Choksi K*, Chaudhari HK**.
(*Junior Resident, **Associate Professor, Seth G S Medical College and K E M Hospital, Mumbai, India.)
Pregnancies in women on renal replacement therapy have higher chance of maternal and fetal complications. Medical management of pregnant women with chronic kidney disease is a great challenge and requires nephrologists, gynecologists and neonatologists to work in liason. This case report gives an overall review of how successful pregnancy rates have improved in women with chronic renal disease with renal replacement therapy.
Renal disease during pregnancy is relatively uncommon. Renal insufficiency is uncommonly associated with pregnancy because many women with significant renal insufficiency or renal failure are either beyond childbearing age or are infertile. Incomplete reporting or data collection and the fact that the incidence of mild renal disease is often not included in many of the reported series could be the other causes. Patient of renal disease have irregular menses and most of the times cannot produce healthy ovum and are infertile. Pregnancy is a challenging experience for women suffering from chronic kidney disease. Damaged kidney cannot adapt to the physiological changes of pregnancy hence, have higher chances of adverse outcome like abortion, preterm labor, preeclampsia and intrauterine fetal demise. Maternal and fetal outcome have inverse relationship with baseline renal function and worsens with proteinuria. It is more challenging for patient of end stage renal disease (ESRD) on dialysis. Fetus is benefited by earlier and intensified clearance of solutes. Despite the fact that mortality remains high and prematurity and low birth weight is commonly seen, the number of successful pregnancies in dialysis patients has increased over time with a gain in fetal survival. The improvement of outcomes between the nineties and now is due to an acquired expertise in dialysis schedules and technique, close monitoring of clinical, biochemical and renal parameters in a pregnant women.
27 year old second gravida married since 9 years, 36 weeks pregnant with chronic kidney disease with anemia and chronic hypertension came with chief complaints of breathlessness on routine activity, generalized body swelling, easy fatigability and decreased urine output. She had no complaints of headache, epigastric pain or blurring of vision. She had no joint pain, rash, photosensitivity or uremic complaints. In her previous pregnancy, she developed hypertension, had a fetal demise and was diagnosed as a case of stage 4 CKD. She had received hemodialysis and was put on oral steroids. On investigations, anti nuclear antibodies were positive. In between pregnancies she was following up regularly with the nephrology department and underwent hemodialysis regularly. On examination in this pregnancy, pallor and a blood pressure of 160/100 mm of Hg was noted .On abdominal examination, uterus was 34 weeks, relaxed with a live fetus in cephalic presentation and she was not in labor. Serum creatinine was 5.7 mg% and hemoglobin was 7.6 gm%. She underwent one session of hemodialysis. She was started on oral nifedipine 10 mg, carvedilol 6.25 mg, sodium bicarbonate and aspirin 75mg. Two packed cell transfusion were given. She went into spontaneous labor and delivered vaginally a baby of 1.8 kg. She had postpartum hemorrhage and was transfused five units of packed cells then. In the post partum period, she was stable and discharged on day10. She has been following up with nephrology department for management of chronic renal disease.
The renal plasma flow and glomerular filtration rate increase by 50% during pregnancy hence average serum urea and creatinine fall by 20-30% in comparison to non-pregnant women. Due to increase filtration, 24 hour protein excretion upto 300mg is considered normal. Baseline renal function determines pregnancy outcome. Women with primary renal disease have successful pregnancy outcome when she is not hypertensive and has low serum uric acid levels. Adverse maternal outcome include gestational hypertension, preeclampsia or eclampsia, anemia, preterm delivery, need for ceserean section( 32% higher chance), postpartum hemorrhage, increased need of blood transfusion and acute renal failure. Adverse fetal outcome include fetal growth restriction, preterm birth( 52% higher chance of preterm delivery), low birth weight and neonatal morbidity. Fetal complications are primarily due intrauterine growth restriction and low birth weight due preterm termination of pregnancy in view of worsening hypertension and non-reassuring non stress test. Patient maintained on dialysis usually abort or end up in preterm delivery at around 32 weeks. Polyhydramnios is seen due to increased placental urea levels which cause fetal diuresis. Women with high baseline serum creatinine are more likely to have accelerated renal damage. Renal function deteriorates in 75% women with severe renal disease and progress to end stage renal disease within one year of delivery when serum creatinine is more than 2mg/dl. Pre pregnancy counseling is a must in women with renal disease. Baseline blood pressure, renal function, urinary proteinuria and complete blood picture should be done. These women should be registered in a tertiary care hospital and should have more frequent antenatal visits. Special attention should be paid to control hypertension and avoid worsening of renal function. They should be advised to have good quality protein intake of atleast 1.2g per day and have a salt restricted diet. Women on angiotensin converting enzyme inhibitors as antihypertensive should be changed over to other anti hypertensives after first trimester as there is risk of oligohydraminos, hypocalvaria, renal failure and IUFD. Anemia should be treated aggressively with hematinics and injection erythropoietin if required to maintain a hemoglobin of 10-11gm%. Successful correction of anemia in chronic renal disease has reduced the associated morbidity and mortality. Low dose aspirin or low molecular weight heparin should be given in women with hypertension and bad obstetric history. Uterine artery Doppler at 20-24 weeks helps to detect fetal growth restriction and surveillance to be done twice weekly depending on severity of renal impairment and hypertension.
Usually women on chronic dialysis do not conceive due to associated amenorrhea and irregular menstrual cycles and even if conceive they tend to abort or have preterm delivery, preeclampsia, placental abruption and still birth. Pregnant women need sessions of dialysis weekly to maintain blood urea of <50mg/dl. Successful pregnancy outcome now occur in 50% of pregnancy with improvised medical management and prompt and regular concurrent nephrology and obstetric management.
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Choksi K, Chaudhari HK. Pregnancy With Chronic Kidney Disease. JPGO 2019. Vol. 6. No. 8. Available from: https://www.jpgo.org/2019/08/pregnancy-with-chronic-kidney-disease.html