pregnancy in hemodialysis dr salwa elwasef

Pregnancy in hemodialysis

By

Salwa Mahmoud Elwasief

welcome

Is pregnancy possible?

Is it possible?

• The chronic kidney disease (CKD) affects 3% of women of

childbearing age. Pregnancy is a rare event in patients on dialysis

• Why?:

• hormonal alterations associated with its treatment

• Associated anemia, BMD

• low libido

• high level of stress in the effected women.

(Suarez et al, 2015)

Anovulatory cycle

If happened, is it possible to continue?

• For women with pre-existing renal failure,

pregnancy is associated with increased rate of

fetal complications and considerable risk of

pregnancy complications.

• End of the text

• changes in CKD therapy and advances in

dialysis techniques have allowed an increase

in fertility in these women over the last

decades, with a calculated frequency from 0.3

to 1.5% per year.

• The rate of live births increased to 40-50%.

(Pipili et al, 2011)

Possible complications

• Polyhydramnios

• worsening maternal hypertension

•abruption placenta

•acute pulmonary edema

• pre-term labor

• fetal growth restriction

polyhydramnios

two reasons:

• hypovolemia during dialysis causes decreased

oncotic pressure

• increased maternal urea leading to osmotic

diuresis of the fetus

Management

Possible complications

• Polyhydramnios

• worsening maternal hypertension

•abruption placenta

•acute pulmonary edema

• pre-term labor

• fetal growth restriction

complication

• Abruptio placenta

• Pulmonary oedema

• Intravenous (IV) labetalol and hydralazine have

long been considered first-line medications .

Available evidence suggests that oral nifedipine

also may be considered as a first-line therapy.

• Parenteral labetalol should be avoided in women

with asthma, heart disease, or congestive heart

failure.

• When urgent treatment is needed before the

establishment of IV access, the oral nifedipine

algorithm can be initiated or a 200-mg dose of

labetalol can be administered orally. The latter

can be repeated in 30 minutes if appropriate

improvement is not observed.

? Ultrafiltration

Accepted rate of weight gain:

• Magnesium sulfate is not recommended as an

antihypertensive agent, but magnesium

sulfate remains the drug of choice for seizure

prophylaxis in severe preeclampsia and for

controlling seizures in eclampsia.

Do not exceed 20 g/48 hr.

• Sodium nitroprusside should be reserved for

extreme emergencies and used for the shortest

amount of time possible because of concerns

about cyanide and thiocyanate toxicity in the

mother and fetus or newborn, and increased

intracranial pressure with potential worsening

of cerebral edema in the mother.

Possible complications

• Polyhydramnios

• worsening maternal hypertension

•abruption placenta

•acute pulmonary edema

• pre-term labor

• fetal growth restriction

Preterm labour

Before 37 weeks

Possible complications

• Polyhydramnios

• worsening maternal hypertension

•abruption placenta

•acute pulmonary edema

• pre-term labor

• fetal growth restriction

IUGR

fetal growth restriction

• Occurrence of hypocalcaemia should be

avoided by giving 1.5–2 g of

supplementary calcium daily that are

necessary for a normal fetal growth in a

woman with a normal dietary calcium

intake of 800 mg/day.

• Weekly check for serum calcium because both

the calcium provided by the dialysate (1.5

mmol/L daily) and calcium intake of chelating

agents might induce maternal hypercalcaemia

and secondary fetal hypocalcaemia and

hyperphosphataemia with impaired skeletal

development

• The placenta converts calcidiol into

calcitriol, thus 25-OH vitamin D must be

measured every trimester, administering

supplements if levels are low

Although primary hyperparathyroidism is known toincrease the frequency of pre-term births by 10–20%, the effects of hyperparathyroidism on thefetus are unknown.

The use of calcitriol is indicated in these cases inorder to control both hyperparathyroidism and1,25-OH-vitamin D deficiency.

Calciferol does not appear to be toxic at reasonabledoses. Dosage adjustments must be based onweekly calcium and phosphorous measurements

• Sevelamer, lanthanum carbonate, aluminium

hydroxide, cinacalcet and paricalcitol have not

been tested or established for use during

pregnancy/lactation

Hemodialysis protocol

Protocol of hemodialysis in pregnancy

• Modality

• Frequency

• Duration

• Ultrafiltration

• Anticoagulants

• Care of acid/base

• Correction of anemia

Multidisciplinary Approach

HD Modalities during pregnancy

• CRRT

• High flux dialysis

• HDF

HD Modality during pregnancy

NX stage

K-DIGO Guideline

Protocol of hemodialysis in pregnancy

• Modality

• Frequency and Duration

• Ultrafiltration

• Anticoagulants

• Care of acid/base

• Correction of anemia

HD dose

• Less complication if more than 20 hours/week

• Target BUN pre-dialysis less than 45-50mg/dl

alkalosis

hypokalemia

hypercalcemia

Protocol of hemodialysis in pregnancy

• Modality

• Frequency and Duration

• Ultrafiltration

• Anticoagulants

• Care of acid/base

• Correction of anemia

Ultrafiltration

• Acceptable rate of weight gain:

0.3-0.5kg/wk

Full-term pregnancy

• Baby: 7.5 pounds

• Placenta: 1.5 pounds

• Amniotic fluid: 2 pounds

• Uterine enlargement: 2 pounds

• Maternal breast tissue: 2 pounds

• Maternal blood volume: 4 pounds

• Fluids in maternal tissue: 4 pounds

• Maternal fat stores: 7 pounds

Protocol of hemodialysis in pregnancy

• Modality

• Frequency

• Duration

• Ultrafiltration

• Anticoagulants

• Care of acid/base

• Correction of anemia

Anticoaggulant

• Heparin does not cross the placenta and is not

teratogenic. It must be used in order to avoid

coagulation of the vascular accesses

• Warfarin crosses the placenta and is

contraindicated in these patient

Protocol of hemodialysis in pregnancy

• Modality

• Frequency

• Duration

• Ultrafiltration

• Anticoagulants

• Care of acid/base

• Correction of anemia

• Anemia during pregnancy is associated with

increased incidence of pre-term births, which

results in greater infant mortality rates

Diet

• High protein

• Low salt

• Vitamins:

water soluble

Drug safety

Name category

ESA

Cinacalcet

Calcium carbonate

calcidol

insulin

Vitamin B

L carnitine

Delivery …… ?

C.S.

Lactation in hemodialysis

For the mother For the kid

Sense of well being Innate immunity

Prophylaxis of breast cancer

Psychology????

Benefits

Contraception in hemodialysis