148

ABSTRACT

OBJECTIVE: To determine the frequency of AKI (acute kidney injury) in patients with APH (antepartum haemorrhage) and Pre-eclampsia/Eclampsia.STUDY DESIGN: A Descriptive Cross Sectional study.

thPLACE AND DURATION: Department of Obstetrics and Gynecology Ayub Teaching Hospital Abbottabad from 08 December 2011 to th07 December 2012.

METHODOLOGY: A Consecutive (Non-probability) sampling technique was adopted for 119 cases presenting with Antepartum hemorrhage and 119 patients with preeclampsia/eclampsia. Patients were selected in a consecutive manner from the OPD, Emergency and labor room. The mean values and frequencies were calculated in terms of percentages for justifying the results.RESULTS: The mean age of the APH (antepartum haemorrhage) group was 27.84 + 6.16 and for patients in preeclampsia/eclampsia group was 27.64 + 6.06 respectively. The mean period of gestation in APH group was 26.34 + 5.68 SD and in preeclampsia/eclampsia group it was 28.94 + 6.43 SD. The frequency of AKI (acute kidney injury) was 7.6% in APH patients and 8.4% in preeclampsia/eclampsia patients. CONCLUSION: The frequency of AKI (acute kidney injury) is more in preeclampsia/eclampsia patient's as compared to antepartum haemorrhage (APH) patients. KEY WORDS: Antepartum hemorrhage, Preeclampsia, Ecclampsia, Acute Kidney Injury, Pregnancy.

HOW TO CITE THIS:Shahid H, Aftab F, Zafar H. Incidence of Acute Kidney Injury in Patients with Antepartum Haemorrhage, Pre Eclampsia/ Eclampsia. Isra Med J. 2017; 9(3): 148-152.

This is an Open Access article distributed under the terms of the Creative Commons Attribution-Non Commercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ORIGINAL ARTICLE ISRA MEDICAL JOURNAL | Volume 9 - Issue 3 | May - Jun 2017

INTRODUCTION

Acute kidney injury (AKI) is a structural and functional disorder of kidney. The diagnosis can be established during 48 hours by various tests and imaging studies. The creatinine levels of 0.3 mg/dL or 50% increase in serum creatinine along with oliguria

1 i.e < 0.5 mL/kg/hr for > 6 hours is categorized as AKI. Major causes of AKI in pregnancy include Antepartum haemorrhage (APH), Postpartum haemorrhage (PPH), puerperal sepsis, disseminated intravascular coagulation (DIC), pre-eclampsia and

2eclampsia. Ante partum haemorrhage (APH) is defined as an excessive per

vaginal bleeding at the time of parturition and after twenty 3weeks of gestation. It complicates 2-5% of all pregnancies. APH

can be due to abruptio placentae, placenta previa, 4indeterminate cause or any local pathology of genital tract. Pre-

eclampsia is defined as recorded high blood pressure of > 140/90mmHg, at least taken 4hours apart and on two separate occasions, along with 300mg proteins in24 hour urine sample. Moreover it should be after 20th week of gestation in a previously normotensive women. The condition usually resolves in sixth postpartum week. Usually 2-3% of pregnancies

5get complicated due to this problem. Eclampsia is the same condition as pre eclampsia that has proceeded to manifest as convulsions. It complicates 1:2000

3pregnancies. A study showed that acute renal failure was associated with, PPH in 27.7%, intra uterine death (IUD) in 27.7%, APH 25%, preeclampsia-eclampsia in 11.11%, and

6septic abortion and puerperal sepsis in 8.3%. Another study showed that pregnancy related AKI was associated with APH in 14% cases, PPH in 24% cases, septic abortion and puerperal sepsis and disseminated intravascular coagulation (DIC) in 31%

7 cases, IUD in 14% and preeclampsia/ eclampsia in 12% cases. In Brazil, the incidence of AKI in patients with abruption and pregnancy related hypertension was reported as 9.1% and

