This document discusses pregnancy in women undergoing hemodialysis. It notes that while rare, pregnancy is possible but comes with increased risks of complications for both the mother and fetus. These can include worsening hypertension, preterm labor, growth restriction, and others. The document provides guidance on managing these risks through frequent hemodialysis, strict fluid control, medication adjustments, nutritional supplementation, and multidisciplinary care. The goal is to allow for safe continuation of pregnancy while minimizing health impacts on the mother and optimizing fetal development.

1. Pregnancy in hemodialysis
By
Salwa Mahmoud Elwasief

2. welcome

3. Is pregnancy possible?

4. Is it possible?
• The chronic kidney disease (CKD) affects 3% of women of
childbearing age. Pregnancy is a rare event in patients on dialysis
• Why?:
• hormonal alterations associated with its treatment
• Associated anemia, BMD
• low libido
• high level of stress in the effected women.
(Suarez et al, 2015)

5. Anovulatory cycle

6. If happened, is it possible to
continue?
• For women with pre-existing renal failure,
pregnancy is associated with increased rate of
fetal complications and considerable risk of
pregnancy complications.

7. • End of the text

8. • changes in CKD therapy and advances in
dialysis techniques have allowed an increase
in fertility in these women over the last
decades, with a calculated frequency from 0.3
to 1.5% per year.
• The rate of live births increased to 40-50%.
(Pipili et al, 2011)

9. Possible complications
• Polyhydramnios
• worsening maternal hypertension
•abruption placenta
•acute pulmonary edema
• pre-term labor
• fetal growth restriction

10. polyhydramnios
two reasons:
• hypovolemia during dialysis causes decreased
oncotic pressure
• increased maternal urea leading to osmotic
diuresis of the fetus

11. Management

12. Possible complications
• Polyhydramnios
• worsening maternal hypertension
•abruption placenta
•acute pulmonary edema
• pre-term labor
• fetal growth restriction

14. complication
• Abruptio placenta
• Pulmonary oedema

15. • Intravenous (IV) labetalol and hydralazine have
long been considered first-line medications .
Available evidence suggests that oral nifedipine
also may be considered as a first-line therapy.
• Parenteral labetalol should be avoided in women
with asthma, heart disease, or congestive heart
failure.

16. • When urgent treatment is needed before the
establishment of IV access, the oral nifedipine
algorithm can be initiated or a 200-mg dose of
labetalol can be administered orally. The latter
can be repeated in 30 minutes if appropriate
improvement is not observed.

17. ? Ultrafiltration
Accepted rate of
weight gain:

18. • Magnesium sulfate is not recommended as an
antihypertensive agent, but magnesium
sulfate remains the drug of choice for seizure
prophylaxis in severe preeclampsia and for
controlling seizures in eclampsia.
Do not exceed
20 g/48 hr.

19. • Sodium nitroprusside should be reserved for
extreme emergencies and used for the shortest
amount of time possible because of concerns
about cyanide and thiocyanate toxicity in the
mother and fetus or newborn, and increased
intracranial pressure with potential worsening
of cerebral edema in the mother.

20. Possible complications
• Polyhydramnios
• worsening maternal hypertension
•abruption placenta
•acute pulmonary edema
• pre-term labor
• fetal growth restriction

21. Preterm labour
Before 37 weeks

22. Possible complications
• Polyhydramnios
• worsening maternal hypertension
•abruption placenta
•acute pulmonary edema
• pre-term labor
• fetal growth restriction

23. IUGR

24. fetal growth restriction
• 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.

25. • Weekly check 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

26. • The placenta converts calcidiol into
calcitriol, thus 25-OH vitamin D must be
measured every trimester, administering
supplements if levels are low

27. 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

28. • Sevelamer, lanthanum carbonate, aluminium
hydroxide, cinacalcet and paricalcitol have not
been tested or established for use during
pregnancy/lactation

29. Hemodialysis protocol

30. Protocol of hemodialysis in
pregnancy
• Modality
• Frequency
• Duration
• Ultrafiltration
• Anticoagulants
• Care of acid/base
• Correction of anemia
Multidisciplinary Approach

31. HD Modalities during pregnancy
• CRRT
• High flux dialysis
• HDF

32. HD Modality during pregnancy

33. NX stage

34. K-DIGO Guideline

35. Protocol of hemodialysis in
pregnancy
• Modality
• Frequency and Duration
• Ultrafiltration
• Anticoagulants
• Care of acid/base
• Correction of anemia

36. HD dose
• Less complication if more than 20 hours/week
• Target BUN pre-dialysis less than 45-50mg/dl
alkalosis
hypokalemia
hypercalcemia

37. Protocol of hemodialysis in
pregnancy
• Modality
• Frequency and Duration
• Ultrafiltration
• Anticoagulants
• Care of acid/base
• Correction of anemia

39. Ultrafiltration
• Acceptable rate of weight gain:
0.3-0.5kg/wk

40. Full-term pregnancy
• Baby: 7.5 pounds
• Placenta: 1.5 pounds
• Amniotic fluid: 2 pounds
• Uterine enlargement: 2 pounds
• Maternal breast tissue: 2 pounds
• Maternal blood volume: 4 pounds
• Fluids in maternal tissue: 4 pounds
• Maternal fat stores: 7 pounds

41. Protocol of hemodialysis in
pregnancy
• Modality
• Frequency
• Duration
• Ultrafiltration
• Anticoagulants
• Care of acid/base
• Correction of anemia

42. Anticoaggulant
• 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 patient

43. Protocol of hemodialysis in
pregnancy
• Modality
• Frequency
• Duration
• Ultrafiltration
• Anticoagulants
• Care of acid/base
• Correction of anemia

44. • Anemia during pregnancy is associated with
increased incidence of pre-term births, which
results in greater infant mortality rates

46. Diet
• High protein
• Low salt
• Vitamins:
water soluble

47. Drug safety
Name category
ESA
Cinacalcet
Calcium carbonate
calcidol
insulin
Vitamin B
L carnitine

48. Delivery …… ?
C.S.

49. Lactation in hemodialysis
For the mother For the kid
Sense of well being Innate immunity
Prophylaxis of breast
cancer
Psychology????
Benefits

50. Contraception in hemodialysis