30yr primi lscs done in govt hospital ,after 5 hrs no urine output ,ARF ,all needfull done ,but useless no response Bp120/50,p100,rr16/min,oxygen saturation 89-90,forcefull breating Pls advice needfull

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HELLP most likely cause d/d HUS / TTP / Hepatitis /ITP/ anti phospholipid syndrome/ lupus flare/AFLP We require the presence of all of the following criteria to diagnose HELLP (Tennessee classification) [16]: ●Microangiopathic hemolytic anemia with characteristic schistocytes (also called helmet cells) on blood smear (picture 1). Other signs suggestive of hemolysis include an elevated indirect bilirubin level and a low serum haptoglobin concentration (≤25 mg/dL). ●Platelet count ≤100,000 cells/microL ●Total bilirubin ≥1.2 mg/dL (20.52 micromol/L) ●Serum AST >2 times upper limit of normal for local laboratory (usually >70 international units/L). Some investigators obtain alanine aminotransferase (ALT) levels instead of, or in addition to, AST levels. An advantage of the AST is that it is a single test that reflects both hepatocellular necrosis and red cell hemolysis. ●Severe renal insufficiency is suggestive of hemolytic uremic syndrome (HUS), which may be caused by a Shiga toxin-producing organism, complement regulatory defect (inherited or acquired), or drug. We do not treat HELLP syndrome with steroids. Initial observational studies and small randomized trials suggested use of glucocorticoids may be associated with more rapid improvement in laboratory and clinical parameters [37-40]. These findings were not supported by subsequent large, well-designed randomized, double-blind, placebo-controlled clinical trials evaluating the use of dexamethasone to improve maternal outcome in patients with HELLP syndrome Laboratory values may initially worsen following delivery. The time course of recovery from HELLP was evaluated in a series of 158 women with the disease [28]. Decreasing platelet counts continued until 24 to 48 hours after delivery, while serum LDH concentration usually peaked 24 to 48 hours postpartum. In all patients who recovered, a platelet count greater than 100,000 cells/microL was achieved spontaneously by the sixth postpartum day or within 72 hours of the platelet nadir. An upward trend in platelet count and a downward trend in LDH concentration should be seen by the fourth postpartum day in the absence of complications. Others have reported similar findings [63]. Recovery can be delayed in women with particularly severe disease, such as those with disseminated intravascular coagulation (DIC), platelet count less than 20,000 cells/microL, renal dysfunction, or ascites [19,64]. These women are at risk of developing pulmonary edema and renal failure.

Get the usg done look for ureters & renal pelvis, occasionally while taking the angles during start and end of suturing the uterine incision, ureters are included. This happens specially when uterine incision is extended during delivery. I was entangled Once in such a situation i tied the lt ureter and latter done usg revealed congenital absence of rt kidney. We immediately opened her again and released the tie. That is why i always say to exteriorise the uterus to close its wound, this precaution wd keep the ureters away

And during routine A/N USG ask your sonographer to mention the maternal renal status, what i am doing without fail

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Accepted urgent indications for RRT in patients with AKI generally include: ●Refractory fluid overload ●Hyperkalemia (plasma potassium concentration >6.5 mEq/L) or rapidly rising potassium levels ●Signs of uremia, such as pericarditis, encephalopathy, or an otherwise unexplained decline in mental status ●Severe metabolic acidosis (pH <7.1) ●Certain alcohol and drug intoxications

We electively initiate RRT prior to the development of severe electrolyte disturbances and volume overload. Thus, we favor electively initiating RRT in patients with K >5.8 to 6.0 mEq/L or severe metabolic acidosis (pH <7.2) despite optimal medical management and who show no sign that kidney function or metabolic acidosis is improving. We electively initiate RRT among patients who are repeatedly in positive fluid balance despite aggressive attempts at diuresis, particularly if they have increasing oxygen requirements. Observational studies have demonstrated an association between the severity of volume overload at the time of initiation of RRT and mortality risk [2-4]. In the absence of clinically significant uremic symptoms or specific indications such as severe electrolyte abnormalities or volume overload, the optimal timing of RRT initiation is controversial. We generally suggest not initiating RRT in the absence of these indications, particularly if the blood urea nitrogen (BUN) is <110 to 120 mg/dL.

The history may also suggest causes of prerenal AKI (such as hyperemesis gravidarum) or ATN/acute cortical necrosis (such as sepsis or hemorrhage related to obstetrical complications including placenta previa, prolonged intrauterine fetal death, or amniotic fluid embolism). All medications should be carefully reviewed. In addition to a careful history, physical examination, and medication review, we obtain the following tests: ●Dipstick urinalysis and microscopic analysis of sediment ●Quantitation of protein excretion by either 24-hour urine collection or by protein-to-creatinine ratio ●Urine culture ●Hemoglobin level and platelet count with peripheral blood smear to evaluate for microangiopathic hemolysis and thrombocytopenia ●Total, direct, and indirect bilirubin concentration; haptoglobin; and lactate dehydrogenase (LDH) to evaluate for hemolysis ●Serum aspartate aminotransferase (AST) and/or alanine aminotransferase (ALT) ●Renal ultrasound In addition to these tests, laboratory tests that suggest other, nonpregnancy-related causes of AKI may also be obtained (such as complement proteins C3, C4, antinuclear antibody [ANA], antineutrophil cytoplasmic antibody [ANCA], etc).

Thanks sir

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Did you check patency of the urinary catheter.Sometimes if catheter is blocked there will not be any collection in the bag.

I.Check urinary catheter patency. 2.Do USG KUB 3.DO Electrolytes estimation.4.platlet r only 27,000/cmm so do coagulation profile. 5 look for haemorrhage concealed/revealed. 6 maintain input/output 7.Think of drug reaction leading to acute renal failure ? Cefalosporines.

The treatment of AKI is supportive. Dialysis should be initiated based on the usual criteria for patients in the nonobstetric setting and particularly if oliguria is present

The most common postpartum infection is endometritis. It is usually due to mixed flora, including anaerobic, gram negative, and gram positive organisms.

Drug treatments reported to be equivalent to clindamycin plus gentamicin include cefotetan, cefoxitin, ceftizoxime, piperacillin with or without tazobactam, and ampicillin and sulbactam [3,65-68]. These drugs, particularly ampicillin and sulbactam, are used as the initial antibiotic choice in some hospitals.

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