Abstract
Purpose
Haemorrhage, preeclampsia and sepsis are the leading causes of renal dysfunction in women with a maternal nearmiss(MNM) complication. The study aimed to assess the prevalence, pattern and follow up of these women.
Methods
This was a hospital based prospective observational study, conducted over one year. All women with a MNM leading to acute kidney injury (AKI) were analysed for fetomaternal outcomes and renal function at 1 year of followup.
Results
The incidence of MNM was 43.04 per 1000 livebirths. 18.2% women developed AKI. 51.1% women developed AKI in the puerperal period. Most common cause of AKI was haemorrhage seen in 38.3% women. The majority of women had s.creatinine between 2.1 to 5 mg/dl and 44.68% required dialysis. 80.8% women recovered fully when the treatment was initiated within 24 h. One patient underwent renal transplant.
Conclusion
Early diagnosis and treatment of AKI results in full recovery.
Introduction
There has been a significant reduction in maternal mortality due to advancements in health care and better availability of health services. We are now able to prevent many maternal deaths in those women who suffer from potentially life-threatening conditions during pregnancy. These women are categorised as ‘maternal near miss’. 1 A Maternal Near Miss Clinic has been functional in our department for the last 4 years. The patients who have had these complications are exclusively followed up in this clinic. A team of doctors comprising obstetricians, nephrologists, cardiologists, urologists, and psychiatrists conduct their evaluation and management. One potential cause of maternal death or near miss is acute kidney injury. Haemorrhage, preeclampsia, and sepsis can lead to renal dysfunction during pregnancy and the postpartum period, but in countries like India, illegal terminations of pregnancy are also an important cause. 2 Timely and aggressive management of these complications can prevent renal injury, however, it still remains a challenging complication. This study aimed to assess the prevalence, pattern, and follow up of those women who survived a pregnancy related acute kidney injury (AKI).
Material and methods
A prospective study was conducted at a tertiary centre in Northern India which caters to referrals from the neighbouring states of Punjab, Haryana, Jammu & Kashmir, Uttar Pradesh, and Himachal Pradesh. All women who were managed in the emergency of the Department of Obstetrics and Gynaecology from 1st November 2018 to 31st October 2019 and who fulfilled the WHO criteria of maternal near miss were recruited for the study. 3 A special register was maintained for records of all women developing maternal near miss events and their relevant data was entered in it on a regular basis and then updated to a soft copy. For this study, records of the women who did not have any underlying renal disease and had suffered AKI following the near miss event were analysed. The demographic details, history, clinical presentation, and laboratory investigations were analysed in detail. Special note was made of the obstetric history, mode and place of delivery, intrapartum and postpartum complications, blood and blood component transfusion, and surgical interventions. These women were followed up at 6 months and 1 year in the near miss clinic.
The Kidney Disease Improving Global Outcomes (KDIGO) criteria were used for defining AKI in these patients 4 i.e. increase in serum creatinine by 0.3 mg/dl (27 umol/l) or more within 48 h or increase in serum creatinine to 1.5 times baseline or more within the previous 7 days, or patient presenting with oliguria (<500 ml/24 h) or anuria (<50 ml/24 h). The patients presenting with evidence of renal disease before pregnancy, renal scarring, small size of kidneys on ultrasound, or elevated serum creatinine >1.2 mg/dl (106 umol/l) prior to gestation were excluded.
The records of follow up visits in the nephrology clinics whether in the institute or outside were reviewed. The women who did not return for follow up in our institute were followed up telephonically. Women were assessed for features of renal failure, the total number of dialysis cycles they received were noted, and trends of urea and creatinine over 1 year were noted. The maternal outcome was defined as complete recovery when the patient's renal function returned to normal and there was no requirement of dialysis, partial recovery when patient's renal function was not normalised, however, dialysis was not required and no recovery when the patient required renal replacement therapy to maintain renal function. 5
Results
In the study period, there were a total of 6024 deliveries resulting in 5994 live births. The total number of maternal near miss cases in this period was 258 giving an incidence of 43.04 near misses per 1000 live births. Out of these 258 women, 47 developed AKI. Thus, the incidence of AKI among near miss cases was 18.2%.
