Successful pregnancy in renal transplant recipients treated with cyclosporine

Gastrointestinal Conditions during Pregnancy

Pregnancy causes anatomic and physiologic changes in the gastrointestinal tract. Pregnant women with intestinal disease such as Crohn disease or ulcerative colitis pose a management challenge in clinical diagnosis, radiologic evaluation, and treatment secondary to potential risk to the fetus. Heightened physician awareness on possible etiologies such as appendicitis, diverticulitis, and rarely colorectal cancer is required for rapid diagnosis and treatment to improve maternal/fetal outcome. A multidisciplinary approach to evaluation is a necessity because radiologic procedures and treatment medications commonly used in nonpregnant patients may have a potential harmful effect on the fetus. The authors review several gastrointestinal conditions encountered during pregnancy and address presentation, diagnosis, and treatment of each condition.

The history of renal transplantation in the Arab world: a view from Saudi Arabia

The first successful renal transplantation in the Arab world took place in Jordan in 1972. Surprisingly, the kidney transplanted was from a non-heart-beating deceased donor. Many Arab countries followed suit, starting their transplantation programs in the 1970s and 1980s, but all were from living related donors. Very few Arab countries managed to start deceased donor programs, notable among which is the Kingdom of Saudi Arabia. Religion has an important part in personal life and government legislation in the Arab world; thus, organ procurement and transplantation had to wait for religious edicts (fatwas) to be passed about the permissibility of organ donation and brain death diagnosis before starting transplantation activities. In Saudi Arabia, the renal transplantation service went through several developmental phases, culminating in the establishment of the Saudi Center for Organ Transplantation, which has become the prototype of a successful multiorgan procurement center to be emulated by Arab and Muslim countries. The story of transplantation in the Arab world is intertwined and shaped by the prevailing socioeconomic and health indicators in the different countries. It also is the story of hard-working pioneers and of human endeavor against adversity, exemplified by 2 of the pioneers having received organ transplants. Arab countries have had more than their fair share of strife and wars, and this has impacted on transplantation services and programs.

Outcome of 234 pregnancies in 140 renal transplant recipients from five middle eastern countries

OBJECTIVE

To study the pregnancy and offspring outcomes in postrenal transplant recipients.

METHODS

This is a retrospective case-note review study investigating the outcome of 234 pregnancies in 140 renal transplant recipients from five different Middle Eastern countries.

RESULTS

Of the overall pregnancies 74.4% were successful albeit with high prevalences of preterm and Caesarean deliveries (40.8% and 53%, respectively). The mean serum creatinine did not rise significantly during pregnancy in the group as a whole but did so in patients who had serum creatinine of or above 150 micromol/L at the beginning of their pregnancies. The mean birth weight was (2,458 g) with 41.3% of the newborns being of low birth weight (<2,500 g). The prevalences of stillbirths were 7.3% and of spontaneous abortion was 19.3%. Preeclampsia and gestational diabetes were observed in 26.1% and 2% of pregnancies, respectively.

CONCLUSIONS

In the presence of good allograft function, the majority of pregnancies in renal transplant recipients have a good outcome but with increased incidence of preeclampsia, reduced gestational age, and low birth weights. Patients with baseline serum creatinine of above 150 micromol/L have an increased risk of allograft dysfunction resulting from the pregnancy.

Medical management of the pregnant patient with inflammatory bowel disease

Gastroenterologists are not infrequently faced with questions regarding pregnancy when advising or treating their patients with inflammatory bowel disease (IBD). To advise patients effectively, the following factors must be considered: (1) the inheritance patterns of IBD for accurate counseling and family planning; (2) the effects of active IBD versus medications or surgery on fertility; (3) the effects of pregnancy on the course of IBD; (4) the effects and potential risks of active IBD versus those of diagnostic tests, medical treatments, and surgical treatments on the developing fetus; (5) approach to delivery; and (6) the risks of breast-feeding while receiving treatment for IBD.

Posttransplant complications encountered in renal transplantation in the Middle East

This paper discusses the commonly seen complications encountered in Middle Eastern transplant recipients, including posttransplant Kaposi's sarcoma, tuberculosis, infective diarrhea, and pregnancy.

Inflammatory Bowel Disease During Pregnancy

The management of both male and female patients with inflammatory bowel disease (IBD) who wish to have a baby is challenging. For women, the most important factor to bear in mind is that the outcome of pregnancy is largely influenced by disease activity at the time of conception. Women with quiescent disease are likely to have an uncomplicated pregnancy with the delivery of a healthy baby, whereas women with active disease are more likely to have complications such as spontaneous abortions, miscarriages, stillbirths, and exacerbation of the disease. This is more true of patients with Crohn's disease than of patients with ulcerative colitis. Although the safety of medications used during pregnancy is an important issue, the impact of the medications used to treat IBD is less important in comparison to disease activity itself. 5-Aminosalicylic acid (5-ASA) products appear to be safe during pregnancy; corticosteroids are probably safe; 6-mercaptopurine and azathioprine should be used with caution; and methotrexate is contraindicated. There are inadequate data on the use of infliximab during pregnancy. In regard to men with IBD, the disease itself does not seem to have any negative impact on fertility. However, there is controversy about the effects of using 6-mercaptopurine and azathioprine prior to and during fertilization. In view of possible adverse pregnancy outcomes, it would be prudent to withhold 6-mercaptopurine and azathioprine therapy in men with IBD for 3 months prior to conception, when feasible. Most IBD medications should be continued before, during, and after pregnancy, with careful attention to the known cautions and exceptions. If IBD in a pregnant patient is in remission, the prognosis for pregnancy is the same as if she did not have IBD. Active disease should therefore be treated aggressively and remission accomplished before pregnancy is attempted. Similarly, a woman who unexpectedly becomes pregnant while her IBD is active should be treated aggressively, as remission remains the greatest investment for a favorable pregnancy outcome.

