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ESSAY 135 - RENAL TRANSPLANT

Posted by Sarwat F.
A woman having a renal transplant contemplating a pregnancy needs detailed counseling regarding interventions and adjustments in management preconceptually. She should be counseled that she needs to be in good general health for 2 years after transplantation. Her condition should be discussed with her physician as her plasma creatinine should be less than 150 umoles per litre, she should have no or minimal proteinuria. There should not be any hypertension or if present it should be easily controlled. It should be made clear with discussion with her physician that there is no evidence of graft rejection and no evidence of pelvicalyceal dilatation on a recent ultrasound or excretory urogram. Her medication like predinisolone used in transplant recipient should be less than 15mg/day. Other medications include cyclosporine A and azathioprine should also be less than 5mg/kg and 2mg/kg/day respectively. Steroids should be kept as low dose as possible because there is association with teratogenic effects, immunosupressives however have no reported teratogenic effect. She should be counseled that if these guidelines are not followed then there is a risk of poorer obstetric outcome and long-term problems.
Her prenatal care will also be modified as this is a high risk pregnancy. Close liaison between physician preferably nephrologists and obstetrician is vital. Visits should be 2 weekly till 32 weeks and weekly thereafter. Renal function checked by monthly creatinine clearance and protein excretion. Full blood count will also be checked monthly Regarding management of hypertension care is required for any superimposed preeclampsia which is difficult to predict because of underlying renal disease, although pregnancy does not adversely affects renal function. Antihypertensive may need to be started at BP as low as 95 mm Hg. Methyldopa, nifedipine and hydralazine are appropriate drugs. Diuretics are avoided. Immunosupressives maintained at prepregnancy levels. Women with renal transplant are at particular risk of specific problems like hyperparathyroidism, urinary tract infection and viral infections so it is important to check liver function tests, serum calcium and phosphate and regular urine cultures. Screening for CMV antibodies is also required at booking. Close fetal surveillance will be required in view of risk of IUGR and stillbirths depending on renal function and local facilities available. If the cause of renal failure in mother is due to certain hereditary conditions genetic counseling will be required. Ultrasonic estimation of fetal size on monthly basis from 24 weeks onwards. Any abnormality in fetal growth may require Doppler studies of umbilical artery and admission for frequent biophysical monitoring. Regarding mode of delivery, spontaneous labour can be awaited if maternal and fetal conditions are satisfactory. Caesarean section is required only for obstetric reasons. A transplanted kidney does not lead to obstructed labour. Steroids increased to cover the stress of delivery and all procedures must be covered by antibiotics.
Posted by Vaijayanti R.
She is advised preconception counselling ; avoid conception for 1 to 2 years following the graft ( to allow for recovery from surgery and stabilization of the transplant), and to use appropriate contraception till then. COCP ( may cause rise in blood pressure and thromboembolism) and Intrauterine devices( reduced efficacy, increased infections) are to be avoided ; Progesterone only contraception , barrier mathods may be used till then.
Each Unit has its own guidelines for conception after a renal transplant, and the same should be followed.
Folic acid ( 400 mcg/day from 12 weeks prior to conception to 13 weeks gestation) is advised.
Diet modifications would include a low protein diet, with adequate natural vitamins and mineral. A low salt diet or fluid restriction will have no bearing on the outcome.Adequate cooking of meat ( prevent listeria, salmonella) and eggs( salmonella)
Life style modifications should include avoiding cat litter, washing hands,washing vegetables ( prevent toxoplasmosis). Avoid excessive exercise to reduce proteinuria.
Apart from this, other interventions would include assessment of her Rubella status, and offer immunization if necessary
Plan pregnancy when renal functions are stable,and there is no evidence of graft rejection,minimal or no proteinuria,minimal or mild hypertension and the drugs ( steroids and immunosuppressants ) are at the lowest maintainence dose.ACE inhibitors for the treatment of hypertension should be replaced by other drugs ( Ca channel blockers, methyldopa).
If she had a heritable cause of renal failure ( autosomal dominant polycystic kindeys) she should be referred to a Genetic Clinic for further counselling.Any underlying cause of the renal failure should be assessed( Diabetes, SLE,reflux nephropathy) and appropriate treatment measures instituted ( insulin and diet control in diabetes)
The risks and possible complications to her ( risk of preeclampsia, graft rejection in puerperium etc) and the preganacy ( miscarrriage, ectopic pregancy, growth restriction, iatrogenic prematurity) should be discussed

