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38]

Case Report

Anesthetic management for cesarean section

in chronic renal failure
Hemlata Kapoor,
ABSTRACT
Kuzhupully Parambhil Krishnan
Kutty Rajeev Pregnancy in chronic kidney disease is rare and is associated with high incidence of maternal
Department of Anaesthesiology, and fetal morbidity. More women with chronic renal failure, due to better management and
Kokilaben Dhirubhai Ambani treatment modalities are able to conceive and carry on their pregnancy and delivery. The case
Hospital and Research Institute, Four report describes anesthesia for caesarean section in a parturient with chronic renal failure and
Bungalows, Andheri (West), Mumbai, reviews the literature.
Maharashtra, India
Address for correspondence:
Dr. Hemlata Kapoor,
Department of Anaesthesiology,
Kokilaben Dhirubhai Ambani Hospital
and Research Institute, Four Bungalows,
Andheri (West), Mumbai - 400 053,
Maharashtra, India.
E-mail: h_sarinkapoor@hotmail.co.uk Key words: Anesthesia, chronic renal insufficiency, pregnancy

INTRODUCTION stage V on routine investigations in the second trimester of

pregnancy. She was on regular follow up with an obstetrician

S
ymptoms of chronic kidney disease (CKD) often appear when
renal impairment is advanced; hence it is often diagnosed
in later stages. CKD is graded into five stages based on the
renal function.[1] Pregnancy in stages 3-5 of CKD is rare due to
reduced fertility and increased incidence of early miscarriage.[2]
In patients with CKD, hypertension and proteinuria are known
to worsen in pregnancy.[3] The anesthesia technique used for
caesarean section should preserve renal function and maintain
fluid balance and hemodynamic stability. We describe the
anesthetic management of a 30-year-old female patient with
CKD stage V for a caesarean section at 32 weeks of pregnancy.
CASE REPORT
A 30-year-old woman was referred for caesarean section
at 32  weeks of pregnancy. She was diagnosed to have CKD
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and a nephrologist at our institute, throughout the antenatal
period. She was managed medically in the antenatal period,
and dialysis was not initiated. At 31 weeks and 5 days of
pregnancy the hemoglobin was 7.9 g/dl and serum creatinine
was 5.6 mg/dl. The serum creatinine at 20 weeks was 3.8 mg/
dl. Though her serum potassium was within normal range it
showed an upward trend in the 31st week of pregnancy. There
was no change in the amount of urine output. An elective
caesarean section was planned when 32 weeks were completed.
The evening before surgery, the patient complained of
discomfort whereas breathing and on auscultation of the
chest, mild crepitations were noted. Her blood pressure was
124/78 mm of Hg and pulse rate was 100/min. Hematological
investigations showed a serum creatinine of 5.89 mg/dl,
potassium of 5 mmol/l, calcium of 9.4 mg/dl and International
Normalized Ratio of 0.90. Urine routine investigation showed
Specific gravity 1.010, pH 7.0, protein+, sugar++, ketones–,
nitrite+, occult blood-trace, pus cells 4-5/hpf, red blood cells
2-3/hpf and epithelial cells 10-12/hpf. The electrocardiogram
and the two-dimensional echocardiogram were normal.

DOI:
The anesthesia plan included insertion of dialysis catheter in the
10.4103/2249-4472.143878 right internal jugular vein under local anesthesia followed by
spinal anesthesia. In the operation theatre electrocardiogram,

