肾移植术后孕早期服用吗替麦考酚酯致胎儿先天性食管闭锁一例

为探讨女性肾移植患者的孕前指导、孕期管理、产后产妇及新生儿的健康管理,该文分析一例肾移植术后10年的31岁女性因妊娠早期服用吗替麦考酚酯导致胎儿先天性食管闭锁的临床资料。该例患者于2009年行肾移植手术,术后长期服用西罗莫司、吗替麦考酚酯等抗排斥药物。发现意外妊娠后将免疫抑制剂方案改为他克莫司单药方案。孕期产检发现羊水增多,未发现胎儿其余发育异常。患者孕期血压控制平稳,移植肾功能未见明显异常,孕33⁺³周剖宫产一女婴。婴儿出生后确诊为先天性食管闭锁。遂行食管-气管瘘修补术+食管端端吻合术。术后随访患儿至出生后7个月,进食精神良好,但相对同月龄婴儿其体质量较轻。其母产后维持单用他克莫司的免疫抑制方案,血清肌酐、血尿素氮维持正常水平,尿量良好,尿常规未见明显异常。该例提示,肾移植术后患者服用吗替麦考酚酯期间建议有效避孕,并在计划妊娠前6周内更换免疫抑制剂用药方案。对于服用吗替麦考酚酯期间意外妊娠的患者,在尽早停药的同时,应充分告知其药物相关的不良孕产结局风险,加强产检及对胎儿畸形的筛查,同时加强产后管理和多学科合作,对新生儿发育畸形做到早发现早干预,提高母婴健康水平及其生活质量。

Fetal congenital esophageal atresia after maternal exposure to mycophenolate mofetil during early pregnancy after kidney transplantation: a case report

To investigate the pre-pregnancy guidance, pregnancy management, postpartum maternal and fetal health management, this article was reported one case of fetal congenital esophageal atresia caused by intake of mycophenolate mofetil during early pregnancy in a 31-year-old female recipient at 10 years after kidney transplantation. The patient received kidney transplantation in 2009 and was given with long-term administration with sirolimus and mycophenolate mofetil after the operation. The immunosuppressant regimen was changed to tacrolimus when unexpected pregnancy was found. Routine pregnancy check-up showed polyhydramnios without any visible abnormal fetal development. Blood pressure and kidney function were normal. A female infant was delivered by cesarean section at 33⁺³ gestational weeks. Congenital esophageal atresia was diagnosed after birth and esophageal-tracheal anastomosis was performed. The infant was followed up for 7 months after birth with lower weight than the peers. The feeding and mental status were normal. The mother continued taking tacrolimus after delivery. Serum creatinine and blood urea nitrogen levels were maintained within normal range. Urine volume was normal and no abnormality was noted in urine routine test. This case prompts that pregnancy should be avoided during intake of mycophenolate mofetil and immunosuppressant regimen should be changed within 6 weeks before planned pregnancy. For women with unexpected pregnancy while taking mycophenolate mofetil, mycophenolate mofetil should be immediately withdrawn. Meantime, physicians should inform the patients of the risk of drug-induced adverse pregnancy outcomes, pay attention to prenatal examination and the screening of fetal malformation. Multi-disciplinary cooperation is recommended to strengthen postpartum management, aiming to deliver early diagnosis and interventions for fetal development malformation and enhance the maternal health status and quality of life.