European Journal of Cardiovascular Medicine

Pregnancy related acute kidney injuries associated with increase rate of maternal morbidity and fetal loss that range from 30-60%, making it as a life threatening. pregnancy related acute kidney injury was until recently believed to be associated with sepsis. Recently, it is mainly associated with Hypertensive conditions of pregnancy which themselves associated with increased risk of cardiovascular diseases. The current study involves the relationship of Hypertensive disorders of pregnancy like Gestational hypertension, preeclampsia, eclampsia, HELLP syndrome affecting pregnancy leading to Acute kidney injury. Preeclampsia when severe or when associate with HELLP, or even HELLP alone can lead to acute renal failure. When pregnancy related acute kidney injury occurs, it also increases the risk of other obstetric complications. [1,2]

AKI in the setting of HELLP syndrome and preeclampsia has been associated with placental abruption and pulmonary oedema and increased maternal morbidity and poor perinatal outcome. Pregnancy related acute kidney injury also lead to long term consequences like chronic or further renal disease in addition to cardiovascular diseases. In the past, AKI was considered to be reversible syndrome, but in recent years, several studies have indicated AKI may increase the risk of chronic kidney disease, increasing kidney damage, or requires dialysis even after. this study is to study the increasing incidence and prevalence of preeclampsia and HELLP and its complications. In the recent years, the rate of pregnancy related acute kidney injury is declining but it remains as a serious problem due to its association with significant adverse maternal and fetal outcomes. According to some studies, maternal mortality and fetal loss in patients with pregnancy related acute kidney injury have risen to 30 and 60%. Longer ICU stay, caesarean delivery, need for dialysis, haemorrhage, placental abruption, and pulmonary edema, may lead to chronic kidney disease cardiovascular diseases, and also a higher risk of maternal death. Fetal complications include stillbirth, perinatal death, delivering low birth weight babies and intrauterine deaths. So, this study helps us to identify the risk and early detection of complications and prevent maternal morbidity, mortality and fetal mortality and improve the perinatal outcome.

It is a Hospital based prospective observational study. In 100 Patients who fulfilled the inclusion criteria are included in the study at modern government maternity hospital, Osmania Medical College. The study was conducted in the department of obstetrics and gynaecology, modern government maternity hospital Petlaburz, Osmania Medical College. This study was conducted between October 2020 and October 2022.

Inclusion criteria:

Antenatal women with hypertensive disorders, antenatal women with Hypertensive disorders with decreased urine out. Antenatal women with Hypertensive disorders with Raised creatinine levels and blood Urea levels. Mother with altered Renal profile in postpartum Period with Hypertensive History Antenatal period.

Exclusion criteria:

acute kidney injury due to Septic abortion, Sepsis, Antepartum or postpartum haemorrhage, Blood reactions, Pre-existing renal diseases, Acute fatty liver of pregnancy and Thromboembolic microangiopathies

Sample size:

Assuming the NICU admissions as 35% (35) with 10% absolute precision, the calculated sample size for the current study is 88. This sample size was calculated using the formula,

Sample size, n =(Z1-α/2) 2 (p) (q) d2

where,

p - proportion of hysterotomy= 35%

q – (1-p) = 65%

d – Level of precision i.e., 10%

n= (1.96)2(35) (65)/102

n = 88

After adding 20% non-response rate, the final sample size used for the study is

100.

Data collection

Subjects were included in the study after written informed consent and data was collected by using pre structured questionnaire. Thorough obstetric, medical and surgical history was taken. the subjects were analysed for the following parameters.

The ethical approval was obtained from the Institutional Review Board (IRB) of Osmania Medical College, Hyderabad. Written informed consent was obtained from each participant who participated in the research study before enrolling. The researchers explained the details of the study and detailed the purpose of the study to the participants. Confidentiality was maintained throughout the period of data collection.  Confidentiality was maintained by limiting the identifying variables to a minimum. Data were analysed in aggregate and access to the collected data was limited only to me, my guide and my co-guide. All information related to the study participants was kept confidential and de-identified data was used for analysis.

