Dr hamada alsedawy hd in pregnancy

1. Pregnancy in end-stage renal
disease patients on dialysis
Hamada mostafa
Mansoura nephrology unit

2. Pregnancy in women with chronic kidney disease has
always been considered as a challenging event both for
the mother and the fetus.
Over the years, several improvements have been
achieved in the outcome of pregnant chronic renal
patients with increasing rates of successful deliveries.
To date, evidence suggests that the stage of renal
failure is the main predictive factor of worsening
residual kidney function and complications in
pregnant women

3. Delayed diagnosis (average 16.5 weeks) due to
frequency of amenorrhea in ESRD women, might
increase the risk of taking dangerous medications in
the early phases of conception.
Because amenorrhea is common during dialysis,
diagnosing pregnancy can be difficult. Beta HCG levels
are elevated in the dialysis population and cannot be
used to estimate gestational age or to diagnose molar
pregnancy; accordingly, a pregnancy diagnosis should
be confirmed with ultrasound. Medications should be
carefully reviewed and teratogenic medications
promptly discontinued

4. Residual renal function might be the key factor to
explaining the improved outcomes of conception
that happened before starting dialysis (in women
already undergoing dialysis the residual renal
function often declines).
Pregnancies started early after dialysis initiation
are characterized by a 30% higher infant survival in
comparison with women with longer HD vintage In
pregnant
on maintenance dialysis for >10 years the fetus
frequently presents anomalies

5. PREGNANCY DURING LONG-TERM DIALYSIS
 End-stage kidney disease is characterized by severe
hypothalamic-pituitary-gonadal dysfunction that is
reversed by transplantation but not by conventional
dialysis. Women of childbearing age undergoing dialysis
have menstrual disturbances, anovulation, and infertility.
 Conception during dialysis is unusual but not
impossible. Hence, adequate contraception remains
important in women of childbearing age undergoing
dialysis who do not wish to become pregnant

6. Menstrual irregularities generally
begin as GFR falls below 15 mL/min,
with amenorrhea typical at GFR
below 5 mL/min Early menopause is
common,
Conception rates appear significantly
lower in women treated with peritoneal
dialysis. Possibly, hypertonic solutions
in the intraperitoneal space or
compression of the fallopian tubes may
interfere with transport of the ovum to
the fallopian tube

7. CONTRACEPTION
 IUD
 Bleeding- Infection
 Oral contraceptives
 Hypercoagulability (access)
 Barriers
 Safety

8. Maternal Complications in Pregnant
Dialysis Patients
 Severe/Accelerated Hypertension.
 •Preeclampsia
 •Anemia.
 •Infections.
 •Polyhydramnios caused mostly by urea-induced fetal
osmotic diuresis
 •Abruptioplacentae. , placental detachment,
 premature rupture of membranes
 •Clotting of vascular access.
 •Risks of Therapeutic interventions: intensive dialysis.-C.S

9. The most common fetal complications are
 restricted intrauterine growth, acute and chronic
fetal suffering, preterm birth
 respiratory difficulty in the newborn, growth in
neonatal intensive care units and uterine or
neonatal death .
 pre-term births occur in 83% of live births (mean
gestational age is ∼32 weeks or even less)
 the newborn present high mortality (18%) and
morbidity (growth retardation in 28–36% and
malformations in 10% of cases

10. Management of Pregnant
Hemodialysis Patients

11. Dialysis Dose At least 20 hours of dialysis/week
Frequency Daily or 6 times/week, >4 h or >20-
h/week of treatment (also a recent study
suggested>36-h/week has better outcome compared
to 20-h/week)
Goal BUN of <40 mg/dL- Predialysis BUN <50 mg/dL
Dialysate Composition Dialysate composition HCO3
25 mEq/L; K+ 3–4 mEq/L. Adjust according to serum
chemistry. Blood pH ~ 7.40
Calcium: 2.5 to 3.0 mmol/L with weekly Ca and Phos
measurement
Sodium: 130 to 135 mEq/L based on serum Na

12. Dialyzer Biocompatible small surface area
dialyzer to avoid excess ultrafiltration.
Heparin does not cross the placenta and
is not teratogenic.
It must be used in order to avoid
coagulation of the vascular accesses.
Warfarin crosses the placenta and is
contraindicated in these patients

