Pregnancy and the kidney, hypertensive disorders in pregnancy
1. Big picture
Pregnancy is a physiological stress test for the kidneys. A healthy kidney adapts by increasing renal plasma flow and glomerular filtration rate (GFR), lowering serum creatinine and tolerating mild physiological hydronephrosis. A diseased kidney may decompensate, and pregnancy-specific disorders such as preeclampsia, HELLP syndrome, thrombotic microangiopathy, acute fatty liver of pregnancy, pyelonephritis, and postpartum acute kidney injury may appear.
The examiner wants you to recognize four patterns:
| Clinical pattern | Think of |
|---|---|
| Hypertension before 20 weeks | Chronic hypertension or underlying renal disease |
| Hypertension after 20 weeks + proteinuria/organ injury | Preeclampsia |
| Hypertension + seizures | Eclampsia |
| Hemolysis + elevated liver enzymes + low platelets | HELLP syndrome |
Core oral-exam sentence:
“In pregnancy, serum creatinine should be lower than in non-pregnant women, so even a ‘normal’ creatinine may indicate kidney injury. New hypertension after 20 weeks with proteinuria or maternal organ dysfunction is preeclampsia until proven otherwise, and severe hypertension or eclampsia is an emergency.”
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