**2.2.4 Cortical necrosis**

It is one of the dreaded histopathological lesions . 50% of all cortical necrosis is pregnancy related. Causes include Abruptio (esp if concealed hemorrhage), septic abortion, placenta previa, prolonged IUD, or amniotic fluid embolism. It is commoner in post partum than antepartum AKI. Renal cortical necrosis may be patchy or total. The triad of anuria, gross hematuria, and flank pain seen in cortical necrosis is unusual in the other causes of renal failure in pregnancy. The diagnosis can be established by ultrasonography which shows a subcapsular hypoechoic band . Renal calcifications on plain film of the abdomen suggest

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cortical necrosis (6 weeks). CT scanning demonstrates hypoechoic or hypodense areas in renal cortex or may demonstrate cortical tram track calcification by 3 weeks. Angiogram shows abrupt cut off of vascularity which is called pruning. No specific therapy is effective. Many patients develop chronic kidney disease. In our study from Osmania General Hospital, Hyderabad, India over 7 years there were total of 105 patients with Renal cortical necrosis (RCN). The mean age was 28.125 ± 12.40 years. Forty one cases (39.04%) resulted from obstetric complications. The most common histology type of RCN was patchy cortical necrosis in 65 patients (62%). All patients required dialysis and the mean duration of dialysis was 3 ± 1weeks. Thirty three (31.42%) patients progressed to end stage kidney disease while 3 underwent renal transplantation. 10(9.5%) patients succumbed to the acute kidney injury (AKI).(Manisha Sahay)

#### **2.2.5 Vascular changes**

May be seen in HUS with glomerular and arteriolar fibrinoid necrosis and thrombi. Glomeruli show mesangiolysis and glomerular simplification.

#### **2.3 Dialysis in pregnancy**

Early dialysis is necessary in pregnant women with renal failure and should be considered when the serum creatinine reaches 3.5 mg/dL or the glomerular filtration rate (GFR) is less than 20 mL/min or blood urea nitrogen is more than 100mg/dl. Longer, more frequent dialysis (20 h/wk) is associated with the best fetal outcome. Hemodialysis may therefore be necessary at least 5 days per week. Careful avoidance of hypotension is important. As pregnancy is a procoagulant state the dose of heparin needs to be increased. Peritoneal dialysis with smaller volumes and frequent exchanges is another option. Peritoneal dialysis may be difficult in the third trimester due to increased uterine size. Premature labor and fetal size that is small for the gestational age are typical in women who deliver on dialysis. Nutritional support that allows weight gains of 0.3 to 0.5 kg/wk should be maintained in the second and third trimesters. Although the spontaneous abortion rate is approximately 50% for pregnant women who require dialysis, the fetal survival rate for pregnancies that continue is as high as 71%.
