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Chronic renal disease and antenatal care

https://doi.org/10.1016/j.bpobgyn.2018.10.002Get rights and content

Highlights

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    Maternal and foetal outcomes for women with CKD have markedly improved.

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    Pre-pregnancy counselling is crucial in preparing for women with CKD for pregnancy. Multidisciplinary team care is critical for a positive patient experience.

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    Medication management includes discontinuation of potentially teratogenic treatments well in advance of a planned pregnancy, notably mycophenolate.

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    Enhanced monitoring during pregnancy is required for women with all stages of CKD.

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    Pregnant women receiving dialysis and transplant recipients need specialist care.

Abstract

In 2018, it is unusual for women with chronic kidney disease (CKD) to be told that pregnancy is not an option. Maternal and foetal outcomes have steadily improved over the last 50 years and a successful pregnancy, resulting in a healthy infant without detrimental to maternal health, is commonplace. Nevertheless, the incidence of adverse outcomes including pre-eclampsia, preterm birth and small-for-gestational age infants is higher for women with CKD than the general population, requiring enhanced monitoring. Furthermore, as women with more advanced renal disease including dialysis recipients are supported in contemplating pregnancy, the importance of an experienced multidisciplinary team (MDT) has become crucial. Pre-pregnancy planning underpins optimisation of pregnancy outcomes.

Introduction

The decision to start a family can be accompanied by a sense of apprehension and this is particularly true for patients with chronic medical conditions. For women with chronic kidney disease (CKD), concerns over the impact of pregnancy on their own health, and CKD on a pregnancy, can accentuate their anxiety.

There have been marked improvements in pregnancy outcomes for women with CKD over the last 50 years, meaning that it is unusual to recommend that women with CKD avoid becoming pregnant (Fig. 1) [1]. Nevertheless, risks of adverse maternal and infant outcomes are higher than in the general population, across the spectrum of severity of renal disease. Pre-pregnancy counselling and additional antenatal care are indicated to optimise outcomes.

Section snippets

Defining chronic kidney disease

CKD is defined as decreased excretory renal function, haematuria or proteinuria persisting for more than 3 months, anatomical abnormalities (such as reflux nephropathy or renal dysgenesis), or genetic variants associated with renal disease (such as Alport syndrome or polycystic kidney disease). Outside of pregnancy, severity of CKD can be staged based on estimated glomerular filtration rate (GFR) and urine albumin excretion rate, usually quantified by a urine albumin:creatinine ratio (uACR).

Pre-pregnancy counselling

Consensus statements published in 2018 recommend that women with CKD should be offered pre-pregnancy counselling by a MDT including an obstetrician, renal/obstetric physician and a specialist midwife [4]. Counselling is not always possible because pregnancy may not be a planned event; however, the aims of pre-pregnancy counselling are to:

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    discuss optimal timing for a planned pregnancy

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    assess and optimise disease stability

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    change agents that are not safe or ideal for use in pregnancy

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    outline the

Antenatal care

Confirmation of successful pregnancy is usually straightforward in women with CKD and preserved renal function. For women with advanced CKD, including those requiring dialysis, serum beta-human chorionic gonadotrophin (β-HCG) levels are elevated as compared to healthy controls at equivalent gestational age due to diminished urinary clearance [54], [55]. This is of clinical significance when a serum β-HCG suggesting 8 weeks gestation is not confirmed by an identified foetal heart rate on

Dialysis and pregnancy

It is rare for patients receiving dialysis to become pregnant because of patient choice, impaired fertility (see Fig. 2) and reduced libido [65]. There are less than 200 pregnancies reported worldwide in women receiving peritoneal dialysis [66], however, the possibility of pregnancy with haemodialysis is no longer inconceivable.

For most women receiving dialysis, the best chance of a successful pregnancy would follow successful renal transplantation. If this is not feasible (due to urological

Renal transplantation and pregnancy

The general principles of managing pregnancy in a renal transplant recipient are the same as for any women with CKD – close attention to fluid status, blood pressure, proteinuria and foetal growth with optimisation of timing of delivery.

Standard care should be supplemented by consideration of the following:

Conflicts of interest

Nil.

Acknowledgements

This work was supported by a grant from Nottingham Hospitals Charity.

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