Management of Pregnancy at Glomerulonephritis

Management and treatment of pregnant with glomerulonephritis are carried out by obstetrician-gynecologist and therapeutist-nephrologist. In early terms of gestation (about 12 weeks) general examination of pregnant should be made to specify the form of disease, to study features of anamnesis and to decide the question of conducting pregnancy.

There are three degrees of risk for pregnant women at glomerulonephritis:

I degree of risk — a latent form of glomerulonephritis;

II degree of risk — a nephrotic form of glomerulonephritis;

III degree of risk — a hypertonic and mixed form of glomerulonephritis.

Pregnancy may be prolonged at chronic, latent form of glomerulonephritis.

The problem of prolongation of pregnancy at I and II degree of risk is solved individually: pregnancy can be prolonged in the absence of signs of exacerbation, expressed hypertension and azotemia, presence of opportunity of strict control of kidney function. Management and treatment of pregnant women are carried out on the basis of a large in-patient department.

Pregnancy is contraindicated in case of III degree of risk in view of high rate of maternal mortality at this pathology.

Pregnancy is absolutely contraindicated at any form of glomerulonephritis proceeding with renal failure.

Thus, the first hospitalization of pregnant with a chronic glomerulonephritis is arranged in term of 10-11 weeks of gestation at a nephrological department for examination and solving the problem of pregnancy prolongation.

The second planned hospitalization is carried out at 20-22 weeks of pregnancy for examination and preventive course of treatment (nonspecific desensitizing therapy, antibacterial therapy for prophylaxis of secondary infection, spasmolytic and metabolic therapy). The treatment aimed at improvement of uteroplacental circulation and prophylaxis of fetus should be administered.

Except for preventive hospitalization in the I and II trimester of pregnancy, the in-patient treatment at any term of gestation is indicated at worsening of general condition, occurrence of signs of threatened abortion, late gestosis , hypoxia of the fetus, etc.

The common therapy of glomerulonephritis with the use of corticosteroids, cytostatic agents and immunodepressants cannot be applied to pregnant women in view of teratogenic effect of these medicines. Therefore a symptomatic therapy is basically administered. A diet limited in salt up to 2 g/day, liquid up to 800 ml/day should be administered; saluretic diuretics (hydrochlorothiazide, ethacrynic acid, furosemide in a dose of 0.04-0.08 g, spironolactone — 0.025 g 6-8 times a day, gradually reducing a dose up to 0.025 g/day.) should be applied. In combination with diuretic medicines potassium chloride, hypotensive therapy (raunatinum, dibazol, papaverine, clophelinum, atenolol, etc) should be applied. With the purpose of albumen replenishment, transfusion of protein and fresh frozen plasma are indicated. Nonspecific desensitizing therapy (dimedrol, pipolphen, suprastin, etc) is administered too. A sedative therapy, metabolic therapy for prophylaxis and treatment of intrauterine fetus are necessary.

The third planned hospitalization should be arranged in term of 36-37 wk of pregnancy. The pregnant is hospitalized at pathologic pregnancy department for examination, determining obstetric management and preparation for labor.

In some cases it is expedient to cause premature labor in woman to avoid fetus death.

Management of Labor. A preferable approach of delivery for pregnant women with glomerulonephritis is delivery through natural maternal passages with a wide application of spasmolytics and analgesics. Management of the 2 stage of labor depends on level of arterial blood pressure, condition of the fetus. Controlled hypotension, shortening of expulsive stage of labor by applying obstetrical forceps or perineotomy are indicated. Cesarean section of patients suffering from glomerulonephritis is operation of choice which is performed basically by urgent indication, for example, at a threatened asphyxia of the fetus.

In puerperal period the observation over a general condition of puerperant, function of kidneys should be continued; in case of aggravation of the disease course the patients should be removed to specialized hospitals or therapeutic departments.

Heart Diseases in Pregnansy. For the last years a clear tendency to increase of cardiac disease incidence in pregnant has been marked. It is explained by improvement of diagnostics, medical treatment of patients with heart diseases, progress of cardiosurgery, perfection of methods of pregnancy and delivery management at heart diseases. Cardiovascular diseases and pregnancy are not a simple combination of two states of woman’s organism.

Pregnancy and labor impose an additional load on the cardiovascular system of the woman. A healthy pregnant overcomes a new burden with ease but patients with cardiovascular diseases often develop circulatory disorders and other complications.

Incidence. The incidence of cardiac diseases is less than 1% among hospital deliveries. The commonest cardiac disease is of rheumatic origin followed by congenital defects.

Effect of Gestation on Cardiovascular Diseases. During pregnancy there is an increased blood vascularity of the enlarging uterus with the interposition of utero-placental circulation. The activities of all systems are increased. To fill up the additional intravascular spaces, the blood volume is markedly raised during pregnancy. The rise is progressive and inconsistent. All the constituents of blood increase in volume during pregnancy.

The increase of plasma volume starts from the 10^th week, expands rapidly thereafter to maximum 35-40% above the non-pregnant level at 32-34 weeks. Total plasma volume increases to the extent of 1.3 litres. Erythrocyte number is increased during pregnancy. The rate of increase almost parallels that of plasma but the maximum is reached to the extent of 20%. The total hemoglobin mass increases during pregnancy to the extent of 18-25%, thus the disproportionate increase in plasma and blood cell volume produces a state of hemodilution during pregnancy. The increased volume of circulatory blood, hemodilution mean extra load for cardiovascular system in pregnancy.

The volume of circulatory blood remains almost static till the term. During labor or shortly thereafter, there is a slight decrease due to dehydration and blood loss during delivery. Blood volume almost returns to normal non-pregnant level by the second week in puerperium.

A normal heart has sufficient reserve power so that the extra load can be well tackled. While a damaged heart with good reserve can even withstand strain but if the reserve is poor, the cardiac failure occurs sooner or later. The cardiac failure occurs during pregnancy between 30-32 weeks but mostly during labor or soon following delivery. Additional factors responsible for determination of cardiac function of the damaged heart are: advancing age, history of previous heart failure, cardiac arrhythmias or left ventricular hypertrophy, pregnancy complications such as anemia, EPH-complex, infection.

Effect of Cardiovascular Disease on Gestation. There is a 38% incidence of fetal death in pregnancies of women with severe heart diseases. Severe maternal hypoxia results in abortions, premature delivery, intrauterine hypoxia, intrauterine growth delay. Excessive anemia, EPH-complex, hemorrhages may occur during pregnancy in women with cardiac diseases. The risk of maternal mortality is considerable and depends on the specific cardiac lesion. Patients with pulmonary hypertension, Eisenmenger’s syndrome, coarctation of aorta with valvular involvement, or Marfan’s syndrome with aortic involvement have a mortality rate in pregnancy of 25-50%. Other conditions such as small septal defects, patent ductus arteriosus, and corrected tetralogy of Fallot have a maternal mortality rate of less than 1%.