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Essay 294 - Renal disease

Posted by reham E.

I would tell the lady that she canconciere but better after the transplant by one year, or until stabilization of renal function has been acheVied 'and immunosupproaon is at Maintnce level' she should take folio acid snpplmentatin preconception al 5mg daily.Well let her know that the best outcome is seen with well control ed blood pressure no protinaria 'We11 take history of MenstrUal cycle) we there regular or not to Calculate for her the ouulatay days to help her concive. 

b) In pregnancy, She should be Managed by Multi displinary team including renal phyaaron. Antenatal care should be at fortnightly interval. Serial assessment of renal function) deterioration maybe Caused by infection, dehydration) increased Blood pressure drug toxicity or graft rejection. at each antenatal Visit FBc , Ureaea and electrolyte andWatt should be made, along with Midstream Urine and PCR. Every 2-4 weeks, she should be offered U/s for growth san along With Doppler studies and from 24 weeks serial Assessment of amniotic fluid volume. she should be monitored early for fear of any abdominal d left illiac Fossa pain for increased risk of ectopic pregnancy 20 to surgery - The fetus is at increased risk of JUUR and preterm delivery. Every 6 weeks she Should be offered, Calcium phosphate and albumin, also 24ha mine collector for creak nine clearance and proton. she is on immunosuppresra) it Must be continued in pregnancy, commonly used are prednisone) azathioprine and tacrotmus. 

Posted by reham E.

I would tell the lady that she canconciere but better after the transplant by one year, or until stabilization of renal function has been acheVied 'and immunosupproaon is at Maintnce level' she should take folio acid snpplmentatin preconception al 5mg daily.Well let her know that the best outcome is seen with well control ed blood pressure no protinaria 'We11 take history of MenstrUal cycle) we there regular or not to Calculate for her the ouulatay days to help her concive. 

b) In pregnancy, She should be Managed by Multi displinary team including renal phyaaron. Antenatal care should be at fortnightly interval. Serial assessment of renal function) deterioration maybe Caused by infection, dehydration) increased Blood pressure drug toxicity or graft rejection. at each antenatal Visit FBc , Ureaea and electrolyte andWatt should be made, along with Midstream Urine and PCR. Every 2-4 weeks, she should be offered U/s for growth san along With Doppler studies and from 24 weeks serial Assessment of amniotic fluid volume. she should be monitored early for fear of any abdominal d left illiac Fossa pain for increased risk of ectopic pregnancy 20 to surgery - The fetus is at increased risk of JUUR and preterm delivery. Every 6 weeks she Should be offered, Calcium phosphate and albumin, also 24ha mine collector for creak nine clearance and proton. she is on immunosuppresra) it Must be continued in pregnancy, commonly used are prednisone) azathioprine and tacrotmus. 

Posted by reham E.

I would tell the lady that she canconciere but better after the transplant by one year, or until stabilization of renal function has been acheVied 'and immunosupproaon is at Maintnce level' she should take folio acid snpplmentatin preconception al 5mg daily.Well let her know that the best outcome is seen with well control ed blood pressure no protinaria 'We11 take history of MenstrUal cycle) we there regular or not to Calculate for her the ouulatay days to help her concive. 

b) In pregnancy, She should be Managed by Multi displinary team including renal phyaaron. Antenatal care should be at fortnightly interval. Serial assessment of renal function) deterioration maybe Caused by infection, dehydration) increased Blood pressure drug toxicity or graft rejection. at each antenatal Visit FBc , Ureaea and electrolyte andWatt should be made, along with Midstream Urine and PCR. Every 2-4 weeks, she should be offered U/s for growth san along With Doppler studies and from 24 weeks serial Assessment of amniotic fluid volume. she should be monitored early for fear of any abdominal d left illiac Fossa pain for increased risk of ectopic pregnancy 20 to surgery - The fetus is at increased risk of JUUR and preterm delivery. Every 6 weeks she Should be offered, Calcium phosphate and albumin, also 24ha mine collector for creak nine clearance and proton. she is on immunosuppresra) it Must be continued in pregnancy, commonly used are prednisone) azathioprine and tacrotmus. 

Renal disase With pregnancy Posted by Peter A.

A.

It is imperative to ascertain the cause that lead to renal transplant as autosomal dominant conditions like polycystic kidneys need genetic counselling. I would like to review the date of transplantation advising against pregnancy before 2 years. I will review the current medications. Immunosuppressive drugs like azathioprine and prednisolone are not contraindicated in pregnancy. Antihypertensive drugs that are teratogenic like ACE inhibitors and angiotensin receptor blockers should be changed.  Urea, electrolytes and creatinine clearance should be reviewed in liaison with nephrologist to rule rejection before getting pregnant. Mild renal impairment is unlikely to affect pregnancy if serum creatinine less than 125 micromole/L, but in severe renal impairment (serum creatinine 180 micromole/L or more) advise against pregnancy. Information leaflet should be provided.

B.

More frequent visits with multidisciplinary approach involving nephrologist and internal medicine physician. Investigations that need to be done are FBC for haemoglobin assessment for anaemia. At initial visit and each trimester, urea electrolytes and creatinine clearancemust be done. Serum creatinine less than 125micromole/l indicates good pregnancy outcome. Midstream urine for dipstick for proteins nitrates and culture/sensitivity must be done. Spot protein/creatinine ratio or 24 hours urine protein estimation must be done as proteinuria > 5gm/day mandates thromboprophylaxis. Screen for Hep B & C, CMV, toxoplasmosis, HIV and rubella immunity as risk of infection increased in immunocompromised patients.

Urine dipstick to rule out UTI and blood pressure keeping it below 130/85 mmHg should be done each subsequent visit.  First trimester scan for dating viability and gross anomaly considering increased risk of miscarriage.  Routine fetal anomaly scan and serial fetal growth monitoring as the risk IUGR and preterm birth increased with renal disease. Renal transplantation per se is not contraindication for vaginal delivery, so caesarean delivery for obstetric causes.

 

renal transplant Posted by namreen M.

The first thing to ascertain is to know about the cause for which transplsnt was undertaken since many conditions like SLE,polycystic kidney disease and diabetes need further assessment.Sle can have deleterious effects on pregnancy and viceversa.Those with PCKD need genetic counselling to confirm about the chances of disease being transmitted to the child.Diabetes can have various implication on the pregnancy and these patients need a different assessment.

Time since the transplant was done is important .Women should be advised to avoid pregnancy for 1 year after a live donor trnsplant and 2 years after a cadver transplant.COCP is an option for contraception as IUDs are better avoided in these patients due to decreased efficacy because of immunosuppressive drugs and increased chances of infection.However delaying pregnancy for more than 5 years is not beneficial due to subfertility and falling graft function due to chronic rejection.

A history of any graft vs host reaction should be sought as this can affect the graft function.

They should be reassured that there are 90% chances of a successful pregnancy after first trimester but witrh increased chances of preterm labour,preeclampsia,SGA,infections like CMV and Hep B.

Vaccines for Hep B ,Strep Pneumonae and tetanus should be offered if not given pretraansplant.Rubella vaccine is contraaindicated in tnis gour due to being a live vaccine.

