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van Buren MC, Gosselink M, Massey EK, van de Wetering J, Lely AT. Counselling on Conceiving: Attitudes and Factors Influencing Advice of Professionals in Transplantation. Transpl Int 2023; 36:11052. [PMID: 37234219 PMCID: PMC10205991 DOI: 10.3389/ti.2023.11052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 04/25/2023] [Indexed: 05/27/2023]
Abstract
Pregnancy after kidney transplantation (KT) conveys risks of adverse pregnancy outcomes (APO). Little is known about performance of pre-pregnancy counselling after KT. This study investigated perceptions of risk, attitudes towards pregnancy and factors influencing advice given at pre-pregnancy counselling after KT. A web-based vignette survey was conducted among nephrologists and gynaecologists between March 2020 and March 2021, consisting of five vignettes containing known risk factors for APO and general questions on pre-pregnancy counselling after KT. Per vignette, attitudes towards pregnancy and estimation of outcomes were examined. In total 52 nephrologists and 25 gynaecologists participated, 56% from university hospitals. One third had no experience with pregnancy after KT. All gave positive pregnancy advice in the vignette with ideal circumstances (V1), versus 83% in V2 (proteinuria), 81% in V3 (hypertension), 71% in V4 (eGFR 40 ml/min/1.73 m2). Only 2% was positive in V5 (worst-case scenario). Chance of preeclampsia was underestimated by 89% in V1. 63% and 98% overestimated risk for graft loss in V4 and V5. Professionals often incorrectly estimated risk of APO after KT. As experience with pregnancy after KT was limited among professionals, patients should be referred to specialised centres for multidisciplinary pre-pregnancy counselling to build experience and increase consistency in given advice.
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Affiliation(s)
- Marleen C. van Buren
- Department of Internal Medicine, Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Margriet Gosselink
- Department of Obstetrics and Gynaecology, Wilhelmina Children’s Hospital Birth Centre, University Medical Center Utrecht, Utrecht, Netherlands
| | - Emma K. Massey
- Department of Internal Medicine, Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Jacqueline van de Wetering
- Department of Internal Medicine, Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - A. Titia Lely
- Department of Obstetrics and Gynaecology, Wilhelmina Children’s Hospital Birth Centre, University Medical Center Utrecht, Utrecht, Netherlands
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Lin Y, Song T, Ronde EM, Ma G, Cui H, Xu M. The important role of MDM2, RPL5, and TP53 in mycophenolic acid-induced cleft lip and palate. Medicine (Baltimore) 2021; 100:e26101. [PMID: 34032749 PMCID: PMC8154508 DOI: 10.1097/md.0000000000026101] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 05/05/2021] [Indexed: 12/11/2022] Open
Abstract
Mycophenolate embryopathy (MPE) is a mycophenolic acid (MPA)-induced congenital malformation with distinctive symptoms. Cleft lip/palate (CLP) is one of the most common symptoms of MPE. The aim of this study was to screen and verify hub genes involved in MPA-induced CLP and to explore the potential molecular mechanisms underlying MPE.Overlapping genes related to MPA and CLP were obtained from the GeneCards database. These genes were further analyzed via bioinformatics. The Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway enrichment analysis results were visualized with the Cytoscape ClueGO plug-in. Gene protein-protein interaction (PPI) networks were constructed based on data obtained from the Search Tool for the Retrieval of Interacting Genes/Proteins (STRING) database.Overall, 58 genes related to MPA and CLP were identified. The genes most relevant to MPA-induced CLP included ABCB1, COL1A1, Rac1, TGFβ1, EDN1, and TP53, as well as the TP53-associated genes MDM2 and RPL5. GO analysis demonstrated gene enrichment regarding such terms as ear, mesenchymal, striated muscle, and ureteric development. KEGG analysis demonstrated gene enrichment in such pathways as the HIF-1 signaling pathway, glycosylphosphatidylinositol-anchor biosynthesis, the TNF signaling pathway, and hematopoietic stem cell development.Bioinformatic analysis was performed on the genes currently known to be associated with MPA-induced CLP pathogenesis. MPA-induced CLP is mediated by multiple ribosome stress related genes and pathways. MDM2, RPL5 and TP53 could be the main contributor in this pathogenesis, along with several other genes. ABCB1 polymorphism could be related to the probability of MPA-induced CLP.
