1. Pregnancy in women undergoing hemodialysis presents many medical, ethical and emotional complexities. Counseling should discuss prognosis factors like residual kidney function and blood pressure control. Outcomes are generally better after kidney transplantation than on dialysis. 2. Managing medications, dialysis prescriptions and nutrition is challenging during pregnancy for hemodialysis patients. Increased dialysis dose, monitoring of anemia, minerals and vitamins is important. Blood pressure and signs of preeclampsia need close monitoring. 3. Successful pregnancies on hemodialysis require multidisciplinary management of dialysis prescriptions, medications, nutrition and fetal monitoring to optimize outcomes for both mother and baby.

1. 10 TIPS to Approach a Pregnant
lady on Hemodialysis
Emad Magdy Shawky
Assistant lecturer of Nephrology
MNDU
Hemodialysis Course, 22th DEC. 2016

2. CHANCE
Kidney Int. 2016 May;89(5)
1
Hormonal changes (Estrogen- progesterone- LH-
Prolactine)
 Anovulation ( with or without Amenorrhea)
 Endometrial changes

3. CHANCE
Kidney Int. 2016 May;89(5)
1
The Miracle Continues
Against All Odds

4. CHANCE1
Increasing incidence
 May reach 7% of women on CHD rising from 1% 1980 (Improving Dx service, better
anemia control)
 More with residual renal function.
 Less with PD.
Increasing survival rates
 1st successful 1971
 30-50% increasing dialysis dose
 85% premature
 35% LBW ( < 2kg)
 Common complications : Respiratory distress- CP- Congenital anomalies
Kidney Int. 2016 May;89(5)

5. CONTRACEPTION2
Medical, Ethical, And Emotional
Complexities
Am J Kidney Dis. 2015 Dec;66(6):951-61

6. CONTRACEPTION2

7. CONTRACEPTION2
Counselling tips for dialysis or pre-dialysis patients who wish
to undertake a pregnancy
 Counselling on pregnancy and contraception should be included in the approach
to all women in childbearing age who start dialysis (not graded).
 The prognostic markers allowing quantification of the probability of a successful
pregnancy are only partially known. Residual kidney function and
normotension are favourable prognostic factors (not graded).
 Counselling should also include the fact that outcomes of pregnancy are better
after transplantation than on dialysis (strong suggestion from large studies in
transplanted patients, and from Registries).

8. CONTRACEPTION2
Historically, renal disease was considered a contraindication to
pregnancy, but now many pregnant women with CKD have
successful outcomes
Am J Kidney Dis. 2015 Dec;66(6):951-61
The key pre-pregnancy factors predicting outcome include
the following:
Degree of renal impairment rather than the aetiology of
renal disease.
Control of hypertension
Degree of proteinuria

9. CONTRACEPTION2

10. CONTRACEPTION2
• HTN, PET, Anemia,
progression to ESRD
• Placental Hge,
polyhydramnios, PROM
Maternal
• Prematurity, LBW, IUGR, CP, Cong
anomalies
• Neonatal death, abortion
Fetal
Hippokratia. 2011 Jan; 15 (Suppl 1): 8–12.

11. CONTRACEPTION2

12. CONTRACEPTION2

13. CONTRACEPTION2

14. CONTRACEPTION2
IUD
Bleeding- Infection
Oral contraceptives
Hypercoagulability (access)
Barriers
Safety
ACKD Journal, Vol 20, No 3 (May), 2013

15. CONTRACEPTION2
IUD
Bleeding- Infection
Oral contraceptives
Hypercoagulability (access)
Barriers
Safety
ACKD Journal, Vol 20, No 3 (May), 2013

16. Difficult
 Pregnancy is often unexpected
 Symptoms in the early phase may mimic different diseases and complications
of dialysis.
 Serum levels of beta-HCG may be increased even in the absence of pregnancy.
 Irregular menstrual cycles and anovulation are common in women on
dialysis,thus making the calculation of gestational age based upon the last
menstrual cycle unreliable.
In this context, early ultrasonography should be used to verify the
presence of a viable foetus and to calculate the gestational age.
Gianfranco Manisco,et al. clin kidney J (2015)
3 Diagnosis of pregnancy in dialysis

17. Challenges In Prescription4
Plasma volume Increased by 30% >>
hemodilution>>anemia
WT gain rate plasma vol plus fetal and placental develop
Polyhydramnios as high BUN>>fetal osmotic diuresis
 Bone and mineral metabolism placenta converts some 25-
hydroxyvitamin D3 to 1,25-dihydroxyvitamin
D3>>adjustment of vitamin D , Ca supplement
Respiratory alkalosis hyperventilation (progest mechanical) –
hyperemesis>>> compensation by M.Acidosis
EPO resistance , cytokine release >> anemia

18. DOSE AND ADEQUACY4.a.
Nephrol Dial Transplant (2015) 0: 1–20
Target BUN < 50 mg/dL
or even < 45 mg/dL

19. DOSE AND ADEQUACY4.a.
Recently, the relationship between dialysis intensity and outcomes has become
clearer, with increased dialysis delivery becoming standard practice and nocturnal
hemodialysis potentially providing superior fertility and outcomes.
Shilpanjali Jesudson, et al. Clin J Am Soc Nephrol 9: 143–149, 2014.

