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Pregnancy After Pancreatic-Renal Transplantation Because of Diabetes

1997; Elsevier BV; Volume: 72; Issue: 11 Linguagem: Inglês

10.4065/72.11.1044

1942-5546

Jo T. Van Winter, Paul L. Ogburn, Kirk D. Ramin, Mary P. Evans, Jorge A. Velosa,

Cardiovascular Issues in Pregnancy

In this article, we describe two pregnancies in the same patient after pancreatic-renal transplantation. Severe, labile hypertension necessitated delivery at 35 weeks during the patient's first pregnancy and at 30 weeks (associated with renal graft obstruction) during her second pregnancy. Women with insulindependent diabetes mellitus who undergo pancreatic-renal transplantation can have a successful pregnancy if adequate multidisciplinary, specialized medical care is rendered. In this article, we describe two pregnancies in the same patient after pancreatic-renal transplantation. Severe, labile hypertension necessitated delivery at 35 weeks during the patient's first pregnancy and at 30 weeks (associated with renal graft obstruction) during her second pregnancy. Women with insulindependent diabetes mellitus who undergo pancreatic-renal transplantation can have a successful pregnancy if adequate multidisciplinary, specialized medical care is rendered. In patients with end-stage renal failure due to diabetes mellitus, the metabolic status improves significantly after combined pancreatic-renal transplantation.1Kirk EP Organ transplantation and pregnancy: a case report and review.Am J Obstet Gynecol. 1991; 164: 1629-1634Abstract Full Text PDF PubMed Scopus (47) Google Scholar, 2Castro LA Baltzer U Hillebrand G Landgraf R Kuhlmann H Land W Pregnancy in juvenile diabetes mellitus under cyclosporine treatment after combined kidney and pancreas transplantation.Transplant Proc. 1986; 18: 1780-1781Google Scholar, 3Tyden G Brattstrom C Bjorkman U Landgraf R Baltzer J Hillebrand G Pregnancy after combined pancreas-kidney transplantation.Diabetes. 1989; 38(Suppl l): 43-45Google Scholar, 4Carmona F Cararach V Bedini JL Mas E Deulofeu P Ricart MJ Successful pregnancy after combined pancreas-kidney transplantation.Eur J Obstet Gynecol Reprod Biol. 1993; 52: 143-145Abstract Full Text PDF PubMed Scopus (14) Google Scholar, 5Barrou B Baldi A Bitker MO Squifflet JP Gruessner RW Sutherland DER Pregnancy after pancreas transplantation: report of four new cases and review of the literature.Transplant Proc. 1995; 27: 3043-3044PubMed Google Scholar This treatment often results in the resumption of normal reproductive function and the potential for conception in women during their reproductive years. Approximately 1 of every 50 women of childbearing age with a functioning transplanted organ (or organs) will become pregnant.1Kirk EP Organ transplantation and pregnancy: a case report and review.Am J Obstet Gynecol. 1991; 164: 1629-1634Abstract Full Text PDF PubMed Scopus (47) Google Scholar Therefore, it is important to understand both the physiologic adaptation of the transplanted organ (or organs) to pregnancy and the effect that pregnancy may have on the long-standing survival of the renal and pancreatic allografts. The confounding effects of preexisting diabetic vascular disease and of immunosuppressive therapy can lead to severe complications in pregnant patients who have undergone transplantation.1Kirk EP Organ transplantation and pregnancy: a case report and review.Am J Obstet Gynecol. 1991; 164: 1629-1634Abstract Full Text PDF PubMed Scopus (47) Google Scholar, 2Castro LA Baltzer U Hillebrand G Landgraf R Kuhlmann H Land W Pregnancy in juvenile diabetes mellitus under cyclosporine treatment after combined kidney and pancreas transplantation.Transplant Proc. 1986; 18: 1780-1781Google Scholar, 3Tyden G Brattstrom C Bjorkman U Landgraf R Baltzer J Hillebrand G Pregnancy after combined pancreas-kidney transplantation.Diabetes. 1989; 38(Suppl l): 43-45Google Scholar, 4Carmona F Cararach V Bedini JL Mas E Deulofeu P Ricart MJ Successful pregnancy after combined pancreas-kidney transplantation.Eur J Obstet Gynecol Reprod Biol. 1993; 52: 143-145Abstract Full Text PDF PubMed Scopus (14) Google Scholar, 5Barrou B Baldi A Bitker MO Squifflet JP Gruessner RW Sutherland DER Pregnancy after pancreas transplantation: report of four new cases and review of the literature.Transplant Proc. 1995; 27: 3043-3044PubMed Google Scholar, 6Armenti VT Ahlswede KM Ahlswede BA Jarrell BE Moritz MJ Burke JF National Transplantation Pregnancy Registry—outcomes of 154 pregnancies in cyclosporine-treated female kidney transplant recipients.Transplantation. 