Pregnancy and Contraceptive Counseling of Women With Chronic Kidney Disease and Kidney Transplants
2007; Elsevier BV; Volume: 14; Issue: 2 Linguagem: Inglês
10.1053/j.ackd.2007.01.003
ISSN1548-5609
Autores Tópico(s)Maternal and fetal healthcare
ResumoWomen with kidney disease of childbearing age should expect proactive counseling regarding pregnancy and contraception. Discussions should include the impact of pregnancy on their kidney disease and the impact of kidney disease on maternal and fetal outcomes. However, nephrologists rarely discuss sexual dysfunction, infertility, menstrual irregularities, and contraception with their premenopausal women patients. This review will consider pregnancy-related issues to discuss when counseling women with all stages of chronic kidney disease. Issues related to contraception in women on dialysis, women with functioning kidney transplants, and those with chronic kidney disease will also be reviewed. Women with kidney disease of childbearing age should expect proactive counseling regarding pregnancy and contraception. Discussions should include the impact of pregnancy on their kidney disease and the impact of kidney disease on maternal and fetal outcomes. However, nephrologists rarely discuss sexual dysfunction, infertility, menstrual irregularities, and contraception with their premenopausal women patients. This review will consider pregnancy-related issues to discuss when counseling women with all stages of chronic kidney disease. Issues related to contraception in women on dialysis, women with functioning kidney transplants, and those with chronic kidney disease will also be reviewed. Fertility in women with chronic kidney disease is generally reduced, in part because of gonadal dysfunction and secondary amenorrhea.1Leavey S.F. Weitzel W.F. Endocrine abnormalities in chronic renal failure.Endocrinol Metab Clin North Am. 2002; 31: 107-119Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar, 2Palmer B. Sexual dysfunction in men and women.Semin Dial. 2003; 10: 48-60Google Scholar, 3Lim V.M. Reproductive function in patients with renal insufficiency.Am J Kidney Dis. 1987; 9: 363-367Abstract Full Text PDF PubMed Scopus (59) Google Scholar There may be a continuum of decreased fertility as the glomerular filtration rate declines, but further study in this area is needed.4Shemin D. Dialysis in pregnant women with chronic kidney disease.Semin Dial. 2003; 16: 379-383Crossref PubMed Scopus (41) Google Scholar When counseling women with chronic kidney disease about pregnancy, it must be clear that information on outcomes is limited. In part, this is because of the lack of systemic data, inability to randomize patients, and difficulty to find appropriate controls.4Shemin D. Dialysis in pregnant women with chronic kidney disease.Semin Dial. 2003; 16: 379-383Crossref PubMed Scopus (41) Google Scholar, 5Hou S. Pregnancy in renal transplant recipients.Adv Ren Replace Ther. 2003; 10: 40-47Abstract Full Text PDF PubMed Scopus (37) Google Scholar For most patients with a serum creatinine (SCr) 2.0mg/dL at the time of conception, one third progress to end-stage renal disease (ESRD) over the postpartum year of follow-up.10Jones D.C. Hayslett J.P. Outcome of pregnancy in women with moderate or severe renal insufficiency.N Engl J Med. 1996; 335: 226Crossref PubMed Scopus (334) Google Scholar This information needs to be conveyed to women with chronic kidney disease who are contemplating pregnancy as well as those who become pregnant (Table 1).Table 1Complication Rates⁎These data do not represent equivalent patient groups; thus, a selection bias exists.1Leavey S.F. Weitzel W.F. Endocrine abnormalities in chronic renal failure.Endocrinol Metab Clin North Am. 2002; 31: 107-119Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar, 3Lim V.M. Reproductive function in patients with renal insufficiency.Am J Kidney Dis. 1987; 9: 363-367Abstract Full Text PDF PubMed Scopus (59) Google Scholar, 6Jungers P. Chauveau D. Pregnancy in renal disease.Kidney Int. 1997; 52: 871-885Crossref PubMed Scopus (133) Google Scholar, 7Surian M. Imbasciati E. Cosci P. Glomerular disease and pregnancy: A study of 123 pregnancies in patients with primary and secondary glomerular diseases.Nephron. 