Pregnancy in women with renal disease. Part I: general principles

The purpose of this review is to improve the basis upon which advice on pregnancy is given to women with renal disease and to address issues of obstetric management by drawing upon the accumulated world experience. To ensure the proper rapport between the respect for patient's autonomy and the ethical principle of beneficence, the review attempts to impart up-to-date, evidence-based information on the predictable outcomes and hazards of pregnancy in women with chronic renal disease. The physiology of pregnancy from the perspective of the affected kidney will be discussed as well as the principal predictors of maternal and fetal outcomes and general recommendations of management. The available evidence supports the implication that the degree of renal function impairment is the major determinant for pregnancy outcome. In addition, the presence of hypertension further compounds the risks. On the contrary, the degree of proteinuria does not demonstrate a linear correlation with obstetric outcomes. Management and outcome of pregnancies occurring in women on dialysis and after renal transplant are also discussed. Although the outcome of pregnancies under chronic dialysis has markedly improved in the past decade, the chances of achieving a viable pregnancy are much higher after transplantation. But even in renal transplant recipients, the rate of maternal and fetal complications remains high, in addition to concerns regarding possible adverse effects of immunosuppressive drugs on the developing embryo and fetus.     

Pregnancy outcomes in women with heart disease

Aim

To evaluate the maternal and fetal outcome of pregnancies complicated by cardiac disease in a developing country.

Methods

A retrospective analysis was carried out of 144 pregnancies in women with cardiac disease who delivered in our unit between 1997 and 2006. Perinatal and maternal outcomes were interpreted according to the type of the heart disease and status of the patient according to the New York Heart Association (NYHA) classification.

Results

The rates of rheumatic and congenital heart disease were 87.5 and 12.5%, respectively. The distribution of the patients according to the NYHA functional classification were 55.6, 36.1 and 8.3% for NYHA classes I, II and III–IV, respectively. There was no maternal mortality. Maternal morbidity was observed in 16 (11.1%) cases. Six perinatal mortalities (4.2%) occurred in this series. There were no significant difference in birth weight, gestational age at delivery and perinatal morbidity between the NYHA stage I–II and stage III–IV groups (P > 0.05), whereas maternal morbidity and cesarean delivery rates were significantly higher in the NYHA stage III–IV group (P < 0.001).

Conclusion

Rheumatic heart disease with pregnancy is still predominant in Turkey. Most of the patients were in a good functional group. Maternal morbidity strongly correlates with maternal cardiac classification.     

Pregnancy complications in women with heart disease

Objective.?To identify pregnancy complications of women with heart disease delivering at a university hospital.

Methods.?A retrospective study was carried out of 193 pregnant women with heart disease delivered at a university hospital between January 1997 and December 2006.

Results.?Rheumatic heart disease (RHD), congenital heart disease (CHD), arrhythmia and cardiomyopathy were observed in 133 (68.9%), 26 (13.5%), 32 (16.6%) and 2 (1%) cases, respectively. Obstetric complication was found in 27 (14%) cases that was composed of preterm delivery (11.4%), gestational diabetes (1%), pregnancy induced hypertension (1%) and postpartum hemorrhage (0.5%). Cardiac complication was observed in 24 (12.4%) cases. Congestive heart failure was the most common cardiac complication which observed in 11 (5.7%) cases. There were four (2.1 %) maternal deaths, three cases in CHD group and one case in RHD group. Preterm infant was observed in 22 (11.4%) cases. Thirteen percent had low birth weight and 8.3% were small for gestational age. There were no perinatal deaths or congenital anomalies.

Conclusion.?Form this study, RHD with pregnancy is still predominant. The most common obstetric complication was preterm delivery. The most common cardiac complication was congestive heart failure.     

