| Abstract|| |
Fertility is markedly reduced in dialysis patients. 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. The reasons for the rarity of pregnancy in dialysis patients are not well understood. In addition, there is a marked increase in the risk of pre-eclampsia, hydramnios, hypertension crisis, early uterine contractions and pre-term delivery. Herein, we report a 38-year-old Saudi woman with chronic renal failure who completed the full term of pregnancy uneventfully on peritoneal dialysis. Using a biocompatible dialysate solution, adequate metabolic and blood pressure control were achieved during pregnancy. The delivered infant was small for gestational age and was born with a ventricular-septal defect. To the best of our knowledge, this is the first case report in the literature of ventricular-septal defect in an infant born to a mother on peritoneal dialysis.
|How to cite this article:|
Alhwiesh A. Pregnancy in peritoneal dialysis and an infant with a ventricular septal defect. Saudi J Kidney Dis Transpl 2015;26:111-4
|How to cite this URL:|
Alhwiesh A. Pregnancy in peritoneal dialysis and an infant with a ventricular septal defect. Saudi J Kidney Dis Transpl [serial online] 2015 [cited 2021 Feb 28];26:111-4. Available from: https://www.sjkdt.org/text.asp?2015/26/1/111/148755
| Introduction|| |
Pregnancy in patients with end-stage renal disease (ESRD) is infrequent. This infrequency is due classically to anovulation, with hyper-prolactinemia being responsible for the oligomenorrhea seen in female patients on dialysis.  Another factor mentioned is the reduced libido of these patients caused by alterations in human chorionic gonadotropin pulses and increased endorphins.  In addition, reduction in renal clearance and consequent serum elevation of leptin alter the hypothalamus-pituitary axis through the "Y" neuropeptide. Even dialysis patients who menstruated were usually anovulatory. Estradiol levels in the patients were similar to levels in normal women during the follicular phase of the menstrual cycle. 
Luteinizing hormone (LH) and follicle-stimulating hormone (FSH) surges did not occur and progesterone remained low. Pregnancy on peritoneal dialysis and hemodialysis comprised 1.2% and 2.2%, respectively.
Increase in the rate of pre-term delivery is largely related to the intervention for pre-eclampsia and intrauterine growth retardation. Women with kidney disease are at significant risk for pre-eclampsia, which is associated with fetal and maternal morbidity. Although this disorder may be more difficult to diagnose in women with baseline hypertension and proteinuria, the features of the pre-eclampsia may include significant worsening of hypertension and proteinuria.
Herein, we report a case of a woman who completed a full-term pregnancy uneventfully on peritoneal dialysis and the infant was born with ventrical-septal defect, which has not been reported previously.
| Case Report|| |
A 38-year-old Saudi woman had end-stage renal failure secondary to focal segmental glomerular sclerosis and was maintained on hemodialysis through right AV fistula. She was shifted to peritoneal dialysis due to patient preferences and was maintained on 10 L 1.36% Dianeal (dextrose dialysis solution produced by Baxter Company) over 9 h, with each fill volume comprising of 2 L and last fill volume comprising of 3 L Extraneal (icodextrin dialysis solution produced by Baxter Company). After two years of peritoneal dialysis, she was discovered to be pregnant and obstetric ultrasound showed a single live product compatible with 16 weeks by measurement of biparietal diameter and cephalic circumference in addition to normal placenta inserted with maturity degree 0 and normal amniotic fluid.
On examination, the patient was afebrile with no lower limb edema. She had blood pressure of 110/70 mm Hg, heart rate of 88/min, respiratory rate of 20/min, weight 52 kg, height 155 cm and body surface area 1.4 m. She had a residual renal function (RRF) of 1.5 L/day and creatinine clearance of 8 mL/min. She also had an expanded abdomen at the expense of the uterus, with a 15-cm pubis fundus diameter. Laboratory studies on admission are shown in [Table 1].
Urinalysis and culture were within the normal limit. Renal ultrasound showed a right kidney size of 79 mm × 30 mm and a left kidney size of 94 mm × 55 mm, with loss of the cortico-medullary differentiation without hydronephrosis.
The peritoneal dialysis prescription was modified to 10 L of Physioneal (dialysis solution produced by Baxter Company), each fill volume of 1.5 L over 9 h, and the last fill of Extraneal solution was discontinued. Her antihypertensive medication lisinopril was replaced by Aldomet (methyldopa) 250 mg three times per day. In addition, the patient continued to receive her usual medications including calcium carbonate 1.2 g three times per day, calcitriol 0.5 mg daily, folic acid 5 mg daily, darbepoitin 60 mg subcutaneously weekly, multivitamins and ferrous sulfate 190 mg daily. The total dietary protein intake was 1.5 g/kg body weight, phosphorus 800 mg/day, 45 Kcal/kg body weight and total liquid intake of 1500 mL/day. She was followed-up on a weekly basis at the peritoneal dialysis unit and obstetrics and gynecology clinic of our hospital. Her average blood pressure ranged from 110/70 to 140/80 mm Hg.