Medications like ACE inhibitors must be stopped and replaced by alternatives which are not teratogenic.Prednisolone and azathioprine can be continued.Dose of cyclosporine may have to be increased and that of tacrolismus decreased in order to avoid toxicity.Mycophenolate mofetil being a tertogenic drug should be avoided.Folic acid should be offered if there are no reasons to delay pregnancy.

BP should be recorded.

Investigations to be done are;

FBC,U&E,LFTs.

Sr.creatinine should be<125 micromol 

Urinary proteins should be<500mg in 24 hrs.

USG.

b)More frequent visits with multidisciplinary approach are required with a renal physician and dietician.

Early referral to a tertiary care centre where facilities for resuscitation of preterm neonates are avalable in addition to availability of a renal transplant unit.

BP should be recorded at 2 weekly intervals.

Renal function should be checked at 4 to 6 weekly intervals

Plasma levels of immunosuppressive drugs are done to avoid any toxicity or adjust the doses.

Screening for CMV and Hep B should be offered twice during pregnancy in addition to routine screening for HIV, syphilis,Rubella.

FBC,LFTs,Creatinine clearance ,24hr urinary proteins and U&E should be done in each trimester.

A care plan should documented in the notes.

In case of  any acute deterioration in the renal function,women can be offered TOP. which is rare if the function of transplant was normal with maintained immunosuppression at the time of conception. 

Essay 294 - Renal disease Posted by Sarah S.

a)I will start asking her more about the cause of renal failure necessitating the renal transplant. If it was inherited cause like adult polycystic kidney disease I will discuss with her the need for genetic counseling. If it was acquired like SLE, it may have adverse effect on pregnancy. I would ask her the date of the operation, as it is recommended to delay the conception for at least 1 year since the transplant. This allows the graft function to be stabilized.  I would enquire if she had history of miscarriage as poor renal function can be associated with increase risk of miscarriage and poor pregnancy outcome. I would review her medication and advice to stop some of  them due to their teratogenic effects like Mycophenolic acid and ACE inhibitors; while she can continue others like prednisolone, Azathioprine. I will note her BMI and current Blood pressure status as poorly controlled hypertension may have a poor pregnancy outcome. I will take her Full blood count to check for her haemoglobin level as chronic anemia is associated with renal impairment and we can optimize it before conception. Renal function test will be taken especially serum craetinine level as a level < 125umol/l is associated with good pregnancy outcome. MSU for culture and sensitivity looking for urinary infection. I will also send 24hour urinary protein for baseline assessment. Screening for HIV, Hepatitis B&C, Syphilis and Rubella will be undertaken. I would advise her to start taking folic acid 3 months before conception and continue the first 3 months of pregnancy.  I will also inform her possible effect of pregnancy on her kidneys. Generally it dosen’t aggrevate graft rejection and if her baseline renal function are normal the overall pregnancy outcome is good. The impact of kidneys on pregnancy may lead to increase likelihood of preeclampsia, prematurity and IUGR. If after assessing she is noted not yet to be fit for conceiving would advise her on proper contraception method. i would give her information leaflet.

b) This case needs to be managed under multidisciplinary team care between obstetrician and nephrologist as the primary team. We may need to involve neonatologists and anesthetist at some point. She should receive low dose aspirin as a measure to reduce risk of preeclampsia. She will require frequent anenatal check up. She will also require serial fetal growth scans as the risk of IUGR is higher than general population. The need for at least monthly renal function assessment will be explained as well as monitoring for drug toxicity at every visit especially if she is on tacrolimus or cyclosporine. MSU will be done frequently to check and treat for asymptomatic and symptomatic bacteriuria so as early treatment can be initiated to reduce the risk of ascending infection and premature delivery. Mode of delivery is to aim for vaginal delivery and caesarean section to be done for obstetric indications. She should continue her medications that are helping to optimize her renal condition and deemed safe to be continued in the pregnancy. 

294 Posted by geeta M.

a)I will ask the duration since transplant as she should wait for 1 year after living related donor and for 2 years if cadaver transplant before she conceives.I will ask about the current status of her graft as graft rejection may affect pregnancy adversely.I will ask in detail about drug history as certain drugs need to be modified beforehand.ACE inhibitors and angiotensin receptor blockers are contraindicated in pregnancy.High dose prednisolone causes fetal adrenal suppression and ACE inhibitors cause oligamnious . she needs to be stabilised on low dose medication.Tacrolimus has to be reduced by 60% to avoid toxicity during pregnancy.Mycofenolate mofetil is teratogenic and hence should be avoided in pregnancy. Cyclosporine metabolism increses during pregnancy and higher doses may be required to maintain plasma levels,but that will be associated with maternal diabetes,hypertension and low birth weight infant.I will ask her the reason for which transplant was done to know whether it was due to a genetic disorder which may need genetic counselling regarding inheritance ,or it was due to some medical condition which may also affect pregnancy.

Her general health should be optimum and blood pressure ,BMI assessed, as uncontrolled hypertension is associated with poor pregnancy outcome.Her renal ultrasound should be normal.She should get vaccinated for tetanus,hepatitis B if not done prior to transplant.But I will advice against rubella live vaccine as it is contraindicated in transplanted patients.There should be no recent episodes of acute graft rejection.Her blood pressure should be less than 140/90 mm Hg,s.creatinine less than 125micromoles/l,proteinuria should be less than 500mg/24 hrs to achieve a good pregnancy outcome.

I will tell her that if graft function is stable and adequate ,then pregnancy does not cause any irreversible deterioration in graft function.But pregnancy is discouraged if poor or deteriorating renal function as increased chance of miscarriage and poor obstetric outcome.

b)She needs to be taken care of by involvement of a multidisciplinary team comprising of nephrologist,obstetrician,specialist midwife,dietician and neonatologist.

She will need more antenatal visits for additional assessments.Her blood pressure needs to be checked every 2 weeks and should be normal or well controlled ,less than 140/90 mm Hg as there is chance of pre-eclampsia.Full blood count should be checked every month to check for anemia and other haematological parameters.Folate and iron supplementation to be given.Since she may be on immunosuppressive drugs,their plasma levels should be checked and drugs maintained at stable doses as any new acute infections may be harmful to fetus.She will need to monitor renal function every 4 -6 weeks in order to detect any evidence of graft rejection.If there is suspicion of any such rejection,a biopsy should be considered for diagnosis.MSU  analysis should be done to detect any UTI or asymptomatic bacteriuria ,which if detected should be treated with 2 weeks course of antibiotics and prophylactic treatment should be considered.Also LFTs ,U & E,plasma proteins,24 hour urine protein and creatinine clearance,calcium level should be done.Since CMV seen more commonly in transplant patients,screening for CMV should be done in each trimester.

There is an increased chance of fetal growth restriction,SGA,prematurity,so she will need to undergo serial scans to detect fetal growth and well being.

C.S only for obstetric indications as transplanted kidney does not obstruct labour.

 

 

 

 

Renal transplant Posted by celine  S.