妊娠合并风湿性心脏病患者心功能状态对妊娠结局的影响

目的探讨妊娠合并风湿性心脏病患者心功能状态对妊娠结局的影响。方法对1993年1月至2006年7月在我院产科分娩的、资料齐全的65例妊娠合并风湿性心脏病患者的临床资料进行回顾性分析。根据患者的二尖瓣狭窄程度分为二尖瓣正常组20例（瓣口面积〉4．0cm^2）、轻度狭窄组11例（瓣口面积2．5—4．0cm^2）、中度狭窄组14例（瓣121面积1．5—2．5cm^2）以及重度狭窄组20例（瓣口面积〈1．5cm^2）;根据是否伴有肺动脉高压分为正常压力组33例[肺动脉压〈30mmHg（1mmHg=0．133kPa）]、轻度升高组18例（肺动脉压31—49mmHg）、中度升高组7例（肺动脉压50～79mmHg）和重度升高组7例（肺动脉压≥80mmHg）;根据孕前是否进行心脏手术分为心脏手术组14例和非心脏手术组51例;根据患者的不同心功能状态分为Ⅰ级组24例、Ⅱ级组13例、Ⅲ级组13例、Ⅳ级组15例,观察各组的围产儿结局。分析以上各种因素对妊娠合并风湿性心脏病患者妊娠结局的影响。结果（1）二尖瓣正常组患者心功能Ⅰ～Ⅱ级者为80％（16／20）,Ⅳ级组患者中,80％（12／15）在中度狭窄组（6例）及重度狭窄组（6例）,与二尖瓣正常组和轻度狭窄组的心功能Ⅳ级发生率（20％,3／15）比较,差异有统计学意义（P〈0．05）。（2）正常压力组患者心功能Ⅰ～Ⅱ级者为73％（24／33）,重度升高组患者心功能Ⅳ级的发生率（6／7）明显高于心功能Ⅰ级的发生率（1／7）,两者比较,差异有统计学意义（P〈0．05）。（3）心脏手术组患者心功能Ⅰ～Ⅱ级发生率为71％（10／14）,Ⅲ级和Ⅳ级的发生率均为14％（2／14）,前后两者比较,差异有统计学意义（P〈0．05）;非心脏手术组患者Ⅰ～Ⅳ级心功能发生率之间分别比较,差异均无统计学意义（P〉0．05）。（4）心功能Ⅰ～Ⅲ级组患者的平均孕周及新生儿平均出生体重分别比较,差异无统计学意义（P〉0．05）;而心功能Ⅳ级组平均孕周为（34．6±3．1）周,新生儿平均出生体重为（2176±186）g,明显低于心功能Ⅰ级组,两组比较,差异有统计学意义（P〈0．05）。心功能Ⅲ～Ⅳ级组患者中,共发生医源性流产和引产9例（14％,9／65）,医源性早产18例（28％,18／65）,胎儿生长受限4例（6％,4／65）,围产儿死亡3例（5％,3／65）;而心功能Ⅰ～Ⅱ级组患者以上指标均为0。（5）65例妊娠合并风湿性心脏病患者中合并心房纤颤者7例,其心功能Ⅲ～Ⅳ级（心功能衰竭）的发生率为6／7。结论妊娠合并风湿性心脏病患者伴中、重度二尖瓣狭窄、重度肺动脉压升高及心房纤颤,容易发生心功能衰竭危及生命,不宜妊娠。已妊娠者应尽早终止妊娠;心功能Ⅲ～Ⅳ级的妊娠合并风湿性心脏病患者的医源性流产、早产和围产儿病率均增加,围产儿结局不良。     

Pregnancy and delivery in women with congenital heart disease

OBJECTIVES: Perinatal care of women with congenital heart disease is very important for obstetrician. DESIGN: The purpose of this study was to analyse the course of pregnancy, delivery and after birth period of women with congenital heart disease. MATERIAL AND METHODS: A group of 35 pregnancies and deliveries in patients with congenital heart disease cured in 1998-2003 in the Department of Obstetrics and of Medical University in Gdansk were analysed. The control group was a total of 1657 deliveries in the Department of Obstetrics in the 1998. For statistical analysis of the results the T-Student test was used with the significance level p = 0.05. RESULTS: Time of pregnancy, birth weight and length were statistically different to the control group. CONCLUSIONS: We found no cardiological complications during pregnancy in patients with congenital heart disease at I and II stage NYHA. Time of pregnancy, birth weight and length were statistically different to the control group.     

Pregnancy in women with systemic sclerosis.

