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British Journal of Healthcare and Medical Research - Vol. 10, No. 6
Publication Date: December 25, 2023
DOI:10.14738/bjhmr.106.15839.
Ugwuene, F. O., Ayogu, M. O., & Nwobodo, E. I. (2023). Changes In Serum Electrolyte, Urea and Creatinine in Pregnant Women with
Prolonged Labour in Enugu State University Teaching Hospital, Enugu, Nigeria. British Journal of Healthcare and Medical Research,
Vol - 10(6). 200-208.
Services for Science and Education – United Kingdom
Changes In Serum Electrolyte, Urea and Creatinine in Pregnant
Women with Prolonged Labour in Enugu State University
Teaching Hospital, Enugu, Nigeria
Ugwuene, Francis O
Department of Medical Laboratory Science,
Enugu State University of Science and Technology (ESUT), Enugu, Nigeria
Ayogu, Martins O
Department of Medical Laboratory Science,
Enugu State University of Science and Technology (ESUT), Enugu, Nigeria
Nwobodo, Emmanuel I
Department of Medical Laboratory Science,
Enugu State University of Science and Technology (ESUT), Enugu, Nigeria
ABSTRACT
Prolonged labour or dystocia could be used to describe the inability of a woman to
proceed with child birth on time upon going into labour. Changes in electrolyte,
urea and creatine in pregnant women with labour and prolonged labour were
studied in Enugu State University Teaching Hospital, using 210 pregnant women.
Among the subjects, 70 were at term, 70 in early normal labour and 70 in prolonged
labour. They were grouped into three for study in the order stated above
respectively. The pregnant women were within the age groups of 20 and 39 years.
Group 1 (70, at third trimester without labour) was used as control to group 2, (70,
in early normal labour that ended in normal delivery), group 2 was used as control
to group 3 (70 in prolonged labour that ended in normal delivery). Serum
electrolytes, urea and creatinine were quantitatively analysed. Significant
decreases were observed in Serum potassium, bicarbonate and significant
increases in urea and creatinine of pregnant women at active labour that ended in
normal delivery when compared with those of the pregnant women at term without
labour. This work also showed a significant increase in Serum Potassium of
pregnant women with prolonged labour when compared with pregnant women at
active labour that ended in normal delivery(P<0.05). There were progressive
increases in Serum chloride, urea and creatinine while there were progressive
decreases in Serum bicarbonate from pregnant women at term with labour to
pregnant women with prolonged labour.
Keywords: Pregnant women, Prolonged Labour, electrolytes, urea and creatinine.
INTRODUCTION
The term prolonged labour or dystocia could be used to describe the inability of a woman to
proceed with child birth on time upon going into labour. There is yet no clear definition of
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Ugwuene, F. O., Ayogu, M. O., & Nwobodo, E. I. (2023). Changes In Serum Electrolyte, Urea and Creatinine in Pregnant Women with Prolonged
Labour in Enugu State University Teaching Hospital, Enugu, Nigeria. British Journal of Healthcare and Medical Research, Vol - 10(6). 200-208.
URL: http://dx.doi.org/10.14738/bjhmr.106.15839.
prolonged labour or dystocia and confusion of terms used by different authors still remain [1,
2]. Prolonged labour typically lasts for 20 hours for prima parae or prima gravide [3].
The codes of diagnosis and prevalence of dystocia can vary in different regions but it is more
common in developing countries [4]. This may partly be due to lack of adequate health care
delivery facilities, poor nutrition, poverty [5], and socio-cultural factors that oppose orthodox
antenatal care and delivery [6]. In most sub-Saharan African Countries, it has become a public
concern and major public resources are being used to manage this highly preventable obstetric
problem and its associate complications [7].
A number of reasons have been advanced for high prevalence of this problem in Nigeria,
including ignorance, poverty, poor public transport system and deficient health institutional
facilities and management [8].
