Mohammed Abdel Gawad is a nephrology specialist who provides care for pregnancy in pre-existing kidney disease. His document outlines general principles of prenatal care including maintaining blood pressure between 110-140/80-90 mmHg, hemoglobin between 10-11 g/dL, daily folic acid, low-dose aspirin, heparin, and a protein diet. He also discusses assessing fetal well-being, identifying urinary tract infections and superimposed preeclampsia. A multidisciplinary team approach including obstetricians, nephrologists and neonatologists is recommended for managing the complexities of pregnancy with pre-existing kidney disease.
- Recorded videos of this lecture:
English Language version of this lecture is available at:
https://youtu.be/i_bUFU-p43Q
Arabic Language version of this lecture is available at:
https://youtu.be/RaIP09m4XMY
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- Recorded videos of this lecture:
English Language version of this lecture is available at:
https://youtu.be/i_bUFU-p43Q
Arabic Language version of this lecture is available at:
https://youtu.be/RaIP09m4XMY
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MANAGEMENT OF DIABETES IN CHRONIC KIDNEY DISEASE (Special reference to Use of...Dr. Om J Lakhani
Talk on MANAGEMENT OF DIABETES IN CHRONIC KIDNEY DISEASE (Special reference to Use of Metformin In CKD).
Presented on 25th June 2017 at THE METFORMIN MEET in Vadodara, India
While it is rare, women on dialysis have become pregnant. Of these pregnancies, about 20 percent will end in miscarriage. A full-term pregnancy lasts about 40 weeks; however, about 80 percent of dialysis pregnancies will only go about 32 weeks, resulting in a premature birth
Newer Oral Anticoagulant in Chronic Kidney DiseaseAbdullah Ansari
Kidney specific mechanisms leading to atrial fibrillation
Possible mechanism of CKD progression in atrial fibrillation
Atherosclerosis Risk in Communities (ARIC) study
Guidelines
Pulmonary embolism & deep vein thrombosis
Nephrotic syndrome
Problems with Vit K antagonists in CKD
Non Vit K oral anticoagulants
Site of action of NOACs and VKAs
Pharmacology of Direct Oral Anticoagulants
Trials for NOACs
Dose NOACs according to renal function
Laboratory monitoring of NOACs
Anticoagulant reversal of NOACs
Diabetes Mellitus Management in CKD (Clinical Tips) - Dr. GawadNephroTube - Dr.Gawad
- Recorded videos of this lecture:
English Language version of this lecture is available at:
https://youtu.be/h3HRvWGUj5A
- Visit our website for more lectures: www.NephroTube.com
- Subscribe to our YouTube channel: www.youtube.com/NephroTube
- Join our facebook group: www.facebook.com/groups/NephroTube
- Like our facebook page: www.facebook.com/NephroTube
- Follow us on twitter: www.twitter.com/NephroTube
MANAGEMENT OF DIABETES IN CHRONIC KIDNEY DISEASE (Special reference to Use of...Dr. Om J Lakhani
Talk on MANAGEMENT OF DIABETES IN CHRONIC KIDNEY DISEASE (Special reference to Use of Metformin In CKD).
Presented on 25th June 2017 at THE METFORMIN MEET in Vadodara, India
While it is rare, women on dialysis have become pregnant. Of these pregnancies, about 20 percent will end in miscarriage. A full-term pregnancy lasts about 40 weeks; however, about 80 percent of dialysis pregnancies will only go about 32 weeks, resulting in a premature birth
Newer Oral Anticoagulant in Chronic Kidney DiseaseAbdullah Ansari
Kidney specific mechanisms leading to atrial fibrillation
Possible mechanism of CKD progression in atrial fibrillation
Atherosclerosis Risk in Communities (ARIC) study
Guidelines
Pulmonary embolism & deep vein thrombosis
Nephrotic syndrome
Problems with Vit K antagonists in CKD
Non Vit K oral anticoagulants
Site of action of NOACs and VKAs
Pharmacology of Direct Oral Anticoagulants
Trials for NOACs
Dose NOACs according to renal function
Laboratory monitoring of NOACs
Anticoagulant reversal of NOACs
Diabetes Mellitus Management in CKD (Clinical Tips) - Dr. GawadNephroTube - Dr.Gawad
- Recorded videos of this lecture:
English Language version of this lecture is available at:
https://youtu.be/h3HRvWGUj5A
- Visit our website for more lectures: www.NephroTube.com
- Subscribe to our YouTube channel: www.youtube.com/NephroTube
- Join our facebook group: www.facebook.com/groups/NephroTube
- Like our facebook page: www.facebook.com/NephroTube
- Follow us on twitter: www.twitter.com/NephroTube
Family planning: is defined as "educational, comprehensive medical or social activities and services which enable individuals, including minors, to determine freely the number and spacing of their children and to select the means by which this may be achieved.
Birth control: Birth control is the use of any practices, methods, or devices to prevent pregnancy from occurring in a sexually active woman. Also referred to as family planning, pregnancy prevention, fertility control, or contraception; birth control methods are designed either to prevent fertilization of an egg or implantation of a fertilized egg in the uterus. Birth control methods may be reversible or irreversible.
Contraception: (birth control) prevents pregnancy by interfering with the normal process of ovulation, fertilization, and implantation. There are different kinds of birth control that act at different points in the process.
Benefits of Family planning
Women/family
• Better health
• Less physical/emotional strain
• Improved quality of life
• Increased educational opportunities
• Increased economic opportunities
• More energy for household activities
• More energy for personal development and community activities
For Children:
• Better health
• More food and other resources available
• Greater opportunity for emotional support from parents
• Better opportunity for education
Factors that affect on the decision of using contraception:
• husband involvement
• Effectiveness--statistics show two numbers:
- Failure rate: no. of women per 100 who become pregnant after 1 yr. when using a birth control consistently & correctly
- Typical use failure rate: takes into account improper or inconsistent use
• Cost
• Ease of use
• Side effects
Family planning methods
• Hormone-based contraceptives
6 types
1) Oral contraceptives (pills)
2) Vaginal ring
3) Transdermal patch
4) Injected hormones
5) Hormonal implants
6) Hormonal IUDs
Oral contraceptives pills
Types of Contraceptives Pills
Combined oral contraceptives (COCs)
Most widely used
Contain both estrogen & progestagen
Triphasic pill
Levels of hormones (estrogen & progestin) fluctuate during cycle
Progestin-only pills (POPs)
Contain only a progestagen, mostly Levonorgestrel (no estrogen).
Especially suitable for breastfeeding women.
How hormonal contraceptives work
FSH & LH trigger ovulation
How to use oral contraceptives
Pre-gestational hypertension, pregnancy induced hypertension and pre-eclampsia
Go over the different forms of hypertension in pregnancy, pathophysiology and treatment
Androgens & Cardiovascular Diseases in Women: From Basic Research to Clinical...InsideScientific
Join Dr. Licy Yanes-Cardozo as she expands on her research exploring the role of androgens on cardiovascular physiology in cis and transgender patients.