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Affiliation(s)
- Yangyang Lin
- Plastic Surgery Hospital of Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam UMC, Amsterdam Medical Centre, Amsterdam, The Netherlands
- People's Hospital of Guangxi Zhuang Autonomous Region, Nanning
| | - Tao Song
- Plastic Surgery Hospital of Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing
| | - Elsa M. Ronde
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam UMC, Amsterdam Medical Centre, Amsterdam, The Netherlands
| | - Gang Ma
- People's Hospital of Guangxi Zhuang Autonomous Region, Nanning
| | - Huiqin Cui
- The Fourth Affiliated Hospital of Guangxi Medical University, Liuzhou, China
| | - Meng Xu
- Plastic Surgery Hospital of Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing
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Iske J, Elkhal A, Tullius SG. The Fetal-Maternal Immune Interface in Uterus Transplantation. Trends Immunol 2021; 41:213-224. [PMID: 32109373 DOI: 10.1016/j.it.2020.01.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 01/10/2020] [Accepted: 01/11/2020] [Indexed: 12/16/2022]
Abstract
Uterus transplants (UTxs) have been performed worldwide. Overall frequencies have been low, but globally initiated UTx programs are expected to increase clinical implementation. The uterus constitutes a unique immunological environment with specific features of tissue renewal and a receptive endometrium. Decidual immune cells facilitate embryo implantation and placenta development. Although UTx adds to the complexity of immunity during pregnancy and transplantation, the procedure provides a unique clinical and experimental model. We posit that understanding the distinct immunological properties at the interface of the transplanted uterus, the fetus and maternal circulation might provide valuable novel insights while improving outcomes for UTx. Here, we discuss immunological challenges and opportunities of UTx affecting mother, pregnancy and healthy livebirths.
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Affiliation(s)
- Jasper Iske
- Division of Transplant Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Institute of Transplant Immunology, Integrated Research and Treatment Center Transplantation, Hannover Medical School, Hannover, Lower Saxony, Germany
| | - Abdallah Elkhal
- Division of Transplant Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Stefan G Tullius
- Division of Transplant Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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Sohail R, Bashir A, Safdar Z, Noreen A. Successful pregnancy in a liver transplant patient of Budd-Chiari syndrome. BMJ Case Rep 2020; 13:13/2/e229315. [PMID: 32041753 DOI: 10.1136/bcr-2019-229315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
In recent years, the number of patients undergoing liver transplant has increased. Successful transplant has resulted in better quality of life and improved fertility in younger women. This is a case study a 31-year-old woman, who had history of Budd-Chiari syndrome and underwent liver transplantation in 2014 with uneventful postoperative course. She was clinically stable on tablet tacrolimus and coumarin with no episode of allograft rejection since transplantation. The patient conceived spontaneously, after 4 years of transplant and during pregnancy, she was managed by multidisciplinary team. During the initial period, the graft and pregnancy continued without complications. However, at 33 weeks, the patient presented with sluggish fetal movements, amniotic fluid index of 3.4 and SD ratio of 3.31 for which she underwent caesarean section. She delivered a healthy female baby of 1.4 kg. This case study concludes that vigilant monitoring of fetal growth is pivotal for optimal fetal outcome.