8 41.8% respectively.Ayub Teaching Hospital receives patients from Northern Areas and Hazara Division where facilities for antenatal checkup are limited. Based on our hospital record over a period of 10

1. Assistant Professor of Gynae / Obstetrics Rawal Institute of Health Sciences Islamabad2. Associate Professor of Pathology Al- Nafees Medical College & Hospital Isra University Islamabad Campus Pakistan

Correspondence to:Humaira ZafarAssociate Professor of Pathology Al- Nafees Medical College & HospitalIsra University Islamabad Campus PakistanEmail: dr.humairazafar@yahoo.com

Received for Publication: 19-10-16Accepted for Publication: 18-03-17

Incidence of Acute Kidney Injury in Patients withAntepartum Haemorrhage, Pre Eclampsia/Eclampsia

1 1 2Hammna Shahid , Farzana Aftab , Humaira Zafar

ISRA MEDICAL JOURNAL | Volume 9 - Issue 3 | May - Jun 2017Hammna Shahid et al.

149

(17.6%) were the age groups >35 years. This is shown in table I.The mean period of gestation in APH group was 26.34 + 5.68 and in preeclampsia/eclampsia group it was 28.94 + 6.43. In APH group, 31 (26%) were in >20-25 weeks of gestation, 54 (45.4%) were in the >25-30 weeks period of gestation while 34 (28.6%) were in >30+ week's period of gestation group. In preeclampsia/eclampsia group, 28 (23.5%) were in >20-25 weeks of gestation, 58 (48.7%) were in the >25-30 weeks period of gestation while 33 (27.8%) were in >30 weeks period of gestation group. This is shown in table I.The mean parity in APH group was 2.58 + 1.99 and in preeclampsia/eclampsia group it was 2.34 + 1.97. While distributing the sample in different parity groups, we found that in APH group: 25 (21%) were primiparous, 46 (38.6%) were in the 1-3 parity, 38 (31.9%) were in >3-5 parity while 10 (8.4%) were in the parity group of greater than 5. In preeclampsia/eclampsia group: 33 (27.7%) were primiparous, 49 (41.1%) were in the 1-3 parity, 30 (25.2%) were in >3-5 parity while 7 (5.9%) were in the parity group of greater than 5 . This is shown in table I.Acute kidney injury was observed in 9 (7.6%) in APH group and 10 (8.4%) patients in preeclampsia/eclampsia group. This is shown in table II.While stratifying the AKI with regards to different age groups, we found that in APH group 9.4% of patients in age groups 15-25 years and 6.4% of patients in the age group >25-35 years developed AKI while no patient in the age group >35 years developed AKI. This is shown in table III.While stratifying the AKI with regards to different age groups, we found that in preeclampsia/eclampsia group 10% of patients in age groups 15-25 years and 8.3% of patients in the age group >25-35 years developed AKI while 4.8% in the age group >35 years. This is shown in table III.While stratifying the AKI regards to period of gestation, we found that in APH group 3.2% of patients in >20-25 weeks of gestation and 5.6% of patients in the >25-30 weeks period of gestation developed AKI and 14.7% in the period of gestation of >30 weeks developed AKI. This is shown in table III.While stratifying the AKI regards to period of gestation, we found that in preeclampsia/eclampsia group 0% of patients in >20-25 weeks of gestation and 6.9% of patients in the >25-30 weeks period of gestation developed AKI and 18.2% in the period of gestation of >30 weeks developed AKI. This is shown in table III.

months, the frequency of AKI differs from the published data in different parts of Pakistan. The study aims to determine the frequency of AKI in such patients so that this study may form the basis of future studies to determine the factors responsible for this variation in AKI in Northern Pakistan.