13. Diet/Vitamin Supplementation
 Malnutrition is common in Pregnancies of for this
reason ESRD patients.
 It is mandatory to avoid proteins restriction <1.2–1.3
g/kg of body weight/day in HD and 1.4 g/kg of body
weight/day in peritoneal dialysis. Moreover, it is
important to add 20 g/ day of proteins to daily maternal
needs for the correct fetal growth
 The caloric intake in this clinical setting should be of
35 kcal/kg of body weight/day in HD and 25 kcal/kg
of body weight/day in peritoneal dialysis

14. Folate supplementation with 1 mg/day should be
administered starting from the first trimester Since
the requirements for vitamins increase due to the
fact that intensive dialysis promotes their
elimination
The main vitamins to be supplemented are vitamin
C, thiamine, riboflavin, niacin and vitamin B6

15. Double dose of MVI
Folic acid 5 mg/daily
Unrestricted diet
Protein intake: 1.5 to 1.8 g/kg/day
Dry Weight
Assess weekly
Increases by 0.5 kg/week in second and third
trimesters

16. Hypertension
 Eighty percent of pregnancies occurred in dialysis women are
complicated by hypertension which was responsible for 1% of
mortality of mothers in the past. To date, mother mortality is
absent Uncontrolled hypertension must be adequately treated,
maintaining diastolic blood pressure <80–90 mmHg As in any
other dialysis patient, the initial treatment consists of adjusting
volumes using ultrafiltration, but if the cause of hypertension is
preeclampsia, fluid extraction could exacerbate hypo perfusion to
the various organs
 Target post dialysis BP of 140/90 mm Hg
 Diagnosis of Preeclampsia Difficult to diagnose; must rely on
worsening BP control

17. Medications are used to treat
hypertension in pregnant women.
 α-methyldopa is commonly used; no adverse side effects
have been observed in infants, and they are relatively few in
the mother: fatigue, depression and, in a small percentage of
patients, hepatitis
 Among β-blockers, only labetalol is widely used because it
does not produce adverse effects on newborns
 Nifedipine, nicardipine and verapamil can be
administered safely. These molecules have been used in
cases of severe hypertension, and do not appear to be
associated with congenital defects when prescribed
during the first trimester

18.  Diuretics can be used when no other alternative
exists, but must be stopped in the case of
preeclampsia
 Thiazides reported neonatal thrombocytopenia,
hemolytic anemia, electrolyte imbalances and
jaundice
 Angiotensin-converting enzyme (ACE)
inhibitors, angiotensin receptor blockers (ARB)
and minoxidil are contraindicated due to their
adverse effects on the newborn

19.  Hydralazine has been used both orally and
intravenously without evidence of severe side
effects. However, it is not effective as oral
monotherapy
 The experience with clonidine and prazosin is
limited, and these drugs do not appear to provide
any serious benefit
 Only limited experience has been gained using
diltiazem. We must remember that combined
therapy with magnesium can lead to severe
episodes of hypotension

20. Anemia
 Anemia during pregnancy is associated with
increased incidence of pre-term births, which
results in greater infant mortality rates
 Since the physiologic changes and demands
of pregnancy may result in worsening of
anemia
 Pregnant women often require an increase of
50–100% of EPO
 dosages to maintain an adequate red cell
mass (hemoglobin of 10–11 g/dL with a
hematocrit of 30–35%)
 No increases of incidence of hypertension nor
teratogenicity have been demonstrated with
the use of erythropoietin during pregnancy

21. Increase in ESA and iron requirements
Target hemoglobin of 10 g/dL
Both the mother and the fetus need 10–
15 mg of iron per day. Oral supplements
would be insufficient.
 Intravenous administration has proven
to be safe and effective in maintaining the
desired serum ferritin levels of 200-
300μg/mL

22. Metabolic Bone Disease
 Occurrence of hypocalcaemia should be
avoided by giving 1.5–2 g of supplementary
calcium daily that are necessary for a normal
fetal growth in a woman with a normal dietary
calcium intake of 800 mg/day.
 However, it is important to check weekly for
serum calcium because both the calcium
provided by the dialysate (1.5 mmol/L daily)
and calcium intake of chelating agents might
induce maternal hypercalcaemia and
secondary fetal hypocalcaemia and
hyperphosphataemia with impaired skeletal
development

23. The placenta converts calcidiol into
calcitriol, thus 25-OH vitamin D must
be measured every trimester,
administering supplements if levels are
low.
Oral phosphorus binders generally not
required ( Sevelamer, lanthanum
carbonate, aluminium hydroxide.)
cinacalcet and paricalcitol have not
been tested or established for use during
pregnancy/lactation

