Pregnancy and Transplantion

Women with end stage kidney disease have hypothalmic gonadal dysfunction and infertility. Infertility also occurs with end-stage disease of other organs such as heart, liver and lung.

However, there is still a risk of unwanted pregnancy and so all women with end-stage organ disease who are of child bearing age need effective contraception.

Within the first months after transplantation, gondal dysfunction rapidly reverses, and female fertility returns, conferring a substantial possibility of conception.

Most transplantation centres have advised that conception is safe after the second post-transplantation year, on the assumption that the graft function well. A consensus conference held by the Women's Health Committee of American Society of Transplantation in 2003 concluded that pregnancy is usually safe after the first year, provided that allograft function is stable and that no rejection episodes have occurred in the year before conception.

Pregnancy after transplantation should be considered a high-risk pregnancy and should be monitored by both an obstetrician and the transplant physician.

Pregnancy should be diagnosed as early as possible.

The principal risks are infection, proteinuria, anaemia, arterial hypertension and acute rejection for the mother, and prematurity and low birth weight for the foetus.

Pregnant women and transplanted patients are at increased risk of infections, especially bacterial urinary tract infections and acute pyelonephritis of the graft.

Urine cultures should be performed monthly and all asymptomatic infections should be treated. Monitoring of viral infections is also recommended.

Acute rejection episodes are uncommon but may occur after delivery. Therefore, immunosuppression should be re-adjusted immediately after delivery.

Because pre-eclampsia develops in 30% of pregnant patients, especially those with prior arterial transplant hypertension, blood pressure, renal function, proteinuria and weight should be monitored every 2-4 weeks, with more attention during the third trimester. Anti-hypertensive agents should be changed to those tolerated during pregnancy. ACE inhibitors and angiotensin II receptor antagonists are absolutely contra-indicated.

Immunosuppressive therapy based on cyclosporine or tacrolimus with or without steroids and azathioprine may be continued in renal transplant women during pregnancy. Other drugs, such as mycophenolate mofetil and sirolimus, are not recommended.

Vaginal delivery is recommended, but caesarean section is required in at least 50% of cases. Delivery should occur in a specialized centre.

In the puerperium, renal function, proteinuria, blood pressure, cyclosporine/tacrolimus blood levels and fluid balance should be closely monitored.

Because of drug transfer into maternal milk, breastfeeding is not recommended.