Dialysis on Pregnancy: An Overview

Abstract

Pregnancy rates in women on dialysis have increased in the last decades, thus making it a topic of growing interest. The rarity of this event is predominantly due to fertility problems and to the high rates of pregnancy failure including stillbirth, fetal, and neonatal deaths. We conducted a narrative review of existing literature in order to analyze the major issues about pregnancy on dialysis to give the reader a fully updated perspective about this topic which, even if not common, is becoming more and more frequent. Even if recently acquired knowledge has improved diagnosis and treatment of dialysis pregnancies focusing on several aspects, pregnancy on dialysis remains a great challenge for obstetricians and should be managed by a multidisciplinary expertise team. Dialysis in pregnancy may be necessary for women previously affected by end stage renal disease (ESRD) becoming pregnant, or in case of acute renal injury presenting for the first time during gestation or, again, in case of existent renal pathology worsening during pregnancy and requiring dialysis. Although some evidence suggests that more intensive dialysis regimens are correlated with better obstetric outcomes, the optimal therapeutic protocol still remains to be established.

The pregnancy journey of a patient with end-stage renal disease on hemodialysis: A case study

“…The recommended approach is to strengthen treatment regimens to achieve improved gestational outcomes while reducing the fetus' exposure to risky medicines and interdialytic weight gain. Intensive dialysis regimens improve the likelihood of conception and are connected to positive pregnancy outcomes, such as gestational age and birth weight, as well as placental development, which is crucial for the health of the fetus [5]. Intensive HD allows the evacuation of extra fluid easier than regular dialysis (20 hours per week), and it reduces variance in intra-dialytic blood pressure, improves blood pressure control, decreases the requirement for antihypertensive drugs, and decreases the usage of diuretics.…”

“…Intensive HD allows the evacuation of extra fluid easier than regular dialysis (20 hours per week), and it reduces variance in intra-dialytic blood pressure, improves blood pressure control, decreases the requirement for antihypertensive drugs, and decreases the usage of diuretics. Also, it enhances uremic toxin clearance, which enhances pregnancy outcomes [5].…”

“…Labetalol, nifedipine, and methyldopa are recommended for the treatment of pregnancy-related hypertension. Hypotension (blood pressure below 120/70 mmHg) should be avoided, and the target blood pressure is less than 140/90 mmHg [5]. Low blood pressure affects fetoplacental circulation and lowers the risk of intrauterine growth restriction, stillbirth, and fetal mortality.…”

Spontaneous Twin Pregnancy: A Challenging and Exceptional Scenario in a Patient on Maintenance Hemodialysis in Sub-Saharan Africa

“…In Cameroon, an observational study over 11 years found a prevalence of 7.14% of pregnancies in hemodialysis (6 pregnancies in 84 women) [ 9 ]. This low prevalence here could be explained by the nonoptimal conditions in hemodialysis that do not favor conception as described in the literature: dialysis duration, optimal treatment of anemia, adequate nutrition, and hemodynamic stability [ 1 , 10 ]. Thus, the spontaneous occurrence of twin pregnancy with maintenance up to 29 weeks in a patient receiving only 4 h hemodialysis a week, with suboptimal medical treatment, seems very surprising.…”

“…The late diagnosis of pregnancy, financial constraints, and consequently late increment of dialysis dose without attaining 36 h per week, anemia, and lack of phosphorus supplements may explain the poor outcome. There is evidence that an intensified dialysis regimen and drug therapy, including blood pressure control and anemia correction, improve the maternal-fetal prognosis in hemodialysis [ 6 , 10 , 17 ]. Our patient did not present a worsening of anemia, which is associated with an increased risk of prematurity [ 16 , 18 ].…”