Pushpalata Sachan

Acute renal failure in pregnancy: Tertiary centre experience from north Indian population

Background: Obstetrical acute renal failure ARF is now a rare entity in the developed countries but still a common occurrence in developing countries. Delay in the diagnosis and late referral is associated with increased mortality. This study aimed to evaluate the contributing factors responsible for pregnancy-related acute kidney failure, its relation with mortality and morbidity and outcome measures in these patients. Materials and Methods: Total 520 patients of ARF of various aetiology were admitted, out of these 60 (11.5%) patients were pregnancy-related acute renal failure. Results: ARF Acute renal failure occurred in 32 (53.3%) cases in early part of their pregnancy, whereas in 28 (46.7%) cases in later of the pregnancy. Thirty-two (53.3%) patients had not received any antenatal visit, and had home delivery, 20 (33.4%) patients had delivered in hospitals but without antenatal care and eight (13.3%) patients received antenatal care and delivered in the hospitals. Anuria was observed in 23 (38.3%) cases, remaining 37 (61.7%) cases presented with oliguria. Septicemia was present in 25 (41.7%), hypertensive disorder of pregnancy in 20 (33.3%), haemorrhage in eight (13.3%), abortion in 5 (8.3%), haemolysis elevated liver enzymes low platelets counts (HELLP) syndrome in one (1.67%) and disseminated intravascular coagulation in one (1.67%). (61.7%) patients were not dialyzed, 33 (55%) recovered normal renal function with conservative treatment. Complete recovery was observed in 45 (75%) patients, five (8.4%) patients developed irreversible renal failure. Maternal mortality was nine (15%) and foetal loss was 25 (41.7%). Conclusion: Pregnancy-related ARF is usually a consequence of obstetric complications; it carries very high morbidity and mortality.

correlation of serum neutrophil gelatinase- associated lipocalin with acute kidney injury in hypertensive disorders of pregnancy

Hypertensive disorders of pregnancy (HDP) remain one of the largest single causes of maternal and fetal morbidity and mortality, accounting for 16.1% of maternal deaths in developed countries. The aim of the study was to evaluate acute kidney injury (AKI) in hypertensive disorders of pregnancy and to examine the correlation of serum neutrophil gelatinase-associated lipocalin (NGAL) with acute kidney injury. This prospective case control study was carried out over a period of 1 year. After written, informed consent and ethical clearance, 149 cases of hypertensive disorders of pregnancy were screened, and seven were lost to follow-up. Acute kidney injury was detected in 88 cases and acute renal failure in 30 cases of HDP. Thirty-one healthy pregnant nonhypertensive women were enrolled as controls. Quantitative measurement of serum NGAL levels was done by enzyme linked immunosorbent assay technique using a sandwich enzyme-linked immunosorbent assay kit. As per the Kidney Diseases Improving Global Outcomes International guidelines acute kidney injury network (AKIN), 50 cases (42.37%) of AKI stage I, 38 (32.2%) cases of AKI stage II, and 30 (25.42%) cases of renal failure were detected. Serum NGAL had a positive association with increasing proteinuria. It also had a positive correlation with systolic blood pressure (r∼0.36), diastolic blood pressure (r∼0.37), and serum creatinine (r∼0.4). NGAL was found to be significantly correlated with creatinine in the cases with the value of the correlation coefficient being 0.4. This direct correlation might be a consequence of endothelial dysfunction on which hypertension and proteinuria probably depends.

Outcomes in hypertensive disorders of pregnancy in the North Indian population.

Introduction: Hypertensive disorders complicating pregnancy seriously endanger the safety of the mother and fetus during pregnancy. Very few studies have explored hypertensive disorders of pregnancy in India, even though this disease has been associated with adverse maternal and perinatal outcomes. This study aimed to analyze the disease pattern and risk factors associated with the disorder and assess the maternal and fetal outcomes in cases of hypertensive disorders of pregnancy. Subjects and methods: This case-control study was carried out over 1 year from 2011 to 2012 at the Department of Obstetrics and Gynecology, King George’s Medical University, Lucknow, Uttar Pradesh, India. A total of 149 patients were enrolled in the study. As seven were lost to follow-up, analysis was carried out on 142 cases. Patients were further classified according to the National High Blood Pressure Education Program Working Group (2000) as having mild preeclampsia (65 cases), severe preeclampsia (32 cases), or eclampsia (45 cases). Thirty-one healthy pregnant non-hypertensive women were enrolled into the study as controls. Results: The most common manifestation was edema, seen in 90% of cases. Proteinuria was also relatively common, 26.76% of patients with proteinuria of ≥300 mg/24 hours, 47.88% with proteinuria of ≥2 g/24 hours, and 25.35% with a urinary protein excretion of 3–5 g/24 hours. Central nervous system involvement was observed in 42.2% of cases, elevated bilirubin levels in 47.0%, visual symptoms in 6.4%, vaginal bleeding in 11.3%, and HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome was reported in 2.80%. Maternal deaths occurred in 2.8% of cases, all of which were from the eclampsia group. Stillbirths occurred in 16.9% of cases, and overall neonatal death observed in 4.23% of cases. Conclusion: Women with hypertensive disorders of pregnancy were more prone to adverse maternal and fetal outcomes than normotensive pregnant women, but we observed a decreasing trend in the present study compared with that reported in other studies, which might be due to the increased number of hospital deliveries that occurred in our study.