1984; 36: 101Crossref PubMed Google Scholar, 9Bar J. Orvieto R. Shalev Y. et al.Pregnancy outcome in women with primary renal disease.Isr Med Assoc J. 2000; 2: 178-181PubMed Google Scholar, 20Brem A.S. Singer D. Anderson L. et al.Infants of azotemic mothers: Report of three live births.Am J Kidney Dis. 1988; 12: 299-303PubMed Scopus (11) Google Scholar, 21Hou S. Modifications of dialysis regimens for pregnancy.Int J Artif Organs. 2002; 25: 823-826PubMed Google Scholar, 23Romao J.E. Luders C. Kahhale S. et al.Pregnancy in women on chronic dialysis: A single center experience of 17 cases.Nephron. 1998; 78: 416-422Crossref PubMed Scopus (55) Google Scholar, 24Elliott D.P. O’Keeffe D.F. Schon D.A. et al.Dialysis in pregnancy: A critical review.Obstet Gynecol Surv. 1991; 46: 319-324Crossref PubMed Scopus (23) Google Scholar, 25Giatras I. Levy D.P. Malone F.D. et al.Pregnancy during dialysis: Case report and management.Nephrol Dial Transplant. 1998; 13: 3266Crossref PubMed Scopus (79) Google Scholar, 27Davison J.M. Dialysis, transplantation, and pregnancy.Am J Kidney Dis. 1991; 17: 127-132PubMed Scopus (170) Google Scholar46,47Renal ConditionPreterm DeliveryFetal Survival by SCr in mg/dLFetal Survival OverallRisk of ESRD by SCr in mg/dL<1.4≥1.4<1.41.4-2.0≥2.0CKD pre-ESRD∼60%†Normal or mildly impaired renal function usually leads to normal obstetric outcome and minimally affects course of disease. Certain rheumatologic conditions, such as scleroderma or SLE, are exceptions to this.12-93%‡The most current data show a survival of 93%.†Normal or mildly impaired renal function usually leads to normal obstetric outcome and minimally affects course of disease. Certain rheumatologic conditions, such as scleroderma or SLE, are exceptions to this.†Normal or mildly impaired renal function usually leads to normal obstetric outcome and minimally affects course of disease. Certain rheumatologic conditions, such as scleroderma or SLE, are exceptions to this.2%35%ESRD∼80%NA40%-50%NARenal transplant∼50%96%75%80%-90%†Normal or mildly impaired renal function usually leads to normal obstetric outcome and minimally affects course of disease. Certain rheumatologic conditions, such as scleroderma or SLE, are exceptions to this.Unknown2-3 yAbbreviation: NA, not applicable. These data do not represent equivalent patient groups; thus, a selection bias exists.† Normal or mildly impaired renal function usually leads to normal obstetric outcome and minimally affects course of disease. Certain rheumatologic conditions, such as scleroderma or SLE, are exceptions to this.‡ The most current data show a survival of 93%. Open table in a new tab Abbreviation: NA, not applicable. Women with chronic kidney disease must also receive counseling and information about fetal outcome. Fetal outcomes are more optimistic and less variable with the improvements in prenatal care that developed over the past several decades, such as corticosteroids for lung maturity, screening for beta Streptococcus, and easier access to neonatal specialty care. However, significant intrauterine growth restriction and preterm labor commonly occur with prematurity and range from 40% to 70% of all pregnancies. Fetal survival is on par with the general population when the mother’s SCr is <.4 mg/dL and probably >70% in those not requiring dialysis.8Hou S. Pregnancy in women with chronic renal disease.N Engl J Med. 1985; 312: 836Crossref PubMed Scopus (67) Google Scholar, 11Hou S. Pregnancy in chronic renal insufficiency and end stage renal disease.Am J Kidney Dis. 1999; 33: 235-252Abstract Full Text Full Text PDF PubMed Scopus (262) Google Scholar Fetal survival is lower with