End stage renal disease disrupts normal gonadal function, which is regained within months of successful renal transplant.(1,2) The patients with advanced chronic renal disease may present with hypothalamic gonadal dysfunction leading to infertility. The optimal timing of pregnancy as per the current recommendations by American Society of Transplantation is that as long as graft function is optimal, defined as, a serum creatinine < 1.5 mg/dl, with < 500 mg/24 hours protein excretion and no concurrent fetotoxic infections or use of teratogenic drugs, and dosing of immunosuppressive drugs is stable at maintenance level, the patient can safely proceed with pregnancy.(3)
If a cesarean delivery is performed, attention should be paid to the the transplanted kidney in the right iliac fossa. The course of transplanted ureter should be kept in mind.
A common concern during pregnancy in posttransplant patients is the optimal choice of immunosuppressive agents with respect to fetal risk of congenital malformations. The current recommendation is to avoid mycophenolate mofetil and m-TOR inhibitor (sirolimus/everolimus) at least 6 weeks prior pregnancy.
Tailoring the dosage of drugs to maintain optimal levels is required as pregnancy alters pharmacokinetics of drugs and plasma drug levels. The recommendation by the American Society of Transplantation Consensus Conference is that to avoid graft rejection, immunosuppressive dosing should be maintained at pre pregnancy levels through frequent monitoring of serum drug levels.(4,5) Based on these recommendations, our patient was shifted to azathioprine from mycophenolate mofetil 1 year prior to pregnancy.
The common complications which may arise in transplant patients are preeclampsia (30% as compared to 5 to 8% in general population), GDM/overt diabetes, infections and anemia. Increased incidence of preeclampsia can be explained due to cyclosporine induced production of thromboxane and endothelin, diabetes due to cyclosporine and steroid use, infections due to generalized immunosuppression and anemia due to bone marrow suppression.
Among kidney transplant recipients, approximately 35% of pregnancies do not progress beyond the 1st trimester due to spontaneous or therapeutic abortion and that overall success rate is > 90% after the 1st trimester as reported by the studies.(7) Most common maternal complication is hypertension.
The prevalence of hypertension in pregnant renal transplant patients (up to 73% in the National Transplantation Registry (NTPR) 50% in Asia).(8-10) Alpha Methyl-dopa is considered the drug of choice because of its well documented safety and lack of teratogenicity.
Maternal renal transplant patients with hypertension are at increased risk for development of superimposed preeclampsia, with an incidence of 15 to 25% compared with normotensive pregnancies.' Other comorbidities to be considered in the maternal transplant recipient include gestational diabetes, anemia, and infections such as urinary tract infections. (6,11) Urinary tract infections occur in up to 42% of pregnant renal transplant patients, although pyelonephritis is rare. (12,13) Most deliveries occur early because of maternal and/or fetal compromise, rather than spontaneous preterm labor21 Transplant recipients are at high risk for premature rupture of membranes, which also contributes to the increased risk for preterm labor. Expert consensus opinion has been that unless there is an obstetric reason to indicate cesarean delivery, vaginal delivery is preferred.4 Immunosuppressive medication exposure may continue after birth if the mother opts to breastfeed. Studies are needed on pharmacokinetics and transfer of immunosuppressive medications to breast milk. Until these studies are available, expert consensus is that breastfeeding need not be seen as absolutely contraindicated.
