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Essay 285 - Renal transplant

Essay 285 - Renal transplant Posted by PAUL A.
A 35 year old nulliparous woman with a renal transplant has been referred for pre-conception assessment and counselling. (a) Justify the information you would obtain from the history and clinical examination with specific reference to her renal transplant [5 marks]. (b) Which investigations will you undertake and why? [4 marks] (c) What would you tell her about the potential effects of pregnancy on her transplanted kidney? [4 marks] (d) What will you tell her about the potential effects of her renal disease on pregnancy? [7 marks].
Posted by Farzana N.
a)History is taken regarding reason for transplant ,if for genetic disease e.g ppolycystic kidney disease,she would require genetic counseling.In case of acquired
a diseases i.e SLE or diabetic nephropathy,she would require assessment of disease status.In case of SLE she should conceive in period of remission at least for 6months.If DM ,blood sugar should be well controlled before conception.
Duration of renal transplant is taken.Pregnanacy is advised at least 2yrs after transplant so that graft rejection and immunosuppressive therapy is stabilized.Enquire about any recent episode of graft rejection.
Drug therapy is reviewed with Renal physician. Corticosteroids,immunosuppressives i.e cyclosporins and azathioprine can be continued in pregnancy. Antihypertensives,ACE inhibitors are teratogenic and impair fetal renal function and should be changed.Antibiotics would need to be changed .Aminoglycosides should be avoided in pregnancy.
She should be advised against pregnancy if active SLE, poorly controlled blood sugar levels or any recent episode of graft rejection .Contraception is provided.
Examination includes palor for anemia,as patients with renal failure are prone to anemia.BP is taken,presense of hypertension adversely affects pregnancy outcome. .Any stigmas of active SLE noted.Funduscopy may be required if she is diabetic.

b) Investigations include FBC-for Hb and degree of anemia,MSU and culture and sensitivity for UTI.24hr protein-If proteinuria is >5gm she would require thromboprophylaxis during pregnancy.In case of SLE ,ESR and antiphospholipid antibodies done.U&E and RFT done to assess creatinine clearance.If se creatinne is <120micromol/l,pregnancy outcome is good.

c)Pregnancy has no long term survival effects if renal function are good and prepregnancy serum creatine.100micromol/l.If the levels are130micromol/l,renal graft survival is65% at 3yrs.About 40% women have proteinuria near term, but it regresses after delivery.

d)Pregnancy with renal disease should receive multidisciplinary care with senior obstetrician, Renal physician ,GP , midwife and specialist nurse.It is associated with significant risk of complications in about 50% of cases.includuing Hypertension or PET 30%,IUGR10-20%,PTD -40-60% and infections especiallyUTIs.She should have close monitoring in pregnancy with frequent antenatal visits, for early identification and treatment.At each visit BP checked ,MSU sent and any infections treated.Serum calcium levels are monitored and maintained.Iron and folate supplements are given.
Fetal growth is monitored by growth scans.If IUGR is suspected dopplers would be done for fetal wellbeing and planning of delivery. during
Transplanted kidney does not obstruct labor, so aim would be vaginal delivery.In case of obstetric reasons CS would be done.Increased steroids and antibiotic cover required labor.
Posted by Dr Dyslexia V.
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a. History pertaining to the cause of the renal impairment must be taken as is it a chronic disease, a familial disease, an acquired disease or due to trauma as it helps for counseling. .Her medical history also must be taken to assess her co morbidity such as diabetes , hypertension , SLE as it need to be optimized prior to pregnancy. The medication which is currently used also must be ascertained as to optimize the treatment and to reduce teratogenecity. Familial history for kidney disease need to be addressed for genetic counseling and decision for prenatal diagnosis. Her HIV or hepatitis status also must be taken due she could have multiple transfusion before.
Clinical examination include her body mass index to ascertain her to assess her VTE risk, Blood pressure to evaluate her hypertension. Per abdominal examination to look for mass and scar site. Per speculum examination to check for genital tract abnormality as it is associated with renal tract abnormality.


b. Baseline investigations of renal function especially creatinine level and urea level should be taken. Cretinine clearance must be assessed to determine the baseline renal function and to determine prognosis .A full blood count to detect underlying anemia and to correct it. A urinalysis should be done to check for proteinuria , hematuria as for detecting current renal status and as a baseline. Presence of leukocytes have to be treated as the risk of urinary tract infection is high in pregnancy and immunosuppresion. Hepatitis, and HIV status should be confirmed as due to the possible history of multiple transfusion prior.

c. An uncomplicated pregnancy does not affect her current renal function. But pregnancy complicated with preeclampsia, hypertension, gestational diabetes could deteriorate the kidney function in pregnancy. Urinary tract infection in pregnancy is also increased which could cause pyelonephritis. .


d. Renal disease should not be affected through the course of an uncomplicated pregnancy. But occasionally it could cause effects such as preeclampsia, hypertension in pregnancy which necessates her for anti hypertensive treatment. Development of gestational diabetes will require higher insulin treatment. Incidents of pre term delivery which includes iaterogenic delivery. There could be a very small probability of miscarriage and second trimester miscarriages in the pregnancy. The probability of the baby having renal problem could be addressed with a detail scan. The risk of intrauterine growth retardation also is increased in this pregnancy which might require regular fetal growth and ultrasound assessment. A vaginal delivery is not containdicated and Caesarean section is only done on obstetric indication
Posted by Sandhya P.
a) Preconception counselling of a woman with renal transplant pivots on the accurate asessment of risk to the woman relative to the chances of a successful pregnancy. A good history and clinical assessment of the woman would be directed to determine the degree of renal impairment & the presence of complications.
The time since transplant should be enquired as also the indication for the transplant -- this because it is ideal to wait for at least 2 yrs after transplant to conceive as she would then be on maintainance levels of immunosuppressive drugs & any chance of acute graft rejection would have passsed. A congenital renal disease in mother can increase risk of anomaly in the fetus . All old records should be verified .
History of drug intake & the doses should be noted as she should be kept on maintainace doses of immunosuppressive drugs .If she is on ACE inhibitors they would have to be changed to safer drugs like beta blockers.
History of current contraception is asked to ensure that she has adequate protection till it is safe for her to conceive .
History of subfertility should also be asked as there can be difficulty in conceiving.
History of smoking , alcohol intake should be asked as for optimal pregnancy outcome it is better if she stops both.
History of UTI & any history of dialysis is enquired.
In clinical examination her general health ,BMI, BP measurement , edema would be noted. Signs of wound infection wpould be looked for.

b) INVESTIGATIONS

RENAL function tests --- Serum creatinine ( less than 180 micriomol/l has good outcome), Urine RE- for protinuria , casts and sugar( proteinuria has worse outcome)
FBC -- to look for anemia or polycythemia , WBC count ot rule out infection or graft rejection .
Tests to detect diabetes -- increased risk for GDM in pregnancy and to rule out preexisting diabetes before conception.
Peripheral smear to look for schizonts or burr cellls which may be suggestive of graft rejection.
Uss of abdomen & pelvis for baseline study .


c)The counselling of this woman should ideally be along with a renal physician .Her anxiety is likely to be high& hence she needs to be told about all facts clearly.
She will be told that most renal grafts function well in pregnancy.However there is higher chance of proteinuria(40%) & uti. IN 15% renal complications may persist after delivery. She should be told that the extra demands of pregnancy can sometimes need dialysis .Though there can be improvement in renal function postnatally the long term effect is not well known.
She will be told that there is no increased risk of graft rejection due to pregnancy per se but if it occurs the diagnosis & treatment can be difficult. (USS, clinical features ,BIopsy)
She should be assured of the safety of immunosuppressive drugs & compliance with treatment emphasised.

d) She will be told that with good prepregnancy renal function(s. creatinine <180 mmol/l, no protinuria or hypertension) 90% have good outcome but it decreases to 70% if complications develop.
She will also be told that she should have care in a tertiary center with multidisciplinary input.
Early booking should be advised as she is at increased risk of early & late fetal loss .She should likewise be apprised of the risk of Preeclampsia(30%) Graft rejection(10%) FGR(20-40%) & preterm labour(40-60%) . Main risk to fetus is of prematurity spontaneous or iatrogenic .
More frequent antenatal visits should be advised with screening for Protinuria & BP at each visit . An early dating scan & detailed anomaly scan at 20 wks should be advised. Serial growth scans & UA Doppler studies are needed due to risk of FGR.
She should be told about the adverse effects of the drugs she is on like predinsolone can ^ risk of GDM for which screening to detect gdm should be done. Cyclosporin can cause FGR & hypertension.Serum levels of these drugs should be monitored and adjustments done as needed.
She should be told that labour& delivery are not different from other women & that the graft doesnt obstruct labour. Caesarean section is done for obsteric indications or when she has any skeletal abnormality. Steroid cover however is needed and prophylactic antibiotics for operative delivery.
Postnatally she should have reveiw of renal function .Brestfeeding is not contraindicated.
the impact of the care of high risk pregnancy on the family unit should be informed .If patient opts against pregnancy despite nulliparity her wishes should be respected & appropriate contraceptive advise should be given.
Posted by clarice M.
a) The indication for the renal transplant is important. Polycystic kidney disease has an autosomal dominant mode of inheritance and the implications of this for the fetus should be discussed. Renal failure secondary to a systemic disease such as Type I Diabetes Mellitus should prompt optimisation of the patient\'s glycaemic control before embarking on a pregnancy.

I would enquire about when the transplant took place as pregnancy outcome is better once the graft has stabilised. This normally takes 1-2 years.

A detailed drug history is important as some antihypertensives such as loop diuretics and ACE inhibitors are teratogenic. Immunosuppresive agents such as tacrolimus, cyclosporine and prednisolone are not known to be teratogenic..

I would also obtain a past medical history and menstrual history as chronic systemic diseases can cause menstrual irregularities or amenorrhoea.

With regards to examination, I would take her blood pressure and check her urine for proteinuria and glycosuria. Patients who have been on long term steroid therapy are at risk for type II diabetes mellitus. I would also check her height and weight to calculate her BMI.

For completion, I would perform an abdominal examination to inspect the graft site.


b) I would send her a mid-stream urine sample to screen for asymptomatic bacteriuria. If proteinuria was present, I would send a urine sample (patient’s 1st void in the morning) for albumin:creatinine ratio. An alternative to this is performing a 24hr urine collection.

If there were concerns about her blood pressure, I would request for 24 hour ambulatory blood pressure monitoring.

I would also send a sample of blood to assess her urea, electrolytes, urea and creatinine levels. The glomerular filtration rate can then be calculated. I would consider imaging if there were concerns about her renal function. This can be an ultrasound scan or isotope imaging of the renal tract and graft.

c) Generally, once the graft is stable, pregnancy does not affect graft function. It is vital that she continues with her immunosuppressive medication during the pregnancy. If there area any concerns regarding graft function in the pre-pregnancy state, delaying pregnancy should be advised to prevent deterioration, as well as to reduce the risk of complications that may arise during the pregnancy.

d) Generally, pregnancy outcome is good if graft function is stable and if the patient is normotensive. However, there are several conditions that can affect both the patient and her unborn child as a result of having a renal transplant. The patient is at increased risk of pregnancy induced hypertension or pre-eclampsia. The patient should have uterine artery dopplers at 20 weeks gestation to assess her risk of developing this. Low dose aspirin given daily until 36 weeks gestation can reduce her risk of hypertensive disorders in pregnancy.

The fetus is at risk from anti-hypertensives such as loop-diuretics and ACE-inhibitors. These should be replaced with methyldopa or labetalol. The fetus is also at risk of intrauterine growth restriction as a result of chronic maternal disease and from labetalol use. Regular growth scans should be incorporated into her care.

There is an increased risk of premature labour, which can be iaitrogenic or spontaneous. The patient should receive the standard dose of intramuscular betamethasone or dexamethasone if there are signs of premature delivery or plans for premature delivery.

Vaginal delivery is not contraindicated and a Caesarean section should be done for the usual obstetric or fetal indications.

Breastfeeding whilst on immunosuppressive drugs is contraindicated due to its toxic effects in the neonate.




Posted by Manoj M.
A 35 year old nulliparous woman with a renal transplant has been referred for pre-conception assessment and counselling. (a) Justify the information you would obtain from the history and clinical examination with specific reference to her renal transplant [5 marks]. (b) Which investigations will you undertake and why? [4 marks] (c) What would you tell her about the potential effects of pregnancy on her transplanted kidney? [4 marks] (d) What will you tell her about the potential effects of her renal disease on pregnancy? [7 marks].

A) Duration of renal transplant is important prior to embarking on pregnancy as pregnancy atleast 2 yrs after transplant has better outcomes.
Current medication history is important especially the type and dose of immunosuppresion prior to conception to minimise any effects of the fetus.
History of underlying hypertension and medications should be elicited as this may cause increase risk of preeclampsia and complication with pregnancy.
History of any underlying medical disorder which led to renal transplant should be obtained because conditions like diabetes, autoimmune conditions may itself need further input with pregnancy.
Her desire for pregnancy should be obtained and current contracetive use established so that this gives adequate protection and avoid unplanned pregnancy.
Her recent renal consultation outcome and plans should be obtained so as to confirm that no concerns of graft rejection prior to embark on pregnancy.
Examination including pallor to exclude anaemia, blood pressure to exclude hypertension, abdominal examination for any underlying masses and previous scar sites.

B)Full blood count to exclude anaemia.
Liver function test, urea,creatine and electrolytes to exclude liver involvement with medications, current creatine levels to suggest if safe to embark on pregnancy and calcium levels as requirements may be altered.
Urine dipstick for leucocytes, nitrates to exclude urinary infection, proteinuria as this may increase risk of preeclampsia with pregnancy.
Mid specimen urine for culture and sensitivitiy to exclude infection and or treat appropriately.
Cytomegalo virus screen as may need antenatal screen if negative during pre-pregnancy.

C) Pregnancy has no adverse effect on transplant kidney if baseline creatine is <125micromol/l
Like other renal condition if underlying renal impairment of transplant kidney with baseline creatine>125micromol/l there is increased risk of worsening of renal impairment with pregnancy.
If pregnancy is embarked prior to 1-2 years of transplant there is increased risk of graft rejection (immunosuppresive state of pregnancy) and may need higher doses of immunosuppresive treatment.
Long term prognosis of transplanted kidney is not significantly affected if pregnancy is embarked after successful graft acception and with normal renal function.
If creatine is above 125 micromol/l with pregnancy this may affect long term prognosis with shortening lifespan of transplanted kidney.
Provide wrriten information and support group information.

D)Effect of her renal disease on her pregnancy depends on baseline serum creatine levels if this is <125micromol/l, without hypertension, proteinuria and no history of recent graft rejection this has optimal outcome with pregnancy.
If serum creatine levels is >125 micromol/l the chance of successful pregnancy beyond 12 weeks is significantly reduced.
If associated with renal impairment, hypertension and or proteinuria this is associated with increased risk of preeclampsia, intrauterine growth retardation, preterm delivery, urinary tract infections.
If renal disease associated with other medical disorders like diabetes / autoimmune conditions this may still increase the risk pregnancy outcomes and will need more close monitoring with multidisciplinary team involving obstetrician, renal physicans, diabetalogist.
If underlying significant proteinuria above 5g/24hrs she will need thromboprophylaxis as increased risk of thrombosis.
She should be advised to contine immunosuppresive therapy as medications like prednisolone, azathioprine, tacrolimus are safe in pregnancy.
Cyclosporin will need growth monitoring as incresed risk of IUGR.
Mycophenolate mofetil safety is not established and avoided in pregnancy with alternative like azathioprine.
Decision to delivery should be on obstetric grounds or if worseing renal failure or graft rejection.
She should have steroid cover for delivery if on maintainance steroids.
Prophylactic antibiotic cover for any surgical intervention and caesarean section for obstetric reason as transplant rerely pose any obstruction for vaginal delivery.
She should be provided with wrriten information.