1994; 57: 502-506Crossref PubMed Scopus (226) Google Scholar In a 32-year-old woman with a 21-year history of juvenile-onset diabetes, end-stage renal failure had developed at the age of 26. Cadaveric pancreatic and renal transplants were placed in 1988, and her diabetes and renal insufficiency resolved. In early 1992, at the age of 30 years, she experienced chronic rejection of her renal allograft; she subsequently received a live-donor renal transplant in September 1992. She received no dialysis before either transplantation. No allograft nephrectomy was performed; therefore, the patient had four kidneys and two pancreases. Good renal and pancreatic function were evident based on a serum creatinine level of 1.0 to 1.2 mg/dL and a fasting blood glucose level of 74 to 102 mg/dL. During the patient's first pregnancy (estimated date of confinement, Jul. 16, 1994), she received maintenance therapy: cyclosporine (150 mg twice a day), prednisone (10 mg daily), and azathioprine (100 mg daily). In addition, she was given a prenatal vitamin preparation containing 1.0 mg of folic acid and an 80-mg aspirin tablet daily. Her mean blood pressure before 20 weeks of gestation was 110/70 mm Hg. The frequency of obstetric ultrasound examinations and determination of laboratory values (such as cyclosporine level) was decided by a team of physicians (perinatologists, transplant physicians, and nephrologists). Laboratory results included a creatinine value that ranged from 1.1 to 1.5 mg/dL, maximal urea concentration of 77 mg/dL, maximal uric acid value of 7.2 mg/dL, a fasting blood glucose value of 90 mg/dL or less, and a 2-hour postprandial blood glucose level of 120 mg/dL or less. Results of liver function tests were normal. At 28 weeks of gestation, the patient had a mild increase in her blood pressure to 120/80 mm Hg, but she had no pronounced weight gain or proteinuria. A localized herpes zoster infection then developed over the left L-4 dermatome; symptoms resolved quickly with 600 mg per day of intravenously administered acyclovir. The patient did well until 35 weeks of gestation, when increasing hypertension developed (156/101 mm Hg), which responded to orally administered hydralazine, 25 mg three times a day. After fetal lung maturity was determined by amniocentesis, labor was induced with intravenously administered oxytocin. A classic cesarean section with intravenous antibiotic coverage was performed because of late decelerations evolving into sustained, severe fetal bradycardia that did not respond to positioning, oxygen therapy, or discontinuation of use of oxytocin. The 2,690-g male newborn had Apgar scores of 0 at 1 minute, 4 at 5 minutes, and 10 at 10 minutes; the umbilical arterial blood gas pH was 7.21. No congenital abnormalities were evident. In the immediate postpartum period, the patient continued to require hydralazine for labile hypertension (107/79 to 159/112 mm Hg). When the patient was examined at 6 weeks after delivery, her blood pressure was normal (108/72 mm Hg), and her renal function was stable (creatinine, 1.1 mg/dL). Postnatally, growth and development of the newborn were normal. The patient became pregnant again 6 months after the birth of her first child (estimated date of confinement, Oct. 20,1995). During the latter half of the second trimester, she was admitted to the hospital three times because of increasing blood pressure. (Her blood pressure returned to normal with bed rest.) The patient did well until 30 weeks of gestation, at which time intermittent pelvic pain developed concomitantly with an increased serum creatinine level (from a baseline of 1.1 mg/dL to 1.6 mg/dL). No cyclosporine toxicity, infection, or preterm labor was evident. Obstruction of the patient's viable kidney graft was suspected because of entrapment between the sacral promontory and the posterior uterine wall. In addition, ultrasound evaluation revealed pronounced hydronephrosis and pyelocaliectasis. Betamethasone was administered to hasten maturation of the fetal lungs. The patient's blood pressure increased to 180/ 110 mm Hg, and her pelvic pain worsened in intensity and became continuous. Results of laboratory tests at that time included a urea concentration of 80 mg/dL, uric acid value of 8.5 mg/dL, and a fasting blood glucose value of 90 to 111 mg/dL; results of liver function tests were normal. Along with these findings, a nonreassuring fetal heart tracing persisted with variable decelerations and decreased long- and short-term viability. Because of concern for possible loss of the viable renal graft (and of the fetus), a decision was made to proceed with repeated classic cesarean section and bilateral tubal ligation. The 1,305-g male neonate had no evidence of any anomalies. Apgar scores were 7 at 1 minute and 9 at 5 minutes. After delivery, the patient did well, and her creatinine level returned to a baseline value of 1.1 mg/dL at 24 hours postpartum. She was dismissed on postoperative day 5, and results of a postpartum examination were normal. The newborn also did well