Parenthood following renal transplantation

Problems Associated with Pregnancy in Renal Allograft Recipients

Of 18 pregnancies in 11 renal transplant recipients, three were terminated and in the remaining 15 (in 8 women) there were 10 live births (including one set of twins), five intrauterine deaths, and one spontaneous abortion. Graft function deteriorated in six women, from obstruction of the transplanted ureter in two, recurrent glomerulonephritis in two, rejection in one, and pelvi-ureteric junction obstruction in one. Hypertension worsened or developed in all but one of the pregnancies and proteinuria appeared in eight. Of the 10 live births only one reached 38 weeks gestation (mean 35 weeks) and four neonates were small for gestational age. One infant died early from intraventricular hemorrhage and hyaline membrane disease, one fetus had hydrocephalus, and the others were normal. Factors associated with a poor fetal outcome were deterioration in graft function during pregnancy, pre-existing hypertension, or the development of hypertension before the third trimester

A prospective study in male recipients of kidney transplantation reveals divergent patterns for inhibin B and testosterone secretions

Background

Male patients with chronic kidney disease often exhibit the biological and clinical hallmarks of an abnormal hypothalamo–pituitary–gonadal axis. It is known that dialysis does not reverse this impaired endocrine status; however, the impact of kidney transplantation (KT) is still controversial. The aim of our study was to investigate the levels of serum gonadotropins, testosterone, and inhibin B during dialysis and after KT.

Methods

A longitudinal and prospective single center study was led in an academic setting. Blood hormones levels were assayed by immunoassays in 53 men (mean age: 37 years) receiving dialysis (T₀) and at 6 months post-KT (T₁₈₀). These data were compared with those from 46 fertile semen donors (mean age: 37 years). The main outcome measure was the between-groups differences in hormones levels. A second criterion was the comparison of T₀ and T₁₈₀ hormones levels according to the immunosuppressive regimen.

Results

For patients ongoing dialysis, luteinizing hormone (LH) and follicle-stimulating hormone (FSH) mean levels were high, whereas testosterone and inhibin B mean levels remained normal. After KT, LH levels returned to normal whereas FSH was significantly increased. Testosterone levels remained normal whereas inhibin B levels significantly decreased. We found that the combination tacrolimus plus mycophenolic acid significantly decreased post-KT inhibin B levels. Moreover, we found that pre-graft inhibin-B level was independent of testosterone and could predict low post-operative inhibin B level with a sensitivity of 77% and a specificity of 92%.

Conclusions

Our study suggests that endocrine secretions of Leydig and Sertoli cells are differently impacted by dialysis, KT and immunosuppressive regimen raising new issues to explore.

Anesthesia for parturient with renal transplantation

Management of successful pregnancy after renal transplantation is a unique challenge to nephrologist, obstetrician, and anesthesiologist, as these patients have altered physiology and are immune-compromised. We present the anesthetic management of three postrenal transplant patients scheduled for cesarean section. While conducting such cases, cardiovascular status, hematological status, and function of transplanted kidney should be assessed thoroughly. Side effects of immunosuppressant drugs and their interaction with anesthetic agents should be taken into consideration. Main goal of anesthetic management is to maintain optimum perfusion pressure of renal allograft to preserve its function.

Female patients suffering from inflammatory bowel diseases are treated less frequently with immunosuppressive medication and have a higher disease activity: a subgroup analysis of a large multi-centre, prospective, internet-based study

BACKGROUND

The introduction of immunosuppressants and biologic agents has led to active debate and research about optimal therapeutic strategies considering risk factors and predictors of clinical outcome in inflammatory bowel disease (IBD). Data about gender-specific treatment differences and risk factors is lacking for IBD. The aim of the present study was to evaluate gender-related differences in the treatment of a distinct IBD patient population treated in the Rhein-Main region, Germany.

METHODS

Data about past medical history, disease status and medical treatment of 986 outpatients treated in ten gastroenterological practices and three hospitals were collected from November 1st 2005-July 31st 2007 and analyzed with regard to gender-related differences in therapy and disease management.

RESULTS

With the exception of an extended disease duration in women, no significant gender-related differences in demographic and clinical characteristics were observed. Men showed a significantly higher remission rate than women (p=0.025), while women received significantly less immunosuppressive medication compared to men (p=0.011). In addition, treatment with immunosuppressants was not different in women with child-bearing potential compared to menopausal women.

CONCLUSION

Our investigation demonstrates for the first time gender-specific differences in the therapeutic management in a large cohort of IBD patients.

