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PREGNANCY
DEFINITION
Stephan Eisenschenk, MD
Department of Neurology
STAGES
• Hypertension-24%
• Glomerulonephritis -17%
Hypertension
Preeclampsia
Premature labor
Miscarriage
Decreased kidney function
Greater risk of urinary tract infections
Acute renal failure
Effect of renal insufficiency on
pregnancy
Fetal survival rates are good, approaching 95% in
most studies.
Complications, including SGA infants, preterm
labor, and stillbirth, are increased even in mild renal
insufficiency.
Factors associated with increased perinatal mortality
and preterm labor were impaired renal function,
early or severe hypertension, and nephrotic-range
proteinuria.
PREGNANCY IN PATIENTS RECEIVING
DIALYSIS
Only 23-55% of pregnancies result in
surviving infants, and a large number of
second-trimester spontaneous abortions
occur.
Approximately 85% of surviving infants
are born premature, and 28% are born
SGA. Hypertension worsens in more
than 80% of pregnant females
Diagnosis of pregnancy is difficult
because levels of beta-hCG are normally
elevated in patients receiving dialysis.
General recommendations
• Place the patient on a transplant list because
outcomes with allograft transplant patients are
markedly better.
• During hemodialysis, pursue uterine and fetal
monitoring and make every attempt to avoid
dialysis-induced hypotension.
• Erythropoietin can also increase hypertension
and must be used cautiously.
• Aggressive dialysis to keep BUN levels <50
mg/dL may be pursued with daily dialysis.
PREGNANCY IN PATIENTS AFTER
TRANSPLANTATION
• Poor pre pregnancy renal function are
important prognostic indicators for the risk
of renal function deterioration.
• An elevated pre pregnancy creatinine level
(ie, >1.4 mg/dL) is not only associated with
a higher risk of renal decline but also with
a decreased fetal survival rate.
• The fetal survival rate is approximately
74% in patients with a creatinine level of
more than 1.4 mg/dL, while it increases to
about 96% in patients with a creatinine
level of less than 1.4 mg/dL.
Diagnostic tests
• History and Physical Exam • Glucose Measurement
• Urine Total Protein • Serum Total Calcium Test
• Creatinine Clearance Test • Serum Magnesium Test
• Blood Urea Nitrogen • Abdominal Ultrasound
• Serum Potassium Test • Abdominal CT Scan
• Serum Creatinine Test • Kidney Scan
• Serum Chloride Test • Serum Parathyroid
• Serum Bicarbonate Test Hormone (PTH) Level Test
• Electrolyte Panel • Urinalysis
• Erythropoietin Test • Biopsy
MANAGEMENT
• General management
• A multidisciplinary approach
• Prenatal visits every 2 weeks until 28 weeks'
gestation and then weekly.
• Check blood pressure. Measure protein excretion,
usually by dipstick. If any worsening proteinuria is
discovered, obtain a 24-urine collection
• Patients who have had a transplant
to wait a year after a living relative
donor transplant and 2 years after a
cadaveric renal transplant before
attempting pregnancy
• Stable Renal function, with a serum
creatinine level of <2.0 mg/dL.
• Discontinue ACE inhibitors, and
make every attempt to decrease
prednisone to 15 mg/d or less,
azathioprine to 2 mg/kg/d or less,
and cyclosporine to 5 mg/kg/d or
less.
• Check of immune status for hepatitis B virus,
herpes simplex virus (HSV), cytomegalovirus
(CMV), and Toxoplasma species
• If rubella titers are low, administer the vaccine
before transplant
• Laboratory work consist of CBC counts,
electrolytes, BUN and creatinine levels, and (if
indicated) a cyclosporin level.
• Perform monthly ultrasounds and urine
cultures.
• Biweekly fetal surveillance with a biophysical
profile is indicated in the third trimester.
OBSTETRIC MANAGEMENT
• Preterm labor. Magnesium can be
cautiously used to avoid toxicity and
respiratory depression.
• The literature reflects a debate about
elective early delivery (34-36 wk) in
patients with chronic renal insufficiency
or those receiving dialysis, especially
when fetal lung maturity is present.
• In patients who have had a transplant,
delaying delivery until the onset of labor
provided, of course, that the mother and
fetus show no signs of distress.
Fetal Surveillance and Timing of
delivery:
• Cesarean section should be
necessary only for purely
obstetric reasons.
• In fact, preterm labor is generally
the rule and may commence
during hemodialysis. The role of
cesarean section in this situation
needs to be carefully considered
• Anemia management
DIALYSIS
• Early dialysis is
necessary in pregnant
women and should be
considered when the
serum creatinine reaches
3.5 mg/dL or the GFR is
less than 20 mL/min.
• Conti
– Longer, more frequent dialysis (20 hrs/week)
is associated with the best fetal outcome.