Pregnancy after Renal transplant is ? high risk? and should be managed in a multidisciplinary clinic with a renal physician.
She is advised of the increased risk of worsening hypertension, superimposed pre eclampsia and anemia; the fetus would be at increased risk of misacarriage, growth restriction, still births, iatrogenic prematurity
She would be required to come more frequently for antnatal checkups( once in 2 weeks till 32 weeks, then once a week till delivery); report immediately if there is any infection.Renal functions ( creatinine clearence,24 hr urinary protein,urea and electrolytes) along with liver functions, plasma protein concentration, urine culture and CBC are to be assessed every month. Intensive fetal cardiac monitoring will begin form 26 to 28 weeks gestation. Serial USGs are done to detect any early growth retardation.
She would also have to periodically be screened for preeclampsia, anemia, and asymptomatic bacteriuria
Antihypertensives for superimposed preeclampsia are started at lower diastolic pressures( 90 to 95 mmHg); methyl dopa, calcium channel blockers may be used.
Immunosuppressants are usually maintained at prepregnancy levels, though dose may need adjustment if WBC or platelet counts fall.
Care should be taken as graft rejection in pregnancy often has a atypical presentation ( preeclampsia, immunosuppressant toxicity)
Delivery will have to conducted in a hospital by a senior Obstetrician. The risk of premature delivery will be higher , especially if associated with preeclampsia, deteriorating renal function or fetal compromise. Vaginal delivery is the accepted method, with Caesarean Section being done for obstetric indications only. A transplanted kidney usually does not obstruct labor. Higher dose of steriods will have to be given to overcome the stress of labor
Graft rejection may happen postpartum when immunocompetance returns to normal.While there is no consensus on breast feeding on immunosuppressants, it would be likely that she would be advised against lactation.
Posted by uma M.
Women seeking advise regarding pregnancy after renal transplant are increasing , 1 in 50 women after transplant become pregnant.
For all women contemplating pregnancy it is ideal that prepregnancy evaluation is done & advice given regarding effects of pregnancy on transplant , effects of transplant on pregnancy, effect of drugs used, likely putcome depending on renal function.
Any interventions &adjustments must be made in collaboration with a Nephrologist. She should be advised not to plan pregnancy for atleast 2 years, this allows time for graft stabilization, & also recovery from surgery, and maintanence levels of immunosuppressive drugs has been reached. She should be warned that as renal function becomes normal she becomes ovulatory and so require contraception, advice regarding that. Pregnancy out come depends on baseline s.creatinine, presence of hypertension, &proteinuria.If graft function is normal out come is excellent with95% sucess rate. She should have strict control of HTN,adjust anti HTN drugs , avoid ACE_ inhibitors as these have effects on fetus.Adjust dose of imunnosupressive drugs. Various drugs used include Prednisolone, azathiprime, cyclosporine&tracolimus which are safe in pregnancy.Maintenance levels include <15mg/day of prednisolone , <2mg/kg/day of azathioprime,<10mg/kg of cyclosporine A. She should be councelled that if ahe enters pregnancy with s. creatinine of> 130umol/l, with HTN, proteinuria outcome might be poor, and likely chance of graft deterioration.

