Wednesday, March 2, 2011

Pregnancy in the Dialysis Patient

While recently reading about hypogonadism in the dialysis population, I came across this review on the pregnancy outcomes in women on dialysis, summarizing observational studies published between 1995 and 2009. I have participated in only a few pregnancy-planning discussions with women with CKD, but they have all been emotionally tough. None of my patients were dialysis patients, however, whom I would have predicted would have even worse outcomes with pregnancy as has been reported for CKD (for example, a rate of preterm delivery of 63% and perinatal death of 4% reported recently here).


The results of this review suggest that the outcomes in women on dialysis, while better than expected in some aspects (for example rate of live birth of 79%), still carry significant risks for the mother and baby (for example, a perinatal death rate of 17.6%).


Among women of childbearing age on dialysis, DaVita reports that only 1-7% can get pregnant – due to complete cessation of the menstrual cycle, or anovulatory cycles. However, some women continue to have menstrual cycles – as you’ll be smart to remember next time you’re asked about a female PD patient with a bloody peritoneal fluid effluent.


Among those who do get pregnant (222 pregnancies studied in this review), an astonishing 79% resulted in a live birth, although only 8% were term births (71% were premature for an overall preterm delivery rate of ~85%!). The two most common reasons for premature birth were premature labor (approximately 1/3rd) and fetal distress (another 1/3rd). Of the remaining 1/3rd, intrauterine growth restriction and hypertensive disease were most common. The rate of delivery by c-section in the subgroup where this data was available, was 37%.


Among the fetal/neonatal complications, prematurity was most common. Three cases of fetal abnormalities were reported, including one case of right-sided pulmonary agenesis. The rate of polyhydramnios was 32%, postulated to be due to increased diuresis by the fetal kidneys due to elevated urea. There were 19 neonatal deaths and 28 perinatal deaths among 159 live births for which this data was reported, yielding a neonatal mortality rate of 11.9% and perinatal mortality rate of 17.6%. It is not clear if perinatal mortality includes neonatal mortality in this article, though the latter percentage by itself is a sobering figure.


Among the maternal complications, hypertensive disease was the most common, though at a reported 30% it is much lower than I would have predicted. Among the 14 women in the cohort on PD, 4 developed peritonitis and 2 developed uterine bleeding so significant to require surgical intervention and, in one case, hysterectomy. The specific adjustments to renal replacement management for pregnant women were not discussed in detail, though included increased time and frequency of dialysis, which was associated with decreased rate of polyhydramnios and improved fetal outcomes.


As it is still a relatively rare event, I would love to hear from any of you who have helped manage pregnant women on dialysis.


Marta Hristova MD

12 comments:

iain said...

A very interesting article, thanks.

I have worked in centres where there have been successful births in dialysis patients. Not PD, however. (Certainly my advice would be for the PD patient to transfer to daily (or 5-6 times weekly) HD sessions as, IMHO, uraemia is better controlled that way.)

We had one pre-term birth in an established HD patient in one centre recently - managed by a joint nephro-obstetric team closely throughout - and 2 others in another centre, in my experience. They both had significant CKD 3/4 which deteriorated in early pregnancy. They were both commenced on 5 times weekly HD (2hr sessions) and delivered early, successfully. The patients remained HD-dependent post-partum.

I must say, I discuss the worst possible outcomes early with my CKD patients and their partners wanting to get/already pregnant. It's a difficult area and I find our local combined nephro-obstetric team most helpful.

Iain

Jenn Trunk said...

I'm a CKD patient. Are there any studies done in patients that aren't on dialysis? I have a group of about 10 women on Facebook...all with FSGS in our case, either wanted to get pregnant in the future or currently already are. It's been very difficult to get any information for those of us afflicted with CKD.

T-diddy said...

@Jenn Trunk: have you read this article from CJASN in 2010?

http://blog.ecu.edu/sites/nephrologyondemand/?p=1617

Anonymous said...

@Jenn Trunk: there are a number of studies looking at outcomes for both the mom and the baby in women with CKD; for example here is a classical one from 15 years ago:
http://www.nejm.org/doi/full/10.1056/NEJM199607253350402

In general, the success of the pregnancy (stable health for mom and healthy baby) depends on the baseline kidney function of the mom, including the Cr (<1.4 mg/dL outcomes are similar to general population) and the presence of proteinuria. There is a link to another study in CKD patients in the first paragraph of the blog post (published in AJKD).

Marta

JC said...

We are currently dialyzing a 41 year old carrying twins. She has been on dialysis approx. 4 years. 2 previous births were high risk and premies(prior to dialysis). Pt relates she and her last baby almost died. At 24 weeks the high risk OB clinic told us to run her 5 days a week (4.75 hrs each session). The ultrasounds have been showing good growth for both babies. Her largest issue is blood pressure control. Hypertension is the cause of ESRD. The plan for the Pt and babies was to have her move into the Ronald McDonald house to be close to OB (which is 1 hr away)at 20 weeks, but Pt refuses. So we continue to monitor closely. She will be c-sectioned around 32 weeks. She was educated on the high risk nature and she chose not to have an abortion. I have not been able to find much info on twin pregnancies and ESRD. I find this case fascinating and I have never encountered twins in my 25 years of nephrology.

Conall O' Seaghdha said...

Fascinating case JC, please let us know how things turn out

Conall

Anonymous said...

I am currently a HD patient with no functional kidneys and I am 18 week pregnant doing HD 20 hours a week. So far do good I see an OB at the U of Washington. HOPING FOR THE BEST FOR MY SON AND I .

Lori Sisneros said...

I am currently a patient on in-center hemodialysis. I only started in March of this year. My center has only treated one person that was pregnant, and now I have just found out I am. I was SO scared. I have had type one diabetes for 26 years which is what killed my kidneys; but I am diagnosed with ESRD and fall into that 1-7% that can get pregnant while on dialysis!
I meet with specialists next week about going through with this pregnancy, and have been searching to find anything on the subject is insane! My center social worker gave me an article from your website and I also really liked the one I read above. My wonder is that all of the comments are from last year, is there anywhere I can find anything newer, information wise? I was pursuing a career in Physical therapy, I know the doctor lingo, and now this kidney mess is in the way and now complicated by pregnancy,so if someone could give me any direction I would surely appreciate it!
Thank you,
Lori Sisneros
keepintouchmt@hotmail.com
(I hope you don't count this as a solicitation.?)

Graham Abra said...

Lori,

Replied to you offline. Let us know if there's anything else we can do to help.

Best,

Graham

Dansev said...

Hey lori, I hope this helps you out . I just gave birth to baby number two a few weeks ago, I'm on home hemo dialysis now for 12 yrs. if you need to know anything, or have questions please email me at danseverino@ hotmail.com. Good luck as I know it's scary. Remember that anything is possible x Danae

Dansev said...

Sorry both children I had whilst on dialysis :)

Anonymous said...

I am 35 and been on dialysis for 7 and a half years. I still have monthly periods but they do not always come at the same time every month. I have not used any form of birth control for 3 years now and I have not conceived. Is there anything I can do to make it easier to conceive?