Statistical analysis

Data were entered into Microsoft Excel data sheet 2016 version and was analysed using STATA version software. Categorical data were represented in frequencies and proportions. Continuous data was Represented as median and interquartile range. Chi-square test and fisher-exact test were used as a test of significance for categorical data, wherever applicable and Mann Whitney test for comparing medians. MS excel and MS word Were used to obtain various graphical representations such as pie charts and bar diagrams. P value off < .05 was considered statistically significant after assuming all the rules of the statistical test

The total sample size of the patients in this study was 100 and the distribution of sociodemographic, clinical and outcome characteristics of the patients are shown the following tables. The mean (SD) S. creatinine was 2.3 (1.2), urea was 52.6 (23.7) and albumin was 2.7(0.5) was present in study.

Table-1: Distribution of Demographic details

The distribution of age of the patients is shown in Table 1. The participants' mean (SD) age was 22.4 (4.7) years. There were 52% of the patients belonged to the age category 21-25 years, and 25% aged less than 26-30 years and 20% aged less than 20 years. About 38% were belonged to 30-34 weeks of gestation, and 24% belonged to >37 weeks of gestation 52% were lower middle class, 12% were upper middle class, 32% were belonged to middle-class socio-economic class as per Modified Kuppuswamy scale.  42% were graduates, 32% were up to 10th, 16% were class 11-12 and 10% were educated up to PG. Almost 78% were working and 22% were not working.

Table-2: Distribution of presentation, gravida and mode of termination

56% were antenatal presentation. Distribution of gravida shows that, 56% were having 2, 14% had 3 and 20% had 10% gravida. Induced delivery (48%) and Emergency LSCS (38%) was the main mode of termination of pregnancy.

Table-1: Distribution of treatment.

Table-3:. Distribution of maternal and fetal outcome

        There were 32 fetal deaths and 1 abortion.

Table-4: Distribution of complications

Neonatal morbidity and mortality is very high because AKI in pregnancy and/or with other complications. Pregnancy needs to be terminated immediately irrespective of gestational age to prevent maternal complications and deaths.

Table-5: Distribution of Birth weight of neonate

Mothers with hypertensive disorders who presented in early preterm (24-32 weeks) delivered babies with less than 1.5 kg and among them 100% perinatal mortality is observed. Babies with <1.5 kg weight, most of them presented with intrauterine death due to abruption or fetal growth restriction.

A hospital-based prospective study was conducted among pregnant women in their third trimester referred to the selected tertiary care hospital in Telangana, South India. This prospective study was conducted among acute kidney injury in pregnancy secondary to hypertensive disorders and maternal and perinatal outcomes. This study was conducted on 100 cases of acute kidney injury in In pregnancy with hypertensive mothers presenting either antenatally or postnatally and their morbidity, mortality and perinatal outcome. Most of the studies that were conducted prior were due to acute kidney injury in pregnancy due to all causes, including haemorrhage, sepsis, blood transfusion reactions, and hypertensive disorders of pregnancy. But this study included only AKI due to hypertensive disorders of pregnancy. Our study shows most of them belonged to the age group of 20-25 years and most were primigravida. The majority of them developed AKI between 30-34 weeks of gestation followed by >37 weeks of gestation. Due to  rapid  progression,  pregnancy  needs  to  be  terminated immediately irrespective of gestational age in maternal interest leading to increased iatrogenic preterm deliveries and caesarean deliveries. When terminated immediately and timely management of AKI resulted in a good maternal outcome, and most of them recovered with medical management but had poor perinatal outcomes.