Pregnancy in renal transplant women is at increased risk of mis carriages,HTN/Preeclampsia(30-40%),graft rejection(10%) , renal impairment (15%), preterm delivery, IUGR, increased UTI.These complications are more common in diabetics. consider as high risk pregnancy.AN care in these patients again should be in laisson with nephrologist,.She should have regular , carefull monitoring of BP, edema, regular assessment of renal function by creatinine clearence & 24 hr protein excretion, s.creatinine_ monthly. Regular check for anaemia should be done as these women are at increased risk of this, prescribe haematinics . at Each visit MSU should be tested for evidence of any infection. While on imunnosupressive drugs monitor Blood counts, LFT, regularly -each month. AS these women are at greater risk of IUGR, monitor fetal growth 2weekly till32 wks , then weekly. Ante natal fetel surveillane should start early as dictated by situation.If pt is on prednisolone screen for GDM .
If there is any deterioration of renal function she should be evaluated for PREeclampsia, rejection, UTI, nephrotoxicity due to cyclosporine.
If there is no deterioration of renal function, worsening HTN OR proteinuria , early delivery is not indicated.
C. SECTION FOR OBSTETRIC INDICATION ONLY. But there is increased incidence of c. section in these women.If on steroids she require stress dose of steroid to cover labour/c.section.Prophylactic antibiotics should be given to cover surgical procedure, including episotomy.Involve neonatologist to assess neonate as these are at risk of thymic atrophy, leukopaenia, depressed haematopoises, adrenocortical failure, septicaemia.
Posted by Sameera C.
She should be managed by obstetrician with experience in taking care of pregnant women with renal transplant along with renal physician.
An enquiry is made about the indication of the renal transplant if this is due to inherited disorder such as polycystic kidney disease, genetic counselling is arranged and she is informed about the availability of prenatal diagnosis. If she had undergone renal transplant due to a chronic renal disorder such as SLE, diabetes mellitus the implications of the disease and their management on pregnancy are explained.
Blood pressure is recorded to exclude hypertension and current renal function is assessed with serum urea, creatinine clearance, and quantitative assessment of protien in 24 hr urinary collection.
The drug treatment related to the renal transplant is reviewed . She is explained that there is no evidence that the steroid treatment is associated with increased risk teratogenicity in humans. If she is on antihypertensive treatment with ACE inhibitors, it is replaced with other safe antihypertensives as ACE inhibitors are teratogenic and associated with impaired fetal renal function. Immunosuppressants are not teratogenic but cyclosporine may have higher risk of IUGR. If she is using antibiotics she is advised to continue antibiotics but they need to be changed to safer ones.
She is advised to postpone her pregnancy at least for 1 or 2 years post transplant because if the renal function is good in the first 2 years post tranplant there is good chance of 5 yr survival . She is advised regarding the appropriate method of contraception to postpone pregnancy. She is informed that poor renal function is associated with infertility due to anovulation
She is explained that pregnancy does not have long term adverse effect on renal allograft. The renal transplant adapts in the same way as normal kidney. The over all outcome of the pregnancy is favourable in the absence of hypertension, infection and protienuria. She is informed that there is increased risk of development of hypertension, IUGR, prematurity, graft rejection and infection particularly urinary tract infection. Blood pressure is monitored regularly and hypertension is treated in the same way as pregnancy induced hypertension. Iron and folate supplements are given, as there is increased risk of anaemia during pregnancy. Any infection is treated promptly with antibiotics.
Her renal function is assessed by creatinine clearance, U& E. quantitative assessment of protien excretion in 24 hr urine and MSU each visit. There is no need to deliver the woman with protienuria if this is not associated with hypertension.
CMV titres are assessed each trimester if she is negative for CMV infection in the first prenatal visit. If blood transfusion is necessary CMV free blood is transfused.
Fetal growth and wellbeing is assessed with serial growth scans and doppler studies of umbilical artery as there is increased risk of IUGR and prematurity.
Caesarean section is indicated only for the obstetric indications and pelvic kidney doesn’t obstruct vaginal delivery because of its location. If caesarean section is indicated it is performed under the cover of prophylactic antibiotics and hydrocortisone.
After delivery the complications such as adrenal insufficiency, transient leukopaenia, thrombocytopaenia, sepsis and infection such as HBV , CMV are anticipated in the neonate. If detected, treatment is provided accordingly.

Posted by Nibedita R.
It is advisable to wait 1-2 years after the transplantation before embarking on a pregnancy. By which time graft function will become stabilised and maintenance levels of immunosuppressive drugs will have been reached, thus minimising risk to foetus and 5 year transplant survival rate of upto 80% can be anticipated.

Genetic counselling should be offered if the reason for transplant was for familial disorders like polycystic kidney disease or medullary sponge kidney. If transplant was due to autoimmune diseases such as SLE, assessment of the disease activity from history, clinical examination and necessary blood investigations like FBC, ESR, antiphospholipid antibodies has to be done.

Assessment of function of the graft from blood pressure, FBC, U&E, creatinine clearance and 24 hour urine for protein excretion.

Pregnancy should be discouraged in the presence of active renal disease and poor renal function. In which case a poor pregnancy outcome is anticipated. Adequate contraception should be maintained till renal function improves.

Pregnancy should be advisable if renal functions are normal. Preconceptional advice such as regular folic acid 400mcg daily, avoidance of smoking, alcohol and healthy dietary advice should be given. Vaccination against rubella if no history of rubella infection.

