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Haemorrhage, hypertension and sepsis cause 75% of maternal death globally, and in Sierra Leone, and commonly cause acute kidney injury(AKI). Pregnancy related AKI (Pr-AKI) is a major preventable cause of maternal and fetal death (6 to 30% mortality rate) in low income countries (LICs). Early detection enabling prompt access to specialist management reduces the need for renal replacement therapy and Pr-AKI related mortality, but is challenging in LICs. Poor access to reliable serum creatinine testing, commonly leads to late or missed Pr-AKI diagnosis. Novel approaches, including access to point-of-care creatinine (POC-Cr) testing for pregnant women in LICs, are required.
A 30 year-old woman, with no past medical, family or social history, was admitted 6 hours post spontaneous vaginal delivery of a live male baby, to a tertiary maternity hospital in Freetown, with ‘chest congestion, difficulty breathing, dizziness, palpitations and headache.’ On examination she was alert, in mild respiratory distress, with bilateral fine crepitations and reduced air entry in the lower lung fields. Her abdomen was soft, with no organomegaly and mild suprapubic tenderness. Her uterus was well contracted, with no vaginal bleeding and normal lochia. (Admission observations:Table 1). She was diagnosed with possible postpartum pre-eclampsia, with differentials of pneumonia and Covid-19, and transferred to high dependency unit. Furosemide, antibiotics, magnesium sulphate protocol, antihypertensive medications and oxygen therapy were administered. She deteriorated, with increasing oxygen requirement to 10L, and negligible urine output. Laboratory testing was unavailable but a novel POC creatinine test, undertaken as part of a research study, found creatinine >620 umol/L. She was prescribed an increased dose of furosemide, started on Continuous Positive Airway Pressure, and referred for specialist nephrology input at a tertiary hospital. After transfer she was pale, in respiratory distress, with distended neck veins, bilateral pedal pitting oedema, widespread bilateral chest crepitations and suprapubic tenderness (Laboratory findings:Table 1). Abdominopelvic ultrasound scan reported a non-visualized left kidney. The uterus was bulky with cystic and echogenic solid material in the endometrial cavity. A diagnosis of Pr-AKI secondary to puerperal sepsis from retained products of conception was managed with vacuum aspiration of pregnancy tissue, antibiotics, fluid restriction and diuretics. She underwent 5 sessions of dialysis with ultrafiltration. Her urine output improved and she was discharged on day 14. Ten months after, repeat POC-Cr was 105 umol/L.
Pr-AKI detection was facilitated by access to a novel POC-Cr test, which prompted referral for specialist nephrology care and hemodialysis at the only public hemodialysis facility in SL. In high income countries, POC testing has improved healthcare outcomes and cost-efficiency (e.g. glucose monitoring) as results are immediately available with limited training requirements. POC-Cr has demonstrated validity, ease of use, improved efficiency and cost-efficiency in non-pregnant patients, including in LICs, but never in a pregnant population, which needs exploration. This case highlights its potential to improve diagnosis and guide life-saving management.