Objective: To determine maternal and fetal outcome in renal transplant recipients.Methodology: Retrospective analysis of the antenatal patients with renal transplantwas done between January 1st 2005 till December 31st 2015 and maternaland fetal outcomes were determined. Data was entered and analyzed in SPSSversion 20.Results: 08 pregnancies in 07 women who had undergone renal transplantwere included in this study. The mean age at the time of transplantation was25.29 ±5.5 years (16-32 years). 25% cases had gestational diabetes mellitus,75% had anemia and 50% had urinary tract infection. The mean birth weightof babies was 2210 ±.638 grams (range1500-3400g). Preterm deliveries comprised37.5% before 34 weeks and 50% after 34 weeks. 37.5% of the neonatesneeded neonatal intensive care unit admission.Conclusion: Pregnancy after renal transplant is safe for mother, fetus and thegraft

Sheikh, Lumaan

Syed, Wajeeha

English

eCommons@AKU

eCommons@AKUDepartment of Obstetrics & Gynaecology Division of Woman and Child HealthJanuary 2017Maternal and fetal outcome in renal transplantrecipientsWajeeha SyedLady Reading Hospital Peshawar Pakistan.Lumaan SheikhAga Khan University, lumaan.sheikh@aku.eduFollow this and additional works at: http://ecommons.aku.edu/pakistan_fhs_mc_women_childhealth_obstet_gynaecolPart of the Maternal and Child Health Commons, Obstetrics and Gynecology Commons, andthe Women's Health CommonsRecommended CitationSyed, W., Sheikh, L. (2017). Maternal and fetal outcome in renal transplant recipients. Journal of Postgraduate Medical Institute, 31(3),319-322.Available at: http://ecommons.aku.edu/pakistan_fhs_mc_women_childhealth_obstet_gynaecol/83JPMI VOL. 31 NO. 3 319MATERNAL AND FETAL OUTCOME  IN RENAL TRANSPLANT RECIPIENTS Wajeeha Syed1, Louman Sheikh2CASE SERIESINTRODUCTIONRenal transplantation is the best option to restore fertility in women with end stage renal failure1,2. This is due to correction of endocrine function post trans-plantation3. Although these pregnancies are successful in 90% of cases, there is still high chance of maternal and neonatal complications such as pre-eclampsia, ges-tational diabetes, preterm births and small for gesta-tional age fetuses4,5. Premature births (<37 weeks) and low birth weight are among the most common neonatal complications. However studies have shown that mater-nal and neonatal outcomes remain favourable with suc-cessive pregnancies in renal transplant recipients6. For those with pre-pregnancy serum creatinine of >1.7mg/dl, there are higher chances of deterioration of renal function after pregnancy7.In this study we describe our experience in Aga Khan University Hospital, Karachi, Pakistan about pregnan-cy outcome in renal transplant recipients and present a retrospective study for the period 2005-2015. This will create awareness among obstetricians dealing with such pregnancies about the expected maternal and fe-tal outcomes and will also be helpful in proper coun-seling of the patients and their families. Also upto our knowledge this is only one of the two studies conduct-ed on this topic in Pakistan so we are able to generate our local data.METHODOLOGYRecords of patients who had pregnancy with renal transplant and had antenatal checkups, delivery and postpartum nephrology follow up at our hospital were retrospectively reviewed between January 1st 2005 till December 31st 2015. Women who became pregnant before renal transplantation or ongoing dialysis or who were lost to follow up regarding renal status after deliv-ery were excluded.This study received approval from ethical review committee of Aga Khan University Hospital Karachi. The medical records were reviewed including maternal age at delivery, underlying cause of renal failure, peritoneal or hemodialysis, duration between transplantation and pregnancy, serum creatinine levels, birth weight, ges-tational age, birth weight centile and Apgar scores at 1 and 5 minutes. Maternal and neonatal complications such as pre-eclampsia, gestational diabetes, anemia, urinary tract infection, small for gestational age, pre-maturity, mode of delivery and neonatal intensive care unit admission were also collected on a structured pro-forma. Data was entered and analyzed in SPSS version 20. Mean