RENAL TRANSPLANT IN PREGNANCY ;SUMMARY FROM TOG 2009( Review Management of women with chronic renal disease in pregnancy) by MH academy

SUMMARY FROM TOG 2009( Review Management of women with chronic renal disease in pregnancy)

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Pregnancy in Renal Transplant Recipients

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Incidence

• Pregnancy occurs in approximately 12% of transplanted women of childbearing age.
• The number of kidney transplant recipients who conceive is increasing.

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Pregnancy Outcomes

Maternal Complications

• Hypertension:
  • Pre-dates pregnancy in about 70% of kidney transplant recipients.
  • Superimposed pre-eclampsia and urinary tract infections (UTIs) occur in up to 40% of cases.
• Acute bacterial pyelonephritis: Relatively common.
• Gestational diabetes: Higher risk in this population.
• Preterm delivery:
  • Preterm premature rupture of membranes (PPROM) and fetal growth restriction (FGR) occur in up to 60% of pregnancies.
• Opportunistic infections:
  • Common in immunosuppressed pregnant patients.
  • Includes rubella, cytomegalovirus (CMV), toxoplasmosis, herpes simplex, and hepatitis B/C.

Fetal Complications

• Miscarriage rate: Similar to the general population.
• Successful gestations: 95% end successfully.
• Congenital anomalies: Incidence similar to the general population.
• Ectopic pregnancy:
  • Higher rate due to adhesions from previous surgeries or peritoneal dialysis.
• Neonatal problems:
  • Thymic atrophy.
  • Transient leucopenia or thrombocytopenia.
  • Adrenocortical insufficiency.
  • Septicaemia.
  • Cytomegalovirus (CMV)/hepatitis infections.

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Recommendations for Management

Timing of Pregnancy

• Guidelines for women who have had renal transplants and are contemplating pregnancy:
  • No rejection episodes in the previous year.
  • Graft function should be adequate and stable.
  • Proteinuria should be minimal (< 500 mg/24 hours).
  • Maintenance immunosuppression should be stable:
    • Prednisolone: 15 mg/day.
    • Azathioprine: 2 mg/kg/day.
    • Ciclosporin: 5 mg/kg/day.
  • No acute infections affecting the fetus (e.g., cytomegalovirus).
  • Co-morbid conditions (e.g., hypertension, diabetes) should be optimally managed.

Pre-pregnancy Counseling

• Discuss risks of:
  • Acute rejection: Occurs in 9–14% of pregnancies; 5% are serious episodes equal to genral population .
  • Graft loss.
• Risk correlates with pre-pregnancy serum creatinine levels and interval since transplant.
• Long-term graft survival: Similar between pregnant and non-pregnant recipients.
• Limited knowledge on the impact of pregnancy on chronic rejection.

Management of Immunosuppressive Regimens

• Continue prednisolone, azathioprine, ciclosporin, and tacrolimus during pregnancy.
• Avoid mycophenolate mofetil (MMF):
  • Associated with increased risk of malformations (e.g., external ear, cleft palate, and lip) and first-trimester pregnancy loss.
• Avoid rituximab, sirolimus, and everolimus due to insufficient safety data.
• Breastfeeding:
  • Controversial, but emerging evidence suggests low levels of drug excretion into breast milk (e.g., azathioprine).

Antenatal Management

• Screen for cytomegalovirus (CMV), HIV, herpes simplex virus (HSV), and hepatitis B/C.
• CMV-negative women: Recheck titres in each trimester.
• Conduct oral glucose tolerance tests (OGTT) or blood sugar monitoring to diagnose gestational diabetes.
• Manage hypertension with:
  • Alpha methyldopa, labetalol, nifedipine.
• Magnesium sulfate prophylaxis:
  • Safe for severe pre-eclampsia.
  • Decrease infusion dose based on elevated creatinine.
• Uric acid: A less helpful marker for pre-eclampsia in transplant patients.

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Labour Management

• Timing: Delivery planned for 38–40 weeks in the absence of obstetric complications.
• Vaginal birth:
  • Preferred route.
  • Prostaglandins and syntocinon are safe for cervical ripening or induction.
• Caesarean section:
  • Performed for obstetric indications or concerns related to severe pelvic osteodystrophy.
  • Liaise with the urology surgical team/renal transplant surgeons for elective C-sections.
• Administer stress dosage steroids to women on immunosuppressive dosages of steroids.

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