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Saudi Journal of Kidney Diseases and Transplantation
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ORIGINAL ARTICLE Table of Contents   
Year : 2010  |  Volume : 21  |  Issue : 4  |  Page : 646-651
Pregnancy during Hemodialysis: A Single Center Experience


1 Service of Nephrology, Hemodialysis and Kidney Transplantation, Military Hospital of Instruction, Mohammed V. Rabat, Morocco
2 Service of Gynecology obstetric, Military Hospital of Instruction, Mohammed V Rabat, Morocco

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Date of Web Publication26-Jun-2010
 

   Abstract 

Successful pregnancy outcome is an uncommon occurrence in women requiring chronic dialysis treatment. We reviewed the course and outcome of 9 pregnancies occurred in women on chronic hemodialysis in our center from 1999-2007; 5 of them ended with delivery of alive newborns, 2 with fetal deaths in-utero, and 2 with abortions. The average age of patients was 34 years. The etiology of the original kidney disease was unknown in 44.4% of the cases, and only 22.2% of the patients maintained diuresis. Dialysis started in 8 cases before the diagnosis of pregnancy. The average gestational age at diagnosis was 14 weeks. We modified the prescription of dialysis in 4 patients by increasing the frequency of the dialysis sessions to 6 per week and in 3 by increasing the duration of each session to 6 hours. Anemia was present in all the cases; 3 patients received erythropoietin and 4 patients required transfusion. The pregnancy was com­plicated in 44% of the cases by a polyhydramnios. The average time at delivery was 33 weeks and it was achieved in 80% of pregnancies through vaginal route. The average weight of newborns was to 2380 g. We conclude that pregnancy in women on hemodialysis is possible. The success of pregnancy may be influenced by the residual diuresis and early diagnosis to improve the quality of dialysis by increasing the dialysis dose.

How to cite this article:
Bahadi A, El Kabbaj D, Guelzim K, Kouach J, Hassani M, Maoujoud O, Aattif M, Kadiri M, Montassir D, Zajjari Y, Alayoud A, Benyahia M, Elallam M, Oualim Z. Pregnancy during Hemodialysis: A Single Center Experience. Saudi J Kidney Dis Transpl 2010;21:646-51

How to cite this URL:
Bahadi A, El Kabbaj D, Guelzim K, Kouach J, Hassani M, Maoujoud O, Aattif M, Kadiri M, Montassir D, Zajjari Y, Alayoud A, Benyahia M, Elallam M, Oualim Z. Pregnancy during Hemodialysis: A Single Center Experience. Saudi J Kidney Dis Transpl [serial online] 2010 [cited 2019 Nov 12];21:646-51. Available from: http://www.sjkdt.org/text.asp?2010/21/4/646/64627

   Introduction Top


Pregnancy is rare among women with end­stage renal disease (ESRD) undergoing hemo­dialysis (HD) and. However, it is difficult, to estimate the actual incidence of conception du­ring ESRD, since most of them are published as case reports that describe successful preg­nancy outcomes, and organized registries of pregnancy in this population is available only in few countries. In addition, data collection may be incomplete, and many pregnancies are lost before they are clinically confirmed.

Estimates of the frequency of conception in dialysis patients range from 1.4% per year in Saudi Arabia [1] to 0.5% in the United States. [2] A review of the literature from 1992 to 1999 by Holley and Reddy concluded that the inci­dence of pregnancy in women during the childbearing age and on chronic dialysis was 1-7%. [3] A report from Belgium, based on a sur­vey to which all the dialysis units in the coun­try responded, estimated the frequency to be 0.3% per year. Only 30-50% of these pregnan­cies resulted in the delivery of a surviving infant. [4] The low survival rate was associated with several specific obstetric complications that occur in dialysis patients, including poly­hydramnios (PHA), preterm labor (PT), hyper­tension (HTN) and intra-uterine growth res­triction (IUGR). [3]

We aim in this study to evaluate the course and outcome of pregnancy in HD women du­ring the childbearing age and the possible fac­tors that may modify this outcome.


   Materials and Methods Top


We retrospectively reviewed 9 pregnancies that occurred in 9 chronic HD women from July 1999 until June 2008. We are interested in the following parameters: age of patients, ori­ginal etiology of the kidney disease, start date of dialysis, the average age at time of preg­nancy, the frequency and duration of HD ses­sions, treatments received for control of ane­mia and blood pressure, obstetric complica­tions, time of delivery, mode of delivery, and birth weight.