and standard deviation were calculated for This case series may be cited as: Syed W, Sheikh L. Maternal and fetal outcome in renal transplant recipients. J Postgrad Med Inst 2017; 31(3):319-22.ABSTRACTObjective: To determine maternal and fetal outcome in renal transplant recip-ients.Methodology: Retrospective analysis of the antenatal patients with renal trans-plant was done between January 1st 2005 till December 31st 2015 and maternal and fetal outcomes were determined. Data was entered and analyzed in SPSS version 20. Results: 08 pregnancies in 07 women who had undergone renal transplant were included in this study. The mean age at the time of transplantation was 25.29 ±5.5 years (16-32 years). 25% cases had gestational diabetes mellitus, 75% had anemia and 50% had urinary tract infection. The mean birth weight of babies was 2210 ±.638 grams (range1500-3400g). Preterm deliveries com-prised 37.5% before 34 weeks and 50% after 34 weeks. 37.5% of the neonates needed neonatal intensive care unit admission.Conclusion: Pregnancy after renal transplant is safe for mother, fetus and the graft.Key Words: Renal transplant, Maternal outcomes, Fetal outcomes, Dialysis1 Department of Gynae and Obstetrics, Lady Reading Hos-pital,Peshawar - Pakistan.2 Maternal Medicine Specialist, Aga Khan Hospital, Karachi - Pakistan.Address for Correspondence:Dr. Wajeeha SyedAssistant Professor, Gynae “C” Unit, Department of Gynae and Obstetrics, Lady Reading Hospital, Peshawar - Pakistan.Email: mohammadab-bas1979@hotmail.comDate Received:  March 30, 2017Date Revised:  June 25, 2017Date Accepted:  July 02, 2017JPMI VOL. 31 NO. 3 320MATERNAL AND FETAL OUTCOME IN RENAL TRANSPLANT RECIPIENTSTable 1: Maternal transplant related dataS.No. Underlying DiseaseHemo- Dialysis (HD)Age at Trans-planta-tionImmunosuppressants use in PregnancyAge at DeliveryDuration from Trans-plantation to Preg-nancy1 Hypertensive nephropathy HD 27 years Cyclosporin, Azathioprine 29 years 2 years2 ------------ ----- 16 years Azathioprine, Prednisolone 20 years 4 years3 Hypertensive nephropathy HD 32 years Azathioprine, Prednisolone, Cyclosporin 36 years 4 years4 IgA nephropathy HD 22 years Azathioprine, Prednisolone 23 years 2 years5 IgA nephropathy HD 22 years Azathioprine, Prednisolone,Cyclosporin 30 years 9 years6 ---------- ------ --------- Azathioprine, Prednisolone,Cyclosporin 35 years 2 years7 Hypertensive nephropathy HD 30 years Azathioprine, Prednisolone,Cyclosporin 33 years 3 years8 Hypertensive nephropathy HD 28 years Azathioprine, Prednisolone,Cyclosporin 35 years 7 yearsTable 2: Maternal co-morbiditiesS.No.Hypertension prior to preg-nancyPre- EclampsiaGestational Diabetes (GDM)Ane-mia UTIGraft lossS. Creat. prior to pregnancy (in mg/dl)Postpartum S.Creat. (in mg/dl)1 Yes No Type 2 DM Yes No Nil 0.8 012 Yes No No Yes No Nil 0.9 1.53 Yes No GDM Yes Yes Nil 01 0.94 Yes No No No Yes Nil 0.9 0.935 Yes No No No Yes Nil 0.9 0.96 Yes No GDM Yes Yes Nil 1.1 0.97 Yes No No Yes No Nil 01 1.28 Yes No No Yes No Nil 2.3 2.8continuous variables. Frequency and percentages were calculated for categorical variables.RESULTS08 pregnancies in 07 women who had undergone renal transplant were included in this study. All of the pregnancies were conceived naturally.The mean age of the patients at the time of delivery was 30.13 ±5.9 years (range 20 -36 years). The mean age at the time of transplantation was 25.29 ±5.5 years (16-32 years). Immunosuppressant therapy comprised cyclosporine, azathioprine and prednisolone.The mean gestational age was 34.87 ±1.8 weeks. The mean birth weight of babies was 2210 ±.638 grams (range1500-3400g). Preterm deliveries comprised 37.5% before 34 weeks and 50% after 34 weeks. 37.5% of the neonates needed neonatal intensive care unit (NICU) admission. 37.5% were normal vaginal deliveries and 62.5% were delivered by cesarean section. There was no miscarriage and only 01 fetus had ventricular septal defect.The mean serum creatinine level prior to pregnancy was 1.1 ±.48mg/dl (range 0.8-2.3mg/dl) and after preg-nancy it was 1.2 ±.65 (range 0.9-2.8mg/dl). All of the pa-tients had hypertension prior to pregnancy while there was no case of superimposed pre-eclampsia. 