Review of the drugs and their effect on pregnancy with the consultation of renal physician and necessary adjustments should be done. Anithypertensives like ACE inhibitors are teratogenic and impair renal function; beta-blockers are associated with IUGR and thus these need to be changed to alternatives. There may be a need to change to renal friendly prophylactic antibiotics. Immunosuppressants are not teratogenic and reduction or cessation of the drug may cause graft rejection. Glucocorticoids are safe to use in pregnancy (not teratogenic).

Outcome of pregnancy is optimum in those without hypertension, proteinuria, recent episodes of graft rejection and in those with normal or near normal renal function. Chances of successful outcome beyond12 weeks are 90% with normal preconceptional renal functions. This goes down to 70% if pregnancy complication occurs before 28 weeks.

Woman should be managed jointly by nephrologist and obstetrician with expertise in the care of pregnant renal transplant recipient. Risk of hypertension and preeclampsia is increased upto 30%. Careful monitoring and control of blood pressure is important.

Pregnancy does not adversely affect long term renal function. Regular assessment of renal function by creatinine clearance, 24 hour urinary protein excretion, U&E, and serum creatinine is essential. FBC and LFT should be checked regularly. Anaemia should be treated by haematinics. Maternal calcium status should be carefully monitored. Both hypo and hypercalcemia are potentially dangerous. Dose of vitamin D and calcium need to be altered accordingly.

Frequency of antenatal visits need to be increased. MSU should be taken and sent at each visit and any infection should be treated promptly. Prednisolone can cause glucose intolerance; hence, GTT and fasting glucose should be checked.

CMV titre should be checked in each trimester if he woman if CMV negative at the onset of pregnancy and only CMV negative blood should be transfused.

Foetal risks involve early pregnancy loss, IUGR (20-40%), preterm delivery (40-60%). Regular assessment of foetal growth by ultrasound and doppler is important.

Unless complicated by poor renal function presence of proteinuria is not an indication for delivery. Labour and delivery in renal transplant patient is not different from other women. Caesarean section is done only for obstetric indication. The graft does not interfere with normal labour (no dystocia). Steroids cover is needed for labour and delivery and prophylactic antibiotics and needed for operative procedures. An expert neonatologist must be present during birth. Neonatal complications are largely due to prematurity and IUGR. Others like adrenal insufficiency, leucopenia, thrombocytopenia, sepsis and CMV/ hepatitis infection.

Breast feeding is safe with immunosuppressive drugs.
Posted by SWATI M.
The woman with the renal trasplant needs to be seen with a renal physician,preferably in a combined clinic to optimise care.The optimum interval between the transplant and pregnancy is important.woman should be adviced to differ pregnancy for 11/2 to 2 years after the transplant.By this time graft acceptance is known and doses for immunosuppresants are adjusted to minimum.
Drugs and dosages adjustments done with advice of renal physician.Minimum number of drugs with minimum maintenance dosage without affecting the efficacy should be the aim.There is a concern regarding the immunosuppressants to be teratogenic, though no reported problem with most of the drugs used.Most data is available about azathioprine use in pregnancy.Change of immunosuppresants to azathioprine is desirable. Antihypertensives ,if using ACE inhibitors needs to be changed due to concern of teratogenicity and growth restriction.Optimum control of blood pressure is needed before pregnancy .
Effective contraception should be continued till time pregnancy is not advisable.
Renal function tests done to know the function of transplated kidney by 24 hour creatine clearance and protein excretion.Viral screen HBV,HIV is important as increased risk of contacting due to repeated haemodialysis.
Modifications in her pregnancy care-She needs increased number of antenatal visits,every 2-4 weeks till 32 weeks and weekly thereafter,along with renal physician.Careful vigilance for hypertension,superimposed preeclampsia by monitoring blood pressure and for proteinuria is important. Antihypertensives doses may need to be adjusted according to blood pressure changes in normal pregnancy.MSU for microscopy and culture ,renal function tests by 24 hour creatine clearance and proteinuria should be performed every month.Vigilance for signs and symptoms of graft rejection is important.
Need fetal growth monitoring by regular ultrasound examination every 2-4 weeks due to increased risk of growth restriction.
Premature induction of labour is indicated if develops severe hypertension,superimposed preeclampsia, deteriorating renal function,fetal compromise.
She needs careful monitoring and control of blood pressure ,fluid balance during labour.Fetus should be monitored by continuous electronic fetal monitoring.Caesarean section should be reserved for obstretric indication only.She needs extra corticosteroid cover by hydrocortisone if on long term corticosteroid treatment.