uncontrolled hypertension, and women should be counseled about active participation in hypertension control.6Jungers P. Chauveau D. Pregnancy in renal disease.Kidney Int. 1997; 52: 871-885Crossref PubMed Scopus (133) Google Scholar, 11Hou S. Pregnancy in chronic renal insufficiency and end stage renal disease.Am J Kidney Dis. 1999; 33: 235-252Abstract Full Text Full Text PDF PubMed Scopus (262) Google Scholar, 12Packham D.K. North R.A. Fairley K.F. et al.Primary glomerulonephritis and pregnancy.Q J Med. 1989; 71: 537PubMed Google Scholar Controlling proteinuria to <300 mg/d during pregnancy has also been associated with lower infant mortality. Patients with baseline kidney dysfunction must be aware of the higher risk of preeclampsia than the general population. Despite the diagnostic dilemma, preeclampsia is diagnosed in up to 30% of pregnancies in women with chronic kidney disease.8Hou S. Pregnancy in women with chronic renal disease.N Engl J Med. 1985; 312: 836Crossref PubMed Scopus (67) Google Scholar Long-term sequelae, including physical, intellectual, and learning abilities, of children born to women with kidney disease are unavailable.4Shemin D. Dialysis in pregnant women with chronic kidney disease.Semin Dial. 2003; 16: 379-383Crossref PubMed Scopus (41) Google Scholar, 13Hou S. Pregnancy in dialysis patients: Where do we go from here?.Semin Dial. 2003; 16: 376-378Crossref PubMed Scopus (30) Google Scholar As with any medical illness or contemplated intervention, outcome information should be provided to enable the woman to make an informed decision about pursuing pregnancy in the setting of chronic kidney disease. If a woman with chronic kidney disease conceives and chooses to continue the pregnancy, therapy needs to be guided by both a nephrologist and obstetrician specializing in high-risk pregnancies. Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers must be stopped when pregnancy is known and discussion about the possible need for alternate antihypertensive medications and the potential for preeclampsia discussed. Women with ESRD should be counseled that kidney transplantation affords the best chances for pregnancy and viable birth.13Hou S. Pregnancy in dialysis patients: Where do we go from here?.Semin Dial. 2003; 16: 376-378Crossref PubMed Scopus (30) Google Scholar If patients decide to attempt conception, they should be particularly informed of low fertility, dialysis needs, and infant survival in women with ESRD. Fertility of the ESRD patient is not precisely known because data are retrospective, based on surveys, and do not adjust for important variables such as contraceptive use, sexual activity, and irregular menses.14Holley J.L. Schmidt R.J. Bender F.H. et al.Gynecologic and reproductive issues in women on dialysis.Am J Kidney Dis. 1997; 29: 685-690Abstract Full Text PDF PubMed Scopus (190) Google Scholar Nonetheless, 1 study based on data from every dialysis unit in Belgium showed a pregnancy rate (including all women of childbearing age) of 0.3 per 100 patient-years in women of childbearing age.15Bagon J.A. Vernaeve H. De Muylder X. et al.Pregnancy and dialysis.Am J Kidney Dis. 1998; 31: 756-765Abstract Full Text PDF PubMed Scopus (167) Google Scholar This is approximately one fortieth the rate of the general population. Data from the largest United States registry found a pregnancy rate of 2.2% over 4 years, similar to the Belgian study.16Okundaye I. Abrinko P. Hou S. Registry of pregnancy in dialysis patients.Am J Kidney Dis. 1998; 31: 766-773Abstract Full Text PDF PubMed Scopus (252) Google Scholar These fertility rates may be higher than rates from 2 decades ago, perhaps because of improvements in dialysis and erythropoietin use that may reduce anovulatory cycles.15Bagon J.A. Vernaeve H. De Muylder X. et al.Pregnancy and dialysis.Am J Kidney Dis. 1998; 31: 756-765Abstract Full Text PDF PubMed Scopus (167) Google Scholar It does appear that pregnancy in women on