The following modifications in the care of the pregnant women were implemented during conception:
  1. The total duration of dialysis was increased from 12h to 18h at least a week so as to have serum urea less than 50 mg/dL in order to better control blood pressure and improve the nutritional status of the pa­tients.
  2. Correction of anemia aiming at a target hemoglobin of 11 g/dL.
  3. Better control of blood pressure of the pregnant women.
  4. Correction of hypocalcemia and metabolic acidosis.
  5. Avoidence of hypotension during hemodia­lysis sessions to prevent its deleterious on the utero-placental circulation and conse­quent uterine contraction.
  6. Close obstetric observation with an ultra­sound of the uterus every week, and moni­toring of the patients weight gain during pregnancy, which was in the range of 0.3 to 0.5 kilograms per week during the se­cond and third trimesters.
  7. The polysulfone dialyzer membranes were used with bicarbonate bath, and the blood flow during the dialysis sessions was main­tained around 250 mL/min.

   Results Top


The average age of patients is 34 years (range from 22 to 40 years). The original kidney di­sease was unknown in 5 cases, while glome­rulonephritis, tubulo-interstitial nephropathy, chronic eclampsia, and nephrolithiasis were diagnosed in the remaining 4 cases. One pa­tient was started on hemodialysis after and the rest before conception with an average dura­tion of 40 months (range from 3 to 72 months). Two patients had a residual urine output of more than one liter per 24 hours and the re­maining patients were anuric [Table 1].

The average gestational age at diagnosis of pregnancy was 14 weeks (range from 7 to 25 weeks). Pregnancy was diagnosed with R HCG in 3 cases, 5 cases by ultrasound, and acciden­tally during a consultation for metrorrhagia in one patient. The frequency of dialysis sessions was increased to 4 per week in 2 cases and 6 in 2 cases, while the duration of the sessions was increased to 6 hours in 3 cases [Table 2].

Anemia was present in all the cases at the time of diagnosis of pregnancy with an average rate of 8.1 g/dL. To improve on these figures we increased the doses of erythropoietin in 3 cases, and required transfusion in managing 5 cases and iron supplementation in 4 cases.

Elevated blood pressure was present in 4 patients and was treated with a calcium inhi­bitor and/or central alfa agonists.

The pregnancies in our patients were compli­cated by polyhydramnios in 4 cases of whom 2 patients required amniocentesis, in addition to intrauterine fetal death at 27 weeks in one and at 33 weeks in another, besides an abortion at 7 weeks in one and at 21 weeks in another.

Five out of 9 pregnancies resulted in alive newborns with an age average to term of 35 weeks and an average weight of 2380 g (1800­2900 g).


   Discussion Top


Disturbances in menstruation and fertility are commonly encountered in women with chro­nic renal failure, usually leading to ameno­rrhea [5] and anovulation. [6],[7] In addition, women with chronic renal failure commonly have ele­vated circulating prolactin levels. [6] Interestingly, erythropoietin has been shown to improve sexual function and to induce regular mens­truation in some studies. [8],[9],[10],[11] Improved techniques of hemodialysis and transplantation also con­tribute to a significant reduction in hormonal disorders and amenorrhea. [12] The success rate of pregnancies has improved with better care. [13],[14] However, we were not able in our study to estimate the rate of pregnancies in our patients.

In women of childbearing age on dialysis, due to irregularity of menstruation, the diag­nosis of pregnancy is often delayed, the mean time of diagnosis being 16.5 weeks, [15] the ave­rage among our patients was 14 weeks late, which is acceptable in comparison with other reports. Early diagnosis of pregnancy in these women is often difficult as irregular mens­truation is common (about 60% of cycles in these women are anovulatory). [16] Early diag­nosis is advantageous for fetal viability, since it allows early review of medications that may be contraindicated in pregnancy, e.g., angio­tensin converting enzyme (ACE) inhibitors, warfarin, and cyclophosphamide, and more in­tensive dialysis early in the pregnancy.

Studies have shown that adequate dialysis, hemodynamic stability and correction of ane­mia and malnutrition are the most important factors for successful pregnancy in a hemo­dialysis patient. The choice of the mode of dia­lysis is controversial. Peritoneal dialysis could improve the outcome of pregnancy among pa­tients with ESRD. [17],[18],[19],[20] However, the experience with peritoneal dialysis (PD) in pregnancy is still limited to a very small number of cases, and most authors agree not to change the mode of dialysis after conception.