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Affiliation(s)
- Rubina Sohail
- Obstetrics & Gyunaecology, Services Institute of Medical Sciences, Lahore, Punjab, Pakistan .,Obstetrics & Gynaecology, Hameed Latif Hospital, Lahore, Punjab, Pakistan
| | - Alia Bashir
- Obstetrics & Gynaecology, Hameed Latif Hospital, Lahore, Punjab, Pakistan
| | - Zara Safdar
- Obstetrics & Gynaecology, Hameed Latif Hospital, Lahore, Punjab, Pakistan
| | - Asifa Noreen
- Obstetrics & Gynaecology, Services Hospital, Lahore, Punjab, Pakistan
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Al-Otaibi T, Gheith OA, Nagib AM, Nair P, Zakaria ZE, Halim MA, Said T, Abdelmonem M, Makkeyah Y, Aboatteya H, Elsawi IS, Atta AF. Pregnancy After Renal Transplant: Single Center Experience From the Middle East in Patients Using Different Calcineurin Inhibitors. EXP CLIN TRANSPLANT 2019; 17:99-104. [PMID: 30777531 DOI: 10.6002/ect.mesot2018.o42] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Pregnancy after kidney transplant has a high risk for maternal and fetal complications; however, it can be successful if patients are properly selected. Here, we studied outcomes and complications of pregnancies in kidney transplant recipients who received calcineurin inhibitor-based immunosuppression. MATERIALS AND METHODS In this case control study, we reviewed patients who became pregnant between 2004 and 2017. For this analysis, each pregnancy was considered an event. We divided pregnancies into 2 groups according to calcineurin inhibitor-based maintenance immunosuppression: group 1 (49 pregnancies) received cyclosporine, and group 2 (33 pregnancies) received tacrolimus. Patients also received steroids and azathioprine. Patients had regular antenatal follow-up at the Hamed Alessa Organ Transplant Center (Kuwait) and in the maternity hospital (monthly until month 7 and then weekly until delivery). RESULTS Of 750 female kidney transplant recipients within childbearing potential, there were 82 pregnancies (10.9%) in 49 recipients (6.5%). Seventy-eight pregnancies were planned, and 4 pregnancies occurred while women were using contraception. There was 1 triple pregnancy, 5 double, and 76 single pregnancies. Two women had preeclampsia as maternal complication, 2 had uncontrolled hypertension, and 7 developed graft dysfunction. Forty-seven women (57.3%) had caesarean section, and the remaining had vaginal deliveries. Of 89 babies, 86 were viable (1 intrauterine fetal death and 2 abortions). Eight babies were delivered prematurely with low birth weight, and 2 needed incubators. Mean serum creatinine levels were 97.9 ± 24, 109 ± 38, 100 ± 39, 120 ± 46, and 115 ± 57 μmol/L at baseline, first, second, and third trimesters, and postpartum, respectively. Twelve patients showed high panel reactive antibodies but without donor-specific antibodies. CONCLUSIONS Posttransplant pregnancy can be successful in most renal allograft recipients, but the increased risk of fetal and maternal complications, including low birth weight, spontaneous abortus, and preeclampsia, should be considered.
