**1.5.4 Renal replacement therapy in pregnancy**

When renal replacement therapy is indicated for medically not amenable acute complications like hyperkalaemia, fluid overload, metabolic acidosis, and uremic encephalopathy either of the modalities (haemodialysis; HD or peritoneal dialysis; PD) can be used during pregnancy however there are no head to head trials comparing the benefit of one over the other. However, studies do suggest that PD may interfere with utero-placental blood flow (Bui et al, 2003).

### **1.6 Outcome of obstetric AKI**

78 Novel Insights on Chronic Kidney Disease, Acute Kidney Injury and Polycystic Kidney Disease

making safe abortions services available and accessible where abortion is not against

ensuring that permitted reasons for abortion are supported by the national legislative

granting access to services for the management of complications arising from unsafe

Providing post abortion counselling and offering contraceptive services, this will also

Similarly, preeclampsia occurs in 3-5% of pregnancies and is associated with increased maternal and foetal mortality especially in developing countries. If women with these problems are identified in antenatal period, safe delivery can be planned before hand (WHO, Dept. of Reproductive Health and Research, Dept. of Maternal, Newborn, Child and Adolescent Health, Dept. of Nutrition for Health and Development, 2011). Some reports have been published where the authors have questioned the importance of presence of skilled birth attendance at delivery and suggested that perhaps partnership between midwives and doctors and timely referral is more important to achieve this target (Cross et al, 2010) of reducing maternal mortality by 2/3 in these regions. Despite efforts from national, international and global health organizations MMR declined by only 5% from 1990-2005. To achieve this target of decline in MMR by 2/3 by 2015 will require tremendous work in this area. Any improvement in the maternal mortality rate will eventually lead to decrease consequences like AKI from various complications during pregnancy in

Timely recognition of the events and adequate replenishment of the fluid volume is essential to prevent more dreaded complication of acute tubular necrosis (ATN). Eventually when AKI ensues management depends on the underlying cause of renal dysfunction. To avoid/ correct hypovolaemia and ascertain fluid balance is important at every stage. Where bleeding is the cause of hypovolaemia, measures to stop bleeding should precede all other procedures, this may necessitate termination of pregnancy, preterm delivery of the foetus and blood transfusion. Efforts should be made not to incite further insult by avoiding or minimising the use of nephrotoxic agents including radio-contrast dyes and various drugs as much as possible. If they have to be used; adjustment of the dose will be required. Equal attention has to be paid to ensure adequate electrolyte balance. Of all potassium requires regular monitoring. Hyperkalaemia demands urgent medical management and if persistent

When infection coexists; use of appropriate antibiotics empirically is justified. Ensuring the safety of antibiotics during pregnancy is of utmost importance. Initial choice of antibiotics may vary according to the hospital protocol and prevalence of antibiotic resistance for the suspected organism. Antibiotic spectrum will often have to be broadened according to the

Safe abortion services are available and accessible.

**1.5.1 Fluid and electrolyte balance (Maynard et al, 2010)** 

may be an indication for renal replacement therapy.

**1.5.2 Appropriate management of sepsis** 

the law;

abortion; and

developing countries.

severity of infection.

**1.5 Management outline** 

process and health systems;

help to avoid repeat abortion.

In the meantime ill-effects of unsafe abortion should be prevented by:

Attempts have been made to derive factors to predict mortality associated with AKI. In general, AKI associated mortality seems to be variably increasing with increasing age, greater degree of illness severity at presentation, presence of chronic kidney disease, need for organ support in form of mechanical ventilation, hypotension or need for inotrope support and so on (Waikar et al, 2008). Degree of change in serum creatinine and need for dialysis as well are associated with increased mortality rates. These estimates however have not been analysed specifically in the setting of pregnancy related AKI.

Table 5 summarizes maternal mortality rates and renal outcome in pregnant women with AKI from different studies. In our experience prolonged duration of oliguria is associated with increased rate of dialysis dependency. Most of pregnant women with acute kidney injury come from rural areas and did not have antenatal check up (Khanal et al, 2010; Ahmad et al, 2001; Hassan et al, 2009). Antenatal check up not only helps in creating awareness among the pregnant mothers to seek help from midwives, it also brings high risk cases to notice and increases the likelihood of referral to experts on time. Sepsis including post abortal sepsis has been found to be associated with severe consequences and poor maternal outcome even in modern days in developing countries. This is probably from poor handling techniques and emphasizes the importance of need to increase the number of trained personnel like midwives to conduct delivery. Late referral to the tertiary care centres and delays in actually reaching the centre due to lack of infrastructure all contribute to the poor outcome. Significant and progressive improvement in mortality rates over decades is evident in table 6. This study analysed the data on pregnancy related AKI over 37 years. Although a progressive decline over each decade can be easily noticed, complications like HUS were associated with adverse maternal outcome. Thus close monitoring of high risk cases, timely recognition of complication, and institution of appropriate management intervention on time are of utmost importance (Stratta, 1996). A review on acute renal

Epidemiology, Causes and Outcome of Obstetric Acute Kidney Injury 81

significantly low in neonates born to pregnant mothers without AKI as compared to those

With the implementation of MDG 5 in developing countries, maternal mortality rates owing to all of these complications will hopefully improve along with improvement in foetal outcome.

