Chronic glomerulonephritis in pregnancy

Chronic glomerulonephritis in pregnancy (CGN) is a chronic bilateral, diffuse lesion of mainly the glomerular apparatus of the kidneys of an immune-inflammatory nature with a pronounced propensity to progress and develop chronic renal failure.

[1], [2], [3], [4], [5], [6], [7], [8], [9], [10],

Causes of chronic glomerulonephritis in pregnant women

In the general population of Ukraine, according to statistical research, the frequency of chronic glomerulonephritis is 97.0 per 100 thousand of the population. The indicator of the frequency of chronic glomerulonephritis in pregnant women is 0.1-0.2%.

In 20-30% of patients with chronic glomerulonephritis is a consequence of acute glomerulonephritis, which can be caused by streptococci (especially hemolytic group A streptococcus, strains 1, 3, 4, 12, 18), staphylococci, pneumococci, adenovirus, rhinovirus infections, mycoplasmas, hepatitis B virus. Regarding the overwhelming majority of cases of chronic glomerulonephritis of unexplained etiology, it can refer to the persistence of the aforementioned infectious factors, schmogamilovirus infection, syphilis, malaria, RDA or pharmacological effect of drugs, vaccines, sera, organic solvents, alcohol, and so on. N.

The pathogenesis of chronic glomerulonephritis in pregnancy consists in the formation of an immunocomplex process, the constituent parts of which are the corresponding antigens, antibodies and complement factor C3. The quantitative and qualitative characteristics of immune complexes that form in the circulatory bed and are fixed in the glomeruli of the kidney subendothelial, subepithelial, ingramembranous, in mesangium, and can form directly in the glomerular structures depend on the degree of phagocytic reactivity of the organism, the quality of the antigen, the quantitative ratio between antigens and antibodies. The postponement of immune complexes initiates a cascade of biochemical cell reactions that are reduced to the formation of cytokines, migration of polymorphonuclear leukocytes, monocytes, eosinophils, activation of intracellular proteolytic enzymes. All these processes lead to damage to the structures of the glomerulus.

Recently, in the progression of chronic glomerulonephritis in pregnancy, great importance is attached to the violation of local hemodynamics, lipid metabolism, platelet activation, hemocoagulation system.

[11], [12], [13], [14], [15], [16]

Symptoms of chronic glomerulonephritis in pregnancy

During pregnancy, acute glomerulonephritis is often not diagnosed and is regarded as severe preeclampsia. The appearance of pre-eclampsia until 28 weeks of gestation, the appearance of hematuria, the detection of elevated titres of antistreptolysin and anti-hyaluronidase, can lead to suspected acute glomerulonephritis. The clinical symptoms of chronic glomerulonephritis during pregnancy depend on the variant, stage and phase of the disease. Most often observed clinical forms of chronic glomerulonephritis, which are characterized by a slight proteinuria, erythrocyte without arterial hypertension. This is a chronic glomerulonephritis with a urinary syndrome and a prehypertensive stage (latent form). The adherence of arterial hypertension indicates sclerosing processes in the kidneys (hypertensive stage of glomerulonephritis). A special form of the disease, which indicates the activity of the process, is glomerulonephritis with a nephrotic syndrome - the presence of edema, proteinuria over 3 g / day, hypodisproteinemia, hyperlipidemia, hypercoagulability of blood. The next stage of the disease is chronic renal failure, which is manifested by an increase in blood levels of urea and creatinine, anemia, a decrease in the concentration ability of the kidneys, arterial hypertension, dystrophic changes in other organs. It is believed that pregnancy does not occur with an increase in creatinine in the blood plasma above 0.3 mmol / l.

The course of pregnancy in women with chronic glomerulonephritis is complicated by the development of severe preeclampsia, anemia, intrauterine retardation of the developed fetus, premature birth. There is a risk of premature detachment of the normally located placenta, hypotonic bleeding.