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Affiliation(s)
- Torki Al-Otaibi
- From the Nephrology Department, Hamed Al-Essa Organ Transplant Center, Sabah Area, Kuwait
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Zaffar N, Soete E, Gandhi S, Sayyar P, Van Mieghem T, D'Souza R. Pregnancy outcomes following single and repeat liver transplantation: An international 2-center cohort. Liver Transpl 2018; 24:769-778. [PMID: 29655314 DOI: 10.1002/lt.25071] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Revised: 03/22/2018] [Accepted: 03/28/2018] [Indexed: 02/07/2023]
Abstract
Due to advances in obstetric and transplant medicine, women with a history of liver transplantation can have successful pregnancies. However, data on pregnancy outcomes is still limited, especially for women who have had a repeat liver transplant following graft rejection. This retrospective study compares pregnancy outcomes in women with single and repeat liver transplants managed at 2 tertiary hospitals in Toronto, Canada and Leuven, Belgium. We identified 41 pregnancies in 28 transplanted women, 6 of whom conceived following a second liver transplant after the first was rejected. Mean maternal age at delivery was 30 ± 7 years, and transplant-to-pregnancy interval was 8.5 ± 5.1 years. All women had normal liver function upon conception. Immunosuppressants included tacrolimus ± azathioprine (n = 26), cyclosporine (n = 4), and prednisone with immunosuppressants (n = 11). There were no maternal deaths. Maternal complications included hypertensive disorders of pregnancy (n = 10), deterioration in renal function (n = 6), gestational diabetes (n = 4), graft deterioration (n = 2), and anemia requiring blood transfusion (n = 1). Fetal/neonatal adverse outcomes included 2 miscarriages, 3 stillbirths, 1 neonatal death, 5 small-for-gestational-age infants, and 1 minor congenital anomaly. Mean gestational age at delivery was 36.7 ± 4.2 weeks. There were 14 (38.9%) preterm births. Outcomes in women with a second transplant were similar to those with a single transplant, except for a higher incidence of hypertensive disorders. In conclusion, with appropriate multidisciplinary care, stable graft function at pregnancy onset, and adherence to immunosuppressive regimens, women with single and repeat liver transplants have low rates of graft complications but remain at increased risk for pregnancy complications. Immunosuppressants and high-dose glucocorticoids can be safely used for maintenance of graft function and management of graft deterioration in pregnancy. Liver Transplantation 24 769-778 2018 AASLD.
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Affiliation(s)
- Nusrat Zaffar
- Division of Maternal and Fetal Medicine, Department of Obstetrics & Gynaecology, Mount Sinai Hospital, University of Toronto, Canada
| | - Elisabeth Soete
- Department of Obstetrics and Gynecology, University Hospital Leuven, Leuven, Belgium
| | - Shital Gandhi
- Division of Obstetric Medicine, Department of Internal Medicine, Mount Sinai Hospital, University of Toronto, Canada
| | - Parastoo Sayyar
- Division of Maternal and Fetal Medicine, Department of Obstetrics & Gynaecology, Mount Sinai Hospital, University of Toronto, Canada
| | - Tim Van Mieghem
- Division of Maternal and Fetal Medicine, Department of Obstetrics & Gynaecology, Mount Sinai Hospital, University of Toronto, Canada.,Department of Obstetrics and Gynecology, University Hospital Leuven, Leuven, Belgium
| | - Rohan D'Souza
- Division of Maternal and Fetal Medicine, Department of Obstetrics & Gynaecology, Mount Sinai Hospital, University of Toronto, Canada
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Qi X, Wang X, Huang X, Wang C, Gu Y, Li Y. Anesthesia management for cesarean section 10 years after heart transplantation: a case report. SPRINGERPLUS 2016; 5:993. [PMID: 27441126 PMCID: PMC4937040 DOI: 10.1186/s40064-016-2701-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/23/2016] [Accepted: 06/28/2016] [Indexed: 11/10/2022]
Abstract
Introduction Pregnancy after organ transplantation is becoming increasingly common. However, reports of the anesthesia for such patients are rare. Heart transplant recipients are always accompanied with pathophysiological changes and present anesthesiologists with challenge. Case description We reported a case of anesthesia management of gravida undergoing cesarean section 10 years after cardiac transplantation. We used two points spinal and epidural anesthesia, combined with phenylephrine throughout the surgery. The course was absolutely successful and both mother and baby got good results. Discussion and evaluation Physiology of heart transplant recipients and key points of anesthesia management were discussed. Conclusions Spinal anesthesia can be performed in heart transplant recipients, however, we have to think twice before anesthesia for this kind of patients.