Also, the incidence of this problem is likely to be high in the rural communities where those
contributing factors are not only more but are influenced by adverse cultural and religious
believes; and where birth labour is conducted by untrained personnel [1,9,10].
In stating the etiology of prolonged labour, it is pertinent to note that prima parous women are
more at risk of complication of pregnancy and child birth than the muti parous women [11].
Anatomically, many studies that examined anthropometric measures as predictors of
fetomaternal disproportion provides evidence that the shorter a woman is, the more likely is
significant disproportion between the fetus and the maternal pelvis, which results in prolonged
labour [12,13]. The obstetric significance of particular height needs to be related to patient’s
genetic background [14]. Soft tissue factors (tumors, full bladder, full rectum, vaginal septum,
fetus size, prominent spines or sacrum, narrow pubic arch) are parts of anatomical features
involved in labour. Although these conditions including psychological and will-power status
come to play, this work is mainly interested and emphatic on serum electrolyte, urea and
creatinine changes with dystocia for correlation with medical advice and management to
prevent dystocia or prolonged labour.
There is paucity of recent work and information on the electrolyte, urea and creatinine changes
and biochemical predictors of dystocia. However, it was reported that the concentration of
ionized calcium inhibits the myometrial response to oxytocin [15], a hormone of the posterior
pituitary gland. It exerts central and peripheral actions on the uterine myometrium, and plays
an essential role in the mechanism of parturition and lactation. It acts through its receptors, the
number of which increases in the uterus towards labour [16]. Electrolytes such as bicarbonates,
calcium, chloride, potassium, sodium etc are substances that become ions in solution and
acquire the capacity to conduct impulses that may aid labour [17].
While normal calcium level during labour, prompts the uterine muscle out of uterine inertia,
Potassium, the main electrolyte found in the body’s intra cellular fluid and stored in the muscle
fibres along with glycogen plays a key role of transporting glucose into the uterine muscle cells
for contractile energy [18]. As glycogen is also broken down to supply glucose to the uterine
muscle energy for contraction, potassium interacts with both sodium and chloride to control
fluid and electrolyte balance which assists in the conduction of nerve impulses required for
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British Journal of Healthcare and Medical Research (BJHMR) Vol 10, Issue 6, December- 2023
Services for Science and Education – United Kingdom
uterine contraction during labour [19, 18,]. When glycogen is broken down to supply energy
during prolonged labour, muscle cells, including uterine cells release potassium from the cells.
Hyperkalemia in dystocia and poor excretion by the kidney or poor fluid management are
disorders associated with cardiopulmonary arrests, capable of increasing mortality risk in
dystocia [18].
Apart from other implications of dystocia such as infections of the uterine tract [11], secondary
amenorrhea [20], haemorrhage and ruptured uterus, electrolytes derangements have been
noted to increase fetal risk of infection, fetal and maternal morbidity and mortality.
MATERIALS AND METHODS
This study was done at Enugu State University of Science and Technology, Parklane, Enugu
State of Nigeria. A total of two hundred and ten (210) subjects in the age of twenty (20) and
thirty-nine (39) years were used in the study. The subjects included both prima gravidae and
multigravidae. Written and informed consents were obtained from both the ethical committee
of the University Teaching Hospital and individual subjects. The women were grouped into
three. Group 1 included seventy (70) women at their third trimester term. Group 2 included
seventy (70) women who had normal labour which ended in normal delivery, while group 3
were seventy (70) women whose Labour had lasted beyond twelve hours who eventually
ended in normal delivery Group 1 was used as control to group 2 women whereas group 2
women were used as control to group 3 women. Venous blood was collected and allowed to
detract for serum collection. Necessary precautions were taken to ensure accuracy of
electrolyte results, such as ensuring that blood specimen was collected within very few seconds
after a tourniquet application and serum specimen was separated from the blood cells and
analyzed within one hour of collection. This is to avoid falsely increased results of potassium,
especially.
