| Abstract|| |
A 25 year old Saudi female, sixth gravida, para four, on renal replacement therapy with regular dialysis for nearly two years, was diagnosed to be pregnant at 12 weeks, with a single viable fetus. She was managed with increased frequency of dialysis and increased doses of anti-hypertensive drugs. For the control of anemia, which was further worsened by the pregnancy, she was treated with r-HuEPO 125 to 150 u/kg 3 times/week along with iron and vitamin supplements to maintain hemoglobin of 90 gm/L. The pregnancy continued to 36 weeks and she had a spontaneous normal delivery of a male baby without any congenital defects, weighing 1605 grams with Apgar score of four at one minute and nine at five minutes.
Keywords: r-HuEPO, ESRF, HD, Pregnancy, Normal delivery.
|How to cite this article:|
Mitwalli A, Malik GH, Fayed H, Al-Mohaya S, Al-Wakeel J, Kechrid S, El Gamal H. Erythropoietin therapy in a pregnant woman on maintenance hemodialysis. Saudi J Kidney Dis Transpl 1994;5:489-92
|How to cite this URL:|
Mitwalli A, Malik GH, Fayed H, Al-Mohaya S, Al-Wakeel J, Kechrid S, El Gamal H. Erythropoietin therapy in a pregnant woman on maintenance hemodialysis. Saudi J Kidney Dis Transpl [serial online] 1994 [cited 2020 Apr 6];5:489-92. Available from: http://www.sjkdt.org/text.asp?1994/5/4/489/41136
| Introduction|| |
In women on regular dialysis treatment, most pregnancies used to end up in early spontaneous abortions  . Therefore, most authorities advised against pregnancy or its continuation if it occurred  . The outlook started changing after the first report of a successful pregnancy in a woman on long term hemodialysis (HD)  .
Erythropoietin has been successfully used to treat anemia in pregnant patients on HD ,,, However, literature is scanty regarding the safety of its use in pregnancy. It is not known whether erythropoietin crosses the placenta or whether its use is associated with birth defects. It has been reported that in animals although no adverse effects were seen at doses generally used in clinical practice, congential anomalies developed at doses of 50° u/kg  ' We describe the use of recombinant human erythropoietin (rHuEPO) during pregnancy in a woman on HD who delivered a live healthy baby without any developmental d effects.
| Case Report|| |
A 25 year old Saudi female, known case of end stage renal failure (ESRF) secondary to chronic pyelonephritis and hypertension was started on maintenance HD on 25th December, 1991. In September 1993, she started gaining weight and attempts at increasing ultrafiltration always resulted in hypotension. On questioning she admitted as having amenorrhea for 3 months. She had been having regular menstruation during the preceding one year and her last menstrual period was on 24th of July 1993. Pregnancy test was positive and obstetrical ultrasound showed a single sac with a viable fetus. Previously, she had four live births and one abortion. She had been on r-HuEpo since February 1992, in a dose of 50 u/kg i.v. twice weekly. Pre-pregnancy hemoglobin was 90 gm/L which fell to 79 gm/L in September 1993. Hemoglobin was maintained around 90 gm/L by a stepwise increase in the dose of rHuEPO to 150 u/kg three times per week [Table 1] along with iron and vitamin supplements. Pre-pregnancy blood pressure was controlled on hydralazine 25 mg three times daily. During pregnancy, hydralazine had to be increased to 150 mg/day and supplemented with labetolol 200 mg/day. The patient was placed on a high calorie diet with the help of the dietician. During each dialysis session, 200 ml of 10% dextrose i.v. and oxygen therapy at 2-3 L/min, through a nasal catheter, were used. Dialyzer type was changed from cuprophan to polyacrylonitrile and frequency of dialysis sessions was increased to four times/week from the month of March 1994. She was subjected to strict fluid assessment on each dialysis session with minimal fluid ultrafiltration if ever needed. These measures were adopted to achieve a serum urea level below 20 mmol/L as has been suggested by Davison, 1991  . On these measures the pregnancy continued without any problems except for hydramnios. She had a spontaneous normal delivery on 6th April, 1994 (at about 36 weeks) of a male baby weighing 1605 gm with length of 40 cm. (Average weight of her previous four babies was 2300 gm). Apgar score was four at one minute and nine at five minutes.
| Discussion|| |
For a successful outcome of pregnancy in ESRF patient on dialysis, one has to give attention to various factors in the management, such as dialysis strategy, management of anemia, proper fluid balance, good blood pressure control and adequate provision of good nutrition  . In the present case, the main problems encountered during pregnancy were anemia, hypertension and hydramnios Blood pressure control and fluid balance could be achieved by increasing the dialysis frequency and by an increase in anti - hypertensive medications.
In pregnancy, anemia is aggravated by the increased fetal demands. Pregnant women usually require iron supplementation because about 800-1000 mg of iron is required by the mother and the fetus during a Successful gestational period  . In pregnant anemic patients on dialysis, blood transfusion is preferably avoided as co-existing hypertension may be exacerbated and circulatory overload may be difficult to control  . Use of erythropoietin in such a situation has obvious advantages. However, Hou noted no difference in the outcome of pregnancy between those treated and those not treated with r-HuEpo  .
Conrad and Borton reported that r-HuEPO in a dose of 50-160 u/kg/week with iron supplmentation could maintain hematocrits of 26.7% to 32% in three pregnant women on HD, with favorable outcome, both maternaland neonatal  . Hou, et al reported five cases who were treated with erythropoietin during pregnancy while on HD  . However only three of these cases were on erythropoietin before pregnancy and only one of them delivered at 34 weeks, the infant weighing 1942 gm with one and five minute apgar scores of nine and nine respectively. Sungur, et al in a case report noted a decreased a response to r-HuEPO and suggested that pregnant patients on HD may require higher doses to maintain their hemoglobin levels within desired limits  . The need for an increased dose of erythropoietin during pregnancy in dialysis patients was reported in other cases as well , . In our case, the target hemoglobin could be maintained by increasing the r-HuEPO dose up to 150 u/kg three times per week without any ill-effects on the fetus. This is in accordance with the observations made by other authors as well  . Teratogenic effects have been noted in animals with erythropoietin doses of 500 u/kg but in clinical practice much lower doses are used for control of anemia  .
Prematurity is a major problem in children born to dialysis patients  . Although, the pregnancy in the present case was almost full term, the patient delivered a low birth weight baby. Earlier reports also show that 20-50% of the infants born to mothers on dialysis are small for gestational age  .
The present case had normal delivery at 36 weeks of pregnancy while on dialysis and on treatment for anemia with r-HuEPO. Also, the use of erythropoietin did not produce any teratogenic effects on the fetus.
| Acknowledgement|| |
We are grateful to Ms. Cathy Hunter, Head Nurse of Renal Dialysis Unit and her team for the efficient management of the patient during hemodialysis. We are also indebted to Ms. Angie Alvarez for her secretarial assistance in the preparation of the manuscript.
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Department of Medicine, King Khalid University Hospital, P.O Box 2925, Riyadh 11461