Safety of immunomodulators and biologics for the treatment of inflammatory bowel disease during pregnancy and breast-feeding

The aim of this article is to critically review available data regarding the safety of immunomodulators and biological therapies during pregnancy and breast-feeding in women with inflammatory bowel disease. Methotrexate and thalidomide can cause congenital anomalies and are contraindicated during pregnancy (and breast-feeding). Although thiopurines have a Food and Drug Administration (FDA) rating D, available data suggest that these drugs are safe and well tolerated during pregnancy. Although traditionally women receiving azathioprine or mercaptopurine have been discouraged from breast-feeding because of theoretical potential risks, it seems that these drugs may be safe in this scenario. Treatment with cyclosporine for steroid-refractory ulcerative colitis (UC) during pregnancy can be considered safe and effective, and the use of this drug should be considered in cases of severe UC as a means of avoiding urgent surgery. Breast-feeding is contraindicated for patients receiving cyclosporine. Biological therapies appear to be safe in pregnancy, as no increased risk of malformations has been demonstrated. Therefore, the limited clinical results available suggest that the benefits of infliximab and adalimumab in attaining response and maintaining remission in pregnant patients might outweigh the theoretical risks of drug exposure to the fetus. Stopping therapy in the third trimester may be considered, as it seems that transplacental transfer of infliximab is low prior to this. Certolizumab differs from infliximab and adalimumab in that it is a Fab fragment of an antitumor necrosis factor alpha monoclonal antibody, and therefore it may not be necessary to stop certolizumab in the third trimester. The use of infliximab is probably compatible with breast-feeding.

Early pregnancy azathioprine use and pregnancy outcomes

BACKGROUND

Azathioprine (AZA) is used during pregnancy by women with inflammatory bowel disease (IBD), other autoimmune disorders, malignancy, and organ transplantation. Previous studies have demonstrated potential risks.

METHODS

The Swedish Medical Birth Register was used to identify 476 women who reported the use of AZA in early pregnancy. The effect of AZA exposure on pregnancy outcomes was studied after adjustment for maternal characteristics that could act as confounders.

RESULTS

The most common indication for AZA use was IBD. The rate of congenital malformations was 6.2% in the AZA group and 4.7% among all infants born (adjusted OR: 1.41, 95% CI: 0.98-2.04). An association between early pregnancy AZA exposure and ventricular/atrial septal defects was found (adjusted OR: 3.18, 95% CI: 1.45-6.04). Exposed infants were also more likely to be preterm, to weigh <2500 gm, and to be small for gestational age compared to all infants born. This effect remained for preterm birth and low birth weight when infants of women with IBD but without AZA exposure were used as a comparison group. A trend toward an increased risk of congenital malformations was found among infants of women with IBD using AZA compared to women with IBD not using AZA (adjusted OR: 1.42, 95% CI: 0.93-2.18).

CONCLUSIONS

Infants exposed to AZA in early pregnancy may be at a moderately increased risk of congenital malformations, specifically ventricular/atrial septal defects. There is also an increased risk of growth restriction and preterm delivery. These associations may be confounded by the severity of maternal illness.

Outcome of pregnancy following renal transplantation

Fertility is restored following renal transplantation, and the potential for motherhood can be realised. This retrospective study reviews the outcome of 53 pregnancies, in 24 patients, between 1988 and 1995. All patients underwent transplant surgery, and received antenatal care at a single centre. The mean age at first conception was 27.6 years, and graft function, as assessed by serum creatinine at the time of antenatal booking, was good. Patients were referred early, seen regularly, and had both obstetrician and nephrologist involved in management. The main maternal complication was hypertension, affecting 50% of patients. Seven patients had a worsening of pre-existing hypertension, whilst four patients developed hypertension for the first time during pregnancy. Graft function was, for the most part, well maintained. Four patients required delivery because of declining renal function, two of these went on to develop frank rejection, necessitating a return to dialysis within 3 months of delivery. These figures however are not higher than have been reported in the non-pregnant population. The overall pregnancy loss was 26%. There were a total of 39 live births. Premature birth was higher than that of the general population, with 57% of infants in the study delivering before 37 weeks' gestation (average 34 weeks' gestation) Of the 39 infants born alive 27% were growth retarded. Congenital abnormalities were, reassuringly, no higher than that in the general population, despite the need to take immunosuppressive drugs. Delivery was by caesarean section in 64% of cases, which may reflect a high degree of clinical caution in this group of patients. The study concludes that, whilst risks are recognised, for both the mother and infant, with a careful, multidisciplinary approach, the outcome is generally good.