Increasing the dialysis dose seems to improve the pregnancy outcome and offers several advantages. It ensures a less uremic environ­ment for the fetus, and allows the mother a more liberal diet (protein and potassium) and fluid intake. It may help control hypertension with a reduction of antihypertensive medica­tions, [17] and may also reduce the amplitude of blood volume and electrolyts shifts. Frequent dialysis sessions make fluid removal and a­chievement of estimated dry weight (EDW) easier. It also lowers the risk of hypotension, which may be associated with fetal distress and premature labour. [21] The dose of dialysis was increased in our patients to 18h per week. The use of high flux dialyzers with biocom­patible membranes with modification of the dialysate (decreased bicarbonate, increased po­tassium concentration) is recommended. [11],[12],[21],[22],[23]

In our patients, we used polysulfone high flux dialyzers and alkalemia was not observed, al­though we used a standard bicarbonate dia­lysate. A careful monitoring of the maternal respiratory rate, O2 saturation, and electrolytes during HD is recommended.

Maternal dry weight and weight gain need to be regularly re-evaluated according to changes in the estimated fetal weight. In the first tri­mester a minimal weight gain of 1-1.5 kg occurs. After the first trimester, weight gain seems to be linear and amounts to 0.45 kg or 1 pound per week. [17] During the third trimester it is also careful to follow fetal weight and growth, using serial ultrasound determinations. If weight gain is excessive, episodes of hypotension can be minimized by the use of isolated ultrafiltration. For a good evaluation of the dry weight of our patients we used to carry out a weekly ultra­sound especially in the third trimester. Scru­pulous monitoring of maternal blood pressure and heart rate before, during, and after dialysis can also help the clinicians estimate more accurately the amount of fluid that has to be removed.

We used a low molecular weight heparin to avoid thrombosis, because it does not cross the placenta and has no teratogenicity. The dose should be reduced to the minimum to prevent high risk of bleeding from these patients.

The intensification of hemodialysis may in­duce hypophasphatemia requiring the reduc­tion of doses of phosphate binders. [24] In addi­tion, uterine contractions can occur due to reduced serum progesterone levels by dialysis and hypercalcemia at the end of dialysis. However, we did not find any of these com­plications in our patients.

All our patients were anemic with average hemoglobin to 8.1 g/dL therefore, and for eco­nomic reasons only three patients received erythropoietin (EPO). Unfortunately transfu­sion was necessary in five patients. The Epo dose in such pregnancies is a matter of con­troversy. [25],[26] A target hematocrit between 30 and 35% is recommended. In humans, strong indirect evidence argues against placental permeability to Epo. [27],[28],[29]

Grossman et al [30] recommend an i.v. 500 mg dose of iron, administered as soon as preg­nancy is diagnosed if transferrin saturation is lower than 30%. Folate supplementation is re­quired, particularly early in fetal neural deve­lopment. [22] the recommended dose is 0.8 to 1 mg/day.

More than half of chronic hemodialysis pregnant women reveal hypertension, [1],[23] and the mechanism of hypertension in this setting is probably multifactorial. [31] In our study, hyper­tension was encountered in 4 of our 9 preg­nancies and controlled by introducing calcium inhibitors alone or associated with a alpha­methyldopa due to there safety profile during pregnancy. [32] Angiotensin receptor blockers are contraindicated during pregnancy due to a teratogenic effect on the fetus. [33]

Malnutrition is common among HD patients. The nutritional problems of patients with ESRD are complicated by the nutritional re­quirements of pregnancy. [34] It has been esti­mated that the minimal daily Dietary Protein Intake (DPI) in pregnant HD patients is 1.8 g/kg/day. [35],[36]

Maternal complications such as thrombosis of arteriovenous fistula due to the state of hypercoagulability. [37]

The polyhydramnios is a part of the rapid changes and frequent concentrations of elec­trolytes and to the decrease in oncotic pressure which increases the volume of water in the amniotic cavity. Ensuring adequate dialysis re­duces the severity of polyhydramnios. Other causes may be behind the constitution of this polyhydramnios as fetal malformations. Four of our patients had presented a polyhydram­nios two of which needed an amniocentesis.

Compared to other series, we encountered less premature repture of membranes and prema­turity, but more polyhydramnios and a compa­rable rate of fetal death in utero. These results can be explained by the absence of neonato­logy service for the care of a newborn pre­maturity.