and was dismissed from the level-2 nursery at 23 days of age. Subsequently, the infant has developed normally. The patient's renal status has returned to its prepregnancy baseline, and she is currently doing well. During the past 2 decades, transplantation of human organs has rapidly changed from a research effort to a realistic option for many patients. The transplants have helped to restore reproductive function in young women who, as a result, are beginning to seek preconception counseling and subsequent obstetric care. Before conception, discussion with the patient should include evaluation of the risks of pregnancy (including the severity of preexisting vascular disease associated with diabetes) and problems with future parenting related to a potential limited life span after transplantation. The patient should also be counseled about the importance of achieving a maintenance immunosuppressive regimen with a stable serum creatinine level of 2.0 mg/dL or less (preferably less than 1.5) without evidence of hypertension for approximately 2 years before attempting to become pregnant.7Pahl MV Vaziri ND Kaufman DJ Martin DC Childbirth after renal transplantation.Transplant Proc. 1993; 25: 2727-2731PubMed Google Scholar, 8Maurer G Abriola D Pregnancy following renal transplant.J Perinat Neonatal Nurs. 1994; 8: 28-36PubMed Google Scholar Moreover, the patient must be aware that pregnancy may be associated with an increased risk of long-term reduced renal function and shorter graft survival. Some studies, however, have suggested that pregnancy has no adverse effect on long-term renal function in renal allograft recipients.9Sturgiss SN Davison JM Effect of pregnancy on long-term function of renal allografts.Am J Kidney Dis. 1992; 19: 167-172PubMed Scopus (77) Google Scholar Finally, the patient must be prepared for the emotional, physical, and financial stresses that usually accompany a high-risk pregnancy. Increased maternal and fetal risks early during pregnancy primarily involve the patient's inability to tolerate the immunosuppressive drugs because of nausea. To prevent rejection of the transplant, this problem must be immediately addressed by early hospitalization, intravenously administered fluid support, and antiemetics as appropriate to ensure scheduled dosing of the immunosuppressive medication. Another potential risk to the fetus is increased anomalies due to the immunosuppressive drugs; however, this has not been reported in other studies.10Gilstrap III, LC Little BB Drugs and Pregnancy. Elsevier, New York1992Google Scholar, 11Ogburn Jr, PL Kitzmiller JL Hare JW Phillippe M Gabbe SG Miodovnik M Pregnancy following renal transplantation in class T diabetes mellitus.JAMA. 1986; 255: 911-915Crossref PubMed Scopus (35) Google Scholar, 12Hou S Pregnancy in organ transplant recipients.Med Clin North Am. 1989 May; 73: 667-683PubMed Google Scholar, 13Framarino di Malatesta ML Poli L Pierucci F Paolucci A Pretagostini R Di Nicuolo A Pregnancy and kidney transplantation: clinical problems and experience.Transplant Proc. 1993; 25: 2188-2189PubMed Google Scholar In addition to the increased maternal risk of opportunistic infection, long-term use of immunosuppressants has been associated with a higher incidence of neoplasm in the mother. The relevance of this observation to exposure in utero is unknown.10Gilstrap III, LC Little BB Drugs and Pregnancy. Elsevier, New York1992Google Scholar A multidisciplinary approach to the patient is appropriate, including assessments by obstetricians and transplant physicians. Support from nurse educators, psychiatrists (if indicated), and social services improves prenatal care. In addition, the patient must routinely have appropriate laboratory follow-up and regular ophthalmic examinations to assess for retinopathy or cataracts. Prenatal visits should be scheduled at least every 2 weeks until 32 weeks' gestation and then weekly thereafter. The patient should have baseline laboratory tests consisting of a complete blood cell count, serum creatinine, fasting serum glucose, hemoglobin A1c(glycosylated hemoglobin), electrolytes, serum and urinary amylase, 24-hour urinary creatinine and protein, urinalysis, urinary Gram stain and culture, and cyclosporine levels at least every month (more often if indicated). Suppressive antibiotic therapy should be considered in the setting of recurrent bacteriuria. In addition, liver function tests should be done, and serum protein, calcium, and phosphate levels should be determined at 6-week intervals.8Maurer G Abriola D Pregnancy following renal transplant.J Perinat Neonatal Nurs. 1994; 8: 28-36PubMed Google Scholar, 11Ogburn Jr, PL Kitzmiller JL Hare JW Phillippe M Gabbe SG Miodovnik M Pregnancy following renal transplantation in class T diabetes mellitus.JAMA. 1986; 255: 911-915Crossref