20. DOSE AND ADEQUACY
Hippokratia. 2011 Jan; 15 (Suppl 1): 8–12.
4.a.

21. J Am Soc Nephrol. 2014; 25:1103–1109.
4.a.

22. J Am Soc Nephrol. 2014; 25:1103–1109.
4.a.

23. J Am Soc Nephrol. 2014; 25:1103–1109.
4.a.

24. Dialyzer type, ultrafiltration volume
Small surface area dialysers
Reduce UF rate per session
Avoid hypotension
Avoid abrupt osmolarity changes
4.b.
High surface area membranes

25. Dialyzer type, ultrafiltration volume
Dry BW assessment
Predicted Wt gain: after 3m>> 0.5 Kg/wk
Clinical: Bp control, (edema not reliable)
Hematocrit & Albumin levels
Measure Hematocrit & Albumin at the initial first-
trimester visit.
4.b.
A rise in either value strongly suggests
intravascular volume contraction, Opposite is
not trueAdvances in Chronic Kidney Disease, Vol 20, No 3 (May), 2013

26. Heparin
Pregnancy is a hypercoagulability state so
theoretically there are increased requirements but
it is not a rule.
4.c.
Individualization
Hemodialysis International 2016; 20:339–348.

27. Dialysate constituents
• 3 meq/l
• Intensive
dialysis with
risk of
hypokalemia
• <25 meq/l
• Target
serum18-22
mmol/l
• 135 mmol/l
4.d.
Hemodialysis International 2016; 20:339–348
.

28. Minerals and water soluble vitamins
Give at increased doses, because
they can be partially removed by
intensive dialysis.
Folic acid at a higher dose of 5
mg daily if on dialysis
4.e.
Hemodialysis International 2016; 20:339–348

29. BMD
Phosphate: monitored frequently- may stop
phosphate binders or need supplementation
(important to fetal skeletal development)
Calcium: increase dialysate calcium to 1.75 mmol/l –
oral supplementation (1-2 g/d)- take care of hyper
or hypocalcemia
5
placenta converts some 25-hydroxyvitamin D3
to 1,25-dihydroxyvitamin D3
Kidney Int. 2016 May;89(5)

30. Anemia6
Target : 11g/dl.
EPO : increase dose by 50%.
Iron : monitored monthly ( IV supp).
CBC weekly.
<8g/dl>> blood trasnfusion. Kidney Int. 2016 May;89(5)

31. Hypertension And Superimposed PET
Target BP 110-140/80-90 mmHg
7

32. Superimposed Preeclampsia
Kavitha Vellanki. Advances in Chronic Kidney Disease, 2013.
Difficult Diagnosis
7
 Already patient has renal impairment ± proteinuria ± the absence
of significant urine output if late stage CKD or 5D
 Hypertension, ↓ GFR or proteinuria can be due to progression
of the renal disorder rather than superimposed preeclampsia

33. When to suspect pre-eclampsia?
 Unexplained rise in BP not responding to fluid removal &
drugs
 Development of classic preeclampsia symptoms (visual
abnormalities severe headache, epigastric pain & hyper-
reflexia)
 Fetal growth restriction and abnormal umbilical artery blood
flow (uterine artery doppler).
 Laboratory abnormalities consistent with the HELLP
syndrome & thrombocytopenia
7
after 20 weeks of pregnancy
Advances in Chronic Kidney Disease, Vol 20, No 3 (May), 2013
Aspirin (75–150 mg/day)
The aim of aspirin is for the prevention
of preeclampsia or perinatal death

34. Fetal Assessment
Serial ultrasound examinations are important for the
early detection fetal growth restriction
Assessment of the fetal heart rate (particularly
during the last portion of a session)
8
Kidney Int. 2016 May;89(5)
Maternal haemodynamic instability may compromise the
uteroplacental circulation and may be associated with the
induction of uterine contractions

35. Nutrition9
Attention to nutritional considerations is essential for a
successful pregnancy because malnutrition is common
in pregnancies of ESRD patients
G. Manisco et al. Clin Kidney J (2015) 0: 1–7

36. 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
The main vitamins to be supplemented are vitamin C, thiamine, riboflavin,
niacin and vitamin B6
9
G. Manisco et al. Clin Kidney J (2015) 0: 1–7

37. Breast Feeding10
PLoS One. 2015 Nov 16;10(11)
 Significant variations in breast milk composition between pre-
and post-HD samples suggest that breastfeeding might be
preferably performed after dialysis treatment.
 In summary, our findings indicate that breastfeeding can be
considered a viable option for newborns of mothers on dialysis.