Posted by J P.
a.I will obtain a detailed history regarding renal transplantation ,time since it was done as its adviced to wait for 1-2 years for stabilisation of allograft and for the drugs to attain maintenance levels.History regarding the cause of renal disease like DM ,SLE will be enquired because this affects the course in pregnancy.Any associated hypertension and the control of disease prior to conception will be enquired because conception has to be planned when renal function is good.Medicatins history is important since certain drugs may be teratogenic like ACE inhibitors used for hypertension and needs drug modification.Family history of renal disease like polycyctic kidneys will be enquired since these may be transmitted to the fetus in autosomal dominant fashion.
Examination would include looking for blood pressure which is important for assessing the prognosis.Stigmata of SLE if present should be looked and edema of legs if persistent may suggest failing renal function if other causes are ruled out.
b.Investigations include MSU for glucose, protein,nitrites ,blood to look for infection and diabetes..Red cell casts in urine may suggest glomerulonephritis.24 hr urinary protein will be done to assess the protein load.Fasting and postprandial glucose levels to see the glycemic control in diabetics will be done.Blood renal parameters to assess the renal function will be ordered.
c. Pregnancy usually does not have adverse effects on renal graft function.Effects of pregnancy on renal function will depend on serum creatinine levels.If sreum creatinine more than 250 micro mol/l may indicate failing renal function .Diabetic nephropathy may worsen in pregnancy and lupus nephritis associated with flares in peurperium.
d.Renal transplantation may not produce significant adverse events if prepregnancy renal function is good,conceived after 2 years of transplantion and no hypertension. Maternal risks may be superimposed pre eclampsia,incresed infections,and pelvic osteodytrophy due to chronic renal failure.Fetal risks are incresed incidence of miscarriages,IUGR, premature delivery,still birth,adrenocortical insufficiency due to high dose of steroids.Familial transmission of renal diseases may occur as autosomal dominant manner.Transplanted kidneys doesnot obstuct labour.Written information will be provided with the details.

Posted by A S.
am

a) Important points in the history include , when did she had the operation, back ground disease and drug history. The duration since surgery should be at least 2 years to ensure graft stability . Diseases as SLE or poly arterites nodosa may worsen the pregnancy outcome and the patient health . Immonosuppresor drugs as azathioprine, cyclosporine and steroids can be continued during pregnancy but for new drugs like tacrolimus or MMF information is limited so they need to be changed . Antihypertensive drugs taken by the patient may need to be modified or changed to other more safe alternatives . Clinical examination will include BP measurement as strict control is essential for a favorable outcome . Signs like pallor or pitting oedema may reflect ameamia or protinuria . Good general health and renal function have abetter prognosis.

b) Investigations for renal function are important prognostic factors . Serum creatinine less than 125 mmol/l has the best prognosis with complication rate 30% and live birth rate 96% . Levels between 125 and 250 mmol/l have complication rate of 50% and live birth rate 70% . Serum creatinne more than 250 mmol/l is indicative of poor renal function and bad prognosis . Serum urea between 15 and 20 mmol/l reflects good renal function. 24 hours protein in urine should be done . Presence of protinuria has bad prognosis. Urinary tract infection detection by MSSU culture is important as the patient is on immunosuppresion and serious infections may occur. Full blood count , liver function tests electrolytes, Ca and P levels should be done . U/S of the kidneys will detect dilatation of renal pelvis with unfavourable outcome.

c) Generally pregnancy is well tolerated by the kidneys if renal functions are good from the start . glomerular filtration rate increases at 6 ws 50% . Hypotention and dehydration in hyperemeses should be avoided. Tight control of BP (140/90) is important for good kidney function . Compression on the kidneys by the gravid uterus may give pain and partial obstruction of urinary outflow . Pyelonephrits may occur and affect the kidney . To improve the pregnancy oucome and support renal function management must be in liaison with renal specialists .

d) The impact of renal disease on pregnancy starts on the first trimester with increased spontaneous miscarriage rates . In the second trimester preterm labour may occur . Intrauterine growth restriction is a possibility and serial growth scans must be carried on . Superimposed PET is common and treatment should be vigorous to avoid kidney function deterioration . . Low dose aspirin is started in early pregnancy prophylactic against PET . Regular renal functions every one month will be done . By the end of pregnancy natural mild decline in renal function may occur and this should be interpreted carefully by nephrologists .Decisions for mode of delivery and time of delivery depends on if complications exist or no . CS is reserved for obstetric reasons respecting maternal wishes after proper counseling.



Posted by H H.
I would ask her of the date she had her renal transplant as 18-24 months should pass before she is allowed to get pregnant to give time for stabilisation of her graft versus host reaction and dose of immunosuppressive therapy , and see if graft rejection occurs. I would ask her of the reason for the renal transplant, for example diabetes, which should be controlled and inherited causes as polycystic kidney as they can be transferred to her fetus and genetic counseling would be advised and by taking family history there is usually other members affected. I would ask her of treatments she is taking as some should be changed before getting pregnant such as angiotensin inhibiting drugs for treatment of hypertension and some immunosuppressive drugs , but azathioprine and corticosteroids are considered safe.I would ask of symptoms of urinary tract infection(frequency,dysuria,urgency) as this should be dealt with promptly . On examination I would measure, her BP as this should be controlled before getting pregnant, and her BMI as she would be advised to loose weght if overweight.


I will do urine examination by dipstix for protein, nitrites(urinary tract infection UTI), glucose (diabetes) and hematuria. I would do culture and sensitivity of urine if there is infection to be treated. I would do FBC to exclude anemia, thrombocytopenia which may be due to drug toxicity and for WBC which increase in infection.I would measure serum creatinine and creatinine clearance which are measures of renal function. Serum Creatinine should be less than 120 umol/ml to allow pregnancy.I would Consult with immunology lab for tests showing graft versus host reaction .


I would tell the patient that there is no evidence that pregnancy would worsen her renal function or increase her graft versus host reaction.I would tell her that, there is increased susceptibility to UTI and this should be early diagnosed and treated , and that hypertension and diabetes can be worsened by pregnancy and these should be controlled to avoid to avoid renal impairment. I would give her written information.



I will tell her that she at increased risk of UTI and if develop pyelonephritis , she is at increased risk of preterm delivery. Will tell her she is at increased risk of developing pre eclampsia with its consequences as eclampsia, HELP syndrome ,placental abruption and deterioration of renal function and I would explain these terms with drawings showing placental separation. Would tell her that her fetus might inherit the condition that necessitated her renal transplant and genetic counseling is needed , and that he or she might be affected by drugs she taking in first trimester so these should be reviewed . I will tell her that the fetus might not grow well in utero and follow up by growth scan is needed and that he or she might be born prematurely. Her newborn might suffer from adrenal insufficiency if she is on corticosteroid therapy and an experienced pediatrician will see to this. She is given written information
Posted by Manoj Babu  R.
(a) Justify the information you would obtain from the history and clinical examination with specific reference to her renal transplant [5 marks].

A history should include enquiry regarding the interval since the transplant and about the immunosuppressive therapy and the dose which she is taking. Usually fertility returns to normal by about 6 months. It is better to delay the pregnancy for up to 2 years after transplant or until the renal function and the dose of immunosuppressive therapy is stabilized. History of hypertension and anti-hyperternsive treatment is important. There is risk of pre-eclampsia and sdhe may need stop drugs like ACE inhibitors and angiotensin receptor blockers once she is pregnant. Also some immunosupressents like OKT3 and antithymocyte globulin has limited safety data during preganancy. History of co-morbidities like diabetes and connective tissue disorders is important as it may adversely affect the pregnancy outcome.

Clinical examination one should look for presence of edema, blood pressure to examination to rule out hypertension and abdominal examination to rule out ascites. These may suggest presence of significant proteinuria and active renal disease.

(b) Which investigations will you undertake and why? [4 marks]

Investigations are aimed at assessing the renal function and to rule out any complications. This includes a serum urea and creatinine. A creatinine level more than 133 micromols/L is associated with adverse pregnancy outcomes. A 24 hour urine protein and serum albumin is important since protinuria more than 500 mg/24 hours is associated with adverse pregnancy outcomes. Hypoalbuminemia can cause venous thrombosis and pulmonary edema.

(c) What would you tell her about the potential effects of pregnancy on her transplanted kidney? [4 marks]

She should be told that pregnancy itself will not affect the renal function significantly if the serum creatinine level less than 133 micromols/L. But presence of hypertension and recurrent urinary tract infections may affect the renal function especially if pre-eclampsia supervenes. She should be told that there a possibility reduced cyclosporine levels due to haemodilution but usually there is no need to increase the dose.


(d) What will you tell her about the potential effects of her renal disease on pregnancy? [7 marks].

She should be told that her renal disease can adversely affect the maternal and fetal outcomes and that depends on the preexisting renal function and complications like hypertension and protinuria. Usually women with serum creatinine less than 133 micromols /l have a better outcome. The complications may include an icreased risk miscarriage in the early preganacy, preterm labour in about 30-50 %, pre-eclampsia in about 30% and IUGR on about 20% cases. She should be told that protinuria can led to hypoalbuminemia and it can lead venous thrombosis and some times pulmonary edema in pregnancy. She may need thromboprophylaxis during pregnancy.

She should be told that there is no contraindication for a vaginal delivery because of the presence of transplanted kidney in the pelvis as usually it will not obstruct the labour. But up to 50% of women may need caesarean section.
Posted by Osman A.
a) Duration of her renal transplant should be asked as pregnancy should be avoided if it is less than 2 years. History of renal transplant rejection should be explored. Underlying of her renal failure is important information (genetic inheritance, SLE or diabetes). Status of her current renal function or presence of other complication like protenuria should be assessed. Her current medication should be reviewed ( prednisolone or other immunosuppressive drugs). Her BMI should be calculated. Her blood pressure should be measured. Presence of edema or anaemia should be assessed.
b) 24 hours urine protein or creatinine should be assessed to know based line of her renal function. Contraception should be ensured if she has severe renal failure. Hepatitis B, C and CMV status should be check as this patient at increased risk to get blood borne infection. Renal failure is at increased risk to develop anaemia, therefore her Hb should be check. Rubella status should be check because this condition is amenable to vaccination. If her underlying cause of renal failure due diabetes, then HbA1C should be check.
c). She should be made aware that her renal function may deteriorate during her pregnancy. Her protenuria may worsen. The underlying caused of her medical illness may get worsen or flare up especially if her medical condition is not in remission (ie SLE). She may require frequent visit for antenatal follow-up. Written information and group support should be provided
d). She should know that she is at increased risk to develop pre-eclampsia or superimposed pre-eclampsia. She is also at increased risk to develop anaemia. Pelvic osterodystrophy is another complication that she should know. Her fetus is at risk to develop IUGR (30%). The risk of stillbirth is also increased. She should know that her baby may develop neonatal adrenal insufficiency (predisolone > 15mg). The fetus is at increased risk of premature delivery. She should be given written information and detail of hospital contact.
Posted by Arun J.
a-I would explore the etiology for renal transplant so as to know the prognosis for transplantation and to discuss genetic issues .I would enquire about when the transplant was done as conception needs to be deffered for atleast a year so as to optimise outcome.I would also ask about the drugs she is on whether on maintenence therapy or not)so that i would advise her on contraception until is on stable maintenence immunotherapy.I would review her records to R/o co morbid diseaseslike Diabetes, hypertension,and also asses whether she is on stable renal function and whether she has had or is having infections such as CMV,HSV,HBV and toxoplasmosis. I would also look for her previous obstetric outcomes from records if any so as to asses outcome in subsequent pregnancy.I would enquire about the contraception she is using ,the method and for how long. so as to advice her on the same if pregnancy has to to delayed.I would check her B.P to R/O hypertension and ascertain her BMI.
b -I would do U& E, serum creatinine and creatinine clearance to asses renal function.Urine routine and MSU culture and sensitivity to R/O urinary tract infection.Urine protein and 24 hr urine protein ( though renal disease patients with grafts may excreate variable amounts ) to R/O excessive proteinuria.I would HBSag antigen, CMV antibodies, HSV,toxoplasma and HCV antibody titers to R/O infection as they are more prone to it because of immunosuppressive drug intake.Drug levels need to be monitored to prevent toxicity and to maintain adequate dose.USS pelvis to R/O obstructive disease if signs and symptoms are suggestive of it.
Biopsy if deterioration of renal function ia present.
Posted by Arun J.
c-I would tell that the incidence of rejection is no higher than that in nonpregnant patient and that graft loss within 2 years of delivery is not affected by pregnancy and it happens in patients with impaired graft function only.
d- Iwould counsel her that stable graft function with no proteinuria ,no hypertension and no evidence of rejection or obstruction is needed for good outcone.There would be no graft rejection if prepregnancy graft function is normal. I would also tell her that she has increased risk of misscarriage , IUGR,PTL low birthweight babies and genetic inheritance depending upon the renal disease.She has increased chance of pre eclampsia ,hypertension and infection. The risks due to drugs are teratogenicity. I would also tell her that there is increased risk of cesarian section .She is also prone to depression because of problems with breast feeding because of drug excreation in breast milk as breast feeding is controversial in graft recepients on immunosuppressive drugs.
Posted by Sowmithya B.
A. The cause of renal failure has to be assessed as certain conditions have adverse impact on pregnancy and hence increased intervention. Polycystic kidney disease is autosomal dominant condition and hence need for prenatal diagnosis. Systemic lupus erythematosis and diabetes can worsen during pregnancy. The duration since renal transplantation has to be enquired as it would be prudent to attempt pregnancy two years after transplant by which time graft would be stabilised and she will be on maintenance dose of immunosuppressive therapy. The associated condition like hypertension has to be evaluated. Her current medication has to be assessed and appropriate modification has to be made based on their tetratogenic potential. Antibiotic therapy has to be reviewed. Nephrologists’ input must be sought regarding the baseline graft function as the level of graft function and presence of hypertension as two important parameters that are shown alter the pregnancy outcome. Previous case notes should be reviewed.
On examination BMI and blood pressure has to be assessed. Anaemia has to be looked for. Any condition that would otherwise contraindicate a pregnancy like active SLE, severe renal failure should be assessed.

B. Blood urea and electrolytes, creatinine clearance and 24 hours urinary protein has to be assessed to assess the base line graft function. If the creatinine is more than 250 mmol/L pregnancy should be discouraged.
Mid stream urine for microscopy and culture should be sought as asymptomatic bacteruria and urinary tract infection can precipitate renal failure and also adverse pregnancy outcomes like preterm labour.
Haemoglobin and haematocrit should be done as anaemia is associated with increased pregnancy related complications like preeclampsia, intrauterine growth retardation.
Level of optimisation of medical disorders predisposing to the renal impairmrnt has to be assessed like diabetes and SLE.

C. Effect of pregnancy on the renal transplant essentially depends on the level of graft function. If associated with severe renal impairment the risk of progression to failure would be around 50%. The aetiology also plays a role. Poorly controlled diabetic status and SLE flare can affect the graft function. Associated conditions like development or worsening of pre-existing hypertension, superimposed preeclampsia or urinary tract infection can also affect graft functioning.