The important information required are as follows:The time since the transplant has taken place,because it is recommended that a waiting period of 1-2 year ,after the transplant will stablize the graft function,and also minimises   immunesupprasant drugs.The women should be counselled that graft from a living ,related Donar has good pronosis (if her graft is from her retated living person).The reason for the transplant  at this young age should be explored to give advice regarding the fetal implications ,as poly cystic kidney disease needs genetic counselling,and Insulindependent Diabetes Mellitus or Systemic lupus related kidney disease needs appropriate preconcepton investigations and counselling.A reliable contraception should be provided to buy time and achieve a successful pregnancy later.It is important to note the recent renal function tests as creatinine values >125umol./l risks  the graft survival of <65% for 3 years.The immunesupprsant drugs she may be on should be reviewed as some of the drugs like mycophenolate mofitil is contraindicated and needs to be changed before conception(atleast 3 months),otherwise prednisalone ,Azathioprine ,Tacrolimus,Cyclosporin are appropriate durging pregnancy.The antihypertensives should also be reviewed as ACE inhibitors and beta blockers needs to be changed to other antihypertensives like nifedepine,labetalol.It Is important that the women should be seen at a special clinic where a nephrologist,specialist nurse and the obstetrician are available for review .She should be assessed for high bloodpressure,BMI,Screened for anemia,Cytomegalovirus,hepatis B,hepatitis C and HIV,Rubella.Urine routine for protienuria,microscopy.Her corcerns should be addressed and most of them want a reassurance for immunesupprasant to be continued in pregnancy and its effects on their fetus.She should be reassured about the good prognosis in majority ,prophalactic folic acid and a patient information leaflet should be provided at this consultation.

B)The women should be seen at the multidiciplinary care service,where a renal specialist,obstetrician ,and specialist nurse are available. A FBC,liverfunction test ,should be checked regularly,anemia is common and iron supplementation is required once nausia/vommiting subsides.The dating scan is important as these women may require early delivery,low dose ecosprin is provided as these women may have early onset preeclampsia,she should be screened for high blood pressure and proteinuria at each visit.There is also risk of frequent urinary tract infection(UTI,)it should be treated and prophalactic antibiotics are recommended if frequent UTI 'S are encountered.A detailed anamoly scan by the fetal medicine unit ,is necessary if there was a genetic basis for the women's renal transplant or if there is a renal or other pathology noted on regular basis.Cytomegalovirus status should be checked at every vist if she was negative to start with.The fetus should be monitored for growth and doppler studies may be required as the fetus is prone for growth restriction.Acute graft rejection may occur during pregnancy,and therefore vigilance is required for fever,oliguria,renal angle tenderness,altered echogenicity of renal parenchyma,and corticomedulary junction.Renal biopsy is not recommended for this diagnosis in pregnancy. Risk of preterm delivery is expected in view of preecampsia,infections,therefore  prophalactic corticosteroids are recommended ,delivery in a tertiary center is appropriate ,caesarean delivery is only for obstetric reasons.Prophalatic antibiotics is given to cover delivery,and parenteral steoids are necessary to cover labour,baby is screened for,HIV,Hepatis B,and C.CMV(if mother was positive).

 

Renal disease Posted by farzana S.

A) Prepregnancy counseling should be given in a multidiciplinary setting,including Renal physician,senior obstetrician ,and  specialist midwife.

An enquiry should be madeof duration since renal transplantation.She should be advised to embark on pregnancy after 12-24 months when graft becomes stable.Any history of graft rejection or infection is taken.Presense of hypertension ,proteinuria,and serum creatinine wil reflect degree of impairment of renal function.Good pregnancy outcome can be expected if she is normotensive or well controlled hypertension,proteinuria less than 500mg or serum creatinine 125micromol/L..USS of allograft for any pelvicaleceal dilatation.

Cause of renal disease should be enquired .If there is a genetic component ,she should be referred to geneticist to assess her risk of transmission to offspring

.Effect of pregnancy on graft functions is explained.No long term detrimental effects are seen if pregnancy occurs with serum creatinine ~125micromol/L.

Drug history is taken.She can continue to take immunosuppressants at maintenance doses i.e prednisolone less than 15mg/day,azathioprine 2mg/kg/day,cyclosporine /tacrolimus.

Antihypertensives,if she is on ACE inhibitors or ARBs would be changed when she becomes pregnant as these drugs are teratogenic.

She should be given folic acid 400micrograms/day or if 5mg /day if she is diabetic.Rubella status is checked and advised against smoking.

B)Antenatal care of this woman should be in a high risk clinic by senior obsterician in collaboration with Renal physician and dietitian.

She should be advised  to book early .Dating scan is done at 10 wks .Down's syndrome screening is by NT at 11-13ks.Booking investigations include FBC for Hb, serum urea,creatinine and any proteinuria as baseline.Serology for HIV,hepa B and C,HSV,and CMV.If she is seronagative,serology should be repeated every trimester, Urine culture is done for asymptomatic bacteriuria.LFTs,bone chemistry and plasma proteins are monitored every trimester.Plasma levels of immunpsupressants are monitored every trimester.

She should be given Aspirin 75mg/day from 12wks for prevention of pre eclampsia,and folic acid 400microgram per day.If anthypertensives are required Aldomet, labetalol or nifidipine  can be given. Riskof VTE is assessed and thromboprophylaxis given.

Antenatal visitsshould be arranged every 2wks.BP and proteinuria checked every visit.FBC and MSU is repeated every 4wks .Any infections are treated and anemia is treated by oral or parenteral iron.

Renal functions are repeated every 4-6wks for early detection of graft rejection.

Oral GTT is done at 24-28wks .Growth scans are done from 24wks every 3-4wks. .She should be informed about signs and symptoms of preterm labor,and advised to report early if she experienced any pain bleeding or  leaking.

Birth plan should be made by 36wks.Advised to deliver in hospital with facilities for maternal and neonatal care.Allograft does not obstruct vaginal delivery.Hence CS is for obstetric indications.

 

 

sma Posted by shah M.

 

A.Renal transplant may be associated with adverse maternal (pregnancy induced hypertension superimposed on chronic hypertension,Preeclampsia)  and fetal(IUGR, stillbirth,LBW,Prematurity) outcome if conceived with uncontrolled maternal hypertension and impaired renal function.So multidisciplinary team input  by consultant obstetrician /renal physician/neonatologist is needed.History is taken to know the indication for renal transplantation (as autosomal dominant condition  like adult polycystic kidney can be inherited to the offspring-to discuss genetic counseling and  prenatal diagnosis).Duration since the transplant  is asked and pregnancy avoided for  2 years as graft rejection occurs  mostly during this period.Contraception advised to delay coneption .Current status is checked by examining blood pressure and  investigations-full blood count-for anaemia,renal function test –blood urea, s.creatinine,24 hour urine protein-( significant if morethan 300 mg/24 hr) or protein creatinine ratio(morethan 30).Associated hypertension,diabetes mellitus,autoimmune disease like SLE- ruled out by blood sugar /HbA1C, autoimmune screening antinuclear antibody, anti bodies to double stranded DNA,APLA.Medication s are modified to avoid teratogenecity(ACE Inhibitors,angiotensin receptor blockers).Immunosuppressants azathioprime and corticosteroids may be continued in lower effective doses to prevent graft rejection. General prepregnancy care like folic acid 400 micrograms to prevent NTD ,rubella sensitivity checked.Infection screening lncluding HIV,Hepatitis B syphilis done as more chance of infection through organ transplant.