Journal of Obstetric Anaesthesia and Critical Care / Jul-Dec 2014 / Vol 4 | Issue 2 81
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Kapoor, et al.: Anesthesia in cesarean section in chronic renal failure patient
noninvasive blood pressure, pulse oximetry, central venous
pressure (CVP) were monitored. The hemodialysis catheter
was inserted under ultrasound guidance. The patient was able
to lie down flat on the operation table without any discomfort.
On auscultation, the breath sounds were equal, and there
were no crepitations. The hemodialysis catheter insertion was
uneventful, and it was used intra-operatively to measure the
CVP. After preloading with 200 ml of normal saline, spinal
anesthesia was given with 8 mg hyperbaric bupivacaine at
L3-L4 intervertebral space using a 25 gauge spinal needle, in
left lateral position. The sensory block was assessed to be till
T6 level. The caesarean section was uneventful and a 1500 g
baby was delivered. The blood pressure remained stable around
120/70 mm of Hg and heart rate of 98 beats/min with an
initial fall after spinal which did not require any intervention.
The systolic blood pressure ranged between 90 and 120 mm
of Hg and diastolic blood pressure between 60 and 70 mm of
Hg. Intra-operatively 500 ml of normal saline was transfused.
Intra-operative blood loss was estimated to be around 100 ml.
For postoperative management, the patient was shifted to
Intensive Care Unit. She was initiated on heparin free dialysis
for 3 h along with transfusion of one unit of packed red blood
cells immediately after shifting. Her blood pressure was stable
at 130/70 mm of Hg and heart rate around 88 beats/min. As the
effect of spinal started wearing off she was given intravenous
paracetamol and a continuous infusion of intravenous fentanyl
at 20 µg/h while the dialysis continued. There was no adverse
sequel of spinal anesthesia like postdural puncture headache.
Patient required one more cycle of dialysis and one more unit
of blood was transfused during her stay. In due course of time,
the patient was discharged from the hospital.
DISCUSSION
Incidence of pregnancy in CKD patients has gradually
increased over the years to 1-7% possibly due to better
dialysis techniques leading to regular menstrual cycles and
improved fertility.[4] Pregnancy in CKD patients is known to
have poor outcomes both for the mother and the fetus and
correlates strongly with the stage of CKD and the amount
of proteinuria.[5] The renal function may deteriorate, and
hypertension can worsen and progress into preeclampsia or
eclampsia. Anemia, which worsens further in pregnancy, is
another cause for concern.
In these patients mean period of pregnancy has been
reported to be 32 weeks.[4] During preanesthetic workup,
other co-morbidities associated with renal failure should be
assessed thoroughly. On clinical examination, features of fluid
overload and uremia should be assessed. Blood investigations
82 Journal of Obstetric Anaesthesia and Critical Care / Jul-Dec 2014 / Vol 4 | Issue 2
for hemoglobin and hematocrit, platelet count, coagulation
profile, serum creatinine, urea, electrolytes and acid base
status should be carried out. Serum electrolytes are monitored
routinely in such patients and serum potassium value before
a caesarean section is essential. An electrocardiogram often
reflects the electrolyte disturbances. A two-dimensional
echocardiogram is useful in evaluating possible adverse
effect of CKD on cardiac function. Dialysis might be required
before caesarean section in order to optimize fluid volume
and electrolyte status. Presently there are no guidelines
regarding initiation of dialysis in a pregnant CKD patient.
Intensification of dialysis is known to improve the maternal
outcome but the extent of beneficial effect on the fetus is
yet to be clearly ascertained. Fetal distress due to dialysis
related hypotension has been reported.[6] Hence initiation of
dialysis in a pregnant female is the attending nephrologists’
prerogative. Our patient was not dialyzed in the antenatal
period but was dialyzed immediately after surgery along with
simultaneous infusion of blood. The blood urea nitrogen in
our patient was 43.9 mg/dl which is much below the target
level of 70 mg/dl set for initiating hemodialysis in such a
patient.[7]
For hypertension, methyl-dopa and calcium channel blockers,
beta-blockers, labetalol and hydralazine are usually used, while
angiotensin converting enzyme inhibitors and angiotensin
receptor blockers are avoided. Since diuretics can lead to
hypovolemia, they are used with caution. Our patient was not
on any antihypertensives. Anemia is a known complication
of CKD and is associated with cardiovascular morbidity.[8]
Hemoglobin and hematocrit are usually gradually corrected
in the antenatal period. Our patient was given erythropoietin
4000 units twice weekly. Platelet dysfunction is another feature
of renal failure which is known to improve with hemoglobin
correction.[9] Hence a recent coagulation profile should always
be done before caesarean section.
The anesthesia plan varies as per the patient profile. Factors
predisposing to hyperkalemia should be avoided. These
include administration of drugs like suxamethonium, acidosis,
hypercarbia, hypoxia, hypothermia, blood transfusion and
inadequate dialysis.
In general anesthesia, there is a possibility of altered drug
clearance leading to accumulation of active metabolites which
could be nephrotoxic. Delayed gastric emptying and altered
gastric pH increase the chances of aspiration pneumonitis.
The risk of anesthetic agents affecting the fetus leading to an
altered APGAR score should be considered. These neonates
often have intrauterine growth retardation, low birth weight
and are premature hence are prone to the adverse effects of
anesthetic agents.
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Kapoor, et al.: Anesthesia in cesarean section in chronic renal failure patient
Regional anesthesia can also be considered for these patients
if the coagulation profile is normal. Peripheral neuropathy
due to CKD should be looked for and documented. Both
epidural and spinal anesthesia have been reported to be safe
in these patients. Though sudden hypotension following
spinal anesthesia leading to decreased uterine blood flow is a
possibility, however, Modi et al. did not report any significant
fall in blood pressure in their case series.[10] Epidural anesthesia
with titration of doses to maintain stable hemodynamic has also
been described.[11] We preferred spinal anesthesia to minimize
the risk to the fetus. The patient had been hemodynamically
stable throughout the antenatal period and her urine output
was adequate. Hence, we postulated that in case there was
hypotension due to spinal anesthesia, fluid could be given
without precipitating pulmonary edema. In addition, we felt
that general anesthesia could aggravate the preexisting renal
disease due to delayed excretion of various metabolites.
Hemodynamic monitoring can be invasive or noninvasive
depending on the patients’ condition. We used the hemodialysis
catheter port for intra-operative CVP monitoring. Since the
blood pressure remained stable, arterial cannulation was not
performed at any stage of the surgery. If possible, arteries in
the upper limb should be preserved for future formation of
arteriovenous fistula. Postoperative dialysis with simultaneous
transfusion of blood was carried out to remove excess fluid and
to correct any rise in potassium.
To conclude, the anesthesia should be planned to preserve the
renal function of the mother and prevent any adverse effect
on the fetus.
Journal of Obstetric Anaesthesia and Critical Care / Jul-Dec 2014 / Vol 4 | Issue 2 83
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Cite this article as: Kapoor H, Krishnan KP, Rajeev K. Anesthetic management
for cesarean section in chronic renal failure. J Obstet Anaesth Crit Care
2014;4:81-3.
Source of Support: Nil, Conflict of Interest: None declared.