Renal disease in pregnancy

There is an intimate relationship between the kidney and pregnancy. Renal plasma flow increases by 50–70% during a normal pregnancy and the glomerular filtration rate by about 50%.1These changes commence in the first trimester and fall in the last trimester reaching normal levels within about four weeks postpartum. These physiological changes are accompanied by striking anatomical changes which consist of dilatation of the ureter, pelvis and calyces, together with an increase in renal parenchymal size. The dilatation i s more marked on the right and may appear in the first trimester. At term, 90% of pregnant women show this change.2

Pregnancy outcome of women exposed to azathioprine during pregnancy

BACKGROUND

Azathioprine (AZP) interferes with nucleic acid synthesis and is teratogenic in animals. In view of the paucity of information on the use of AZP during pregnancy we investigated this subject in a prospective, controlled, multicenter study. Our objective was too determine whether exposure to AZP during pregnancy increases the risk for major malformations and to determine the effect on pregnancy outcome.

METHODS

Pregnant women on AZP who contacted one of seven teratogen information services were compared to a cohort of pregnant women who contacted two of the seven teratogen information services and took nonteratogenic treatments during their pregnancy.

RESULTS

Follow-up was completed on 189 women in the AZP group and compared to 230 women in the control group. The rate of major malformations did not differ between groups with six neonates in each; the AZP rate was 3.5% and the control group rate was 3.0% (p = .775; OR 1.17; CI: 0.37, 3.69). The mean birth weight and gestational age were lower in the AZP group (2,995 g vs. 3,252 g [p = .001, difference of mean: 257, 95% CI: 106.3, 408.1] and 37.8 weeks vs. 39.1 weeks [p = .001, difference of mean: 1.3, 95% CI: .5, 2.0], respectively). The AZP group had more cases of prematurity (21.4% vs. 5.2% [p < .001; OR 4.0; 95% CI: 2.0, 8.06]) and low birth weight (23% vs. 6.0% [p < .001; OR 3.81; 95% CI: 2.0, 7.2]).

CONCLUSIONS

These results suggest that AZP (50-100 mg/day) does not triple the rate of birth defects; however, it is associated with lower birth weight, gestational age, and prematurity. Larger studies are needed to confirm these observations.

Considerations in the medical management of pregnancy in transplant recipients

Pregnancy, although rare in the patient with end-stage renal disease, is not uncommon in the transplant recipient. Physicians taking care of transplant recipients must be able to inform patients about the potential risks of pregnancy in this setting. The patient and her partner must know that the risks associated with pregnancy increase with worsening kidney function and hypertension. Current consensus opinion is that pregnancy can be relatively safely undertaken by 1 year after transplant if the patient has had no rejections during the year, allograft function is adequate, there are no infections that could affect the fetus, the patient is not taking teratogenic medications, and immunosuppressive medication dosing is stable. Consideration must be given to immunosuppression during pregnancy both with respect to the specific agents as well as the level of dosing. None of the medications are FDA category A; all are B or higher. Part of planning for pregnancy should include an evaluation of immunosuppression medication and a plan to modify the regimen prior to conception if its use may be risky for the developing fetus. Rejection can occur during a kidney transplant, so maintaining adequate immunosuppression is important. Other issues that need to be managed when caring for a pregnant transplant patient include: potential for infection (urinary tract infections are very common), hypertension, and anemia. The type of delivery, posttransplant contraception, and breast-feeding also need to be addressed.

Human pregnancy safety for agents used to treat rheumatoid arthritis: adequacy of available information and strategies for developing post-marketing data

For female patients with rheumatoid arthritis, the availability of a host of new disease modifying antirheumatic drugs has raised important questions about fetal safety if a woman becomes pregnant while she is being treated. In addition, there is limited safety information regarding many of the older medications commonly used to treat rheumatoid arthritis in women of reproductive age. Current summary pregnancy risk information for selected medications used to treat rheumatoid arthritis is reviewed in the context of the pregnancy label category. In addition, the strengths and weaknesses of post-marketing strategies for developing new pregnancy safety information are described.

Grossesse après transplantation rénale. Suivi obstétrical et retentissement sur le greffon rénal

OBJECTIVE

The aim of this study is to give the results of our experience about pregnancies among the renal transplantation patients and to assess the impact of the pregnancy on renal graft function.

PATIENTS AND METHODS

Twenty pregnancies from 17 renal transplant recipients were analysed and long-term outcome of the renal graft was studied. We analysed the outcomes from clinical and biological data before, during and after pregnancy.

RESULTS

Mean patient age was 30.3+/-3.5 years and meantime between transplantation and the onset of pregnancy was 62.4+/-34.5 months. There was no significant difference between the biological data before and after pregnancy. We did not observe any acute rejection. The mean maternal complications were preeclampsia in 35%, low birth weight in 39%, prematurity in 45% and cesarean sections in 55%. There is no impact of the pregnancy on the renal graft during the follow-up (3 years). The follow-up revealed 2 cases of chronic rejection.