Change the drugs and doses to prepregnancy schedule in postnatal period.Advice on contraception,combined pills will be contraindicated if severe hypertension ,increased risk of pelvic infection with IUD use with immunosuppresants.

Posted by vijaya L.
Pre-pregnancy ?
She should be advised to wait at least for two years after the transplant for the optimal outcome. During this time she would need effective contraception because as the renal function returns to normal her fertility improves.
A detailed history of the transplant and renal function since transplant should be taken for accurate counseling so that she can make an informed choice.
The outcome is better with transplant from a living relative (than cadaver), with fewer episodes of transplant rejection.
Renal function should be normalized so that she is normotensive and her creatinine level is less than 125 micro moles/l prior to pregnancy.
Prednisolone, Cyclosporin, Azothioprine and Tacrolimus can be continued during the pregnancy as well. Mycophenolate moftil is teratogenic and should be stopped and if this action increases the chance of rejection, pregnancy should be discouraged.
Anemia should be corrected, folic supplementation started and susceptibility for rubella, CMV and chickenpox should be checked for.
Prenatal diagnosis may be required if the renal failure was due to a congenital disorder.

During pregnancy ?
Antenatal care should ideally be delivered by, an obstetrician with an experience in renal disease in collaboration with nephrologist.
CMV titers should be done every trimester if she was negative prepreganacy.
More frequent monitoring for hypertension is necessary. Should be seen weekly from 32 weeks onwards.
Serum creatinine, FBC and MSU should be checked for at each visit.
Some women might need prophylactic antibiotics for increased risk of urinary tract infection
Immunosuppressive therapy needs to be continued and incidence of IUGR is higher with Cyclosporin.
Serum calcium levels may have to be monitored in case renal function is less than optimal and supplemented accordingly.
Iron supplementation is also required.
Transplant will not cause obstruction of labor hence cesarean section is determined by obstetric indications.
Dating ultrasound and serial ultrasound examination for fetal growth is necessary as IUGR is common.
parenteral steriods are necessary during the labor.








Posted by narmin B.
As there is a risk of rejection of the transplanted kidney she should be advised to avoid pregnancy for 2 years from the time of renal transplant. The other benefit of this waiting time is reducing the high dose of steroids and immunosuppressive drugs to their maintenance dose. An appropriate method of contraception such as progesterone only pill or barrier methods should be recommended. Combined oral contraception pill is relatively contraindicated because of hypertension which is common in these patients.


It must be explained that pregnancy has no adverse effect on the transplanted kidney and in the presence of normal renal function, the pregnancy outcome is good in 70% to 80% of cases. This rate will reduce to 30% to 40% if renal function tests were abnormal. Complications of pregnancy will be in the form of early or late fetal loss, preeclampsia,super imposed pre-eclampsia, intrauterine growth retardation (IUGR) and prematurity.


If the reason for kidney transplant is a genetic disease such as polycystic kidney, a genetic counselling is required to estimate the risk of inheritance to the baby if possible.

There should be liaison with renal surgeon. Renal function tests, urea, electrolytes, creatinine and uric acid should be checked prior to pregnancy and if there was any abnormality, referral to nephrology team is necessary.

As soon as pregnancy is noticed she should be booked for antenatal care.
Immunosuppressive and steroids are safe during pregnancy and needs to be continued. The patient should be reassured that these medications are not teratogenic. Antibiotics should also need to be reviewed for teratogenicity. Angiotensin converting enzyme inhibitors (ACEIs), which are given for hypertension, can cause oligohydramnios and intrauterine growth retardation therefore another antihypertensive such as methyl dopa should be given during pregnancy. ACEIs can be recommenced after delivery. As there may be a need for early delivery because of pre-eclampsia or IUGR, dating scan in first trimester is necessary to determine gestational age accurately. Particular attention should be paid to fetal kidneys during anomaly scan at 18 to 20 weeks. Urine analysis for infection and protein and blood pressure measurement are required in each visit. Renal function tests must be requested every month and if there was any abnormality, referral to nephrology team is required. As there is a risk of preterm labour, steroids should be given at 26 weeks to prevent respiratory distress and intraventricular haemorrhage. Fetal growth should be checked at 26 weeks and if there was any evidence of growth retardation, it should be repeated every fortnight. Doppler studies and amniotic fluid index are also required in the presence of IUGR. If there was fetal compromise, early delivery may be required. In addition observation for signs and symptoms of pre-eclampsia or super imposed pre-eclampsia is necessary. Mother should be asked to report symptoms such as headache, epigastric pain and visual disturbances. In the presence of severe pre-eclampsia, delivery must be considered.