The pregnancy was uneventful and delivery was induced at the 37 th week of gestation. She had normal vaginal delivery of a female baby with a weight of 1500 g, length 42 cm and Apgar score of 7-8. During delivery, peritoneal dialysis was held and vancomycin and ceftriaxone single doses were administered as prophylaxis. At the time of birth, the infant's creatinine was 1.6 mg/dL and it took five days to normalize to 0.2 mg/dL. The baby had mild ventricle septal defect. Peritoneal dialysis was restarted the following day to delivery with 10 L physioneal over 9 h, each fill volume comprising 2 L, and the mother was discharged after three days in a stable condition.
| Discussion|| |
Most studies of hormone abnormalities in dialysis published in 1998 by the Nephrology Department of Rush Presbyterian Hospital in Chicago, IL, USA , established that of 6230 women between the ages of 14 and 44 years (4531 on hemodialysis and 1699 on peritoneal dialysis) in 930 dialysis centers in the period between 1992 and 1995, only 128 (2%) managed to become pregnant [109 (2.4%) on hemodialysis and 19 (1.1%) on peritoneal dialysis]. Of these 128 patients, 48 (37.5%) managed to complete the pregnancy successfully. ,,,, This is not an encouraging prognosis for pregnancy in patients who are already on renal replacement therapy; however, the prognosis was better for patients who began dialysis after the onset of pregnancy.
Because of anatomical and functional changes that occur during pregnancy, the renal replacement method to begin with is controversial. ,,,,
There are some reports in which PD could have a better outcome, but no comparative, randomized, prospective studies of HD and PD are available to determine the best method. Our patient had a full-term pregnancy uneventfully by using a biocompatible dialysate solution with adequate metabolic and blood pressure control achieved during pregnancy. The other important factor that maintained the dialysis adequacy in our patient was her low body surface area and good RRF, and that we used more intensive dialysis with the Blood Urea Nitrogen being maintained at under 50 mg/dL (17 mmol/L) or even under 45 mg/dL (16 mmol/L). ,
Ameliorating the uremic milieu can avoid polyhydramnios, help control hypertension, increase birth weight and gestational age of the fetus and improve the maternal nutrition. Pregnant women often require higher doses of erythropoietin to maintain an adequate red cell mass (hemoglobin of 10-11 g/dL), as the physiologic changes and demands of pregnancy may result in worsening of anemia. Transferrin saturation should be maintained around 30%. Metabolic acidosis and hypocalcemia should be corrected. Maternal hemodynamic instability may compromise the utero-placental circulation and may be associated with the induction of uterine contractions.  In peritoneal dialysis, we should reduce the volumes of the dialysis solution (1.5 L) and increase the frequency of dialysis besides the modification of the amount of calories and protein ingestion (1 g/kg/day) and addition of supplements of water-soluble vitamins and zinc.
Treatment of hypertension must be performed under strict supervision and pharmacological adjustment. Our patient was on lisinopril during the first trimester, and most of the case series that linked the use of angiotensinconverting enzyme (ACE) inhibitor with fetopathy occurred during the second and third trimesters. , The possibility of lisinoprilinduced ventricular septal defect cannot be ruled out. A retrospective cohort study used automated clinical and pharmacy databases to examine the reported association between the use of ACE inhibitors during pregnancy and the risk of malformations in the offspring. 
This study included 755 mother-infant pairs exposed to ACE inhibitors, 17,507 mother- infant pairs exposed to other antihypertensive agents, 31,274 mother-infant pairs with untreated maternal hypertension and 416,218 mother-infant pairs without hypertension or exposure to antihypertensive drugs. Compared with the pregnant women without hypertension, the hypertensive pregnant women had a 40-50% increased risk of delivering a live born infant with a congenital heart defect regardless of whether they were managed with the ACE inhibitors, other antihypertensive drugs or no treatment.
| Acknowledgment|| |
The author wish to express their thanks and appreciation to the staff nurses of the peritoneal dialysis unit and the obstetrics and gynecology nurses for their great support during the hospitalization of the patient.
Conflict of interest: None
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Dr. Abdullah Alhwiesh
King Fahd University Hospital, Alkhobar
Kingdom of Saudi Arabia