D. Mother carries increased risk of developing hypertension or proteinuria, superimposed preeclampsia during pregnancy. Increased incidence of infection and risk of developing diabetes has to be explained because of immunosuppressive drugs and the need for multidisciplinary care involving nephrologist and need for frequent antenatal checkups has to be emphasized. Fetus is also at increased risk of miscarriage, still birth intrauterine growth retardation and prematurity and hence increased need for ante partum fetal surveillance. Increased need for emergency delivery in the event of uncontrolled hypertension, fetal compromise, and renal impairment has to be explained. All the problems get worsened following unplanned pregnancy and hence effective contraception should be advised. Written information has to be given. Patient wishes should be taken into account.
Posted by Mark D.
I will enquire about if she has any symptoms at present. If she has vomitings, pain in abdomen, occasional fever then she may have graft reaction and review for renal physician would be arranged. I will enquire when was the transplant done because it is advisable to wait for at least 2 yreas post transplant before planning pregnancy to confirm well functioning and accepted graft.i will about the psot surgical period , any complications ,and if she received any blood transfusions. I will also chek the cause for renal failure leading to transplant. The causes like polycystic kidneys(autosomal dominant) will need genetic counselling and information about prenatal diagnostic tests.if it was diabetic nephropathy then diabetes control would be checked.i will ask which medications she is taking like immunosuppresants,steroids and anti hypertensives if she has hypertension. Drugs like ACE inhibitors,diuretics would have to be changed to safer drugs in pregnancy. At examination I will check for pallor which is suggestive of anemia which is common in these patients. I will check BP, BMI,auscultate chest for any advantitious sounds, per abdomen examination to asses any tenderness over the transplanted kidney.


I will check urine for proteinuria and nitrites and leucocutes. If positive I will ask for 24 hour urinary proteins to asses the preexsiting proteinuria.this would be baseline so as to be able to diagnose superimposed preeclampsia during pregnancy. If nitrites positive I will send urine for Culture and sensitivity and treat UTI.
I will check FBC to r/o anemia, baseline liver and renal function tests including urea ,creatining, creatining clearance and eGFR to check for graft functioning. I will offer screening for HIV and HbsAg if she has had blood transfusions in the past.

Due to increased blood volume and stroke volume in pregnancy the kidneys are at higher load.i will tell her that Most patients with well functioning graft tolerate pregancy well . however in case of ill functioning graft with high creatinines or heavy proteinuria upto 40% patients will go into end stage renal failure during preganacy or within 1 year of delivery. This depends on control of hypertension, UTI, and serum creatinine levels.



Most patients with well functioning grafts tolerate pregnacy well with good outcomes. The potential effects on mother are pregnacy induced hypertension, superimposed preeclampsia and its complications. Worsening proteinuria would cause pulmonary odema and increased risk of venous thrombosis. Acute deterioration in renal function may occur with UTI,dehydration,uncontrolled hypertension hence she would have to attend 2 weekly visitis at the antenatal clinic to detect these complications early.
Fetal implications will be miscarriage,prematurity,IUGR, and rarely sudden still births.
If the risk of transmitting disorder to fetus if there is genetic cause for renalk failure and would need prnatal diagnostic tests for it.
I will tell her that immunosuppresants like azathioprine,cyclosporin and steroids are not teratogenic.steriods in high doses may cause fetal adrenal suppression.
I will also let her know that transplanted kidneys do not obstruct labour and she can have a normal vaginal delivery.
I will provide written information to back up vebal counselling.
Posted by S M.
a)
I would find out when the renal transplant was done because she should not conceive for 2 years following the procedure. This allows for the graft function to be stabilised. The reason for the transplant is important. I would ask whether she was still under the care of a renal physician and transplant team; and if her condition was well controlled. This is necessary because it should be well controlled before conception. The drugs that she is taking are important since some may have adverse effects on the fetus such as anti hypertensive ACE inhibitors. The presence of comorbidities such as hypertension may have an effect on a future pregnancy either by itself or superimposed with preeclampsia. If she is diabetic, the involvement of a diabetic team, monitoring of blood glucose levels and insulin doses; and increase surveillance of the fetus will be necessary.
In the examination, I would measure the blood pressure since hypertension would need to be controlled before the woman conceives. I would do an abdominal and vaginal examination to determine if the transplanted kidney was palpable and may obstruct delivery of the baby.

b)
I would do a full blood count to ensure that she is not anaemic and there is no underlying infection. I would also do a C reactive protein which would be raised with an infection. Urea, creatinine and serum electrolytes would indicate whether the renal function was normal. A dipstick of the urine should be done for protein or blood which may point to renal disease. A better assessment of urine protein can be achieved with a 24 hour urine protein excretion test. Renal function should be determined because if abnormal the woman should be monitored by the renal team and pregnancy should be delayed. A microscopy, culture and sensitivity of a mid stream urine sample should be tested for a urinary tract infection.

c)
I will tell her that the effect of pregnancy on the renal transplant depends on the creatinine levels at conception. Pregnancy has no adverse long term effect on the transplant in women with baseline creatinine levels of less than 100 umol/l. If the creatinine level is more than 130 umol/l there is a risk that the function of the graft will deteriorate. I will provide her with written information.

d) I will tell her that renal disease can cause effects on her and a fetus. A successful pregnancy outcome ranges between 75-95%.There is an increased risk of maternal and fetal morbidity and mortality. There is an increased risk of hypertension, preeclampsia and urine infections. There is increased risk of intrauterine growth restriction and preterm delivery. Therefore more frequent antenatal visits will be needed, serial ultrasound scans and midstream urine tests at each visit. The pregnancy risks are worse in women with diabetes and /or poor graft function. In the presence of diabetes a multidisciplinary approach will be needed with her being cared for and monitored by a diabetic nurse and physician. I will tell her than the immunosuppressants used to prevent graft rejection do not have an effect on the fetus. But ACE inhibitors use for hypertension would need to be changed to antihypertensives that do not have a harmful effect on the fetus. I will provide her with written information.
Posted by Ron C.
A.
On history taking I will focus on exact reason fro transplant; congenital or acquired, to identify causal co-morbidity requiring treatment or affecting pregnancy and likelihood of congenital renal problems in offspring. For the latter family history of renal problems is useful as well. I’ll ask when it was done, whether renal function is stable and how long it has been so. Instable renal function or short transplant-pregnancy interval will reduce chances for successful pregnancy whilst increasing risks. I’d ask about her medication, as some may be teratogenic and must be discontinued. On physical examination blood pressure is a very important prognostic factor. I’ll look for signs of anaemia (more common in renal problems), oedema in legs and tenderness at the transplant site to identify graft problems/suboptimal renal function.

B.
Assessment requires multi-disciplinary approach. Investigations include bloods for FBC (anaemia) and 24-hours-creatinin clearance, renal function + electrolytes to get a baseline, which is of prognostic value. An ultrasound of the kidneys is needed to assess current status and identify any problems, such as signs of rejection etc. Genetic screening/counseling is only needed if the woman’s renal problem was congenital.

C.
If her renal function is good and stable, pregnancy can be pursued. Risk for rejection is not increased and renal function will usually not worsen, nor will life-expectancy or transplant be negatively affected in long term. This is in contrast to a not stable renal function, where risks for reduced graft survival, worsening renal function and graft rejection are increased during pregnancy and long-term as well. In women with a poor baseline renal function, morbidity and mortality in subsequent years is increased as well

D.
There is increased risk for urinary tract infections, low dosed prophylactic maintenance antibiotics may sometimes be needed. Immunosuppressive medication can in most cases be continued. If necessary doses of some may need adjustment based on serum levels. She is more prone to develop pregnancy-related hypertensive disease (PIH, PET, HELLP, eclampsia), which on turn will again negatively affect renal function. These complications, or an isolated worsening renal function may necessitate iatrogenic premature delivery with all its associated mortality and morbidity (admission to neonatal intensive care unit, respiratory and feeding problems etc). Blood pressure and proteinuria therefore need to be monitored meticulously at regular intervals. If the maternal renal problem is congenital, there is potential for similar problems in the foetus and anomaly scan in a tertiary centre is warranted. As IUGR is more common, serial 4-weekly growth scans are also needed. The mode of delivery will be determined by obstetric factors only.
Posted by dr neelangini G.
a) History of duration of surgery , as less than one year graft is not stable & more than 5 years may lead to postpartum impaired renal function secondary to chronic rejection. Cause of the transplant whether genetic disease like polycystic kidney disease or other nongenetic. Type of transplant , if live related donor, pregnancy may be considered after one year & if cadaveric transplant , it is better to wait for two years.
Drug history in deatail to be taken as these patients are on immunosuppressant drugs like Steroids , azathioprine, cyclosporine. These drugs may lead to repeated infections , prematurity & increased risk of congenital anomalies.Contraception history should be taken as she needs contraception till she is allowed to get pregnant according to stability of the graft & other associated illnesses & biochemical investigations. Ideally low dose COCs are better as there may be failed efficacy of IUDs(Cu-T) as patients are on immunosuppressants & there may be repeated infctions.
History of chronic diseases like Diabetes, hypertension, heart disease , inflammatory bowel disease , SLE, thyroid disorder which get deteriorated due to pregnancy. History of vaccination like Rubella ,to be taken as live vaccines are contraindicated after transplant.
Patient should have thorough general examination including her Blood pressure, oedema, as uncontrolled hypertension is not advisable . Thyromegaly should be ruled out . pallor should be seen to rule out chronic anaemia.

b) Investigations like FBC & peripheral smear to look for anaemias,& haemolytic anaemias, urine,to see proteins as it should be less than 500 mg /day to be pregnant.,sp gravity to see renal function,MSSU for microscopy as to rule out bacteriurea,Fasting BSL should be estimated to know the diabetic status /base line level. Rubella , cytomegalovirus, Toxoplasmosis antibody titer should be tested as these are common infection in patients on immunosuppressants. Serum creatinine, blood urea, serum uric acid level should be measured to know current renal function, as serum creatinine level should be less than 2 mg/dl for patients contemplating pregnancy. USG & IVP to know any pelvicalyceal dilatation .

C) Pregnancy does not appear to have generally any adverse effect on longterm survival of renal allograft. The maintenance dose of immunosuppressants to keep on lowest possible level to avoid fetal hazards. Because of increased GFR in pregnancy there may be reduced blood level of immunosuppressant drugs. She should be advised that her antenatal check up to be more organised in such a way that ,during visits she should under go investigation like serum creatinine,blood urea,LFT,Hb & serial USG for IUGR.

D)She is more prone to eclampsia, infections like asymptomatic bacteruria, pyelonephritis &1st trimester miscarriage-35% ,preterm labour,PROM-30%,IUGR-30%,.congenital anomalies of fetus ,because of immunosuppressant,& repeated infections.If she develops recurrent bacteriurea she shoud be under antibiotics throughout pregnancy. During labor if she required induction or augmentation by oxytosin ,she may develop oedema due to water retention.She shoud be told that ,she can deliver vaginally,as renal transplant itself is not an indication for CS.
Posted by Priti T.
prt

a]Patient is adviced to wait 2 years after the renal transplant before embarking on pregnancy.As with time the graft function will stabilise and the maintainence level of immunosuppresive drugs would be reached.She should be asked in history regading the reason of transplant.Genetic counselling needs to be offered if it was for the familial disorders like polycystic kidney&medullary sponge kidney.Her prevoius operative notes can be checked to know whether the transplant was due to SLE,Diabetes mellitus or Chronic renal failure.Hx of various drugs she has taken is noted .Antihypertensives taken to control B.P like ACE inhibitors should be changed in consultation with the renal physician.Hx of prophylactic antibiotics taken is noted as anti folate antibiotics need to be replaced.Clinically patient is examined for anaemia.B.P.is checked to assess hypertension.BMI and oedema is noted.

b]Patient should be investigated with FBC as anaemia need to be corrected.For her LFT,U&E ,serum creatinine,Creatinine clearence,24 hours protein and protein creatinine ratio is done to assess graft function and liver function.
Maternal calcium levels are done as both hypo/hypercalcemia in dangerous and dose of vitaminD/calcium should be altered.
Urine MSU for culture and senstivity is done to treat UTI.
GTT 75gm 2 hours and fasting glucose is done if the patient is on steroids.
Patient should be screened for rubella,Hepatitis B,HIV and syphilis.


c]Pregnancy does not affect the long term renal function.Women with severe renal impairment,serum creatinine more than 250 micromol/l should be advised against pregnancy asits associated with adverse obstetric outcome.Women with normal or mildly impaired pre pregnancy renal function,s.creatinine less than 125 micromol/l[1.4mg/dl] can hope for good pregnancy outcome.Patient should have multidisciplinary care under renal physician.She should be told that B.P. needs to be controlled strictly.Increasing proteinuria requires consultation with nephrologist and thromboprophylaxis.Transplanted kidney does not obstruct labour or delivery.CS needs to be done for obstetric indications only and written information is provided for the same after reassuring the patient.Immunosuppressive drugs like ciclosporin,prednisolon.azathiaprine and tacrolimus are safe in pregnancy and not teratogenic.
Serious rejection episodes occur only in 5% of pregnancies with graft.

d]Pregnancy and foetal risks associated with renal transplant should be explained to the patient.There is increased risk of early pregnancy loss.Risk of IUGR associated is 20-40%and the risk of pretern delivery is 40-60%.There is a chance of superimposed preeclampsia around 30%.She should be advised low dose aspirin to reduce complications and Folic acid 5mg/day is given preconceptionally 3 months before pregnancy.
She should be adviced dating scan at 10-11 weeks of pregnancy.Prenatal diagnosis and counselling is needed for the inherited diseases.More frequent antenatal checkups are required for the foetal growth retardation.Regular USG assessment of foetal growth and wellbeing should be done if there is associated SLE and Diabetes mellitus.Written information and the name of support groups are given for the same
Posted by S M.
SM reply.
a)
It is imperative to ascertain the cause that lead to renal transplant as autosomal dominant conditions like polycystic kidneys need genetic counseling prior to planning a pregnancy. The duration since the transplant must be enquired into. A minimum of two years since transplant ensures adequate time for stabilization of the patient and reduced risk of graft rejection. Her drug history must be enquired into .ACE inhibitors for hypertension cause IUGR , hence must be stopped during pregnancy. Azathioprine,cyclosporine and tacrolimus are safe in pregnancy. Antibiotics must be reviewed with the renal physician. If her blood sugars are poorly controlled contraception must be advised till better control is achieved so as to have better pregnancy outcome. Anemia treatment must be enquired into as anemia is common in these women due to lack of erythropoietin. Notes from the renal physician /surgeon must be studied for any special instructions. Her menstrual history and fertility treatment if any must be enquired into.
On examination, BMI must be calculated as increased BMI increases maternal mortality and morbidity. Pallor must be checked for as anemia is common in these women and needs treatment. Fundoscopy must be done if the woman is diabetic. Anasraca indicates significant proteinuria. Signs of DVT must be looked for as proteinuria predisposes to hypercoagulable state.
b)
Investigations that need to be done are FBC for hemoglobin assessment for anemia.Urea electrolytes and creatinine clearance must be done. Serum creatinine > 120 micromol/l indicatesgood 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.
c)
Potential effects of pregnancy on her transplanted kidney are that urinary tract infections ,hypertension and proteinuria can cause rapid deterioration in renal functions. Diabetic nephropathy can deteriorate in 50% of the cases. End stage renal disease is seen in about 50 % of severe renal impairment in pregnancy.Lupus flares or nephritis has poor outcome .The transplanted kidney does not obstruct normal vaginal delivery.
d)
The effects of her renal disease on pregnancy are that she has a higher risk of developing pregnancy induced hypertension, pre-eclampsia, preterm delivery , diabetes mellitus , anemia ,infections especially urinary tract infections and osteodystrophy . She also has a significant risk of developing venous thrombo-embolism. The risk of miscarriage , preterm delivery , IUGR and stillbirth too are significantly higher. Hence close survelliance is required in pregnancy. Aspirin must be started in the first trimester. Growth scan every 2 weekly from 28 weeks will be arranged for her . In case of deterioration of hypertention or renal functions , preterm delivery may be required. I will offer her relevant written material and support group addressess.
Posted by A H.
a) In the history, I would find out why she needed the transplant. If due to end-stage renal disease secondary to chronic medical conditions like diabetes and SLE,these would have to be well controlled prior to pregnancy to improve outcome.
.The time since the transplant occurred will be noted. She would be advised to wait for at least one year due to her age, but preferably two years so as to reduce the risk of graft rejection.
Current medications and theier dosage will be asked. Most immunosuppressive drugs are not teratogenic. She will be prescribed the safest drug at the lowest dose which is effective.
A menstrual history will be taken because regular ovulatory cycles are established within six months of a successful transplant. Reliable, safe contraception will be advised until she is fit to start her family.
The source of the transplanted kidney will be established as success of transplant is higher if the donor is a living relative compared to cadaveric organs.
Blood pressure will be measured, so that it can be well controlled prior to conception to reduce the risk of complications like pre-eclampsia. Signs of chronic illnesses will be sought in order that her general health can be optimised prior to conception.

