Reference no: EM134005906
Pregnancy Case Study
A 20-year-old female was referred to our clinic at 12 weeks' gestation with stage 5 chronic kidney disease (CKD; eGFR 10 ml/min/1.73 m2). She was born with a solitary kidney. She had multiple episodes of urinary tract infections in her childhood. At 8 years of age, she had severe pyelonephritis. This was complicated by acute kidney injury and subsequently chronic renal impairment. Her additional medical history included childhood asthma, hypothyroidism, and a history of smoking. She had been on salbutamol puffer, thyroxin, ferrous fumarate, prenatal vitamins, and low-dose aspirin (started a week before her nephrology assessment). During her first visit in our clinic, she complained of anorexia, nausea, and vomiting. She also complained of fatigue with a decrease in her functional capacity.
On physical examination, her blood pressure was 110/79 mmHg, and her heart rate was 84 beats per minute. Her jugular venous pulsation was 2 cm above the sternal angle. Auscultation of her heart and lungs were normal. Routine laboratory investigations are summarized in Table 33.1. Other pertinent investigations showed a PTH of 46.9 pg/ml and a hemoglobin A1C 5.4%. Her previous workup included a negative HIV, HBV, and HCV screening. On abdominal ultrasound, her right (solitary) kidney measured 8 cm in length with a thin cortex and increased echogenicity of the corticomedullary junction.
After counseling her on the maternal and fetal risks related to her advanced kidney disease, and discussion of her management, she decided to carry on with her pregnancy. She also agreed to initiate renal replacement therapy, the decision being made based on her increased serum urea and aforementioned symptoms. A tunneled hemodialysis (HD) catheter was inserted within a week of her assessment, and in-center HD was initiated with a schedule of three sessions per week (4 h per session).
For the remainder of her first trimester, her nausea and vomiting started to improve after initiating HD and adding pyridoxine/doxylamine therapy. In the second trimester, epoetin alfa and IV iron sucrose were initiated for a decreasing hemoglobin. At the same time, her blood pressure gradually increased, reaching 150/90mmHg at 22 weeks gestation, but subsequently improved after instituting antihypertensive management with labetalol. At 30 weeks gestation, her obstetrical ultrasound revealed an amniotic fluid index greater than the 95th percentile; this was in keeping with polyhydramnios. Given this finding and her high urea nitrogen level, her frequency of HD was increased to five times per week. She was also seen weekly at the high-risk pregnancy clinic to monitor fetal well-being and to guide her dialysis requirements.
Finally, she was induced and delivered vaginally at 38 weeks' gestation; her baby boy weighed 5 lbs. and 13 oz. at birth. Post delivery she continued HD. She had poor milk production and her son had to be supplemented with formula. Her transplant workup was started soon thereafter.
1. What was the likelihood of this woman becoming pregnant given her GFR?
2. What are the maternal risks associated with pregnancy and CKD?
3. What are the fetal risks associated with pregnancy and CKD?
4. How does the delivery of HD differ in a woman who is pregnant? Meaning, what do we need to specifically monitor during treatments and nutrient intake.