METHODOLOGY

The study was conducted in Obstetrics and Gynaecology unit of Ayub Teaching Hospital Abbottabad over the period of one year

th thi.e 08 December 2011 to 07 December 2012. The sample size was 238 and Consecutive (Non-probability) sampling technique was adopted for the study proceedings.For ethical concerns approval of the Institutional Ethical Committee was obtained. Diagnosed women of all ages and parity with antepartum haemorrhage and pre eclampsia/ eclampsia were included in the study. The patients with existing renal disease prior to pregnancy (glomerulonephritis, renal insufficiency, renal stones etc were amongst the exclusion criteria) Patients with elevated serum creatinine prior to gestation were also excluded from the study. Informed consent was taken from all the willing patients. Data was collected and then recorded on a proforma and entered into computer using SPSS version 20.0 for analysis. Variables included in the study were the age groups, parity and gestational period. For the quantitative variables mean . standard deviation (SD ) was used, while for qualitative variables frequencies in terms of percentages were calculated.

RESULTS

A total of 238 cases were studied. 119 consecutive patients of antepartum hemorrhage (Group A) were enrolled in the study and 119 patients of preeclampsia/eclampsia (Group B) were enrolled in the study in consecutive manner. The mean age and standard deviation for patient's in APH was 27.84 + 6.16 and for patients in preeclampsia/eclampsia group was 27.64 + 6.06 respectively. This is shown in table - I.While distributing the patients in both groups with regards to age, in APH group, 64 (53.8%) were in the age group 15-25 years, 47 (39.5%) were in the age group >25-35 years and 8 patients (6.7%) were the age groups >35 years. In preeclampsia/ eclampsia group, 50 (42%) were in the age group 15-25 years, 48 (40.3%) were in the age group >25-35 years and 21 patients

TABLE -I: AGE RANGES, GESTATIONAL PERIOD AND PARITY DISTRIBUTION IN APH AND PRE ECLAMPSIA GROUPS (N=238)

ISRA MEDICAL JOURNAL | Volume 9 - Issue 3 | May - Jun 2017

150

Hammna Shahid et al.

11proteinuria and depressed GFR.The AKI was noted in 10 (8.4%) of patients. The findings are in favour of various studies, which showed 4-23% incidence of AKI. 15,16 The recovery in preeclampsia patients is generally good. The results of current study revealed 60% patients of AKI regained normal renal function. Two patients had dialysis but completely recovered afterwards, and two patients died secondary to acute kidney injury. A study report by Mjahed K et al, showed that 32% of AKI patients required dialysis with complete recovery of renal function afterwards. While 14±8

11days were the mean duration of recovery. However, AKI secondary to chronic renal failure leads to high mortality rate

12even up to 17-18%. Mjahed K et al, narrated that mortality rate is 32.6% in eclampsia patients and with AKI. While it is low i.e

11 16,9.1% in eclampsia patients without AKI. The results of current study showed that AKI is seen in later part of pregnancy and in the puerperium. This is in favour of published studies by Joaquín ZM et al (2005) and Rani etal

17-19 (2002). In addition, it was noted in current study multigravida, haemorrhage and septic abortions were the important predisposing factors. This is in accordance with the study conducted by Akhter et al. He found that obstetrical

DISCUSSION

Preeclampsia is a multisystem disorder of which usually 9,10 complicates 4%-5% of pregnancies. While the incidence of

eclampsia/ seizures is seen in 0.3% to 0.9% of women having pre eclampsia. The maternal mortality in such cases is about

110.5–10%.In current study 27.7% of patients were primigravidas, while 72.3% were multigravidas having a mean age of 28.94 + 6.43 years. This was in contrast with studies, who reported that pre eclampsia is seen 52-73% primigravidas and in the same age

9,10group. The mean gestational age of current study was 27.64 + 6.06 weeks. The results are in accordance to the published studies by

11,12Mjahed K et al (2004) and Aali et al (2004). While it was thobserved that pre-eclampsia is commonly noticed in >20 week

of pregnancy. This finding is different from the published study in Japan. Koga K in 2003 concluded that this condition is

