Pregnancy in patients on chronic dialysis: a single center experience and combined analysis of reported results

OBJECTIVE(S): Pregnancy is rare in patients on chronic dialysis, with only a 30-50% rate of successful delivery reported in a previous review article. The pregnancy outcome has improved in recent decades, but data on pregnancy outcome are limited due to the small sample size of previous case series. This study investigated the pregnancy outcome in patients on chronic dialysis over the past 15 years in a single center, and also performed a combined analysis of results of individual cases from previously reported series to obtain overall estimates of rates of successful delivery. STUDY DESIGN: Medical records for a total of 13 pregnancies in 13 women undergoing chronic dialysis (10 on hemodialysis and 3 on peritoneal dialysis) during the period from 1990 to 2006 in our hospital were retrospectively reviewed. Data on the changes in dialysis regimen, medical complications, obstetric conditions, and perinatal problems were collected. An electronic search of PubMed identified 10 case series studies and 12 case reports published after 1990 with adequate individual information available. Pooled data from a total of 131 cases, including our patients (117 hemodialysis and 14 peritoneal dialysis), were analyzed using the chi(2)-test and the t-test to compare the rate of successful delivery and birth weight in the hemodialysis group and the peritoneal dialysis group, and in pregnancies with conception prior to and those with conception after starting dialysis. RESULTS: Among the 10 pregnant women who decided to continue their pregnancies in our hospital, 5 delivered live newborns and 5 pregnancies ended with intra-uterine fetal demise or neonatal death. The overall rate of successful delivery was 70.9% (83 out of 117) in patients on hemodialysis and 64.2% (9/14) in patients on peritoneal dialysis. The birth weight for these groups was 1483+/-116 and 1623+/-320 g, respectively. The difference in the rates of successful delivery in these two groups was not significant (p=0.61). However, the birth weight was significantly greater in patients who conceived after than those who conceived prior to starting hemodialysis (1529+/-132 g versus 1245+/-200 g; p=0.04). CONCLUSIONS: This study found that the outcome of pregnancy on chronic dialysis has improved in recent decades, but our study showed no significant difference in the rate of successful delivery between patients on hemodialysis and those on peritoneal dialysis.     

Pregnancy in chronic renal insufficiency: single centre experience from North India

Background  Renal disease during pregnancy is relatively uncommon. The diagnosis of renal disease before or during pregnancy was only 0.03% in a population-based study of pregnant women with kidney disease. However, there is a paucity of scientific data regarding the general topic of renal disease in pregnancy on which to base clinical management and counselling recommendations. Materials and methods  A retrospective analysis of 14 year period was carried out in a referral hospital in northern India. Pregnant women were analyzed with respect to degree of renal impairment for the effect of renal disease on course of pregnancy, complications during pregnancy and perinatal outcome. Results  Outcome of 30 pregnancies (29 women) was available during the study period of 14 years. Pregnancy outcome was comparable in all types of glomerulonephritis. Progression of the disease during pregnancy was observed in total six patients. Proteinuria was in the range of 800 mg/day to 6.2 g/day (2.802 ± 1.519 g/day). Anemia was identified in 12(46.1%) and 3(7.7%) required multiple blood transfusions. Twenty-four (90%) women developed hypertension during pregnancy. Mild hypertension was seen in 40% patients and, 43.3% had severe hypertension requiring drug therapy. Obstetrical complications included a high frequency of preterm delivery (85%) and caesarean section (30%). Overall fetal survival rate was 77%. Conclusions  Most women with chronic renal disease will have a successful outcome if they receive proper prenatal care. Pregnant women with moderate or severe renal insufficiency have increased rates of complications due to worsening renal function, hypertension, and other obstetrical complications, but fetal survival is high.     

Obstetric outcomes in women with end-stage renal failure requiring renal dialysis.

