Pregnancy is one of the most graceful periods of woman life. With the improvements and advancement in renal replacement therapy and dialysis technology, even women on dialysis can conceive and have kids. But it is considered high risk and challenging for both mother and fetus.
Due to the underlying kidney disease and dialysis treatment many women of childbearing age cannot get pregnant. Pregnancy is complicated in dialysis patients due to complications like anemia, hypogonadism, lower libido, and poor self-image. Some present with no menstruation and some have irregular periods, hormonal imbalances resulting in anovulatory cycles are also common. Even if the patient on dialysis does get pregnant it is difficult to keep the fetus out of complications and maintaining a pregnancy to near term is said to be challenging.
Primarily it is difficult to diagnose whether a woman on dialysis is pregnant due to the presence of irregular periods, nausea and vomiting which is seen in both dialysis patients and a healthy pregnant woman. Additional to this human chronic gonadotropin and pregnancy-associated plasma protein-A serum levels are higher in dialysis patients even without pregnancy. This delayed diagnosis might result in an increased risk of taking dangerous medication which might harm the fetus during the early phases of conception. So ultrasound becomes a mandatory modality to confirm pregnancy among women on dialysis treatment.
Successful outcomes of pregnancies are seen in women who are pregnant before starting dialysis treatment and whom the residual renal function is still present. The longer time on dialysis reduces the chances of conception. Studies have shown the best period for conception has been within 2 years of starting dialysis treatment.
When it comes to dialysis treatment in pregnant women it is difficult to assess the volume status to adjust ultrafiltration because of the expected increase in total body water up to 9 liters in all pregnant women. Individualizing the dialysis prescription and aggressive management of dialysis treatment in pregnant women with more intense dialysis schedule with BUN <18 mmol/l which results in better uremic environment, and weekly Kt/V of about 6 – 8 can be achieved by increasing the frequency of dialysis and switching to long nocturnal dialysis treatment said to be adequate and near-normal biochemical functions can be achieved during pregnancy.
Special concentration towards monitoring fetal heart rate during dialysis treatment combined with measures to prevent hypotension during the treatment should be followed. Dialysate concentration should be carefully monitored and individualized with low recommended bicarbonate concentration to avoid alkalinization which might occur because of most frequent dialysis sessions.
Maternal dry weight and ideal weight gain should be regularly evaluated and adjusted according to the estimated weight of the fetus. Fetal weight and growth can be directly evaluated by ultrasound which helps to individualize the dialysis prescription accordingly. Maternal blood pressure and heart rate should be monitored due to the risk of hypertension which is common in pregnancy. Ultrafiltration should be individualized to avoid hypertension, hypotension, and arrhythmia. Severe maternal weight loss due to rapid and excessive ultrafiltration to be avoided as this reduces fetal-placental blood flow which is harmful to the fetus.
High biocompatible dialyser membrane with low surface area and increased time on dialysis to be prescribed in pregnant dialysis patients to avoid excessive fluid loss.
The major challenge for a pregnant dialysis patient is maintaining proper nutrition as malnutrition is common in dialysis patients. Requirements of vitamins increase because of vitamin losses due to intense dialysis treatments. Calcium supplements may be necessary for normal fetal growth. Anemia is common in pregnant dialysis patients and increases in about 50 – 100% of erythropoietin dosages that help to maintain adequate red cell mass with target hemoglobin (Hb) of about 10 – 11 g/dl. Heparin used during dialysis will not cross the placenta and does not alter the physiological functions of the fetus. Target blood pressure of < 140/90 mmHg to be maintained along with glycemic control of hemoglobin A1C at 7%.
Because of abnormal composition such as high levels of creatinine, urea and uric acid present in breast milk. Breastfeeding after dialysis session is preferred.
Successful dialysis in pregnant women is seen in recent years due to improved expertise in dialysis schedules and techniques, close monitoring of weight gain along with better pharmacological and nutritional management which is very much essential in these groups of patients.
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