1. 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

2. 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.

3. 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.

4. 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.

5. 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.

6. 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

7. 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

8. 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. .

9. 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)

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

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

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

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

14. Relation of age and etiology2 4 6 8 10 12 14 16
<20
21-25
26-30
31-35
>35
APH
PPH
POC
PUERs
Pmtp
Sepabr

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

16. Distribution of pt. urine output wise
anuria
nonoliguric
oliguria
TOTAL
No of pt. %
8 20.0

17. 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
7.76±4.90 (mg %)
Peak serum potassium
4.5±1.53 (mEq/l)

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

19. Correlation Urine output and S.Creatinine

20. 28% underwent HD 3-5 times
31% underwent HD 6-8 times

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

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

23. Correlation of S.Cr and Oliguria and Survival
YES
TOTAL
> Col %
0 0.0
4 44.4
4 21.1
>2.5 Col %
5 55.6
TOTAL Row % Col %

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

25. 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)..

26. 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.

27. 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.

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

29. Thank U