b) Blood will be drawn to determine urea and serum creatinine levels. Serum creatinine less than 125 micromol/l is associated with a 90-97% successful pregnancy rate once the pregnancy survives the first trimester. Liver function tests will be done as a baseline for monitoring during the pregnancy. Haemoglobin levels will be done and anaemia corrected prior to pregnancy. Renal ultrasound to rule out hydronephrosis or other pathology will be done.

c) the potential effects of pregnancy on the transplant depends on the baseline creatinine levels. If the creatinine is less than 100 micromol/l, there will be no adverse effect on the renal graft. If serum creatinine is greater than 130 micromol/l, there is an increased risk of deteriorating renal function, with a graft survival of 65% at 3 years after pregnancy. New long term kidney problems can develop after pregnancy.

d)The effect of the transplant on pregnancy depend several factors.
She will be told that if her blood pressure is normal, there is no protein in her urine, her serum creatinine is near normal(less than 130micromol/l, and she had no recent episodes of graft rejection her outcome is good.
However, she will be told of a twenty percent risk of first trimester miscarriage, but if pregnancy goes beyond twelve weeks, her success is about 95% if renal function is normal and 75% if renal function is impaired.
Complications that can arise include preterm delivery, pre-eclampsia, intrauterine growth restriction, graft rejection and urinary tract infections.
Posted by Ahmad A.
Detailed history related to renal transplant should be obtained. I would ask about the indication for renal transplant, I would ask about any chronic illness like systemic lupus eyrthrematosis (SLE) affecting the renal condition. Also, congenital disorder like Polycystic kidney of recessive or dominant disorder, as it may pass to offspring. I would ask about the duration since she had the transplant. As, it is more recommended to postpone pregnancy if the period less than 2 years. I would ask if she is taking antihypertensive like Diuretics, and possibility of change AC inhibitors to methyl dopa or combined alpha and beta blockers. As, foetal anomalies are significantly higher with AC inhibitors. I would ask about the different medication of immunosupressents like Azathioporine, Cyclosporines and corticosteroids. Different doses should be adjusted before pregnancy starts.

Investigations should be ordered includes renal functions tests, BUN, creatinine, creatinine clearance& serum electrolytes. Pregnancy will deteriorate the impaired renal functions. Glomerular filtration rate should be calculated and the risk will be higher in case with reduced rate. Rule recurrent renal infection with repeated urine test, microscopically and culture & sensitivity, also to detect proteinuria. Full blood count should be requested as the incidence of anaemia with renal impairment specially with vitamin B12 deficiency. General pre-pregnancy screen should be ordered as Rubella IgG, Hepatitis B&C, HIV, and TPHA.


There are some potential effects of the pregnancy over her transplant kidney, as the rejection rate is higher especially with short duration since transplant. Also, it may deteriorate the renal functions. Urinary tract infection is more common with pregnancy as a result of asymptomatic bacteriuria and back pressure over the ureter. That may be deteriorated with transplanted kidney.


There are some potential effects of the renal disease on the pregnancy, Genetic disorder may pass to the offspring. There is high incidence of miscarriage rate. Also, there is increase chance of anaemia and deteriorating the systemic disorder like SLE & Hypertension. So, there is increase chance of pre-eclampsia, preterm delivery, intrauterine growth restriction (IUGR). As effect of immunosupressents there is increase incidence of Gestational DM specially with steroid use.
Posted by Kp K.
The successful outcome of the pregnancy in a well functioning renal transplant is no defferent than the general population. The history of duration of transplant will give information on stabilisation of renal function as it takes 1-2 years for stabilisation so an advice to delay pregnancy can be given. It also gives information whether she Is on maintenance doses of immunosuppressive drugs. Her control of hypertension and the antihypertensive drugs she is on should be enquired as ACE inhibitors and diuretics need to be change as they have adverse effect on the baby. Her status regarding graft rejection and frequent admission s in the hospital for treatment would help to assess the severity of her condition. Clinical examination would aim to rule out her general status and well-being. Blood pressure to assess the hypertension status. Oedema will give the sign of hypoalbunemia. Gentle and deep abdominal examination to rule out tenderness to rule out pyelonepritis any and masses. Chest examination for adventitious sound and to rule out pulmonary oedema.


Mid stream urine to rule out infection. Full blood count for anemia, neutrophilia and thrombocytopenia..Urea and creatinine for renal status, if very high creatinine to advice against pregnancy. Ultrasound for hydronephrosis , calculi and abdominal masses

I would tell her that if transplanted kidney is well functioning pregnancy per se has no adverse effects and generally has a good pregnancy outcome. Pregnancy does cause graft rejection in 10 % of cases should be informed. Malfunctioning kidney can get worse in pregnancy and it is advisible to dalay the pregnancy. Increase incidence of UTI in pregnancy.

Pregnancy with renal impairment is associated with increase risk of miscarriages(first and second trimester), preeclampsia, intrauterine growth retardation and iatrogenic prematurity. If renal transplant well functionally than pregnancy has good outcome. In severe malfunctioning kidney along with hypertension there is risk of preeclampsia and IUGR and hence should be advice against pregnancy and contraceptive s should be offered.
Regular bloods to check for renal functions and serial growth scans to monitor fetal growth is mandatory along with liquor volume and umbilical Doppler measurement.. Admission is required if rising serum creatinine or severe uncontrolled hypertension. In these cases along with severe IUGR , premature delivery is anticipated. There is increase risk of polyhydramnios and cord prolapse. If significant proteinuria is present, it can lead to pulmonary oedema and thrombosis.
Increased incidence of UTI and need of antibiotics should be explained. Patient should be informed about the safety of immunosuppressive drugs as stopping of them would lead to graft rejection. Compliance with this drug is required.
During labour intravenous steroids required. Caesarean section for only obstetric indication Epidural not contraindicated in labour. Continuous CTG monitoring required during labour.
Breast feeding not contraindicated .


Posted by Maayka ..
nellie

a) It would be pertinent to find out what was the cause of renal failure requiring the transplant. If it was SLE or diabetic nephropathy than it is likely that these changes can still occur with the new kidney. If it was not related to present state, like an infection, then there is less likely deterioration in function. How long ago was the transplant would be determined as it is advised that although fertility returns immediately, a period of 1-2 yrs after will allow the kidney the opportunity to be rejected and treated and of immunosuppressive drugs to be reduced to maintenance levels then. A history of graft rejection likewise important to know and how long ago it occurred. The drugs used presently would be asked about since most can be used in pregnancy with some noted side effects. The drug mycophenolate mofetil though is best avoided since it has association of increased fetal malformations. Use of any contraception should be inquired or advised until it is certain that her renal status is near normal. Examination will look specifically for any signs of hypertension and hypoalbuminenia in the form of oedema. Signs of graft rejection such as fever, oliguria and graft tenderness should be looked for.

b) It is important to obtain a baseline assessment of her kidney function, therefore serum creatinine and 24 hr urine for protein, Cr clearance will be done. Also an MSU to rule out UTI. Baseline FBC and LFTs should be done since anaemia is commom if renal deterioration occurs and the effects of the drugs on white cell count and liver function can be monitored. Ca levels should be checked because of the risks of hypocalcaemia and hypercalcaemia.

c) If there is no hypertension and development of proteinuria in pregnancy, there is a good chance that the renal allograft will not be affected if baseline serum creatinine was near normal. There are some problems which can arise but it is unsure if it is as a result of pregnancy. About 10% women die 1-7 years after a pregnancy. It is important that the immnosuppressive drugs are not stopped or reduced because then there is a high chance of graft rejection.

d) What ever the cause of her having a renal transplant, the risks now to the pregnancy is of development of anaemia, pre- eclampsia, preterm delivery, IUGR and of graft rejection and infection. There can be effects on the neonate especially as a result of use of the immunosupressive drugs – of thymic hyperplasia, thrombocytopenia, depressed haemopoiesis and septicaemia.
The outcome is successful in 97% of cases without any existing hypertension or proteinuria
Posted by PAUL A.
a)History is taken regarding reason for transplant ,if for genetic disease e.g ppolycystic kidney disease,she would require genetic counselling (1) .In case of acquired
a diseases i.e SLE or diabetic nephropathy,she would require assessment of disease status.In case of SLE she should conceive in period of remission at least for 6months.If DM ,blood sugar should be well controlled before conception.
Duration of renal transplant is taken.Pregnanacy is advised at least 2yrs after transplant (1) so that graft rejection and immunosuppressive therapy is stabilized.Enquire about any recent episode of graft rejection (1) .
Drug therapy is reviewed (1) with Renal physician. Corticosteroids,immunosuppressives i.e cyclosporins and azathioprine can be continued in pregnancy. Antihypertensives,ACE inhibitors are teratogenic and impair fetal renal function and should be changed.Antibiotics would need to be changed .Aminoglycosides should be avoided in pregnancy.
She should be advised against pregnancy you were asked about clinical assessment, not to advise her if active SLE, poorly controlled blood sugar levels or any recent episode of graft rejection .Contraception is provided this is not clinical assessment .
Examination includes palor for anemia,as patients with renal failure are prone to anemia.BP is taken,presense of hypertension adversely affects pregnancy outcome (1) ? BMI . .Any stigmas of active SLE noted.Funduscopy may be required if she is diabetic.

b) Investigations include FBC-for Hb and degree of anemia (1) ,MSU and culture and sensitivity for UTI.24hr protein-If proteinuria (1) is >5gm she would require thromboprophylaxis during pregnancy.In case of SLE ,ESR and antiphospholipid antibodies done why? .U&E and RFT what is this? done to assess creatinine clearance.If se creatinne is <120micromol/l,pregnancy outcome is good.

c)Pregnancy has no long term survival effects if renal function are good and prepregnancy serum creatine.100micromol/l (1) you wrote 120 above. Why the difference? .If the levels are130micromol/l,renal graft survival is65% at 3yrs.About 40% women have proteinuria near term, but it regresses after delivery.

d) Pregnancy with renal disease should receive multidisciplinary care with senior obstetrician, Renal physician ,GP , midwife and specialist nurse (1) .It is associated with significant risk of complications in about 50% of cases.includuing Hypertension or PET 30%,IUGR10-20%, PTD what is this? You will lose marks -40-60% and infections especiallyUTIs (1) . She should have close monitoring in pregnancy with frequent antenatal visits, for early identification and treatment.At each visit BP checked ,MSU sent and any infections treated.Serum calcium levels are monitored and maintained.Iron and folate supplements are given you are not answering the question – what will you tell the woman about the POTENTIAL EFFECTS of renal disease on pregnancy? .
Fetal growth is monitored by growth scans.If IUGR is suspected dopplers would be done for fetal wellbeing and planning of delivery. during
Transplanted kidney does not obstruct labor, so aim would be vaginal delivery (1) .In case of obstetric reasons CS would be done.Increased steroids and antibiotic cover required labor why does she need antibiotics? Which antibiotic and why? .
Posted by PAUL A.
X

a. History pertaining to the cause of the renal impairment (1) if inherited, refer for genetic counselling must be taken as is it a chronic disease, a familial disease, an acquired disease or due to trauma as it helps for counseling. .Her medical history also must be taken to assess her co morbidity such as diabetes , hypertension , SLE is this different from the cause of renal failure? as it need to be optimized prior to pregnancy. The medication which is currently used also must be ascertained as to optimize the treatment and to reduce teratogenecity any examples of drugs that you will stop / change? . Familial history for kidney disease need to be addressed for genetic counseling and decision for prenatal diagnosis. Her HIV or hepatitis status also must be taken due she could have multiple transfusion before.
Clinical examination include her body mass index to ascertain her to assess her VTE risk, Blood pressure to evaluate her hypertension (1) . Per abdominal examination to look for mass and scar site. Per speculum examination to check for genital tract abnormality as it is associated with renal tract abnormality.


b. Baseline investigations of renal function especially creatinine level and urea level should be taken (1) . Cretinine clearance must be assessed to determine the baseline renal function and to determine prognosis .A full blood count to detect underlying anemia (1) and to correct it. A urinalysis should be done to check for proteinuria , hematuria as for detecting current renal status and as a baseline. Presence of leukocytes have to be treated as the risk of urinary tract infection is high in pregnancy ? 24h urine protein and immunosuppresion. Hepatitis, and HIV status should be confirmed (1) as due to the possible history of multiple transfusion prior.

c. An uncomplicated pregnancy does not affect her current renal function (1) . But pregnancy complicated with preeclampsia, hypertension, gestational diabetes could deteriorate the kidney function in pregnancy is this reversible or permanent? . Urinary tract infection in pregnancy is also increased which could cause pyelonephritis. does pregnancy cause rejection? Written information .


d. Renal disease should not be affected through the course of an uncomplicated pregnancy you were asked about renal disease on pregnancy . But occasionally it could cause effects such as preeclampsia, hypertension in pregnancy which necessates her for anti hypertensive treatment. Development of gestational diabetes will require higher insulin treatment ? relevance to the question . Incidents of pre term delivery which includes iaterogenic delivery ? meaning?? . There could be a very small probability of miscarriage and second trimester miscarriages in the pregnancy presume this applies to all pregnancies . The probability of the baby having renal problem could be addressed with a detail scan. The risk of intrauterine growth retardation restriction also is increased in this pregnancy which might require regular fetal growth and ultrasound assessment (1) . A vaginal delivery is not containdicated (1) and Caesarean section is only done on obstetric indication
you have not answered the question. You have not indicated that this is what you will tell her. Then you have not explained the effects of renal disease on pregnancy

• If inherited renal condition, explain risk of passing condition to the fetus and offer genetic counselling
• Underlying disease such as SLE may have direct effects on pregnancy
• Drugs may have direct effects on fetus (examples). Need to use alternative drugs or minimum effective dose
• If good and stable renal function, obstetric outcomes are good (>90% pregnancies progress beyond fetal viability). Pregnancy however associated with increased risk of PIH, pre-eclampsia, IUGR, pre-term delivery
• Need for multi-disciplinary care in a tertiary centre with more frequent visits, scans and blood tests
• Poor renal function associated with reduced fertility, increased risk of miscarriage and worsening of obstetric outcome
• Renal transplant does not obstruct labour and vaginal delivery should be anticipated. CS for obstetric reasons
Posted by PAUL A.
a) Preconception counselling of a woman with renal transplant pivots on the accurate asessment of risk to the woman relative to the chances of a successful pregnancy waste of time & space . A good history and clinical assessment of the woman would be directed to determine the degree of renal impairment & the presence of complications waste of time & space .
The time since transplant should be enquired as also the indication for the transplant -- this because it is ideal to wait for at least 2 yrs (1) after transplant to conceive as she would then be on maintainance levels of immunosuppressive drugs & any chance of acute graft rejection would have passsed. A congenital inherited renal disease in mother can increase risk of anomaly in the fetus (1) . All old records should be verified .
History of drug intake & the doses should be noted as she should be kept on maintainace doses of immunosuppressive drugs .If she is on ACE inhibitors they would have to be changed to safer drugs like beta blockers (1) .
History of current contraception is asked to ensure that she has adequate protection till it is safe for her to conceive .
History of subfertility should also be asked as there can be difficulty in conceiving.
History of smoking , alcohol intake should be asked as for optimal pregnancy outcome it is better if she stops both.
History of UTI & any history of dialysis is enquired.
In clinical examination her general health ,BMI, BP measurement (1) , edema would be noted. Signs of wound infection wpould be looked for which wound??? .

