Acute renal morbidities with obstetrical emergencies: An important women health issue

Objective: To observe the impact of acute renal morbidities with obstetrical emergencies on maternal health. Methods: In this study pregnant women between 28-40 weeks gestational period and delivered women in their puerperal period up to 42 days after delivery having acute renal problems associated with obstetrical emergencies were included. Pregnant and delivered women with obstetrical emergencies and associated other morbidities were excluded. These women were registered on the predesigned proforma after taking written informed consent and taking approval from institutional ethic research committee. The data was collected and analyzed on SPSS version 21. Result: Out of these 196 total registered women, majority of these women 81(41.32%) were between 21-30 years of age and multiparous women with parity four and above were 83(42.34%). Commonest presenting symptoms were generalized oedema 123(62.75%) and oligouria 92(46.93%). Frequent obstetrical emergencies observed were pre-eclampsia 53(27.04%), post partum haemorrhage 48(24.48%) and ante partum haemorrhage 36(18.36%) women. The complete recovery was observed in 86(43.87%) women, while mortality was seen in 56(28.57%) women. Conclusion: Renal morbidities were more frequently observed in obstetrical emergencies leading to high morbidity and mortality rate.


INTRODUCTION
Acute renal failure is a clinical syndrome characterized by an abrupt decrease in the glomular filtration rate, rising in plasma urea and creatinine levels, and urine out put less than 300 ml in 24 hours. The obstetrical acute renal morbidities, a serious maternal health issue mainly concerned with the life of mother. 1 There is a decrease in the rate of acute renal morbidities in the developed countries because of the improvement of the obstetrical care, and decrease in the infection rate. 2 Under developed world is still facing the same situation. The incidence of obstetric related acute renal failure in developing countries like Pakistan has not changed significantly. There is no such local data available in the past to compare with. Only few scanty studies are available which showed pregnancy related acute renal failure (ARF) rate 7-10%. 3 However in recent reports published from developing countries, the frequency of obstetric acute renal morbidity have been reported to be varying between 4-15%. 4 In recent years the rates are increased in both Canada and the United States. 5 In Canada, obstetric acute renal failure increased significantly, from 1.6 per 10 000 deliveries in 2003 to 2.3 per 10 000 deliveries in 2007, whereas the rate in the United States increased from 2.3 in 1998 to 4.5 per 10 000 deliveries in 2008. 6 This increase is an alarming sign, because obstetric acute renal failure is associated with maternal morbidity as well as fatality rate corresponding to 2.9%. 1 Major risk factors for obstetric acute renal failure includes chronic hypertensive disease, pre-eclampsia, postpartum haemorrhage, ante partum haemorrhage, sepsis, and other infections. 7 The most common type of obstetric hemorrhage is postpartum hemorrhage (PPH), mainly primary. 8 Invasive hemodynamic monitoring and mechanical ventilation may be indicated in the event of acute hemorrhage requiring massive fluid resuscitation. Disseminated intravascular coagulopathy, acute kidney injury, and lung injury can result from hemorrhage and protracted hypovolemia. 9 The acute obstetrical renal morbidity is a serious maternal health issue endangering the life of the women, such types of the studies will help in taking timely appropriate measures in managing obstetrical emergencies and proper handling the high risk cases as well as managing the renal morbidities with multidisciplinary approach so as to decrease the mortality rate. Our objective was to observe the impact of acute renal morbidities with obstetrical emergencies on maternal health.

METHODS
This study was carried out at the Department of Obstetrics and Gynaecology of Liaquat University of Medical and Health Sciences Jamshoro from 1 st September 2013 to 31 st August 2016. This was an observational study on 196 pregnant and delivered women with obstetrical emergencies and renal morbidities.
The renal morbidities were diagnosed on the basis of history of sudden oliguria (urine out put <300 ml/ 24 hours), or with anuria and increase in the level of renal function tests, while the pregnant and delivered women with liver disorders, cardiac and respiratory problems were excluded. Sample size was estimated by formula (N= (Z) 2 (pq)/e 2 . Confidence interval 95%. Sampling technique is Non -Probability Purposive. These women were registered on the predesigned proforma after taking written informed consent and approval from Institutional ethic research committee. The study variables were the age of women, gestational period, in delivered women postnatal period, symptomatology, general, obstetrical examination finding. Investigations complete blood count, renal functions tests, ultrasonographic record. All these women were managed with institutional management protocol and where ever required with multidisciplinary approach. The management out come was recoded in terms of complete recovery when renal functions were with in normal limit, partial recovery when there was improvement in renal functions but was not with in normal limit and mortality.
The data was collected and analyzed on SPSS version 21 (IBM SPSS 21, INC USA, 2012). Categorical variables were analyzed with frequency and percentage; means with standard deviation were calculated for age. Qualitative type of analyses was done with statistical Chi-Square test P-Value <0.05 was considered significant.

DISCUSSION
Obstetrical acute renal failure is a rare entity in developed world. In the early days of dialysis, obstetric renal failure was a major part of the work of a renal unit. Acute renal failure was estimated to occur in one in 1400 to one in 5000 pregnancies in the UK; over the next 20-30 years medical complications of pregnancy remained a regular and frightening reason for acute renal referrals. Hammersmith Hospital in West London had a special interest in acute renal failure from the 1940s, and attracted many referrals. In their 1965 report by Smith K et al study 10 obstetric renal failures accounted for 15% of cases requiring dialysis between 1957 and 1965, but it is still higher in developing countries like Pakistan. This is commonly observed in pregnant women as well as in the women in their puerperal period.
In this study acute renal morbidities with obstetrical emergencies were observed mostly in younger women having mean age±SD:26.52±5.993, grandmultiparous women (Para 4 and above) 83(42.34%), mostly these referred women were delivered 137(69.89%), while pregnant women were 59(30.10%), these women were in their late pregnancy and with obstetrical emergencies. This is inconsistent with Nigerian study. 11 This difference could be due to the quality of referral cases as this hospital is main tertiary care referral hospital of whole interior province receiving patient in emergencies. There is strong association between occurrence of any delay and poor maternal outcomes with life threatening conditions 12 , where as Joseph KS et al. study 13 reported that pregnant women with acute renal failure at appropriate gestational period, prompt delivery will prevent further detoriation of the condition.
The general condition of these women was poor, majority of these women presented with oedema 123(62.75%), oliguria 92(46.93%), anuria 68(34.69%), status of shock 59(30.10%). On investigation highly raised blood urea level above 151mg/dl was reported in 78(39.79%), serum creatinine level above 7mg/dl in 63(32.14%). Ultrasound examination report showed severe degree renal parenchymal changes in 45(22.95%) women, same is reported by Piccoli GB et al study. 14 In this study complete recovery rate was 86 (43.87%), this is inconsistent with Gurrier C et al study 15 where it is reported that the majority of pregnancy-associated kidney injuries were transient; this difference could be due to the early diagnosis, proper referral, and appropriate management. Low complete recovery rate in this study could be due to the late referral,unbooked status, poverty, poor general health, and mismanagement at local maternity units same could be the reason of high mortality rate in this study 56(28.57%) with associated obstetrical emergency conditions like postpartum haemorrhage, ante partum haemorrhage, puerperal sepsis, eclampsia, ruptured uterus, these were the women who were anaemic,late referral, and in morbid condition, same is reported by other studies. [16][17][18][19][20] The bias in study can be the no screening tests about renal function during pre pregnancy period as well as during pregnancy tenure for assessing renal status so that in high risk cases for subsequent obstetrical emergencies appropriate and immediate intervention with multidisciplinary approach could decrease morbidity and mortality.