Physiologic Changes in Females Urinary Tract

during Pregnancy
The rate of urine formation by a pregnant woman is usually slightly increased
because of increased fluid intake and increased load or excretory products. But in
addition, several special alterations of urinary function occur.
First, the renal tubules reabsorptive capacity for sodium, chloride, and water is
increased as much as 50% as a consequence of increased production of steroid
hormones by the placenta and adrenal cortex.
Second, the glomerular filtration rate increases as much as 50 per cent during
pregnancy, which tends to increase the rate of water and electrolyte excretion in
the urine.

Anatomy : Kidney
A remarkable number of changes are observed in the urinary system as a result of
pregnancy (Table).

Kidney size increases slightly during pregnancy, the kidney was 1.5 cm longer during
the early puerperium than when measured 6 months later using radiographs.

The glomerular filtration rate and renal plasma flow increase early in pregnancy, as
much as 50 percent by the beginning of the second trimester, and the latter even
greater. Both relaxin and neuronal nitric oxide synthase may be important for
mediating the increased GFR and plasma flow during pregnancy. Elevated GFR
persists until term, even though renal plasma flow decreases during late pregnancy.

Renal Changes in Normal Pregnancy

Alteration

Clinical Relevance

Increased renal
size

Renal length approximately 1

cm greater on radiographs

Postpartum decreases in size should not be mistaken

for parenchymal loss

Dilatation of
pelves, calyces,
and ureters

Resembles hydronephrosis on Not to be mistaken for obstructive uropathy;

ultrasound or IVP (more
retained urine leads to collection errors; upper
marked on right)
urinary tract infections are more virulent; may be
responsible for "distention syndrome" elective
pyelography should be deferred to at least 12 weeks
postpartum

Increased renal
hemodynamics

GFR and renal plasma flow

increase ~50%

Serum creatinine and urea nitrogen values decrease

during normal gestation; > 0.8 mg/dL (> 72 umol/L)
creatinine already suspect; protein, amino acid, and
glucose excretion all increase

Changes in
acidbase
metabolism

Renal bicarbonate threshold

decreases; progesterone
stimulates respiratory center

Serum bicarbonate and Pco2 are 45 mEq/L and 10

mm Hg lower, respectively, in normal gestation; a
Pco2 of 40 mm Hg already represents CO2 retention

Alteration

Clinical Relevance

Renal water
handling

Osmoregulation altered:
Serum osmolality decreases 10 mOsm/L (serum Na 5
osmotic thresholds for AVP
mEq/L) during normal gestation; increased
release and thirst decrease;
metabolism of AVP may cause transient diabetes
hormonal disposal rates
insipidus in pregnancy
increase
*AVP =vasopressin; IVP = intravenous pyelography.

Kallikrein, a tissue protease synthesized in cells of the distal renal tubule, is found
increased excretion at 18 and 34 weeks, which returned to nonpregnant levels at
term.

As with blood pressure, maternal posture may have influence renal function. Late in
pregnancy, urinary flow and sodium excretion less than half the excretion rate in the
supine position compared with that in the lateral recumbent position.

Anatomy : Ureters
After the uterus rises completely out of the pelvis, it rests upon the ureters, laterally
displacing and compressing them at the pelvic brim.
Hydroureter and hydronephrosis is from an effect of progesterone. The relatively abrupt
onset of dilatation in women at midpregnancy, however, is more consistent with ureteral
compression from an enlarging uterus rather than a hormonal effect.
Elongation accompanies distention of the ureter, which is frequently thrown into curves of
varying size, the smaller of which may be sharply angulated.

Anatomy : Bladder
Only few significant anatomical changes in the bladder before 12 weeks.
From that time after that, the increased size of the uterus, together with the hyperemia that
affects all pelvic organs, and the hyperplasia of the muscle and connective tissues, elevates
the bladder trigone and causes thickening of its posterior, or intraureteric, margin.
Continuation of this process produces marked deepening and widening of the trigone. The
bladder mucosa undergoes no change other than an increase in the size and tortuosity of its
blood vessels.
Toward the end of pregnancy, particularly in nulliparas in whom the presenting part often
engages before labor, the entire base of the bladder is pushed forward and upward,
converting the normal convex surface into a concavity. As a result, difficulties in diagnostic
and therapeutic procedures are greatly increased. In addition, the pressure of the presenting

part impairs the drainage of blood and lymph from the base of the bladder, often rendering
the area edematous, easily traumatized, and probably more susceptible to infection.

Physiology : Loss of Nutrients

One unusual feature of the pregnancy-induced changes in renal excretion is the remarkably
increased amounts of various nutrients in the urine. Amino acids and water-soluble vitamins
are lost in the urine of pregnant women in much greater amounts than in nonpregnant
women.

Physiology : Tests of Renal Function

The physiological changes in renal hemodynamics have several implications for the
interpretation of tests of renal function.

Serum creatinine decrease from a mean of 0.7 mg/dL to 0.5 mg/dL, whereas values
of 0.9 suggest underlying renal disease and should prompt further evaluation.
Creatinine clearance in pregnancy should be 30% higher than the 100 to 115 mL/min
normally measured in nonpregnant women. Creatinine clearance is a useful test to
estimate renal function in pregnancy.

Serum urea nitrogen levels decrease from a mean 1.2 mg/dL to 0.9 mg/dL, whereas
values of 1.4 mg/dL suggest underlying renal disease and should prompt further
evaluation.

During the day, pregnant women tend to accumulate water in the form of dependent
edema, and at night, while recumbent, they mobilize this fluid and excrete it via the
kidneys. This reversal of the usual nonpregnant diurnal pattern of urinary flow causes
nocturia, and the urine is more dilute than in the nonpregnant state.

Physiology : Urinalysis

Glucosuria during pregnancy is not necessarily abnormal. The appreciable increase in

glomerular filtration, together with impaired tubular reabsorptive capacity for filtered
glucose, accounts in most cases for glucosuria.

Proteinuria normally is not evident during pregnancy except occasionally in slight

amounts during or soon after vigorous labor.

Hematuria most often suggests a diagnosis of urinary tract disease. Difficult labor
and delivery can cause hematuria because of trauma to the lower urinary tract.

Urinary Tract Infection caused by Pregnancy

Urinary tract infections are more concerning in pregnancy due to the increased risk of
kidney infections. During pregnancy, high progesterone levels decreased the muscle tone
activity of the ureters and bladder, which leads to a greater likelihood of reflux, where urine
flows back up the ureters and towards the kidneys.
Also, if bacteriuria is present in preganant women, they do have a 25-40% risk of a kidney
infection. Thus if urine testing shows signs of an infectioneven in the absence of symptoms
treatment is recommended. Cephalexin or nitrofurantoin are typically used because they
are generally considered safe in pregnancy. A kidney infection during pregnancy may result
in premature birth or pre-eclampsia .