b) INVESTIGATIONS

RENAL function tests --- Serum creatinine (1) ( less than 180 micriomol/l has good outcome), Urine RE ?? - for protinuria , casts and sugar( proteinuria has worse outcome)
FBC -- to look for anemia (1) or polycythemia , WBC count ot rule out infection or graft rejection .
Tests to detect diabetes -- increased risk for GDM in pregnancy and to rule out preexisting diabetes before conception.
Peripheral smear to look for schizonts or burr cellls which may be suggestive of graft rejection.
Uss of abdomen & pelvis for baseline study why?? .


c)The counselling of this woman should ideally be along with a renal physician (1) .Her anxiety is likely to be high& hence she needs to be told about all facts clearly.
She will be told that most renal grafts function well in pregnancy.However there is higher chance of proteinuria(40%) & uti. IN 15% renal complications may persist after delivery. She should be told that the extra demands of pregnancy can sometimes need dialysis .Though there can be improvement in renal function postnatally the long term effect is not well known (1) .
She will be told that there is no increased risk of graft rejection due to pregnancy per se (1) but if it occurs the diagnosis & treatment can be difficult. (USS, clinical features ,BIopsy)
She should be assured of the safety of immunosuppressive drugs & compliance with treatment emphasised.

d) She will be told that with good prepregnancy renal function(s. creatinine <180 mmol/l, no protinuria or hypertension) 90% have good outcome (1) but it decreases to 70% if complications develop.
She will also be told that she should have care in a tertiary center with multidisciplinary input (1) .
Early booking should be advised as she is at increased risk of early & late fetal loss .She should likewise be apprised of the risk of Preeclampsia(30%) Graft rejection(10%) FGR ?? (20-40%) & preterm labour(40-60%) are the risks quoted higher than normal? How will the woman know this? . Main risk to fetus is of prematurity spontaneous or iatrogenic .
More frequent antenatal visits should be advised with screening for Protinuria & BP at each visit . An early dating scan & detailed anomaly scan at 20 wks should be advised you are not answering the question . Serial growth scans & UA Doppler studies are needed due to risk of FGR.
She should be told about the adverse effects of the drugs (1) she is on like predinsolone can ^ use abbreviations and you will lose marks. A single mark may be the difference between passing and failing the exam risk of GDM for which screening to detect gdm should be done. Cyclosporin can cause FGR & hypertension.Serum levels of these drugs should be monitored and adjustments done as needed.
She should be told that labour& delivery are not different from other women & that the graft doesnt obstruct labour (1) . Caesarean section is done for obsteric indications or when she has any skeletal abnormality. Steroid cover however is needed and prophylactic antibiotics for operative delivery why? Which antibiotic will you give? .
Postnatally she should have reveiw of renal function .Brestfeeding is not contraindicated not answering the question. You could have written the same answer with fewer words, saving time for other questions .
the impact of the care of high risk pregnancy on the family unit should be informed what is the impact and are there any studies that have measured it? .If patient opts against pregnancy despite nulliparity her wishes should be respected & appropriate contraceptive advise should be given.
Posted by PAUL A.
a) The indication for the renal transplant is important (1) . Polycystic kidney disease has an autosomal dominant mode of inheritance and the implications of this for the fetus should be discussed. Renal failure secondary to a systemic disease such as Type I Diabetes Mellitus should prompt optimisation of the patient\'s glycaemic control before embarking on a pregnancy.

I would enquire about when the transplant took place as pregnancy outcome is better once the graft has stabilised. This normally takes 1-2 years (1) .

A detailed drug history (1) is important as some antihypertensives such as loop diuretics and ACE inhibitors are teratogenic. Immunosuppresive agents such as tacrolimus, cyclosporine and prednisolone are not known to be teratogenic..

I would also obtain a past medical history and menstrual history as chronic systemic diseases can cause menstrual irregularities or amenorrhoea.

With regards to examination, I would take her blood pressure and check her urine for proteinuria and glycosuria. Patients who have been on long term steroid therapy are at risk for type II diabetes mellitus. I would also check her height and weight to calculate her BMI (1) Excellent approach – makes marking easy and the examiner will like this. However, using a different paragraph for every point could waste your space, although this should not be a major issue .

For completion, I would perform an abdominal examination to inspect the graft site.


b) I would send her a mid-stream urine sample to screen for asymptomatic bacteriuria. If proteinuria was present, I would send a urine sample (patient’s 1st void in the morning) for albumin:creatinine ratio. An alternative to this is performing a 24hr urine collection (1) .

If there were concerns about her blood pressure, I would request for 24 hour ambulatory blood pressure monitoring.

I would also send a sample of blood to assess her urea, electrolytes, urea and creatinine levels (1) . The glomerular filtration rate can then be calculated. I would consider imaging if there were concerns about her renal function. This can be an ultrasound scan or isotope imaging of the renal tract and graft.
Hepatitis / HIV screen; FBC – all investigations always begin with this (anaemia)
c) Generally, once the graft is stable, pregnancy does not affect graft function (1) . It is vital that she continues with her immunosuppressive medication during the pregnancy. If there area any concerns regarding graft function in the pre-pregnancy state, delaying pregnancy should be advised (1) to prevent deterioration, as well as to reduce the risk of complications that may arise during the pregnancy.

d) Generally, pregnancy outcome is good if graft function is stable and if the patient is normotensive (1) . However, there are several conditions that can affect both the patient and her unborn child as a result of having a renal transplant. The patient is at increased risk of pregnancy induced hypertension or pre-eclampsia (1) . The patient should have uterine artery dopplers at 20 weeks gestation to assess her risk of developing this. Low dose aspirin given daily until 36 weeks gestation can reduce her risk of hypertensive disorders in pregnancy.

The fetus is at risk from anti-hypertensives such as loop-diuretics and ACE-inhibitors. These should be replaced with methyldopa or labetalol drugs in general as there are other drugs with potential adverse effects . The fetus is also at risk of intrauterine growth restriction as a result of chronic maternal disease and from labetalol use. Regular growth scans should be incorporated into her care.

There is an increased risk of premature labour, which can be iaitrogenic or spontaneous. The patient should receive the standard dose of intramuscular betamethasone or dexamethasone if there are signs of premature delivery or plans for premature delivery.

Vaginal delivery is not contraindicated (1) and a Caesarean section should be done for the usual obstetric or fetal indications.

Breastfeeding whilst on immunosuppressive drugs is contraindicated due to its toxic effects in the neonate. inherited condition may affect fetus. Underlying disease such as SLE may have direct effect on fetus; need for multidisciplinary care in a tertiary centre with more frequent visits
Posted by PAUL A.
A 35 year old nulliparous woman with a renal transplant has been referred for pre-conception assessment and counselling. (a) Justify the information you would obtain from the history and clinical examination with specific reference to her renal transplant [5 marks]. (b) Which investigations will you undertake and why? [4 marks] (c) What would you tell her about the potential effects of pregnancy on her transplanted kidney? [4 marks] (d) What will you tell her about the potential effects of her renal disease on pregnancy? [7 marks].

A) Duration of renal transplant is important prior to embarking on pregnancy as pregnancy atleast 2 yrs after transplant has better outcomes (1) .
Current medication history is important especially the type and dose of immunosuppresion prior to conception to minimise any effects of the fetus anti-hypertensives like ACE-I terratogenic .
History of underlying hypertension and medications should be elicited as this may cause increase risk of preeclampsia and complication with pregnancy.
History of any underlying medical disorder which led to renal transplant should be obtained because conditions like diabetes, autoimmune conditions may itself need further input with pregnancy (1) .
Her desire for pregnancy should be obtained and current contracetive use established so that this gives adequate protection and avoid unplanned pregnancy.
Her recent renal consultation outcome and plans should be obtained so as to confirm that no concerns of graft rejection prior to embark on pregnancy.
Examination including pallor to exclude anaemia, blood pressure BMI to exclude hypertension, abdominal examination for any underlying masses and previous scar sites.

B)Full blood count to exclude anaemia (1) .
Liver function test, urea,creatine and electrolytes (1) to exclude liver involvement with medications, current creatine levels to suggest if safe to embark on pregnancy and calcium levels as requirements may be altered.
Urine dipstick for leucocytes, nitrates to exclude urinary infection, proteinuria as this may increase risk of preeclampsia with pregnancy (1) 24h protein excretion .
Mid specimen urine for culture and sensitivitiy to exclude infection and or treat appropriately.
Cytomegalo virus screen as may need antenatal screen if negative during pre-pregnancy Rubella, hepatitis, HIV screen .

C) Pregnancy has no adverse effect on transplant kidney (1) if baseline creatine is <125micromol/l
Like other renal condition if underlying renal impairment of transplant kidney with baseline creatine>125micromol/l there is increased risk of worsening of renal impairment with pregnancy.
If pregnancy is embarked prior to 1-2 years of transplant there is increased risk of graft rejection (immunosuppresive state of pregnancy) and may need higher doses of immunosuppresive treatment this is questionable .
Long term prognosis of transplanted kidney is not significantly affected if pregnancy is embarked after successful graft acception and with normal renal function.
If creatine is above 125 micromol/l with pregnancy this may affect long term prognosis with shortening lifespan of transplanted kidney this is also questionable .
Provide wrriten information (1) and support group information.

D)Effect of her renal disease on her pregnancy depends on baseline serum creatine levels if this is <125micromol/l, without hypertension, proteinuria and no history of recent graft rejection this has optimal outcome with pregnancy (1) you mean good outcome .
If serum creatine levels is >125 micromol/l the chance of successful pregnancy beyond 12 weeks is significantly reduced.
If associated with renal impairment what is renal impairment? If a woman presents with serum Cr of 120microM, will you not say she had renal impairment? , hypertension and or proteinuria this is associated with increased risk of preeclampsia, intrauterine growth retardation, preterm delivery, urinary tract infections these are increased even in women with good renal function .
If renal disease associated with other medical disorders like diabetes / autoimmune conditions this may still increase the risk pregnancy outcomes (1) and will need more close monitoring with multidisciplinary team involving obstetrician, renal physicans will you only do this if there was an underlying medical disorder? , diabetalogist.
If underlying significant proteinuria above 5g/24hrs she will need thromboprophylaxis as increased risk of thrombosis.
She should be advised to contine immunosuppresive therapy as medications like prednisolone, azathioprine, tacrolimus are safe in pregnancy.
Cyclosporin will need growth monitoring as incresed risk of IUGR.
Mycophenolate mofetil safety is not established and avoided in pregnancy with alternative like azathioprine are there drugs that have potential effects on pregnancy? .
Decision to delivery should be on obstetric grounds or if worseing renal failure or graft rejection.
She should have steroid cover for delivery if on maintainance steroids.
Prophylactic antibiotic cover for any surgical intervention which antibiotic and why? and caesarean section for obstetric reason as transplant rerely pose any obstruction for vaginal delivery (1) .
She should be provided with wrriten information.
Posted by PAUL A.
a.I will obtain a detailed history regarding renal transplantation ,time since it was done as its adviced to wait for 1-2 years (1) for stabilisation of allograft and for the drugs to attain maintenance levels.History regarding the cause of renal disease like DM ,SLE will be enquired because this affects the course in pregnancy (1) may be inherited condition .Any associated hypertension and the control of disease prior to conception will be enquired because conception has to be planned when renal function is good.Medicatins history is important since certain drugs may be teratogenic like ACE inhibitors (1) used for hypertension and needs drug modification.Family history of renal disease like polycyctic kidneys will be enquired since these may be transmitted to the fetus in autosomal dominant fashion.
Examination would include looking for blood pressure which is important for assessing the prognosis.Stigmata of SLE if present should be looked and edema of legs if persistent may suggest failing renal function if other causes are ruled out BMI .
b.Investigations include MSU for glucose, protein,nitrites ,blood to look for infection and diabetes..Red cell casts in urine may suggest glomerulonephritis.24 hr urinary protein will be done to assess the protein load (1) .Fasting and postprandial glucose levels to see the glycemic control in diabetics will be done. Blood renal parameters what are these? to assess the renal function will be ordered FBC – anaemia; screening for rubella, hepatitis, HVI .
c. Pregnancy usually does not have adverse effects on renal graft function (1) .Effects of pregnancy on renal function will depend on serum creatinine levels.If sreum creatinine more than 250 micro mol/l may indicate failing renal function .Diabetic nephropathy may worsen in pregnancy and lupus nephritis associated with flares in peurperium.
d.Renal transplantation may not produce significant adverse events if prepregnancy renal function is good,conceived after 2 years of transplantion and no hypertension (1) . Maternal risks may be superimposed pre eclampsia,incresed infections,and pelvic osteodytrophy due to chronic renal failure.Fetal risks are incresed incidence of miscarriages,IUGR, premature delivery,still birth (1) ,adrenocortical insufficiency due to high dose of steroids.Familial transmission of renal diseases may occur as autosomal dominant manner (1) .Transplanted kidneys doesnot obstuct labour (1) .Written information (1) will be provided with the details.
Posted by PAUL A.
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a) Important points in the history include , when did she had the operation, back ground disease and drug history. The duration since surgery should be at least 2 years (1) to ensure graft stability . Diseases as SLE or poly arterites nodosa may worsen the pregnancy outcome and the patient health (1) IF INHERITED CONDITION, GENETIC COUNSELLING . Immonosuppresor drugs as azathioprine, cyclosporine and steroids can be continued during pregnancy but for new drugs like tacrolimus or MMF what is this? information is limited so they need to be changed . Antihypertensive drugs ? example taken by the patient may need to be modified or changed to other more safe alternatives (1) . Clinical examination will include BP measurement as strict control is essential for a favorable outcome . Signs like pallor or pitting oedema may reflect ameamia or protinuria . Good general health and renal function have abetter prognosis ? BMI .

b) Investigations for renal function (1) which tests will you request? are important prognostic factors . Serum creatinine less than 125 mmol/l has the best prognosis with complication rate 30% and live birth rate 96% . Levels between 125 and 250 mmol/l have complication rate of 50% and live birth rate 70% . Serum creatinne more than 250 mmol/l is indicative of poor renal function and bad prognosis . Serum urea between 15 and 20 mmol/l reflects good renal function. 24 hours protein in urine should be done . Presence of protinuria has bad prognosis. Urinary tract infection detection by MSSU culture (1) is important as the patient is on immunosuppresion and serious infections may occur. Full blood count , liver function tests electrolytes, Ca and P levels should be done why? . U/S of the kidneys will detect dilatation of renal pelvis with unfavourable outcome.

c) Generally pregnancy is well tolerated by the kidneys if renal functions are good from the start . glomerular filtration rate increases at 6 ws 50% will this necessarily happen in a transplanted kidney? . Hypotention and dehydration in hyperemeses should be avoided. Tight control of BP (140/90) is important for good kidney function what will you tell her about the effect of pregnancy on her kidney? You are not answering the question . Compression on the kidneys by the gravid uterus may give pain and partial obstruction of urinary outflow . Pyelonephrits may occur and affect the kidney . To improve the pregnancy oucome and support renal function management must be in liaison with renal specialists .

d) The impact of renal disease on pregnancy starts on the first trimester with increased spontaneous miscarriage rates . In the second trimester preterm labour may occur . Intrauterine growth restriction is a possibility surely these apply to all pregnancies even in healthy women and serial growth scans must be carried on . Superimposed PET is common (1) and treatment should be vigorous to avoid kidney function deterioration . . Low dose aspirin is started in early pregnancy prophylactic against PET . Regular renal functions every one month will be done not answering the question . By the end of pregnancy natural mild decline in renal function may occur and this should be interpreted carefully by nephrologists .Decisions for mode of delivery and time of delivery depends on if complications exist or no . CS is reserved for obstetric reasons respecting maternal wishes after proper counseling.