Women have higher plasma concentrations of androgens than estrogens, yet the role of androgens in physiological processes and diseases is not completely understood. High levels of androgens in women are associated with a negative cardiometabolic profile, whereas in men, low levels of androgens are associated with an increased incidence of cardiovascular diseases.The biology behind androgens’ sex difference is not completely understood.
In this webinar, Dr. Yanes-Cardozo discusses two clinical situations that are associated with high levels of androgens. Polycystic Ovary Syndrome (PCOS), the most common endocrine disorder in reproductive-aged women, is associated with a modest elevation of plasma levels of androgens. In transmen individuals (female to male), plasma concentrations of androgens are elevated to achieve similar levels found in cisgender men and much higher than in PCOS women. The role that these two different plasma concentrations play in cardiovascular physiology and pathophysiology remains unclear. Gaps and opportunities in basic research and clinical practice are highlighted.
Key Topics Include:
- Review the key role of androgens in cardiovascular pathophysiology
- Discuss potential mechanisms by which androgens mediate a deleterious cardiometabolic profile in females
- Interpret gaps and opportunities in basic and clinical practice in conditions of androgen excess
high risk pregnancy with fetuses at risk of complications. This presentation is for students of medicine. Includes basic scanning for dating, anomaly, well-being assessment and growth restriction. Includes twins
Embracing GenAI - A Strategic ImperativePeter Windle
Artificial Intelligence (AI) technologies such as Generative AI, Image Generators and Large Language Models have had a dramatic impact on teaching, learning and assessment over the past 18 months. The most immediate threat AI posed was to Academic Integrity with Higher Education Institutes (HEIs) focusing their efforts on combating the use of GenAI in assessment. Guidelines were developed for staff and students, policies put in place too. Innovative educators have forged paths in the use of Generative AI for teaching, learning and assessments leading to pockets of transformation springing up across HEIs, often with little or no top-down guidance, support or direction.
This Gasta posits a strategic approach to integrating AI into HEIs to prepare staff, students and the curriculum for an evolving world and workplace. We will highlight the advantages of working with these technologies beyond the realm of teaching, learning and assessment by considering prompt engineering skills, industry impact, curriculum changes, and the need for staff upskilling. In contrast, not engaging strategically with Generative AI poses risks, including falling behind peers, missed opportunities and failing to ensure our graduates remain employable. The rapid evolution of AI technologies necessitates a proactive and strategic approach if we are to remain relevant.
Unit 8 - Information and Communication Technology (Paper I).pdfThiyagu K
This slides describes the basic concepts of ICT, basics of Email, Emerging Technology and Digital Initiatives in Education. This presentations aligns with the UGC Paper I syllabus.
Model Attribute Check Company Auto PropertyCeline George
In Odoo, the multi-company feature allows you to manage multiple companies within a single Odoo database instance. Each company can have its own configurations while still sharing common resources such as products, customers, and suppliers.
2024.06.01 Introducing a competency framework for languag learning materials ...Sandy Millin
http://sandymillin.wordpress.com/iateflwebinar2024
Published classroom materials form the basis of syllabuses, drive teacher professional development, and have a potentially huge influence on learners, teachers and education systems. All teachers also create their own materials, whether a few sentences on a blackboard, a highly-structured fully-realised online course, or anything in between. Despite this, the knowledge and skills needed to create effective language learning materials are rarely part of teacher training, and are mostly learnt by trial and error.
Knowledge and skills frameworks, generally called competency frameworks, for ELT teachers, trainers and managers have existed for a few years now. However, until I created one for my MA dissertation, there wasn’t one drawing together what we need to know and do to be able to effectively produce language learning materials.
This webinar will introduce you to my framework, highlighting the key competencies I identified from my research. It will also show how anybody involved in language teaching (any language, not just English!), teacher training, managing schools or developing language learning materials can benefit from using the framework.
Macroeconomics- Movie Location
This will be used as part of your Personal Professional Portfolio once graded.
Objective:
Prepare a presentation or a paper using research, basic comparative analysis, data organization and application of economic information. You will make an informed assessment of an economic climate outside of the United States to accomplish an entertainment industry objective.
Operation “Blue Star” is the only event in the history of Independent India where the state went into war with its own people. Even after about 40 years it is not clear if it was culmination of states anger over people of the region, a political game of power or start of dictatorial chapter in the democratic setup.
The people of Punjab felt alienated from main stream due to denial of their just demands during a long democratic struggle since independence. As it happen all over the word, it led to militant struggle with great loss of lives of military, police and civilian personnel. Killing of Indira Gandhi and massacre of innocent Sikhs in Delhi and other India cities was also associated with this movement.
Palestine last event orientationfvgnh .pptxRaedMohamed3
An EFL lesson about the current events in Palestine. It is intended to be for intermediate students who wish to increase their listening skills through a short lesson in power point.
3. Is pregnancy with pre-existing kidney
disease is a common problem?
What is the frequency or incidence of
conception & pregnancy in a woman
with pre-existing kidney disease?
4. Is Pregnancy with ESRD is a
Common Problem?
Country
Years
Period
Number of
Patients on HD
% of
conception
per year
European Transplant &
Dialysis Association
(13 European countries)
(1)
1970-1980 13,000 <1%
USA (2) 1992-1995
6230 women
(age14-44)
0.5%
Belgium (3) 1989 -1996 4,545 0.3%
Japan (4) 1977-1996
38,889
(age 32.7 ± 5.0)
3.4%
(1) Br J Obstet Gynaecol.1980;87(10):839-845.
(2) Okundaye I et al. Am J Kidney Dis. 1998;31(5):766-773.
(3) Jacques A et al. Am J Kidney Dis. Vol 31, No 5 (May), 1998
(4) Toma H et al. 1999;14(6): 1511-1516.
5. Is Pregnancy with ESRD is a
Common Problem?
Plant L et al. Renal disease in pregnancy. London: RCOG Press; 2008:272.
1 in 200 women of childbearing age
on dialysis become pregnant
6. Reproductive dysfunction in uremic women
CKD – Pregnancy Relationship
Effect of CKD on Pregnancy Effect of Pregnancy on CKD
CKD Classification in Pregnancy
Pre-Pregnancy Counseling in
CKD
Contraception
in Childbearing Age
General Principles of
Prenatal Care
CKD ND CKD 5D
When to dialyse? Dialysis Regimen & Precautions
When to Terminate
Pregnancy
Normal Physiology during pregnancy
Talk
Outline
10. Reproductive and sexual
dysfunction in uremic women
Dysregulation of the menstrual cycle, leading to
amenorrhea by the time the patient reaches ESRD.