Complete axial torsion of pregnant uterus with leiomyoma.

Uterine torsion is defined as a rotation of the uterus of more than 45° along its long axis. It is a rare complication during pregnancy; a common cause of torsion can be uterine myoma. Here we describe the case of a 27-year-old G2P1+0 woman at 15 weeks 3 day pregnancy, who presented to our outpatient department as a case of acute abdomen, in a state of shock. Clinical findings did not correlate with investigation. On lapratomy she was diagnosed as a case of complete axial torsion of pregnant uterus with fundal myoma with massive abruption. Early diagnosis and timely intervention would help in improving both maternal and fetal outcome.

Correlation of serum neutrophil gelatinase associated lipocalin with disease severity in hypertensive disorders of pregnancy

Background: Vascular endothelial dysfunction is considered central to the pathogenesis of hypertensive disorders of pregnancy (HDP). Serum level of neutrophil gelatinase-associated lipocalin (NGAL) is closely related to endothelial injury. The aim of this study was to examine the correlation of serum NGAL with disease severity in HDP. Materials and Methods: This prospective case-control study was carried out for one year. After informed consent, ethical clearance, total 1,850 pregnant women were screened. Analysis was performed on 142 cases of HDP and 31 healthy controls. Quantitative measurement of serum NGAL levels was done by the enzyme linked immunosorbent assay (ELISA) technique, by using sandwich ELISA kit. Results: Mean serum NGAL value in patients with oliguria was significantly higher when compared with non-oliguric patients (P < 0.001). Serum NGAL had a positive correlation with systolic blood pressure (r ~ 0.5973), diastolic blood pressure (r ~ 0.6195), blood urea (r ~ 0.4392), serum creatinine (r ~ 0.6112), serum uric acid (r ~ 0.3878). Sensitivity and specificity of serum NGAL using a cut-off value of 545 pg/ml, for the diagnosis of HDP, was 97.89% and 93.55% respectively, using 95% confidence interval. Conclusion: Between the two groups, we found that serum NGAL had a positive correlation with disease severity and better sensitivity and specificity in the evaluation of HDP.

Prognostic significance of urinary NGAL in chronic kidney disease.

Background Chronic kidney disease (CKD) is a worldwide public health problem. Recently urinary NGAL (uNGAL) has been proven to be a useful (potentially ideal) biomarker for early detection of CKD. The aim of the present study was to examine the correlation of uNGAL with severity of renal impairment in CKD and to evaluate its prognostic value in these subjects. Methods This was a prospective study carried out over a period of 24 months in subjects with CKD due to primary chronic glomerulonephritis. New cases of CKD stage II, III, IV aged between 18 and 65 years were enrolled as per KDIGO (Kidney Disease: Improving Global Outcomes) guidelines 2012. A total of 90 subjects completed the study up to the end-point. The primary follow-up end-point was 18 months, or decreased glomerular filtration rate of less than 15 mL/min. Secondary follow-up end-point was the number of subjects who expired during this period. Results Multiple regression model of estimated glomerular filtration rate showed significant associations with log uNGAL (β=0.38, P<0.001), Ca×PO4 (β=0.60, P<0.001), hemoglobin (β=0.37, P<0.001), urine protein (β=0.34, P<0.001), serum albumin (β=0.48, P<0.001), and systolic blood pressure (β=0.76, P<0.001). Receiver operator curve for uNGAL considering the progression of CKD showed area under the curve for uNGAL was 0.878 (95% confidence interval: 0.68–0.96). Cut-off value for uNGAL was log 3.5 unit with a sensitivity of 93.08% and specificity of 71.43% for predicting the progression of CKD. Kaplan–Meier survival curve showed that patients with log uNGAL levels <3.51 unit had a survival rate of 71.4% while patients with NGAL level >3.51 unit had a renal survival rate of 14.7%. Conclusion Our study result showed that uNGAL has a positive correlation with disease severity which signifies the prognostic importance of uNGAL in CKD.

Diagnostic accuracy of spot albumin creatinine ratio and its association with fetomaternal outcome in preeclampsia and eclampsia

Introduction: Hypertensive disorders in pregnancy are one of the leading causes of maternal and perinatal mortality. Proteinuria is one of the common and important features of preeclampsia. To evaluate the diagnostic accuracy of albumin-creatinine ratio (ACR) in woman with preeclampsia and eclampsia and examine the association between ACR and fetomaternal outcome. Materials and Methods: Prospective study carried out over a period of 1 year in the Department of Obstetrics and Gynaecology, after informed consent and ethical clearance total ninety pregnant women from gestational age 20 to 40 weeks were enrolled, including, thirty preeclampsia, thirty antepartum eclampsia, considered as cases and thirty normotensive pregnant women as controls. Preeclampsia was defined as per National High Blood Pressure Education Program 2000 working group. All patients were asked for a spot midstream urine sample, followed by 24 h urine collection. Urinary protein was estimated by the sulfosalicylic acid method and creatinine by the Jaffes method. The urinary ACR was determined by automated analyzer. Results: Mean value of urinary ACR of controls was significantly lower (0.103 ± 0.037) as compared to both groups. On comparing between groups the difference was significant (<0.001), a strong correlation between urinary ACR levels and 24 h urinary proteins was observed. Conclusion: In our study, an association of raised ACR values with severity of disease as well as with adverse fetomaternal outcome was observed.