Hemodialysis may therefore be necessary at
least 5 days per week
– Careful avoidance of hypotension is
important.
– Peritoneal dialysis with smaller volumes and
frequent exchanges is another option.
– Premature labor and fetal size that is small
for the fetus' gestational age are typical in
women who deliver on dialysis.
• Nutritional support that allows weight gains of 0.3
to 0.5 kg/wk should be maintained in the second
and third trimesters.
• A daily oral intake of 70 gm protein, 1,500 mg
calcium, 50 mM potassium and 80 mM sodium is
advised, with supplements of dialyzable vitamins.
• Vitamin D supplements can be difficult to judge in
patients who have had parathroidectomy. In
addition, the placenta produces hydroxyvitamin D,
one reason why oral supplementation may have to
be curtailed.
Renal Transplantation
Guidelines for pregnancy in kidney
transplant recipient
Two years posttransplant, with
good general health and serum
creatinine less than 2.0 mg/dL
(preferably <1.5 mg/dL)
No recent or ongoing rejection
Normotension, or minimal
antihypertensives
Absent or minimal proteinuria
No evidence of pelvicalyceal
dilation on renal ultrasonogram
Immunosuppression
Prednisone - Less than 15 mg per day
mg/kg/d
Calcineurin inhibitor–based therapy -
Therapeutic levels
Mycophenolate mofetil and sirolimus
PRECONCEPTION GUIDELINES
A wait of 18 months to 2 years post-
transplant is advised before conception.
Also, if function is well maintained at 24
months, there is a high probability of
allograft survival at 5 years
Good general health about 2 years since transplantation
Stature compatible with good obstetric outcome
No or minimal proteinurea
Absence of hypertension
No evidence of graft rejection
Stable renal function with plasma creatinine of 2
mg/100 ml or less (preferably less than 1.5 mg/100 ml)
Drug therapy reduced to maintenance levels:
prednisone 15 mg/day or less, and azathioprine 2
mg/kg body weight/day or less. Safe doses of
cyclosporine-A, have not yet been established because
of limited clinical experience, but 5 mg/kg body weight
per day or less is quoted anecdotally
NURSING MANAGEMENT
• Assess for risk for fluid overload
• Fluid intake should be carefully
monitored & intake should equal
output
• Evaluate the degree of edema.
• Discuss the importance of
nutritional modifications and
refer to dietician
• Teach family on home BP
monitoring
• Instruct the patient & family on about
importance of recognizing & reporting
signs of fluid & electrolyte imbalance,
HELLP syndrome, medicine induced
side effects etc
• Modify home activities to reduce onset
of dangerous hypertension & avoid
added fatigue factors
• Teach patient to avoid infection
• Teach the patient the signs &
symptoms of preterm labour & report
it( 4 painless contractions per hour
unrelieved by rest of 1 hour)
• Avoid using urinary catheters
• Always run a clean catch urine
specimen
• Start fetal surveillance with electronic
fetal monitoring , BPP, NST
• After 24 weeks of gestation evaluate
for fetal IUGR
• Assess for hypertensive disorders of
pregnancy & or DIC
• Assess for signs of fluid, electrolyte,
acid base imbalance
• Perform dialysis as ordered.
• Weight the patient at each dialysis
exchange
NURSING DIAGNOSIS
• Imbalanced nutrition less than body
requirement related to dietary restriction.
• Fluid volume excess related to compromised
regulatory mechanism
• High risk for decreased cardiac output
related to fluid volume overload,
accumulated toxins
• High risk for injury ( hypocalcemia)related
to increased phosphorus level, renal failure
• High risk for injury related to bone
marrow suppression secondary to
insufficient renal production of
erythropoietic factor
• High risk for impaired skin integrity
related to edema
• High risk for self esteem disturbance
related to loss of body function,
prolonged dialysis
• High risk for noncompliance related to
lack of resources, knowledge deficit.
BIBLIOGRAPHY
• Blackburn ST. Maternal, Fetal & neonatal physiology.3rd edition. Missouri:
Elsevier; 2007
• Arias F, Daftary SN, Bhide AG. High risk pregnancy & delivery. 3 rd edition.
Noida: Elsevier; 2008
• Mudaliar AL, Menon MK. Clinical obstetrics.10th edition. Chennai: Orient
Longman; 2005.
• Evans AT. Manual of Obstetrics. 7th edition. New Delhi: Wolter Kluwer Pvt
Ltd; 2007
• Ladewig PW, London ML, Olds SB. Maternal newborn nursing. California:
Addison Wesley nursing; 2007
• Gilbert ES. High risk pregnancy & delivery. 4th edition. Missouri: Mosby;
2007
• http://www.womenshealthsection.com/content/obsmd/obsm004.php3
• http://www.ackdjournal.org/article/S1548-5595(07)00005-5/abstract
• http://emedicine.medscape.com/article/246123-overview
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