Anovulation, even
with preserved
menstrual cycles.
LH surge Absent.
Abnormalities in
endometrial
morphology
Decreased kidney prolactin
clearance in advanced CKD.
Matuszkiewicz-Rowinska Jet al. Nephrol Dial Transplant. 19(8):2074-2077, 2004
Low levels of
estrogen &
progesterone.
Actually, they do get pregnant !!
11. Reproductive dysfunction in uremic women
CKD Classification in Pregnancy
Normal Physiology during pregnancy
Talk
Outline
12. CKD Classification & GFR
Estimation in Pregnancy
None of the eGFR formulas is valid for
pregnancy.
S.Cr remains the standard for
assessment of renal function during
pregnancy.
Kavitha Vellanki. Advances in Chronic Kidney Disease, Vol 20, No 3 (May), 2013
Which eGFR formula to use in
Pregnant CKD?
13. CKD Classification & GFR
Estimation in Pregnancy
CKD Classification in Pregnancy
Mild Moderate Sever
S.Cr
< 1.5 mg/dL
S.Cr
1.5-2.5 mg/dL
S.Cr
> 2.5 mg/dL
This classification based on the difference between these
category levels regarding:
1- CKD progression.
2- Maternal outcome.
3- Fetal outcome.
Kavitha Vellanki. Advances in Chronic Kidney Disease, Vol 20, No 3 (May), 2013
14. Reproductive dysfunction in uremic women
CKD – Pregnancy Relationship
Effect of CKD on Pregnancy Effect of Pregnancy on CKD
CKD Classification in Pregnancy
Normal Physiology during pregnancy
Talk
Outline
15. CKD – Pregnancy
Relationship
Etiology (other than lupus nephritis) is probably not
a major determinant of worsening renal disease if
above factors are well controlled
- Gianfranco Manisco et al. Clin Kidney J, 0: 1–7, 2015
- Kavitha Vellanki. Advances in Chronic Kidney Disease, Vol 20, No 3 (May), 2013
16. Mark A. Brown. Comprehensive Clinical Nephrology. 5th
edition, chapter 45, 2015
CKD – Pregnancy Relationship
Effect of CKD on Pregnancy
Outcome % in all
stages is highly
affected by level
of control of
hypertension
17. Jesudason S et al. Clin J Am Soc Nephrol. 9: 143–149, 2014
Vázquez-Rodríguez JG. Cir; 78: 99–102, 2010
Outcomes in mild & moderate stages are highly
affected by level of control of hypertension
CKD – Pregnancy Relationship
Effect of CKD on Pregnancy
18. CKD – Pregnancy Relationship
Effect of Pregnancy on CKD
Renal Outcome
Mild
S. Cr < 1.5
g/dl
<10% → decline in renal function
Moderate
S.Cr 1.5-3
g/dl
30 % → GFR decline in 3rd
trimester or
early postpartum
Risk of an irreversible loss of GFR
> 50 % if uncontrolled hypertension
10% → progresses to ESRD within
6-12 months after delivery.
Sever
S.Cr > 3
g/dl
Progression to ESRD is high.
Gianfranco Manisco et al. Clin Kidney J, 0: 1–7, 2015
Mark A. Brown. Comprehensive Clinical Nephrology. 5th
edition, chapter 45, 2015
Outcome % in all
stages is highly
affected by level
of control of
hypertension
19. Reproductive dysfunction in uremic women
CKD – Pregnancy Relationship
Effect of CKD on Pregnancy Effect of Pregnancy on CKD
CKD Classification in Pregnancy
Pre-Pregnancy Counseling in
CKD
Normal Physiology during pregnancy
Talk
Outline
20. Pre-Pregnancy
Counseling in CKD
Discuss with the patient the possible
adverse events which may arise during or
as a consequence of her pregnancy
Mark A. Brown. Comprehensive Clinical Nephrology. 5th
edition, chapter 45, 2015
21. Reproductive dysfunction in uremic women
CKD – Pregnancy Relationship
Effect of CKD on Pregnancy Effect of Pregnancy on CKD
CKD Classification in Pregnancy
Pre-Pregnancy Counseling in
CKD
Normal Physiology during pregnancy
Talk
Outline
General Principles of
Prenatal Care
23. General Principles of
Prenatal Care & Management
Problem How to manage?
Hypertension
Anemia
Folic acid
Aspirin (75–150 mg/day)
Heparin
Protein Diet
Urinary tract infection
Assessment of fetal well-being
Superimposed preeclampsia
24. Problem How to manage?
Hypertension Target BP 110-140/80-90 mmHg
Anemia
Folic acid
Aspirin (75–150 mg/day)
Heparin
Protein Diet
Identification and management of
urinary tract infection
Assessment of fetal well-being
Identification of superimposed
preeclampsia
Gianfranco Manisco et al. Clin Kidney J, 0: 1–7, 2015
Reddy SS, Holley JL. Adv Chronic Kidney Disease; 14:146–155, 2007
This range of treatment is not based on solid
pregnancy outcome data
But is thought to be the range that reduces maternal
risk for severe hypertension while providing sufficient
systemic BP to maintain placental perfusion
General Principles of
Prenatal Care & Management
25. Problem How to manage?
Hypertension Target BP 110-140/80-90 mmHg
Anemia
Folic acid
Aspirin (75–150 mg/day)
Heparin
Protein Diet
Identification and management of
urinary tract infection
Assessment of fetal well-being
Identification of superimposed
preeclampsia
Ines et al. Clinical Medicine 2013, Vol 13, No 1: 57–62
General Principles of
Prenatal Care & Management
26. Problem How to manage?
Hypertension Target BP 110-140/80-90 mmHg
Anemia
Folic acid
Aspirin (75–150 mg/day)
Heparin
Protein Diet
Identification and management of
urinary tract infection
Assessment of fetal well-being
Identification of superimposed
preeclampsia
Ines et al. Clinical Medicine 2013, Vol 13, No 1: 57–62
General Principles of
Prenatal Care & Management
27. Problem How to manage?
Hypertension Target BP 110-140/80-90 mmHg
Anemia
Folic acid
Aspirin (75–150 mg/day)
Heparin
Protein Diet
Identification and management of
urinary tract infection
Assessment of fetal well-being
Identification of superimposed
preeclampsia
Take Care
Diuretics
may cause reduction in maternal plasma
volume, uteroplacental or renal perfusion.
General Principles of
Prenatal Care & Management
Gianfranco Manisco et al. Clin Kidney J, 0: 1–7, 2015
28. Problem How to manage?
Hypertension Target BP 110-140/80-90 mmHg
Anemia Maintain Hemoglobin 10–11 g/dl
Folic acid
Aspirin (75–150 mg/day)
Heparin
Protein Diet
Identification and management of
urinary tract infection
Assessment of fetal well-being
Identification of superimposed
preeclampsia
- Khalafallah AA et al. BMJ Open. 2(5). pii:e000998, 2012
- BaruaM et al. Clin JAmSoc Nephrol. 3(2):392-396, 2008.
