ACUTE RENAL FAILURE

IN PREGNANCY

DR SWETA SINGH
ADDITIONAL PROFESSOR
OBSTETRICS AND GYNAECOLOGY
AIIMS BHUBANESWAR
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SPECIFIC LEARNING OBJECTIVES
• Causes of AKI in pregnancy

• Key management principles

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RENAL CHANGES IN NORMAL
PREGNANCY

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 RENAL DISORDERS IN
PREGNANCY

• Urinary tract infection

• Chronic renal disease

• Acute renal failure

• Pregnancy in renal transplant recipients

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URINARY TRACT INFECTION IN
PREGNANCY

• Asymptomatic bacteriuria

• Acute cystitis

• Acute pyelonephritis

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CHRONIC RENAL DISEASE IN
PREGNANCY
Diseases: Factors determining pregnancy outcome:
• Chronic glomerulonephritis
• Hypertension predating pregnancy
• IgA nephropathy
• Chronic pyelonephritis
• Urolithiasis • Renal function:
• Polycystic kidneys • Mild impairment: S Cr < 1.5mg%
• Pheochromocytoma
• Moderate impairment: S Cr 1.5-3mg%
• Diabetic nephropathy
• Severe impairment: S Cr >3mg%
• Wegener’s granulomatosis
• Renal artery stenosis
• Takayasu arteritis • Type of disease
• Lupus nephropathy (SLE)
• Periarteritis nodosa
• Scleroderma
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ACUTE RENAL FAILURE IN
PREGNANCY
• Pregnancy-related acute kidney injury (AKI) is acute kidney injury
occurring during pregnancy, labor and delivery, and/or the
postpartum period

The two categories are:

• Diseases or conditions that are specific and unique to pregnancy
• Diseases or conditions that happen to coincide with pregnancy (i.e.,
not pregnancy-specific)

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CLINICAL FEATURES OF AKI IN
PREGNANCY
• AKI is a clinical diagnosis based on the abrupt deterioration in
kidney function

• Despite efforts to standardize the definition in the general

literature, AKI has been variably defined during pregnancy,
ranging from serum creatinine levels of greater than 0.8 mg/dL
or doubling of the serum creatinine to dialysis requirement

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CAUSES OF AKI IN PREGNANCY

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CAUSES OF AKI IN PREGNANCY

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AKI: POST DELIVERY DAY3

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CHALLENGES OF AKI IN
PREGNANCY
Management of AKI in pregnancy is challenging as:
a. Both maternal and fetal health must be considered

b. The cardiovascular and renal adaptations of pregnancy add to the

complexity of diagnosis and management

c. A multi-disciplinary team (Critical care specialist, obstetrician,

nephrologist, neonatologist) is often needed to optimize all aspects
of the pregnant woman’s care

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KEY MANAGEMENT PRINCIPLES
1. Stabilize the patient

2. Treat the underlying cause

3. Prevent progression of kidney damage

4. Maintain supportive care

5. Optimize fetal health

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 MANAGEMENT OF AKI IN PREGNANCY
1. STABILISE THE PATIENT

• Basic assessment of airway, breathing and circulation

(Emergency situations)

• Assess and restore hemodynamic stability

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 MANAGEMENT OF AKI IN PREGNANCY:
2.IDENTIFY AND TREAT UNDERLYING CAUSE
• Commonest cause of AKI in pregnancy: Reduced renal perfusion
• Pregnancy specific causes of AKI :
1. Hypertensive disorders of pregnancy
• Preeclampsia
• Eclampsia
• HELLP syndrome
• Acute fatty liver of pregnancy
• Thrombotic thrombocytopenic purpura/hemolytic uremic syndrome
(TTP/HUS)
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D/D AFLP/HELLP/TTP/HUS

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 MANAGEMENT OF AKI IN PREGNANCY:
2.IDENTIFY AND TREAT UNDERLYING CAUSE
• 2.Volume depletion:
a) Obstetric hemorrhage – Uterine blood flow increases from 50 cc/min prior to
pregnancy to approximately 1000 cc/min at term. Causes include:
• Induced or spontaneous abortion
• Ectopic pregnancy
• Placenta previa
• Placental abruption
• Intra- or post-partum hemorrhage

• b)Hyperemesis gravidarum –Very severe, refractory, and untreated cases can lead to
severe dehydration, hypovolemia and prerenal AKI
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 MANAGEMENT OF AKI IN PREGNANCY:
2.IDENTIFY AND TREAT UNDERLYING CAUSE
• 3. Infection:
• Pyelonephritis – This occurs in 1-2% of pregnancies and is associated with maternal and
fetal complications including sepsis, preterm labor and adult respiratory distress
syndrome.
• Chorioamnionitis – Intrauterine infection involving the chorion and amniotic
membranes. This most commonly results from ascending infection of organisms
colonizing the lower genital tract.
• Septic abortion – This has become less common, but it is still a significant cause of
maternal mortality and morbidity, including AKI
• Pneumonia

