The smart way to learn. The smart way to teach.

MRCOG PART 2 SBAs and EMQs

Course PAID
notes326
EMQ1469
SBA2065
Do you realy want to delete this discussion?
Forum >>

Essay 285 - Renal transplant

Posted by PAUL A.
(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 (1) .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 (1) for beta blocker.Reason for transplantation is tobe noted from history .If reason is genetic disease she need genetic counseling before conception (1) .clinical examination is to be done to note degree of anaemia it need correction before conception. BP BMI is to be measured as it should be well controlled.

(b)Assesment of renal function (1) 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% (1) 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 24h urine protein, rubella, hepatitis… .

(c)Pregnancy has no adverse effect on renal allograft function in woman with base line creatinine level<100 micromol/L (1) .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 (1) .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 (1) . 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 good candidate should

(a)

History
• Date of renal transplant – advisable to delay pregnancy for at least 2 years after cadaveric donor or 1 year after living donor transplant (1)
• Reason for renal transplant - hereditary condition that may need genetic counselling or medical condition that may affect pregnancy (1)
• Current state of transplanted kidney – pregnancy should be avoided if graft is being rejected (1)
• Drug history – some drugs such as ACE inhibitors contra-indicated in pregnancy (associated with oligohydramnios and PDA); high dose prednisolone may cause fetal adrenal suppression (1)

Examination

• BMI & BP – untreated hypertension poor prognostic indicator (1)

(b)

• FBC – anaemia associated with renal impairment (1)
• Renal function tests, especially serum creatinine: levels above 150 microM/L associated with poor pregnancy outcome (1)
• MSU – screen for UTI, 24h urine for protein – provides base-line measure of proteinuria (1)
• Screen for Hep B & C, CMV, toxoplasmosis, HIV and rubella immunity as risk of infection increased in immuno-suppressed patients. Avoid live rubella vaccine if non-immune / low titres (1) .

(c)

• Know the importance of joint counselling with a nephrologists (1)
• Explain that pregnancy does not induce rejection or influence the risk of rejection of the transplant (1)
• If renal function is stable and serum creatining below 150 microM/L, then the consensus is that pregnancy does not adversely affect graft function (1)
• In women with poor / deteriorating renal function, the effect of pregnancy on graft function is unknown but pregnancy should be discouraged (1)
• Provide written information (1)

(d)
• If inherited renal condition, explain risk of passing condition to the fetus and offer genetic counselling (1)
• Underlying disease such as SLE may have direct effects on pregnancy (1)
• Drugs may have direct effects on fetus (examples). Need to use alternative drugs or minimum effective dose (1)
• 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 (1)
• Need for multi-disciplinary care in a tertiary centre with more frequent visits, scans and blood tests (1)
• Poor renal function associated with reduced fertility, increased risk of miscarriage and worsening of obstetric outcome (1)
• Renal transplant does not obstruct labour and vaginal delivery should be anticipated. CS for obstetric reasons (1)
dsad Posted by PAUL A.

asd