25% cases had gestational diabetes mellitus ,75% had anemia and 50% had urinary tract infection. There was no case of graft loss uptill one year after delivery.JPMI VOL. 31 NO. 3 321MATERNAL AND FETAL OUTCOME IN RENAL TRANSPLANT RECIPIENTSTable 3: Pregnancy outcomesS.No.Gestational Age (in weeks) Baby SexBirth Weight (in kg)Birth Weight (centile)Apgar Score (at 1 min.)Apgar Score (at 5 min.)1 33 Female 1.5 1.1 8 92 33 Male 1.7 1.3 8 93 36 Male 2.3 31.1 6 94 35 Male 2.4 41.9 8 95 36 Male 2.7 24 8 96 38 Male 3.4 68 8 97 35 Female 1.6 06 8 98 33 Female 2.08 20 8 9DISCUSSIONOur review of the pregnancies after renal transplant favours the findings of previous studies on same topic.Transplanted kidney does not usually obstruct the birth channel and vaginal delivery can be accomplished in most cases if there are no maternal or fetal contrain-dications. The cesarean section rate in our study was 62.5% mainly due to obstetrical reasons. Cesarean rate of 55% reported by Ducrame etal8 and 50% by Bouttar et al5 are also mainly due to obstetrical indications. Maternal renal transplant patients with hyperten-sion are at an increased risk of superimposed pre-ec-lampsia. In our analysis hypertension before pregnancy was present in all cases but there was no case of su-perimposed pre-eclampsia. Other studies quot figure of 70% for hypertension before pregnancy and 30-40% for pre-eclampsia9.The difference may be explained by small sample of our study and also because of good control of blood pressure during pregnancy with only one antihypertensive agent. 02 out of total 8 patients (25%) had gestational diabetes while a rate of 13.3% was found in a study conducted in Taiwan10. Use of steroid is one of the pre-disposing factor for the development of gestational di-abetes in patients with renal transplant. Renal transplant recepients are at an increased risk of infections during pregnancy, especially bacterial uri-nary tract infections and acute pyelonephritis of the graft. Anemia is common in renal transplant recepi-ents especially iron deficiency due to increase use of iron after transplant. Erythropoeitin production from a well functioning allograft begins and sustains to normal within a month after transplantation11. There was a high frequency of anemia and urinary tract infection in our study. This corresponds with the results of 40% anemia by del Mar Colon et al12 and Bouattar et al5 who found anemia in 80% and urinary tract infection in 20%. No patient in our case however needed erythropoietin or blood transfusion and all the patients responded well to iron therapy. Table 4: Perinatal co-morbiditiesS.No.Sponta-neousMiscar-riageCongen-italAnomalyPreterm <34 weeksPreterm 34-37 weeksStillbirth Mode of DeliveryReason for Cesar-eanNICU ad-mission1 Nil Nil Yes No Nil C/S* IUGR** Yes2 Nil Nil Yes No Nil C/S IUGR Yes3 Nil Nil No Yes Nil C/S Previous 2 cesareans Nil4 Nil Nil No Yes Nil SVD*** ------ Nil5 Nil Nil No Yes Nil SVD ------ Nil6 Nil VSD*** No No Nil C/S ------ Nil7 Nil Nil No Yes Nil C/S Previous 1 cesarean Yes8 Nil Nil Yes No Nil SVD -------- Nil* C/S= cesarean section, ** IUGR= intra-uterine growth restriction, ***SVD= spontaneous vaginal delivery  JPMI VOL. 31 NO. 3 322MATERNAL AND FETAL OUTCOME IN RENAL TRANSPLANT RECIPIENTSCONTRIBUTORSWS conceived the idea, planned the study, and drafted the manuscript. LS helped acquisition of data, did statistical analysis and critically revised the manuscript. All authors contributed significantly to the submitted manuscript.Prematurity and its associated risks are the main issue in babies born to renal transplant recepients. About 37.5% fetuses were born premature before 34 weeks and 50% were born premature after 34 weeks with NICU admission rate of 37.5% due to severe intra-uterine growth restriction. Prematurity rate of 33-60% has been reported in other studies13,14. Use of cyclospo-rine and azathioprine may account for low birth weight and prematurity15. Pregnancy outcome depends on pre-pregnancy serum creatinine level7. No miscarriage was observed in our study similar to other studies which show that 95% gestations end successfully16. In one of a local study there were15 miscarriages out of total 68 patients17.However these pregnancies were unplanned and conceived with high baseline serum creatinine.There