DISCUSSION AND CONCLUSION

A multi-disciplinary approach of pregnancy in renal recipients and an interval of 2 years after kidney transplantation are necessary. There are more complications during pregnancy without increased risks of graft lose.

Species comparison of anatomical and functional immune system development

The components of the immune system have not been traditionally emphasized as potential target organs in standard developmental and reproductive toxicity (DART) protocols. A number of workshops have been organized in recent years to examine scientific questions that underlie developmental immunotoxicity tests, and the interpretation of results as they relate to human risk assessment. A key question that must be addressed is to determine the most appropriate species and strains to model the developing human immune system. The objective of this review is to compare the anatomical and functional development of the immune system in several species important to either preclinical studies for drug development or safety assessments for chemicals, with what is known in humans. The development of the immune system in humans will be compared to what is known in mice, rats, dogs and nonhuman primates.

Pregnancy in renal transplant recipients

Most women of childbearing age who receive a renal transplant have a return of normal menses and have the ability to become pregnant. Most studies indicate that pregnancy does not adversely affect the transplant kidney's survival as long as renal function is good and serum creatinine is stable before pregnancy. The experience with immunosuppressive drugs has been surprisingly reassuring with no increase in congenital anomalies with cyclosporine, prednisone, and azathioprine. There is little experience with newer drugs. Pregnant transplant recipients need to be monitored for opportunistic infections, which may adversely affect the fetus, including herpes, toxoplasmosis, and CMV. Hypertension, urinary tract infections, and anemia are other common problems in pregnant transplant recipients. Despite a high frequency of premature births, over 80% of pregnancies result in surviving infants.

Teratogen update: azathioprine and 6-mercaptopurine

BACKGROUND

Cyclosporine (CsA) therapy must often be continued during pregnancy to maintain maternal health in such conditions as organ transplantation and autoimmune disease. This meta-analysis was performed to determine whether CsA exposure during pregnancy is associated with an increased risk of congenital malformations, preterm delivery, or low birthweight.

METHODS

Various health science databases were searched to identify relevant articles. Articles selected for inclusion in the study were required to be free of any apparent selection bias and report outcomes in at least 10 newborns exposed to CsA in utero, specifically commenting on the presence or absence of congenital malformations. Article selection and data extraction were performed by two independent reviewers, with adjudication in cases of disagreement. To assess risks of CsA exposure, a summary odds ratio was calculated. Prevalence of malformations was calculated as a rate for all cyclosporine-exposed live births and for the subgroups identified. Ninety-five percent confidence intervals were constructed for both the odds ratio and prevalence rates.

RESULTS

Fifteen studies (6 with control groups of transplant without use of cyclosporine; total patients: 410) met the inclusion criteria for major malformations, 10 for preterm delivery (4 with control groups; total patients: 379) and 5 for low birth weight (1 with control groups; total number of patients: 314). The calculated odds ratio of 3.83 for malformations did not achieve statistical significance (CI 0.75-19.6). The overall prevalence of major malformations in the study population (4.1%) also did not vary substantially from that reported in the general population. OR for prematurity [1.52 (CI 1.00-2.32)] did not reach statistical significance although the overall prevalence rate was 56.3%. The OR for low birth weight [1.5 (CI 0.95-2.44 based on 1 study)].

CONCLUSIONS

CsA does not appear to be a major human teratogen. It may be associated with increased rates of prematurity. More research is needed to evaluate whether cyclosporine increases teratogenic risk.

Pregnancy after liver transplantation

The first known posttransplantation pregnancy was in 1958 in a renal transplant recipient who had received a kidney from her identical twin sister. The first known posttransplantation pregnancy in a liver transplant recipient was in 1978. Information available from female kidney transplant recipients helped in the decision making involved in the management of this case, as well as those that followed. Over the last 20 years, issues specific to liver transplantation and pregnancy have been identified. Similar to the kidney transplant recipient population, when prepregnancy recipient graft function is stable and adequate, pregnancy appears to be well tolerated. Also similar to kidney transplant recipients, there has been no evidence of a specific malformation pattern among the children, and although prematurity and low birth weight occur, overall newborn outcomes have been favorable. Pregnancy in the setting of recurrent liver disease, such as recurrent hepatitis C, poses a potential problem among liver transplant recipients, as well as the possible adverse effects of immunosuppression on maternal kidney function. Also of significance, peripartum graft deterioration has more severe consequences in this transplant recipient population. Therefore, pregnancy must be considered carefully in this transplant recipient group. Since 1991, the National Transplantation Pregnancy Registry (NTPR) has studied the safety of pregnancy outcomes in solid-organ transplant recipients. The purpose of this review is to catalog studies in the literature, as well as to present current data from the registry with management guidelines.

