ACUTE KIDNEY INJURY IN PATIENTS PRESENTING WITH PLACENTAL ABRUPTION AT TERTIARY CARE HOSPITAL

The comparison of the incidence of obstetric acute kidney injury (AKI) in this study and previous studies in developed countries over the past half-century demonstrates that the incidence of obstetric AKI in developed countries has significantly decreased from 40% of all cases to 10% of all cases. Nevertheless, it remains a major public health problem in developing countries. † Obstetric AKI accounts for approximately a quarter of dialysis needs in pregnancy and contributes significantly to maternal morbidity and mortality, with reported mortality rates between 30% and 60%. Large-scale observational studies from several countries, including Bangladesh and Pakistan, reported a prevalence of pregnancy-related AKI as high as 11%–36% in Pakistan during the past decade (9%–13% in neighbouring India 9. In a 25-year study from 1990 to 2014, obstetric causes were determined to be the cause of 25.6% of all AKI cases. Emerging facts hint that the changing pattern of AKI could be associated with an increasing trend of hypertensive disorders of pregnancy and treatment as well. In addition, the maternal mortality rate in pregnant women with ARF is increased by a factor of 4.5, the risk of cesarean delivery by 1.49, and the risk of stillbirth or perinatal death by a factor of up to four. ³

Placental abruption: This is the most important cause of significant bleeding in later pregnancy and is defined as the separation of a normally implanted placenta after 20 weeks of gestation and before delivery. Clinically, placental abruption is characterized by painful vaginal bleeding, uterine tenderness, and contractions, while placenta accreta is usually associated with painless vaginal bleeding, especially in the third trimester. ⁴ The condition is associated with high levels of perinatal morbidity and mortality, with reported rates of perinatal death as high as 20%–67%, depending on gestational age, birth weight, and severity of placental separation. ⁵ As such, it continues to hold its place as the leading cause of stillbirth and therefore the largest proportion of perinatal loss.

The precise etiology of placental abruption remains unknown, but maternal smoking, hypertensive disorders of pregnancy, intrauterine growth restriction (IUGR), advanced maternal age, male fetal sex, and a history of previous placental abruption have been consistently associated. ⁶ Other established risk factors include alcohol intake, cocaine use, and cigarette smoking. Although the relationship of these factors with placental abruption is well established, there is scant evidence regarding the association of opioid use and placental abruption. ⁷˒⁸

Several mechanisms have been proposed through which placental abruption may lead to acute renal dysfunction, including severe blood loss with resulting hypovolemia and hypotension; disseminated intravascular coagulation; systemic microvascular injury; and the release of inflammatory cytokines and vasoactive mediators that result in renal ischemia and damage138. ⁹˒¹⁰ It is unclear, however, whether this kidney injury is fully reversible or whether it causes a permanently increased risk of renal impairment in affected women.

AKI has long been recognized as a transient and reversible process. However, an already accumulating body of data suggests a relationship between AKI and an increased risk of post-AKI chronic kidney disease (CKD) and permanent renal impairment. AKI has become a significant cause of maternal morbidity, mortality, and adverse fetal outcomes among obstetric populations. There is an obvious clinical significance to this problem, yet few local or international data exist from studies specifically investigating the burden of acute kidney injury (AKI) in women with placental abruption. Determining the prevalence of acute kidney injury (AKI) and its associated factors in this population is crucial to improving risk stratification, guiding preventive measures, and the development of management strategies to reduce maternal and fetal complications.

It was an observational descriptive cross-sectional study carried out over 6th months from April 2025 to October 2025 in the Department of Obstetrics and Gynaecology, Civil Hospital Karachi, after approval from the Institutional Ethical Review Committee and CPSP. The objective of this study was to assess the prevalence of AKI among women with placental abruption.

