Management of Pregnancy at Pyelonephritis

High risk groups for pregnants with pyelonephritis include the following:
- Women with acute pyelonephritis occurred firstly during pregnancy are determined as patients of the first degree of risk.
- Pregnants with chronic pyelonephritis occurred prior to pregnancy are determined as patients of the second degree of risk.
- Women with pyelonephritis complicated with azotemia or hypertension, or women with pyelonephritis of the only kidney refer to the highest risk group in pregnancy, called the third degree of risk.

Pregnancy is contraindicated for patients with the third group of risk, because it may lead to maternal and perinatal death.

Treatment of pyelonephritis during pregnancy should be only at the in-patient department.

Patients with chronic pyelonephritis should be hospitalized thrice during pregnancy for prophylactic treatment.

The first hospitalization is in term before 10 weeks of pregnancy to examine the general condition of pregnant, the state of the renal system and find the opportunity to prolong pregnancy

The treatment includes: antibiotic therapy (penicillin 10,000,000 units daily intramuscularly, or ampicillin 500 mg four times a day, or pyopen 1g four times a day) during 7-8 days.

The second prophylactic hospitalization should be arranged in term of 20-22 weeks of gestation to treat a patient for prevention of pyelonephritis.

The following treatment is administered: antibiotic therapy (cephuroxim 500 mg 4 times a day; gentamicin, kanamycin, oleandomycin may also be used). Nevigramon, negram should be administered in doses of 2 capsules 4 times a day during 10 days. Furagin may be administered in a dose of 0.1 g 4 times a day during 4 days, and then 0.2 g 3 times a day during 10 days. Urosulfan is usually prescribed by 0.5 g 3-4 times a day during 12-14 days. Diet limited in salt and water should be administered. Bed regimen in cases of elevated temperature is necessary. Antihistaminic drugs, spasmolytics, treatment to prevent fetal hypoxia and premature labor are of importance for these patients.

The third hospitalization is necessary in the third trimester of pregnancy, in term of 34-36 weeks of pregnancy, for general examination, choice of way of delivery and preparation for delivery. Antibiotics may be used by indication, the treatment for fetal hypoxia, for improvement of placental microcirculation is usually provided.

The natural maternal passages are the best way for patients with pyelonephritis. Cesarean section is contraindicated due to infectious process and may be done only by absolute indication; intraperitoneal operation is preferable.

During postpartum period there is a high risk of development of infections, so antibiotic therapy is administered with the prophylactic purpose.

Pregnancy and Glomerulonephritis. Glomerulonephritis is an infectious-allergic disease of kidneys with glomerular affection. Glomerulonephritis is encountered in 0.1-0.2 % of pregnants; it is the most dangerous kidney disease, because a complicated course of pregnancy accompanying it is more frequent than at other diseases. The nephrogenous culture of β-hemolitic streptococcus of A group, type 12 is a causative agent of this disease. Glomerulonephritis develops in 10-15 days after the suffered scarlatina, quinsy, streptococcic pyodermia. Noninfectious glomerulonphritis after vaccination, inoculations is encountered more rarely. The essence of pathological process at glomerulonephritis is determined by autoallergization. An infectious factor quickly loses its dominant value, and illness acquires the form of autoagressive process.

Acute and chronic forms of glomerulonephritis are distinguished. The clinical picture of acute glomerulonephritis at pregnancy is vague. During pregnancy acute glomerulonephritis usually proceeds as severe forms of gestoses. The clinical manifestations in such cases are elevation of arterial blood pressure, edema, proteinuria. In contrast to gestoses acute glomerulonephritis is marked by expressed hematuria, cylindruria. The titre of antistreptolysin and antihyaluronidase rises. The onset of the disease is acute, with occurrence of chill, headache, edema. All these symptoms appear in pregnant in 1-2 weeks after quinsy. Acute glomerulonephritis is contraindication to prolongation of pregnancy.

Chronic glomerulonephritis can proceed in a latent, nephrotic, hypertensive and mixed form.

