Author Information
Chakre S*, Mayadeo NM**, Pardeshi S*, Mali K*.
(* Assistant Professor, Professor, Department of Obstetrics
and Gynecology, Seth GS Medical College & KEM Hospital ,
Mumbai , India
Abstract
End stage renal disease is associated with
ovarian dysfunction, anovulation, amenorrhea, high prolactin level, and loss of
libido. Kidney transplantation improves renal function resulting in improved
endocrine functions and resumption of ovulation and fertility.[1]
Pregnancy is uneventful in well tolerated renal graft recipients on stable
immunosuppressive therapy. Our case report presents successful pregnancy
outcome in a renal transplant patient.
Introduction
Kidney transplantation improves the quality of life
including successful pregnancy. However pregnancy can affect the renal graft
because of hemodynamic changes, hypertension, and impairment of renal function,
urinary tract infections and rejection.[2] Pregnant transplant
patient is at a risk of developing preeclampsia, gestational diabetes, preterm
delivery and increased rate of cesarean section. Cesarean births increase due
to higher incidence of prematurity, uncontrolled hypertension, fetal distress, growth
restricted low birth weight babies and preterm premature rupture of membrane
due to steroid use.[3] Pregnancy in a renal transplant recipient is
a high risk pregnancy and the patient should be treated jointly by an
obstetrician, nephrologist and urologist.
Case Report
A thirty years old gravida 3, para 1, living 1,
spontaneous abortion 1 with previous lower segment cesarean section (LSCS) done
9 years back and with a history of renal transplantation was registered at 24
weeks of gestation for antenatal care. She was diagnosed with malignant hypertension
9 years back in her first pregnancy. She was delivered by LSCS for
preterm breech with superimposed severe preeclampsia at 32 weeks of gestation
with baby weight of 900 g. She developed renal failure after delivery. Renal
Doppler was suggestive of left renal artery stenosis. She then underwent renal
angioplasty in view of deranged renal parameters (serum creatinine 3.8 mg/dl)
six years back. Despite her renal angioplasty the renal parameters never
improved hence DTPA (diethylene triamine penta acetic acid) scan was done to
look for renal perfusion which was suggestive of reduced renal function. The left
kidney was transplanted in the left iliac fossa by anastomosing the left renal
artery to the left internal iliac artery and the left renal vein to the left
external iliac vein four years back. She was on immunosuppressant agents - cyclosporine
and prednisolone. She developed toxicity to cyclosporine three months later so
it was discontinued; prednisolone was tapered to 5 mg dose. After
transplantation renal parameters (serum creatinine 1.4mg/dl) and blood pressure
were normal. She was advised to plan a pregnancy. She was regularly following
with the nephrologist with renal
function tests and urinalysis results. She conceived two years back but aborted
spontaneously. She conceived for the
third time, one year back. She was advised to continue prednisolone 5 mg OD and
was started on calcium channel blocker (Amlodipine) 5 mg OD. Both drugs were
continued in the same dose throughout the pregnancy as renal parameters and
blood pressure were under control. Elective LSCS with tubal ligation was
planned at term for previous LSCS with breech presentation. Baby with birth
weight of 2.1 kg was delivered. Postpartum course was uneventful. Mother and
baby were discharged on day 7 and were advised to follow with weekly renal
function test till 12 weeks which were normal.
Discussion
Although pregnancy in renal transplanted patient
is often unproblematic, complications can be serious. The American society of
transplantation advised pregnancy planning at any time as long as the graft is
optimal and immunosuppressive dosing is stable.[4] The renal graft
function is defined adequate when serum creatinine is less than 1.5 mg/dl, 24 hours urinary protein excretion is less than
500 mg/dl and there is no evidence of infection.[2] Pregnancy leads to an increase in
glomerular filtration rate that leads to hyperfilteration. In renal transplant
patient successful outcome of pregnancy is dependent on prepregnancy serum
creatinine level. If prepregnancy serum creatinine level is less than 1.4 mg/dl,
there is 96% chance of a successful pregnancy. If prepregnancy serum creatinine
level is more than 1.4 mg/dl, rate of successful pregnancy is 70-75% and in 30%
there is chance of an abortion. Our patient had serum creatinine 3.8 mg/dl
before transplant and this might have resulted in spontaneous abortion. Subsequent
renal function may worsen in patients having raised serum creatinine before
pregnancy or hypertension during pregnancy.[5] Other causes of
worsening of renal function in women with renal transplant are acute on chronic
rejection, recurrent kidney diseases, dehydration, obstruction of transplanted
ureter by the pregnant uterus, infection and medication toxicity. A gravida
with a renal transplant is immunocompromised and hence is at an increased risk
of developing and transmitting viral infections to the baby. Care of the
patient includes checking for urinary tract infections, treating symptomatic or
asymptomatic bacteriuria with penicillin and cephalosporin to avoid renal and
fetal compromise, control of proteinuria, hypertension and preeclampsia. In
pregnant renal transplant patient vaginal delivery is recommended. LSCS should
be performed for standard obstetric indications, such as previous LSCS with
breech in our patient.[6] Infection and fluid overload should be
avoided.[4] Instrumental delivery should be minimized. Contraception
counseling should be done as ovulation resumes after renal transplant. Low dose
oral contraceptive pills, barrier method and permanent method for family
planning are advised. In our patient tubal ligation was done. As there is risk
of potential infection, intrauterine contraceptive devices should be avoided.[7]
Conclusion
Pregnancy in our patient ended in a live birth.
During pregnancy there is risk to the graft, to the mother and to the fetus.
Joint effort by the urologist, nephrologist, obstetrician and pediatrician
would be necessary for planning, continuation of pregnancy and for a favorable
outcome. Timing of pregnancy depends on optimum graft function and not on the
time since the transplant.
References
- Palmer BF. Sexual dysfunction in uremia. J Am Soc Nephrol 1999;10(6):1381-8.
- Tan PK, Tan A, Koon TH, Vathsala A. Effect of pregnancy on renal graft function and maternal survival in renal transplant recipients. Transplant Proc 2002;34(4):1161-3 http://www.ncbi.nlm.nih.gov/pubmed/12072304
- Hirachan P, Pant P, Chhetri R, Joshi A, Kharel T. Renal Transplantation and Pregnancy. Arab Journal of Nephrology and Transplantation 2012 Jan;5(1):41-6
- McKay DB, Josephson MA, Armenti VT, August P, Coscia LA, Davis CL, Davison JM et al; Women's Health Committee of the American Society of Transplantation. Reproduction and transplantation: report on the AST Consensus Conference on Reproductive Issues and Transplantation. Am J Transplant 2005 Jul;5(7):1592-9 http://www.ncbi.nlm.nih.gov/pubmed/15943616
- Sibanda N, Briggs JD, Davison JM, Johnson RJ, Rudge CJ. Pregnancy after organ transplantation: a report from the UK Transplant pregnancy registry. Transplantation 2007 May 27;83(10):1301-7.
- EBPG Expert Group on Renal Transplantation.European Best Practices Guidelines Renal Transplantation (Part 2). Nephrol Dial Transplant 2002;17(Suppl 4):50-55.
- Lessan-Pezeshki M. Pregnancy after renal transplantation: points to consider. Nephrol Dial Transplant. 2002;17(5):703-7.
Chakre S, Mayadeo NM , Pardeshi S, Mali
K. Pregnancy in a Renal Transplant Recipient. JPGO 2014. Volume 1 Number 11. Available from: http://www.jpgo.org/2014/11/pregnancy-in-renal-transplant-recipient.html