease creatinine of HTN would sugest this) |
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HTN and pregnancy with CKD
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If HTN before, less reduction in BP during preg. Same goes if they had CKD before.
in fact, if CKD stage 4-5, BP will go UP during pregnancy! HTN is a risk factor for poor preg outcomes in all stages of CKD!!! |
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Affects of HTN during preg
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abnormal endothel cells, less placental perfusion, prematurity, intrauterine growth retardation.
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categories of HTN in preg
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Pre-existing - if mild, it improves if renal func is normal. if not mild or moderate to severe chronic kidney disease, it worsens.
Pregnancy-induced HTN - usually early in preg. this is a red flag for underlying renal disease. Pre-eclampsia (no HTN after the preg) - systemic disorder and histo is related to thrombotic microangiopathies. |
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Pre-eclampsia
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After 20th week. May be earlier if pt had chronic kidney disease or HTN.
Often hours to days before the delivery. |
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signs of pre-eclampsia
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HTN, rapid weight gain/edema, proteinuria
sometimes acute renal failure, encephalopathy (HA, headache, sz), fetal distress due to placental dysfunction. |
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HELLP syndrome
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a variant of pre-eclampsia that is a little more serious
Hemolysis, elev liver enzymes, low platelets. |
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Lab studies for pre-clampsia
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proteinuria, low platelets, high serum uric acid (the last one isn't really good...)
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Pathogen of pre-eclampsia
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Endothel cell activ and proliferation so small vessels are occluded. Microthrombi in placenta, kidney, nervous system, liver.
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VEGF and sFlt-1 findings in pre-eclampsia
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Flt1 - tyrosine kindase receptor - soluble form released by placenta. It binds VEGF (also released by placenta)
So the soluble form binds VEGF. Normally, surge in sFlt1 before labor. But in pre-eclamptic pts (5 weeks before), you often see excess sFlt-1 and decreased VEGF (endothel cell is dysfunctional and procoag and vasoconstricting) |
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risk factors for pre-eclampsia
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first or wifely-spaced preg
maternal age CKD pre-existing HTN obestity multiple pregs |
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Mgmt of pre-eclampsia
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admit with bed rest.
fluids (NO DIURETICS - WILL WORSEN TISSUE PERFUSION!!!) IV magnesium induce delivery |
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how to manage non-preeclamptic HTN in preg
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target 120/80
seatch for underlying kidney disease after preg. want more vascular volume in a preg pt so no diuretics and ACE/ARBs are teratogenic after 1st trim. wanna use methyl dopa (can cause false positive coombs), nifedipine, labetolol or IV nitrates. |
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Preg in renal transplant recipients
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the rejection risk is lower during preg and more risk for 3-6 months post-partum.
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Preg in women on dialysis
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it is possible but hard.
they are less fertile and have high risk for HTN, preeclamp, fetal loss, abrupption, prematurity, and IUGRestriction. |
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Summary
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Chronic kidney disease modifies the physiological responses to pregnancy
Chronic kidney disease and hypertension are independent and interrelated risk factors for adverse fetal and maternal outcomes in pregnancy The magnitude of risk varies with severity of CKD and HTN The greatest risks are to the fetus Pre-eclampsia is a systemic condition unique to pregnancy Successful pregnancy is common in transplant patients and challenging in dialysis patients |
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General recs if someone with CKD wants to get preg
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CKD stages1 and 2
The risks are greater than normal but the chances of a good outcome are 95% or better Should be managed in consultation with Materno-fetal Medicine service or High Risk OB clinic CKD stages 3 and 4 Significant incidence prematurity and preeclampsia But good outcomes can be achieved with intensive prenatal management CKD stage 5 High risk adverse outcome And note - Hypertension worsens risks at all levels of CKD |