ESAs at doses higher than
needed before pregnancy
(Doubling of the baseline EPO
requirements is not infrequent)
Intravenous iron as required
General Principles of
Prenatal Care & Management
29. Problem How to manage?
Hypertension Target BP 110-140/80-90 mmHg
Anemia Maintain Hemoglobin 10–11 g/dl
Folic acid
Aspirin (75–150 mg/day)
Heparin
Protein Diet
Identification and management of
urinary tract infection
Assessment of fetal well-being
Identification of superimposed
preeclampsia
- Khalafallah AA et al. BMJ Open. 2(5). pii:e000998, 2012
- BaruaM et al. Clin JAmSoc Nephrol. 3(2):392-396, 2008.
General Principles of
Prenatal Care & Management
30. Problem How to manage?
Hypertension Target BP 110-140/80-90 mmHg
Anemia Maintain Hemoglobin 10–11 g/dl
Folic acid
for every pregnant woman
(5 mg daily if on dialysis)
Aspirin (75–150 mg/day)
Heparin
Protein Diet
Identification and management of
urinary tract infection
Assessment of fetal well-being
Identification of superimposed
preeclampsia
Stover J. Adv Chronic Kidney Dis. 14(2):212-214, 2007
General Principles of
Prenatal Care & Management
31. Problem How to manage?
Hypertension Target BP 110-140/80-90 mmHg
Anemia Maintain Hemoglobin 10–11 g/dl
Folic acid
for every pregnant woman
(5 mg daily if on dialysis)
Aspirin (75–150 mg/day)
Heparin
Protein Diet
Identification and management of
urinary tract infection
Assessment of fetal well-being
Identification of superimposed
preeclampsia
Use Low-dose aspirin (75-150 mg/day) if
if there is no obvious contraindication
serum creatinine above 1.5
mg/dl
If one of the following in a
previous pregnancy:
A- early-onset severe
preeclampsia
B- fetal loss
Askie LM et al. Lancet. 369(9575):1791-1798, 2007.
General Principles of
Prenatal Care & Management
32. Problem How to manage?
Hypertension Target BP 110-140/80-90 mmHg
Anemia Maintain Hemoglobin 10–11 g/dl
Folic acid
for every pregnant woman
(5 mg daily if on dialysis)
Aspirin (75–150 mg/day)
Heparin
Protein Diet
Identification and management of
urinary tract infection
Assessment of fetal well-being
Identification of superimposed
preeclampsia
Askie LM et al. Lancet. 369(9575):1791-1798, 2007.
The aim of aspirin is for the prevention of preeclampsia or
perinatal death
General Principles of
Prenatal Care & Management
33. Problem How to manage?
Hypertension Target BP 110-140/80-90 mmHg
Anemia Maintain Hemoglobin 10–11 g/dl
Folic acid
for every pregnant woman
(5 mg daily if on dialysis)
Aspirin (75–150 mg/day)
creatinine > 1.5 mg/dl
previous pregnancy complications
Heparin
Protein Diet
Identification and management of
urinary tract infection
Assessment of fetal well-being
Identification of superimposed
preeclampsia
Askie LM et al. Lancet. 369(9575):1791-1798, 2007.
General Principles of
Prenatal Care & Management
34. Problem How to manage?
Hypertension Target BP 110-140/80-90 mmHg
Anemia Maintain Hemoglobin 10–11 g/dl
Folic acid
for every pregnant woman
(5 mg daily if on dialysis)
Aspirin (75–150 mg/day)
creatinine > 1.5 mg/dl
previous pregnancy complications
Heparin
Nephrotic Syndrome
Serum Albumin of <2.5 g/l
Protein Diet
urinary tract infection
Assessment of fetal well-being
superimposed preeclampsia
Davison JM, Nelson-Piercy C, Kehoe S, Baker P, eds. Renal disease in pregnancy. London: RCOG Press; 2008:21-30
General Principles of
Prenatal Care & Management
35. Problem How to manage?
Hypertension Target BP 110-140/80-90 mmHg
Anemia Maintain Hemoglobin 10–11 g/dl
Folic acid
for every pregnant woman
(5 mg daily if on dialysis)
Aspirin (75–150 mg/day)
creatinine > 1.5 mg/dl
previous pregnancy complications
Heparin
Nephrotic Syndrome
Serum Albumin of <2.5 g/l
Protein Diet
urinary tract infection
Assessment of fetal well-being
superimposed preeclampsia
General Principles of
Prenatal Care & Management
36. Protein diet
Pregnant females are
counseled to have high
protein intake.
even when the ideal protein intake
in normal pregnancy has not yet
been assessed.
Low-protein diet is an
important tool in the
management of CKD.
Piccoli GB et al. Nephrol Dial Transplant. 26(1):196-205. 2011.
Little is known about the risk and
benefits of LPD in pregnant CKD.
Supplementary of
20 g/day necessary
for correct
development of the
fetus
1 g/kg/day
related to a
sufficient
mother intake
Recommended
Protein Intake
Pregnant CKD
37. Problem How to manage?
Hypertension Target BP 110-140/80-90 mmHg
Anemia Maintain Hemoglobin 10–11 g/dl
Folic acid
for every pregnant woman
(5 mg daily if on dialysis)
Aspirin (75–150 mg/day)
creatinine > 1.5 mg/dl
previous pregnancy complications
Heparin
Nephrotic Syndrome
Serum Albumin of <2.5 g/l
Protein Diet 1 g/kg/day + 20 g/day
urinary tract infection
Assessment of fetal well-being
superimposed preeclampsia
General Principles of
Prenatal Care & Management
38. Problem How to manage?
Hypertension Target BP 110-140/80-90 mmHg
Anemia Maintain Hemoglobin 10–11 g/dl
Folic acid
for every pregnant woman
(5 mg daily if on dialysis)
Aspirin (75–150 mg/day)
creatinine > 1.5 mg/dl
previous pregnancy complications
Heparin
Nephrotic Syndrome
Serum Albumin of <2.5 g/l
Protein Diet 1 g/kg/day + 20 g/day
Urinary tract infection
Early identification &
management
Assessment of fetal well-being
superimposed preeclampsia
General Principles of
Prenatal Care & Management
39. Problem How to manage?
Hypertension Target BP 110-140/80-90 mmHg
Anemia Maintain Hemoglobin 10–11 g/dl
Folic acid
for every pregnant woman
(5 mg daily if on dialysis)
Aspirin (75–150 mg/day)
creatinine > 1.5 mg/dl
previous pregnancy complications
Heparin
Nephrotic Syndrome
Serum Albumin of <2.5 g/l
Protein Diet 1 g/kg/day + 20 g/day
Urinary tract infection
Early identification &
management
Assessment of fetal well-being Regular Assessment
superimposed preeclampsia
General Principles of
Prenatal Care & Management
40. Problem How to manage?
Hypertension Target BP 110-140/80-90 mmHg
Anemia Maintain Hemoglobin 10–11 g/dl
Folic acid
for every pregnant woman
(5 mg daily if on dialysis)
Aspirin (75–150 mg/day)
creatinine > 1.5 mg/dl
previous pregnancy complications
Heparin
Nephrotic Syndrome
Serum Albumin of <2.5 g/l
Protein Diet 1 g/kg/day + 20 g/day
Urinary tract infection
Early identification &
management
Assessment of fetal well-being Regular Assessment
Superimposed preeclampsia Difficult Challenge !!!
