Management of women with chronic renal disease in pregnancy

Correlations between Maternal and Fetal Outcomes in Pregnant Women with Kidney Failure

BACKGROUND

Kidney function impairment in pregnancy is challenging, with incidence and prognosis only partially known. Studies concerning maternal and fetal outcomes in pregnancies occurring in patients with renal injury and the therapeutic strategies for improving the prognosis of these patients are scarce due to the limited number of cases reported.

OBJECTIVES

We aimed to establish correlations between the main maternal and fetal outcomes in patients with severe CKD or AKI in pregnancy to improve the prognosis, referring to a control group of patients with mild kidney impairment.

METHODS

For this purpose, we conducted a retrospective study, at University Emergency Hospital in Bucharest, Romania, from January 2019 until December 2021, selecting 38 patients with AKI and 12 patients diagnosed with advanced CKD, compared to 42 patients displaying borderline values of serum creatinine (0.8-1 mg/dL), reflecting the presence of milder kidney impairment.

RESULTS

The probability of having a child that is premature and small for gestational age, with a lower Apgar score and more frequent neonatal intensive care unit admissions, delivered by cesarean section, is higher in patients with highly reduced kidney function.

CONCLUSION

Severe kidney function impairment is associated with a grim fetal prognosis and obstetrical complications.

Haemolysis, elevated liver enzymes and low platelets: Diagnosis and management in critical care

A thirty-year-old pregnant woman was admitted to hospital with headache and gastrointestinal discomfort. She developed peripheral oedema and had an emergency caesarean section following an episode of tonic-clonic seizures. Her delivery was further complicated by postpartum haemorrhage and she was admitted to the Intensive Care Unit (ICU) for further resuscitation and seizure control which required infusions of magnesium and multiple anticonvulsants. Despite haemodynamic optimisation she developed an acute kidney injury with evidence of liver damage, thrombocytopenia and haemolysis. Haemolysis, Elevated Liver enzymes and Low Platelets (HELLP) syndrome, a multisystem disease of advanced pregnancy which overlaps with pre-eclampsia, was diagnosed. HELLP syndrome is associated with a range of complications which may require critical care support, including placental abruption and foetal loss, acute kidney injury, microangiopathic haemolytic anaemia, acute liver failure and liver capsule rupture. Definitive treatment of HELLP is delivery of the fetus and in its most severe forms requires admission to the ICU for multiorgan support. Therapeutic strategies in ICU are mainly supportive and include blood pressure control, meticulous fluid balance and possibly escalation to renal replacement therapy, mechanical ventilation, neuroprotection, seizure control, and management of liver failure-related complications. Multidisciplinary input is essential for optimal treatment.

Serious kidney disease in pregnancy: an Australian national cohort study protocol

BACKGROUND

Maternal kidney disease (acute kidney injury (AKI), advanced chronic kidney disease (CKD), dependence on dialysis or a kidney transplant) has a substantial impact on pregnancy, with risks of significant perinatal morbidity. These pregnancies require integrated multidisciplinary care to manage a complex and often challenging clinical situation. The ability to deliver optimal care is currently hindered by a lack of understanding around prevalence, management and outcomes in Australia. This study aims to expand an evidence base to improve clinical care of women with serious kidney impairment in pregnancy.

METHODS/DESIGN

The "Kidney Disease in Pregnancy Study" is a national prospective cohort study of women with stage 3b-5 CKD (including dialysis and transplant) and severe AKI in pregnancy, using the Australasian Maternity Outcomes Surveillance System (AMOSS). AMOSS incorporates Australian maternity units with > 50 births/year (n = 260), capturing approximately 96% of Australian births. We will identify women meeting the inclusion criteria who give birth in Australia between 1st August 2017 and 31st July 2018. Case identification will occur via monthly review of all births in Australian AMOSS sites and prospective notification to AMOSS via renal or obstetric clinics. AMOSS data collectors will capture key clinical data via a web-based data collection tool. The data collected will focus on the prevalence, medical and obstetric clinical care, and maternal and fetal outcomes of these high-risk pregnancies.

DISCUSSION

This study will increase awareness of the issue of serious renal impairment in pregnancy through engagement of 260 maternity units and obstetric and renal healthcare providers across the country. The study results will provide an evidence base for pre-pregnancy counselling and development of models of optimal clinical care, clinical guideline and policy development in Australia. Understanding current practices, gaps in care and areas for intervention will improve the care of women with serious renal impairment, women with high-risk pregnancies, their babies and their families.