dialysis is more common if the woman has residual kidney function.17Davison J.M. Baylis C. Renal disease.in: de Swiet M. Medical Disorders in Obstetric Practice. Blackwell, Oxford, England2005: 226-305Google Scholar Thus, the more common clinical scenario is pregnancy in a woman who is just beginning dialysis. However, pregnancy in any woman on dialysis, whether she is an established dialysis patient or just beginning renal replacement therapy, is fraught with potential complications. Even with aggressive management, a patient must be aware that infant survival has been reported at 40% to 50% in the last 10 years15Bagon J.A. Vernaeve H. De Muylder X. et al.Pregnancy and dialysis.Am J Kidney Dis. 1998; 31: 756-765Abstract Full Text PDF PubMed Scopus (167) Google Scholar, 16Okundaye I. Abrinko P. Hou S. Registry of pregnancy in dialysis patients.Am J Kidney Dis. 1998; 31: 766-773Abstract Full Text PDF PubMed Scopus (252) Google Scholar, 18Toma H. Tanabe K. Tokumoto T. et al.Pregnancy in women receiving renal dialysis or transplantation in Japan: A nationwide survey.Nephrol Dial Transplant. 1999; 14: 1511-1516Crossref PubMed Scopus (139) Google Scholar, 19Chao A.-S. Huang J.-Y. Lien R. et al.Pregnancy in women who undergo long-term hemodialysis.Am J Obstet Gynecol. 2002; 187: 152-156Abstract Full Text Full Text PDF PubMed Scopus (77) Google Scholar (Table 1). Over 80% of infants are premature, with an average gestational age of 32 weeks.15Bagon J.A. Vernaeve H. De Muylder X. et al.Pregnancy and dialysis.Am J Kidney Dis. 1998; 31: 756-765Abstract Full Text PDF PubMed Scopus (167) Google Scholar, 16Okundaye I. Abrinko P. Hou S. Registry of pregnancy in dialysis patients.Am J Kidney Dis. 1998; 31: 766-773Abstract Full Text PDF PubMed Scopus (252) Google Scholar, 17Davison J.M. Baylis C. Renal disease.in: de Swiet M. Medical Disorders in Obstetric Practice. Blackwell, Oxford, England2005: 226-305Google Scholar, 18Toma H. Tanabe K. Tokumoto T. et al.Pregnancy in women receiving renal dialysis or transplantation in Japan: A nationwide survey.Nephrol Dial Transplant. 1999; 14: 1511-1516Crossref PubMed Scopus (139) Google Scholar Early delivery is usually caused by premature labor, premature rupture of membranes, and cervical incompetence.13Hou S. Pregnancy in dialysis patients: Where do we go from here?.Semin Dial. 2003; 16: 376-378Crossref PubMed Scopus (30) Google Scholar For the few infants who have been followed over the first year of life, there were no major growth or developmental abnormalities.20Brem A.S. Singer D. Anderson L. et al.Infants of azotemic mothers: Report of three live births.Am J Kidney Dis. 1988; 12: 299-303PubMed Scopus (11) Google Scholar If a pregnant dialysis patient chooses to continue her pregnancy, she will need to be prepared to commit to a much more intensive dialysis regimen. The current recommendations for hemodialysis during pregnancy are 20 or more h/wk and the goal of blood urea nitrogen <mg/dL.21Hou S. Modifications of dialysis regimens for pregnancy.Int J Artif Organs. 2002; 25: 823-826PubMed Google Scholar This recommendation is made for peritoneal dialysis too. Patients on peritoneal dialysis can continue with this dialysis modality, but technical problems can ensue.4Shemin D. Dialysis in pregnant women with chronic kidney disease.Semin Dial. 2003; 16: 379-383Crossref PubMed Scopus (41) Google Scholar Hemoperitoneum could be a sign of placenta previa or spontaneous abortion. Previously, patients may have had hemoperitoneum with menstruation or ovulation and may not think there is cause for concern. The gravid uterus may limit adequate peritoneal volumes, and patients should achieve a minimum of 8 to 12 L of dialysate exchanges per day, according to the 3 largest studies in the literature.22Redrow M. Cherem L. Elliott J. et al.Dialysis in the management of pregnant patients with renal insufficiency.Medicine. 