General Principles of
Prenatal Care & Management
41. Superimposed Preeclampsia
Diagnosis of superimposed preeclampsia in
CKD pregnant is difficult
Already patient has
renal impairment
± proteinuria
± the absence of significant
urine output if late stage
CKD or 5D
↑ BP, ↓ GFR, ↑ serum urate,
or ↑ protein excretion
can be due to progression the
renal disorder rather than
superimposed preeclampsia
- Kavitha Vellanki. Advances in Chronic Kidney Disease, Vol 20, No 3 (May), 2013
- Napolitano R et al. Prenat Diagn. 32(2):180-184, 2012.
42. Superimposed Preeclampsia
Diagnosis of superimposed preeclampsia in
CKD pregnant is difficult
- Kavitha Vellanki. Advances in Chronic Kidney Disease, Vol 20, No 3 (May), 2013
- Napolitano R et al. Prenat Diagn. 32(2):180-184, 2012.
When to suspect pre-eclampsia?
after 20 weeks of pregnancy
Unexplained rise in BP not
responding to fluid removal & drugs
Development of classic
preeclampsia symptoms
(visual abnormalities, severe
headache, epigastric pain &
hyper-reflexia)
Laboratory abnormalities
consistent with the HELLP
syndrome & thrombocytopenia
Fetal growth restriction and
abnormal umbilical artery blood
flow (uterine artery doppler).
44. Superimposed Preeclampsia
fms-like tyrosine kinase-1
(sFlt1), a placental
antiangiogenic factors to both
vascular endothelial growth
factor and placental growth
factor (PIGF)
Sharon E. Maynard et al. J Am Soc Nephrol 20: 14–22, 2009Levine RJ et al. Gynecol Obstet Invest. 74(4):274-281, 2012.
PIGF
Placental
development
sFlt1
Endothelial
damage
New hope for diagnosis
46. Problem How to manage?
Hypertension Target BP 110-140/80-90 mmHg
Anemia Maintain Hemoglobin 10–11 g/dl
Folic acid
for every pregnant woman
(5 mg daily if on dialysis)
Aspirin (75–150 mg/day)
creatinine > 1.5 mg/dl
previous pregnancy complications
Heparin
Nephrotic Syndrome
Serum Albumin of <2.5 g/l
Protein Diet 1 g/kg/day + 20 g/day
Urinary tract infection
Early identification &
management
Assessment of fetal well-being Regular Assessment
Superimposed preeclampsia Difficult Challenge !!!
General Principles of
Prenatal Care & Management
47. Reproductive dysfunction in uremic women
CKD – Pregnancy Relationship
Effect of CKD on Pregnancy Effect of Pregnancy on CKD
CKD Classification in Pregnancy
Pre-Pregnancy Counseling in
CKD
Normal Physiology during pregnancy
Talk
Outline
General Principles of
Prenatal Care
CKD 5D
Dialysis Regimen & Precautions
48. Pregnant CKD 5D
Dialysis Prescription
Item How to deal with?
Duration, Frequency & Efficacy >24h/w, Urea<50
Dialysate K 3mEq/L
Dialysate Bicarbonate 25mEq/L
Ca, Pi & PTH balance Ca 1.75-2.5mmol/L,↑ dialysate P
Dialysate Na 135mEq/L
Heparnization heparin if no vaginal bleeding
Blood Flow Gradual increase
Filter Flux & S.A. ??
AVF Cannulation Rope Ladder
Dialysis Decubitus left lateral decubitus
Minerals and water soluble vitamins Increase Supplements
Fetal Assessment Every session, esp at the end of session
UF & Dry weight Assessment Assess regularly Big challenge
49. Pregnant CKD 5D
Dialysis Prescription
Intensive HD: average dialysis time of
more than 20-24 hours per week
or
switching to long nightly dialysis
Target: Urea < 50 mg/dL
or even < 45 mg/dL
What is the Evidence?
Gianfranco Manisco et al. Clin Kidney J, 0: 1–7, 2015
Nadeau-Fredette et al. Advances in Chronic Kidney Disease, Vol 20, No 3 (May), pp 246-252, 2013.
Duration, Frequency
& Efficacy
50. Pregnant CKD 5D
Dialysis Prescription
Nocturnal dialysis program.
All women conceived during chronic NHD treatment after a
NHD vintage of 3 ± 2 years.
None of them had conceived during previous conventional HD.
Canada: Clin JAmSoc Nephrol. 2008;3(2):392-396.
Singapore: Int J Gynaecol Obstet. 2006;94(1):17-22.
Duration, Frequency
& Efficacy
France: Nephrologie. 2004;25(7):287-292.
Italy: Ren Fail. 2002;24(6):853-862.
51. Pregnant CKD 5D
Dialysis Prescription
Percentage of Living Infants
Spontaneous
Abortion
Neonatal&
InfantDeath
Preterm
Preterm
IUGR
IUGR
IUGR
Duration, Frequency
& Efficacy
Preterm
Preterm
Stillbirth
Canada: Clin JAmSoc Nephrol. 2008;3(2):392-396.
Singapore: Int J Gynaecol Obstet. 2006;94(1):17-22.
IUGR not reported
France: Nephrologie. 2004;25(7):287-292.
Italy: Ren Fail. 2002;24(6):853-862.
52. Pregnant CKD 5D
Dialysis Prescription
Percentage of Pre-eclampsia
Not Reported
Duration, Frequency
& Efficacy
Canada: Clin JAmSoc Nephrol. 2008;3(2):392-396.
Singapore: Int J Gynaecol Obstet. 2006;94(1):17-22.
France: Nephrologie. 2004;25(7):287-292.
Italy: Ren Fail. 2002;24(6):853-862.
54. Pregnant CKD 5D
Dialysis Prescription
Item How to deal with?
Duration, Frequency & Efficacy >24h/w, Urea<50
Dialysate K 3mEq/L
Dialysate Bicarbonate 25mEq/L
Ca, Pi & PTH balance Ca 1.75-2.5mmol/L,↑ dialysate P
Dialysate Na 135mEq/L
Heparnization heparin if no vaginal bleeding
Blood Flow Gradual increase
High vs Low flux ??
