| Abstract|| |
An 18-year-old woman patient was discovered to have severe anemia and advanced renal failure during a routine prenatal follow-up at her 6th week of gestation. During the first few weeks of therapy, the hemodialysis frequency was increased gradually, and Erythropoietin was administered with intravenous iron therapy to keep the patient's hemoglobin above 115 gm/L. Blood pressure rose was controlled by alpha methyldopa. Obstetric follow-up consisted of monitoring the fetal activity and growth, placental maturity, and umbilical artery perfusion. On the 32nd week of gestation, the patient had a normal vaginal delivery of live female weighing 2,100 gm. the patient had a completely uneventful postpartum course, and the newborn baby was well. In conclusion, our index case illustrates that intensified dialysis regimens and attentive medical care results in a successful outcome of pregnancy in patients with end stage renal disease on hemodialysis.
Keywords: Pregnancy, Hemodialysis, Renal failure
|How to cite this article:|
Abd KH, Al-Shamma I. Successful pregnancy in a patient with hemodialysis in Iraq. Saudi J Kidney Dis Transpl 2007;18:257-60
| Introduction|| |
The first successful full term pregnancy that occurred in a 35-year-old dialysis patient was described in 1971 by Confortini. Since then, 120 cases of conception in end- stage renal disease (ESRD) patients, were published in almost 30 years and the frequency of conception on dialysis has increased.
However, the successful outcome is rare. Gestation in uremic patients exposes the mother to the risk of hypertension and fluid overload. Furthermore, there is increased risk on the fetus of neonatal mortality, prematurity, and small for gesta-tional-age.
We report on an 18-year-old woman who was discovered to have ESRD at six weeks during her first gestation with a successful outcome. This may be the first reported case of successful pregnancy in a woman on chronic hemodialysis in Iraq.
| Case Report|| |
An 18-year-old woman patient was discovered to have severe anemia and advanced renal failure during a routine prenatal follow-up at her 6th week of gestation. She was normotensive with a blood pressure of 120/75 mmHg. Laboratory investigations revealed hemoglobin 50 g/L, blood urea 150 mg/dl( 54 mmol/L), and serum creatinine 7.2 mg/dl (813 µmol/L); creatinine clearance was 14 ml/min. An ultrasound of the abdomen confirmed the presence of bilateral small kidneys and loss of cortical thickness that were compatible with chronic renal failure, and a single viable fetus of 7 weeks of age. Sub clavian double lumen catheter was inserted and hemodialysis was initiated. The patient decided to continue with the pregnancy, and the obstetrician was consulted for follow-up with the nephrologist.
During the first few weeks of therapy, the hemodialysis frequency was increased gradually from twice weekly sessions (8 hours/week) to four times weekly (14-16 hours/week) in order to maintain blood urea nitrogen levels between 60-90 mg/dl (20-30 mmol/L). The patient was dialyzed with a high-flux polysulphone membrane (1.4m 2 ) dialyzer and by using a standard acetate solution. During each dialysis session, the blood flow was gradually increased from 100 to 300 ml/min. Standard unfractionated heparin was used for anticoagulation. Aspirin in a dosage of 100 mg daily was prescribed to decrease the risk of preeclmapsia.
Erythropoietin (Epo) 4000 IU Subcutaneously was administered twice or thrice weekly, with intravenous iron therapy to keep the patient's hemoglobin above 115 gm/L. She received folic acid 20-25 mg/day, vitamin D 0.25 mcg/ every other day, and calcium carbonate 1-2 gm/day. Her blood pressure rose toward the end of the second trimester and was controlled by alpha methyldopa 250mg thrice daily.
Obstetric follow-up consisted of monitoring the fetal activity and growth, placental maturity, and umbilical artery perfusion. Resistive index was 0.5 and the fetal heart rate was 127-150 beat /minute. The amniotic fluid volume was monitored once weekly with suggestions to temporize the gestation till the 35 th week. We contemplating an elective caesarean section at that stage. Serial ultrasonography revealed normal fetal growth and normal blood flow in the umbilical vessels.
