Pregnancy in a renal transplant recipient requires prepregnancy counseling and additional surveillance because maternal complications and graft-related concerns influence care.
Prepregnancy counseling
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Recommend effective contraception until prepregnancy counseling has occurred because maternal morbidity and mortality are increased.
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Conception is not advised during the first year after renal transplantation; the acute rejection risk during that year is 10–15%.
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Discontinue teratogenic medications, including mycophenolate mofetil, angiotensin-converting enzyme inhibitors and angiotensin receptor antagonists.
Pregnancy risks and delivery
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Pregnancy outcomes depend on renal function and the coexistence of hypertension and proteinuria.
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Hypertension predates pregnancy and persists in more than 50% of pregnant renal transplant recipients. All recipients have an increased risk of pre-eclampsia.
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Gestational diabetes mellitus is a risk. Tacrolimus, ciclosporin and prednisolone have dose-dependent diabetogenic effects.
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Cesarean delivery rates are higher because pre-eclampsia or fetal growth restriction can lead to medically indicated preterm delivery.
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Renal transplantation is not a contraindication to vaginal delivery.
Graft function and medication exposure
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Acute graft rejection occurs in approximately 5% of pregnancies.
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A creatinine rise exceeding 20% during pregnancy is most commonly due to pre-eclampsia.
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Transplant rejection can be treated with corticosteroids and tacrolimus or ciclosporin. The passage states that most of these drugs are actively transported across the placenta.
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Infants exposed to biologic drugs in utero should avoid live vaccines during the first six months because immunomodulator levels may persist.
Antenatal care and thrombosis prevention
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Use a multidisciplinary approach with high-risk pregnancy care and extra monitoring. Manage pre-eclampsia and eclampsia with the usual drugs.
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Proteinuria adds to pregnancy-related hypercoagulability and venous thromboembolism risk. Give heparin prophylaxis and assess additional thromboembolism risk factors.