OBJECTIVE: To study obstetric outcomes in women with end-stage renal failure undergoing chronic renal dialysis. METHODS: A retrospective review of the database from the High-Risk Pregnancy Clinic at Singapore General Hospital, Singapore. RESULTS: From 1995 to 2004, 7 women treated with chronic renal dialysis had a total of 11 pregnancies. There were 2 pregnancy losses at previable gestation ages and 9 live births. Median gestational age at delivery was 31 weeks, and mean birth weight was 1390 g. Seven newborns had a low birth weight and 5 required neonatal intensive care. Severe hypertension occurred in 4 women for a total of 7 pregnancies. Other complications included polyhydramnios (n=2), preterm prelabor rupture of membranes (n=2), obstetric cholestasis (n=2), postpartum hemorrhage (n=1), thrombosis of the arteriovenous fistula (n=2), postpartum peritonitis (n=1), and fetal anomaly (n=1). There were no maternal deaths. CONCLUSION: Such pregnancies are high-risk, particularly because of maternal hypertension and prematurity. They should be managed by multidisciplinary teams, and prepregnancy counseling should not be neglected.     

Pregnancy outcome after third trimester amniocentesis: a single center experience

Objective: To evaluate pregnancy outcome following late amniocentesis (>24 weeks of gestation). Study design: A retrospective cohort of all women with singleton pregnancy that underwent late amniocentesis in one tertiary center. Results: Pregnancy outcome was validated in 168 women who underwent late amniocentesis. Overall, for the all study group the mean gestational age for amniocentesis was 31.6?±?2.3 weeks and the mean gestational age at delivery was 38.1?±?2. Indications for late amniocentesis included abnormal ultrasonographic findings (n?=?120), suspected intrauterine infection (n?=?23), advanced maternal age (n?=?13), abnormal first or second trimester biochemical markers (n?=?8) and others. The overall rate of spontaneous preterm delivery (<37 weeks) was 8% (13/168) with mean gestational age at delivery of 34.7?±?1.3. In only five cases (3%), delivery occurred ≤ 34 weeks of gestation. In one case (0.60%) of amniocentesis performed at 32 weeks of gestation, delivery occurred within 48 hours and in other four cases (2.40%) delivery occurred within 10 days. When amniocentesis was performed due to ultrasonographic findings to rule out chromosomal abnormalities (n?=?117/182), abnormal karyotype was found only in three cases. Conclusions: The risk of significant prematurity following late amniocentesis is low. This information is important when counseling patients considering performing one.     

Pregnancy outcomes in women with heart disease: Experience of a tertiary center in the Netherlands

ObjectivesClinical data of pregnant women with heart disease were obtained with the intention to provide input for local counseling and management guidelines.Study designRetrospective data from all pregnant women with congenital or acquired heart disease between 2000 and 2011 in the VU University Medical Centre Amsterdam.Main outcome measuresMaternal and neonatal outcomes were evaluated.ResultsData of 122 women with 160 pregnancies were obtained. The most common heart diseases were congenital heart disease (n = 65, 53.3%) and arrhythmia (n = 20, 16.4%). Based on the functional criteria of the New York Heart Association (NYHA), 114/122 patients (93.4%) were classified NYHA class I–II. Patients in NYHA class III–IV (n = 8/122, 6.6%), mainly had a history of myocardial infarction or pulmonary hypertension. There were 156 singleton and 4 twin pregnancies. 22 (13.5%) pregnancies were complicated by hypertensive disorders. Heart failure developed in 11 women (9.0%), 37.5% in NYHA class III–IV and 6.5% in NYHA class I–II. Mean gestational age and birth weight were 270 days and 3196 g in NYHA class I–II compared to 237 days and 1972 g for NHYA class III–IV. There were two maternal deaths (1.6%) and 5 fetal deaths (3.1%). There were 29 (12.8%) preterm births, 20 (12.8%) neonates small for gestational age and 34 (21.8%) admittances on the Neonatal Intensive Care Unit (NICU).ConclusionsPregnancy in women with pre-existing heart disease in all NYHA classes is associated with increased maternal morbidity and perinatal morbidity. Risk of structural fetal anomalies is especially high in women with congenital heart disease.     

