FIGURE 53-4 Blood volume expansion in 44 normally pregnant women at term compared with 29 who had eclampsia; 10 with moderate chronic renal insufficiency (CRI)-serum creatinine 1.5 to 2.9 mg/dL; and four with severe CRI-serum creatinine �3.0 mg/dL . (Data from Cunningham, 1990; Zeeman, 2009.) greater augmentation of renal plasma low and GFR (Baylis, 2003; Helal, 2012). With progressively declining renal function, there is little, if any, augmented renal plasma low. In one study, only half of women with moderate renal insuiciency demonstrated a pregnancy-augmented GFR, and women with severe disease had no increase (Cunningham, 1990).
Importanty, severe chronic renal insuiciency curtails normal pregnancy-induced hypervolemia. Blood volume expansion during pregnancy is related to disease severity and correlates inversely with serum creatinine concentration. As shown in Figure 53-4, women with mild to moderate renal dysfunction have normal blood volume expansion that averages 55 percent. With severe renal insuiciency, however, volume expansion averages only 25 percent, which is similar to that seen with hemoconcentration from eclampsia. In addition, these women have variable degrees of chronic anemia due to intrinsic renal disease.
Renal Disease with Preserved Function
In some women, although glomerular disease has not yet caused renal dysfunction, incidences of pregnancy complications are still increased. As shown in Table 53-4, these problems are less frequent than in cohorts of women with moderate and severe renal insuiciency. Two earlier studies illustrate this. In one describing 123 pregnancies in women with biopsy-proven glomerular disease, only a few of the women had renal dysfunction, yet 40 percent developed obstetrical or renal complications (Surian, 1984). In another study of 395 pregnancies in women with preexisting glomerulonephritis and minimal renal insuiciency, impaired renal function developed in 15 percent during pregnancy, and 60 percent had worsening proteinuria (Packham, 1989). Only 12 percent had antecedent chronic hypertension, however, more than half of the 395 pregnancies were complicated by hypertension. he perinatal mortality rate was 140 per 1000, but even without early-onset or severe hypertension or nephrotic-range proteinuria, the perinatal
TABLE 53-4. Complications (Percent) Associated with 5000 Chronic Renal Disease During Pregnancy 4500 90th .�2500 apreeclampsia only.
NS = not stated.
Data from Alsuwaida, 2011; Cunningham, 1990; Farwell, 2013; Feng, 2015; Imbasciati, 2007; Maruotti, 2012; Nevis, 2011; Packham, 1989; Piccoli, 201 Oa, 2011; Stettler, 1992; Surian, 1984; Trevisan, 2004.
death rate was 50 per 1000. Importantly, in 5 percent of these women, worsening renal function was permanent.