Transplanted kidney does not cause obstructed labour and normal delivery is possible. Intravenous steroids should be given during labour because of stress of labour. Prophylactic antibiotics and thromboprophylaxis are also mandatory. Caesarean section may be required because of obstetric reasons. Regional anaesthesia is appropriate and general anaesthisia can be given if necessary.

Posted by Rani M.
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Posted by Rani M.
dear paul, i\'m really fed up. i tried writing this answer three times but when i click submit it does n\'t go. it comes server error. but when it writ short message like this or just xxx it goes. can u help me. it is exhausting to write whole answer online and then it does not submit
Posted by Rani M.
pregnancy, Discuss interventions and adjustments in management which may be advised prior to conception. how will her renal transplant modify her pregnanacy care.


A: The woman is advised to defer pregnancy for 1- 2 years after the renal transplant as by this time transplant function has been stabilised and the drugs are at the maintemanace doses, thus minimising toxicity. history is taken to know the cause of renal failure which if genetic like polycystic kidneys, genetic counselling is offered. If she is on antihypertensives or antibiotics they may need to be modified to safer alternatives during pregnancy like stopping ACE inhibitors ( risk of IUGR, oligohydramnios, fetal death) , pure beta blockers (risk of IUGR ). If she is on mycophenolate mofetil, pregnancy is hazardous due to risk of teratogenicity, so pregnancy should be avoided till 6 weeks after stoppping the drug,There is no evidence of teratogenicity with other drugs like azathioprine, cyclosporin, tacrolimus and prednisolone at maintenance doses. so she is advised not to stop drugs,. any modification in her drugs should be done in close consultation with nephrologist and woman is informed regarding any potential deterioration in renal function.
Renal function are checked and preganancy is deferrd till renal status is stabilised. preganancy outcome is succesfull in 97% of cases if creatinine clearance is less than 120 micromolll while only in 75% cases if creatinine clearance ia more than 130 micro mol l l.Need for closer surveillance is emphasized dur to 10 % risk of graft rejection, 30 % risk of hypertension & preeclampsia, higher risk of infections, esp. UTI and fetal risks such as IUGR,& both early and late preganancy losses( 50-60%).Folic acid suplementaion is provided to minimise the risk of nueral tube defects.
During pregnancy she is managed in close liason with nephrologist, physician and an obstetrician experienced in managing such mothers. Renal function is regularly monitored by serum urea, creatinine, creatinine clearance and 24 hour urinary protein excretion.
there is need for good control and monitoring of B.P.. due to adverse outcomes associated with it.
M.S.U. is checked at each visit to detect UTI and asymptomatic bacteruria and any infection is promptly treated.
Iron supplementaion is provided due to higher risk of anemia.
Calcium and vit D doses may need to be altered as both hypo and hypercalcemia can be a problem.
C.M.V. titres are checked in each trimester.
Fetal monitoring is done by serial growth scans due to higher risk of IUGR ( 20% risk asssociated with Azathioprine and 30- 40% risk with cyclosporin)
due to side effect of prednisolone, her blood sugar may need to be checked frequently.
Renal ultrasound is done if there is any suspician of graft rejection suggested by fever, liguria, swelling and tenderness in the renal angle . any deterioration in renal function is an indication for delivery.
Mode of delivery is vaginal unless there is any obstetric indication for cesarean section. any surgery including episiotomy is to be covered by prophylactic abtibiotics.
I.V. Hydrocortisone is given during labour as in any woman on long term steriods.
Baby should be examined and followed up with a neonatologist. cord blood sample are taken. baby is at a higher risk of thymic atrophy, adrenal insufficiency, transient leucopenia, thrombocytopenia and depressed haemopoesis.
Breast feeding is not contraindicated
Posted by Rani M.
Dear Paul,
Thanks for your suggestion of using wordpad , copying and then pasting my answer. this was successful and is more convenient. But please mark my answer also. though you have already written answer plan, but checking my answer will help me to build up my style and to know where i go wrong. thanks, charu