Acute Renal Problems Still a Great Challenge in Obstetrics

Objective: To assess the early risk factors and outcomes of the patients presented with acute renal issues, at tertiary care Hospital. Methodology: This descriptive study was conducted at gynaecology and obstetrics department of Liaquat University of medical and health Sciences. Study duration was six months from June 2019 to November 2019. Women having age more than 18 years, developed renal impairment as serum creatinine level more than 1.2 mg/dl were included. All data was collected via self­made proforma. SPSS version 20 was used for the data analysis. Results: Total 58 women having renal problems during pregnancy were studied, their mean age was 28.40+4.68 years and mean gestational age was 28.40+4.68 years. Most of the women 70.2% were un­booked. Parity 1­3 was commonest. Anaemic women were on high risk of renal impairment as most of the patients had moderate anemia. Hypertension was in 35.1% patients, placental abruption was in 10.5% cases, tow patients had diabetes, 12.3% presented with pregnancy induced hypertension and postpartum haemorrhage was in 05.3% cases. There was a significant negative correlation between haemoglobin level and serum creatinine level, (r­value 0.029). Original Research Article Abbasi et al.; JPRI, 32(29): 42-47, 2020; Article no.JPRI.62262 43 Conclusion: Anemia was the commonest reason for renal impairment during pregnancy. Most of the women were un­booked, having high parity and were presented with anemia. This morbidity can be decreased and prevented by stabilizing the haemoglobin level by taking proper antenatal care.


INTRODUCTION
Acute kidney injury (AKI) itself is a known clinical condition defined by a rapid reduction in the rate of glomerular filtration resulting in decline in the excretion of the nitrogenous wastes such as creatinine, urea and further uremic pollutants. In early pregnancy, obstetric AKI commonly results from septic abortions as well as by postpartum hemorrhage, antepartum hemorrhage, pregnancy toxemia and late pregnancy HELLP syndrome [1,2]. It is a complex multietiology involving condition that can take place during pregnancy and at postpartum periods at any time. It is a serious obstetric complication associated with severe foetomaternal mortality and morbidity [3]. The incidence has declined due to improvements in reproductive health but it is still correlated with significant perinatal mortality and maternal morbidity [4]. It may be due to ischemic tubular necrosis or decline in renal perfusion from various conditions encountered during pregnancy [4]. Major PRAKI factors involving hypertensive conditions during pregnancy, sepsis, obstetric hemorrhage, acute fatty liver and thrombotic microangiopathy during pregnancy, [5] and freshly reported 10.55% incidence of postpartum AKI (PPAKI) along with sepsis and haemorrhage being the most common etiologies [4,6]. Acute renal failure poses a high risk for bilateral cortical necrosis of kidney in pregnancy and thus of chronic kidney dysfunction [7]. Cortical necrosis of kidney is a rare phenomenon and is responsible for just 2% of all ARF events [7]. In normal pregnancy, substantial variations occur within urinary tract: because of interstitial and renal vascular space size expansions, the kidneys volume raised by around 11.5 cm [8]. More than 90% of pregnant females undergo physiological hydronephrosis marked by dilation of ureter, calyces, and renal pelvis [8,9]. Upto the 16th week postpartum, this anatomical irregularity could be functional and induces urinary stasis within ureter, contributing to urinary tract infection development [8]. Pregnancy associated acute kidney injuries are still common in developed countries; and its incidence there varies considerably from one country to the other and within the same country, from one region to the other [10]. Many national and international studies showed different responsible factors and incidence of acute renal problems as in a local recent study observed that postpartum haemorrhage (PPH) in addition to Sepsis is the leading factors for Pregnancy associated acute kidney problems [11]. Another study observed puerperal sepsis was the most common etiological cause of pregnancyrelated acute kidney injury [12]. This study has been conducted to evaluate the risk factors of acute renal problems and outcome at tertiary care Hospital.

MATERIALS AND METHODS
This descriptive study was performed in the department of gynaecology and obstetrics of Liaquat University of medical and health Sciences. Study duration was six months from year from June 2019 to November 2019. All the women having age more than 18, developed renal impairment as serum creatinine level more than 1.2 mg/dl were included. Patients those were already known regarding renal problems before the pregnancy, history of diabetes mellitus and hypertension were excluded. Complete clinical examination including blood pressure and required laboratory investigation were done. Patients were interviewed regarding age, parity, booking status, socioeconomic status and residential status. After taking informed consent a 5 ml blood sample was taken from each patient to assess the haemoglobin level, serum creatinine level, blood urea and uric acid level. Anemia was defined as normal = haemoglobin level >11 g/dl, mild= haemoglobin level 910.9 g/dl, moderate haemoglobin level 78.9 g/dl and severe haemoglobin level <7 g. All data was collected via selfmade proforma. SPSS version 20 was used for the data analysis.