B.Early booking done with dating scan  .Multi disciplinary team (consultant obstetrician preferably single lead clinician, renal physician ,anesthetist and neonatologist to optimize care.Increased antenatal visits   to detect consequences(pregnancy induced hypertension, with or with out super imposed hypertension, preeclampsia,graft rejection ) with serial monitoring of blood pressure, proteinuria, renal function test (blood urea, serum creatinine , 24 hour urine protein/protein creatinine ratio ).However In majority with well controlled renal function and blood pressure at conception complication do not occur.Control of autoimmune diseases like SLE, Uncontrolled Diabetes mellitus.Genetic counseling and prenatal diagnosis – amniocentesis /PCR in case of autosomal dominant condition like maternal  adult polycystic disease.  Infection screening for HIV,Hepatitis B ,syphilis is done if not done  prepregnancy and appropriate management with infection specialist.Mid stream urine for culture and sensitivity and treatment if appropriate. fetal surveillance done by,CTG,fetal growth scan 2-4 weekly with umbilical artery Doppler  to detect iugr,low birth weight as it  helps to improve perinatal morbidity . Medicines are modified to avoid teratogenecity (ACE Inhibitors, angiotensin receptor blockers).Immunosuppressants like azathioprime and corticosteroids are continued  as they are safe in pregnancy.delivery is planned in obstetric unit under single lead clinician with liaison with renal physician and anesthetist. CS fo r obstetric reason or if transplanted kidney obstructing labour.

Posted by Angeldust S.

(a) My assesment includes history taking to enquire regarding her cause of renal failure requiring transplant, as causes likely polycystic kidney disease has a genetic predisposition and she may require genetic counselling. I will ask if her graft and renal function has been stable as prognosis of the pregnancy is better with a stable graft function. If the graft function is poor, she should be advised to postpone pregnancy and commence contraception. A drug history is taken for teratogenic immunosuppressive drugs e.g. MMF is obtained and switched to safer drugs e.g. Azathioprine. Anti-hypertensives like ACE-inhibitors and ARBs should be changed as they are unsafe in pregnancy. I will ask about pre-exisiting conditions e.g. diabetes and hypertension which can worsen renal function and has related complications in pregnancy and I will optimise the control accordingly.

On examination, I will take her height, weight and calculate her BMI as obesity will further increase the risk of pre-eclampsia in this patient. I will advise on weight control and dietary advice accordingly. I will check her baseline BP and urine for proteinuria.

Investigations will include baseline haemoglobin for anemia. Oral Iron supplements is commenced if necessary. Baseline renal function indices like serum urea, creatinine and 24 hour urinary protein is obtained. Midstream urine is sent for culture and sensitivity to screen for urinary tract infection to allow early treatment.

(b) Additional interventions for the mother include management under a multidisciplinary team including obstetrician, senior midwife and renal physician preferably in a tetiary centre, The frequency of visits is increased to 2 week-ly from 28-32 weeks and weekly thereafter for closer surveillance of renal function and fetal well-being. Bp, urinalysis for proteins is checked at every visit to look for pre-eclampsia. MSU for culture and sensitivity is done every visit to look for UTI. Antibiotic prophylaxis is given if recurrent UTI as UTI is detrimental to graft function. Haemoglobin count is checked at booking and at 28 weeks, or more frequently if any suspision of anemia and to treat with iron supplements and EPO if necessary. There should be a low threshold for admission to hospital if there is worsening BP signifiying PIH/pre-eclampsia or worsening renal function. Serum creatinine and urea is checked every visit and 24 hour urinary protein is rechecked if there is evidence of worsening proteinuria on dipstick.

As the fetus is at risk of IUGR, fetal surveillance includes regular ultrasound for growth (AC+ EFW) to exclude fetal growth restriction, uterine artery dopplers for risk of pre-eclampsia and umbilical artery doppler if any evidence of FGR. THe woman should be advised to deliver in a tetiary centre with neonatologist support as she is at risk of pre-term delivery. The mother should be advised that caesarean section is only for obsetric reasons as the transplanted kidney does not obstruct labour. Continous EFM is advised if the fetus is growth-restriced.

 

Posted by biba W.

a) I will take a history regarding the cause of renal failure and transplant. If it is secondary to polycystic kidneys, genetic counseling is required as the condtion is autosomal dominant. If the cause is diabetes mellitus or systemic lupus erythematosus, the condition needs to be optimized before pregnancy. I will ask when the transplant took place as pregnancy is not recommended within 2 years of renal transplant. Effective contraception should be given. I will also ask about related complications like hypertension and proteinuria and their control as the prognosis of renal impairment during pregnancy is dependent on the control of hypertension and proteinuria. I will also take a drug history. ACE inhibitors and angiotensin-receptor blockers should be stopped as they are teratogenic. Immunosuppressive agents are not teratogenic but cause fetal growth restriction. I will also ask about the severity of renal impairment as prognosis of renal disease is worse with more severe renal impairment. Blood pressure measurement and BMI should be measured to assess control of hypertension. Obesity can increase risk for pre-eclampsia. Urinalysis should be done to assess degree of proteinuria. Renal function should be assessed by serum urea, electrolytes and creatinine levels. Creatinine clearance and 24 hour urine total protein should be performed to assess proteinuria. Full blood count should be taken to assess for anemia secondary to renal impairment. Patient should be seen by a multidisplinary team involving renal physician, senior obsterician and specialist midwife. Verbal and written information about her condition should be given. She should be counselled about the risk of pregnancy on renal failure, risk of renal failure on her pregnancy and fetus.

b) The patient should be managed by a multidisciplinary team consisting of renal physician, senior obstetrician, specialist midwife and anaesthetist. Early booking visit is recommended for accurate dating and early control of renal impairment. At the booking visit, the patient should be counselled on the risk of renal impairment on her pregnancy, which includes, pre-eclampsia, pregnancy-induced proteinuria and anemia. She should also be counselled on risk to her fetus which include stillbirth, miscarriage, preterm delivery and fetal growth restriction. Folic acid supplementation should be given preconception and for first 12 weeks of pregnancy. Aspirin should be given from 12 weeks of gestation to prevent pre-eclampsia. Blood pressure and urinalysis for proteinuria should be checked at booking visit and at every antenatal visit to screen for pre-eclampsia and also assess control of hypertension. Strict blood pressure control is necessary as hypertension can worsen renal function. Full blood count should be done at booking visit and at 28 weeks of gestation to screen for anemia which is a complication of renal failure. Erythropoietin and iron tablets can be given if found to have iron deficiency anemia. Urinary tract infection can lead to worsening of renal function so mid stream urine should be collected at every visit and screen for urinary tract infection. Infection should be treated aggressively and prophylatic antibiotics can be considered if there is recurrent urinary tract infection. Renal function should be assessed by serum urea, electroytes and creatinine, creatinine clearance and urine dipstick for proteinuria. These tests should be done at booking visit and every visit. Baseline 24 hour urine total protein should be measured in early pregnancy and repeated if urine dipstick showed worsening proteinuria. In view of the risk of fetal growthh restriction, serial ultrasound for fetal size with abdominal circumference/estimated fetal weight and umbilical artery dopplers for fetal well being should be performed from 26-28 weeks of gestation. Medicine that is harmful to the fetus like ACE inhibitors should be stopped and replaced. Patient should be reviewed every 2 weeks till 28 to 32 weeks then weekly to delivery.