A more frequent is a latent form (approximately in 65% of pregnant). It is characterized by inconstant microproteinuria, microhematuria; single cylinders can be determined (not constantly) in urinary sediment. The latent form of glomerulonephritis proceeds without a hydropic syndrome and hypertension.

A nephrotic form is encountered approximately in 5% of pregnant with glomerulonephritis. A complex of symptoms is characteristic of this form: proteinuria (up to 30-40 g/l), hypoproteinemia (blood protein decreases down to 40-50 g/l), the expressed edema and hypercholesterinemia. In urinary sediment red corpuscles and different cylinders are revealed — hyaline, granular, waxy. Permeability of endothelium of glomerular capillary net is sharply increased; canalicular reabsorption of albumen is disturbed.

A hypertensive form is characterized by expressed hypertensive syndrome, moderate hematuria, proteinuria and cylindruria. Edema is not characteristic of this form of glomerulonephritis. On a background of expressed hypertension, hypertrophy of the left heart ventricle, spasm of arterioles of eye grounds are revealed in patients. Arterial hypertension at chronic glomerulonephritis develops due to decrease of renal blood flow and increase of renin and angiotensin production, as well as the increased production of aldosterone. The incidence of this form makes up approximately 7% of the total number of pregnant with glomerulonephritis.

A mixed (edematous-nephrotic) form is characterized by the most expressed vascular changes and hypertension accompanied with hypertrophy of the left ventricle, vascular change of eye grounds, marked dystrophic processes in kidneys, severe proteinuria, cylindruria, hematuria, edema. The incidence of this form is approximately 25%. At this form of glomerulonephritis the attack of cramps, similar to eclampsia, can develop even in the absence of late gestosis.

Effect of Glomerulonephritis on Pregnancy. Pregnancy on a background of chronic glomerulonephritis proceeds with serious complications. Approximately in 40 % of women with this pathology the EPH-complex develops very early (before 28 weeks), it proceeds in a very serious form (preeclampsia of a serious degree, eclampsia, HELLP-syndrome). Acute respiratory infections, influenza, tonsillitis provoke the occurrence of gestosis.

The most common complication of pregnancy at glomerulonephritis is disturbance of uteroplacental circulation. Vascular spasms, kidney ischemia, hypertension, increase of fibrinogen content lead to insufficiency of placenta blood supply. Besides, the immunological balance between a maternal organism and fetus is broken. Getting into mother’s blood flow, antigens of placental tissue cause sensibilization with development of antibodies not only to tissues of placenta, but also to vital organs of the pregnant woman, including kidneys, resulting in changes known as a vicious circle.

The disturbances of uteroplacental circulation lead to pathology of fetus. In 12-15 % of cases the pregnancy is complicated by intrauterine death of fetus, congenital anomalies of fetus, intrauterine growth retardation, hypoxia of the fetus. The adverse conditions of fetation are aggravated by anemia accompanying glomerulonephritis. The rate of perinatal mortality is extremely high — from 140 up to 400‰ and over. Pregnancy at glomerulonephritis is frequently complicated by premature detachment of normally located placenta, which proceeds in a serious form, and is accompanied by a massive hemorrhage, fast addition of coagulopathic disturbances. In 15 % of patients with glomerulonephritis, fetus wastage occurs prematurely in various terms (early and late abortions, premature labor). The frequency of maternal mortality at glomerulonephritis makes up 27.1 %.

Effect of Pregnancy on Glomerulonephritis. The course of glomerulonephritis at pregnancy is worsened. Decrease of tonus of ureters and renal pelves, retention of urine in the urinary bladder and ureters contribute to addition of a secondary infection, deterioration of kidney condition, thus causing the development of renal failure.

These processes are more expressed after 20 weeks of pregnancy, in connection with increase of progesterone level in blood. Neuroendocrinal changes, characteristic of gestational process, the immune derangements at pregnancy produce an unfavourable effect on the course of glomerulonephritis, contribute to the development of functional decompensation, progressing of disease. Pregnancy represents a high degree of risk for transition of disease into a terminal stage of chronic uremia.