A Non-probability consecutive sampling technique was used to enrol a total of 139 pregnant females. Eligible women were aged 20–45 years at presentation with singleton pregnancies with a cephalic fetal presentation, a gestational age of ≥20 weeks, parity and gravidity of ≥1, and placental abruption as a confirmed diagnosis at presentation. Women with a history of nephrotoxic drugs, diabetes mellitus, sepsis, diarrhea, connective tissue disorders, vasculitis, or autoimmune diseases would be excluded. Hypertensive disorders of pregnancy data were collected through a comprehensive history and chart review.

Sample size The sample size was calculated based on anticipated acute kidney injury frequency,4 to be 10%, with a 95% confidence interval and a margin of error of 5%, and a minimum required sample size of 139 participants, using the WHO sample size calculator.

Following informed consent, demographic and clinical data were captured on a pro forma. Venous blood samples were obtained at admission under aseptic technique and then sent to the hospital laboratory for serum creatinine determination. Urinary output was measured and recorded in ml/hr by a calibrated measuring container. Patients were then followed up during their hospital stay until discharge.

Acute kidney injury was diagnosed using accepted international clinical criteria and was defined to be present if at least one of the following conditions developed during the hospitalization: (1) an increase in serum creatinine by > 0.3 mg/dL within 48 h compared to baseline values obtained at admission or documented within the last six months; or (2) an increase in serum creatinine by> 50% within 7 days compared to baseline values; or (3) a decrease in urine output to < 0.5mL/kg/h for at least 6h, based on the direct urine output monitoring chart.

Data were entered and analysed using Statistical Package for the Social Sciences (SPSS) version 27. Data was described as mean ± standard deviation for quantitative variables and frequency and percentage for qualitative variables. We conducted stratification by potential effect modifiers, including maternal age, gestational age, inter-pregnancy interval, gravidity, and parity. The Chi-square test and Fisher’s exact test were used to evaluate post-stratification associations between categorical variables. A p-value ≤ 0.05 was used as a criterion for statistical significance.

1.      Akhtar T, Shaikh SN, Bhutto A. FREQUENCY OF ABRUPTION PLACENTA IN GRAND MULTIGRAVIDA. Pak Armed Forces Med J. 2020 Jan. 27 [cited 2026 Feb. 8];70(Suppl-1):S74-77.

2.      Kister TS, Remmler J, Schmidt M, Federbusch M, Eckelt F, Isermann B, et al. Acute kidney injury and its progression in hospitalized patients-Results from a retrospective multicentre cohort study with a digital decision support system. PLoS One. 2021 Jul 12;16(7):e0254608. doi: 10.1371/journal.pone.0254608.

3.      Naqvi R. Epidemiological trends in community acquired acute Kidney Injury in Pakistan: 25 years Experience from a Tertiary Care Renal Unit. Pak J Med Sci. 2021 Mar-Apr;37(2):312-319. doi: 10.12669/pjms.37.2.3876.

4.      Prakash J, Niwas SS, Parekh A, Pandey LK, Sharatchandra L, Arora P. Acute kidney injury in pregnancy in developing countries: etiology and outcome. J Obstet Gynaecol Res. 2017;43(4):623-629.

5.      Novotny S, Lee-Plenty N, Wallace K, Kassahun-Yimer W, Jayaram A, Bofill JA, Martin JN Jr. Acute kidney injury associated with preeclampsia or hemolysis, elevated liver enzymes, and low platelets syndrome. Pregnancy Hypertens. 2020 Jan;19:94-99.doi: 10.1016/j.preghy.2019.11.010.

6.      Piccoli GB, Zakharova E, Attini R, Ibarra Hernandez M, Covella B, Alrukhaimi M, et al. Acute Kidney Injury in Pregnancy: The Need for Higher Awareness. A Pragmatic Review Focused on What Could Be Improved in the Prevention and Care of Pregnancy-Related AKI, in the Year Dedicated to Women and Kidney Diseases. J Clin Med. 2018 Oct 1;7(10):318. doi: 10.3390/jcm7100318.