AVF Cannulation Rope Ladder
Dialysis Decubitus left lateral decubitus
Minerals and water soluble vitamins Increase Supplements
Fetal Assessment Every session, esp at the end of session
UF & Dry weight Assessment Assess regularly Big challenge
55. Pregnant CKD 5D
Dialysis Prescription
The potassium
concentration in dialysate
must also be adjusted to
reflect the more intensive
HD regimen,
Gianfranco Manisco et al. Clin Kidney J, 0: 1–7, 2015
Nadeau-Fredette et al. Advances in Chronic Kidney Disease, Vol 20, No 3 (May), 2013
usually with a
concentration of
3.0 mEq/L.
Dialysate K
56. Pregnant CKD 5D
Dialysis Prescription
↑ circulating progesterone
Gianfranco Manisco et al. Clin Kidney J, 0: 1–7, 2015
Nadeau-Fredette et al. Advances in Chronic Kidney Disease, Vol 20, No 3 (May), pp 246-252, 2013.
Relative hyperventilation
Mild respiratory alkalosis
Subsequent reduction in
serum bicarbonate of
approximately
4 mEq/L
To ensure the physiologic
expression of respiratory alkalosis
that is associated with pregnancy,
dialysate bicarbonate usually
reduced to 25 mEq/L to maintain
serum bicarbonate in the usual
pregnancy range of 18 to 22
mmol/l
Normal Pregnancy Physiology
Dialysate
Bicarbonate
57. Pregnant CKD 5D
Dialysis Prescription
Intensive dialysis and increased
phosphate requirements for fetal
bone formation
Decrease S.Phosphate levels
(hypophosphatemia)
Phosphate levels need to be
monitored frequently
Supplement with
oral phosphate
increased dialysate
phosphate
Tennankore KK et al.. Nat Rev Nephrol. 8(9):515-522, 2012.
Stop phosphate
binders
Dialysate P
58. Pregnant CKD 5D
Dialysis Prescription
Increase dialysate
calcium to 1.75 -
2.5 mmol/L
Predialysis and postdialysis calcium
levels should be measured to avoid
hyper- and hypocalcaemia
oral calcium
(1.5-2g/d)
Gianfranco Manisco et al. Clin Kidney J, 0: 1–7, 2015
BaruaM et al. Clin JAmSoc Nephrol. 3(2):392-396, 2008
Take care of Hypercalcemia
Occasionally placental
production of vitamin D–like substances and PTHrP
Dialysate Ca
59. Pregnant CKD 5D
Dialysis Prescription
Vit D
Occasionally placental
production of vitamin D–like substances and PTHrP
60. Pregnant CKD 5D
Dialysis Prescription
Item How to deal with?
Duration, Frequency & Efficacy >24h/w, BUN<50
Dialysate K 3mEq/L
Dialysate Bicarbonate 25mEq/L
Ca, Pi & PTH balance Ca 1.75-2.5mmol/L,↑ dialysate P
Dialysate Na 135mEq/L
Heparnization heparin if no vaginal bleeding
Blood Flow Gradual increase
High vs Low flux ??
AVF Cannulation Rope Ladder
Dialysis Decubitus left lateral decubitus
Minerals and water soluble vitamins Increase Supplements
Fetal Assessment Every session, esp at the end of session
UF & Dry weight Assessment Assess regularly Big challenge
61. Pregnant CKD 5D
Dialysis Prescription
Dialysate Na
J Prakash . Indian Journal of Nephrology, Vol. 22, No. 3, May-June, 2012
Gianfranco Manisco et al. Clin Kidney J, 0: 1–7, 2015
Reduction in serum sodium during pregnancy
necessitates a concomitant reduction in dialysate
sodium concentration to around 135 mmol/l.
62. Pregnant CKD 5D
Dialysis Prescription
Item How to deal with?
Duration, Frequency & Efficacy >24h/w, BUN<50
Dialysate K 3mEq/L
Dialysate Bicarbonate 25mEq/L
Ca, Pi & PTH balance Ca 1.75-2.5mmol/L,↑ dialysate P
Dialysate Na 135mEq/L
Heparnization heparin if no vaginal bleeding
Blood Flow Gradual increase
High vs Low flux ??
AVF Cannulation Rope Ladder
Dialysis Decubitus left lateral decubitus
Minerals and water soluble vitamins Increase Supplements
Fetal Assessment Every session, esp at the end of session
UF & Dry weight Assessment Assess regularly Big challenge
63. Pregnant CKD 5D
Dialysis Prescription
Dialysis heparin
requirements are often
increased because
of the hypercoagulable
state of pregnancy
(this is not the situation for every
pregnant woman and is assessed by
monitoring dialysis adequacy and
dialyser clotting)
Piccoli GB et al. Clin J Am Soc Nephrol. 5(1):62, 2010.
Smith WT et al. Int Urol Nephrol. 37(1): 145–51, 2005.
Heparinization should be
minimal to prevent
obstetric bleeding.
It is safe to use heparin whenever there is no vaginal
bleeding.
Heparnization
64. Pregnant CKD 5D
Dialysis Prescription
Item How to deal with?
Duration, Frequency & Efficacy >24h/w, BUN<50
Dialysate K 3mEq/L
Dialysate Bicarbonate 25mEq/L
Ca, Pi & PTH balance Ca 1.75-2.5mmol/L,↑ dialysate P
Dialysate Na 135mEq/L
Heparnization heparin if no vaginal bleeding
Blood Flow Gradual increase
High vs Low flux ??
AVF Cannulation Rope Ladder
Dialysis Decubitus left lateral decubitus
Minerals and water soluble vitamins Increase Supplements
Fetal Assessment Every session, esp at the end of session
UF & Dry weight Assessment Assess regularly Big challenge
65. Pregnant CKD 5D
Dialysis Prescription
At each HD session, blood
flow gradually increased over
1st 30 minutes of HD, from
180 to 300 ml/min
Blood Flow
66. Pregnant CKD 5D
Dialysis Prescription
Item How to deal with?
Duration, Frequency & Efficacy >24h/w, BUN<50
Dialysate K 3mEq/L
Dialysate Bicarbonate 25mEq/L
Ca, Pi & PTH balance Ca 1.75-2.5mmol/L,↑ dialysate P
Dialysate Na 135mEq/L
Heparnization heparin if no vaginal bleeding
Blood Flow Gradual increase
Filter Flux & S.A. ??
AVF Cannulation Rope Ladder
Dialysis Decubitus left lateral decubitus
Minerals and water soluble vitamins Increase Supplements
Fetal Assessment Every session, esp at the end of session
UF & Dry weight Assessment Assess regularly Big challenge
72. Pregnant CKD 5D
Dialysis Prescription
Item How to deal with?