OBJECTIVE: To determine pregnancy outcomes in women with systemic sclerosis. METHODS: Women of childbearing age with systemic sclerosis seen at the University of Pittsburgh between 1987 and 1996 were observed prospectively. Pregnancy outcomes included abortion, miscarriage, preterm and term birth, and perinatal death. Complications of pregnancy and scleroderma were determined during and after pregnancy. RESULTS: Fifty-nine women with systemic sclerosis had 91 pregnancies during the 10-year period. No increase in the frequency of miscarriage was found, except in those with long-standing diffuse scleroderma. Preterm births occurred in 29% of pregnancies, and all but one of the infants survived. Symptoms related to scleroderma, particularly Raynaud phenomenon, improved during pregnancy, but esophageal reflux became worse. After pregnancy, some women with diffuse scleroderma had increased skin thickening. There were three cases of renal crisis during pregnancy, all in women with early diffuse scleroderma. Four women had five healthy infants while taking angiotensin-converting-enzyme inhibitors. CONCLUSION: Women with systemic sclerosis can safely have healthy pregnancies. Those with early diffuse scleroderma should wait until their disease stabilizes before becoming pregnant to decrease the risk of renal crisis. High-risk pregnancy management should be standard for all scleroderma pregnancies because of the high frequency of premature births.     

妊娠合并心脏病妊娠风险及分娩方式评估

妊娠合并心脏病是导致孕产妇死亡发生的重要原因之一,此类患者妊娠前及围产期的评估管理对降低孕产妇死亡率、改善母儿预后有重要作用。文章就目前国内外妊娠合并心脏病妊娠风险评估及分娩方式选择做一总结,为广大临床工作者对妊娠合并心脏的诊疗及管理提供参考。     

Pregnancy associated with renal glucosuria.

On reviewing 17,647 pregnancies over a 6-year period, 291 of 17,229 singleton pregnancies were noted to be associated with renal glucosuria. On analyzing these 291 pregnancies in 277 women, renal glucosuria was more frequently observed in those women with blood group types A and B and less in those with blood group type O. The incidence of renal glucosuria in nulliparous women, 2.8%, was significantly higher than that in parous women, 1.1%. A significantly high incidence of prematurity, 25.0%, was noted in women who persistently spilled a large amount of glucose.     

Pregnancy in women with different types of von Willebrand disease

The course and outcome of pregnancy in women with different types of von Willebrand disease (3 type I, 1 subtype IIA, and 1 subtype IIB) are described. In all patients, factor VIII increased and reached normal levels before delivery, whereas the bleeding time remained prolonged; in subtypes IIA and IIB the abnormal multimeric structure of von Willebrand factor remained unchanged. Deliveries were uneventful in all patients, with two spontaneous vaginal deliveries and three cesarean sections, despite the fact that no replacement therapy was given. Hence, the most important determinant of abnormal hemorrhage during delivery is low factor VIII; the prolonged bleeding time can be compensated for by meticulous surgical hemostasis and efficient contraction of the uterus. Replacement therapy with plasma derivatives can usually be avoided providing that normal factor VIII levels have been attained at delivery.     

Pregnancy in Jamaican women with homozygous sickle cell disease. Fetal and maternal outcome

The outcome of 664 pregnancies in 297 Jamaican women with homozygous sickle cell (SS) disease over the period 1959-1984 was reviewed. Overall, the spontaneous abortion rate was 118 per 1000 pregnancies, the stillbirth rate 128 per 1000 births, and perinatal mortality 171 per 1000 births. There was a striking secular increase in both spontaneous abortions and stillbirths which was accounted for, in part, by a trend for abortions to increase with maternal age up to the age of 30 years, a greater proportion of patients in the high-risk 25-29 year age group occurring in the 1980-1984 period. Another factor contributing to the poor obstetric performance in the 1980-1984 period was probably an increased survival and pregnancy rate in high-risk patients. Seven women had pregnancy-related deaths giving a pregnancy mortality rate of 1.1%.     

