Download - Dr Edi Hidayat, FK. UNSRI, Gangguan Ginjal Pada Wanita Hamil

7/28/2019 Dr Edi Hidayat, FK. UNSRI, Gangguan Ginjal Pada Wanita Hamil

1/19

PENYAKIT-PENYAKIT GINJAL

PD KEHAMILAN

Dr.Edi Hidayat

Kajian Div. Ginjal Hipertensi


2/19

Important points:

UTI maternal morbidity + perinatal

morbidity via Prematurity.

Renal disease PET + IUGR.

Hypertension + proteinuria in first or earlysecond trimester suggest pre-existing renal

disease.

Serum creatinine is mandatory to exclude pre-existing renal disease.


3/19

Perubahan fisiologis pd kehamilan

Tjd dilatasi ureter dan kaliks renalis (dapat dilihat dg

USG)

renal plasma flow + glomerularfiltration

ekskresi protein urin dan creatinine clearance.Sehingga:

Batas teratas creatinine clearance serum menjadi

65 mol/L.

Batas teratas untuk proteinuria selama kehamilan

menjadi 300mg/24 hours.


4/19

Urinary tract infection

Incidence: Lebih sering dijumpai selama kehamilan

krn dilatasi traktus urinarius bag atas yg

fisiologis. Asymptomatic bacteriuria: 4-7%, 40% of

akan menjadi symptomatic UTI.

Cystitis: 1% dari seluruh kehamilan.

Pyelonephritis: 1 to 2% dari seluruh

kehamilan.


5/19

Faktor predisposisi:

- Riwayat UTI sebelumnya.

- Diabetes mellitus, polycystic kidneys, batu sal

kemih, abnormalitas traktus urinarius (duplex

kidney or ureter)

- Neuropathic bladder( spina bifida atau

multiple sclerosis).

- obat2an: steroids atau immunosuppression.


6/19

Gejala klinis:

Asymptomatic: Asymptomatic bacteriuria +

pasien dg faktor presisposisi: midstream

urine specimens (antenatal screening).

Gambaran klinis meliputi:- Cystitis: urinary frequency, dysuria,

haematuria, protienuria dan nyeri suprapubic

- Pyelonephritis: demam, nyeri pinggangdan/atau nyeri abdominal, muntah dan

menggigil.


7/19

Diagnosis

Proteinuria Urine dipstick.

MidStreamUrine Bacteriuria: >100.000

organisms/ml urine

MidStreamUrine kultur dan tes sensitivitas.

Darah leukositosis


8/19

Penatalaksanaan

Asymptomatic bacteriuria: 3-hari antibiotik(oral) untuk mencegah pyelonephritis +

persalinan preterm.

Cystitis akut: 7-hari antibiotik (oral).

- kultur Urine dan tes sensitivitas harus

dikerjakan untuk memastikan eradikasi

organisme. Recurrent bacteriuria dijumpai pd

15% of wanita hamil dan membutuhkan

antibiotic lini ke-2

- USG harus dikerjakan pada pasien dg > 2

UTIs ( kultur +ve ).


9/19

Penatalaksanaan

Pyelonephritis:

- antibiotics selama 10-14 hari.

- IV antibiotik jika pasien dg muntah atau demam

tinggi- rehidrasi cairan IV

- periksa fungsi ginjal

- USG u menyingkirkan hydronephrosis, batu ginjaldan abnormalitas kongenital (risk factors).

Antibiotik prophylactic : > 2 UTIs (positive culture)yaitu recurrent UTI atau dg faktor risiko > 1.


10/19

Regimen pengobatan UTI pd kehamilan:

Oral antibiotics:

- amoxicillin 500 mg3xsehari.

- Cefadroxil 500mg2xsehari.

- Cephalexin 250 mg3xsehari.

- nitrofurantoin 100 mg3xsehari (tidak bolehtrimester 3).

- trimethoprin 200 mg2xsehari (tidak bolehtrimester). 1

IV antibiotics untuk

pyelonephritis:- Cefuroxime 750mg

3xsehari

- Augmentin 1gram

3xsehari- Gentamicin 2-5mg/kgdibagi tiap 8 jam uorganisme yg resistenatau wanita yg alergi

penicillin dancephalosporin

Prophylaxis of UTI:

- Cephalexin 250 mg 1xsehari.