Nonhuman primates: their role in assessing developmental effects of immunomodulatory agents

There are close physiologic similarities between humans and macaques that make them well suited for preclinical testing of biopharmaceutics. These include menstrual cycles of similar length and hormonal control, comparable cellular and endocrine processes of implantation, and similar timetables of prenatal development. Three teratogenic agents have induced abnormal development of the macaque thymus that is a key organ in the development of the fetal immune system. Embryonic exposure to triamcinolone acetonide, a potent corticosteroid, during critical periods of thymus development caused marked hypoplasia, depletion of thymic lymphocytes, and reduction of epithelial elements. Aplasia and hypoplasia of the thymus were a distinct feature of the "retinoid syndrome" in cynomolgus macaques following exposure to 13-cis-retinoic acid (Accutane) in early pregnancy, the time of neural crest migration. Experimentally induced zinc deficiency in rhesus macaques from conception to 1-year of age caused severe alterations in immunocompetence. More recent studies have shown that the levels of IgG and IgA in cervicovaginal lavages of the rhesus macaque exhibit specific temporal patterns during the normal menstrual cycle. Taken together, theses data suggest that several macaque species are appropriate animal models for preclinical safety assessment of immunomodulatory drugs. Current teratology protocols in these models may require slight modifications to adequately assess the safety of these biologics.

Treating inflammatory bowel disease during pregnancy: risks and safety of drug therapy

The safety of drug therapy for inflammatory bowel disease during pregnancy is an important clinical concern. Current available information is largely derived from animal studies and clinical experience among patients with inflammatory bowel disease and autoimmune disorders and organ transplant recipients. However, these data are confounded by various factors including difficulty projecting the results of animal studies to humans, methodological deficiencies of some studies, insufficient experience with certain agents, difficulty distinguishing the fetal effects of underlying disease from drug therapy and a need to consider the impact of background rates of adverse fetal outcomes which apply to all pregnancies. In inflammatory bowel disease, the effects of active inflammation on the fetus are believed to be more harmful than those of drug treatment, and therapy is often justified to induce or maintain remission during pregnancy. The choice of appropriate treatment is determined by the severity of the disease and the potential for drug toxicity. No causal relationship has been established between exposure to sulfasalazine or other 5-aminosalicylic acid drugs and the development of congenital malformations. These drugs may be used with relative safety during pregnancy and lactation. Considerable experience with corticosteroids have shown them to pose very small risk to the developing fetus. Current evidence indicates that maternal use of azathioprine is not associated with an increased risk of congenital malformations, though impaired fetal immunity, growth retardation or prematurity is occasionally observed. Preliminary evidence derived from patients with inflammatory bowel disease show no significant fetal toxicity following first trimester exposure to mercaptopurine, though its elective use in pregnancy is controversial. Cyclosporin is not teratogenic, but may be associated with growth retardation and prematurity. Pregnancy should be avoided in women treated with methotrexate because of its known abortifacient effects and risk of causing typical malformations. Although treatment with metronidazole or ciprofloxacin for short durations appear to be devoid of adverse fetal reactions, the effect of prolonged exposure as required in Crohn's disease remains unknown.

Multiple pregnancies in women after renal transplantation. Case report that rises a management dilemma

OBJECTIVES

To report the pregnancy outcome in women with multiple pregnancies after renal transplantation.

MATERIALS AND METHODS

We report two cases of multiple pregnancies (triplets and twins) in renal allograft recipients and evaluate the pregnancy courses and maternal and fetal outcome of these patients.

RESULTS

After fetal reduction from triplet to twin pregnancy the first patient delivered healthy twin babies at 36 weeks gestation. Six months after delivery the woman is well with no signs of renal function impairment. Although the second patient did not meet the optimal criteria for consideration of pregnancy in renal transplant recipients, she delivered normal twin babies at 33 weeks' gestation. Maternal complications during pregnancy included preeclampsia, mild deterioration of renal function tests, and secondary complications due to drug therapy that was resolved after delivery. No graft rejection episodes were noted in either case during pregnancy.

CONCLUSIONS

Multifetal gestation in renal allograft recipients represents a high-risk pregnancy that should be managed at a tertiary care institution. The overall outcome in properly consulted patients can be considered favorable. Based on our limited experience with two cases, we suggest reduction of triplets to a twin pregnancy which is consistent with the current literature data.

