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Saudi Journal of Kidney Diseases and Transplantation
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EDITORIAL Table of Contents   
Year : 1997  |  Volume : 8  |  Issue : 1  |  Page : 3-7
Pregnancy in Women Treated with Dialysis


Department of Medicine, Rush Medical College, Chicago, USA

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How to cite this article:
Hou S. Pregnancy in Women Treated with Dialysis. Saudi J Kidney Dis Transpl 1997;8:3-7

How to cite this URL:
Hou S. Pregnancy in Women Treated with Dialysis. Saudi J Kidney Dis Transpl [serial online] 1997 [cited 2014 Nov 28];8:3-7. Available from: http://www.sjkdt.org/text.asp?1997/8/1/3/39395
Pregnancy is generally considered to be dangerous in women with renal disease, and particularly so, in women with end-stage renal disease requiring dialysis. The likelihood of conception in these patients is much lower than in the general population and when conception does occur, the birth of a healthy infant is less likely for a dialysis patient than for a healthy woman.


   Frequency of Conception Top


Most of the literature about pregnancy in dialysis patients is in the form of case reports. There are a few studies in which investigators have used the population of women of child-bearing age, on dialysis, to determine the frequency of conception. The European Dialysis and Transplant Association (EDTA) reported 115 pregnancies in 13,000 women followed by the EDTA (0.9%) [1] . No time period is given and thus, it is not possible to determine a yearly conception rate. Souqiyyeh and colleagues reported on 27 pregnancies in 22 women aged 21 to 40 years, dialyzed in the Kingdom of Saudi Arabia over a 5-year period (1985-1990) [2] . These cases were drawn from 300 married women in 21 dialysis units, accounting for half of the married women on dialysis during that 5-year period. Thus, pregnancy occurred in 7.3% of women on hemodialysis, or approximately 1.5% per year. Both these reports included only hemodialysis patients. A newly established registry for pregnancy in dialysis patients in the United States has collected information on approximately half of the women of childbearing age treated in American dialysis units. For women in this registry, the frequency of conception was 0.5% per year [3] .


   Diagnosis Top


Pregnancy is frequently recognized late in dialysis patients. Making the diagnosis requires a high index of suspicion and pregnancy should be a consideration in the evaluation of dialysis patients with abdominal symptoms.

The B sub-unit of human chronic gonadotropin may be borderline elevated even in non­pregnant dialysis patients and during preg­nancy, the values may be higher than expected for the stage of gestation [4] . The diagnosis of pregnancy should be confirmed, and the gestational age determined, by ultrasound.


   Fetal Outcome Top


The three reports listed above [1],[2],[3] are the basis for predicting the outcome of pregnancy. Of the 115 pregnancies reported by the EDTA, 46 were electively terminated. Of the remaining 69 pregnancies, only 16 (23%) resulted in surviving infants. Souqiyyeh, et al reported that 30% of pregnancies in their study resulted in live births. Thirty-six percent of the 320 pregnancies reported to the American Registry resulted in surviving infants. Pregnancy losses in dialysis patients often occur late. Fifty percent of pregnancy losses are accounted for by stillbirth, second trimester spontaneous abortion or neonatal death secondary to complications of pre­maturity. In contrast to the general population where 95% of spontaneous abortions occur in the first trimester, 40% of spontaneous abortions in dialysis patients occur in the second trimester.


   Maternal Complications Top


Two maternal deaths have been reported to the American Registry in 320 pregnancies. One woman had a serum creatinine of 133 µmol/L at the beginning of pregnancy. Renal failure was one of the many compli­cations of a fulminant lupus flare she had during her pregnancy. The second was an unexplained death in a woman with chronic glomerulonephritis on dialysis for 10 years who died 12 hours post-partum. Hypertension is common in pregnant dialysis patients. A compilation of 68 case reports of pregnancy in dialysis patients showed a frequency of hypertension of 50% [5] . Five cases, where­in the patient required intensive care unit admission for hypertension, have been reported to our registry. Two such episodes occurred post-partum. Other maternal complications have included respiratory failure, bleeding and infection.