Evident from the history, it is certain that maternal mortality rates from complications that can occur in pregnancy can be improved. Efforts have been put forward to increase the skilled birth attendants to assist delivery. However difficulties associated with overall health system and physical infrastructure, political instability and high illiteracy rates etc. creates hindrance to smooth development and therefore difficulty in achieving goals in developing countries.

Increased incidence of preterm deliveries associated with preeclampsia and its adverse long term renal/ cardiovascular outcome demand further research to understand the basis of the

Agida ET, Adeka BI, Jibril KA: Pregnancy outcome in eclamptics at the University of Abuja

Ahmad W, Ziaulllah, Rizwanul-Haque M, Shari T. Acute renal failure: causes and outcome.

Ahman E, Shah I: Unsafe abortion: worldwide estimates for 2000. *Reprod Health Matters* 2002;

Ali A, Zaffar S, Mehmood A, Nisar A. Obstetrical acute renal failure from Frontier Province:

Babinard J, Roberts P. Maternal and Child Mortality Development Goals: What Can the

Baylis C, Davison JM. Pregnancy and Renal Disease. In: Jurgen F, Johnson RJ, Feehally J.

Beaufils M. Pregnancy. In: Davison A, Cameron J, Grunfeld, Ponticelli C, Ritz E, Winearls C,

Bellomo R, Kellum J, Ronco C: Acute renal failure: time for consensus. *Intensive Care Med*

Bellomo R, May C, Wan L: Acute renal failure and sepsis. *N Engl J Med* 2004; 351: 2347-2349;

Transport Sector Do? *The International Bank for Reconstruction and Development/The* 

Ypersele C. Oxford text book of clinical nephrology. 3rd ed. Great Clarendon Street:

a 3 years prospective study. *J Postgrad Med Inst* 2004; 18:109-17.

*Comprehensive clinical nephrology*. 4th ed. New York: Elsevier; 2010

Teaching Hospital, Gwagwalada, Abuja: a 3 year review. *Niger J Clin Pract*; 13: 394-

who developed AKI during pregnancy (Gul et al, 2004).

**1.7 Future perspective of obstetric acute kidney injury** 

American college of obstetricians and gynaecologist guidelines

Royal college of obstetricians and gynaecologists guidelines

Oxford university press; 2005: 1604-12.

WHO Guidelines on reproductive and sexual health

Society of Obstetric Medicine of Australia and New Zealand guidelines

*Proceeding Shaikh Zayed Postgrad Med Inst* 2001; 15:23-8.

problem.

**1.8 Recommendations** 

**2. References** 

398.

10: 13-17.

*World Bank*; 2006

2001; 27: 1685-1688.

author reply 2347-2349.

failure in hypertensive pregnant women which was conducted over 12 years included 9600 women with hypertension. 31 of these women developed AKI, all were in the postpartum period. Of these there were 2 maternal deaths and 50% of the patients from the preeclamptic group required dialysis. All patients had acute tubular necrosis (ATN). In the chronic hypertensive group with super imposed pre-eclampsia, 42% required dialysis and 3 had cortical necrosis (Sibai et al, 1990).


Table 5. Renal outcome in Obstetric AKI.


Table 6. Total Number and Main Causes of PR\_ARF (obstetric AKI) Observed in 37 Years at Department of Nephrology and Clinical Obstetrics Torino, Italy (P Stratta,1996).

Both ante partum or post partum haemorrhage can lead to pre renal azotemia. Haemorrhage due to abruptio placentae has been found to be associated with increased risk of irreversibility of renal function in some series due to the development of cortical necrosis (Turney et al, 1989; Sibai et al, 1993). It is unclear why BRCN occurs more frequently during pregnancy, but this complication has been associated with septic abortions, preeclampsia, abruptio placentae, postpartum accidents, and haemorrhage. Bilateral renal cortical necrosis has been frequently mentioned to be associated with irreversibility of the renal function (Turney et al, 1989).

Foetal outcome is also poor. Intra-uterine death and still birth has been reported as high as 30-70% (Ali et al, 2004; Prakash et al, 2007; Khanal et al, 2010). High incidence of foetal loss was associated with increased incidence of dialysis dependency in mothers. This could be owing to the increased severity of illness (Khanal et al, 2010). Perinatal mortality is significantly low in neonates born to pregnant mothers without AKI as compared to those who developed AKI during pregnancy (Gul et al, 2004).

With the implementation of MDG 5 in developing countries, maternal mortality rates owing to all of these complications will hopefully improve along with improvement in foetal outcome.