Finally, the weight of our newborns was higher than in other reports.

We conclude that pregnancy in women on hemodialysis is possible. The success of preg­nancy may be influenced by the residual diu­resis and early diagnosis to improve the qua­lity of dialysis by increasing the dialysis dose.

 
   References Top

1.Souquiyyeh MZ, Huraib SO, Saleh AG, et al. Pregnancy in chronic hemodialysis patients in the kingdom of Saudi Arabia. Am J Kidney Dis 1992;19:235.  Back to cited text no. 1      
2.Okundaye I, Abrinko P, Hou S. Registry of pregnancy in dialysis patients. Am J Kidney Dis 1998;31:766.  Back to cited text no. 2      
3.Holley JL, Reddy SS. Pregnancy in dialysis patients: a review of outcomes, complications, and management. Semin Dial 2003;16:384-8.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]  
4.Bagon JA, Vernaeve H, De Muylder X, Lafon­taine JJ, Martens J, Van Roost G. Pregnancy and dialysis. Am J Kidney Dis 1998;31:756-65.  Back to cited text no. 4      
5.Holley JL, Schmidt RJ, Bender FH, Dumler F, Schiff M. Gynecologic and reproductive issues in women on dialysis. Am J Kidney Dis 1997; 29:685-90.  Back to cited text no. 5  [PUBMED]  [FULLTEXT]  
6.Ginsburg ES, Owen WF Jr. Reproductive endo­crinology and pregnancy in women on hemo­dialysis. Semin Dial 1993;6:105-16.  Back to cited text no. 6      
7.Lim VS, Henriquez C, Sievertsen G, Frohman LA. Ovarian function in chronic renal failure: Evidence suggesting hypothalamic anovulation. Ann Intern Med 1980;93:21-7.  Back to cited text no. 7  [PUBMED]    
8.Tsakiris D, Visvardis G, Papadopoulou D, Papadimitriou M. Study of endocrine function in patients under hemodialysis during therapy with erythropoeitin. Kidney Int 1993;44:912.  Back to cited text no. 8      
9.Schaefer RM, Kokot F, Kurner B, Heidland A. Normalization of elevated prolactin levels in hemodialysis patients on erythropoietin Nephrol 1988;50:400-1.  Back to cited text no. 9      
10.Kokot F, Wiecek A, Shmidt-Gayk H, et al. Function of endocrine organs in hemodialized patients of long term erythropoetin therapy Artificial Organs 1995;19:428-35.  Back to cited text no. 10      
11.Schaefer RM, Kokot F, Wernze H, Geiger H, Heidland A. Improved sexual function in HD patients on recombinant erythropoietin: a pos­sible role for prolactin. Clin Nephrol 1989;31: 1-5.  Back to cited text no. 11      
12.Pelissier C, Boulet G, Caby J. Pregnancy in periodic hemodialysis: 16 cases including 1 only childbirth with alive child. Gynecologie 1987;5:315-23.  Back to cited text no. 12      
13.Hassan K, Al-Shamma I. Successful pregnancy in a patient with hemodialysis in Iraq. Saudi J Kidney Dis Transplant 2007;18(2):257-60.  Back to cited text no. 13      
14.Romao Jr JE, Luders C, Kahhale S, et al. Preg­nancy in women on chronic dialysis. A single­center experience with 17 cases. Nephron 1998;78:416-22.  Back to cited text no. 14      
15.Confortini P, Galanti G, Ancona G, Giongio A, Bruschi E, Lorenzini E. Full term pregnancy and successful delivery in a patient on chronic hemodialysis. Proc Eur Dial Transplant Assoc 1971;8:74-80.  Back to cited text no. 15      
16.Espersen T, Schmitz O, Hansen HE, Moller J, Klebe JG. Ovulation in uremic women: the reproductive cycle in women on chronic HD. Int J Fertil 1988;33:103-6.  Back to cited text no. 16      
17.Jakoubi 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;79:808-81.  Back to cited text no. 17      
18.Redrow M, Cherem L, Elliott J, et al. Dialysis in the management of pregnant patients with renal insufficiency. Medicine (Baltimore) 1988; 67:199-208.  Back to cited text no. 18  [PUBMED]    