• If inherited renal condition, explain risk of passing condition to the fetus and offer genetic counselling
• Underlying disease such as SLE may have direct effects on pregnancy
• Drugs may have direct effects on fetus (examples). Need to use alternative drugs or minimum effective dose
• If good and stable renal function, obstetric outcomes are good (>90% pregnancies progress beyond fetal viability). Pregnancy however associated with increased risk of PIH, pre-eclampsia, IUGR, pre-term delivery
• Need for multi-disciplinary care in a tertiary centre with more frequent visits, scans and blood tests
• Poor renal function associated with reduced fertility, increased risk of miscarriage and worsening of obstetric outcome
• Renal transplant does not obstruct labour and vaginal delivery should be anticipated. CS for obstetric reasons
Posted by PAUL A.
I would ask her of the date she had her renal transplant as 18-24 months (1) should pass before she is allowed to get pregnant to give time for stabilisation of her graft versus host reaction and dose of immunosuppressive therapy , and see if graft rejection occurs. I would ask her of the reason for the renal transplant, for example diabetes, which should be controlled and inherited causes as polycystic kidney as they can be transferred to her fetus and genetic counseling would be advised (1) and by taking family history there is usually other members affected. I would ask her of treatments she is taking as some should be changed before getting pregnant such as angiotensin inhibiting drugs for treatment of hypertension (1) and some immunosuppressive drugs , but azathioprine and corticosteroids are considered safe.I would ask of symptoms of urinary tract infection(frequency,dysuria,urgency) as this should be dealt with promptly . On examination I would measure, her BP as this should be controlled before getting pregnant, and her BMI as she would be advised to loose weght if overweight (1) .


I will do urine examination by dipstix for protein, nitrites(urinary tract infection UTI), glucose (diabetes) and hematuria 24h protein . I would do culture and sensitivity of urine if there is infection to be treated. I would do FBC to exclude anemia (1) , thrombocytopenia which may be due to drug toxicity and for WBC which increase in infection.I would measure serum creatinine and creatinine clearance which are measures of renal function (1) . Serum Creatinine should be less than 120 umol/ml to allow pregnancy.I would Consult with immunology lab for tests showing graft versus host reaction Suggest you consult a basic science / immunology book about graft Vs host reaction .


I would tell the patient that there is no evidence that pregnancy would worsen her renal function or increase her graft versus host reaction graft rejection is very different from graft Vs host reaction (-1). This occurs in bone marrow transplant and the transplanted white cells reject the host .I would tell her that, there is increased susceptibility to UTI and this should be early diagnosed and treated , and that hypertension and diabetes can be worsened by pregnancy are these the effects of pregnancy on the transplanted kidney? and these should be controlled to avoid to avoid renal impairment. I would give her written (1) information.



I will tell her that she at increased risk of UTI and if develop pyelonephritis , she is at increased risk of preterm delivery. Will tell her she is at increased risk of developing pre eclampsia with its consequences as eclampsia, HELP syndrome ,placental abruption (1) and deterioration of renal function and I would explain these terms with drawings showing placental separation. Would tell her that her fetus might inherit the condition that necessitated her renal transplant (1) and genetic counseling is needed , and that he or she might be affected by drugs (1) she taking in first trimester so these should be reviewed . I will tell her that the fetus might not grow well in utero and follow up by growth scan is needed and that he or she might be born prematurely. Her newborn might suffer from adrenal insufficiency if she is on corticosteroid therapy and an experienced pediatrician will see to this. She is given written information
Posted by PAUL A.
(a) Justify the information you would obtain from the history and clinical examination with specific reference to her renal transplant [5 marks].

A history should include enquiry regarding the interval since the transplant and about the immunosuppressive therapy and the dose which she is taking. Usually fertility returns to normal by about 6 months. It is better to delay the pregnancy for up to 2 years (1) after transplant or until the renal function and the dose of immunosuppressive therapy is stabilized. History of hypertension and anti-hyperternsive treatment is important. There is risk of pre-eclampsia and sdhe may need stop drugs like ACE inhibitors (1) and angiotensin receptor blockers once she is pregnant. Also some immunosupressents like OKT3 and antithymocyte globulin has limited safety data during preganancy. History of co-morbidities like diabetes and connective tissue disorders is important as it may adversely affect the pregnancy outcome (1) inherited condition may be passed on to fetus .

Clinical examination one should look for presence of edema, blood pressure to examination to rule out hypertension and abdominal examination to rule out ascites. These may suggest presence of significant proteinuria and active renal disease BMI .

(b) Which investigations will you undertake and why? [4 marks]

Investigations are aimed at assessing the renal function and to rule out any complications. This includes a serum urea and creatinine. A creatinine level more than 133 micromols/L is associated with adverse pregnancy outcomes (1) . A 24 hour urine protein and serum albumin is important since protinuria more than 500 mg/24 hours is associated with adverse pregnancy outcomes. Hypoalbuminemia can cause venous thrombosis and pulmonary edema MSU for UTI; rubella, hepatitis, HIV screen; FBC - anaemia.

(c) What would you tell her about the potential effects of pregnancy on her transplanted kidney? [4 marks]

She should be told that pregnancy itself will not affect the renal function significantly if the serum creatinine level less than 133 micromols/L (1) . But presence of hypertension and recurrent urinary tract infections may affect the renal function especially if pre-eclampsia supervenes. She should be told that there a possibility reduced cyclosporine levels due to haemodilution but usually there is no need to increase the dose.


(d) What will you tell her about the potential effects of her renal disease on pregnancy? [7 marks].

She should be told that her renal disease can adversely affect the maternal and fetal outcomes and that depends on the preexisting renal function and complications like hypertension and protinuria. Usually women with serum creatinine less than 133 micromols /l have a better outcome (1) . The complications may include an icreased risk miscarriage in the early preganacy, preterm labour in about 30-50 %, pre-eclampsia in about 30% and IUGR on about 20% cases (1) . She should be told that protinuria can led to hypoalbuminemia and it can lead venous thrombosis and some times pulmonary edema in pregnancy. She may need thromboprophylaxis during pregnancy.

She should be told that there is no contraindication for a vaginal delivery because of the presence of transplanted kidney in the pelvis as usually it will not obstruct the labour (1) . But up to 50% of women may need caesarean section.
Posted by PAUL A.
a) Duration of her renal transplant should be asked as pregnancy should be avoided if it is less than 2 years (1) . History of renal transplant rejection should be explored. Underlying of her renal failure is important information (genetic inheritance, SLE or diabetes) (1) . Status of her current renal function or presence of other complication like protenuria should be assessed. Her current medication should be reviewed ( prednisolone or other immunosuppressive drugs) anti-hypoertensives like ACE-I should be stopped . Her BMI should be calculated. Her blood pressure (1) should be measured. Presence of edema or anaemia should be assessed.
b) 24 hours urine protein or creatinine why OR? Are these alternatives? should be assessed to know based line of her renal function. Contraception should be ensured if she has severe renal failure. Hepatitis B, C and CMV status should be check as this patient at increased risk to get blood borne infection. Renal failure is at increased risk to develop anaemia, therefore her Hb should be check (1) . Rubella status should be check because this condition is amenable to vaccination (1) HIV . If her underlying cause of renal failure due diabetes, then HbA1C should be check.
c). She should be made aware that her renal function may deteriorate during her pregnancy will pregnancy make long-term renal function worse? . Her protenuria may worsen. The underlying caused of her medical illness may get worsen or flare up especially if her medical condition is not in remission (ie SLE). She may require frequent visit for antenatal follow-up is this effect of pregnancy on renal function? . Written information (1) and group support should be provided
d). She should know that she is at increased risk to develop pre-eclampsia or superimposed pre-eclampsia. She is also at increased risk to develop anaemia. Pelvic osterodystrophy is another complication that she should know. Her fetus is at risk to develop IUGR (30%). The risk of stillbirth is also increased (1) . She should know that her baby may develop neonatal adrenal insufficiency (predisolone > 15mg). The fetus is at increased risk of premature delivery. She should be given written information and detail of hospital contact.
potential effects of inherited conditions, drugs; need for increased surveillance and multi-disciplinary care; transplanted kidney does not obstruct labour
Posted by PAUL A.
a-I would explore the etiology for renal transplant so as to know the prognosis for transplantation and to discuss genetic issues (1) .I would enquire about when the transplant was done as conception needs to be deffered for atleast a year (1) most will say 2 years so as to optimise outcome.I would also ask about the drugs she is on whether on maintenence therapy or not)so that i would advise her on contraception until is on stable maintenence immunotherapy are there drugs that you would change? .I would review her records to R/o co morbid diseaseslike Diabetes, hypertension,and also asses whether she is on stable renal function and whether she has had or is having infections such as CMV,HSV,HBV and toxoplasmosis how will you assess this? You were asked about Hx and examination . I would also look for her previous obstetric outcomes nulliparous woman from records if any so as to asses outcome in subsequent pregnancy.I would enquire about the contraception she is using ,the method and for how long. so as to advice her on the same if pregnancy has to to delayed.I would check her B.P to R/O hypertension and ascertain her BMI (1) .
b -I would do U& E, serum creatinine and creatinine clearance to asses renal function (1) .Urine routine and MSU culture and sensitivity to R/O urinary tract infection.Urine protein and 24 hr urine protein (1) ( though renal disease patients with grafts may excreate variable amounts ) to R/O excessive proteinuria.I would HBSag antigen, CMV antibodies, HSV,toxoplasma and HCV antibody titers (1) rubella immunity, HIVto R/O infection as they are more prone to it because of immunosuppressive drug intake.Drug levels need to be monitored to prevent toxicity and to maintain adequate dose.USS pelvis to R/O obstructive disease if signs and symptoms are suggestive of it.
Biopsy if deterioration of renal function ia present.
c-I would tell that the incidence of rejection is no higher than that in nonpregnant patient and that graft loss within 2 years of delivery is not affected by pregnancy (1) you will not get 4 marks just for this and it happens in patients with impaired graft function only.
d- Iwould counsel her that stable graft function with no proteinuria ,no hypertension and no evidence of rejection or obstruction is needed for good outcone.There would be no graft rejection if prepregnancy graft function is normal this was mentioned in (c ) where it was relevant . I would also tell her that she has increased risk of misscarriage , IUGR,PTL low birthweight babies (1) and genetic inheritance (1) depending upon the renal disease.She has increased chance of pre eclampsia ,hypertension and infection. The risks due to drugs are teratogenicity from which drugs? . I would also tell her that there is increased risk of cesarian section .She is also prone to depression because of problems with breast feeding because of drug excreation in breast milk as breast feeding is controversial in graft recepients on immunosuppressive drugs why should this increase the risk of depression??? .
Posted by PAUL A.
A. The cause of renal failure has to be assessed as certain conditions have adverse impact on pregnancy and hence increased intervention. Polycystic kidney disease is autosomal dominant condition and hence need for prenatal diagnosis (1) . Systemic lupus erythematosis and diabetes can worsen during pregnancy. The duration since renal transplantation has to be enquired as it would be prudent to attempt pregnancy two years (1) after transplant by which time graft would be stabilised and she will be on maintenance dose of immunosuppressive therapy. The associated condition like hypertension has to be evaluated. Her current medication has to be assessed and appropriate modification has to be made based on their tetratogenic potential which drugs might you expect to change?. Antibiotic therapy has to be reviewed. Nephrologists’ input must be sought regarding the baseline graft function as the level of graft function and presence of hypertension as two important parameters that are shown alter the pregnancy outcome. Previous case notes should be reviewed.
On examination BMI and blood pressure has to be assessed (1) . Anaemia has to be looked for. Any condition that would otherwise contraindicate a pregnancy like active SLE, severe renal failure should be assessed.

B. Blood urea and electrolytes, creatinine clearance (1) and 24 hours urinary protein has to be assessed to assess the base line graft function. If the creatinine is more than 250 mmol/L pregnancy should be discouraged.
Mid stream urine for microscopy and culture (1) should be sought as asymptomatic bacteruria and urinary tract infection can precipitate renal failure and also adverse pregnancy outcomes like preterm labour.
Haemoglobin (1) and haematocrit should be done as anaemia is associated with increased pregnancy related complications like preeclampsia, intrauterine growth retardation restriction .
Level of optimisation of medical disorders predisposing to the renal impairmrnt has to be assessed like diabetes and SLE.
hepatitis, HIV, rubella screening
C. Effect of pregnancy on the renal transplant essentially depends on the level of graft function. If associated with severe renal impairment the risk of progression to failure would be around 50% the effect of pregnancy in these circumstances is debatable . The aetiology also plays a role. Poorly controlled diabetic status and SLE flare can affect the graft function these are not direct effects of pregnancy on renal function . Associated conditions like development or worsening of pre-existing hypertension, superimposed preeclampsia or urinary tract infection can also affect graft functioning.

D. Mother carries increased risk of developing hypertension or proteinuria, superimposed preeclampsia during pregnancy. Increased incidence of infection and risk of developing diabetes has to be explained because of immunosuppressive drugs and the need for multidisciplinary care involving nephrologist (1) and need for frequent antenatal checkups has to be emphasized (1) . Fetus is also at increased risk of miscarriage, still birth intrauterine growth retardation and prematurity (1) and hence increased need for ante partum fetal surveillance. Increased need for emergency delivery in the event of uncontrolled hypertension, fetal compromise, and renal impairment has to be explained. All the problems get worsened following unplanned pregnancy and hence effective contraception should be advised. Written information (1) has to be given. Patient wishes should be taken into account.
Posted by PAUL A.
I will enquire about if she has any symptoms at present. If she has vomitings, pain in abdomen, occasional fever then she may have graft reaction and review for renal physician would be arranged. I will enquire when was the transplant done because it is advisable to wait for at least 2 yreas (1) post transplant before planning pregnancy to confirm well functioning and accepted graft.i will about the psot surgical period , any complications ,and if she received any blood transfusions. I will also chek the cause for renal failure leading to transplant. The causes like polycystic kidneys(autosomal dominant) will need genetic counselling (1) and information about prenatal diagnostic tests.if it was diabetic nephropathy then diabetes control would be checked.i will ask which medications she is taking like immunosuppresants,steroids and anti hypertensives if she has hypertension. Drugs like ACE inhibitors (1) ,diuretics would have to be changed to safer drugs in pregnancy. At examination I will check for pallor which is suggestive of anemia which is common in these patients. I will check BP, BMI (1) ,auscultate chest for any advantitious sounds, per abdomen examination to asses any tenderness over the transplanted kidney.


I will check urine for proteinuria and nitrites and leucocutes. If positive I will ask for 24 hour urinary proteins to asses the preexsiting proteinuria .this would be baseline so as to be able to diagnose superimposed preeclampsia during pregnancy. If nitrites positive I will send urine for Culture and sensitivity and treat UTI (1) .
I will check FBC to r/o anemia (1) , baseline liver and renal function tests including urea ,creatining, creatining clearance (1) and eGFR to check for graft functioning. I will offer screening for HIV and HbsAg (1) rubella, Hep Cif she has had blood transfusions in the past.