Duration, Frequency & Efficacy >24h/w, BUN<50
Dialysate K 3mEq/L
Dialysate Bicarbonate 25mEq/L
Ca, Pi & PTH balance Ca 1.75-2.5mmol/L,↑ dialysate P
Dialysate Na 135mEq/L
Heparnization heparin if no vaginal bleeding
Blood Flow Gradual increase
Filter Flux & S.A. High flux, Low S.A.
AVF Cannulation Rope Ladder
Dialysis Decubitus left lateral decubitus
Minerals and water soluble vitamins Increase Supplements
Fetal Assessment Every session, esp at the end of session
UF & Dry weight Assessment Assess regularly Big challenge
73. Pregnant CKD 5D
Dialysis Prescription
AVF
Cannulation
Risk for vascular access
dysfunction because of increased
frequency of dialysis
Avoided by rotating the needle
sites using rope ladder
technique
74. Pregnant CKD 5D
Dialysis Prescription
Item How to deal with?
Duration, Frequency & Efficacy >24h/w, BUN<50
Dialysate K 3mEq/L
Dialysate Bicarbonate 25mEq/L
Ca, Pi & PTH balance Ca 1.75-2.5mmol/L,↑ dialysate P
Dialysate Na 135mEq/L
Heparnization heparin if no vaginal bleeding
Blood Flow Gradual increase
Filter Flux & S.A. High flux, Low S.A.
AVF Cannulation Rope Ladder
Dialysis Decubitus left lateral decubitus
Minerals and water soluble vitamins Increase Supplements
Fetal Assessment Every session, esp at the end of session
UF & Dry weight Assessment Assess regularly Big challenge
75. Pregnant CKD 5D
Dialysis Prescription
Dialysis in left lateral
decubitus position
Dialysis
Decubitus
St George Hospital, Renal Department Guidelines for Pregnancy & Dialysis,
2013.
Gianfranco Manisco et al. Clin Kidney J, 0: 1–7, 2015
76. Pregnant CKD 5D
Dialysis Prescription
Item How to deal with?
Duration, Frequency & Efficacy >24h/w, BUN<50
Dialysate K 3mEq/L
Dialysate Bicarbonate 25mEq/L
Ca, Pi & PTH balance Ca 1.75-2.5mmol/L,↑ dialysate P
Dialysate Na 135mEq/L
Heparnization heparin if no vaginal bleeding
Blood Flow Gradual increase
Filter Flux & S.A. High flux, Low S.A.
AVF Cannulation Rope Ladder
Dialysis Decubitus left lateral decubitus
Minerals and water soluble vitamins Increase Supplements
Fetal Assessment Every session, esp at the end of session
UF & Dry weight Assessment Assess regularly Big challenge
77. Pregnant CKD 5D
Dialysis Prescription
Gianfranco Manisco et al. Clin Kidney J, 0: 1–7, 2015
Stover J. Adv Chronic Kidney Dis. 14(2):212-214, 2007.
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
Minerals and
water soluble
vitamins
78. Pregnant CKD 5D
Dialysis Prescription
Item How to deal with?
Duration, Frequency & Efficacy >24h/w, BUN<50
Dialysate K 3mEq/L
Dialysate Bicarbonate 25mEq/L
Ca, Pi & PTH balance Ca 1.75-2.5mmol/L,↑ dialysate P
Dialysate Na 135mEq/L
Heparnization heparin if no vaginal bleeding
Blood Flow Gradual increase
Filter Flux & S.A. High flux, Low S.A.
AVF Cannulation Rope Ladder
Dialysis Decubitus left lateral decubitus
Minerals and water soluble vitamins Increase Supplements
Fetal Assessment Every session, esp at the end of session
UF & Dry weight Assessment Assess regularly Big challenge
79. Pregnant CKD 5D
Dialysis Prescription
Gianfranco Manisco et al. Clin Kidney J, 0: 1–7, 2015
Careful uterine and fetal
monitoring during
hemodialysis
Assessment of the fetal
heart rate
(particularly during the last
portion of a session)
Fetal
Assessment
80. Pregnant CKD 5D
Dialysis Prescription
Item How to deal with?
Duration, Frequency & Efficacy >24h/w, BUN<50
Dialysate K 3mEq/L
Dialysate Bicarbonate 25mEq/L
Ca, Pi & PTH balance Ca 1.75-2.5mmol/L,↑ dialysate P
Dialysate Na 135mEq/L
Heparnization heparin if no vaginal bleeding
Blood Flow Gradual increase
Filter Flux & S.A. High flux, Low S.A.
AVF Cannulation Rope Ladder
Dialysis Decubitus left lateral decubitus
Minerals and water soluble vitamins Increase Supplements
Fetal Assessment Every session, esp at the end of session
UF & Dry weight Assessment Assess regularly Big challenge
81. Pregnant CKD 5D
Dialysis Prescription
What is the importance of maintaining adequate
intravascular volume?
Avoid dialysis hypotension and
volume contraction which may
result in hemodynamic
compromise, reduced
uteroplacental perfusion, and
premature labor.
Preservation of GFR
and good pregnancy
outcome for mother
and baby
Piccoli GB et al. Clin J Am Soc Nephrol. 5(1):62, 2010.
UF & Dry weight
Assessment
82. Pregnant CKD 5D
Dialysis Prescription
Body weight gain
1 to 2 kg during
the first three
months
Institute of Medicine and National Research Council. Weight Gain During Pregnancy:
Reexamining the Guidelines. The National Academies Collection: Reports Funded by
National Institutes of Health. Washington, DC: National Academies Press; 2009.
then
0.5 kg a week
during the rest of
pregnancy
Normal body
weight gain
in pregnancy
UF & Dry weight
Assessment
How to assess intravascular volume in
pregnancy?
Tools to asses intravascular volume during
pregnancy
83. Pregnant CKD 5D
Dialysis Prescription
Blood pressure
out of target
Respiratory
compromiseClinical signs
of
hypervolemia
Edema is an
unhelpful sign in
pregnancy
Nadeau-Fredette et al. Advances in Chronic Kidney Disease, Vol 20, No 3 (May), pp 246-252, 2013.
UF & Dry weight
Assessment
How to assess intravascular volume in
pregnancy?
Tools to asses intravascular volume during
pregnancy
84. Pregnant CKD 5D
Dialysis Prescription
Measure
Hematocrit &
Albumin at the
initial first-
trimester visit.
A rise in either
value strongly
suggests
intravascular
volume
contraction.
Hematocrit
& Albumin
levels
Opposite is not true
UF & Dry weight
Assessment
How to assess intravascular volume in
pregnancy?
Tools to asses intravascular volume during
pregnancy
85. Pregnant CKD 5D
Dialysis Prescription
Item How to deal with?