7.      Prakash J, Ganiger VC, Prakash S, Iqbal M, Kar DP, Singh U, Verma A. Acute kidney injury in pregnancy with special reference to pregnancy-specific disorders: a hospital based study (2014-2016). J Nephrol. 2018 Feb;31(1):79-85. doi: 10.1007/s40620-017-0466-y

8.      Naqvi R, Ahmed E, Sheikh R, Rizvi A. Obstetrical acute kidney injury: 25 years’ experience from nephrology care unit in Pakistan. Open Access Library J 2015; 2(8):1-7. doi: 10.4236/oalib. 1101778.

9.      Zafar S, Jaleel R, Lodhani KK. Frequency of factors leading to acute renal failure in obstetric patients. Professional Med J 2021; 28(5):640-46.doi.org/10.29309/TPMJ/2021.28.05.4204

10.   Mohammad N, Qazi Q, Liaqat N. Frequency of adverse perinatal outcomes in patients with pregnancy related acute renal (kidney) injury in a tertiary care hospital. Pak J Med Sci. 2024;40(10):2267-2270. doi: https://doi.org/10.12669/pjms.40.10.9228

11.   Trakarnvanich T, Ngamvichchukorn T, Susantitaphong P. Incidence of acute kidney injury during pregnancy and its prognostic value for adverse clinical outcomes: A systematic review and metaanalysis. Medicine (Baltimore). 2022;101(30):e29563. doi: 10.1097/ MD.0000000000029563

12.   Bentata Y, Housni B, Mimouni A, Abouqal R. Obstetric acute renal failure in an intensive care unit in Morocco. Int J Gynaecol Obstet. 2011; 115(2):196-8.

13.   Huang C, Chen S. Acute kidney injury during pregnancy and puerperium: A retrospective study in a single centere. BMC Nephrol 2017; 18(1):146. doi: 10.1186/s12882-017- 0551-4.

14.   Silva GB Jr, Monteiro FA, Mota RM,. Acute kidney injury requiring dialysis in obstetric patients: A series of 55 cases in Brazil. Arch Gynecol Obstet. 2009; 279(2):131- 137.

15.   Miguil M, Salmi S, Moussaid I, Benyounes R. Insuffisance renale aigue hemodialysee en obstetrique. Nephrol Ther. 2011; 7(3):178-181.

16.   Drakeley AJ, Le Roux PA, Anthony J, Penny J. Acute renal failure complicating severe preeclampsia requiring admission to an obstetric intensive care unit. Am J Obstet Gynecol 2002; 18

17.   Mal P, Ahsan MN, Kumar M, Gurbukshani S, Fatima A, Khanzada I. Acute Kidney Injury Due to Obstetric Complications. J Coll Physicians Surg Pak 2023; 33(05):535-538.

18.   Ansari MR, Laghari MS, Solangi KB. Acute renal failure in pregnancy: one year observational study at Liaquat University Hospital, Hyderabad. J Pak Med Assoc. 2016;66(1):61-64.

19.   Mehrabadi A, Liu S, Bartholomew S, Hutcheon JA, Kramer MS, Liston RM. Hypertensive disorders of pregnancy and risk of severe maternal morbidity. Obstet Gynecol. 2015;125(4):905-912.

20.   Gammill HS, Jeyabalan A. Acute renal failure in pregnancy. Crit Care Med. 2015;43(3):720-726.

21.   Goplani KR, Shah PR, Gera DN, Gumber M, Dabhi M, Feroz A. Pregnancy-related acute renal failure: a single-center experience. Indian J Nephrol. 2018;18(1):17-21.

22.   Acharya A, Santos J, Linde B, Anis K. Acute kidney injury in pregnancy—current status. Adv Chronic Kidney Dis. 2020;27(6):508-517.

23.   Bentata Y. Acute kidney injury in pregnancy: current concepts and new insights. Nephrol Ther. 2019;15(5):315-324.