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 MANAGEMENT OF AKI IN PREGNANCY:
2.IDENTIFY AND TREAT UNDERLYING CAUSE
•4. Obstruction – Although uncommon in pregnancy, the overdistended, gravid uterus is a risk
factor. Additional contributors are:
•Polyhydramnios (increased amniotic fluid)
•Multi-fetal gestation (twins and higher)
•Large uterine fibroids

•5. Cardiovascular collapse – While any cardiovascular collapse can lead to AKI during
pregnancy, amniotic fluid embolism or “anaphylactoid syndrome of pregnancy” occurs only
in pregnancy
• It presents suddenly with fulminant respiratory failure, hypoxemia, cardiogenic shock, and
hypotension, and is often accompanied by disseminated intravascular coagulation and multi-
organ failure
•Maternal mortality is estimated to be as high as 60%

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 MANAGEMENT OF AKI IN PREGNANCY
3. PREVENT PROGRESSION OF KIDNEY DAMAGE
• Maintain adequate renal perfusion to
limit ongoing damage and reverse any
pre-ischemic changes
• Volume resuscitation should be
accomplished with intravenous
crystalloid or colloid solutions as well
as blood and blood products as
indicated
• Volume status should be monitored
clinically, with close attention to urine
output and pulmonary function
• Invasive hemodynamic monitoring in
an ICU setting is often warranted
• All nephrotoxic medications should be
stopped or the dose adjusted to prevent
further renal damage
• Pharmacologic therapies to prevent
progression of renal decline are largely
secondary
• Vasoactive and diuretic medications may
affect fetal well-being by reducing uterine
blood flow and placental perfusion
• Post-renal causes of progressive renal
injury such as obstruction of the urinary
tract by the pregnant uterus can be
relieved by ureteral stents, percutaneous
nephrostomy, or delivery, if indicated.
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 MANAGEMENT OF AKI IN PREGNANCY
4. MAINTAIN SUPPORTIVE CARE
• Hyperkalemia – should be promptly corrected using glucose/insulin
or potassium-binding resins such as polystyrene sulfonate

• Metabolic acidosis – Intravenous bicarbonate can be used for acute

correction of acidosis while the underlying cause is being treated

• Anemia – acute treatment is with red blood cell transfusion.

Exogenous erythropoietin may be considered for chronic anemia.

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 MANAGEMENT OF AKI IN
PREGNANCY
4. MAINTAIN SUPPORTIVE CARE
• Renal replacement
therapy/dialysis – Indications for
renal replacement therapy in
pregnancy are similar to those in
the nonpregnant patient:
a. Volume overload
b. Hyperkalemia refractive to
medical management
c. Metabolic acidosis
d. Symptomatic uremia
• Hemodialysis is generally used in the
acute setting.
• Recommendations in pregnancy:
a. Increase in dialysis time and
frequency
b. Keeping serum urea <45-60 mg/dL
c. Minimizing fluid shifts and
hypotension, which can affect fetal
well-being.
• Renal replacement therapy is often
short term in AKI in pregnancy until
there is recovery of renal function
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 MANAGEMENT OF AKI IN PREGNANCY
5.OPTIMIZE FETAL HEALTH
• In general, maternal health takes priority; however, the fetal condition should be optimized
whenever possible
• Fetal well-being and neonatal outcomes are closely linked to maternal status. Adequate blood
flow to the uterus and feto-placental unit are key factors in preventing fetal compromise; as such,
intravascular volume depletion should be avoided and hypotension treated promptly
• Fetal monitoring –
• For viable pregnancies (greater than 23-24 weeks of pregnancy), fetal well-being should be
assessed at least daily
• Fetal heart rate monitoring (continuous or intermittent) and/or biophysical profile evaluation by
ultrasound may be used depending on the clinical situation
• If preterm delivery is indicated after 24 weeks but prior to 34 weeks, then antenatal
glucocorticoids should be administered
• Maternal-fetal medicine specialists and neonatologists should be closely involved if preterm
delivery is a consideration
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CONCLUSION

CAUSES OF AKI IN PREGNANCY KEY MANAGEMENT PRINCIPLES

1. Stabilize the patient

2. Treat the underlying cause

3. Prevent progression of kidney damage

4. Maintain supportive care

5. Optimize fetal health

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Thank You
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