妊娠合并心脏病122例临床分析

本文分析了上海瑞金医院三年中122例妊娠合并心脏病的临床资料,其中先心病43例,心肌炎39例,风心病27例,其他13例。122例中剖宫产77例,占67.11％,发生心衰的10例中有6例是风心病,本组孕产妇死亡2例亦为风心病。本文认为风心病合并妊娠为孕产妇死亡的首要原因,应加强监护,对心功能Ⅲ—Ⅳ级者、严重风心病者、肺动脉高压及紫绀型心脏病者不宜妊娠。要加强对早期心衰的诊治,把好孕30～34周、产时、产后24小时“三大关口”。妊娠合并心脏病的分娩方式以剖宫产为宜,阴道分娩者也应尽量缩短产程。     

Acute Renal Insufficiency in Pregnancy: A Review of Thirty Cases

A review of women with acute changes in renal function during pregnancy including cases with only mild or moderate azotemia was performed to determine the etiology, associated disorders and frequency of this problem in an inner-city population. A retrospective review of the clinical and laboratory data of all patients admitted to the Tulane Obstetric Service at Charity Hospital of New Orleans from 1985-1989 that contained a final diagnosis of hypertension, pre-eclampsia/eclampsia or renal disease was performed to determine if acute renal insufficiency or renal failure occurred during that admission. Renal disease was defined as a serum creatinine level of greater than or equal to 1.2 mg/dl with either a rising or falling level during the hospitalization. Thirty cases of either acute renal insufficiency or renal failure during pregnancy were identified with an incidence of one in 450 deliveries. Seventeen women had either pre-eclampsia or eclampsia. Their clinical and biochemical characteristics were reviewed and found to be similar to those of the 13 women who had other causes of acute renal dysfunction complicating their pregnancies. The mean serum creatinine for all patients in this series was 3.4 mg/dl (range: 1.2-16). Four patients required dialysis, two of whom never regained function. There were no cases of cortical necrosis. Most patients still had abnormal renal function at the time of discharge. There were 21 live births and 9 fetal deaths. Fetal death was more likely to occur with shorter gestation, higher serum creatinine, and lower platelet count. Even in cases with mild acute renal insufficiency complicating pregnancy, there was significant maternal morbidity and fetal mortality. Pre-eclampsia/eclampsia was the most common disorder associated with this problem in pregnancy. In an inner-city population, acute renal insufficiency and renal failure in pregnancy occur more frequently than previously reported; recognition of this problem is necessary to provide appropriate follow-up.     

Association between delivery of small-for-gestational-age neonate and long-term maternal chronic kidney disease

Objective: To investigate whether delivery of a small for gestational age (SGA) neonate poses a risk for subsequent long-term maternal renal disease.

Study design: A population-based study was conducted. Comparison was performed regarding the incidence of long-term renal morbidity in a cohort of women with and without a previous delivery of a SGA neonate. Deliveries occurred during a 25-year period, with a mean follow-up duration of 11.2?years. Renal morbidity included kidney transplantation, chronic renal failure and hypertensive renal disease. Cox proportional hazards model was used to estimate the adjusted hazards ratio (HR) for renal-related hospitalizations and mortality.

Results: Out of 99?342 deliveries that met the inclusion criteria, 10?701 (10.7%) occurred in patients who had at least one previous delivery of a SGA neonate. During the follow-up period, patients with a delivery of an SGA neonate had higher rates of renal-related hospitalizations (0.2% versus 0.1%; OR?=?1.6, 95% CI 1.01–2.5; p?=?0.04). In a Cox proportional hazards model, adjusted for confounders, previous delivery of a SGA neonate was independently associated with subsequent maternal renal-related hospitalizations (adjusted HR, 1.7; 95% CI 1.1–2.8).

Conclusion: Delivery of a SGA neonate is an independent risk factor for long-term maternal renal disease.     

Kyphoscoliosis and Pregnancy: A Case Report and Review of the Literature

this case report of a woman with severe (Grade IV) kyphoscoliosis describes the complexities of providing care to women with this debilitating maternal condition. The literature was reviewed for the related obstetrical management issues associated with kyphoscoliosis and pregnancy. Incidence and causes of kyphoscoliosis are described, as well as recognized methods of determining the severity of spinal curvature. The three health considerations for pregnant women with kyphoscoliosis are reviewed. Cardiopulmonary complications may arise in women with primary curvature in the thoracic spine. Conversely, women with the primary curvature in the lumbar spine have a higher risk of such obstetrical complications as cephalopelvic disproportion. Finally, a concern in women with kyphoscoliosis is whether pregnancy will worsen spinal curvature. This article emphasizes the importance of a multidisciplinary approach in caring for obstetrical patients with kyphoscoliosis.     