- amoxicillin 250 mg 1xsehari


11/19

Gangguan ginjal (renal impairment):

Etiology:

1. reflux nephropathy

2. diabetes

3. systemic lupus erythematosus (SLE)

4.Glomerulonephritis.5. polycystic kidney disease.

Klasifikasi : mild, moderate atau severe tergantung

serum creatinine.Creatinine tergantung massa otot cth: laki-laki dg

berat 85 Kg dg ggn ginjal moderate setara dg ggn

ginjal severe pada perempuan 50-kg


12/19

Tampilan klinis:

hypertensi dan proteinuria haematuria pd kehamilan

awal. Harus diperiksa ureum and creatinine serum.

Pengaruh kehamilan pd gangguan ginjal:

- mild impairment (creatinine < 125 mol/l): dptmentoleransi kehamilan dg baik, tanpa penurunan

fungsi ginjal.

- severe renal impairment (creatinine > 250 mol/l):

risiko tinggi untuk permanent loss fungsi ginjal

selama dan setelah kehamilan dan bahkan dpt tjd end

stage renal failure.


13/19

Effect of renal impairment on pregnancy :

1. PET, IUGR, spontaneous and iatrogenic premature delivery.

- severe renal impairment + hypertension have < 50 % chance ofsuccessful pregnancy because of severe, early-onset of PET

with severe IUGR.

- premature delivery is justified in rapidly worsening renal

function to avoid dialysis even in the absence of PET.2. severe renal impairment polyhydramnios and risk of cord

prolapse due to fetal polyuria in response to high osmotic load

from increased maternal urea.

3. nephrotic syndrome and heavy protienuria severehypoalbuminria with associated risks of pulmonary oedema

and thrombosis.


14/19

management of renal impairment prepregnancy counseling and multidisciplinary care.

Documenting baseline values (prepregnancy & early pregnancy)

for creatinine, uric acid, albumin and protein.

Kontrol ketat hypertensi dg antihypertensive agents

Stop angiotensin-converting enzyme (ACE) inhibitors saat

hamil atau begitu didiagnosis hamil

stop diuretics kecuali ada severe hypoalbuminaemia dan

pulmonary oedema.

Dirawat bila: hypertensi memburuk, creatinine meningkat, dan

peningkatan proteinuria krn risiko tinggi PET pd TD meningkat

& proteinuria


15/19


16/19

Renal transplants

Pregnancy outcome in well functioning renal transplants issimilar to the general population.

Pregnancy should be delayed for 1-2 years to allow graftfunction to stabilize and immunosuppression to reach

maintenance levels. Risks in pregnancy: is related to pre-pregnancy renal function

and to the presence of hypertension.

Women are immunosuppressed and prone to infection.

Immunosuppressive drugs used in pregnancy: prednisolone,azathioprine, cyclosporine and tacrolimus.

Women using cyclosporine and tacrolimus are advised not tobreastfeed.


17/19

Dialysis

pregnancy on dialysis is unusual: end-stage renalfailure reduces fertility.

Patients on dialysis should be advised not to getpregnant.

Common risks: anaemia and haemorrhage.

Increased risks of:miscarriage, fetal death, pre-eclampsia, pre-termlabour, PROM, polyhydramnios and placentalabruption.

Pregnant women require increasing dialysis tomaintain the pre-dialysis urea < 15-20 mmol/l.

Poor obstetric outcome is similar with bothhaemodialysis and peritoneal dialysis.


18/19

Acute renal failure

It is rare in pregnancy.

Commonest causes: pre-eclampsia, haemorrhage, infections,drugs (NSAID) and obstruction due to ureteric damage orstones.

Most commonly complicates early post partum period.

Characterized by: oliguria, a rising urea and creatinine,metabolic acidosis and hyperkalaemia.

In obstetrics there may be an associated coagulopathy.

A rise in urea (without concomitant rise in creatinine) isobserved following antenatal corticosteroid administration.

haemolytic uraemic syndrome: rare cause, occurs postpartum,associated with renal failure + thrombocytopenia.characterized by microaniopathic haemolytic anaemia(diagnosed on blood film).


19/19