There are three degrees of risk, which determine the frequency of the unsuccessful outcome of pregnancy and childbirth for the mother and fetus and guide the physician regarding the prognosis or therapeutic tactics:

• To I (minimal) degree of risk it is necessary to bear chronic glomerulonephritis with urinary syndrome and prehypertensive stage. The period of pregnancy in these patients is accompanied by an increase in proteinuria in the third trimester, the emergence of hypertension, the swelling of the lower extremities, which are most often reversible and disappear after delivery. In addition, 20% of women have persistent clinical and laboratory remission after the termination of pregnancy, as a result of hormonal influence (increase in pregnancy products of glucocorticoids);
• To II (expressed) degree of risk carry a chronic glomerulonephritis with a nephrotic syndrome and a prehypertensive stage. In patients with nephrotic form of chronic glomerulonephritis during pregnancy, there is usually a further increase in protein loss in the urine, development of hypertension, impaired renal function. In case of nephrotic form of the disease and at the persistent desire of the woman, pregnancy can be preserved with the possibility of prolonged treatment in the nephrologic and specialized obstetric hospitals;
• The III (maximum) degree of risk includes a combination of the hypertensive stage of the disease with chronic renal failure, acute glomerulonephritis. Bearing in pregnancy is contraindicated.

Classification

The clinical classification of chronic glomerulonephritis adopted in Ukraine includes variants (urinary syndrome, nephrotic syndrome), stages (pre-hypertensive, hypertensive, chronic renal failure), additional characteristics (hematuric component) and phasic (exacerbation, remission).

[17], [18], [19], [20]

Management of pregnancy in chronic glomerulonephritis

The decision regarding the possibility of bearing pregnancy should be taken together with the nephrologist in the first trimester, since the interruption of pregnancy at a later date may lead to an exacerbation of chronic glomerulonephritis due to a violation of the rheological properties of blood and a decrease in the production of glucocorticoids.

In the planned order the patient is hospitalized in a specialized obstetric hospital at least twice during pregnancy:

• up to 12 weeks. For the decision of a question on possibility of bearing of pregnancy, development of the individual plan of management of pregnancy, forecasting of possible complications;
• in 37-38 weeks. For comprehensive examination and treatment, dynamic monitoring of the fetus, prenatal preparation, timing and optimal method of delivery.

Indications for immediate hospitalization are:

• progression of proteinuria, hematuria;
• occurrence or progression of arterial hypertension;
• the occurrence or progression of renal failure;
• appearance of signs of intrauterine growth retardation.

Treatment of chronic glomerulonephritis during pregnancy

Pathogenetic treatment of chronic glomerulonephritis during pregnancy is limited due to embryotoxic and teratogenic effects of cytostatics.

Treatment includes appropriate regimen, diet, sanation of foci of infection and symptomatic therapy.

The patients' mode excludes physical activity, work in harmful enterprises, associated with long standing, walking, overheating, hypothermia. Mode of work - sedentary, it is desirable to have a day's rest in bed

The diet is limited to the restriction of sodium chloride in the diet, control of the drinking regime, exclusion of extractives, spices, seasonings. It is not recommended to abuse fats of animal origin. Appointed foods that are rich in potassium, especially against the background of saluretic treatment.

If the kidney function is not impaired, we recommend reinforced protein nutrition (120-160 g protein per day). At a nephrotic syndrome the use of sodium chloride up to 5 g / day and a liquid up to 1000 l is limited, at a hypertensive stage - only salts.

Phytotherapy consists in the appointment of decoctions of birch leaves, cornflowers, oats, parsley seeds, kidney tea, etc.

If necessary (renal failure), diuretic drugs (hypothiazide, furosemide, ureitis) can be used with an additional prescription of potassium preparations against the background of a potassium-rich diet.

Used drugs hypotensive effect - methyldopa 0.25-0.5 g 3-4 times a day; clonidine 0,075-0,15 mg 4 times a day; nifedipine 10-20 mg 3-4 times a day; metoprolol 12.5 - 100 mg twice a day.

Antiplatelet agents are also prescribed. The dose of these drugs should be selected taking into account the level of daily proteinuria, the parameters of the blood coagulation system, individual tolerance: dipyridamole, starting from 75 mt / day with a gradual increase in the dose (proteinuria more than 3.0 g) to the maximum tolerated (225-250 mg / day) .

In case of severe anemia (hemoglobin <70 g / l) and insufficient effectiveness of gemostimulating therapy, it is necessary to transfuse washed erythrocytes or, in their absence, erythrocyte mass. To correct the hemostasis, fresh frozen plasma is used.