STUDY OF OBSTETRICAL ACUTE RENAL FAILURE IN A TERTIARY CARE CENTRE Dr.Uma Gupta Dr.D.Saha Dr.Neelam Kumari Dr.Nikhat ERA’S LUCKNOW MEDICAL COLLEGE, LUCKNOW VPIMS LUCKNOW

INTRODUCTION Obstetrical acute renal failure(ARF) - 3rd world countries Overall survival rate –in ARF still does NOT exceed > 50%. Ignorance, poverty, delayed referral, grand multi-parity and lack of medical infrastructure are major factors to - higher mortality and morbidity.

Obst. ARF Definition ARF is a clinical syndrome characterised by: an abrupt decrease in the glomerular filtration rate leading to - rising plasma urea and creatinine levels. urine output of < 400 ml in 24 hours.

Objective The study was undertaken to evaluate how common is acute obstetrical renal failure in our practice. To evaluate the etiology, laboratory parameters, complications and causes of death, management strategies and prognosis of the patients with obstetrical acute renal failure Also study survival of the patients with renal replacement therapy.

Material and Methods: This is a review of case records of 3 years at a tertiary care hospital in Lucknow, UP, of patients suffering from ARF of obstetrical origin at Department of Nephrology and Department of Obstetrics and Gynecology, from 2006 to 2008.

Exclusion Criteria 1. Known renal disease 2. History of hypertension, diabetes before gestation. 3. History of NSAID abuse or analgesic nephropathy. 4. Previous urological surgery. 5. History of renal stone. 6. History of reflux nephropathy. 7. Any elevated urea, creatinine shown prior to gestation

Obst. ARF Problems specifically related to pregnancy as cause of ARF were taken as etiology. Each patient - examined including a detailed history, physical examination, urinary output, BP etc. Specific inquiry were made as to mode of delivery

Obst. ARF Need for blood transfusion, operating intervention Method of renal replacement therapy and frequency of dialysis were studied. All patients on admission - baseline CBC, urea and creatinine, electrolytes, LFT, hepatitis screening and coagulation profile ultrasound abdomen. .

Vascular access -subclavian or femoral route. Obst. ARF For Hemodialysis, Vascular access -subclavian or femoral route. Patients too ill - for hemodialysis on account of poor homodynamic status, coagulopathies- on ventilators were offered PD.(peritoneal dialysis)

Obst. ARF End Points Patient discharged live from the hospital with good urinary output and being dialysis independent. Good urinary output (urinary volume between 800-1.2 litre with no evidence of fluid overload

DISTRIBUTION MEAN Age Mean age 30.1 ± 1.0818 Youngest – 15 yrs Oldest – 46 yrs

Age and parity correlation Para 3-4 were ↑ Age gr 26 and above ↑

Etiology APH – 7.5% PPH - 15% POST OP- 15% PUERSepsis- 20% POSTMTP 37.5% SEP.AB 5%

Relation of age and etiology 2 4 6 8 10 12 14 16 <20 21-25 26-30 31-35 >35 APH PPH POC PUERs Pmtp Sepabr

Haemoglobin status Very severeAnemia- 35% Severe anemia - 52% Mild anemia- 13%

Distribution of pt. urine output wise anuria nonoliguric oliguria TOTAL No of pt. % 13 32.5 8 20.0 19 47.5 40 100.0

Severity of Renal Failure Data Range Mean Day of referral (days) 4-10 5.3 days Peak pre-dialysis urea 64-657 197.35±103.26 (mg %) Peak pre-dialysis S.creatinine 1.6 -23.8 7.76±4.90 (mg %) Peak serum potassium 1.5 - 6.5 4.5±1.53 (mEq/l)

Correlation of S. Creatinine levels with etiology 90% pts had Cr. level of 2.5mg%. Only 10% in range Of 1.5-2.5mg% P.SEPSIS PPH SP.AB

Correlation Urine output and S.Creatinine

28% underwent HD 3-5 times 31% underwent HD 6-8 times

Correlation of S.Cr and Anuria and Survival YES TOTAL >2.5 Row % 5 38.5 8 61.5 13 100.0

Correlation of S.Cr and Nonoliguria and Survival YES TOTAL >2.5 Row % 3 37.5 5 62.5 8 100.0

Correlation of S.Cr and Oliguria and Survival YES TOTAL >1.5 - 2.5 Col % 0 0.0 4 44.4 4 21.1 >2.5 Col % 10 100.0 5 55.6 15 78.9 TOTAL Row % Col % 10 52.7 100.0 9 47.4 100.0 19 100.0 100.0

OBST-ARF Mean stay 22.87±14.43 (Min.- 6.4 days. Max. 65 days) Mean Expenditure: Rs. 38,811±19.55 ( Min. Rs.6430/- Max 73,5000/-)

Most patients - Home delivery assistance (TBA). Obst. ARF Most patients - Home delivery assistance (TBA). Majority - grand-multiparous with low Hbs. The TBAs - no or little training – management of these cases and certainly there are no facilities to manage blood loss, get IV access etc. Not surprisingly 50% of patients referred from periphery required blood transfusions(1-8 units)..

Most of patients recovered with hemodialysis Most of patients recovered with hemodialysis. Only 35% required hemodialysis for 4 weeks. Septicemia was main cause of deaths in 2/3 our patients.

Conclusions Oliguria is not present in all cases of acute renal failure. For this reason the serum urea and creatinine levels should be determined in all high-risk cases Anuric patients with high BUN and S.Cretinine levels with septicaemia often had poor outcome Obstetrical acute renal failure needs vigilance and immediate management to get best results and reduce cost and hospital stay.

. Population control does need more emphasis as multiparity lead to more complications. Adequate liaison among the Gynaecology / Obstetrics and Nephrology colleagues.

Thank U