Due to increased blood volume and stroke volume in pregnancy the kidneys are at higher load.i will tell her that Most patients with well functioning graft tolerate pregancy well pregnancy will not affect graft rejection . however in case of ill functioning graft with high creatinines or heavy proteinuria upto 40% patients will go into end stage renal failure during preganacy or within 1 year of delivery is it clear that this is because of pregnancy? . This depends on control of hypertension, UTI, and serum creatinine levels.



Most patients with well functioning grafts tolerate pregnacy well what does this mean? You made the same ststement when asked about effect of pregnancy on renal function with good outcomes. The potential effects on mother are pregnacy induced hypertension, superimposed preeclampsia and its complications. Worsening proteinuria (1) would cause pulmonary odema and increased risk of venous thrombosis. Acute deterioration in renal function may occur with UTI,dehydration,uncontrolled hypertension hence she would have to attend 2 weekly visitis at the antenatal clinic to detect these complications early (1) .
Fetal implications will be miscarriage,prematurity,IUGR, and rarely sudden still births.
If the risk of transmitting disorder to fetus (1) if there is genetic cause for renalk failure and would need prnatal diagnostic tests for it.
I will tell her that immunosuppresants like azathioprine,cyclosporin and steroids are not teratogenic.steriods in high doses may cause fetal adrenal suppression (1) .
I will also let her know that transplanted kidneys do not obstruct labour (1) and she can have a normal vaginal delivery.
I will provide written information (1) to back up vebal counselling.
Posted by PAUL A.
a)
I would find out when the renal transplant was done because she should not conceive for 2 years (1) following the procedure. This allows for the graft function to be stabilised. The reason for the transplant is important why? . I would ask whether she was still under the care of a renal physician and transplant team is she likely to be discharged? ; and if her condition was well controlled. This is necessary because it should be well controlled before conception. The drugs that she is taking are important since some may have adverse effects on the fetus such as anti hypertensive ACE inhibitors (1) . The presence of comorbidities such as hypertension may have an effect on a future pregnancy either by itself or superimposed with preeclampsia. If she is diabetic, the involvement of a diabetic team, monitoring of blood glucose levels and insulin doses; and increase surveillance of the fetus will be necessary.
In the examination, I would measure the blood pressure since hypertension would need to be controlled before the woman conceives. I would do an abdominal and vaginal examination to determine if the transplanted kidney was palpable and may obstruct delivery of the baby NO, it does not .

b)
I would do a full blood count to ensure that she is not anaemic (1) and there is no underlying infection. I would also do a C reactive protein which would be raised with an infection. Urea, creatinine and serum electrolytes would indicate whether the renal function was normal (1) . A dipstick of the urine should be done for protein or blood which may point to renal disease. A better assessment of urine protein can be achieved with a 24 hour urine protein excretion test. Renal function should be determined because if abnormal the woman should be monitored by the renal team and pregnancy should be delayed. A microscopy, culture and sensitivity of a mid stream urine sample should be tested for a urinary tract infection (1) screen for rubella, hepatitis, HIV .

c)
I will tell her that the effect of pregnancy on the renal transplant depends on the creatinine levels at conception. Pregnancy has no adverse long term effect on the transplant in women with baseline creatinine levels of less than 100 umol/l (1) . If the creatinine level is more than 130 umol/l there is a risk that the function of the graft will deteriorate. I will provide her with written information (1) .

d) I will tell her that renal disease can cause effects on her and a fetus. A successful pregnancy outcome ranges between 75-95%.There is an increased risk of maternal and fetal morbidity and mortality. There is an increased risk of hypertension, preeclampsia and urine infections. There is increased risk of intrauterine growth restriction and preterm delivery (1) . Therefore more frequent antenatal visits will be needed (1) , serial ultrasound scans and midstream urine tests at each visit. The pregnancy risks are worse in women with diabetes and /or poor graft function. In the presence of diabetes a multidisciplinary approach will be needed so you will not do this if she was not diabetic??? with her being cared for and monitored by a diabetic nurse and physician. I will tell her than the immunosuppressants used to prevent graft rejection do not have an effect on the fetus. But ACE inhibitors use for hypertension would need to be changed to antihypertensives that do not have a harmful effect on the fetus (1) . I will provide her with written information.
Posted by Arun J.
Dear Dr paul

In my answer i had written that i would review the patients records to see whether she has had any infection and stable renal function. Is reviewing of records not possible in history taking?.In the question it was mentioned that she is a nullipara only and not nulligravida .So she would have misscarried before isnt it.So i thought i would question her previous obstetric history.Please clarify it to me.
Posted by PAUL A.
A.
On history taking I will focus on exact reason fro transplant; congenital or acquired, to identify causal co-morbidity requiring treatment or affecting pregnancy and likelihood of congenital renal problems in offspring (1) . For the latter family history of renal problems is useful as well. I’ll ask when it was done, whether renal function is stable and how long it has been so. Instable unstable renal function or short transplant-pregnancy interval how long is short? will reduce chances for successful pregnancy whilst increasing risks. I’d ask about her medication, as some may be teratogenic ? example and must be discontinued. On physical examination blood pressure (1) BMI is a very important prognostic factor. I’ll look for signs of anaemia (more common in renal problems), oedema in legs and tenderness at the transplant site to identify graft problems/suboptimal renal function.

B.
Assessment requires multi-disciplinary approach waste of time and space . Investigations include bloods for FBC (anaemia) (1) and 24-hours-creatinin clearance, renal function + electrolytes to get a baseline (1) , which is of prognostic value. An ultrasound of the kidneys is needed to assess current status and identify any problems, such as signs of rejection etc no marks for this . Genetic screening/counseling is only needed if the woman’s renal problem was congenital rubella, hepatitis, HIV screening .

C.
If her renal function is good and stable, pregnancy can be pursued. Risk for rejection is not increased (1) and renal function will usually not worsen, nor will life-expectancy or transplant be negatively affected in long term. This is in contrast to a not stable renal function, where risks for reduced graft survival, worsening renal function and graft rejection are increased during pregnancy and long-term as well this is uncertain. Is this something which would have happened or is is due to pregnancy . In women with a poor baseline renal function, morbidity and mortality in subsequent years is increased as well

D.
There is increased risk for urinary tract infections, low dosed prophylactic maintenance antibiotics may sometimes be needed how does the examiner know that you know when this will be needed? . Immunosuppressive medication can in most cases be continued. If necessary doses of some may need adjustment based on serum levels. She is more prone to develop pregnancy-related hypertensive disease (PIH, PET, HELLP, eclampsia) (1) , which on turn will again negatively affect renal function. These complications, or an isolated worsening renal function may necessitate iatrogenic premature delivery with all its associated mortality and morbidity (admission to neonatal intensive care unit, respiratory and feeding problems etc). Blood pressure and proteinuria therefore need to be monitored meticulously at regular intervals. If the maternal renal problem is congenital, there is potential for similar problems in the foetus particularly relevant to inherited as opposed to congenital disorders and anomaly scan in a tertiary centre is warranted. As IUGR is more common, serial 4-weekly growth scans are also needed. The mode of delivery will be determined by obstetric factors only (1) transplanted kidney will not obstruct labour .
Posted by Atashi S.
(a)I will take information from history how long she have renal transplant as she should be advised to delay pregnancy of about 1 to 2 year.Information regarding medication including immunosupressive agent and anti hypertensive agent should be noted as dose of immunosupressant would be minimum as possible and if she is on ACE inhibitor it need to be changed for beta blocker.Reason for transplantation is tobe noted from history .If reason is genetic disease she need genetic counseling before conception.clinical examination is to be done to note degree of anaemia it need correction before conception. BP is to be measured as it should be well controlled.

(b)Assesment of renal function is important by serum creatinin and urea level as preconceptinal normal renal function associated with 85%survival rate in 5year and 90% good pregnancy outcome.Full blood count to detect Hb% and to see any sign of infection .Blood sugar level should be asses as use of prednisolone for immunosuppression may led to glucose intolerence. A mid stream specimen of urine is to be tested for routine and microscopic examination to rule out UTI before conception.

(c)Pregnancy has no adverse effect on renal allograft function in woman with base line creatinine level<100 micromol/L.woman who enter pregnancy with creatinine level>130 micromol/L renal graft survival is only 65% in 3 year.About 15% of woman devolop sgnificant impairment of renal function during pregnancy and this may persist after delivery . About 40% of woman devolop significant proteinuria towars term , but this usually regress postpartum.


(d)Outcome is optimal in those without hypertention, proteinuria,recent episodes of graft rejection and in woman with normal or near normal renal function.Incidence of problems in pregnancy is about 50% and includes hypertention /preeclamsea(30%),Graft rejection 10%,IUGR 20 to 40%., preterm delivery 45 to 60%and infection especially urinary tract infection. Chance of successfull outcome beyond 12 week is about 97% in those with baseline creatinine level>125micromol /l .It is reduced to 75% with base line creatinine level>125 micro mol/ l.
Posted by PAUL A.
a) History of duration of surgery , as less than one year graft is not stable ? meaning – can renal function not be stable? & more than 5 years may lead to postpartum impaired renal function secondary to chronic rejection so women should not get pregnant because you are either worrying about sub-acute or chronic rejection?? . Cause of the transplant whether genetic disease like polycystic kidney disease or other nongenetic why? . Type of transplant , if live related donor, pregnancy may be considered after one year & if cadaveric transplant , it is better to wait for two years (1) .
Drug history in deatail to be taken as these patients are on immunosuppressant drugs like Steroids , azathioprine, cyclosporine. These drugs may lead to repeated infections , prematurity & increased risk of congenital anomalies which anomalies? .Contraception history should be taken as she needs contraception till she is allowed to get pregnant according to stability of the graft & other associated illnesses & biochemical investigations. Ideally low dose COCs are better as there may be failed efficacy of IUDs(Cu-T) ?? meaning? Which is more likely to fail? COCP or IUCD? as patients are on immunosuppressants & there may be repeated infctions.
History of chronic diseases like Diabetes, hypertension, heart disease , inflammatory bowel disease , SLE, thyroid disorder ? relevance to renal transplant which get deteriorated due to pregnancy. History of vaccination like Rubella ,to be taken as live vaccines are contraindicated after transplant.
Patient should have thorough general examination including her Blood pressure, oedema, as uncontrolled hypertension is not advisable . Thyromegaly ? relevance should be ruled out . pallor should be seen to rule out chronic anaemia. BMI

b) Investigations like FBC & peripheral smear to look for anaemias (1) ,& haemolytic anaemias, urine,to see proteins as it should be less than 500 mg /day to be pregnant.,sp gravity to see renal function are there more useful tests for renal function? ,MSSU for microscopy as to rule out bacteriurea (1) ,Fasting BSL should be estimated to know the diabetic status /base line level. Rubella , cytomegalovirus, Toxoplasmosis antibody titer should be tested as these are common infection in patients on immunosuppressants (1) hepatitis, HIV . Serum creatinine, blood urea, serum uric acid level should be measured to know current renal function (1) , as serum creatinine level should be less than 2 mg/dl for patients contemplating pregnancy. USG & IVP to know any pelvicalyceal dilatation .

C) Pregnancy does not appear to have generally any adverse effect on longterm survival of renal allograft (1) . The maintenance dose of immunosuppressants to keep on lowest possible level to avoid fetal hazards. Because of increased GFR in pregnancy there may be reduced blood level of immunosuppressant drugs. She should be advised that her antenatal check up to be more organised in such a way that ,during visits she should under go investigation like serum creatinine,blood urea,LFT,Hb & serial USG for IUGR.

D)She is more prone to eclampsia, infections like asymptomatic bacteruria, pyelonephritis &1st trimester miscarriage-35% ,preterm labour,PROM-30%,IUGR-30% (1) ,.congenital anomalies of fetus ,because of immunosuppressant which drugs are terratogenic? ,& repeated infections.If she develops recurrent bacteriurea she shoud be under antibiotics throughout pregnancy. During labor if she required induction or augmentation by oxytosin ,she may develop oedema due to water retention.She shoud be told that ,she can deliver vaginally,as renal transplant itself is not an indication for CS (1) .
Posted by PAUL A.
prt

a] Patient is adviced Not answering the question – you were asked to tahe a Hx, not advise the woman to wait 2 years after the renal transplant before embarking on pregnancy.As with time the graft function will stabilise and the maintainence level of immunosuppresive drugs would be reached.She should be asked in history regading the reason of transplant.Genetic counselling needs to be offered if it was for the familial disorders like polycystic kidney (1) &medullary sponge kidney.Her prevoius operative notes can be checked to know whether the transplant was due to SLE,Diabetes mellitus or Chronic renal failure.Hx of various drugs she has taken is noted .Antihypertensives taken to control B.P like ACE inhibitors (1) should be changed in consultation with the renal physician.Hx of prophylactic antibiotics taken is noted as anti folate antibiotics need to be replaced.Clinically patient is examined for anaemia.B.P.is checked to assess hypertension.BMI (1) and oedema is noted.

b]Patient should be investigated with FBC as anaemia (1) need to be corrected.For her LFT,U&E ,serum creatinine,Creatinine clearence,24 hours protein and protein creatinine ratio is done to assess graft function (1) and liver function.
Maternal calcium levels are done as both hypo/hypercalcemia in dangerous and dose of vitaminD/calcium should be altered.
Urine MSU for culture and senstivity is done to treat UTI 24h urine protein .
GTT 75gm 2 hours and fasting glucose is done if the patient is on steroids.
Patient should be screened for rubella,Hepatitis B,HIV and syphilis (1) .


c]Pregnancy does not affect the long term renal function (1) .Women with severe renal impairment,serum creatinine more than 250 micromol/l should be advised against pregnancy asits associated with adverse obstetric outcome.Women with normal or mildly impaired pre pregnancy renal function,s.creatinine less than 125 micromol/l[1.4mg/dl] can hope for good pregnancy outcome you were not asked about pregnancy outcome. You were asked about effect of pregnancy on renal function .Patient should have multidisciplinary care under renal physician.She should be told that B.P. needs to be controlled strictly.Increasing proteinuria requires consultation with nephrologist and thromboprophylaxis.Transplanted kidney does not obstruct labour or delivery this is the effect of the kidney on pregnancy. You were asked about the effect of pregnancy on the kidney .CS needs to be done for obstetric indications only and written information (1) is provided for the same after reassuring the patient.Immunosuppressive drugs like ciclosporin,prednisolon.azathiaprine and tacrolimus are safe in pregnancy and not teratogenic.
Serious rejection episodes occur only in 5% of pregnancies with graft.

d]Pregnancy and foetal risks associated with renal transplant should be explained to the patient.There is increased risk of early pregnancy loss.Risk of IUGR associated is 20-40%and the risk of pretern delivery is 40-60%.There is a chance of superimposed preeclampsia around 30% (1) . She should be advised low dose aspirin to reduce complications and Folic acid 5mg/day is given preconceptionally 3 months before pregnancy.
She should be adviced dating scan at 10-11 weeks of pregnancy
not answering the question – what are the potential effects of renal transplant on pregnancy? .Prenatal diagnosis and counselling is needed for the inherited diseases the effect is that an inheritable renal disease may be passed on to the fetus .More frequent antenatal checkups are required (1) for the foetal growth retardation restriction .Regular USG assessment of foetal growth and wellbeing should be done if there is associated SLE and Diabetes mellitus.Written information and the name of support groups are given for the same
Posted by syeda sajida M.
a) I will enquire about the reason of her transplant, whether it was due to diabetes,SLE , polycystic disease of kidney, trauma, or chronic infection as it will help for proper prepregnancy councelling as well as her care during pregnancy delivery and postpartum period.Duration of transplant is important as if it is around two years or more, less chance of graft rejection and she may be on maintaince dose of immunosuppression.If she is on antihypertensive therapy like ACE inhibitors needs to be changed to methyldopa, labetelol,or nifedipine.i will also enquire about prednisolone which can be continued during pregnancy.Immunosuppressive medication like Azothiaprine can also be continued. If she is diabetic how is her HbA1c level as high levels are associated with miscarriage and fetal anamolies.
On clinical examination I will note her general appearence nutritional status, sign of anaemia like pallor tachycardia which is associated with chronic renal disease, oedema due to hypoproteinaemia,blood pressure,pulse.