On the 31 st week of gestation, ultrasonography revealed mild polyhydramnios with increased resistive index of the umbilical artery, and decreased placental flow. On the 32nd week of gestation, the patient developed a sudden premature rupture of the membrane, which was followed 12 hours later by normal vaginal delivery of a live female weighing 2,100 gm. The patient had a completely uneventful postpartum course. The newborn baby was admitted to the neonatal intensive care immediately after birth, she had mild respiratory distress and required only supplemental oxygen and was discharged, well, the next day.
| Discussion|| |
Most ESRD women have abnormalities in the hypothalamic-pituitary-gonadal axis that result in anovulation, absent, scanty, or irregular menses, and infertility. This usually results in decreased chances of gestation in this population.
The precise fertility rate in women on chronic dialysis therapy is unknown. Existing data are based on surveys and retrospective studies, which may overestimate the rate.
The largest study is from the registry for pregnancy in dialysis patients (RPDP), which has collected data from almost 1000 dialysis units in the United States. This study reported a pregnancy rate of 2.2% in women of childbearing age on hemodialysis or peritoneal dialysis over a 4-year period.7 In a large survey of more than 1700 Japanese dialysis units, 3.4% of women of childbearing age on dialysis became pregnant at some point in time, with only 49% of the pregnancies yielding a live infant.
Previous studies had indicated that adequate dialysis, hemodynamic stability, and the correction of anemia and malnutrition are the most important factors for a successful pregnancy in chronic hemodialysis patients. The report of the registry of pregnancy in dialysis patients proposed a trend toward a better pregnancy outcome and reduced fetal prematurity in patients with a weekly dialysis dose exceeding 20 h. There was also a positive correlation between birth weight and dialysis time.
After renal failure has been diagnosed, we started our patient on 8h to 20 h/ week hemodialysis from the time of diagnosis of renal failure. We used high-flux dialyzers to keep her pre-dialysis urea concentration lower than 60 mg/dl( 30mmol/L) to reduce the incidence of Polyhydramnios. It is important to avoid interdialytic body-weight gain by intensive hemodialysis and to prevent hemodialysis-related hypotension, which is detrimental for the fetus. Bicarbonate dialysate solution is the mode of choice in hemodialysis, but this type of solution was not available in our center so we maintained our patient on acetate dialysate.
Just as in the general dialysis population, hypertension is extremely common in pregnant women; the RPDP reported 79% of the patients were hypertensive, and 48% who had blood pressures greater than 170/110 mm Hg at some point during pregnancy. Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers are contraindicated during pregnancy. The most commonly used antihypertensive drugs remain older agents, including alpha-methyl-dopa and hydralazine, which safety in pregnancy is well documented.
Hypertension or hypotension was avoided throughout the entire pregnancy in our patient. Her monthly blood sugar check-up was normal.
Correction of anemia possibly increases the success rate of pregnancy and prevents hypoxemic stress in the fetus, but increased doses of Epo should be administered to counteract the Epo hyporesponsiveness of pregnancy. Epo does not pass through the human placenta, and no Epo-related teratogenicity has been reported.
Adequate dietary prescription is mandatory for maternal health and fetal development. With intensive hemodialysis, dietary restrictions could be liberalized without exposing the patient to the risk of azotemia and hyperkalemia. In our patient, the serum albumin level was maintained between 35 and 42 g/L, although there is a physiological decrease in the serum albumin concentration in normal pregnancy.
In conclusion, our index case illustrates that intensified dialysis regimens and attentive medical care results in a successful outcome of pregnancy in patients with end stage renal disease on hemodialysis.
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Kais Hasan Abd
Dept. of Nephrology & Renal Transplantation, Specialized Surgical Hospital, Baghdad Medical City, Baghdad