Table 1 shows the demographic details and the birth outcomes of the 47 women with AKI. Only 23 (48.9%) women had live born babies with 20 (42.6%) patients delivering stillborn babies, all experiencing intrauterine fetal death before admission to the hospital. Amongst the live borns, 2 babies died in the neonatal period. These 21 babies were followed until 1 year of age and are healthy.
Demographic details of the patients.
VD: vaginal delivery; LSCS: lower segment caesarean section.
The pregnancy complications leading to AKI in our patients are described in Table 2. Haemorrhage, was the most common with a variety of precipitating causes. Two patients required uterine artery embolisation and 4 required peripartum hysterectomy.
Obstetric complications leading to AKI.
Sepsis led to AKI in 7 patients. Four patients had obstetric (direct) causes (2 being post abortal and 2 being post lower segment caesarean section [LSCS]) and 3 patients had non obstetric (indirect) causes. The 2 postabortal patients had dilatation and curettage for unwanted pregnancy. One patient each had sepsis following Ludwig's angina, acute pyelonephritis, and empyema thoracis.
Two patients developed AKI following acute gastroenteritis with unidentified pathogens. One woman developed AKI associated with diabetic ketoacidosis. She was admitted at 26 weeks and 3 days gestation with anuria and intrauterine fetal death (IUFD). She was inadequately supervised and unaware of her diabetic status. No antenatal history or investigation was suggestive of chronic kidney disease. One patient had a history of chronic hypertension with intermittent headaches and was found to have benign intracranial hypertension and acute kidney injury. Dialysis was not required and she is under nephrology follow up since her delivery. The cause of her AKI was not identified. Another patient had a history of blood transfusion in a community health centre in view of moderate anaemia at 38' weeks gestation, following which she developed fever with chills and rigours and was referred to our institute. On evaluation, creatinine was raised and fetal heart was absent. The patient underwent a vaginal delivery and her creatinine was normalised at 6 weeks postpartum.
Most women had Stage 2 AKI by KDIGO criteria, and almost 80% of women in this category had full recovery at the end of 1 year. More than 50% of these women required dialysis during admission and some required dialysis even after discharge (Table 3). Only 6 patients required dialysis after discharge and only 1 patient did not recover her renal function and had to undergo a renal transplant. Two patients had creatinine levels of more than 10 mg/dl. Both of them required long term dialysis after discharge. At the end of 1 year, 1 was fully recovered and one was partially recovered. Three patients were lost to follow up at the end of 1 year.
Relation between (1) serum creatinine levels and (2) obstetric complication with requirement for dialysis and renal recovery (conversion factor for creatinine mg/dl to umol/l: × 88.4).
The majority of the patients had a hospital stay of 1 to 3 weeks. Of all the patients who developed AKI, one third (34.1%) had to be intubated and required intensive care. For the patients who were transferred to ICU the average ICU stay was 9.5 days. All the women with haemorrhage as the cause of their AKI had received blood product replacement. The average number of red cell units transfused was 5.
As is clear from Table 4, the time taken to initiate dialysis was an indicator of outcome. Eighty eight percent of patients whose treatment was started within 24 h of the onset of AKI recovered fully at the end of 1 year. The management of the patient who had no recovery at the end of the study was delayed by 3 days. The number of dialysis episodes during admission was also predictive of recovery. As the number of dialyses required increased, the rate of full recovery decreased.
Relation between (1) initiation of management and (2) number of dialysis and recovery at 1 year.
3 patients were lost to follow up.
The average number of dialysis needed per case was 7.7. A total of 21 women required dialysis for the management of AKI. Amongst these women, two patients had a septic abortion, two had hypertension related AKI, and one each had haemorrhage and diabetes mellitus. At the end of 6 months, 4 of the 6 women no longer required dialysis. Dialysis was stopped at 7 months for 1 patient with haemorrhage-related AKI and one patient who required a renal transplant. She had pre-eclampsia with massive abruption leading to AKI. There were no mortalities amongst the patients at 1 year of follow up.