In the present study, the maternal and perinatal outcome was studied, and most of the antenatal mothers with hypertensive disorders present to a tertiary care hospital with complications like antepartum eclampsia, HELLP, Abruption, pulmonary oedema, press, and AKI. So the early detection of hypertensive mothers and the prevention of serious complications it’s very important to prevent maternal morbidity and mortality. My study on “AKI in pregnancy secondary to hypertensive disorders” among 100 mothers showed that: Incidence is 1.9%. Regular antenatal check-ups, early detection of gestational hypertension, and Identifying the high-risk mothers who are prone to hypertension in pregnancy are very important to prevent maternal morbidity and mortality and also for Prevention of perinatal morbidity and mortality. (3-8) In the present study, we found that most hypertensive  mothers  end  up  with  acute  kidney  injury  and  other complications of hypertensive disorders, Which leads to intrauterine death, need for early termination Of pregnancy, poor Perinatal outcome, need for dialysis To the mother, death, Increased ICU admissions for mother, increased morbidity, prolonged hospital stay, Future development of chronic hypertension, multiorgan involvement. Early termination of pregnancy leads to Preterm deliveries, low birth weight, respiratory distress, increased NICU admissions, Prolonged hospital stay, sepsis, perinatal mortality and morbidity.

Table-6. Comparison of present study results with other studies (9-17)

From this study, primigravida, Younger and elderly age groups Are more prone to developing hypertensive disorders, which lead to AKI And other complications.  Most of these patients present in 3rd trimester, and they present with the rapid  development  of  complications,  multiorgan involvement, and poor perinatal outcome.  Most of the Antenatal mothers  who  present  with  late-term  pregnancy  with  gestational hypertension, HELLP or antepartum or imminent eclampsia respond to induction, have a vaginal delivery and also have a good perinatal outcome. But some of the mothers delivered by a caesarean section either because of failed induction or due to the development of complications like abruption, AKI, OR other fetal indications. But mothers who are presenting in preterm with hypertensive disorders, most of them end up with renal involvement, which is an indication for termination of pregnancy and have poor neonatal outcomes.

Strengths

1. To the best of our knowledge, this is one of the first study on acute kidney injury in pregnancy secondary to hypertensive disorders and maternal and perinatal outcome
2. A single investigator had conducted the data collection for the entire study.

Therefore, the chances of observer bias and interviewer bias might be avoided.

1. The main strength of the study is the inclusion of adequate representative sample of pregnant women in our study which resulted in the increased power of our study and hence the generalisability to the similar setting.

1. A dedicated software was used for the data collection and analysis which had reduced the chance of errors.

Limitations

1. One of the limitations is that since the study was a hospital-based study there was a chance of selection bias.
2. As with all other cross-sectional studies, temporal association could not be established with this study, since there is always a chance of reverse causal association and hence a cohort study with would have been more ideal.

Nine patients died and 1 patient had chronic hypertension. 72% of the babies admitted to NICU, there were 32 fetal deaths and 1 abortion. Neonatal morbidity and mortality are very high because of AKI in pregnancy and  with  other  complications.  Pregnancy  needs  to  be  terminated immediately,  irrespective  of  gestational  age  to  prevent  maternal complications and deaths. This study concludes that acute kidney injury treated with dialysis in pregnancy is rare and typically occurs in an otherwise healthy woman who acquired A major pregnancy-related medical condition. While  assessment  for  comorbid  conditions  suggests  chronic  kidney disease, hypertension, and diabetes reminds central to identifying women at risk for hypertensive disorders of pregnancy, my data suggested severe AKI May be occurring through a variety of physiologic mechanisms that may not be predictable from pre-pregnancy health status. Fortunately with ongoing improvements in obstetric care, multidisciplinary approaches and new insights into the diagnosis and management of preeclampsia and its complications maternal and perinatal mortality in this conditions are avoidable.  Knowledge  of  associated  characteristics  and  outcomes presented in this study provides important prognostic information for patients, a framework for physicians to understand severe pregnancy- related AKI in the current era, and informed strategies to better identify women at risk. And also concluded from this study that prevention is always better than cure.

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