|Year : 2010 | Volume
| Issue : 4 | Page : 646-651
|Pregnancy during Hemodialysis: A Single Center Experience
Abdelali Bahadi1, Driss El Kabbaj1, Khalid Guelzim2, Jaouad Kouach2, Mohammed Hassani1, Omar Maoujoud1, Mohammed Aattif1, Mouncif Kadiri1, Dina Montassir1, Yassir Zajjari1, Ahmed Alayoud1, Mohammed Benyahia1, Mostapha Elallam1, Zouhir Oualim1
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 Publication||26-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 2020 Jun 2];21:646-51. Available from: http://www.sjkdt.org/text.asp?2010/21/4/646/64627
| Introduction|| |
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  to 0.5% in the United States.  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%.  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.  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). 
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|| |
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:
- 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.
- Correction of anemia aiming at a target hemoglobin of 11 g/dL.
- Better control of blood pressure of the pregnant women.
- Correction of hypocalcemia and metabolic acidosis.
- Avoidence of hypotension during hemodialysis sessions to prevent its deleterious on the utero-placental circulation and consequent uterine contraction.
- 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.
- The polysulfone dialyzer membranes were used with bicarbonate bath, and the blood flow during the dialysis sessions was maintained around 250 mL/min.
| Results|| |
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|| |
Disturbances in menstruation and fertility are commonly encountered in women with chronic renal failure, usually leading to amenorrhea  and anovulation. , In addition, women with chronic renal failure commonly have elevated circulating prolactin levels.  Interestingly, erythropoietin has been shown to improve sexual function and to induce regular menstruation in some studies. ,,, Improved techniques of hemodialysis and transplantation also contribute to a significant reduction in hormonal disorders and amenorrhea.  The success rate of pregnancies has improved with better care. , 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,  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).  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. ,,, 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,  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.  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. ,,,,
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.  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.  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. , A target hematocrit between 30 and 35% is recommended. In humans, strong indirect evidence argues against placental permeability to Epo. ,,
Grossman et al  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.  the recommended dose is 0.8 to 1 mg/day.
More than half of chronic hemodialysis pregnant women reveal hypertension, , and the mechanism of hypertension in this setting is probably multifactorial.  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.  Angiotensin receptor blockers are contraindicated during pregnancy due to a teratogenic effect on the fetus. 
Malnutrition is common among HD patients. The nutritional problems of patients with ESRD are complicated by the nutritional requirements of pregnancy.  It has been estimated that the minimal daily Dietary Protein Intake (DPI) in pregnant HD patients is 1.8 g/kg/day. ,
Maternal complications such as thrombosis of arteriovenous fistula due to the state of hypercoagulability. 
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.
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Driss El Kabbaj
Service of Nephrology, Hemodialysis and Kidney Transplantation, Military Hospital of Instruction, Mohammed V, Rabat
[Table 1], [Table 2]
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