Pregnancy in dialysis-dependent women

PIPILI, C., GRAPSA, E., KOUTSOBASILI, A., SORVINOU, P., POIRAZLAR, E., KIOSSES, D. and XATZIGEORGIOU, G. (2011), Pregnancy in dialysis-dependent women—the importance of frequent dialysis and collaborative care: A case report. Hemodialysis International, 15: no. doi: 10.1111/j.1542-4758.2011.00552.x

http://onlinelibrary.wiley.com/doi/10.1111/j.1542-4758.2011.00552.x/abstract

Abstract

An increasing number of successful pregnancies have been reported among women on chronic hemodialysis. Even with reduced fertility and high risk of complications, women of childbearing age receiving hemodialysis, should not be discouraged from pregnancy. Practitioners should be familiar with the effects of renal disease on pregnancy, consult patients about the possibility of pregnancy and its hazards and provide, if necessary, prompt surveillance and treatment. This paper describes the case of an unplanned but successful pregnancy of a woman receiving hemodialysis, emphasizing pregnancy management, mother's response evaluation, and infant growth.

Introduction
There is an increasing literature reporting high rates of successful pregnancies in women with end stage renal disease (ESRD) on hemodialysis (HD). These references suggest that dialysis women of childbearing age, even with reduced fertility and at high risk of complications, should not be discouraged from pregnancy. There are impressive advances on dialysis technique and maternal-fetal care. While in 1980 the successful outcome rate was only 23%,1 in 1998 this increased to 50%2 and during the last decade reached the 81.3%.3 Practitioners should be familiar with the effects of renal disease on pregnancy, consult patients about the possibility of pregnancy and its hazards and provide, if necessary, prompt surveillance, and treatment. This paper delineates the case of an unplanned but successful pregnancy of a dialysis-dependent woman, emphasizing pre- and postpregnancy management of obstetrical complications, the mother's response evaluation, and infant growth. It also describes the current optimal approach to this group of patients.

Case study
This 35-year-old woman on maintenance HD for 4 years, due to glomerulonephritis, reported amenorrhea and had a positive pregnancy test. Her medical history was not notable for oligomenorrhoea or other gynecological problems. She was treated with on line hemodiafiltration for 4 hours, 3 times a week, through a well-functioning left brachio-cephalic arteriovenous fistula, without significant complications. Her medications consisted of darbopoetin 80 mcg intravenously (IV)/week, sevelamer hydrochloride 8 g/d, paricalcitol injections 5 mcg at the end of each second dialysis session and levocarnitine with vitamin complex B vials at the end of every HD session.

[etc, details of the case study]

Discussion
In the past, pregnancy for dialysis patients of child-bearing age constituted an inaccessible dream. Indeed, women with ESRD had low fertility, due to altered levels of HCG and reduced renal leptin clearance, anovulatory cycles, and hyperprolactinemia leading to oligomenorrhea.4 Furthermore, chronic disease complications such as anemia, polypharmacy, depression, loss of sexual desire, and difficulties in marital life result in reduced conception.3 However, the hormonal contraception, which is avoided in immunocompromised patients, is not practiced routinely in women with chronic kidney disease stages 4–5, and leading to a lot unplanned pregnancies, necessitating special multidisciplinary antenatal care for better infant survival.

In this respect, published evidence shows a surprising high successful rate of pregnant deliveries. Although there is a wide variation, most recent data report 79%5 to 81%3 successful pregnant deliveries among dialysis-dependent women. The main factors for this success seem to be the increased duration and frequency of HD sessions, the ample supplementation of erythropoietin, iron, follate, and vitamins and the adequate maternal nutrition in combination with the effective pharmaceutical support and close obstetric monitoring, as well as the advances of neonatal care.3,6 It seems that women on nocturnal HD present the best outcome.7,8 Furthermore, the progress and the accumulate experience of obstetricians in combination with the tight obstetric surveillance—for the diagnosis and management of possible complications and the optimal timing of delivery—contribute to successful results.

However, pregnancy and delivery in women with ESRD is still linked with an increased number of complications. Thus, 5.8% of pregnancies are spontaneously miscarried, while 71% of them end in preterm labor (mean gestational age 32.9±6.7 weeks) and 37% of them are undergone by caesarian section.5 There is a high rate (80%) of perinatal morbidity and mortality due to prematurity,9,10 intrauterine growth retardation (57%),9 polyhydramnion (71%),6 respiratory distress syndrome (14–80%),3 and maternal hypertensive disease (30.2%).5,6 Infants usually have a low birth weight (1511±284 g)6—associated with the maternal dietary regime during pregnancy, the time of initiating HD, tolerance to pregnancy hemodynamic changes6—and long stay in neonatal intensive care (7–95 days).11 Of note is that infant malformations and maternal mortality are in line with the risk in the overall population.3 Moreover, maternal complications include: (i) hypertension, difficult to be differentiated between pre-eclampsia or inadequate dialysis, (ii) deterioration of ESRD, anemia due to expansion of intravascular volume without the increase on red cell production,10 and (iii) HD complications such as thrombosis of vascular access due to the physiological procoagulant state of pregnancy and hypotension because of rapid fluid removal carrying risk for fetal distress.5

Although, our patient's pregnancy characteristics (preterm with a low–birth-weight baby and obstetric complications) are consistent with previous reports, there were some unusual features on which to focus. Her cervical incompetence and the marked cervical dilatation after a few contractions are common in HD patients (in terms of premature labor and early delivery), but rarely they have been recognized early and treated by placement of cervical cerclage. There has been at least 1 case reporting the contribution of early cervical ligation to successful delivery a multigravida with a previous history of cervical insufficiency commencing on dialysis in the context of acute kidney injury.12 Moreover, the use of progesterone for preventing premature labor and bromcriptine for discontinuation of lactation, commonly applied in clinical practice, have not been discussed in HD literature. Progesterone administration is associated with a reduction of delivery risk before 32, 35, and 37 weeks in women who are at high risk for premature delivery.13 The risk of prematurity in pregnant women on HD is as high or higher than in any other group under the obstetrician's care. One should institute appropriate measures on time to avoid premature birth and fatal lossespecially as premature births often occur without warning.14

In addition, the details of organization of care, mother's response in combination with her postnatal evaluation and infant growth curve have rarely been reported. Surviving infants do not appear with high frequency of long-term growth and development abnormalities. Pediatric evaluation of children born to dialysis patients followed up for a period ranging between 2.5 and 5.5 years, showed a good long-term outcome15; mild motor retardation has been reported in such infants previously.7,14 Nevertheless, the effects of hypertension, prematurity and systemic disease on the growth and development of babies born to uremic mothers need to be elucidated.

Other issues addressed in our report are the mother's education and counseling that strongly contributed to successful delivery. We ask though patients to follow a regimen that is very demanding. It is not uncommon to have difficulties in tolerating it just when they need it most. Our patient did not manage to reduce the food consumption and her anxiety level thus increasing the risk for complications the last gestational months.

In conclusion, this paper stresses that pregnancy in women with ESRD represents a potential, challenging, and demanding situation. With the increasing and shared experience, better policies will be drawn. Based on the series of articles published recently, there has been a broad consensus about which practices should be followed, described in Table 4. However, the heterogeneity of data prevents the development of successful evidence-based strategies. The familiarization of practitioners with the advances in pregnancy of women treated with HD would hopefully stimulate multicenter prospective studies that will lead to additional measures for maternal, antenatal, and neonatal care.
[table 4. Current general suggested practices for successful pregnancy on dialysis dependent women]