TEXT BOOK READING

PRINCIPLES AND PRECTICE OF

DIALYSIS
 CHAPTER 32
PREGNANCY IN THE
CHRONIC DIALYSIS
PATIENT
Oleh

dr Frensi Ayu Primantari

MATERI
• INCIDENCE AND DIAGNOSIS
• DIALYSIS PRESCRIPTION IN THE PREGNAN PATIENT
• MANAGEMENT OF ANEMIA
• NUTRITION
• PREGNANCY OUTCOMES
• MATERNAL COMPLICATIONS
• MANAGEMENT OF HYPERTENSION IN PREGNANCY
• LABOR AND DELIVERY
• SUMMARY AND RECOMENDATIONS
 INCIDENCE AND DIAGNOSIS
• Infertility is common in dialysis patients with the incidence
of pregnancy in the end-stage kidney disease (ESKD)

• Fertility improved by :

- transplantation (the most effective way to restore fertility in

these patients)

- intensification of the dialysis prescription (increased the

conception rate to 16,5% in a small series)

(Okundye IB,Abrinko P, Hou S, Registry for Pregnancy in dialysis patients, Am J Kidney Dis 1998;31 :766-773)
• Patient with ESKD usually are amenorrhea
due to hormonal imbalance
• Difficulties in determine amenorrhea in
pregnancy
• β-hCG increase in patient with ESKD in the
absent of pregnancy.
• Obstetric ultrasound is favored for
estimation of gestational age in pregnant
women with ESKD
(Hou.S.Grossman S. Onstetric and Gynaecologic issies)
 DIALYSIS PRESCRIPTION IN THE PREGNANT
PATIENT
• The improvement in outcome observed in recent
years probably reflect more aggressive
management of woman with ESRD who become
pregnant. These includes :
1) More intensive dialysis schedule with blood urea
nitrogen (BUN) level < 16-18 mmol/L
2) Careful uterine and fetal monitoring during
dialysis includes :
- Fetal Heart Rate
- Maternal Hemodinamic to maintain a good
uteroplacenter circulation
(Bamberg C. Diekmann F, Haase M, et al. Pregnancy and intensified hemodialisis)
• Nocturnal dialysis with a mean dialysis duration :
1. 36 hours preconception

resulted in a mean
gestational age
of 36,2 weeks
and mean
birth weight
2.417,5 ± 657 g.

2. 48 hours during pregnancy

In a study by Hladunewich et al that compared outcomes
between a Canadian and American cohort of pregnant dialysis
women.
(Halndunewich MA,Hou S, Odutayo A, et al. Intensive Heodialysis associated with improved pregnancy outcomes. 2014)

Canadian American

Live birth rates 86,4% 61,4%

Gestational age 36,2 weeks 27 weeks

Mean of Dialysis 43 hours/week 17 hours/week

Hours/week

HD frequency in a week 5 times

Length of HD per session 8-10 hours

 Commonly Used Drugs in Hemodialysis and
Their Use in Pregnancy
Drug Safety data Dosing and Pharmacology

Erythropoietin FDA category C Dosing similar to nonpregnant

state, typical pregnancy
requirement is double the
baseline dose, placental kinetics
unknown

Paricalcitol FDA category C Similar to nonpregnant state

Calcitriol FDA category B Similar to nonpregnant state

Calcium acetate FDA category C Similar to nonpregnant state

Savelamelar/lanthanum FDA category C No safety data/guidelines availble

Intravenous iron FDA category B Similar to nonpregnant state

Heparin FDA category C Similar to nonpregnant state, does

not cross the placental barrier
• Daily dialysis offers the advantage of :
1. Decreased risk of hypotension owing to
decreased fluid removal per session
2. Allow for high protein intake to meet
caloric needs of the fetus and mother.
3. reduces placental urea and thus reduces
fetal osmotic diuresis and resulting
complications such as polyhidramnions.