isam Posted by IE M.

a-Pregnancy with renal transplant carries increased risks to the mother and her fetus so it need good assessment with multidisciplinary team (MDT) including an obstetrician and a nephrologist  so as to optimize the condition of the patient before pregnancy. If the condition is not controlled contraceptives should be advised so as to avoid unintended pregnancy. Assessment should be done by taking history asking about any symptom now, like fever, abdominal pain, burning micturition and dizziness to exclude any acute condition. Ask about the reason for transplant is it for  familial causes like polycystic  kidney which need genetic counseling. The time passed  since transplant was done because 2 year is needed for better outcome of pregnancy, less chance of graft rejection and  enough  period for adjustment of the drugs doses. The drug like ACE inhibitor, steroid and immunosuppressant taken by the patient should be known so as to be modified with MDT. Examine the patient BP,  P and BMI because there are increased risk of preeclampsia and hypertension. Look for pallor for anaemia and dehydration. Abdominal examination for masses and tenderness lower limb oedema . investigation FBC for anaemia . dipstick test for protein and leukocytes for infection. Assess the renal function by urea and electrolytes serum creatinine , CPR.
b-this is a high risk pregnancy should be followed in a MDT including an obstetrician and renal physician. Additional interventions should be taken like: Folic acid 5mg should be supplied until 12 week of pregnancy because increased risk of neural tube defect. Aspirin 75 mg from 12 week of pregnancy because increased risk of preeclampsia and hypertension. Screan for anaemia and correct by iron because more risk for anaemia. More frequent visit and fetal growth monitoring because risk of IUGR. Measuring BP and test for protein every visit because of increased risk of preeclampsia. Uterine ateery Doppler at 20 -24 weeks to screen for preeclampsia. Revice the medication with MDT stop ACE inhibitors and adjust steroid and immunosuppressant. Serum creatinine and urea and electrolytes done to monitor renal functions. Delivery plan by normal vaginal delivery and caesarean section for obstetric indications only  because kidney transplant dose not obstruct labour.           

Posted by Shahla  K.

25 Year old lady with renal transplant contemplating pregnancy needs preconceptional assessment in a multidisciplinary unit involving senior obstetrician, nephrologists, neonatologist anesthetist, and senior midwife. The aim is to find out the effect of renal transplant on pregnancy and pregnancy on renal transplant.

History of the cause of the renal failure in reproductive age investigated. The inherited genetic cause can reoccur in her sibling need preconception genetic counseling. Medical condition like diabetes, blood pressure SLE can affect her pregnancy as well need to optimize before conception.  Certain causes like scleroderma, poly arteritis nodosa pregnancy contraindicated

Need to know the duration of the transplant, the graft and immune suppressant need in one to two  years for adjustment, therefore advice for contraception in first two years.

Drug history should be taken, as some drugs are taratogenicity, like antihypertensive, Angiotensin receptor blocker should replace by the drug which is has no effect on the fetus.

Safety of immunosuppressant discussed with nephrologists.

History of any graft rejection enquires. As pregnancy should be avoided near event of rejection.

Her menstrual history, menarche, last menstrual period, and regularity of cycle inquired as the renal disease can affect the fertility. Past obstetric history taken.

On examination, Blood pressure, pulse, BMI , urine dipstick should be checked as baseline

Her renal status should be assess by serum creatinin, electrolyte urine protein should be checked FBC and LFT assess. Need Infection screening of HIV, HbsAg, cytomegalovirus, as a baseline.

b) Regarding care of post renal transplant patient regard as high risk pregnancy needs multidisciplinary care by senior obstetrician, nephrologists and neonatologist.

She should be booked   in tertiary care unit. More frequent visits should be planned.

Every visit blood pressure, urine protein should be checked. There is risk of anemia and urinary tract infection screen by screening with FBS, urine culture.

Due to prednisolone risk of Diabetes , screen with booking GCT. And repeated in each trimester

 

                Anomaly scan at 18-22 weeks and cardiac scan at 24 week.

There is risk of Fetal growth restriction therefore growth scan at 28 weeks if normal repeat at 32 week.

Risk of preeclampsia, need vigilance in screening the patient to report when symptomatic, check BP proteinurea each visit, and prescribe aspirin as prophylaxis. blood pressure maintain below 140/90 mm hg.

She is at risk of preterm labor, need timely diagnosis and steroid injection FOR LUNG MATURITY.

Information leaflet and support group contact details provided.

 

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Posted by afraa A.

 (A)  

       Prepregancy councellling for this lady should include information about the time that she had the transplant because she need to dealy the pregnancy for 2 years after transplant 

   The cause of her renal disease needs to be clearly known because some disease like polycystic kidney disease is autosomal dominant and it needs genetic councilling 

   Her medical comorbidities like hypertension and diabetes needs to be well controlled prepregnancy .

   I will ask her about her history of rejection and if she had acute or recent rejection she should delay pregnancy because it will increase the risk of rejection .

   Drug history is very imporatnt and she needs to know that azathioprin is not contraindicated while cyclosporin  is not teratogenic but no available evidance  about mofitil and mycophenolate.   ACE inhibiters and AR blocker are teratogenic and should be stopped during pregnancy . 

  vaccination history should be known because she is liable to infection , immunization aginst hepatitis B and CMV and tetanus , if not done pretransplant but rubella vaccine is contracindicated

  Relaible contarceptive method is advice untill she had her medical condition controlled , progesterone implants and injection and low dose COCP is her option , iud may incraese the risk of infection . 

   Folic acid 5 mg prepregnancy is adviced especially if she is diabetic 

(B)

     This high risk pregnancy , follow up should be in consultant led unit by multidiciplinery team which include obsterician , nephrologist , midwife and specialized nures

   Her medication should be reviwed agian once she is pregnant

    She had increased risk of miscarrage so the viability scan in early pregnancy should be asked for , 20 weeks anomaly scan should be requested also 

 Baseline renal function test with GFR as baseline tests should be done and repeated ever 4- 6 weeks to detect rejection early. also i will ask for 24 hour urinery protein measurment . 

she will need more frequent antenatal visits 

 I will ask for serial growth scan because she had increased risk of SGA nad IUGR . 

  She had increased risk of preclampsia  so the use of 75mg  aspirin may reduce the risk of SGA and IUGR 

She needs hydrocrtisone during labour to overcome the stress of labour 

The transpalnted kidney doesnot prevent vaginal delivery and c/s in indicated for obstetric reasone . 