Pregnancy in Jamaican women with homozygous sickle cell disease. Fetal and maternal outcome

Summary. The outcome of 664 pregnancies in 297 Jamaican women with homozygous sickle cell (SS) disease over the period 1959–1984 was reviewed. Overall, the spontaneous abortion rate was 118 per 1000 pregnancies, the stillbirth rate 128 per 1000 births, and perinatal mortality 171 per 1000 births. There was a striking secular increase in both spontaneous abortions and stillbirths which was accounted for, in part, by a trend for abortions to increase with maternal age up to the age of 30 years, a greater proportion of patients in the high-risk 25–29 year age group occurring in the 1980–1984 period. Another factor contributing to the poor obstetric performance in the 1980–1984 period was probably an increased survival and pregnancy rate in high-risk patients. Seven women had pregnancy-related deaths giving a pregnancy mortality rate of 1.1%.     

Pregnancy outcome in women with morbid obesity.

OBJECTIVE: To study the effects of morbid obesity defined as a first trimester maternal body mass index of >40 on the perinatal outcome. METHODS: One hundred and eighty-eight singleton pregnancies of women with first trimester BMI >40 who delivered at Al-Mafraq Hospital, Abu Dhabi during 1996-1998 were studied. A control group of normal body mass index matched for age and parity were selected and the perinatal variables were compared between groups. Morbidly obese women with diabetes and hypertension antedating the index pregnancy were later excluded and the data were re-analyzed. RESULTS: Morbidly obese women were noted to have significantly adverse perinatal outcomes including hypertensive disorders of pregnancy (28.8 vs. 2.9%, P<0.0001), gestational diabetes (24.5 vs. 2.2%, P<0.0001), cesarean section (15.2 vs. 9.3%, P<0.05) and macrosomia (32.6 vs. 9.3%, P<0.001) compared to non-obese women. However, we noted a significantly lower rate of prematurity in the obese group (0.5 vs. 5.3%, P<0.001). Even when morbidly obese women with (a) diabetes and hypertension antedating the index pregnancy and (b) those who developed gestational diabetes and/or pregnancy-induced hypertension during the index pregnancy were excluded from the analysis, significant differences in the perinatal outcomes still persisted. CONCLUSION: Morbid obesity appears to be an independent risk factor for adverse perinatal outcome.     

Pregnancy in Jamaican women with homozygous sickle cell disease. Fetal and maternal outcome

Summary. The outcome of 664 pregnancies in 297 Jamaican women with homozygous sickle cell (SS) disease over the period 1959–1984 was reviewed. Overall, the spontaneous abortion rate was 118 per 1000 pregnancies, the stillbirth rate 128 per 1000 births, and perinatal mortality 171 per 1000 births. There was a striking secular increase in both spontaneous abortions and stillbirths which was accounted for, in part, by a trend for abortions to increase with maternal age up to the age of 30 years, a greater proportion of patients in the high-risk 25–29 year age group occurring in the 1980–1984 period. Another factor contributing to the poor obstetric performance in the 1980–1984 period was probably an increased survival and pregnancy rate in high-risk patients. Seven women had pregnancy-related deaths giving a pregnancy mortality rate of 1·1%.     

Pregnancy outcome in women with heart disease undergoing induction of labour

OBJECTIVE: To examine the safety and outcome of induction of labour in women with heart disease. DESIGN: Prospective single-centre comparative study. SETTING: Major university-based medical centre. POPULATION/SAMPLE: One hundred and twenty-one pregnant women with heart disease. METHODS: The sample included all women with acquired or congenital heart disease who attended our High-Risk Pregnancy Outpatient Clinic from 1995 to 2001. The files were reviewed for baseline data, cardiac and obstetric history, course of pregnancy and induction of labour and outcome of pregnancy. Findings were compared between women who underwent induction of labour and those who did not. Forty-seven healthy women in whom labour was induced for obstetric reasons served as controls. MAIN OUTCOME MEASURES: Pregnancy outcome. RESULTS: Of the 121 women with heart disease, 47 (39%) underwent induction of labour. There was no difference in the caesarean delivery rate after induction of labour between the women with heart disease (21%) and the healthy controls (19%). Although the women with heart disease had a higher rate of maternal and neonatal complications than controls (17%vs 2%, P= 0.015), within the study group, there was no difference in complication rate between the patients who did and did not undergo induction of labour. CONCLUSION: Induction of labour is a relatively safe procedure in women with cardiac disease. It is not associated with a higher rate of caesarean delivery than in healthy women undergoing induction of labour for obstetric indications, or with more maternal and neonatal complications than in women with a milder form of cardiac disease and spontaneous labour.