Pregnancy in chronic renal insufficiency and end-stage renal disease

Childbearing is important to women with renal disease, but pregnancy has generally been regarded as very high risk in these women. In this review, an attempt is made to clarify the nature and severity of those risks in the settings of chronic renal insufficiency and end-stage renal disease, including dialysis patients and transplant recipients. Hypertension is the most common life-threatening problem in all three groups. A wide range of antihypertensive medications have been used, with angiotensin-converting enzyme inhibitors the only drugs absolutely contraindicated because of their association with neonatal anuria, pulmonary hypoplasia, and neonatal death. Women with serum creatinine levels of 1.4 mg/dL or greater are at risk for accelerated loss of renal function compared with women who don't become pregnant. Transplant recipients have a risk for loss of renal function similar to controls as long as renal function is well preserved. The frequency of conception is decreased in women with renal insufficiency and markedly decreased in dialysis patients (0.5% per year). Return of fertility is the rule in transplant recipients. Exposure to immunosuppressive drugs, including prednisone, azathioprine, cyclosporine, and tacrolimus, has not been associated with an increase in congenital anomalies. These drugs, particularly cyclosporine, have been associated with small-for-gestational-age babies. Transplant recipients are at risk for infections that have implications for the fetus, including cytomegalovirus, herpes simplex, and toxoplasmosis. All groups have an increased risk for prematurity and intrauterine growth restriction. The percentage of pregnancies resulting in surviving infants in women with renal insufficiency and transplant recipients ranges from 70% to 100%. For women who conceive after starting dialysis, the likelihood of a surviving infant is approximately 50%.

Immunosuppressive drugs in pregnancy

Successful pregnancies are now common in female organ transplant recipients. Despite high rates of success, pregnancy in an organ transplant recipient should be managed as a high-risk condition with emphasis on prevention and prompt treatment of rejection episodes. The number of immunosuppressive drugs and drug combinations has increased in recent years. Data accrued by a national registry indicate that pregnancy is generally successful in patients maintained on some combination of cyclosporine, azathioprine, and steroids. Relatively little information is available regarding the safety of some of the newer immunosuppressive agents in pregnancy. Until additional information is collected, transplant physicians and obstetricians must balance the efficacy of immunosuppressants in preventing allograft rejection in the mother against possible adverse drug reactions in both the mother and fetus.

Immunosuppressant therapy during gestation

Use of immunosuppressants during pregnancy is indicated for anti-rejection therapy in transplantation patients and treatment of autoimmune diseases. Maternal side effects include nephrotoxocity and hepatotoxicity. All immunosuppressant drugs cross the placenta. Immunosuppressant use during the first trimester is not strongly associated with an increased risk of congenital anomalies, although some agents (eg, azathioprine) may be associated with slightly increased frequencies of birth defects. Effects of exposure to this class of drugs during the second and third trimesters affects the fetus' immune system. The result is an infant with a transiently compromised immune system at an increased risk of slightly lower birth weight. Other direct toxic effects of the drugs on the infant's pancreas, liver, and lymphocytes are reported. Certain agents (eg, penicillamine, chloroquine) should be avoided during pregnancy, if possible. However, their use cannot be discontinued during pregnancy given the life-threatening nature of the indication for use of immunosuppressants.

Safety of corticosteroids and immunosuppressive agents in ulcerative colitis

For many years, corticosteroids have been the mainstay for treating acute ulcerative colitis. In patients with refractory disease, immunosuppressive therapy may be indicated, including azathioprine or its metabolite 6-mercaptopurine, cyclosporin and possibly methotrexate. Their benefits in ulcerative colitis must be weighed up against their possible adverse effects, the availability of surgical cure for this condition, and the long-term risk of carcinoma complicating colitis that applies in patients with chronic extensive disease. Information about the safety of corticosteroids and immunosuppressive agents has accumulated as a result of their extensive use in inflammatory bowel disease, organ transplantation and various other disorders.

Pregnancy following renal transplantation: the experience in Hong Kong

OBJECTIVE

To assess the outcome of pregnancies occurring after renal transplantation, and to review the factors conductive to a favourable outcome.

METHOD

A retrospective review of 8 pregnancies occurring after renal transplantation from 1988 to 1992 in a tertiary referral centre in Hong Kong.

RESULT

A very high successful pregnancy rate was achieved with minimal maternal and perinatal morbidity in the cases reviewed.

CONCLUSION

Good prepregnancy counselling and stringent criteria for pregnancy assessment appears to be crucial factors for a favourable pregnancy outcome.

Pregnancy after organ transplantation

With the advent of new immunosuppressive agents in the 1980s, transplant recipients are living longer, healthier lives. Women who before did not have a chance to live, much less conceive, are now carrying and delivering healthy children. Obstetric management of such patients is discussed in this article. Two case reports of women who became pregnant after liver and heart transplants are presented. Perinatal nurses in the high-risk arena have the opportunity to collaborate with other health care specialists to care for this new group of patients.