(Chan CT. Cardiovascular effects frequent intensive

hemodialysis. 2004)
• While maternal and fetal outcomes
do not significantly differ between
hemodialysis and peritonela dialysis,
intensification of the dialysis
prescription is easier on hemodialysis.
(Deering S, Seiken G. Dialysis In Belfort M, Saade G, Foley M, et al eds. Critical Care Obstetric 5th Edition. 2010)

• Rarely, complications such as lacerations of the

gravid uterine veins from trauma to the
peritoneal dialysis catheter and preterm delivery
from peritonitis during pregnancy have been
reported (Deering S, Seiken G. Dialysis In Belfort M, Saade G, Foley M, et al eds. Critical Care Obstetric 5th Edition. 2010)
• Dializers used during pregnancy range
from standard high-flux dializers with
blood flows ranging from 200-400 ml/mnt
• In patients dialyzing with arteriovenous
fistulae, the risk of anuerysmal dilatation
of fistual due to histologic changes in the
vessel wall associated with the hormonal
changes in pregnancy
• Heparin does not cross the placental
barrier and can be used safely with
hemodialysis in pregnancy, without
necessaitating a dose reduction
• The physiologic weight gain associated with
pregnancy, which is recomended to be :
- 1-1,5 kg within th 1st trimester
- 0,3-0,5 kg/wk
- With daily dialysis, BP goal of < 140/90 mmHg
should be achievable with minimal
antihypertensives
• Persistent elevations in BP despite optimal fluid
removal should raise the suspicion of Pre-
eclampsia
(Hou S, Grossman S. Obstetrics and Gynaecology Issues In : Daugirdas J, Blake P, eds. Handbook of Dialysis. 4th Ed. 2007)
• The pregnant patient is predisposed to
respiratory alkalosis as a result of progesterone-
induced hyperventilation
• Hence, a bicarbonate solution concentration as
low as 25 mM is preferred to standard higher
concentrations to avoid superimposed metabolic
alkalosis
• Mother will need 2 g of oral calcium per day
• The placenta secretes calcitriol which also aids in
positive calcium balance

(Hous S, Pregnancy In chronic Renal Insuficiency and End Stage Renal Disease. 1999)
• Intensive dialysis regiment during
pregnancy can result in
hypophosphatemia
• Most patients often do not require any
phosphate binder, and at times, addition
of phosphorus to dialysate may be
necessary
• There is no experience with savelamer or
lanthanum in pregnancy. There is limitted
data currently on the effect of pregnancy
on dialysis-associated metabolic bone
disease profile
MANAGEMENT OF ANEMIA
• Anemia is common in pregnancy due to volume expansion
• In pregnant patients with ESKD, this physiologic anemia is
exaggregated, and most patients will require erythropoietin and
iron supplementation
• Accentuated anemia and increased erythropoiesis-stimulating
agents (ESA) requirements are attributed to cytokine-induced
erythropoietin resistance and the effect of plasma volume expansion
leading to hemodilution
• ESA is not associated with fetal congenital anomalies at usual dose,
and if patients are on ESA when they become pregnant, the dose is
typically doubled for the length of pregnancy
• Intravenous iron supplementation can be given in pregnant dialysis
patients, given the expected physiologic need for an extra 700 to
1,150 mg of elemental iron during pregnancy
• The US Food And Drug Administration has labelled intravenous iron
is category B for pregnancy

(Bagon JA, Vernaeve H, De Muydler X, et al. Pregnancy and Dialysis. 1998)

 NUTRITION
• Protein intake should be increased to meet the
metabolic needs of the mother and the growing
fetus. For this, a daily protein intake of 1,8 g/kg
is recomended
• Folate supplementation is higher than usual
doses is recomended for the pregnant mother
on dialysis and prevention of neural tube defects
(Hou S, Grossman S, Obstetric and Gynaecology Issues In : Daugirdas J, Blake P, Ing T, eds. Hanndbook of Dialysis. 4t
ed. 2007)
 PREGNANCY OUTCOMES
• FETAL OUTCOMES
• With intensification of dialysis dose, the rate of live births has
escalated from 23% in the 1970s to high of 87%
• In the Canadian cohort and in the nocturnal hemodialysis
cohort reported by Barua et al, the mean duration of the
pregnancy was 36 weeks compared to 32 weeks on previous
reports
• Enhanced solute clearance with these regimens appears
directly related to fetal outcomes with significant negative
corellation noted between blood urea nitrogen (BUN) and
birth weight/gestational age
• The ability to maintain maternal BP throughout pregnancy
with minimal to no antihypertensives also offers improved
fetal perfusion.
 MATERNAL COMPLICATION
• Hypertension is the major clinical concern with regard to the
pregnant mother on dialysis
• This could manifest as gestational hypertension, preeclampsia,
or eclampsia.
• High placental urea leads to increased fetal solute diuresis
resulting in complication s such as polyhidramnions
• Other frequently reported coplication s include gestational
DM, Premature Rupture of Membrane, chorioamnionitis,
placental abruption, and hemorrage postpartum
 MANAGEMENT OF HYPERTENSION IN
PREGNANCY
• Hypertension is notable for earlier onset (<24 weeks) in
pregnant dialysis patients compared to pregnant
woman without ESKD. About 80% of all pregnant
women on dialysis have a BP of 140/90 mmHg or
above and 40% have severe hypertension as
defined by systolic BP > 200 mmHg or dialstolic
BP > 110 mmHg
• Improved surveillance measures that include
weekly weight change assesments and daily BP
measurements at home are therefore
recomended. Fluid status is first determined
when the mother is found to be hypertensives
Antihypertension Medication in Pregnancy
(DimarcoGS,ReuterS,HillebrandU.TheSolubleVEGFreceptorsFlt1contributesto endothelialdysfunctioninCKD.2009)