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Affiliation(s)
- Xiaofei Qi
- Department of Anesthesiology, Shenzhen Maternity and Child Healthcare Hospital, Southern Medical University, Shenzhen, 518028 Guangdong China
| | - Xiaolei Wang
- Department of Anesthesiology, Sun Yat-Sen Cardiovascular Hospital of Shenzhen, Shenzhen, 518028 Guangdong China
| | - Xiaolei Huang
- Department of Anesthesiology, Shenzhen Maternity and Child Healthcare Hospital, Southern Medical University, Shenzhen, 518028 Guangdong China
| | - Chenhong Wang
- Department of Gynecology and Obstetrics, Shenzhen Maternity and Child Healthcare Hospital, Southern Medical University, Shenzhen, 518028 Guangdong China
| | - Yin Gu
- Department of Anesthesiology, Shenzhen Maternity and Child Healthcare Hospital, Southern Medical University, Shenzhen, 518028 Guangdong China
| | - Yuantao Li
- Department of Anesthesiology, Shenzhen Maternity and Child Healthcare Hospital, Southern Medical University, Shenzhen, 518028 Guangdong China
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Norrman E, Bergh C, Wennerholm UB. Pregnancy outcome and long-term follow-up after in vitro fertilization in women with renal transplantation. Hum Reprod 2014; 30:205-13. [PMID: 25376456 DOI: 10.1093/humrep/deu293] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
STUDY QUESTION What is the child morbidity after IVF in women who have received a kidney transplant? SUMMARY ANSWER Overall, obstetric outcome and morbidity in children of women who had undergone renal transplantation and IVF treatment were favourable. WHAT IS KNOWN ALREADY There are several studies of the obstetric outcome in women with spontaneous conception after solid organ transplantation as well as studies of obstetric outcome after IVF in general. There are only a few case reports of women with kidney or pancreas-kidney transplantation and deliveries after IVF treatment. STUDY DESIGN, SIZE, DURATION A population-based retrospective register study was carried out in Sweden including all women with solid organ transplantation and deliveries after IVF; however, only women with kidney transplants were recruited. It also included information on all singleton deliveries after kidney transplantation and spontaneous conception between 1973 and 2012. PARTICIPANTS/MATERIALS, SETTING AND METHODS We cross-linked the IVF registers with the Medical Birth Register, the Patient Register and the Cause of Death Register. Study group 1 consisted of women with kidney transplantation and deliveries after IVF treatment. Study group 2 consisted of women with kidney transplantation and singleton deliveries after spontaneous conception. Group 3 (control group to singletons in study group 1) consisted of women without organ transplantation and with singleton deliveries after IVF, matched for maternal age, parity and date of birth. Group 4 (control group to study group 2) consisted of women without organ transplantation and with singleton deliveries after spontaneous conception, matched for maternal age, parity and year of birth. MAIN RESULTS AND THE ROLE OF CHANCE Seven singletons and one set of twins were born after organ transplantation and IVF. All women in this group had renal transplants. Among singletons, two (28.6%) were preterm births (PTB), one (14.3%) had very low birthweight (VLBW) (672 g) and one (14.3%) was small for gestational age (SGA). Two infants had minor birth defects. One woman developed pre-eclampsia (14.3%). Mean age at follow-up of the children was 9.7 years (SD 4.2). Two children were diagnosed with hyperactivity disorders. There were 199 singletons born after renal transplantation and spontaneous conception. The rates of pre-eclampsia (23.6%), PTB (48.5%), LBW (43.7%) and SGA (21.2%) were significantly higher in pregnancies of women with renal transplants who had conceived spontaneously than in pregnancies where there was no transplantation and conception was spontaneous. Neonatal morbidity, early neonatal and infant mortality were all significantly higher. No increase in birth defects was seen. Mean age at follow-up of the children was 14.7 years (SD 9.4). Acute bronchitis, systemic lupus erythematosus and hyperactivity disorders were more common in children delivered to women with renal transplantation than in children delivered to women with no transplanted organs. Otherwise, long-term child morbidity was comparable. LIMITATIONS, REASONS FOR CAUTION The women who had received renal transplants and who had given birth after IVF were a small group and may represent a selected group of comparatively healthy women. WIDER IMPLICATIONS OF THE FINDINGS The results are important to transplant recipients with infertility problems. Neonatal outcomes after maternal renal transplantation and spontaneous conception were in agreement with the literature. Long-term follow-up of this group of children has long been asked for and findings are included in this report. STUDY FUNDING/COMPETING INTERESTS No conflict of interest was reported. The study was supported by grants from Swedish Association of Local Authorities and Regions and by grants from the University of Gothenburg/Sahlgrenska University hospital (LUA/ALF 70940).
