Late pregnancy in women with renal transplants: A multidisciplinary guide

Kidney transplant recipients are at risk of complications in late pregnancy, with increased rates of pre-eclampsia, intrauterine growth restriction and preterm birth. It is recommended that these women receive more intensive monitoring after 20 weeks' gestation, ideally provided by a multidisciplinary team in a tertiary centre. This review focuses on the management of late pregnancy in kidney transplant recipients, from the perspective of different members of the multidisciplinary team. This includes evidence and guidance to inform the nephrologist, obstetrician, obstetric anaesthetist, transplant surgeon, midwife, and a summary of the woman's perspective. The review outlines a late pregnancy and early postnatal care pathway as a common algorithm to be used by the whole multidisciplinary team.

Pregnancy in kidney transplantation women: perinatal outcomes and impact on kidney function

OBJECTIVES

This study aimed to evaluate maternal and perinatal outcomes in pregnancies after kidney transplant (KT) and the impact of pregnancy on graft function.

METHODS

A descriptive and retrospective case-control study included 43 pregnancies in women after KT, followed in our institution, from January 1991 to December 2019. The control group included 200 non-transplanted pregnant women. Statistical analysis used SPSS 25.0 (SPSS Inc., Chicago, IL), and a p value of .05 was considered statistically significant.

RESULTS

We studied 43 pregnancies in 37 KT women. The live birth rate of KT pregnant was 81.4%. The mean interval between transplantation and pregnancy was 4.6 years (range 1-16). We found a higher rate of obstetric complications in pregnancies after KT: miscarriage (14.0%, OR 6.7 (2.0-22.1), p < .001), preeclampsia (31.4%, OR 25.7 (7.7-85.3), p < .001), and fetal growth restriction (37.1%, OR 37.6 (9.9-142.3), p < .001). The rate of urogenital infections and anemia during pregnancy was higher in the KT group (p < .001). The gestational age at delivery was 35.0 ± 2.8 weeks and premature delivery was observed in 24 (68.6%) cases. The cesarean rate was higher in the KT group (p < .001). In the KT group, there were two neonatal deaths due to prematurity complications. Renal function deterioration, measured by serum creatinine levels, was observed in two pregnancies. Immunosuppressive therapy was used in all pregnancies after KT, and dosage escalation of immunosuppressive therapy was necessary for 69.8%.

CONCLUSIONS

A higher rate of adverse obstetric outcomes was found in KT pregnant. Kidney function remained stable in most pregnancies. An antenatal and postpartum multidisciplinary approach is essential to improve outcomes and minimization of complications.

Uterine Transplantation: Scientific Impact Paper No. 65 April 2021

A uterine transplant, or womb transplant, provides a potential treatment for women who cannot become pregnant or carry a pregnancy because they do not have a womb, or have a womb that is unable to maintain a pregnancy. This is estimated to affect one in 500 women. Options for those who wish to start a family include adoption and surrogacy, but these are associated with legal, cultural, ethical and religious implications that may not be appropriate for some women and their families. A womb transplant is undertaken when the woman is ready to start a family, and is removed following the completion of their family. Womb transplants have been performed all over the world, with more than 70 procedures carried out so far. At least 23 babies have been born as a result, demonstrating that womb transplants can work. While the procedure offers a different option to adoption and surrogacy, it is associated with significant risks, including multiple major surgeries and the need to take medications that help to dampen the immune system to prevent rejection of the womb. To date there has been a 30% risk of a transplant being unsuccessful. Although the number of transplants to date is still relatively small, the number being performed globally is growing, providing an opportunity to learn from the experience gained so far. This paper looks at the issues that have been encountered, which may arise at each step of the process, and proposes a framework for the future. However, long term follow-up of cases will be essential to draw reliable conclusions about any overall benefits of this procedure.

Pregnancy in Kidney Transplant Recipients

Women with end-stage kidney disease commonly have difficulty conceiving through spontaneous pregnancy, and many suffer from infertility. Kidney transplantation restores the impairment in fertility and increases the possibility of pregnancy. In addition, the number of female kidney transplant recipients of reproductive age has been increasing. Thus, preconception counseling, contraceptive management, and family planning are of great importance in the routine care of this population. Pregnancy in kidney transplant recipients is complicated by underlying maternal comorbidities, kidney allograft function, the effect of pregnancy on the transplanted kidney, and the effect of the maternal health on the fetus, in addition to immunosuppressive medications and their potential teratogenesis. Given the potential maternal and fetal risks, and possible complications during pregnancy, pretransplant and prepregnancy counseling for women of reproductive age are crucial, including delivery of information regarding contraception and timing for pregnancy, fertility and pregnancy rates, the risk of immunosuppression on the fetus, the risk of kidney allograft, and other maternal complications. In this article, we discuss aspects related to pregnancy among kidney transplant recipients and their management.

Pregnancy after Solid Organ Transplantation

PURPOSE

To explore the reproductive decision-making process with women who were organ transplant recipients (renal, lung, & heart transplants).

STUDY DESIGN AND METHODS

Grounded theory guided data collection and analyses. Mixed methods with audiotaped telephone interviews and a written survey measuring social support were used. As social support is critical for women who are organ transplant recipients considering pregnancy, a search for disconfirming evidence for social support via a survey and interviews was included.

ANALYSES

Verbatim responses were analyzed through the constant comparative method using open, axial, and selective coding. Trustworthiness was established through prolonged engagement, member checking, and thick descriptions.

RESULTS

Participants included 10 women who were solid organ recipients (2 lung, 1 heart, and 7 renal transplant recipients). The core theme was Wanting a child. Other themes included Getting information, Advocating, Dealing with problems, Preparing, Talking, Supporting, Coping, and Advising others. There was no evidence of a lack of social support as evaluated via the survey or interviews.

CLINICAL IMPLICATIONS

This study provides new knowledge on clinical decision-making about pregnancy for women who are solid organ recipients and for healthcare professionals. Nurses can use these data to help guide women on how to obtain the most accurate information to make a personal decision about pregnancy and to develop support from their healthcare team and family.