Pregnancy Complicated by Maternal Heart Disease: A Review of 281 Women

Objectives

To study maternal heart disease in an Indian setting for: (1) different etiological factors, (2) different types of lesions, and (3) maternal and perinatal outcome.

Methods

281 women with heart disease who delivered ≥28 weeks of gestation at different teaching institutions (tertiary care centres) in India were studied.

Results

Rheumatic heart disease (n = 195; 69.4 %) with isolated mitral stenosis (n = 75; 26.7 %) were the commonest. Septal defect (n = 27; 9.6 %) was the predominant lesion among the congenital heart disease (n = 60; 21.3 %) patients, whereas in the miscellaneous group (n = 26; 9.2 %), ischemic heart disease (n = 10; 3.6 %) was the leading cause. Multiple cardiac lesions were also diagnosed in 100 (35.58 %) women. In 87 (31 %) women, diagnosis was made first time in labor. Majority n = 131, (46.6 %) had spontaneous vaginal delivery and few (n = 9; 3.3 %) required induction of labor. Cardiac complications were noted in 72 women (25.6 %). There were three (1.06 %) maternal deaths and perinatal mortality was 4 % (n = 11).

Conclusion

In this study, rheumatic heart disease in pregnancy is still predominant though acquired cardiac lesions are rising. In rheumatic heart disease, mitral valve involvement was the commonest and multiple valve lesions were a major observation. Most common obstetric complication was small for gestation baby. Maternal morbidities in the unbooked women are high and congestive cardiac failure was the major cardiac complication.     

Extra-adrenal Phaeochromocytoma in Pregnancy: A Diagnostic Dilemma

Pregnancy associated phaeochromocytoma is a rare and poorly recognized phenomenon with high morbidity and mortality rates for both mother and fetus. However, early recognition and treatment can reduce significantly the maternal and fetal mortality. We report a case of extra-adrenal phaeochromocytoma presenting in the second trimester of pregnancy, and review the literature with respect to the appropriate investigation and treatment of this condition.     

Pregnancy outcome of patients with known celiac disease

OBJECTIVE: Celiac disease is a permanent intolerance to gluten, probably induced by an autoimmune mechanism. Controversy exists regarding the association between celiac disease and infertility, abortions, intra-uterine growth restriction (IUGR) and stillbirths. The present study was designed to investigate pregnancy outcome of patients with celiac disease. METHODS: A retrospective comparison between all pregnancies of women with and without known celiac disease, delivered during the years 1988-2002, was conducted. RESULTS: During the study period there were 48 deliveries of patients with celiac disease and 143,663 pregnancies of patients without known celiac disease. No statistically significant differences were noted between the groups regarding maternal or perinatal outcomes, including fertility treatments (0% among patients with known celiac versus 2.5% among patients without known celiac sprue; p=0.267), recurrent abortions (0 versus 5.2%; p=0.103), perinatal mortality (2.1 versus 1.4%; p=0.668). However, higher rates of labor induction (29.2 versus 11.9%; p<0.001) and IUGR (6.3 versus 2.1%; p=0.042) were found among patients with celiac disease as compared to patients without known celiac disease. CONCLUSION: The course of pregnancy of patients with celiac disease including perinatal outcomes is favorable. Since we found higher rates of IUGR, careful surveillance should be performed for early detection of IUGR. Further, prospective studies should focus on screening for celiac disease among patients presenting with IUGR of an unknown etiology.     

Clinical Conundrum: A Complex Case of Pott Disease in Pregnancy

Spinal tuberculosis (TB) is a rare form of extrapulmonary TB that can be clinically difficult to diagnose, particularly in pregnancy. This 24-year-old G2, P0 patient was diagnosed at 19 weeks gestation, 2 days after a protracted admission for hyperemesis gravidarum, COVID-19 infection, and unexplained transaminitis with bilateral lower limb weakness and urinary retention. She underwent emergent spinal decompression surgery with expectant management on intravenous antitubercular medication and cesarean delivery at 34³ weeks gestation. Spinal tuberculosis is a difficult diagnosis, impacted by medical comorbidities, pregnancy, and diagnostic bias. This case describes successful antenatal management of spinal tuberculosis and highlights the importance of interdisciplinary care.     