Role of squamous cell carcinoma antigen in monitoring of treatment response of cervical and vaginal malignancies

Introduction: As per GLOBOCAN 2012 report Worldwide fourth most common cancer in the female is cervical cancer and approximately 528,000 new cases was found in 2012 in large majority of global burden was found in less developed country. India, the second most populous country in the world, accounts for 27% of the total cervical cancer deaths. The aim of this study was to assess the efficacy of squamous cells carcinoma antigen (SCC-Ag) in monitoring of response to treatment in cervical and vaginal cancer patients. Materials and Methods: This prospective case–control study was carried out over a period of 1 year in the Department of Obstetrics and Gynecology in collaboration with the Department of Internal Medicine and Pathology. Histopathologically confirmed study group included 8 cases of Stage I, 15 cases of Stage II, 15 cases of Stage III, 8 cases of Stage IV cervical malignancy, and 5 cases of vaginal carcinoma. About 15 healthy cervical cytology-negative women were taken as controls. Results: Out of 51 cancer cases SCC-Ag level were determined in only Stage I, II, III, and IV cases, assess the response to treatment. The mean SCC-Ag level in all four stage groups decreased significantly after post treatment as compared to pre treatment (P < 0.001) and the decrease in post treatment SCC-Ag level increased linearly with stage severity. Similarly, comparing the total or overall (Stage I + Stage II + Stage III) mean change (pre-post) in SCC-Ag level, t-test further revealed significant (P < 0.001) and decrease of 66.2% at posttreatment as compared to pretreatment. Conclusion: SCC-Ag might be a useful marker in monitoring the response to treatment.

Inevitable cesarean myomectomy and delivery of baby through the same incision

Leiomyoma is the commonly encountered benign tumor in women of reproductive age group. Cesarean myomectomy is associated with increased morbidity and mortality mainly due to the risk of associated hemorrhage. Although there are some case series that have demonstrated the safety of myomectomy during cesarean section, a 32-year-old female G2P1 + 0 was referred to the emergency department of obstetrics and gynecology with a complaint of pain in the lower abdomen with amenorrhea of 8 months. Her transabdominal ultrasound report showed a huge fibroid in the lower uterine segment of 16 cm × 12 cm × 14 cm predominantly in the anterior wall of the uterus. Here, cesarean myomectomy was done under spinal anesthesia before the delivery of alive and healthy male baby, weighing 3.0 kg successfully without any complication. Though the cesarean myomectomy is difficult and is associated with increased morbidity because of risk of associated hemorrhage; thus, we do not always recommend but it could be performed in unavoidable conditions

Cardiovascular risk factors in chronic kidney disease stage–V: A tertiary centre experience

Background: CKD is defined by the presence of kidney damage or decrease function irrespective of cause for three or more months. The term kidney failure is the end stage of CKD with severe reduced function or dialysis. CVD is the leading cause of morbidity and mortality in CKD patients, accounting for 40% of hospitalization and almost 50% of deaths. This Prospective cross sectional study was carried out over a period of one year. The aim of this study was to observe CKD specific cardiovascular risk factors and cardiovascular events among patients with CKD stage –V before initiation of dialysis. Methods: 290 CKD stage-V patients were evaluated as per inclusion criteria (age more than 18 years and patients with CKD stage-V (Estimated glomerular filtration rate (eGFR) <15ml/min/1.73m2 for more than three months). 5 ml of venous blood sample was collected after overnight fasting. The level of serum urea, creatinine, albumin, cholesterol, triglyceride, high density lipoprotein (HDL), low density lipoprotein (LDL), phosphorus, calcium, hemoglobin, glucose were measured. Spot urine samples were tested for albumin/ creatinine ratio (ACR). Estimated glomerular filteration rate was estimated using Modification of Diet in Renal Disease Results: Among traditional risk factors 87.9% had hypertension, and 22.4% had diabetes mellitus. Regarding dyslipidemia 44.6% had raised LDL cholesterol and 57.3% had showed increased triglyceride level. Anemia showed the highest prevalence (94.2%) among CKD specific factors. More than 50% of study population had hypocalcemia and hyperphosphoatemia. Prevalence of cardiovascular events in CKD-V patient showed that 20.5% had ischemic heart disease, 40% heart failure, 5.2% arrhythmias and 20% had left ventricular hypertrophy. More than half of patient had cardiovascular events about one third had single events and rest of the patient have two or more cardiac events. Conclusion: The result of this study suggests that both cardiovascular risk factors and events are prevalent among patients with CKD stage-V. Cardiovascular risk factors in chronic kidney disease stage-V: A tertiary centre experience