risks of another preg with acute renal failure

[expert@preeclampsia.org]

I lost my little girl on April 30, 2007 at 33 weeks gestation due to an acute placenta abruption which clotted. I have factor V leiden and was on lovenox injections once a day. In addition, I developed pre-eclampsia at delivery. I also developed pre-e in a prior pregnancy 15 months ago. I am 39 years old and do not have chronic high blood pressure, do not smoke, drink or do any recreational drugs. There is a long span of time between my first two children and my third and fourth pregnancies and a change in fathers.

After delivery this time I was placed on magnesium sulfate. I knew rather quickly that something was wrong because I could not move on my own, could hardly speak and felt like a brick was on my chest. Unfortunately, the nurse didn't listen to me nor did she catch the warning signs...no reflexes especially since I am normally very reactive, little urine output. I quickly reached toxic levels of mag in my system. My blood was finally checked and I had a level of >14 (14 was the highest lab value) where a level of 7 is normal for this type of treatment (I do not know what the measurement is). It took 2 full days for the mag level to go below 14. It turns out that I suffered from acute renal failure. Nobody can tell me what caused it though the abruption is suspected. My creatinine levels were 2.9 at the highest and I was told that I was very close to receiving dialysis. I spent a week in the hospital for high blood pressure and poor kidney function.

It is now almost 6 weeks after delivery and my creatinine level was at 1.2 last week. I am told that my filtration is low, but nothing to be concerned with and I still have protein in my urine. The nephrologist said that I wouldn't have any lingering effects from the renal failure. But at the same time he said that I should not get pregnant again. My OB said that he would not deter me from another pregnancy as long as my kidneys do not show any signs of disease. I still have a lot of emotional healing to do, but he said that a six month wait is recommended.

I have a few of questions:
Could the toxic levels of magnesium sulfate created my kidney problems are evened worsened them if they were preexisting? What are the risks of another placenta abruption? Should I be on a higher amount of lovenox because I still clotted quickly? I assume that I will develop pre-eclampsia again so can I insist on steroid injections and is there anything I can do to reduce my chances? Most importantly, with the kidney failure, as long as my kidney function returned to normal would another pregnancy be out of the question and if not what types of testing should be done during the pregnancy? There is always a risk with pregnancy, but I do not wish to risk my life unnecessarily.

Thank you for the help.

[expert@preeclampsia.org]

There are questions for both nephrologists and obstetricians here and I will focus on the former. Also all answers are hypothetical as we do not have all the chart information here.

Abruption leads to two forms of acuter renal failure, the most common being acute tubular necrosis, but rarely acute cortical necrosis, usually of the “patchy” or incomplete variety. However the latter is usually associated with very severe initial degrees of functional failure and this patient never required dialysis. Acute renal failure is usually completely reversible, normal function returning in 2-3 weeks or sooner. Rarely, and especially if the failure occurred when minimal unrecognized chronic disease was present, recovery can be slower, thus the patient may have a lower creatinine level shortly.. Thus knowing the creatinine level before the abruption even in the remote past would help the analysis here. At any rate if this creatinine value signals residual mild renal dysfunction (Here a creatinine level of 1.2 mg% is a value that could conceivably be at the upper limits of normal in a large muscular individual, but unusual in women) and the abnormal proteinuria continues, her nephrologist will most certainly do further testing, including quantifying the creatinine clearance and proteinuria, respectively, and other tests they do in the face of persistant proteinuria, possibly even suggesting renal biopsy.

For advice on future conception it is better to await assurance we are at a steady state point, and no further evaluation is necessary. However mild dysfunction, with no or controlled hypertension is still associated with good pregnancy outcomes, the repeat preecampsia is more prevalent (here >25%). All this means is future pregnancies should be watched closely, best by a high risk OB specialist, and when renal disease is present the nephrologist should also be considered for the team

The reason the Mg rose so quickly is the kidneys were not functioning, but Mg does not aggravate preeixting disease.

There is an increased incidence of repeat abruption, but that is in the OB specialists’ domain.