牙周病与不良妊娠结局关系的研究

随着对牙周病深入研究发现,其可能是不良妊娠结局的危险因素。动物研究表明,牙周感染可导致出生动物低体质量,死亡率高。已有临床病例研究证实,牙周炎与早产儿,低出生体质量儿和子痫前期之间有相关性。微生物学研究为牙周病与妊娠不良结局之间的关系提供了有力的证据。但也有研究认为．牙周病并不是早产儿,低出生体质量儿的危险因素。牙周病与不良妊娠之间的关系仍不十分明确,进一步探讨牙周病与妊娠不良结局之间的作用机制,为预防与临床治疗提供新信息。     

Pre-pregnancy care and counselling in chronic renal patients

Pre-pregnancy planning in chronic renal patients has relied mainly on information gleaned from case reports, small series and variable registries. Nevertheless, guidelines have emerged to help clinicians in the care of their patients, so that as with other chronic medical conditions, it is becoming recognised as part of the traditional organisation of care associated with pregnancy. Nevertheless, most chronic renal patients do not plan their pregnancies with their health care team, and this complex behaviour is affected by the quality of the relationship with the team and by the woman’s attitude to her health and beliefs. The basic components of pre-pregnancy counselling should be analysis of risks, provision of health education and advice, and then making specific helpful interventions. Such ‘active preparation for pregnancy’ should be individualised to each woman’s needs and involve her partner. The ethical controversies associated with the need to understand the psychology of women who pursue parenthood, despite substantial risk to their own health and that of their unborn baby, should not be underestimated.     

Morphological changes in endometrium of hemodialyzed women of reproductive age

Aim. The aim of the study was to evaluate endometrial morphology and its correlation with hormonal profile in uremic women of reproductive age undergoing hemodialysis.

Materials and methods. Sixty-three hemodialyzed women aged 18–45 years were enrolled into the study, 38 of whom gave their informed consent to undergo endometrial aspiration biopsy and measurement of hormonal profile.

Results. Abnormal endometrial morphology was noted in 79% of the hemodialyzed women. Atrophic endometrium was observed in almost all uremic patients with secondary amenorrhea. Endometrial biopsy revealed one case of adenocarcinoma in situ. Analysis of the relationship between hormonal profile and endometrial morphology revealed the substantial influence of estradiol on endometrium.

Conclusions. Abnormal endometrial changes are often noted in uremic women of reproductive age undergoing hemodialysis. Endometrial biopsy should be carried out as a safe and convenient procedure for the detection of pathological changes in uremic women.     

宫内早孕合并左侧输卵管伞部妊娠一例及文献复习

宫内孕合并异位妊娠临床罕见,近年来随着辅助生殖技术的兴起,其发病率有所上升。其临床表现不一,主要取决于种植于宫腔外的异位妊娠胚胎的发育情况,轻者可无明显症状或体征,严重者可致患者腹腔大出血、失血性休克甚至死亡。由于宫内孕合并异位妊娠十分凶险,临床上应尽早诊断,采取个体化治疗,以确保母儿安全。现报道1例罕见的宫内早孕合并左侧输卵管伞部妊娠病例,并进行相关文献复习,总结宫内孕合并异位妊娠的相关知识,以期引起妇产科医生的重视。     

Acute Pancreatitis in Pregnancy: A Ten-Year Review

Objective: to review our experience with pancreatitis during pregnancy and to describe maternal and fetal outcomes associated with this rare medical complication.Study Design: we undertook a ten-year retrospective review of the medical records at British Columbia Women’s hospital from 1985 to 1994. Charts containing a diagnosis of pancreatitis during pregnancy were analysed. The presumptive aetiology and the antenatal and postpartum outcomes were extracted and compared to previously published series.Results: twelve cases of pancreatitis during pregnancy were found. The assigned aetiology was gallstone disease in nine cases (75%), hyperlipidaemia in one case (8%), and idiopathic in two cases (17%). The median gestational ages at presentation and delivery were 33 and 36 weeks, respectively. Median birth weight at delivery was 2,760 g. There was no severe maternal or neonatal morbidity. The estimated period prevalence of pancreatitis in pregnancy during this time was 1:5,617.Conclusions: the prevalence of pancreatitis during pregnancy is low. Although the effects of this rare complication on the mother and fetus are still poorly defined, we have identified a high rate of labour induction for maternal reasons and subsequent iatrogenic prematurity is not clearly justified.