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Affiliation(s)
- Emma Norrman
- Department of Obstetrics and Gynaecology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital/Östra, Gothenburg, Sweden
| | - Christina Bergh
- Reproductive Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Ulla-Britt Wennerholm
- Department of Obstetrics and Gynaecology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital/Östra, Gothenburg, Sweden
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Jabiry-Zieniewicz Z, Dabrowski FA, Pietrzak B, Wielgos M. Pregnancy complications after liver transplantation. Int J Gynaecol Obstet 2014; 128:27-9. [DOI: 10.1016/j.ijgo.2014.07.032] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2014] [Revised: 07/14/2014] [Accepted: 09/10/2014] [Indexed: 12/27/2022]
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Rupley DM, Janda AM, Kapeles SR, Wilson TM, Berman D, Mathur AK. Preconception counseling, fertility, and pregnancy complications after abdominal organ transplantation: a survey and cohort study of 532 recipients. Clin Transplant 2014; 28:937-45. [PMID: 24939245 DOI: 10.1111/ctr.12393] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/18/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND Pregnancy after solid organ transplant is a significant priority for transplant recipients but how patients report being counseled is unknown. METHODS We performed a single-center retrospective cohort study and telephone survey of female patients ages 18-49 at the time of kidney, pancreas, or liver transplant from 2000 to 2012 (n = 532). Data on pregnancy counseling, fertility, and maternal, fetal- and transplant-specific outcomes were collected. Multivariate Cox models assessed the impact of pregnancy on graft-specific outcomes. RESULTS The survey response rate was 29% (n = 152). One-third (n = 51) of women were actively counseled against pregnancy by one or more providers. A total of 17 pregnancies occurred among nine patients (5.9%), with 47% live births, 47% early embryonic demises, 5.9% stillbirths. Of live births, 50% were premature. Gestational complications, including diabetes, hypertension, and preeclampsia were present in 88% of mothers. Pregnancy after transplant was associated with higher rates of acute rejection than nulliparous transplant recipients (33% vs. 5.6%, p = 0.07) but did not significantly affect graft survival (HR = 1.00, 95% CI 0.99-1.01), after stratifying by organ and adjusting for clinical factors. CONCLUSION This study suggests that transplant patients are being counseled against pregnancy despite acceptable risks of complications and no specific effects on long-term graft function.
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Affiliation(s)
- Devon M Rupley
- Section of Transplantation Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI, USA
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11
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Pregnancy after heart and lung transplantation. Best Pract Res Clin Obstet Gynaecol 2014; 28:1146-62. [PMID: 25179291 DOI: 10.1016/j.bpobgyn.2014.07.019] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2014] [Revised: 07/18/2014] [Accepted: 07/21/2014] [Indexed: 12/31/2022]
Abstract
Patients awaiting transplantation should be counseled regarding posttransplant contraception and the potential adverse outcomes associated with posttransplant conception. Pregnancy should be avoided for at least 1-2 years post transplant to minimize the risks to allograft function and fetal well-being. Transplant patients, particularly lung transplant recipients, have an increased risk of maternal and neonatal pregnancy-related complications, including prematurity and low birth weight, postpartum graft loss, and long-term morbidity and mortality compared to other solid-organ recipients. Therefore, careful monitoring by a specialized transplant team is crucial. Maintenance of immunosuppression is recommended, except for mycophenolate and mammalian target of rapamycin inhibitors (mTORi), which should be replaced before conception. Immunosuppressants must be regularly monitored and dosing adjusted to avoid graft rejection. Monitoring during labor is mandatory and epidural anesthesia recommended. Vaginal delivery should be standard and cesarean delivery only performed for obstetric reasons. Breastfeeding poses risks of neonatal exposure to immunosuppressants and is generally contraindicated.