RESULTS
Total 58 women having renal problems during pregnancy were studied, their mean age was 28.40+4.68 years and mean gestational age was 28.40+4.68 years. Most of the women 70.2% were unbooked and 29.8% were booked. Edema was seen in 21.1% of the patients. Most of the women had parity 13 followed by 15.8% were nulliparous, 24.6% had parity 46 and only 03.5% had parity more than 6. Majority of the patients had poor and middle socioeconomic status as 29.8% and 59.6% respectively Table 1.
According to the risk factors anaemic women were on high risk of renal impairment as most of the patients had moderate anemia. Hypertension was seen in 35.1% patients, abruption was in 10.5% cases, tow patients had diabetes, 12.3% presented with pregnancy induced hypertension and postpartum haemorrhage was in 05.3% cases Table 2.

DISCUSSION
Renal insufficiency in pregnancy is mostly due to prerenal and ischemic causes, but can be due to specific pregnancy disorders. In this study, mean age was 28.40+4.68 years and mean gestational age was 28.40+4.68 years and 24.6% had parity 46. Most of the women 70.2% were unbooked. In comparison to our results, Arrayhani et al. [13] reported an age range of 1840 years and an average age of 29±6 years. The patients participating in the study had a median parity of 05. Similarly, Bokhari SR et al. [14] reported mean age for remaining 41 subjects as 26±6 years, wherein Multigravida patients were 22 (54%), and primigravida were 19 (46%). The patients who did not obtain antenatal care of any form were 20 (48%), traditional birth attendants had visited 13 (31%) subjects, and gynecologist provided sufficient antenatal care was received by just 8 (19%) subjects.   In the present study, majority of the patients had poor and middle socioeconomic status as 29.8% and 59.6% respectively. As well as Chaudhri N et al. [15] reported that most patients were from low socioeconomic setting. According to the risk factors anaemic women were on high risk of renal impairment as most of the patients had moderate anemia. Hypertension was seen in 35.1% patients, abruption was in 10.5% cases, two patients had diabetes, 12.3% presented with pregnancy induced hypertension and postpartum haemorrhage was in 05.3% cases. Similar to our results, Aggarwal RS et al. [16] reported that hemorrhage in 15(30%) subjects was an etiological factor for ARF, in 10(20%) cases APH and in 5(10%) cases PPH had been etiological factor for ARF. 11(22%) cases had undergone lower segment Csection (LSCS), whereas 36(78%) cases had undergone normal vaginal delivery. In 20 patients (40%), puerperal sepsis appeared as an etiological factor, whereas pre eclampsia, HELLP syndrome and eclampsia represented 18(36%) cases. 2(4%) patients on presentation had disseminated intravascular coagulation, however hemolytic uremic syndrome was diagnosed in only 1(2%) case. In another study of Goplani et al. [17] also mentioned that the hemorrhage as the etiology for ARF was present in 38.56% of the patients, APH in 14.28% and PPH in 24.28% of patients. Preeclampsia, eclampsia and HELLP syndrome accounted for 28.57% of patients with pregnancyrelated ARF. Ansari MR et al. [18] reported that the excessive obstetric bleeding has been a major factor for PRAKI. In Pakistan 28% and in India 5% cases of PRAKI have been observed [13].
Our results were relevant to the study of Ali et al. [19] that showed obstetric hemorrhage leading to AKI among 58% of cases. Study conducted by Sivakumar et al. [20] reported that the PE as a cause of renal impairment to 75.2% of cases in Turkey. Hassan et al. [21] from Pakistan reported a substantially higher incidence of PRAKI (30%) in their series. The most frequent factor of renal cortical necrosis of kidney is obstetrical complications. Most patients in present study were found with >1 etiological factors, with the most frequent factor being sepsis. Preeclampsia was exacerbated by DIC bleeding and abruption of the placenta resulting in hemodynamic disruption (APH, ATN), IUD and occasionally RPOC induced sepsis. Only in a few cases, Preeclampsia by itself was accountable.

CONCLUSION
Results of the current study revealed that the anemia was the commonest reason for renal impairment during pregnancy. Most of the women were unbooked, having high parity and were presented with anemia. By taking above scenario, this morbidity can be decreased and prevented by stabilizing the haemoglobin level by taking proper antenatal care. This was a single center and small sample size study. However multicenter and large sample size studies should be done on this subject.

CONSENT AND ETHICAL APPROVAL
As per international standard or university standard written ethical approval has been collected and preserved by the author(s). All of the partaking patients enrolled following informed consent.