1988; 67: 199-208Crossref PubMed Scopus (75) Google Scholar, 23Romao J.E. Luders C. Kahhale S. et al.Pregnancy in women on chronic dialysis: A single center experience of 17 cases.Nephron. 1998; 78: 416-422Crossref PubMed Scopus (55) Google Scholar, 24Elliott D.P. O’Keeffe D.F. Schon D.A. et al.Dialysis in pregnancy: A critical review.Obstet Gynecol Surv. 1991; 46: 319-324Crossref PubMed Scopus (23) Google Scholar Possibly, a higher peritoneal dialysis dose will be beneficial, as it has been in hemodialysis. Although a nephrologist will be prescribing the dialysis regimen, the patients should be proactive about assisting with blood pressure management. Hypertension is one of the most dangerous potential problems for the patient,13Hou S. Pregnancy in dialysis patients: Where do we go from here?.Semin Dial. 2003; 16: 376-378Crossref PubMed Scopus (30) Google Scholar both during pregnancy and also in the postpartum period. As in patients with chronic kidney disease, pregnant patients with ESRD should stop their angiotensin-converting enzyme inhibitors and angiotensin receptor blockers because of known fetal abnormalities and death. Clearly, pregnant dialysis patients need to be closely monitored by a specialist in high-risk obstetrics (at least every 2 weeks and every week during the third trimester) with frequent assessments by their nephrologist.25Giatras I. Levy D.P. Malone F.D. et al.Pregnancy during dialysis: Case report and management.Nephrol Dial Transplant. 1998; 13: 3266Crossref PubMed Scopus (79) Google Scholar Patients should be considered for interventions that are thought to improve risk for prematurity, such as intravaginal progesterone.26DaFonseca E.B. Carvalho M.H.B. Zugaib M. Prophylactic administration of progesterone by vaginal suppository to reduce the incidence of spontaneous preterm birth in women at risk: A randomized placebo-controlled double-blind study.Am J Obstet Gynecol. 2003; 188: 419-424Abstract Full Text Full Text PDF PubMed Scopus (647) Google Scholar Also, women should be aware that maternal death rates during pregnancy approach 1% (3 of 382 patients from the US registry),16Okundaye I. Abrinko P. Hou S. Registry of pregnancy in dialysis patients.Am J Kidney Dis. 1998; 31: 766-773Abstract Full Text PDF PubMed Scopus (252) Google Scholar which is much higher than the general population but not different from the nonpregnant dialysis population of similar age.13Hou S. Pregnancy in dialysis patients: Where do we go from here?.Semin Dial. 2003; 16: 376-378Crossref PubMed Scopus (30) Google Scholar The pregnant woman on dialysis should therefore be informed of the risks of pregnancy, including fetal outcomes, maternal complications, and options for pregnancy termination. Using professionals from multiple disciplines (obstetrics, nephrology, social work, and perinatology) to counsel the woman should be encouraged. Life for the family after successful pregnancy should also be explored in these conversations, including the time constraints of dialysis for the mother and care of a premature infant. Soon after kidney transplantation, gonadal dysfunction improves27Davison J.M. Dialysis, transplantation, and pregnancy.Am J Kidney Dis. 1991; 17: 127-132PubMed Scopus (170) Google Scholar and rates of conception are higher than those seen in the ESRD population.28Hou S. Pregnancy in renal transplant recipients.Adv Ren Replace Ther. 2003; 10: 40-47Abstract Full Text PDF PubMed Scopus (26) Google Scholar Before kidney transplantation, women should be counseled about the likelihood of improved fertility and the need for contraception. Despite improved conception rates after successful transplantation, many transplant centers encourage women to wait 18 to 24 months after transplantation before conceiving. Because of the relatively low rates of rejection under current immunosuppression protocols, a recent concensus panel suggested that conception may be considered within the first year after transplantation in some women.29McKay D.B. Josephson M.A. Armenti V.T. et al.Reproduction and transplantation: Report on the AST Consensus Conference on Reproductive Issues and Transplantation.Am J Transplant. 