Discussion
There are very few facility based follow up studies that have evaluated the repercussions of a near miss event in pregnant women, especially from countries such as India. India is going through a phase of obstetric transition where the maternal deaths due to direct obstetric causes are declining and indirect causes are increasing. 6 Health facilities now need to concentrate on various organ dysfunctions that occur when a mother experiences a life threatening complication. There is a high prevalence of adverse health outcomes in women even up to 1 year following a near miss event.
Pacagnella 7 found that women experiencing maternal related near miss events suffer severe handicaps relating to their illness even after discharge from the hospital. This included a deterioration in vital organ functioning and risk of death in the 5 years after the near miss event.
Haemorrhage was the most common cause of AKI in our review which is similar to results of studies conducted by Ali et al., Rizwan et al. and Ansari et al. in India.8–10 The patients with postpartum haemorrhage were managed with either uterine artery embolisation or peripartum hysterectomy. However, the two lines of management did not affect the rate of recovery in our study.
Pre-eclampsia and eclampsia were the most common reasons for AKI in studies conducted by Silva Jr et al. and Hashim et al.11,12 The difference in these most common causes may be as these two studies address patients with obstetric AKI requiring dialysis. However, in our study, we have taken all patients with AKI irrespective of their requirement of dialysis. In our study, the patients with eclampsia had full recovery (100%) as compared to those with severe pre eclampsia.
Two women developed sepsis following dilatation and curettage for unwanted pregnancy before referral to our centre, and both required dialysis. This fact further emphasises the need for universal availability of safe abortion.
We found that most patients who developed AKI were in their late pregnancy or were postpartum. This is similar to findings of Gopalani et al. and Ansari et al.10,13 However, many previous studies have also reported AKI to occur more commonly in early pregnancy. 14 This may be attributed to septic abortion in those times.
In our study, around 45% of women who suffered AKI following near miss events required dialysis. A similar study was conducted in our institute 3 years prior. 15 The dialysis rate was 30% in that study following obstetric AKI. This indicates that dialysis has increased amongst the obstetric population. The long term follow up, as is evident from our study, suggests that recovery of renal function is faster and permanent if the decision for dialysis is taken earlier. Complete recovery was seen in more than 80% of our patients. Timing of referral is important: two patients whose serum creatinine was more than 10 mg/dl were referred after 72 h and both required long term dialysis. At the end of 1 year one patient underwent a renal transplant, the causative event in this patient was severe pre-eclampsia leading to massive abruption.
Conclusion
Acute kidney injury occurred in 18% of cases of women who suffered from a maternal near miss event during pregnancy or postpartum in our institutions. As AKI is a preventable complication in most cases, all health care facilities should be equipped to manage obstetric haemorrhage, pre eclampsia and sepsis as they are leading causes of obstetric AKI. Prompt management of these complications can prevent the development of AKI. Aggressive monitoring of patients in the postpartum period can reduce the further morbidity caused by postpartum haemorrhage. However, if AKI has developed, early referral to a centre where dialysis is available, may improve the recovery of the patient and prevents permanent damage. Long term follow up of all women with maternal near miss events should be encouraged.
Footnotes
Acknowledgements
None.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship and/or publication of this article.
Informed consent
Verbal informed consent was obtained from the patient(s) for their anonymized information to be published in this article.
Ethical approval
The Ethical Committee of PGIMER, Chd approved this study.
Guarantor
Dr Geetika Thakur
Contributorship
Geetika Thakur researched literature and conceived the study. Geetika Thakur and Aruna Singh was involved in the protocol development, patient recruitment and data analysis. Geetika Thakur wrote the first draft of the manuscript. All authors reviewed and edited the manuscript and approved the final version of the manuscript.