b)Iwill do FBC to see Hb for anaemia. LFTs and RFTs to assess the severity of condition.24 hrs urine collection for proteins and creatinine clearence gives idea about renal condition, MSU to exclude any infection.If diabetic HbA1c and blood sugar series.if she is having SLE anti-La,anti-Ro,ANA ,anti cardiolipin Ab,anti DNA Abs need to be done.

c)if she does not have any recent episode of graft rejection,her renal functions are not severely impaired( serum creatinine is less than 125mmol/l) then pregnancy will not adversely effect her disease. There is chance that her renal functions may detiorate in later part of pregnancy ,she may develop proteinuria, pregnancy induced hypertension, with superimposed PET . there is increased chance of urinary tract infection. In case of SLE ,lupus nephritis may develop.

d)She may develop proteinuria ,PIH with superimposed PET.
If proteinuria >5 grams increased risk of VTE. There is increased risk of anaemia ,pelvic osteodystrophy secondary to renal failure.
Risk of abruption secondary to PIH and PET.There is increased risk of UTI.
There is increased risk of miscarriage but after the first trimester 94%pregnancies are successful.IUGR, preterm delivery due to detiorating condition may lead to increased perinatal morbidity and mortality.There is risk of stillbirth and fetal adrenocortical insufficiency ,thymic atrophy,congenital infections,septicaemia and bone marrow hypoplasia.
Posted by PAUL A.
SM reply.
a)
It is imperative to ascertain the cause that lead to renal transplant as autosomal dominant conditions like polycystic kidneys need genetic counseling (1) prior to planning a pregnancy. The duration since the transplant must be enquired into. A minimum of two years (1) since transplant ensures adequate time for stabilization of the patient and reduced risk of graft rejection. Her drug history must be enquired into .ACE inhibitors for hypertension cause IUGR (1) main effect is on fetal kidneys , hence must be stopped during pregnancy. Azathioprine,cyclosporine and tacrolimus are safe in pregnancy. Antibiotics must be reviewed with the renal physician. If her blood sugars are poorly controlled ? relevance to renal transplant contraception must be advised till better control is achieved so as to have better pregnancy outcome. Anemia treatment must be enquired into as anemia is common in these women due to lack of erythropoietin. Notes from the renal physician /surgeon must be studied for any special instructions. Her menstrual history and fertility treatment if any must be enquired into.
On examination, BMI must be calculated as increased BMI increases maternal mortality and morbidity. Pallor must be checked for as anemia is common in these women and needs treatment. Fundoscopy must be done if the woman is diabetic. Anasraca indicates significant proteinuria. Signs of DVT must be looked for as proteinuria predisposes to hypercoagulable state. ? BP
b)
Investigations that need to be done are FBC for hemoglobin assessment for anemia (1) .Urea electrolytes and creatinine clearance (1) must be done. Serum creatinine > 120 micromol/l indicatesgood 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 (1) must be done as proteinuria >5gm/day mandates thromboprophylaxis.
c)
Potential effects of pregnancy on her transplanted kidney are that urinary tract infections ,hypertension and proteinuria can cause rapid deterioration in renal functions. Diabetic nephropathy can deteriorate in 50% of the cases. End stage renal disease is seen in about 50 % of severe renal impairment in pregnancy is this a consequence of pregnancy? .Lupus flares or nephritis has poor outcome .The transplanted kidney does not obstruct normal vaginal delivery asked about effect of pregnancy on the kidney .
d)
The effects of her renal disease on pregnancy are that she has a higher risk of developing pregnancy induced hypertension, pre-eclampsia, preterm delivery (1) , diabetes mellitus , anemia ,infections especially urinary tract infections and osteodystrophy . She also has a significant risk of developing venous thrombo-embolism. The risk of miscarriage , preterm delivery , IUGR and stillbirth too are significantly higher. Hence close survelliance is required in pregnancy. Aspirin must be started in the first trimester. Growth scan every 2 weekly from 28 weeks will be arranged for her . In case of deterioration of hypertention or renal functions , preterm delivery may be required. I will offer her relevant written material (1) and support group addressess.
Posted by PAUL A.
a) In the history, I would find out why she needed the transplant. If due to end-stage renal disease secondary to chronic medical conditions like diabetes and SLE,these would have to be well controlled prior to pregnancy to improve outcome (1) ? inherited disorder .
.The time since the transplant occurred will be noted. She would be advised to wait for at least one year due to her age ? relevance of her age , but preferably two years so as to reduce the risk of graft rejection no evidence that earlier pregnancy increases risk of rejection .
Current medications and theier dosage will be asked. Most immunosuppressive drugs are not teratogenic do you know of any drugs she might be using that are terratogenic? . She will be prescribed the safest drug at the lowest dose which is effective.
A menstrual history will be taken because regular ovulatory cycles are established within six months of a successful transplant. Reliable, safe contraception will be advised until she is fit to start her family.
The source of the transplanted kidney will be established as success of transplant is higher if the donor is a living relative compared to cadaveric organs.
Blood pressure will be measured (1) BMI , so that it can be well controlled prior to conception to reduce the risk of complications like pre-eclampsia. Signs of chronic illnesses will be sought in order that her general health can be optimised prior to conception.

b) Blood will be drawn to determine urea and serum creatinine levels (1) . Serum creatinine less than 125 micromol/l is associated with a 90-97% successful pregnancy rate once the pregnancy survives the first trimester. Liver function tests will be done as a baseline for monitoring during the pregnancy. Haemoglobin levels will be done and anaemia (1) corrected prior to pregnancy. Renal ultrasound to rule out hydronephrosis or other pathology will be done.

c) the potential effects of pregnancy on the transplant depends on the baseline creatinine levels. If the creatinine is less than 100 micromol/l, there will be no adverse effect on the renal graft (1) . If serum creatinine is greater than 130 micromol/l, there is an increased risk of deteriorating renal function, with a graft survival of 65% at 3 years after pregnancy is this a pregnancy effect? . New long term kidney problems can develop after pregnancy.

d) The effect of the transplant on pregnancy depend several factors you were asked about the potential effects, not the factors they depend on .
She will be told that if her blood pressure is normal, there is no protein in her urine, her serum creatinine is near normal(less than 130micromol/l, and she had no recent episodes of graft rejection her outcome is good (1) .
However, she will be told of a twenty percent risk of first trimester miscarriage, but if pregnancy goes beyond twelve weeks, her success is about 95% if renal function is normal and 75% if renal function is impaired.
Complications that can arise include preterm delivery, pre-eclampsia, intrauterine growth restriction, graft rejection and urinary tract infections (1) potential effects of drugs, increased antenatal visits; need for multi-disciplinary care .
Posted by PAUL A.
Detailed history related to renal transplant should be obtained. I would ask about the indication for renal transplant, I would ask about any chronic illness like systemic lupus eyrthrematosis (SLE) affecting the renal condition. Also, congenital disorder like Polycystic kidney of recessive or dominant disorder, as it may pass to offspring (1) . I would ask about the duration since she had the transplant. As, it is more recommended to postpone pregnancy if the period less than 2 years (1) . I would ask if she is taking antihypertensive like Diuretics, and possibility of change AC inhibitors to methyl dopa or combined alpha and beta blockers. As, foetal anomalies are significantly higher with AC inhibitors (1) . I would ask about the different medication of immunosupressents like Azathioporine, Cyclosporines and corticosteroids. Different doses should be adjusted before pregnancy starts. ? examination

Investigations should be ordered includes renal functions tests, BUN, creatinine, creatinine clearance& serum electrolytes (1) . Pregnancy will deteriorate the impaired renal functions. Glomerular filtration rate should be calculated and the risk will be higher in case with reduced rate. Rule recurrent renal infection with repeated urine test, microscopically and culture & sensitivity, also to detect proteinuria (1) 24h urine protein . Full blood count should be requested as the incidence of anaemia (1) with renal impairment specially with vitamin B12 deficiency. General pre-pregnancy screen should be ordered as Rubella IgG, Hepatitis B&C, HIV, and TPHA (1) .


There are some potential effects of the pregnancy over her transplant kidney, as the rejection rate is higher especially with short duration since transplant no evidence that pregnancy affects risk of rejection . Also, it may deteriorate the renal functions. Urinary tract infection is more common with pregnancy as a result of asymptomatic bacteriuria and back pressure over the ureter. That may be deteriorated with transplanted kidney.


There are some potential effects of the renal disease on the pregnancy, Genetic disorder may pass to the offspring (1) . There is high incidence of miscarriage rate. Also, there is increase chance of anaemia and deteriorating the systemic disorder like SLE & Hypertension. So, there is increase chance of pre-eclampsia, preterm delivery, intrauterine growth restriction (IUGR) (1) . As effect of immunosupressents there is increase incidence of Gestational DM specially with steroid use will require more frequent antenatal visits, multi-disciplinary care; underlying disease like SLE may have direct effect on pregnancy; written information .
Posted by PAUL A.
The successful outcome of the pregnancy in a well functioning renal transplant is no defferent than the general population waste of time & space – you were asked about Hx . The history of duration of transplant will give information on stabilisation of renal function as it takes 1-2 years for stabilisation so an advice to delay pregnancy can be given (1) . It also gives information whether she Is on maintenance doses of immunosuppressive drugs. Her control of hypertension and the antihypertensive drugs she is on should be enquired as ACE inhibitors and diuretics need to be change (1) as they have adverse effect on the baby. Her status regarding graft rejection and frequent admission s in the hospital for treatment would help to assess the severity of her condition. Clinical examination would aim to rule out her general status and well-being. Blood pressure (1) ? BMI to assess the hypertension status. Oedema will give the sign of hypoalbunemia. Gentle and deep abdominal examination to rule out tenderness to rule out pyelonepritis any and masses. Chest examination for adventitious sound and to rule out pulmonary oedema.


Mid stream urine to rule out infection. Full blood count for anemia (1) , neutrophilia and thrombocytopenia..Urea and creatinine for renal status (1) , if very high creatinine to advice against pregnancy. Ultrasound for hydronephrosis , calculi and abdominal masses 24h urine protein, rubella, hepatitis, HIV screening

I would tell her that if transplanted kidney is well functioning pregnancy per se has no adverse effects (1) and generally has a good pregnancy outcome. Pregnancy does cause graft rejection in 10 % of cases ? evidence that rejection is CAUSED by pregnancy as opposed to simply happening during pregnancy should be informed. Malfunctioning kidney can get worse in pregnancy and it is advisible to dalay the pregnancy. Increase incidence of UTI in pregnancy.

Pregnancy with renal impairment is associated with increase risk of miscarriages(first and second trimester), preeclampsia, intrauterine growth retardation and iatrogenic prematurity (1) . If renal transplant well functionally than pregnancy has good outcome (1) . In severe malfunctioning kidney along with hypertension there is risk of preeclampsia and IUGR and hence should be advice against pregnancy and contraceptive s should be offered.
Regular bloods to check for renal functions and serial growth scans to monitor fetal growth is mandatory along with liquor volume and umbilical Doppler measurement.. Admission is required if rising serum creatinine or severe uncontrolled hypertension. In these cases along with severe IUGR , premature delivery is anticipated. There is increase risk of polyhydramnios and cord prolapse why??? . If significant proteinuria is present, it can lead to pulmonary oedema and thrombosis.
Increased incidence of UTI and need of antibiotics should be explained. Patient should be informed about the safety of immunosuppressive drugs as stopping of them would lead to graft rejection what about potential effect of drugs? . Compliance with this drug is required.
During labour intravenous steroids required. Caesarean section for only obstetric indication (1) Epidural not contraindicated in labour. Continuous CTG monitoring required during labour.
Breast feeding not contraindicated .
Posted by PAUL A.
nellie

a) It would be pertinent to find out what was the cause of renal failure requiring the transplant. If it was SLE or diabetic nephropathy than it is likely that these changes can still occur with the new kidney (1) inherited condition may affect fetus . If it was not related to present state, like an infection, then there is less likely deterioration in function. How long ago was the transplant would be determined as it is advised that although fertility returns immediately, a period of 1-2 yrs (1) after will allow the kidney the opportunity to be rejected and treated and of immunosuppressive drugs to be reduced to maintenance levels then. A history of graft rejection likewise important to know and how long ago it occurred. The drugs used presently would be asked about since most can be used in pregnancy with some noted side effects. The drug mycophenolate mofetil though is best avoided since it has association of increased fetal malformations ? anti-hypertensives . Use of any contraception should be inquired or advised until it is certain that her renal status is near normal. Examination will look specifically for any signs of hypertension (1) BMI and hypoalbuminenia in the form of oedema. Signs of graft rejection such as fever, oliguria and graft tenderness should be looked for.

b) It is important to obtain a baseline assessment of her kidney function, therefore serum creatinine and 24 hr urine for protein, Cr clearance (1) will be done. Also an MSU to rule out UTI (1) . Baseline FBC and LFTs should be done since anaemia (1) is commom if renal deterioration occurs and the effects of the drugs on white cell count and liver function can be monitored. Ca levels should be checked because of the risks of hypocalcaemia and hypercalcaemia rubella, hepatitis, HIV screening .

c) If there is no hypertension and development of proteinuria in pregnancy, there is a good chance that the renal allograft will not be affected if baseline serum creatinine was near normal (1) . There are some problems which can arise but it is unsure if it is as a result of pregnancy (1) . About 10% women die 1-7 years after a pregnancy. It is important that the immnosuppressive drugs are not stopped or reduced because then there is a high chance of graft rejection.

d) What ever the cause of her having a renal transplant, the risks now to the pregnancy is of development of anaemia, pre- eclampsia, preterm delivery, IUGR (1) and of graft rejection and infection. There can be effects on the neonate (1) especially as a result of use of the immunosupressive drugs – of thymic hyperplasia, thrombocytopenia, depressed haemopoiesis and septicaemia.
The outcome is successful in 97% of cases this is higher than in normal healthy women!! without any existing hypertension or proteinuria
Posted by PAUL A.
Dear Dr paul

In my answer i had written that i would review the patients records to see whether she has had any infection and stable renal function. Is reviewing of records not possible in history taking?.In the question it was mentioned that she is a nullipara only and not nulligravida .So she would have misscarried before isnt it.So i thought i would question her previous obstetric history.Please clarify it to me.

That is not what you wrote in your answer. Your statement above is:

i would review the patients records to see whether she has had any infection and stable renal function.

the statement in your answer was:

I would review her records to R/o co morbid diseaseslike Diabetes, hypertension, and also asses whether she is on stable renal function and whether she has had or is having infections such as CMV,HSV,HBV and toxoplasmosis

these statements are different. It implied that you will rule out diabetes from the medical records AND THEN do an assessment ... and the question I asked you was how you will do this assessment. It was not obvious that this was by looking at the records because that is not how we assess renal function

With respect to nulliparity, you simply said obstetric Hx. You should have said you were looking for a Hx of miscarriages.