24. Vitamin D analogs
 Vitamin D analogs to maintain PTH levels, as in general
dialysis patients
Although primary hyperparathyroidism is
known to increase the frequency of pre-term
births by 10–20%, the effects of
hyperparathyroidism on the fetus are unknown.
The use of calcitriol is indicated in these cases in
order to control both hyperparathyroidism and
1,25-OH-vitamin D deficiency. Calciferol does not
appear to be toxic at reasonable doses. Dosage
adjustments must be based on weekly calcium
and phosphorous measurements

25. Recommended interventions
and target values in pregnant
women on dialysis

26.  Prevent metabolic acidosis
 Intensify dialysis treatment
 Increase the frequency of dialysis
sessions (5–7 per week)
 Maintain a predialysis BUN <16–18
mmol/L
 Increase in maternal weight of 1–1.5 kg
in the first trimester; thus 0.45–1 kg per
week in the last trimester
 Use the minimum possible dose of
heparin
Use biocompatible membranes

27. Blood pressure control
Medications to avoid: diuretics, ACE
inhibitors and ARB
Preferred treatments: α-methyldopa,
labetalol,nifedipine,nicardipine,verap
amil
Maintain diastolic blood pressure
between 80 and 90 mmHg
Prevent hypotension and volume
decrease

28. Calcium/phosphorous metabolism
 Avoid hypocalcaemia and
hyperphosphataemia
 Provide calcium supplementation of 1.5–
2 g daily, dietary calcium of 800 mg daily
and dialysate calcium of 1.5 mmol/L
If necessary, use calcium chelating
agents and vitamin D. Avoid postdialysis
hypercalcaemia

29.  Anemia
Provide iron (10–15 mg/day) and folic acid (1 mg/day)
supplementations
Increase of 50–100% EPO dosage
Maintain hemoglobin at 10–11 g/dL, hematocrit at 30–
35% and
Serum ferritin of 200–300 μg/mL
 Nutrition
Provide protein intake of 1.2–1.4 g/kg pre-pregnancy
weight/day +20 g/day
Provide calories intake of 25–35 kcal/kg/pregnant
weight/day
Provide water-soluble vitamins supplementation

30. Case scenario
 A 42years old pregnant 35 WK G6P5 known to be
HCV, HTN, CKD5HD SINCE 3 Years
 Presents to ER with premature rupture of
membranes CS delivery done mother was admitted
at gynecology department for 2days
 Baby admitted to neonatal care
 RESPIRATORY DISTRESS (difficulty breathing
cyanosis, and apnea, primary bradycardia,
intubated at delivery till cyanosis disappear and
heart rate rise to 110/min on MV for 6 days then
weaning with oxygen nasal mask)
 Neonatal jaundice 2 days recovery on
phototherapy treatment
 Prognosis of baby is good

31. Nephrology consultation
 Head neck examination patient looks pallor
fatigue with congested neck veins
 Chest clear
 Heart S1 ,S2
 Abdomen lax .scar of cs .no ascites
 Upper limbs Left brachiocephalic fistula
 Bilateral lower limbs edema
 Mother with past history of DVT Left leg
fracture of right leg

32. Dialysis prescription during pregnancy
HD Session 3 /week 5 hours on
bicarbonate HD –medication aldomet
Investigation
 4/10/2017
S.cr6.9-urea69-K4, 4 Na 135 Ph. 7, 35 pco2 27 Hco3 14,9
WBC 12,1 HB 7,2 PLT 230
 5/10/2017
ALT 10 AST 41 CR 6, 1 UREA 59 Na 135 k4,4 wbc 13,9 HB
8,2 PLT 250 INR 1,08
PH 7,33 PCO2 34 HCO3 17,9

33. HD SESSION done in ICU after CS
delivery
NEXT DAY SECOND SESSION DONE in ICU
for uncontrolled HTN 220/150 After given
epilat 20 tab, labipress200 tab blood
pressure decline to 120/80 then start HD
UF 2000ml 2hr heparin free
Patient stable transfer to nephrology
department for 2days then discharge for
follow up OPD

35. References
 Brenner and Rector's the Kidney 10 th2016
Hypertension and Kidney Disease in
Pregnancy P1635 CHAPTER 49
 National Kidney Foundations Primer on
Kidney Diseases 6th 2014 p434CHAPTER 50
 Clin Kidney J (2015) 8: 293–299
Dialysis in Special Situations G. Manisco
et al.

36. THANKYOU