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  • Approximately 40% of female transplant recipients are of childbearing age (18–49 years)

  • Until recently, delaying pregnancy for up to 24 months after transplantation was recommended

    • Currently pregnancy may be considered after 1 year from transplantation if the following criteria are met:

      • No graft rejection in past year

      • Stable graft function

        • For renal transplants, require serum creatinine

          • <1.5 mg/dL with minimal proteinuria

      • Low risk of infections such as cytomegalovirus (CMV), toxoplasmosis

      • Not currently taking teratogenic medications

      • Immunosuppressant dosing at stable maintenance levels with the ability to be monitored during pregnancy.

  • It is important to individualize timing for each patient

    • The better optimized graft function, the greater the likelihood of successful maternal and fetal outcomes

  • All pregnancies posttransplant are considered high-risk

    • Need close surveillance by transplant physicians and high-risk perinatologists

    • Live birth rate of 72.9% in renal transplant recipients

    • Goals of pregnancy

      • Maintain maternal health and graft function with stable immunosuppressant dosing

      • Minimize pregnancy complications such as preterm delivery, hypertensive disorders, and fetal growth restriction

  • Cesarean deliveries only for obstetric indications

    • Pelvic kidney transplants not indication for cesarean delivery

    • Even with thoracic transplant recipients, cesarean sections would not prevent cardiac overload

    • Concern that cesarean section would increase risk of maternal infection if presence of significant immunosuppression

  • Pregnancy complications

    • Hypertension

      • Common in renal and hepatic transplant patients before and during pregnancy (50–75% incidence)

      • Aggressive management required: Early use of antihypertensive medications when mild hypertension arises

        • Methyldopa is the antihypertensive agent of choice followed by alpha and beta blockers, calcium channel blockers, and thiazides.

        • Blood pressure should be kept close to normal

        • May lead to fetal growth restriction

      • Preeclampsia

        • Difficult to diagnose due to high incidence of preexisting hypertension and proteinuria

        • Approximately three to four times more common than in general population

        • May lead to higher rates of cesarean delivery

      • Hemolysis elevated liver enzymes, lower platelets (HELLP) syndrome in hepatic patients may be difficult to diagnose

        • Elevation of liver enzymes may be due to HELLP or due to progression of hepatic disease

    • Preterm delivery (<37 weeks gestation)

      • Common: Up to 50% of infants are born premature

        • Mean gestational age at delivery in renal transplant patients: 34 weeks

      • As a result, have complications of premature delivery, especially those at < 34 weeks gestation

        • Neonatal death

        • Cerebral palsy

        • Blindness, deafness

        • Learning disabilities, low intelligence quotients

    • Urinary tract infections

      • Common in female transplant recipients with an increased risk during pregnancy.

    • Low birth weight (<2500 g)

      • Up to 20% of infants

      • May lead to early delivery

      • Increased incidence partially due to increased risk of hypertensive disorders

        • Serial sonograms to monitor fetal growth recommended

  • Graft rejections

    • Difficult to detect: acute rejection rates during pregnancy/postpartum period range from 9% to 15%

    • Must maintain immunosuppression to avoid rejection

    • Acute rejection associated with poorer pregnancy outcomes and recurrent rejection episodes after delivery

    • Lung transplant patients have higher rate of rejection for unknown reasons

    • Three factors most associated with rejection: history of medically ...

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