Pregnancy after renal transplantation: 25 years experience in Spain

OBJECTIVE

To study the outcome of pregnancy in renal transplant patients in Spain.

DESIGN

A retrospective review based on two consecutive national inquiries.

SETTING

Departments of Obstetrics and Gynaecology and Renal Transplant Units in Spain.

SUBJECTS

Pregnant women who had renal transplants between 1965 and 1989.

MAIN OUTCOME MEASURES

From the preliminary inquiry the frequencies of miscarriage, therapeutic abortion, preterm birth, fetal malformation, twins, stillbirths, neonatal deaths and loss of maternal renal function were recorded. The subsequent, more detailed inquiry provided additional information including donor type, previous rejection episodes and interval between rejection and pregnancy, previous creatinine level, previous hypertension and development of hypertension in pregnancy, developments during labour and delivery and the occurrence of intra uterine growth retardation and low birth weight.

RESULTS

The preliminary inquiry yielded information about 133 pregnancies. The miscarriage rate was 10% and the therapeutic abortion rate was 16%. Of the 99 pregnancies that continued, 46% ended before term and 53% progressed to term. The perinatal mortality rate was 107.8 per 1000 and 4% of the infants had minor congenital malformations. The second inquiry yielded more detailed data about 66 pregnancies. There were no therapeutic abortions and 12% of the pregnancies ended in miscarriage. Among the 58 pregnancies that reached > or = 28 weeks gestation, preterm birth occurred in 28 (48%) and intra uterine growth retardation occurred in 17 (29%). Among 48 women with normal renal function before pregnancy, the perinatal mortality rate was 68 per 1000, the miscarriage rate was 8% and in 10 of these women (21%) renal function was impaired after pregnancy. In contrast, among 18 women with impaired renal function before pregnancy, the perinatal mortality rate was 142 per 1000, the miscarriage rate was 22% and in six of these women (33%) renal function deteriorated after the pregnancy. Impairment of renal function was most common in women with hypertension during pregnancy or with rejection episodes during the year before conception.

CONCLUSIONS

Women with a renal transplant can have a successful pregnancy, but there are definite risks for both mother and fetus. Pregnancy should be discussed with the woman and encouraged only if there is good renal graft function.

Effect of pregnancy on long-term function of renal allografts

Pregnancy in renal allograft recipients is associated with hyperfiltration with the potential for glomerular damage and adverse effects on long-term graft prognosis. We have undertaken a case-controlled study of posttransplant follow-up for a mean of 12 years (range, 4 to 23) in 36 female renal allograft recipients, 18 who became pregnant and 18 controls (matched to underlying disease and renal function) who did not. Assessments included plasma creatinine (PCr), glomerular filtration rate (GFR) by infusion clearance of inulin (Cin), mean arterial pressure (MAP), and documentation of antihypertensive therapy. By the end of follow-up, PCr in the pregnancy group (112 +/- 73 mumol/L [1.26 +/- 0.83 mg/dL]) and controls (127 +/- 52 mumol/L [1.44 +/- 0.59 mg/dL]) had increased by 19% and 8%, respectively, and GFR in the pregnancy group (58 +/- 29 mL/min) and controls (56 +/- 32 mL/min) had decreased by 18% and 7%, respectively. Graft loss or chronic rejection occurred in two patients in each group and there was a death in the pregnancy group 9 years after the second of two successful pregnancies. MAP in the pregnancy group (96 +/- 12 mm Hg) had decreased by 1%, and in the controls (101 +/- 9 mm Hg) had increased by 5%. Two patients in the index group and three in the control group commenced antihypertensive therapy during follow-up. There was, therefore, no evidence of an adverse effect of pregnancy in renal allograft recipients on long-term renal function or development of hypertension.

Outcome of pregnancy following renal transplantation

Successful renal transplantation improves fertility with 1 in 50 women of childbearing age becoming pregnant. Pregnancy following renal transplantation is associated with increased maternal and fetal complications. In Belfast 118 women of childbearing age (15-45 yrs) have received a renal allograft and of these 14 (12%) have become pregnant. Twenty-seven pregnancies have resulted in 23 live births (including one set of identical twins), 1 still birth and 4 first trimester abortions. The most frequent complications were hypertension and prematurity. In this group of patients, whose sole immunosuppressive therapy was azathioprine and prednisolone, pregnancy post transplantation was associated with frequent successful outcome and a low incidence of maternal and fetal complications.