ELECTROLYTES: Potassium, chloride and sodium were analyzed using ion selective electrode
(ISE) technique. In this technique, the membrane electromotive force is determined by the
difference in concentration of the ion in the test solution and the internal filling solution. This
follows the principle of potentiometry, in which the transducer or sensor converts the activity
of specific ion dissolved in solution into an electric potential. The difference in potential that
exist between an indicator electrode and reference electrode is measured. [21, 22, 23]. The
ability to provide sensitive, reliable and inexpensive measurements of these clinically
important analytes on small sample volume in a biological sample within a very short time
frame has made ISE technique essential in clinical laboratory analysis [23].
UREA: Modified Berthelot method [24, 25] was used in the estimation of urea. This method uses
the biochemical principle of hydrolyzation of urea to ammonia and carbondioxide by urease
enzyme. The ammonia formed here further reacts with alkaline hypochlorite (Sodium
hypochlorite) to form a monochloroamine which in turn further reacts with phenolic
chromogens in the presence of a nitropruside (Sodium nitropruside) as a catalyst to form a blue
coloured complex at 37oc incubation. The intensity of the coloured complex formed is directly
proportional to the amount of urea present in the specimen. The nitropruside also enhances
the intensity of the blue coloured complex. The intensity of the coloured complexed is
determined by mathematically comparing the absorbance reading (optical density) of test and
standard in spectrophotometer at a wavelength of 630 nanometer (nm).
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Ugwuene, F. O., Ayogu, M. O., & Nwobodo, E. I. (2023). Changes In Serum Electrolyte, Urea and Creatinine in Pregnant Women with Prolonged
Labour in Enugu State University Teaching Hospital, Enugu, Nigeria. British Journal of Healthcare and Medical Research, Vol - 10(6). 200-208.
URL: http://dx.doi.org/10.14738/bjhmr.106.15839.
REACTIONS: The stages of reaction are given as shown below.
Urea (2H2NCONH2) + H20
urease
→ Ammonia (2NH3) + Carbondioxide (CO2)
2NH3 + hypochlorite (ocl) → Monochloroamine (NH2CL)
NH2CL + one phenol molecule → Benzoquinone monochloroamine(An intermediate
compound)
Benzoquinone Monoamine + 2nd Phenol Molecule
nitropruside
→ Blue coloured
in dophenol
OR
2H2NCONH3 + H20
Urease
→ 2NH3 + CO2
NH3 + OCL → NH2CL
[26, 27]
Nitropruside played very important roles in this reaction to produce indophenol. It is said that
the purpose of introducing nitropruside is to form aqua pentacynoferrate first, which serves as
the coupling reagent to accelerate the reaction. It is therefore more appropriate to consider
nitropruside as a reaction reagent rather than just a catalyst.
CREATININE: Jaffe Reaction for Alkaline Picrate method [28,29], was used for the quantitative
estimation of serum creatinine. The biochemical principle of this analytical techniques is based
on the fact that picric acid in alkaline medium reacts with creatinine to form an orange coloured
complex with the alkaline picrate. The intensity of the colour formed is directly proportional to
the amount of creatinine present in the Serum Specimen.
Creatine + Alkaline picrate
PH 9.2
→ Orange coloured complex
In their first systematic study of the chemistry of the Jaffe Reaction, Greenwald and Gross, 1925,
suggested that the orange colour was due to a salt of creatinine, piaric acid and sodium
hydroxide formed as a result of a keto-enol transformation in creatinine molecule. It should be
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noted that beyond 15 minutes of incubation at room temperature, Jaffer reaction is not specific
for creatinine
DATA ANALYSIS
These were done using student t- test for comparism of two group of results and anova for
comparism of three group of results at 95% level of significance (Pc 0.05)
RESULT
The result obtained from the research work are as shown in the tables below.
Table 1
Parameters Group 1: Pregnant women at
term without labour (control)
n=70 mean + SD
Group 2: Pregnant women at active
labour that ended in normal delivery
n = 70 mean+SD
P.
