Useful notes (O&G, MFM)

Chronic kidney disease

Pre-pregnancy

CKD stage:

Pre-pregnancy eGFR:

Proteinuria:

Baseline bloods: (FBC, haematinics, U&Es, LFTs, calcium, phosphate, bicarbonate)

Stop/rationalise medications: (methotrexate, cyclophasmide, mycophenolate, ARBs)

Delay pregnancy:

  • >1 year (renal transplant, glomerulonephritis)
  • >6 months (lupus nephritis/vasculitis once quiescent)
  • After transplant (dialysis)

Contraception

Blood pressure:

Glycaemic control:

  • HbA1C

Pregnancy risks:

  • Infertility
  • Miscarriage and fetal loss
  • Preterm birth & neonatal care
  • FGR
  • Caesarean section

Antenatal

Stop/rationalise medications: (ACE-inhibitors)

Renal monitoring:

  • Serial renal function (FBC, haematinics, U&Es, LFTs, calcium, phosphate, bicarbonate) and proteinuria testing
  • Serial weights, fluid balance
  • Vitamin D testing
  • Bicarbonate replacement (aim >16)

Anaemia:

  • Consider Ferinject
  • Consider EPO (Hb <100, ferritin >100)

Hypertension:

  • Aspirin 150 mg OD
  • Enhanced monitoring (aim <130/80)

VTE:

  • PCR >300: LMWH
  • <300: treat as one risk factor

Diabetes:

  • OGTT if taking tacrolimus/cyclosporin

Fetal:

  • Test for anti-Ro/La (lupus)
  • Serial growth scans (consider from 24 weeks)

Peripartum

Delivery indications:

  • Standard obstetric
  • Worsening renal function
  • Symptomatic hypoalbuminaemia
  • Pulmonary oedema
  • Refractory hypertension

Labour:

  • Fluid balance

Postnatal:

  • Avoid NSAIDs
  • Early renal follow-up
  • Contraception

Dialysis

  • Initiate if urea >17 (unless iatrogenic birth would be better)
  • Aim for urea <12
  • Switch from peritoneal to haemodialysis

Staging

Stage 1: eGFR >=90 with other evidence of renal disease (e.g., proteinuria)

Stage 2: eGFR 60-89

Stage 3a: eGFR 45-59

Stage 3b: eGFR 30-44

Stage 4: eGFR 15-29

Stage 5: eGFR <15

Prognosis (without dialysis)

Stage 1-2:

  • Renal deterioration: reversible (8%), progressive (3%)
  • PET: 10-20%
  • SGA: 25%
  • Preterm birth <34 weeks: 10%

Stage 3-5:

  • Live birth rate (after 12 weeks): 98%
  • Preterm birth <34 weeks: 26% (usually driven by hypertension)
  • SGA <10th: 36%
  • Severe SGA <3rd: 22%
  • Significant worsening (>25%) or needing dialysis: 46%
  • Postpartum eGFR change equivalent to 2.5 years progression (or 4.5 years with a transplant) which is greater in women with hypertension

Resources

Clinical guideline for renal disease in pregnancy (Wiles, et al. 2019) https://bmcnephrol.biomedcentral.com/articles/10.1186/s12882-019-1560-2

Pregnancy outcomes with CKD 3-5 (Wiles, et al. 2021) https://academic.oup.com/ndt/article/36/11/2008/6032223