   Management Top


Dialysis Modality

In 1988, a report was published describing eight pregnancies in patients on continuous ambulatory peritoneal dialysis (CAPD) resulting in six surviving infants [6] . This experience was encouraging when compared with the earlier EDTA report, but it was in part a reflection of an overall improvement in the outcome of pregnancy for dialysis patients. With, a larger population it appears that there is no difference in pregnancy outcome in women treated with hemodialysis and peritoneal dialysis. Pregnancy per se is not a reason to switch from hemodialysis to peritoneal dialysis.

Intensive Dialysis

There are theoretical reasons for favoring an increase in the intensity of dialysis. Women who start dialysis after conception have a better fetal survival than women who conceive after starting dialysis. Seventy percent of pregnancies in the former group result in surviving infants. Daily dialysis allows the patient to abandon a protein restricted diet and consume the amount of protein required for normal fetal develop­ment. Also, daily dialysis results in smaller inter-dialytic weight gain and consequently, lesser risk of hypotension during dialysis. Souqiyyeh and colleagues found a signi­ficantly longer weekly dialysis time in women whose pregnancies reached 28 weeks (n=10), compared to the women whose pregnancies ended before 28 weeks (n=17). The mean number of hours of dialysis weekly was 12 in the first group and 10.4 in the second group. These are both shorter hours than the six times weekly dialysis we propose. Increasing the amount of dialysis for CAPD patients is problematic. During the third trimester, most women require a decrease in exchange volume because of the increasing size of the fetus. The use of a cycler at night and frequent exchanges during the day are needed, even to continue the pre-pregnancy amount of dialysis.

Anemia

During pregnancy, the hematocrit usually drops dramatically even in women treated with erythropoietin (EPO). Plasma volume appears to increase but the patient is unable to increase red cell mass on a fixed dose of EPO. The dose should be doubled when the diagnosis of pregnancy is made and increased further, on the basis of weekly hematocrit measurements. The safety of EPO in pregnancy has not been definitively established. It does cross the placenta in some animal models but not others. It has not been found to cross the placenta in the few cases in which cord blood levels were measured. Hypertension does not appear to be more difficult to control in a pregnant woman treated with EPO than in other pregnant dialysis patients [7] . Without EPO, transfusions are frequently required.

Hypertension

Because severe hypertension may occur suddenly, a pregnant dialysis patient should be taught to measure her own blood pressure. When the blood pressure is increased, the first approach to treatment is to remove fluid with dialysis. If medications are used, the drugs with the longest follow-up and evidence for safety are alpha methyldopa and hydralazine [8] . Alpha methyldopa is often poorly tolerated because it causes somnolence and depression. There are some concerns about beta blockers since they have been associated with respiratory depression of the infant at birth, small for gestational age babies and in animals, with a decreased ability to tolerate anoxic stress [9],[10],[11] . With widespread use, most of those concerns have not be borne out. Labetalol has also been widely used without difficulty [12] . Calcium channel blockers have not been used for as long a time, but appear to be safe [13] . The one group of anti-hyper­tensive drugs which is strongly contraindicated is angiotensin converting enzyme (ACE) inhibitors [14],[15] . These have been asso­ciated with oligohydramnios leading to neonatal death from pulmonary hypoplasia. Several infants exposed to ACE inhibitors in the third trimester have had neonatal anuria requiring dialysis.

Hypertensive crises can be treated with intravenous hydralazine, intravenous labetalol, and in refractory cases, low doses (30 mg boluses) of diazoxide. Nitroprusside should be avoided because the risk of maternal and fetal cyanide toxicity is increased in renal failure. If nitroprusside becomes necessary, cyanide levels should be carefully monitored.

Peritoneal Dialysis

There are several problems that are specific to peritoneal dialysis. In addition to the difficulties associated with delivering an increased amount of dialysis, the increased intra-abdominal volume may result in early satiety, thus making it difficult to meet the nutritional needs of pregnancy.

Catheter Placement

Peritoneal catheters have been placed during pregnancy as late as 29 weeks gestation. Reports of catheter malfunction are rare. There have been three instances of fetal position interfering with catheter drainage. Catheter leaks are not any more common than when catheters are placed in non-pregnant women. The most dramatic catheter compli­cation described is laceration of a distended superficial uterine vein by the catheter resulting in substantial bleeding. Because of possibilities such as this and because a bloody dialysate may herald spontaneous abortion or placental separation, any blood tinged dialysate should be aggressively investigated and the patient should be hospitalized for observation.