was only one case of ventricular septal defect in our study. Very few studies in literature report associa-tion of congenital heart defect with azathioprine. The rate of malformation is however not higher than in gen-eral population18. The patients in our study had a relatively short inter-val between transplantation and pregnancy (4.13 ±2.588 years). Thompson et al19 found a mean time of 6.5 years in 48 cases and concluded that early pregnancies after transplantation had a poor prognosis. But our findings differed from their results. We did not observe acute re-jection episode and the serum creatinine level remained stable during pregnancy as reported by Bouattar et al5. Stable graft function and base line serum creatinine before pregnancy accounts for this. Lindheimer et al20 noted 5% acute rejection episodes.CONCLUSIONPregnancy after renal transplant is safe for mother, fetus and the graft but multidisciplinary approach is needed to prevent complications.REFERENCES1. Hou S. Pregnancy in renal transplant recipients. Adv Chronic Kidney Dis 2013; 20:253-9.2. Fuchs KM, Wu D, Ebcioglu Z. Pregnancy in renal trans-plant recipients. Semin Perinatol 2007; 31:339-47. 3. Celik G. Biochemical parameters, renal function and out-come of pregnancy in kidney transplant recipient. Trans Proceed 2011; 43:2579-83 .4. Gill JS, Zalunardo N, Rose C, Tonelli M. The pregnancy rate and live birth rate in kidney transplant recipients. Am J Transplant 2009; 9:1541-9.5. Bouattar T, Hakim H, Rhou H, Benamar L, Bayahia R, Ouzeddoun N. Pregnancy in renal transplant recipients. Transplant Proc 2009; 41:1586-8.6. Coscia LA, Constantinescu S, Moritz MJ, Frank A, Ramirez CB, Maley WL et al. Report from the National Transplan-tation Pregnancy Registry (NTPR):outcome of pregnancy after transplantation. Clin Transpl 2009:103-22.7. Sibanda N, Briggs JD, Davison JM, Johnson RJ, Rudge CJ. Pregnancy after organ transplantation: a report from the UK Transplant pregnancy registry. Transpl 2007; 83:1301-7.8. Ducarme G, Ceccaldi PF, Toupance O, Graesslin O, Rieu P, Gabriel R. Pregnancy after renal transplantation. Obstetri-cal follow up and impact on renal graft function. Gynecol obstet Fertil 2oo6; 34:209-13.9. Miranda CT, Melarango C, Camara NO, Pacheco-Silva A, Medina-Pestana PJ. Adverse effects of pregnancy on renal allograft function. Transplant Proc 2002; 34:506-7.10. Li YP, Shih JC, Lin SY, Lee CN. Pregnancy outcomes after kidney transplantation. a single center experience in Tai-wan. Taiwan J Obstet Gynaecol 2016; 55:314-8.11. Lorenz M, Kleytzmayer J, Perschl A, Furrer A, Horl WH, Sunder-Plassmann G. Anemia and Iron deficiencies among long term renal transplant recipients. J Am Soc Nephrol 2002; 13:794-7.12. del Mar Colon M, Hibbard JU. Obstetric considerations in the management of pregnancy in kidney transplant recip-ients. Adv Chronic Kidney Dis 2007; 14:168-77.13. Ketel E, Bruno RM, Duarte M, Santos AF, Bittar AE, Bianco PD et al. Pregnancy outcome after renal transplantation. Transplant Proc 2004; 36:870-1.14. Davison JM, Bailey DJ. Pregnancy following renal trans-plantation. J Obstet Gynaecol Res 2003; 29:227-33.15. Lessan-Pezeshki M. Pregnancy after renal transplantation: points to consider. Nephrol Dial Transplant 2002; 17:703-7.16. Stratta P, Canavese C, Giacchino F, Mesiano P, Qnaglia M, Rossetti M. Pregnancy in kidney transplantation :sat-isfactory outcomes and harsh realities. J Nephrol 2003; 16:792-80617. Naqvi R. Obstetrics in renal transplantation: A series of cases of pregnancy post transplant observed over 24 years. Nephrol 2010.18. Cleary BJ, Kallen B. Early pregnancy azathioprine use and pregnancy outcomes. Birth Defects Res A Clin Mol Teratol 2009; 85:647-54.19. Thompson BC, Kingdon EJ, Tuck SM, Fernando ON, Sweny P. Pregnancy in renal transplant recipients: the Royal Free Hospital experience. QJM 2003; 96:837-44.20. Lindheimer MD, Grunfeld JP, Davison JM: Renal disorders. In Barron WM, Lindheimer MD(eds), Medical disorders during pregnancy,3rd ED. Mosby Inc St.Louis;2000:39-70.

Maternal and fetal outcome in renal transplant recipients

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Maternal and fetal outcome in renal transplant recipients

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