Duration, Frequency & Efficacy >24h/w, BUN<50
Dialysate K 3mEq/L
Dialysate Bicarbonate 25mEq/L
Ca, Pi & PTH balance Ca 1.75-2.5mmol/L,↑ dialysate P
Dialysate Na 135mEq/L
Heparnization heparin if no vaginal bleeding
Blood Flow Gradual increase
Filter Flux & S.A. High flux, Low S.A.
AVF Cannulation Rope Ladder
Dialysis Decubitus left lateral decubitus
Minerals and water soluble vitamins Increase Supplements
Fetal Assessment Every session, esp at the end of session
UF & Dry weight Assessment Assess regularly Big challenge
86. Normal Physiological Renal Changes during Pregnancy
Reproductive and sexual dysfunction in uremic women
CKD – Pregnancy Relationship
Effect of CKD on Pregnancy Effect of Pregnancy on CKD
CKD Classification in Pregnancy
Pre-Pregnancy Counseling in
CKD
General Principles of
Antenatal Care & Management
CKD ND CKD 5D
When to dialyse? Dialysis Regimen & Precautions
87. It is generally recommended to commence
dialysis at
eGFR 20 ml/min
Urea 50 mg/dl
S.Cr 3.5-5 mg/dl
- Gianfranco Manisco et al. Clin Kidney J, 0: 1–7, 2015
- Asamiya Y et al. Kidney Int. 75;1217-1222, 2009.
Pregnant CKD ND
When to Initiate Dialysis?
Better outcomes of pregnancy. May reduce incidence of
polyhydramnios, lower urea and lowers water load, also
reducing risk of dialysis-induced hypotension.
90. Normal Physiological Renal Changes during Pregnancy
Reproductive and sexual dysfunction in uremic women
CKD – Pregnancy Relationship
Effect of CKD on Pregnancy Effect of Pregnancy on CKD
CKD Classification in Pregnancy
Pre-Pregnancy Counseling in
CKD
General Principles of
Antenatal Care & Management
CKD ND CKD 5D
When to dialyse? Dialysis Regimen & Precautions
When to Terminate
Pregnancy
91. Mark A. Brown. Comprehensive Clinical Nephrology. 5th
edition, chapter 45, 2015
When to Terminate
Pregnancy?
92. Normal Physiological Renal Changes during Pregnancy
Reproductive and sexual dysfunction in uremic women
CKD – Pregnancy Relationship
Effect of CKD on Pregnancy Effect of Pregnancy on CKD
CKD Classification in Pregnancy
Pre-Pregnancy Counseling in
CKD
Contraception
in Childbearing Age
General Principles of
Antenatal Care & Management
CKD ND CKD 5D
When to dialyse? Dialysis Regimen & Precautions
When to Terminate
Pregnancy
93. Contraception
Kavitha Vellanki. Advances in Chronic Kidney Disease, Vol 20, No 3 (May), 2013
Sexually active women who have normal periods
should use contraception if they do not wish to
become pregnant (esp if S.Cr > 3g/dl)
Although the frequency of conception in dialysis
patients is low
Contraception is advisable because of poor
pregnancy outcomes with advanced CKD
Complications of pregnancy are higher than
those of using oral contraceptives.
94. Contraception
Oral contraceptives is safe in most dialysis
patients, but these drugs should be avoided in
patients with lupus and patients with problems of
clotting vascular access.
Which Method to Use?
Intrauterine devices may be associated with
increased bleeding because of heparin use with
hemodialysis.
Commonly used barrier methods of
contraception are safe.
Kavitha Vellanki. Advances in Chronic Kidney Disease, Vol 20, No 3 (May), 2013
96. Diagnosis of Pregnancy
in Dialysis Patients
A high degree of suspicion is
required to make the diagnosis
of pregnancy
Difficult to Diagnose !!
Amenorrhea is frequent in CKD 5D
Nausea, vomiting, fatigue & soft
signs of pregnancy are often
attributed to the kidney condition,
volume overload & erythropoietin
deficiency.
Because beta HCG is removed by
the kidney, beta HCG levels are
higher at each stage of gestation
than in women with normal renal
function.
Borderline positive HCG levels can
be seen in nonpregnant CKD 5D.
The stage of gestation must
be determined by
ultrasound
Gianfranco Manisco et al. Clin Kidney J, 0: 1–7, 2015
Buckner CL et al. Ann Clin Lab Sci. 37(2):186-191, 2007.
98. Repeat pregnancies in women who become pregnant on
dialysis are not uncommon.
(In the 318 women whose pregnancies are recorded by the National
Registry for Pregnancy in Dialysis Patients (NPDR), eight women
became pregnant twice, eight women became pregnant three times,
and one woman conceived four times.)
Most pregnancies occur during first few years on dialysis,
but conception rates as a function of time on dialysis have
not been determined.
Pregnancy has occurred in women who have
been on dialysis for as long as 20 years.
Pregnancy in Dialysis
When? How many times?
Hou S. Am J Kidney Dis. 33(2):235, 1999.
101. Problem How to manage?
Hypertension Target BP 110-140/80-90 mmHg
Anemia Maintain Hemoglobin 10–11 g/dl
Folic acid
for every pregnant woman
(5 mg daily if on dialysis)
Aspirin (75–150 mg/day)
creatinine > 1.5 mg/dl
previous pregnancy complications
Heparin
Nephrotic Syndrome
Serum Albumin of <2.5 g/l
Protein Diet 1 g/kg/day + 20 g/day
Urinary tract infection
Early identification &
management
Assessment of fetal well-being Regular Assessment
Superimposed preeclampsia Difficult Challenge !!!
General Principles of
Prenatal Care & Management
102. Dialysis Prescription
Item How to deal with?
Duration, Frequency & Efficacy >24h/w, Urea<50
Dialysate K 3mEq/L
Dialysate Bicarbonate 25mEq/L
Ca, Pi & PTH balance Ca 1.75-2.5mmol/L,↑ dialysate P
Dialysate Na 135mEq/L
Heparnization heparin if no vaginal bleeding
Blood Flow Gradual increase
Filter Flux & S.A. High flux, Low S.A.
AVF Cannulation Rope Ladder
Dialysis Decubitus left lateral decubitus
Minerals and water soluble vitamins Increase Supplements
Fetal Assessment Every session, esp at the end of session
UF & Dry weight Assessment Assess regularly Big challenge
103. It is generally recommended to commence
dialysis at
eGFR 20 ml/min
Urea 50 mg/dl
S.Cr 3.5-5 mg/dl
Pregnant CKD ND
When to Initiate Dialysis?
104. Mark A. Brown. Comprehensive Clinical Nephrology. 5th
edition, chapter 45, 2015
When to Terminate
Pregnancy?
106. Contraception
Sexually active women who have normal periods
should use contraception if they do not wish to
become pregnant (esp if S.Cr > 3g/dl)
Contraception is advisable because of poor
pregnancy outcomes with advanced CKD