 

 

Posted by Veera V.

a)      Preconception counselling for this patient should include history taking on the nature of the underlying disease that had caused the renal failure. Diabetes, autoimmune disease such as SLE, polyarteritis nodosa, scleroderma, genetically inherited disorders such as Polycystic Kidney. Knowing if the underlying condition can be inherited should prompt us to refer this patient for preconception genetic counselling. History and physical examination   should focus on symptoms of renal failure such as pallor, oedema, breathlessness, uremic symptoms such as nausea and vomiting. If her disease is not well controlled even after transplant we need to counsel to postpone her plans for conceiving and offer appropriate contraception method. Combined oral contraception pills are usually effective, efficacy of IUCD method can be affected by anti-inflammatory properties of immunosuppressant agents used to prevent graft organ rejection. Pregnancy can be planned in a patient that had maintained at least 2 years of good health  after transplantation or if  there is no graft rejection  in within a  year. We must make sure that her graft is functioning well and her immunosuppression is at stable dose. So we need to repeat her serum creatinine, urea and urine protein 24 hours.  We must make sure she is not having any acute infections and her Blood pressure must be normal and well controlled. .Her renal scan should be normal her medications should be reviewed and modified if necessary.  ACE inhibitors and Angiotensin receptor blocker is contraindicated in pregnancy. Immunosuppressant drugs such prednisolone, azathioprine, cyclosporine and tacrolimus can affect her future pregnancy and their effects must be discussed. Prednisolone crosses the placenta and generally considered non teratogenic yet there are some cases of cleft palate reported. Azathioprine is associated with low birth weight, prematurity, neonatal jaundice and respiratory distress. Cyclosporine can cause low birth weight, diabetes in pregnancy and hypertension. Patient’s vaccination history should be explored and if needed, we may need to Vaccinate against Hep B, Strep pneumonia, tetanus if not done pre-transplant. Rubella vaccine (live) contraindicated in transplant patients. Pregnancy occurs in 5-12% of women of reproductive age following renal transplant. 50% of these pregnancies are unplanned. Pregnancy success rate exceeds 90% after the first trimester.

b)      Patient should be followed up in combined care with a nephrologist involved. Patient’s BP should be monitored regular preferably every week. We need to examine her full blood count every month to look for signs of infection, anaemia and agranulocytosis due to the the immunosuppressive drugs. Renal function should be monitored every 4 weeks to detect evidence of rejection and we need to consider renal biopsy if we suspect organ rejection. Blood investigations will include urea and electrolytes, serum creatinine, calcium, phosphate and 24hours urine protein. Regular screening for urinary tract infection with mid-stream urine is important and if infection sets in need to be treated aggressively with appropriate antibiotics. Patient should have a dating scan to confirm her dates and thereafter need for regular scan monthly to detect signs of IUGR and SGA. Detail scan should be done at 18 -24wks. CMV and Herpes testing (cervical culture) twice during pregnancy .

RENAL TRANSPLANT Posted by afraa A.

 (A) 
       Prepregancy assessment for this lady should include information about the time that she had the transplant because she need to dealy the pregnancy for 2 years after transplant , but not more than 5 years .
   The cause of her renal disease needs to be clearly known because some disease like polycystic kidney disease is autosomal dominant and it needs genetic councilling . 
   Her medical comorbidities like hypertension and diabetes needs to be well controlled prepregnancy .
   I will ask her about her history of rejection and if she had   recent rejection  she should delay pregnancy at least 1 year after the recent rejection  .
   Drug history is very imporatnt and she needs to know that pridnisolone is safe in pregnancy,  azathioprin is not contraindicated and  cyclosporin  is not teratogenic but no available evidance  about mofitil and mycophenolate.   ACE inhibiters and AR blocker are teratogenic and should be stopped during pregnancy .
  vaccination history should be known because she is liable to infection , immunization aginst hepatitis B and tetanus , if not done pretransplant but rubella vaccine is contracindicated , CMV serology to be undertaken prepregnancy and at every trimester if negative
   Bp measurement as abaseline , with the BMI , RFT,  FBC , needs to be done
 
(B)
     This is high risk pregnancy , follow up should be in consultant led unit by multidiciplinery team which include obsterician , nephrologist , midwife and specialized nurse .
   Her medication should be reviwed agian once she is pregnant
    She had increased risk of miscarrage so the viability scan in early pregnancy should be asked for , 20 weeks anomaly scan should be requested also but she no increased risk of congenital anomalies .
Blood pressure should be not more than  140/90
Baseline renal function test with GFR as baseline tests should be done and repeated ever 4- 6 weeks to detect rejection early. also i will ask for 24 hour urinery protein measurment . MSU should be done evry 2 weeks and prompt treatment of asymptomatic bacterurea if present .
  she will need more frequent antenatal visits every 2weeks .
  Drug level of immunosuppressive medication should be done each trimester to avoid toxixity .
  I will ask for serial growth scan because she had increased risk of SGA nad IUGR every 3-4 weeks .
  She had increased risk of preclampsia  so the use of 75mg  aspirin daily from 12 weeks may reduce the risk of SGA and IUGR .
Clear delivery plan should be documented in the patient ANC card by 36 weeks .
She needs hydrocortisone intravenously  during labour to overcome the stress of labour .
The transpalnted kidney does not prevent vaginal delivery and c/s in indicated for obstetric reasone .

 

Essay 294 - Renal disease Posted by hoba K.
A 25 year old woman with a renal transplant attends for pre-conception counseling. (a) Discuss and justify your assessment [10 marks]. The patient is best seen and counseled in a joint clinic. I will ask the patient about the duration since she had the transplantation as it is recommended to delay pregnancy until after 2 years of successful transplantation. I will ask her about the cause of her renal disease, if it was genetic as polycystic kidney I will offer genetic counseling about the chance of transmitting the disease to the baby, if it was because of SLE nephropathy I will ask her about the time when she had the last flare and advise delaying pregnancy until at least 6 months after the last flare as well as asking about the respiratory, cardiac and skin manifestations to obtain an idea about disease control, if it was diabetes I will ask about visual symptoms due to retinopathy and neurological symptoms due to neuropathy, if it was hypertension I will ask about symptoms of uncontrolled disease as headache, visual symptoms, chest pain and shortness of breath will review her medications to optimize her immunosuppressive medications and prophylactic antibiotics in liaise with nephrologists and if on ACEI or ARBS I will advice her to stop these as soon as pregnant and will be switched to labetalol, if on hypoglycemics these should be stopped except for metformin again after counseling with diabetecians and if on methotrexate for SLE I will advice against pregnancy until after 3 months of stopping it. I will ask about symptoms of anaemia as fatigue and shortness of breath and palpitations since it is common in these patients. examination will include blood pressure, BMI, pulse for tachycardia that may be due to anaemia, cardiac examination for murmurs related to lupus vulvular disease ,chest auscultation for evidence of lupus related pulmonary fibrosis, neurological examination for diabetic neuropathy, fundus examination for diabetic retinopathy. investigations will include base line renal functions ( urea & electrolytes),serum creatinine.MSU for evidence of UTI, casts, proteinurea and haematurea. Baseline FBC for evidence of anaemia with serum ferritin for screening and diagnosis of iron deficiency anaemia. other investigations will depend on the cause,HBA1c for disease control if diabetic,if SLE echocardiography for pulmonary hypertension and valvular disease, CXR with or without pulmonary functions if evidence of restrictive lung disease and antibody screening (ANA, anti ds DNA, lupus anticoagulants, anticardiolipin igG and igM,C3,C4) to detect disease activity. (b) Discuss the additional interventions you would recommend during the antenatal period [10 marks]. She will require her ANC to be under a multidisciplinary team consisting of obstetricians, nephrologists with probable input from diabeticians or SLE specialists or geneticists depending on the cause of renal failure in addition to later input from neonatologists.she will require frequent reviews every 2 weeks with the MDT in addition to midwifery visits until 24-28 weeks then weekly until delivery.renal functions should be monitored at least every 4 weeks with urea,electrolytes and serum creatinine as well as MSU for proteinurea,casts and evidence of infection due to high risk of recurrent UTI which should be aggressively treated. blood pressure should be checked every visit as well as asking about symptoms as headache,blurring of vision and epigastric pain due to high risk of preeclampsia as well as prescribing aspirin 75 mg/d starting from 12 weeks until delivery.the original disease should be monitored and optimized in liaise with other members of the team.if the cause of renal failure is genetic,referral to fetal medicine unit and genetic counseling about possibilities of disease transfer and feasibility of prenatal diagnosis should be recommended. Due to high risk of SGA baby,scans for growth and amniotic fluid amount and umbilical artery Doppler should be offered every 4 weeks starting from 24-28 weeks as well as uterine artery Doppler at 20-23 weeks if indicated.antenatal steroids should be offered if renal functions or blood pressure control are deteriorating.discussion regarding delivery should take place at 36 weeks,timing of delivery should be individualized.vaginal delivery is not contraindicated, caesarean section for obstetric reasons. delivery in consultant led unit. continous fetal monitoring, monitoring fluid input and output and blood pressure monitoring. anaesthetic review should be offered in the third trimester. discussion with neonatologists about baby monitoring after delivery should be offered.
Posted by geeta G.

