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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
7/28/2019 Dr Edi Hidayat, FK. UNSRI, Gangguan Ginjal Pada Wanita Hamil
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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.
7/28/2019 Dr Edi Hidayat, FK. UNSRI, Gangguan Ginjal Pada Wanita Hamil
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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.
7/28/2019 Dr Edi Hidayat, FK. UNSRI, Gangguan Ginjal Pada Wanita Hamil
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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.
7/28/2019 Dr Edi Hidayat, FK. UNSRI, Gangguan Ginjal Pada Wanita Hamil
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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.
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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.
7/28/2019 Dr Edi Hidayat, FK. UNSRI, Gangguan Ginjal Pada Wanita Hamil
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Diagnosis
Proteinuria Urine dipstick.
MidStreamUrine Bacteriuria: >100.000
organisms/ml urine
MidStreamUrine kultur dan tes sensitivitas.
Darah leukositosis
7/28/2019 Dr Edi Hidayat, FK. UNSRI, Gangguan Ginjal Pada Wanita Hamil
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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 ).
7/28/2019 Dr Edi Hidayat, FK. UNSRI, Gangguan Ginjal Pada Wanita Hamil
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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.
7/28/2019 Dr Edi Hidayat, FK. UNSRI, Gangguan Ginjal Pada Wanita Hamil
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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
7/28/2019 Dr Edi Hidayat, FK. UNSRI, Gangguan Ginjal Pada Wanita Hamil
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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
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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.
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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.
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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
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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.
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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.
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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).
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