Peritonitis

Because of the connection between the  Fallopian tube More Detailss and the peritoneum, peritonitis has the potential to lead to intrauterine infection. There are two cases reported in whom premature labor followed peritonitis resulting in stillbirth in one and birth of a premature infant in the other [16],[17] . Similarly, obstetric infection can lead to generalized peritonitis and there is also a report of peritonitis requiring the removal of the catheter following delivery in a patient who developed post-partum endometritis [18] . When peritonitis occurs, the safest drugs for use are penicillins and cephalosporins. No problems have been reported with the use of vancomycin. Aminoglycosides carry the risk of fetal o to toxicity and there is concern about the development of arthropathy in newborns exposed to quinolones.


   Obstetric Problems Top


Premature Labor

Only 20% of infants born to dialysis patients are born at term. Almost as many are born prior to 28 weeks gestation with a degree of prematurity which carries a high risk of developmental abnormalities. There is a continuum from second trimester spon­taneous abortions to premature births. Thus, the most sophisticated methods available need to be employed to decrease the risk of premature births. We have started home contraction monitoring, midway through the second trimester. Many second trimester losses occur with few contractions prior to cervical dilatation. Careful examination and ultrasound, if a specially trained ultrasono­grapher is available, should be started in the second trimester so that cervical cerclage can be placed if necessary.

If premature contractions occur, several treatments are available. Beta agonists can be used in women who are not severely hypertensive, but are often poorly tolerated and ineffective. Magnesium has been used both intra-peritoneally and intravenously [6] . It must be used with extreme caution to avoid magnesium intoxication. It can be placed in the peritoneal fluid to give a concentration of 5 mg/dl. It can be given intravenously in two 2-gram divided doses with measurement of serum magnesium levels between the two doses. Supplemental magnesium can then be given after each hemodialysis treatment. The greatest risk is associated with failure of the physicians caring for the patient, to be aware of the implications of her renal failure. All personnel concerned with the patient's care should be advised against using the usual obstetric magnesium regimen. The same caution applies to the use of magnesium in the treatment of pre-eclampsia.

Indomethacin has been successful in delaying delivery in pregnant dialysis patients [7] . It is particularly effective when polyhydramnios is present. There are several precautions that should be taken when it is used. Ultrasound should be performed every few days to look for oligohydramnios. Indomethacin is usually needed for longer than the 72 hours usually used and fetal echocardiogram should be done to detect any evidence of right heart strain suggesting narrowing of the ductus arteriosus. Nifedipine has been used to stop premature labor but it should not be used in conjunction with magnesium because the combination can cause profound hypotension.

Five percent of pregnancies result in still births. The best available monitoring for fetal well-being should be used once the fetus has reached a stage of gestation at which viability would be possible. Contraction stress testing should be avoided because of the risk of precipitating premature labor. There have been reports of fetal demise as early as four days after a reassuring non­stress test; hence twice weekly monitoring is advisable [19] .

Delivery

Cesarian section need be performed only for the usual obstetric indications. Peritoneal dialysis has been resumed as early as 24 hours post-partum, when extra-peritoneal Cesarian section has been performed [6] .


   Conclusion Top


Pregnancy in dialysis patients remains dangerous and the likelihood of successful outcome is still less than 50%. However, with vigilant care, the risk to the mother can be minimized. A successful outcome requires close co-operation of the nephrologist, obstetrician and pediatrician.