a) initial assessment aims to make sure that renal function is stabilised on minimum dose of medication for optimal pregnancy outcome. it includes detailed history regarding menstrual cycle as they may be having irregular cycle because of either medications or disease as such. obstetric history including any complications in previous pregnancies for example eclampia or APH as it may complicate future pregnancy. history of any contraception being used at present. Ask the reason for renal transplant as some diseases like auto immune disease may recurr and may affect the transplant. time interval since transplant as it takes time for the transplanted kidney to get stabilised, better to postpone pregnancy for 2 years after transplant.patient should be on minimum dose of corticosteroids and immunosuppressive drugs.assess the patient for risk of venous thromboembolism.

examination  for pulse , blood pressure, weight BMI. assess general condition of patient including pallor because these patients are at increased risk of anaemia. look for any abdominal distension or tenderness

investigations include FBC, urea, electrolytes, serum creatinine, MSU, urine culture to assess baseline renal function. renal USG and doppler to assess renal size and blood flow.

Take opinion from nephrologist and renal transplant physician for further management and reduction in medicine dose if possible.

b)her pregnancy should be managed in a joint clinic with consultant obstetrician, nephrologist and senior midwife. she should be counselled regarding effect of renal transplant on pregnancy and vice versa. pregnancy generally does not any adverse effect on transplanted kidney. renal transplant patients are at increased risk of maternal and fetal complications including pre-eclampsia, eclampsia, abruption,miscarriage, IUGR, preterm delievry and still birth. this patient will require more freq antenatal visits, fortnightly till 26 weeks and more frequent after that depending on the course of pregnancy. In every visit she should be checked for MSU, FBC, urea, creatinine and electrolytes. These patient are at increased risk of anaemia and vitamin D deficiency and so require these supplements. As she is at incresed risk of pregnancy complications, she will require fetal growth scan along with doppler studies every 2-4 weeks after 24 weeks depending on the progress. If the renal disease leading to transplant was of genetic nature, she needs to be referred for genetic counselling. renal transplant is not an indication for caesarean section, vaginal delievry is possible, CS only for obstetric indications all the information should be provided in a written form which is easily understandable by the patient. she should be provided details of support groups and contact details in case of emergency

Posted by UwaChuks U.
From history I will ensure that patient is In good health for the past 2years, and there's no graft rejection. I will ask if she is up to date with hepatitis B,Rubella, and Pneumococal vaccinations.history of other co-mobidities such as diabetes and this should be well controlled.i will review medications by discontinuing ACE inhibitor or ARB. Will ensure that the patient is not taking cytotoxic drugs such cyclophosphamide . Cytotoxic drugs should be stopped 3months before conception.if there's family or personal history of renal disease patient should be referred for genetic conselling. On examination I will check blood pressure and make sure is < 140/90 , if not well controlled advised against pregnancy .during this initial assessment I will perform FBC to detect aneamia and treat accordingly, also will do 24 hours urine colllection for protein clearance if there's protenuria on dipstick . Protenuria and hypertension is associated with adverse outcomes. Serum creatinine level will be checked and for good outcome it should be 250mmol/L pregnancy should discouraged and adequate contraception should be offered. I will check immunity for rubella and hepatitis B, hepatitis C. Hepatitis B vacine can be given in pregnancy. I will also test for cytomegalovirus , toxoplasmosis to make sure there's no ongoing infection, I will also do midstream urine for culture and sensitivity and treat any infection accordingly . I will do viability USS at 7-9weeks because miscarriage is about 30%, if pregnancy passes first trimester about 96% progress to term.at 10 weeks I will do baseline line FBC and serum creatinine , this will help to assess the disease progression during the pregnancy.24 hours urine collection for protein clearance will be done and nephrotic range will necessitate thromboprophylatics. Also if there's marked protenuria and there's other factors for VTE thromboprophylatics should be given.baseline liver function test should be done and repeat every 6 weeks. I will do MSU culture and sensitivity for asymtomatic bacturia and treat accordingly, and repeat every month or if symptomatic .i will offer aspirin 75 mg from 12 weeks till delivery.i will perform dating scan and screen for down syndrome at 11-13+6 weeks. Will perform anomaly scan at 18-20+6 weeks and growth scan from 24 weeks every 4 weeks. I will perform OGTT at 26-28 weeks.
GV Posted by Vandana G.
A.     During pre-conception counseling of a renal transplant woman, history is taken enquiring the disease for which renal transplant was performed as a genetic disease may necessitate referal to a geneticist for genetic counseling, too. Also how long has it been since the transplant was performed and when was the last episode of graft vs host reaction, if any. It is suggested to use effective contraception to avoid pregnancy for 2years since transplant as there are maximum chances of graft rejection during this time. History suggestive of present urinary tract infection (burning micturition or increased frequency), fever, loin pain, nausea, vomiting and hematuria should be asked and pregnancy deferred in presence of these symptoms.         The drugs the patient is taking should be reviewed by a combined obstetrician and renal physician to assess their safety in pregnancy. ACE inhibitors given for hypertension in renal disease are teratogenic and should be stopped in pregnancy. Among the immunosuppressants; azathioprine, cyclosporine, tacrolimus and prednisolone (low dose) should be continued in pregnancy. They are not teratogenic but growth restriction has been observed with cyclosporine. The woman's BP should be measured apart from the routine examination and maintained at less than 140/90mm Hg.         The baseline values for blood urea, serum creatinine, 24hrs urinary protein and creatinine clearance should be measured. Also, pregnancy should be planned only when serum creatinine is less than 125mmol/l and 24hrs urinary protein less than 300mg/ day. Its also an opportunity to assess the immunity status against rubella, HIV and Hepatitis B as routine and CMV (cytomegalovirus) specifically in renal transplant patients. B. The woman should have regular antenatal supervised by a multidisciplinary team comprising of a high risk pregnancy senior obstetrician, renal physician and specialist midwife at least. Apart from the routine antenatal care, special care should be taken to detect and treat anemia with oral iron. Erythropoeitin injections sometimes advised by renal physicians can also be used as considered safe in pregnancy. There is a possibility of both hyper- and hypo- calcemia. The calcium and vitaminD levels should be kept low in pregnancy.      Blood pressure should be regularly monitored and kept at less than 140/90 mm Hg. Depending on the risk of pre-eclampsia, low dose aspirin may be started from 12 weeks of pregnancy as a prevention. Pre-eclampsia if present is treated in the usual manner.      Renal function should be monitored regularly by creatinine clearance, serum creatinine and blood urea. Effective GFR measurement may not be appropriate in pregnancy. In the event of any deterioration in renal function, reversible causes like infection and dehydration should be looked for and treated. If urinary protein on dipstix is more than +1, the 24hrs urinary protein and creatinine protein ratio should be measured. Asymptomatic bacteruria in these patients should be treated at any time. CMV titres should be measured in each trimester if she was seronegative before pregnancy.       The fetal growth should be monitored regularly with serial growth scans and umbilical artery dopplers.       The lady should be counseled regarding the safety of immunosuppressants and necessity to continue the same in pregnancy due to the increased risk of graft rejection. With azathioprine use, mother's total leucocyte counts need to be monitored.        Renal transplant is not an indication for induction of labor or termination of pregnancy at any stage or cesarean section. Renal surgeon's opinion should be seeked in case of cesarean section. During delivery, antibiotic prophylaxis should be given for even minor procedures like episiotomy. During labor corticosteroid cover should be given to cover the stress.
Posted by Michelle G.