13commonly seen in less than 20 gestational weeks. However the incidence of eclampsia is 5-7%. As reported by Koga K et al

13,14 and Imasawa T et al. However, hypertension is the commonest presentation of pre-eclampsia, followed by

TABLE - II: FREQUENCY OF ACUTE KIDNEY INJURY IN APH AND PREECLAMPSIA/ECLAMPSIA GROUPS (N=238)

TABLE III: DIFFERENCES OF AGE RANGES, GESTATIONAL PERIOD AND PARITY AMONST AKI PATIENTS (BOTH GROUPS) – (N=238)

ISRA MEDICAL JOURNAL | Volume 9 - Issue 3 | May - Jun 2017

151

7. Ansari MR, laghari MS, Solangi KB. Acute renal failure in pregnancy:one year observational study at Liaquat University Hospital, Hyderabad. J Pak Med Assoc. 2008;58(4):61-64.

8. Silva GB, Monteiro FA, Mota RM, Paiva JG, Correia JW, Bezerra FJG, et al. Acute kidney injury requiring dialysis in obstetric patients: a series of 55 cases in Brazil. Arch Gynecol Obstet. 2009;279(2):131-37.

9. Molnar AO, Coca SG, Devereaux PJ, Jain AK, Kitchlu A, Luo J, et al. Statin use associates with a lower incidence of acute kidney injury after major elective surgery. J Am Soc Nephrol. 2011;22(5):939-46.

10. Chan P, Brown M, Simpson JM. Proteinuria in preeclampsia: how much matters? Br J Obstet Gynecol. 2005;112(1):280-85.

11. Mjahed K, Alaoui SY, Barrou L. Acute renal failure during Eclampsia: Incidence, risks factors and outcome in Intensive Care Unit. Renal Failure. 2004;26(3):215-21.

12. Aali BS, Ghafoorian J, Mohamad-Alizadeh S. Severe preeclampsia and eclampsia in Kerman, Iran: complications and outcomes. Med Sci Monit. 2004;10(2):163-67.

13. Koga K, Osuga Y, Yoshino O. Elevated serum soluble vascular endothelial growth factor receptor 1 levels in women with preeclampsia. J Clin Endocrinol Metab. 2003;88(2):2348-51.

14. Imasawa T, Nishiwaki T, Nishimura M. A case of “pure” preeclampsia with nephrotic syndrome before 15 weeks of gestation in a patient whose renal biopsy showed glomerular capillary endotheliosis. Am J Kidney Dis. 2006;48(3):495-501.

15. Karumanchi SA, Maynard SE, Stillman IE. Preeclampsia: A renal perspective. Kidney Intern. 2005;67(1):2101-13.

16. Walker JJ. Pre-eclampsia. Lancet. 2000;356(5):1260-65.17. Tuffnell DJ, Jankowicz D, Lindow SW. outcomes of severe

preeclampsia/ eclampsia in Yorkshire 1999/2003. Br J Obstet Gynecol. 2005;112(4):875-80.

18. Joaquín ZM, Armando OC, Hugo MZ. Clinical evolution of hypertension and proteinuria in patients who developed preeclampsia. Int J Gynecol Obstet. 2005(3);5:1.

19. Rani PU, Anuradha NG. Changing trends in pregnancy related acute renal failure. J Obstet Gynecol. 2002;52(3):36.

20. Akhter M, Ali A, Zaffar S, Mehmood A, Nisar A. Obstetrical acute renal failure from Frontier Province: A 3 years prospective study. J Postgrad Med Inst. 2004;18(1):109-17.

21. Ansari MR, Laghari MS, Solangi KB. Acute renal failure in pregnancy: one year observational study at Liaqat University Hospital, Hyderabad. J Pak Med Assoc. 2008;58(2):61-64.

22. Celic C, Gezginc K, Alintepe L, Tonbul HZ, Yaman ST, Akyurek C, Turk S. Results of the pregnancies with HELLP syndrome. Ren Fail. 2003;259(1):613-18.