 
   References Top

1.Successful pregnancies in women treated by dialysis and kidney transplantation. Report from the registration committee of the European Dialysis and Transplant Association. Br J Obstet Gynaecol 1980;87:839-45.  Back to cited text no. 1  [PUBMED]  
2.Souqiyyeh MZ, Huraib SO, Saleh AG, Aswad S. Pregnancy in chronic hemodialysis patients in the Kingdom of Saudi Arabia. Am J Kid Dis 1992;19:235-8.  Back to cited text no. 2  [PUBMED]  
3.Okundaya IB, Hou SH. Results of pregnancy in women undergoing dialysis. JASN 1995;3:398.  Back to cited text no. 3    
4.Schwarz A, Post KG, Keller F, Molzahn M. Value of human chronic gonadotropin measurements in blood as a pregnancy test in women on maintenance hemodialysis. Nephron 1985;39:341-3.  Back to cited text no. 4  [PUBMED]  
5.Hou SH. Pregnancy in women on haemodialysis and peritoneal dialysis. Baillieres, CHn Obstet Gynaecol 1994;8:481-500.  Back to cited text no. 5    
6.Redrow M, Cherern L, Elliott J, et al. Dialysis in the management of pregnant patients with renal insufficiently. Medicine­Baltimore 1988;67:199-208.  Back to cited text no. 6    
7.Hou S, Orlowski J", Pahl M, Ambrose S, Hussey M, Wong D. Pregnancy in women with end-stage renal disease: treatment of anemia and premature labor. Am J Kidney Dis 1993;21:16-22.  Back to cited text no. 7    
8.Ounsted MK, Moar VA, Good FJ, Redman CW, Hypertension during pregnancy with and without specific treatment; the development of the children at the age of four years. Br J Obstet Gynaecol 1980;87:19-24.  Back to cited text no. 8    
9.Gladstone GR, Hordof A Gersony WM. Propranolol administration daring pregnancy: effects on he fetus. J Pediatr 1975;86:962-4.  Back to cited text no. 9    
10.Pruyn SC, Phelan JP, Buchanan GC. Long term ropranolol therapy in pregnancy: maternal and fetal outcome. Am J Obstet Gynecol 1979;135:485-9.  Back to cited text no. 10  [PUBMED]  
11.National High Blood Pressure Education Program Working Group Report on High Blood Pressure in pregnancy. Am J Obstet Gynecol 1990; 163:1691-712.  Back to cited text no. 11    
12.Jouppila P, Kirkinen P, Koivula A, Ylikorkala O. Labetolol does not alter the placental and fetal blood flow or maternal prostanoids in preeclampsia. Br J Obstet Gynaecol 1986;93:543-7.  Back to cited text no. 12  [PUBMED]  
13.Walters BN, Redman CW. Treatment of severe pregnancy-associated hypertension with the calcium antagonist nifedipine. Br J Obstet Gynaecol 1984;91:330-6.  Back to cited text no. 13  [PUBMED]  
14.Hanssens M, Keirse MJ, Vankelecom F, Van Assche FA. Fetal and neonatal effects of treatment with angiotensin-converting enzyme inhibitors in pregnancy. Obstet Gynecol 1991;78:128-35.  Back to cited text no. 14  [PUBMED]  
15.Ferris TF, Weir EK. Effect of captopril on uterine blood flow and prostaglandin E synthesis in the pregnant rabbit. J Clin Invest 1983;71:809-15.  Back to cited text no. 15  [PUBMED]  [FULLTEXT]
16.Jakobi P, Ohel G, Szylman P, Levit A, Lewin M, Paldi E. Continuous ambulatory peritoneal dialysis as the primary approach in the management of severe renal insufficiency in pregnancy. Obstet Gynecol 1992;79:808-10.  Back to cited text no. 16  [PUBMED]  
17.Gadallah MF, Ahmad B, Karubian F, Campese VM. Pregnancy in patients on chronic ambulatory peritoneal dialysis. Am I Kidney Dis 1992;20:407-10.  Back to cited text no. 17    
18.Tison A, Lozowy C, Benjamin A, Usher R, Prichard S. Successful pregnancy complicated by peritonitis in a 35 year old CAPD patient. Pent Dial Int 1996;16Suppll:S489-91.  Back to cited text no. 18    
19.Cattran DC, Benzie RJ. Pregnancy in a continuous ambulatory peritoneal dialysis patient. Perit Dial Bull 1985;3:13-14.  Back to cited text no. 19    

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Correspondence Address:
Susan Hou
Renal Section, Rush Presbyterian, St. Luke's Medical Center, 1653, West Congress Parkway, Chicago, IL 60612
USA
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PMID: 18417776

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    Frequency of Con...
    Diagnosis
    Fetal Outcome
    Maternal Complic...
    Management
    Obstetric Problems
    Conclusion
    References
 

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