2005; 5: 1592-1599Crossref PubMed Scopus (355) Google Scholar Graft function should be stable and immunosuppressants should be at baseline levels before conception.6Jungers P. Chauveau D. Pregnancy in renal disease.Kidney Int. 1997; 52: 871-885Crossref PubMed Scopus (133) Google Scholar, 30Davison J.M. Baylis C. Pregnancy in patients with underlying renal disease.in: Davison A.M. Oxford Textbook of Clnical Nephrology (ed 3). Oxford University Press, Oxford, England2005: 2253-2254Google ScholarTable 2 contains 1 set of recommendations for preconception counseling in women with kidney allografts.Table 2Guidelines for Preconception Counseling in a Renal Allograft RecipientGood general health for 2 years after transplantationMinimal or no proteinuriaWell controlled hypertensionNo evidence of allograft rejectionNo obvious pelvicalyceal distension or other abnormalities on imagingStable renal function and serum creatinine <2.0 mg/d; optimally 35Mifepristone (RU-486)Adrenal insufficiency, coagulopathy, porphyria Open table in a new tab Oral contraceptive pills (OCPs) typically contain an estrogen and a progestin. Failure rates for perfect use in the general population are 0.1% but 3% for typical use. Absolute contraindications to OCPs relevant to a population with chronic kidney disease include significant cardiovascular disease, history of venous thromboembolism (related to the estrogenic component), smokers aged more than 35 years, and impaired liver function. Systemic lupus erythematosis, hypertriglyceridemia, hypertension, and diabetes mellitus are relative contraindications, and lower-dose OCP combinations may be reasonable in the latter 2 disease states. Progestin-only pills can be considered for patients who cannot take estrogen.38Speroff L. Glass R.H. Kase N.G. Clinical Gynecologic Endocrinology and Fertility. (ed 6). Lippincott Williams & Wilkins, Philadelphia, PA1999Google Scholar, 39Wright J. Wyatt S. The Washington Manual TM Obstetrics and Gynecology Survival Guide. Lippincott, Williams & Wilkins, Philadelphia, PA2003: 229-246Google Scholar They are considered to have failure rates that are minimally higher than combination pills but still under 4%. Injectable medroxyprogesterone (Depo-provera, Pfizer, New York, NY) is given every 12 weeks. Severe cardiovascular disease and depression are relative contraindications while coagulation disorders are absolute contraindications. Levonorgestrel (Norplant 2, Wyeth, Madison, NJ) will last for 5 years with a failure rate of 0.05%. Absolute contraindications include thromboembolic disease. Relative contraindications include age >35 years, diabetes mellitus, hypercholesterolemia, hypertension, cardiovascular disease, and immunocompromised states. Transdermal patch systems include OrthoEvra (Johnson & Johnson, New Brunswick, NJ), which contains an estrogen and progestin preparation and has similar precautions to OCPs. Obesity (over 200 lb) is a contraindication, primarily because of deliverability of the compounds. Although there are no well-documented data regarding dialysis access clotting and hormonal contraception, nephrologists should inform patients of this potential risk. Among the hormonal therapies, one is not necessarily better than another, with research in this area sorely lacking. Primarily, a patient and care provider need to decide on a method that is acceptable and easy to use, given the risks and benefits listed earlier. Barrier methods of contraception include condoms (failure rate of 14%), spermicides (20%-25%), and diaphragms and cervical caps (18%-20%). Combinations of condoms and spermicides bring the failure rate down to 3% to 5% in the general population. Long-acting methods of contraception include injectables, rods, rings, and patches. These methods have extremely low failure