Medication Dose Comments Safety in

Pregnancy

Metyldopa 500-3000 mg in Drug Of 1st choice Category B

devided dose
Labetalol 200-1200 mg in Efficacy and safety Category B
devided doses similar to
methyldopa
Other beta Variable Reports of IUGR Category C
blockers and fetal
bradichardia
Diuretics Variable May cause Category B/C
diminished
volume expansion
in pregnancy

Ca channel Variable Consedered to be Category C

Blockers relatively safe
Cont’d
Clonidine 0,1-0,8 mg in Limited data Category C
devided doses

Hydralazine 30-200 mg in May not be Category C

devided doses effective as a single
agent

Minoxidil 2,5-10 mg in Limited data Category C

devided dose

Alpha blockers Variable Limited data Category B/C

ACEI Contraindicated Renal dysplasia Category D
ARB Contraindicated Neonatal anuric Category D
renal failure
 LABOR AND DELIVERY
• Pregnant woman on dialysis are considered high risk
pregnancies and need close coordination care between the
nephrologist and obstetrician
• Biweekly antenatal monitoring to screen for fetal well being,
biometry, amniotic fluid index, cervical length, and umbilical
artery pulsatility should begin at 26 weeks of gestation and
increased to weekly profiles near term.
• Caesarean sections are performed for obstetric indications
• Newborn should be monitored in high risk neonatal care unit
• The baby’s BUN and creatinin will initially be elevated. This
leads to solute diuresis necessating careful monitoring of
volume status and electrolytes
 Highlights of Hemodialysis Management
during Pregnancy
Prepregnancy During Pregnancy After Delivery
High-risk for fetal loss (<20 Best result with intense Readjust dry weight and
weeks) dialysis regimens of 5-7 antihypertensives
times/wk of 8-10 h/session
Stop ACEI and ARB before Expected weight gain 1-1,5 Watch for postpartum
or right after conception kg in first trimester and 0,3- preeclampsia
0,5 kg/wk thereafter
Confirm pregnancy with Oral calcium and
obstetric ultrasound in phosphate supplements
addition to β-hCG results may be needed
Preconseption counseling ESA dose is tipically
about higher risks of early doubled for the length of
pregnancy losses, stillbirth, pregnancy
fetal prematurity, and
preeclampsia
Prepregnancy During Pregnancy After Delivery

Intravenous iron to
supplement in the extra
700-1,100 mg of elemental
iron needed

Protein intake of 1,8 g/kg/d

and folate dose of 4-5 mg/d

Close surveillance for

preeclampsia
 SUMMARY AND
RECOMENDATION
• In summary, while the management of pregnancy in a patient
on dialysis remains complex and chalenging, huge strides have
been made over the last decade in terms of gestational age,
live birth rate and minimizing maternal complications with
intesification of the dialysis prescription
• Having an international registry for pregnancy outcomes in
dialysis patients will help pool experience with the complex
interface of pregnancy-related physiologic needs and absence
of the optimal renal adaptive response to this state
• Close multispeciality monitoring and communication is the key
to succesful maternal and fetal outcomes, which will hopefully
be the standard of care with pregnancy in this population
TERIMAKASIH