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Abstract
Over the past 10 years, heart transplantation survival has increased among transplant recipients. Because of improved outcomes in both congenital and adult transplant recipients, the number of male and female patients of childbearing age who desire pregnancy has also increased within this population. While there have been many successful pregnancies in post-cardiac transplant patients reported in the literature, long-term outcome data is limited. Decisions regarding the optimal timing and management of pregnancy in male and female post-cardiac transplant patients are challenging and should be coordinated by a multidisciplinary team of healthcare providers. Pregnant patients will need to be counseled and monitored carefully for complications including rejection, graft dysfunction, and infection. This review focuses on preconception counseling for both male and female cardiac transplant recipients. The maternal and fetal risks during pregnancy and the postpartum period, including risks to the fetus fathered by a male cardiac transplant recipient will be reviewed. It also provides a brief summary of our own transplant experience and recommendations for overall management of pregnancy in the post-cardiac transplant recipient.
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Affiliation(s)
- Marwah Abdalla
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, NY
| | - Donna M Mancini
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, NY.
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Zheng S, Easterling TR, Hays K, Umans JG, Miodovnik M, Clark S, Calamia JC, Thummel KE, Shen DD, Davis CL, Hebert MF. Tacrolimus placental transfer at delivery and neonatal exposure through breast milk. Br J Clin Pharmacol 2014; 76:988-96. [PMID: 23528073 DOI: 10.1111/bcp.12122] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2012] [Accepted: 03/10/2013] [Indexed: 01/16/2023] Open
Abstract
AIM(S) The current investigation aims to provide new insights into fetal exposure to tacrolimus in utero by evaluating maternal and umbilical cord blood (venous and arterial), plasma and unbound concentrations at delivery. This study also presents a case report of tacrolimus excretion via breast milk. METHODS Maternal and umbilical cord (venous and arterial) samples were obtained at delivery from eight solid organ allograft recipients to measure tacrolimus and metabolite bound and unbound concentrations in blood and plasma. Tacrolimus pharmacokinetics in breast milk were assessed in one subject. RESULTS Mean (±SD) tacrolimus concentrations at the time of delivery in umbilical cord venous blood (6.6 ± 1.8 ng ml(-1)) were 71 ± 18% (range 45-99%) of maternal concentrations (9.0 ± 3.4 ng ml(-1)). The mean umbilical cord venous plasma (0.09 ± 0.04 ng ml(-1)) and unbound drug concentrations (0.003 ± 0.001 ng ml(-1)) were approximately one fifth of the respective maternal concentrations. Arterial umbilical cord blood concentrations of tacrolimus were 100 ± 12% of umbilical venous concentrations. In addition, infant exposure to tacrolimus through the breast milk was less than 0.3% of the mother's weight-adjusted dose. CONCLUSIONS Differences between maternal and umbilical cord tacrolimus concentrations may be explained in part by placental P-gp function, greater red blood cell partitioning and higher haematocrit levels in venous cord blood. The neonatal drug exposure to tacrolimus via breast milk is very low and likely does not represent a health risk to the breastfeeding infant.