A 25 year old woman with a renal transplant attends for pre-conception counseling. (a) Discuss and justify your assessment [10 marks]. (b) Discuss the additional interventions you would recommend during the antenatal period [10 marks].

Assessment would include a thorough history of when and why she required a renal transplant, what her current renal function is and what immunosuppressive medication she is on to prevent organ rejection.  It would be important to assess whether she was on any teratogenic medication.  If she required a renal transplant for an autoimmune diseases such as systemic lupus erthematosus then presence of anti-la and anti-ro antibodies should be checked as these can cause fetal heart block, SLE can also cause increase risk of miscarriage and deteriation in renal function and she may require antenatal anticoagulation treatment to prevent venous thrombois.  The history would also include her obstetric and gyanecological history if previous successful pregnancies, period of trying to concieve, past cervical smear tests.  I would involve her renal physicians in a multi-disciplinary team approach, in counselling her for future pregnancy regarding possibility of deteriation in renal function.   Her general health would be assessed in particular her blood pressure and whether she had co-existing hypertension from her renal impairment and consider changing her antihypertensive treatment to labetalol or methyldopa that is safe in pregnancy, ace inhibitor are not recommended in pregnancy due to possible teratogenic effects.  A protein creatinine ratio should be sent to check if pre-exisitng proteinuria and a urine MSU to treat any exisitng urinary tract infection.  A full blood count should be done to check  if previous existing anaemia due to renal failure, and erthropoitin treatment may be required to boost Hb.  Her current reneal function should be checked.  Her rubella status, along with whether she was up to date with her pneumococcus and influenza vaccines should be checked and these offered to her if required.  She should be advised to start 5mg folic acid pre-conception.

 

b. During the antenatal period she should managed within a multidisciplinary team including her renal physicians, a maternal medicine obstetric consultant and specialist midwife.  Aspirin 75mg at 12 weeks should be commenced if pre-existing hypertension, as she is at risk of developing superimposed pre-eclampsia.  Her risk of venous thrombosis should be assessed and antenatal low molecular weight heparin should be started once pregnancy test positve if previous DVT/PE or prothrombotic disease process present like SLE.  Blood pressure should be checked every fortnight for first and second trimester and weekly after that, renal function should be monitored at minimum every 4 weeks, though more frequently if any clinical deteriation or development of pre-eclampsia.  If SLE then maternal blood sould be checked for anti-ro or anti-la antibodies and if positive referral should be made to fetal medicine specialist.  The baby should have serial growth scans if maternal renal function is poor or hypertension present, to ensure adequate growth during pregnancy.  There may be a need for premature delivery if rapidly deteriating maternal renal function or organ rejection, and steriods should be given in timing manner to boost fetal lung maturity.  The woman may require high dose oral steriods during pregnancy to prevent organ rejection, and should therefore should receive IV hydrocortisone during labour.  IOL and labour is not contraindicated and depends on the gestation and indication for delivery and should be on a consultnat led labour ward.  Caesarean section may be required in premature delivery of a IUGR baby.  An anaesthetist review should be arranged antenatally due the possibility of the lady needed dialysis and ICU admission.

renal transplant Posted by koukab A.

a)i ll do assessment by history,examination and investigations.regarding history i ll ask about reason for renal transplant whether it was acquired or inherited disease of kidney that led to transplant as inherited disease need prepregnancy genetic counselling.time since transplantation is important as in case of living donor,it should be waited for one year and in case of cadaveric donor should be waited for two years before getting pregnant.i ll do all assessment in multidisciplinary clinic involving nephrologist.drug history is important as dose for immunosupressant drugs should be adjusted if needed and antihypertensive like ACE inhibitors or angiotensor receptor blockers cause congenital abnormalities and contraindicated in pregnancy so need to change for safe antihypertensive in pregnancy.i ll look for overall general health status of pt. like for any symptoms needing further evaluation.history of any other medical or surgical illness.family history for hypertension and diabetes mellitus.social history for her occupation.history of smoking and alcohol intake.vaccination status will be checked.regarding examination BP should be checked.BMI should be measured.watch for pallor.regarding investigation i ll check FBC to look for Hb to rule out anaemia.renal function test including urea,creatinine and electrolytes are important as creatinine value less than 125mmol will indicate good pregnancy outcome and value upto 180mmol is contraindication for pregnancy.BSL fasting,LFTs will be checked.urine for MSSU to rule out UTI and to look for protein and glucose in urine.USG KUB ll be to look for status of kidney,ureter and bladder.                                                                        b) additional intervention for antenatal period will be that it needs multidisciplinary management.nephrologist should be involved.more frequent antenatal visits like initially every 2weeks and then weekly from 28-32wks onward.BP and proteinuria ll be checked at each visit.FBC and RFT ll be checked 4weekly.screening for CMV and hepatitisb and c willbe done twice in pregnancy in addition to routine screening for HIV,rubella and syphilis.drug levels for immunosuppresive drugs will be monitored.antihypertensive drug dosage will be adjusted according to BP.serial growthscan for fetus will be done 4wkly from 28wks onward as there is risk of IUGR.delivery will be in consultant led unit and mode of delivery will be by SVD but CS will be reserved for obstetrical indications only.