23. Hachim K, Badahi K, Benghanem M, Fatihi EM, Zahiri K. bstetrical acute renal failure. Experience of nephrology department, Central University Hospital Ibn Rochd, Casablanca. Nephrologie. 2001;22(1):29-31.

24. Selcuk NY, Odabas AR, Cetenkaya R, Tonbol HZ, San A. Outcome of pregnancies with Help syndrome complicated

haemorrhages was the significant predisposing factor for AKI in 2058 % to 63% patients. Many other studies revealed that

eclampsia-preeclampsia are amongst the major causes of 22-24obstetrical ARF. Venturae et al described that 74.5% cases of

25eclampsia and 47.7% preeclampsia land up in ARF. There are studies from the Kashmir Valley that address the issue of pregnancy related AKI. Pandith reported the incidence of AKI as 6% in the Kashmir Valley, which is similar to incidence of 8.4% AKI for eclampsia and 7.6% for antepartum hemorrhage in our study. Another study reported by Hassan I et al, showed that AKI was found in 18.6% of patients with APH and 11.6% patients of preeclampsia/eclampsia. The incidence variation amongst the studies conducted in Pakistan and other developed countries might be due to good antenatal care abroad. Thus, reducing the incidence of obstetrical hemorrhages and AKI by early detection

26,27of eclampsia-preeclampsia. In our study, the incidence of AKI was 8.4% in preeclampsia/eclampsia and APH. This is different from an

28Indian study results which revealed 23.8% incidence of AKI.

CONCLUSION

The frequency of AKI (acute kidney injury) is more in preeclampsia/eclampsia patients i.e 8.4% as compared to 7.6% in APH patients.

Contribution of Author:Shahid H: Conceived idea, Sample collection, Data recording on SPSS, Data analysis, Result writingAftab F: Sample collection, Data recording on SPSSZafar H: Introduction, Table formations for results, Discussion writing, Reference citation, Final formatting of entire manuscript

Disclaimer: None.Conflict of Interest: None.Source of Funding: None.

REFERENCES

1. Molitoris BA. Acute Kidney Injury. Cecil Medicine. 2007;23(2):862-66.

2. Hassan I, Junejo AM, Dawani ML. Etiology and outcome of acute renal failure in pregnancy. J Coll Physicians Surg Pak. 2009;19(3):714-17.

3. Tower C. Obstetrical emergencies. Obstetrics by ten teachers. 2011;19(2):241-57.

4. Dutta DC. Antepartum haemorrhage. Textbook of obstetrics. 2006; 6(4):243-46.

5. Kenny LC. Pre eclampsia and other disorders of placentation. Obstetrics by ten teachers. 2011;19(1):120-31.

6. Shaikh QA, Shaikh NA, Soomro AA, Shaikh GS, Shaikh AR. Pregnancy related acute renal failure; an experience at Nephro- urology department, Chandka Medical College teaching hospital, Larkana. Professional Med J. 2008;15(3): 129-32.

Hammna Shahid et al.

ISRA MEDICAL JOURNAL | Volume 9 - Issue 3 | May - Jun 2017

152

27. Hassan I, Junejo AM, Dawani ML. Etiology and outcome of acute renal failure in pregnancy. JCPSP. 2009;19(11):714-17.

28. Prakash J, Tripathi K, Pandey LK, Sahai S, Usha, Srivastava PK. Spectrum of renal cortical necrosis in acute renal failure in eastern India. Postgrad Med J. 1995;71(1):208-10.

by acute renal failure (1989–1999). Ren Failure. 2000;22(2):319-27.

25. Ventura JE, Villa M, Mizraji R, Ferreiros R. Acute renal failure in pregnancy. Ren Failure. 1997;19(2):217-20.

26. Pandith. Incidence of PRAKI as 6% in Kashmir Valley. Indian J Obstet Gynecol 2006;12(4);310-15.

Hammna Shahid et al.