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Affiliation(s)
- Songmao Zheng
- Department of Pharmaceutics, University of Washington, Seattle, WA, USA
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Mohamed-Ahmed O, Nelson-Piercy C, Bramham K, Gao H, Kurinczuk JJ, Brocklehurst P, Knight M. Pregnancy outcomes in liver and cardiothoracic transplant recipients: a UK national cohort study. PLoS One 2014; 9:e89151. [PMID: 24586554 PMCID: PMC3929648 DOI: 10.1371/journal.pone.0089151] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2013] [Accepted: 01/15/2014] [Indexed: 11/18/2022] Open
Abstract
Introduction There are an increasing number of reports of pregnancy in transplant recipients but many questions remain regarding the effect of the transplant on pregnancy outcome, the pregnancy on the graft and the medication on the fetus. The majority of studies reporting outcomes in transplant recipients have focused on women with kidney transplants, and have included retrospective, voluntary registries or single centre studies. Methods The UK Obstetric Surveillance System (UKOSS) was used to prospectively identify all pregnant women with a liver or cardiothoracic transplant in the United Kingdom, between January 2007 and January 2012. Data were collected on demographics, transplant characteristics, immunosuppression regimens, antenatal care, maternal, graft and neonatal outcomes. In an exploratory analysis, we tested for associations between “poor fetal outcome” and medications used before or during pregnancy. Results and conclusions We report 62 pregnancies in 56 liver transplant recipients and 14 pregnancies in 14 cardiothoracic transplant recipients (including 10 heart, three lung and one heart-lung recipient). Liver transplant recipients, in comparison to cardiothoracic, had similar livebirth rates (92% vs. 87%) but better fetal outcomes (median gestational age 38 weeks vs. 35 weeks; median birthweight 2698 g vs. 2365 g), fewer caesarean deliveries (47% vs. 62%), fewer maternal intensive care (ICU) admissions (19% vs. 29%) and fewer neonatal ICU admissions (25% vs. 54%). Nine women (12%) were taking mycophenolate mofetil at conception, which was associated with adverse fetal outcomes. Pregnancy in transplant recipients may have successful outcomes, but complication rates are high, emphasising the role of pre-conception counselling and further research into the long-term effect on maternal and graft survival rates.
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Affiliation(s)
- Olaa Mohamed-Ahmed
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, United Kingdom
- * E-mail:
| | - Cathy Nelson-Piercy
- Division of Women’s Health, King’s College London, Women’s Health Academic Centre, King’s Health Partners, United Kingdom
- Obstetric Medicine, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Kate Bramham
- Division of Women’s Health, King’s College London, Women’s Health Academic Centre, King’s Health Partners, United Kingdom
| | - Haiyan Gao
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, United Kingdom
| | - Jennifer J. Kurinczuk
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, United Kingdom
| | | | - Marian Knight
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, United Kingdom
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Ozkan O, Akar ME, Ozkan O, Erdogan O, Hadimioglu N, Yilmaz M, Gunseren F, Cincik M, Pestereli E, Kocak H, Mutlu D, Dinckan A, Gecici O, Bektas G, Suleymanlar G. Preliminary results of the first human uterus transplantation from a multiorgan donor. Fertil Steril 2012; 99:470-6. [PMID: 23084266 DOI: 10.1016/j.fertnstert.2012.09.035] [Citation(s) in RCA: 157] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2012] [Revised: 09/18/2012] [Accepted: 09/19/2012] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To describe the first-year results of the first human uterus transplantation case from a multiorgan donor. DESIGN Case study. SETTING University hospital. PATIENT(S) A 21-year-old woman with complete müllerian agenesis who had been previously operated on for vaginal reconstruction. INTERVENTION(S) Uterus transplantation procedure consisting of orthotopic replacement and fixation of the retrieved uterus, revascularization, end to site anastomoses of bilateral hypogastric arteries and veins to bilateral external iliac arteries and veins was performed. MAIN OUTCOME MEASURE(S) Resumption of menstrual cycles. RESULT(S) The patient had menarche 20 days after transplant surgery. She has had 12 menstrual cycles since the operation. CONCLUSION(S) We have described the longest-lived transplanted human uterus to date with acquirement of menstrual cycles.
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Affiliation(s)
- Omer Ozkan
- Department of Plastic Surgery, Akdeniz University, Antalya, Turkey
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