CHAPTER 73: Obstetric and Gynecologic Care

OBSTETRIC AND GYNECOLOGIC CARE AFTER TRANSPLANTATION

Pregnancy

• 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 ...