Solid organ transplantation in pregnancy (tog 9 oct 2015) by MH ACADEMY by Dr Maria Rafi

✨ Pregnancy and  Renal Transplant Recipients ✨

📌 Importance of Prepregnancy Counselling

• Increased maternal morbidity and mortality in women with medical comorbidities without prepregnancy counselling.
• Safe and effective contraception is essential until prepregnancy counselling occurs.

⏳ Timing for Conception Post-Transplant

• Conception is discouraged within the first year post-transplant due to:
  • Higher doses of immunosuppressants.
  • Difficulty in assessing graft stability.
  • Acute rejection risk: 10–15%, especially in recipients under 45 years.

🩺 Assessment of Risks Based on Graft Function

• Stable graft function (1 year post-transplant) reduces pregnancy risks.
• Women with normal estimated glomerular filtration rate (eGFR):
  • No conclusive evidence of increased risk of graft rejection or deterioration.
• Conditions impacting risks:
  • Diabetes-related nephropathy:
    • Risk of neuropathy and retinopathy.
    • Poor diabetic control increases pregnancy risk.
  • Lupus:
    • Antibody profile influences pregnancy risk.

💊 Medications to Discontinue Prior to Pregnancy

• Teratogenic medications to stop:
  • Mycophenolate mofetil:
    • Switch to azathioprine 3 months before conception.
    • Recommended wash-out period: 3 months.
    • Azathioprine is considered safe and does not deteriorate graft function.
  • ACE inhibitors (ACEi) and angiotensin receptor antagonists:
    • Switch to alternative antihypertensives.
  • Statins:
    • Discontinue before conception.

🤰 Effects of Renal Transplantation on Pregnancy

• Prepregnancy renal function predicts outcomes:
  • Poor pregnancy outcomes (e.g., preterm birth, neonatal death) are linked to higher creatinine levels.
• Hypertension:
  • Present in >50% of renal transplant recipients.
  • 16% of normotensive women pre-pregnancy develop hypertension during pregnancy.
  • Associated risks:
    • Pre-eclampsia.
    • Fetal growth restriction.
    • Preterm delivery.
    • Neonatal intensive care admission.
    • Perinatal death.
• Proteinuria:
  • Prepregnancy protein loss >1 g/day increases maternal renal function loss risk postpartum.
  • Adds complexity to diagnosing pre-eclampsia.

🌱 Impact of Pregnancy on Renal Transplants

• Studies show no significant difference in graft survival between pregnant and nulliparous recipients:
  • 5-year unadjusted graft survival rate: Pregnant (89%) vs. controls (85.3%).
  • Acute rejection rate during pregnancy: 4.2%.
  • UK data show graft rejection during pregnancy: <2%.
• Treatment of rejection:
  • Corticosteroids and optimization of tacrolimus/ciclosporin.

🩺 Antenatal Management

• Multidisciplinary care:
  • Obstetrician, transplant team, and midwifery support.
• Monitoring:
  • Renal function: Monthly checks.
  • Tacrolimus/ciclosporin blood levels: Regularly monitored.
  • Blood pressure: Maintain <140/90 mmHg.
• Erythropoietin requirements:
  • In normal pregnancy, erythropoietin concentration increases 2–4 fold.
  • This increase may not occur even in the absence of significant transplant dysfunction.
  • Clinicians should consider treatment with erythropoietin-stimulating agents during pregnancy in iron-replete, anaemic women.
• Screening and scans:
  • Routine 12-week and 20-week scans.
  • Serological screening for chromosomal trisomy:
    • Affected by renal excretion of β-human chorionic gonadotrophin (β-hCG).
    • Significant renal dysfunction may lead to false positive results.
    • If high-risk results are observed with impaired renal function and raised β-hCG, consider:
      • Detailed ultrasound screening.
      • Noninvasive prenatal testing (NIPT).
• Fetal growth scans:
  • Conducted at 26–28 weeks and 32–34 weeks due to the risk of growth restriction.

• 👶 Intrapartum Management

• Preferred mode of delivery:
  • Vaginal delivery unless contraindicated.
• Caesarean delivery:
  • Risk of trauma to renal graft: 1–2%.
  • Requires multidisciplinary assessment.
• Steroid use:
  • Prednisolone >7.5 mg/day: IV hydrocortisone during labor.

🏥 Postpartum Management

• Blood pressure:
  • Target: <140/90 mmHg.
  • Safe antihypertensives for breastfeeding: Enalapril.
• Contraception:
• Progesterone-only pill, Mirena intrauterine system