Introduction We report a case of end stage renal disease with two previous cesarean sections on regular hemodialysis who developed eclampsia.
Case report A 3rd gravida with 26 weeks gestation was admitted from the casualty on 11th November, 2004 at 6.30 AM for acute diarrhea of one day. She had two cesarean sections earlier. She was apparently normal till two years back, when in April 2002 she developed acute gastroenteritis, acute renal failure and cortical necrosis. She was on regular biweekly hemodialysis in our institution since then. When seen at 6 weeks of gestation she was advised termination of pregnancy which she refused and did not attend the antenatal clinic. She developed two episodes of generalised tonic clonic seizures soon after admission.
Keywords : end stage renal disease, hemodialysis, eclampsia
We report a case of end stage renal disease with two previous cesarean
sections on regular hemodialysis who developed eclampsia.
A 3rd gravida with 26 weeks gestation was admitted from the casualty on 11th November, 2004 at 6.30 AM for acute diarrhea of one day. She had two cesarean sections earlier. She was apparently normal till two years back, when in April 2002 she developed acute gastroenteritis,acute renal failure and cortical necrosis. She was on regular biweekly hemodialysis in our institution since then. When seen at 6 weeks of gestation she was advised termination of pregnancy which she refused and did not attend the antenatal clinic. She developed two episodes of generalised tonic clonic seizures soon after admission.
Her pulse rate was 100/minute and blood pressure 240/120 mmHg. Other systems were within normal limits except that she was in the postictal phase. The uterus was 26 weeks size, relaxed, and had nontender scar. The fetal heart was regular, and Bishop’s score was zero. The diagnosis was acute renal failure wih eclampsia. She was started on Pritchard’s magnesium sulphate regimen, nifedipine and antibiotics. Labor was induced with 50µg of misoprostol given vaginally 6 hourly.
Relevant investigations revealed - hemoglobin-10 g/dL. platelets - 1.4
lakh/mm3
, normal bleeding time, clotting time, and prothrombin time,
blood urea-139 mg/dL, serum creatinine – 7.8 mg/dL, uric acid - 9.7
mg/dL and liver function tests within normal limits. She underwent
hemodialysis in the afternoon and delivered a stillborn male fetus at
9.30 PM after the third dose of misoprostol. As placental expulsion
was incomplete blunt cuvettage without anesthesia was done to remove
retained pieces. Prophylactic rectal misoprostol 800µg was given to
prevent postpartum hemorrhage. Postdialysis blood urea and serum
creatinine were 64 mg/dL and 4.3 mg/dL respectively. She made a fast
recovery. Her blood pressure returned to normal. She underwent one
more dialysis on the 4th day and went home on the 5th day. Contraceptive
advice was given. She continues to have dialysis twice a week.
Child bearing, may be important to women with renal disease, but pregnancy has generally been regarded as carrying a very high risk in these women. Hypertension is the most common life-threatening problem.Pregnant women with serum creatinine levels of 1.4 mg/dL or greater are at risk for accelerated loss of renal function compared with women who do not become pregnant 1 . Women on dialysis have low fertility, which returns to normal following renal transplantation. For women on dialysis, the likelihood of a surviving infant is approximately 50% 2. Amoah and Arab 3 reported a pregnancy in a woman with complete anuria.Although she delivered prematurely, the fetal growth remained normal throughout gestation.
Women with end stage renal disease should be advised against pregnancy
in the first place. If at all they conceive, termination of pregnancy
should be recommended. If they opt for continuation of pregnancy
they should be monitored very closely with rigid blood pressure control
and regular hemodialysis.
