Pregnancy on Intensified Hemodialysis: Fetal Surveillance and Perinatal Outcome

Abstract

Objectives: To evaluate the effect of intensive fetal surveillance via Doppler ultrasound and fetal non-stress test on the perinatal outcome of pregnant women undergoing an intensified hemofiltration scheme. Methods: Five consecutive pregnancies of women undergoing intensified hemodialysis were analyzed due to the following parameters: maternal background, hemodialysis schedule during pregnancy, blood pressure, occurrence of fetal complications, occurrence of obstetric complications, gestational week at delivery, mode of delivery, and newborn outcome and follow-up. Results: All pregnancies resulted in a live birth, mean gestational age was 32 weeks. Intrauterine growth restriction occurred in 4 fetuses, pathological umbilical artery flow velocity waveforms in 2. The mean birth weight was 1,764 g (range 1,274–2,465 g). Cesarean section was performed in 3 patients because of fetal distress. None of the patients developed severe complications like pre-eclampsia. Conclusions: Although intensified dialysis enables the maintenance of stable uteroplacental and fetal perfusion, intensive fetal monitoring is mandatory to reduce perinatal morbidity and mortality in pregnant women on maintenance dialysis.

Pregnancy Outcomes According to Dialysis Commencing Before or After Conception in Women with ESRD

“…Although prematurity is very likely, a large proportion do progress to a satisfactory duration. Other studies from the recent era report a median GA of 31-33 weeks (2,6,9,10,20), with superior GA in patients treated with nocturnal hemodialysis (16,18). Most infants born were of low BW (,2500 g), which correlated with prematurity, although a large proportion of babies were on or below the 10th centile of weight for GA. Our median BW was similar to that in other recent studies, which reported median or mean BW ranging from 1483 to 1765 g (6)(7)(8)(9)(10)20), but it remains substantially less than the mean BW (6 SD) of 2417.56657 g reported in pregnancies managed with nocturnal hemodialysis (16).…”

“…However, given prolonged waiting times for organs, this may occur after the reproductive years have passed. With studies such as ours demonstrating improved outcomes for women with CKD who commence dialysis in pregnancy, as well as the growing body of evidence regarding intensive dialysis regimens to improve outcomes (6)(7)(8)(9)(10)16), there may be a shift in the way women are counseled regarding pregnancy on dialysis, toward a less discouraging attitude (2). This may provide an avenue for motherhood in women who otherwise may not have an opportunity.…”

“…Factors crucial to successful pregnancy outcome include increased dialysis delivery to optimize biochemical measures, particularly urea (6)(7)(8)(9)(10)(11)(12)16,18), control of hypertension, correction of anemia (7,15), close fetal monitoring (8,10), and a multidisciplinary approach to patient care (2,3,8). An important limitation of ANZDATA data are limited detail regarding such individual patient care, which would assist in further interpreting the differing outcomes observed in our cohort.…”

“…Conception rates in women undergoing long-term dialysis have been estimated at 0.3 per 100 patient-years (4,5) or ranging from ,1% to 7% of women (3). Recently, the relationship between dialysis intensity and outcomes has become clearer (6)(7)(8)(9)(10)(11)(12)(13)(14)(15), with increased dialysis delivery becoming standard practice and nocturnal hemodialysis potentially providing superior fertility and outcomes (16)(17)(18). Recent reports suggest that results of these pregnancies are superior to those reported prior to the 1990s, with fetal survival rates of up to 70%-90% (3)(4)(5)(6)(7)9,10,16,(19)(20)(21).…”

Pregnancy in Dialysis Patients

“…In light of the heterogeneity of the data, any attempt to correlate outcomes with dialysis therapy is hazardous; however, that the best results are reported in settings of long daily dialysis suggests that dialysis efficiency plays an important role. More in detail, the three series that were free of neonatal death and stillbirth are those that used the longest and most intensive treatments (long nightly dialysis and "as much dialysis as the patients could tolerate") (5,15,17). These account for 15 of 15 live infants of 16 conceptions (one elective termination), which is a favorable outcome in comparison with the 46 of 60 live infants with the other dialysis schedules, although the difference does not reach statistical significance (P ϭ 0.059).…”