Value
Sodium (mmoL/L) 143.43 + 1.78 143.22 + 11.9 0.171
Potassium (“) 143.43+ 0.44 3.57 + 0.17 0.001
Bicarbonate (“) 25.51 + 1.64 23.48 + 1.34 0.035
Chloride (mmoL/L) 103.89+ 1.29 104.29 + 1.45 0.461
Urea (mmoL/L) 3.52+0.58 4.40+0.96 0.001
Creatinine(mmoL/L) 37.03+6.36 41.18+7.9 0.932
Table 2
Parameters Group 2: Pregnant women at
active Labour that ended in
normal delivery, n=70 mean + SD
Group 3: Pregnant women with
prolonged labour that ended in nomal
delivery, n = 70 mean+SD
P.
Value
Sodium (mmoL/L) 143.22 + 11.9 141.97 + 3.19 0.17
Potassium (mmoL/L) 3.57+ 0.17 4.43 + 0.50 0.001
Bicarbonate
(mmoL/L)
23.48 + 1.34 22.18 + 0.95 0.035
Chloride (mmoL/L) 104.29+ 1.45 105.43 + 1.63 0.461
Urea (mmoL/L) 4.40+0.96 4.93+0.96 0.001
Creatinine(mmoL/L) 41.18+7.9 81.33+13.05 0.932
Table 3
Parameters Group 1:
Pregnant women
at term without
Labour n=70
mean + SD
Group 2: Pregnant
women at active
labour that ended in
normal delivery, n = 70
mean+SD
Group 3: Pregnant
women with prolonged
labour that ended in
normal delivery, n = 70
mean+SD
P.
Value
Sodium (mmoL/L) 143.43 + 1.78 143.22 + 11.9 141.97 + 3.19 0.435
Potassium (mmoL/L) 3.88+ 0.44 3.57 + 0.17 4.43 + 0.50 0.001
Bicarbonate (mmoL/L) 25.51 + 1.64 23.48 + 1.34 22.18 + 0.96 0.001
Chloride (mmoL/L) 103.89+ 1.29 104.29 + 1.45 105.43 + 13.05 0.001
Urea (mmoL/L) 3.52+0.58 4.40+0.96 4.93+0.96 0.001
Creatinine(mmoL/L) 38.03+6.36 41.18+7.9 81.33+13.05 0.001
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Ugwuene, F. O., Ayogu, M. O., & Nwobodo, E. I. (2023). Changes In Serum Electrolyte, Urea and Creatinine in Pregnant Women with Prolonged
Labour in Enugu State University Teaching Hospital, Enugu, Nigeria. British Journal of Healthcare and Medical Research, Vol - 10(6). 200-208.
URL: http://dx.doi.org/10.14738/bjhmr.106.15839.
Table 1 shows the mean and standard deviation of serum sodium, potassium, Bicarbonate,
Chloride, Urea and creatinine obtained from pregnant women at term without Labour (Group
1) to compare with that of pregnant women at active Labour that ended in normal delivery
(Group 2). There were significant decreases in potassium, Bicarbonate and significant increases
in urea and creatinine (P< 0.05)
Table 2 shows the mean and standard deviation of pregnant women at active Labour that ended
in normal delivery (Group 2) to compare with that of pregnant women with prolonged Labour
that ended in normal delivery (Group 3). There were significant increases in potassium,
creatinine and urea while there was significant decrease in Serum bicarbonate (<0.05)
Table 3 shows the mean and standard deviation of the electrolyte stated, urea and creatinine
obtained from pregnant women at term without labour, pregnant women at active labour that
ended in normal delivery and pregnant women with prolonged labour that ended in normal
delivery. There were progressive significance increases in creatinine urea and chloride from
pregnant women at term without labour, pregnant women at active labour to pregnant women
with prolonged labour where the incidence is high [4,30]
DISCUSSION
Protracted and prolonged labour are major causes of maternal and perinatal mortality and
morbidity, especially in developing countries. This study on the serum electrolyte, urea and
creatinine in pregnant women in active labour who had normal delivery within a normal period
of labour and those who had prolonged labour with normal delivery was done to determine the
changes in serum electrolyte, urea and creatinine during the above-named conditions and
wether the knowledge of such changes could be used to manage, reduce or stop prolonged
labour or dystocia during child birth.