19.Gadallah MF, Ahmad B, Karubian F, Campese VM. Pregnancy in patients on chronic ambu­latory peritoneal dialysis. Am J Kidney Dis 1992;20:407-10.  Back to cited text no. 19  [PUBMED]    
20.Giatras I, Delphine P, Malone D. Pregnency during dialysis: case report and management guidlines. Nephrol Dial Transplant 1998;13: 3266-72.  Back to cited text no. 20      
21.Hou S. Pregnancy in women on hemodialysis and peritoneal dialysis. Bailleres Clin Obstet Gyneacol 1994.8:481-500.  Back to cited text no. 21      
22.Haase M, Morgera S, Bamberg C, et al. A systematic approach to managing pregnant dialysis patients-the importance of an inten­sified haemodiafiltration protocol. Nephrol Dial Transplant 2005;20:2537-42.  Back to cited text no. 22  [PUBMED]  [FULLTEXT]  
23.Hou SH. Frequency and outcome of pregnancy in women on dialysis. Am J Kidney Dis 1994; 23:60-3.  Back to cited text no. 23  [PUBMED]    
24.Toma H, Tanabe K, Tokumoto T, Kobayashi C, Yagisawa T. Pregnancy in women receiving renal dialysis or transplantation in Japan: a nationwide survey. Nephrol Dial Transplant 1999;14:1511-6.  Back to cited text no. 24  [PUBMED]  [FULLTEXT]  
25.McGregor E, Stewart G, Junior BJ, Rodger RS. Successful use of recombinant human erythro­poietin in pregnancy. Nephrol Dial Transplant 1991;6:292-3.  Back to cited text no. 25      
26.Amoedo ML, Fernandez E, Borras M, Pais B, Montoliu J. Successful pregnancy in a hemo­dialysis patient treated with erythropoietin. Nephron 1995;70:262-3.  Back to cited text no. 26      
27.Eichorn KH, Bauer C, Eckhard KU, Zimmer­mann AH, Huch R. Lack of associations bet­ween fetal and maternal serum- erythropoietin at birth. Eur J Obstet Gynecol Reprod Biol 1993;50:47.  Back to cited text no. 27      
28.Schneider H, Malek AR. Lack of permeability of the human placenta for erythropoietin. J Perinat Med 1995;23:71-6.  Back to cited text no. 28      
29.Pokonen F, Rosenlof K, Rutanen EM, Fyhrquist F. Erythropoeitin binding sites in human fetal tissues. Acta Endocrinol 1997;116:561-7.  Back to cited text no. 29      
30.Grossman SD, Hou S, Moretti MI, Saran S. Nutrition in the pregnant dialysis patient. J Renal Nutr 1993;3:56-66.  Back to cited text no. 30      
31.Eroglu D, Lembet A, Ozdemir FN, et al. Preg­nancy during hemodialysis: perinatal outcome in our cases. Transplant Proc 2004;36:53-5.  Back to cited text no. 31      
32.Pryde PG, Sedman AB. Angiotensin conver­ting enzyme inhibitors fetopathy. J Am Soc Nephrol 1993;3:1575-82.  Back to cited text no. 32      
33.Paller MS. Hypertension in pregnancy. J Am Soc Nephrol 1998;9:314-21.  Back to cited text no. 33  [PUBMED]  [FULLTEXT]  
34.Ikizler A, Hakim RM. Nutrition in end-stage renal disease. Kidney Int 1996;50:343-57.  Back to cited text no. 34      
35.Alvestrand A. Nutritional requirements of dia­lysis patients. In: Manning S, ed. The Prin­ciples and practice of Nephrology. Mosby, St Louis, 1995;761-766  Back to cited text no. 35      
36.Avram MM, Bonomini LV, Sreedhara R, Mitt­man N. Predictive value of nutritional markers (albumin, creatinine, cholesterol, and hemato­crit) for patients on dialysis for up to 30 years. Am J Kidney Dis 1996;28:910-7.  Back to cited text no. 36      
37.Tan LK, Kanagalingam D, Tan HK, Choong HL. Obstetric outcomes in women with end­stage renal failure requiring renal dialysis. Int J Gynaecol Obstet 2006;94:17-22.  Back to cited text no. 37  [PUBMED]  [FULLTEXT]  

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Correspondence Address:
Driss El Kabbaj
Service of Nephrology, Hemodialysis and Kidney Transplantation, Military Hospital of Instruction, Mohammed V, Rabat
Morocco
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    Tables

  [Table 1], [Table 2]

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