Drug administration to the pregnant or lactating woman: a reference guide for dermatologists

Dermatologists are occasionally faced with the problem of appropriate systemic drug administration to the lactating or pregnant woman. The physician's responsibility is to be aware of the potential risk of prescribing a specific therapeutic agent, to inform the mother of this risk, and to administer an alternate, less deleterious drug, if available. The purpose of this review is to provide guidelines for dermatologists who must consider the risks to the fetus or neonate of drug administration to the pregnant woman or lactating mother.

Successful pregnancy in a renal transplant recipient taking cyclosporin A: hormonal and immunological studies

A successful pregnancy following renal allotransplantation is reported. Until now azathioprine has been used as the standard immunosuppressive agent in such cases. Because of the potential teratogenicity of azathioprine, low doses of cyclosporin A, a new immunosuppressive drug, was used in our pregnant recipient. We present the management and the outcome of the pregnancy, as well as the hormonal and immunological follow up.

Autoimmune disease in pregnancy

Autoimmunity, whether present in a recognized syndrome such as systemic lupus erythematosus or represented by the production of subclasses of autoantibodies, adversely affects reproduction. While fertility of patients with autoimmune disorders is generally unimpaired, important exceptions exist. Recent data regarding the impact of intercurrent pregnancy upon women with SLE suggest that the overall course of this disorder is not affected. The impact of SLE and related autoimmune phenomena during pregnancy primarily relates to adverse fetal outcome. Pregnancy wastage is excessive, and premature delivery and poor fetal growth are commonly encountered. The occurrence of fetal complications correlates with the level of maternal disease activity and the presence of specific autoantibodies. Management of pregnancy complicated by SLE or the production of autoantibodies associated with poor reproductive outcome should be directed at maintaining maternal disease quiescence. The adverse effect of the maternal disorder on fetal growth and development far outweighs actual or theoretical risks attributable to maternal drug therapy.

Pregnancy in organ transplant recipients

Pregnancy in women who are renal transplant recipients carries risks of hypertension and worsening of renal function for the mother and risks of prematurity, growth retardation, and infection in the infant. The risks for mother and child are greater if the transplant recipient has moderate renal insufficiency or hypertension prior to conception; even in patients with moderate renal insufficiency, birth of a viable infant is the rule. Pregnancy should not be discouraged in renal transplant recipients, but both mother and fetus should be carefully followed through the pregnancy and neonatal period. The restoration of fertility should be included as a benefit of transplant in discussions with young women deciding between dialysis and transplant for treatment of renal failure.

Management of heart transplant recipients: guidelines for the obstetrician-gynecologist

As the number and survival time of heart transplant recipients continue to increase, their quality of life, including sexuality and childbearing, have become important issues. Reproduction is possible for both male and female patients after the transplant. Counseling for contraception when sterilization is not desired must take into account the increased risk of infection and genital carcinoma associated with immunosuppressant drug therapy. Teratogenicity has not been reported either with traditional immunosuppressive agents (prednisone, azathioprine) or with cyclosporine. Osteoporosis prophylaxis is particularly important in the female heart transplant recipient, because the chronic use of prednisone increases this risk. Guidelines are provided to counsel patients in these areas.

Renal transplantation and pregnancy

Renal transplantation is usually accompanied by an improvement in reproductive function. The possibility of conception in women of childbearing age emphasizes the need for counseling, and couples who want a child should be encouraged to discuss all implications, with the advice based on strict guidelines. If a recipient becomes pregnant, she must be monitored as a high-risk patient. Management requires particular attention to BP control, renal function, and all infection, as well as fetal surveillance. Just under 40% of conceptions do not go beyond the first trimester, but of those that do, greater than 90% end successfully. In most patients, renal hemodynamics improve during gestation, but permanent impairment occurs in 15% of pregnancies. Other patients may experience transient deterioration in late pregnancy (with or without proteinuria). Patients have a 30% chance of developing hypertension, preeclampsia, or both. Despite its pelvic location, the transplanted kidney rarely produces dystocia and experiences no apparent mechanical injury during vaginal delivery. Thus, cesarean section should be reserved for obstetric reasons only. Aseptic technique, bacterial prophylaxis even for trivial surgery, and steroid augmentation are necessary. Preterm deliveries occur in 45% to 60%, and intrauterine growth retardation in at least 20%, of gestations. Neonatal complications include respiratory distress syndrome, leukopenia, thrombocytopenia, adrenocortical insufficiency, and infection. No predominant or frequent developmental abnormalities have been described, and data on infancy and childhood are encouraging. Future goals should be to improve prepregnancy assessment criteria, to reassess the rationale and implications of immunosuppression during pregnancy, and to monitor the remote effects of pregnancy on both renal prognosis and the offspring.