Making reference to the result of this work; in Table 1, significant decreases were observed in
serum potassium, bicarbonate and significant increases in urea and creatinine of pregnant
women at active labour that ended in normal delivery when compared with those of pregnant
women at term without labour. The decrease in potassium and bicarbonate could be traced to
inefficient management of fluid and increase in secretion of adenocorticotropic hormone and
cortisol in labour [31, 32]. Although optimal level of potassium in physiological amount is
essential for muscle contraction for active labour, the possibility in such scenario is that other
factors such as optimal levels of calcium and phosphate may have been sufficient enough to
enable the active labour and normal delivery. [33, 34]. However, Yusuf et al, observed a
significantly reduced serum potassium in hypertensive pregnant women compared with
normal pregnant women (35). They therefore, as a result of this, proposed that such a decrease
is a signal pathologic cause of hypertension in pregnancy, especially if accompanied with raised
serum sodium.
There were significant increases in urea and creatinine. This may be suggestive of impaired
renal function, because usually, glomerular filtration rate increase in pregnancy between 40-
50%, evidenced in a decrease in serum urea and creatinine [36, 2011].
Table 2 showed a significant increase in serum potassium of pregnant women with prolonged
labour when compared with pregnant women at the active labour that ended in normal
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delivery. This was in contrast to serum potassium decrease in pregnant women at active labour
when compared with that of pregnant women at term without Labour. Fluid and electrolyte
changes are well documented in obstructed labour due largely to abnormal metabolic activities,
prolonged starvation of patients from food and water, excessive uterine contractions and
muscular activities. Hyperkalemia in this case is caused by increased potassium release from
cells, impaired excretion by the kidney or poor fluid management in such labour in addition to
the other reasons sortly mentioned above [37, 38]
Table 3 showed that there were progressive increases in serum chloride, creatinine and urea
while there were progressive decreases in serum bicarbonate from pregnant women at term
without labour that ended in normal delivery when compared with pregnant women with
prolonged labour that ended in normal delivery. Although there were progressive increases in
serum chloride the changes were not significant, thereby agreeing with non-significant changes
in serum sodium seen in the same table. This is in consonance with the intracellular and extra
cellular biochemical sequence of chloride and sodium levels in physiological and
pathophysiological states.
The progressive increase in creatinine is agreement with the past works of Akinkugbe et al,
oguntayo et al and Ekanem et al whose reports show that creatinine and urea rise in pregnancy
and prolonged labour could be as result of water loss during labour and prolonged labour,
increase in phosphokinase and muscle contraction during labour and prolonged labour and or
impaired excretion by the kidney. [38,36,39]. The progressive decreases in bicarbonate in
labour and prolonged labour still points to the reason that there is progressive inefficient fluid
management and increase in secretion of adeno corticotropic hormone and cortisol in labour
and prolonged labour which invariably cause reduction in serum bicarbonate.
CONCLUSION
By this work in labour and prolonged labour there were progressive increase in serum urea
and creatinine, progressive decrease in serum bicarbonate and increase in serum potassium in
prolonged labour. For these reasons morbidity and mortality are recurrent in labour and
prolonged labour.
RECOMMENDATION
This work therefore recommends a regular check on fluid and electrolyte, urea and creatinine
status of pregnant women in labour for better management possible prevention of prolonged
labour and mortality.
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Labour in Enugu State University Teaching Hospital, Enugu, Nigeria. British Journal of Healthcare and Medical Research, Vol - 10(6). 200-208.
URL: http://dx.doi.org/10.14738/bjhmr.106.15839.
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