rates, ranging from 0.05% to 0.4% in the general population. Intrauterine devices (IUDs) have general failure rates of 0.1% to 2% and primarily work as a result of local inflammation. This is an excellent option for those who cannot tolerate hormonal therapies. Various types will function from 1 to 10 years. Intact immunologic function is necessary for efficacy40Zerner J. Doil K.L. Drewry J. et al.Intrauterine contraceptive device failures in renal transplant patients.J Reprod Med. 1981; 26: 99-102PubMed Google Scholar so relative contraindications include immunosuppressed states, such as renal transplantation, not only because of infection risk but also because of reduced effectiveness.41Davison J.M. Bailey D.J. Pregnancy following renal transplantation.J Obstet Gynaecol Res. 2003; 29: 227-233Crossref PubMed Scopus (113) Google Scholar Antibiotic prophylaxis is not recommended at the time of IUD placement in the general population but might be a consideration for patients with chronic kidney disease given their relative immunodeficiency from chronic kidney disease. Patients on peritoneal dialysis should also consider potential increased risk of IUDs; there have been case reports of peritonitis associated with IUD placement.42Ron-El R. Bukovsky I. Kharasch J. et al.Pneumococcal peritonitis with the presence of an intrauterine device.Int J Gynaecol Obstet. 1985; 23: 339-341Abstract Full Text PDF PubMed Scopus (14) Google Scholar Patients who want to avoid pregnancy may consider forms of sterilization. Tubal ligation carries a failure rate of <0.1% in the general population and likely much lower in a population with chronic kidney disease. However, patients often require general anesthesia for the procedure, which may carry its own risks in a medically ill population with chronic kidney disease. Complications include a slight risk of bleeding and infection, with changes in the menstrual cycle and pelvic pain in some. Peritoneal dialysis patients could be at high risk for complications/infection with tubal ligation, but no clear studies on this aspect of the procedure have been reported. Vasectomy is an alternate sterilization method for patients’ partners. The failure rate is <1%, and complications are rare. Given the high rates of fetal and maternal complication in pregnant women with renal disease, elective abortion may be considered. Nonhormonal options include suction curettage, which can be performed during the first trimester. Dilation and evacuation is performed after 13 to 16 weeks. Hormonal options would include mifepristone (RU-486), which is a progesterone antagonist. Contraindications specific to the population with chronic kidney disease would include adrenal insufficiency and any coagulopathy or porphyria. This is specifically for first-trimester abortions. Side effects can include vaginal bleeding, abdominal pain, and nausea and vomiting. Misoprostol is a prostaglandin analog and can be used in conjunction with mifepristone or alone for elective second-trimester terminations.43Grimes D. Chaney E.J. Connell E.B. et al.FDA approval of mifeprostone: An overview.Contraception Rep. 2000; 11: 4-12Google Scholar, 44Goldberg A. Greenberg M.B. Darney P.D. Misoprostol and pregnancy.N Engl J Med. 2000; 344: 38-47Google Scholar One key to success in the care and counseling of women with chronic kidney disease who are contemplating or choosing to avoid pregnancy is a multidisciplinary approach with a nephrologist, obstetrician, and, eventually, pediatrician, familiar with high-risk patients. This team approach allows for optimal counseling and, hopefully, optimal outcomes.6Jungers P. Chauveau D. Pregnancy in renal disease.Kidney Int. 1997; 52: 871-885Crossref PubMed Scopus (133) Google Scholar Although the data available are sparse, convening a specific team to address the patient’s concerns will probably add a level of comfort to everyone involved with both maternal and fetal care.
Referência(s)