Pregnancy in a Renal Transplant Recipient

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

1. Palmer BF. Sexual dysfunction in uremia. J Am Soc Nephrol 1999;10(6):1381-8.
2. 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
3. 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
4. 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
5. 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.
6. EBPG Expert Group on Renal Transplantation.European Best Practices Guidelines Renal Transplantation (Part 2). Nephrol Dial Transplant 2002;17(Suppl 4):50-55.
7. Lessan-Pezeshki M. Pregnancy after renal transplantation: points to consider. Nephrol Dial Transplant. 2002;17(5):703-7.

Citation

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