Inflammatory bowel disease and pregnancy

Despite the lack of prospective studies on the relationship between inflammatory bowel disease (IBD) and pregnancy, the evidence strongly supports the conclusions that fertility is compromised in active Crohn's disease; heredity plays an important role in type and location of disease; fetal outcome is essentially no different than in the general population, except in the presence of active Crohn's disease during pregnancy; and the course of IBD during pregnancy is influenced by disease activity or lack of it before pregnancy. The major influence on outcome of pregnancy, fetal outcome, and course of IBD is the favorable effect of drug therapy on the disease. Most drugs, including sulfasalazine, 5ASA products, corticosteroids, and immunosuppressives, are safe, certainly safer than permitting the disease to be active and allowing for the possibility of surgical intervention during pregnancy. Episiotomy is contraindicated in women with Crohn's disease and perirectal complications. Cesarean section probably is indicated in most patients with Crohn's disease with colonic involvement.

Platelet and hemorrhagic disorders associated with pregnancy: a review. Part I

Disorders of coagulation remain an important potential cause of maternal morbidity and mortality. Bleeding disorders in pregnancy, unlike disorders of hypercoagulability, most often can have little impact on the mother but devastating consequences for the fetus. Further complicating the issue is that not all disorders of coagulation are inherited. Some are due to maternal illnesses unique to pregnancy, others are due to drug ingestion, and yet others remain idiopathic. In still other instances, thrombocytopenia is a minor consequence of a more severe disorder and will resolve when the inciting agent is removed or treated. A basic understanding of the pathophysiology of various conditions that lead to bleeding diathesis in pregnancy is necessary in order to effectively manage these varied clinical disorders. In addition, knowledge of whether the major morbidity is fetal or maternal or both can impact management. This review is concerned with the etiology, pathophysiology, diagnosis, and general management of commonly encountered disorders in pregnancy that place the mother and fetus at increased morbidity and mortality because of the potential for hemorrhage. Acutely acquired disorders and the resultant maternal manifestation versus a chronic disease process that is altered by the state of pregnancy are distinguished. Where possible, the incidence and prognosis of the disorder are provided. Actual cases are included to illustrate how similar presentations of distinctly different disorders can confuse and complicate an accurate diagnosis that is essential for appropriate management.

Pregnancy and kidney transplantation: experience in a developing country

Between January 1968 and December 1992, 136 kidney transplants were performed in the University Hospital of Ribeirão Preto, with women of childbearing age (14 to 40 years) as receptors. From this population, 19 patients became pregnant at least once after transplantation, and 2 were transplanted inadvertently during the first trimester of their pregnancies. There was a total of 25 pregnancies and 27 offspring. The mean age at the time of conception was 28.6 years (23 to 41 years), with a mean interval of 3.5 years from transplant to conception (< 1 to 16 years). All patients continued their immunosuppressive regimens during the entire pregnancy, but only 5 of 25 were taking cyclosporine. There were two miscarriages (8%) and two therapeutic abortions (8%); of those that passed the 20th week of pregnancy, the mean gestation time at delivery was 35 weeks (range, 28 to 38 weeks) with an incidence of prematurity (gestation < 37 weeks) of 67%, and their offspring weighed from 670 to 3,100 g (mean, 2,236 g), presenting a very high incidence of low birthweight (64%). There was one stillborn and one neonatal death. The most common complications that occurred during pregnancy were infections (especially urinary tract and vaginal mycotic infections) followed by hypertension. The obstetric complications were distributed as follows: premature rupture of membranes in 27%, fetal distress in 24%, preterm labor in 24%, and oligohydramnios in 10%. Lower segment cesarean section was necessary in 16 of 21 cases (76%), and all were for obstetric reasons. One patient died during the puerperium because of sepsis.(ABSTRACT TRUNCATED AT 250 WORDS)

Pregnancy in renal allograft recipients: problems, prognosis and practicalities

Improvements in reproductive function invariably follow renal transplantation. The possibility of conception in women of childbearing age emphasizes the need for compassionate and comprehensive counselling. Couples who want a child should be encouraged to discuss all the implications. Therapeutic abortion is undertaken in 20% of conceptions and the spontaneous abortion rate is about 14%, the same as for the normal population. Of the conceptions that continue beyond the first trimester, 93% end successfully. In most women, renal function is augmented during pregnancy, but permanent impairment occurs in 15% of pregnancies. In others there may be transient deterioration in late pregnancy (with or without proteinuria). There is a 30% chance of developing hypertension, pre-eclampsia or both. Preterm delivery occurs in 45-60%, and intrauterine growth retardation in at least 20% of pregnancies. Despite its pelvic location, the transplanted kidney rarely produces dystocia and is not injured during vaginal delivery. Caesarean section should be reserved for obstetric reasons only. Neonatal complications include respiratory distress syndrome, leucopenia, thrombocytopenia, adrenocortical insufficiency and infection. No predominant or frequent developmental abnormalities have been described and data on infancy and childhood are encouraging. Future clinical and laboratory research needs to focus on improving prepregnancy assessment criteria, better understanding of the mechanisms of gestational renal dysfunction, proteinuria and the rare, but devastating, accelerated rejection, assessing the side-effects and implications of immunosuppression in pregnancy and learning more about the remote effects of pregnancy on both renal prognosis and the offspring.

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.