PubMed Scopus (35) Google Scholar, 14Davison JM Lindheimer MD Pregnancy in renal transplant recipients.J Reprod Med. 1982; 27: 613-621PubMed Google Scholar Although immunosuppressive therapy is usually maintained at preconception levels, adjustments may be necessary if the maternal leukocyte and platelet counts decrease. Constant surveillance is necessary for determination of any evidence of viral (cytomegalovirus, herpes simplex virus) or bacterial infections due to the immunosuppressed status of the patient. Infection must be treated early and aggressively (as was obvious in our patient who had a herpes zoster infection during her first pregnancy). As pregnancy approaches viability, monitoring of the patient and fetus is necessary. After 20 weeks' gestation, close monitoring of fetal well-being should begin with ultrasonography every 3 to 4 weeks. Antepartum nonstress testing should begin at 28 weeks if the fetus has evidence of growth retardation or the patient has complications such as hypertension. Hypertension can be the seminal event in preeclampsia, or it can accompany renal graft rejection, cyclosporine toxicity, or pregnancy-related progression of the patient's underlying disease, especially when preexisting vascular disease is associated with diabetes mellitus. A sudden increase in blood pressure necessitates hospitalization because both acute rejection and preeclampsia can progress rapidly. When renal function is deteriorating rapidly, renal biopsy should be done if the diagnosis is uncertain. If signs of acute rejection are evident, high-dose corticosteroids should be administered intravenously.12Hou S Pregnancy in organ transplant recipients.Med Clin North Am. 1989 May; 73: 667-683PubMed Google Scholar If biopsy reveals glomerular capillary endotheliosis (a finding consistent with preeclampsia) and the fetus is at 30 weeks or more of gestation, delivery should occur. If signs or symptoms of severe disease are absent, prolongation of the pregnancy is justified when the fetus is immature. The patient, however, should remain hospitalized for close observation. If cyclosporine toxicity is evident, the dose of the drug should be reduced. The fetus must be closely monitored with daily nonstress testing and amniotic fluid evaluation. Worsening maternal renal function (associated with renal graft compression during our patient's second pregnancy) or hypertension may cause a nonreassuring fetal heart tracing. This fetal compromise may result in a hostile fetal environment and necessitate delivery. When delivery is indicated, the type of delivery depends on obstetric and maternal indications. Because of maternal complications or evidence of placental insufficiency, cesarean section seems to be the most common type of delivery in women with a history of insulin-dependent diabetes mellitus who have undergone renal transplantation (with or without pancreatic transplantation).2Castro LA Baltzer U Hillebrand G Landgraf R Kuhlmann H Land W Pregnancy in juvenile diabetes mellitus under cyclosporine treatment after combined kidney and pancreas transplantation.Transplant Proc. 1986; 18: 1780-1781Google Scholar, 3Tyden G Brattstrom C Bjorkman U Landgraf R Baltzer J Hillebrand G Pregnancy after combined pancreas-kidney transplantation.Diabetes. 1989; 38(Suppl l): 43-45Google Scholar, 4Carmona F Cararach V Bedini JL Mas E Deulofeu P Ricart MJ Successful pregnancy after combined pancreas-kidney transplantation.Eur J Obstet Gynecol Reprod Biol. 1993; 52: 143-145Abstract Full Text PDF PubMed Scopus (14) Google Scholar, 11Ogburn Jr, PL Kitzmiller JL Hare JW Phillippe M Gabbe SG Miodovnik M Pregnancy following renal transplantation in class T diabetes mellitus.JAMA. 1986; 255: 911-915Crossref PubMed Scopus (35) Google Scholar The decision to perform a classic cesarean section in our patient was based on her history of multiple laparotomies with the development of dense adhesive disease, sustained fetal bradycardia, and inability to develop an adequate bladder flap. For any invasive procedures, the patient's dose of corticosteroids will need to be increased, and antibiotic coverage will be necessary. Routine procedures such as placement of a Foley catheter or intrauterine pressure monitoring are associated with an increased risk of infection in transplant recipients. After delivery, the patient must be closely monitored for possible deterioration of renal function or sudden exacerbation of hypertension. The risks of preterm delivery and of intrauterine growth retardation are increased in women with renal transplants.11Ogburn Jr, PL Kitzmiller JL Hare JW Phillippe M Gabbe SG Miodovnik M Pregnancy following renal transplantation in class T diabetes mellitus.JAMA. 1986; 255: 911-915Crossref PubMed Scopus (35) Google Scholar, 15Ha J Kim SJ Kim ST Pregnancy following renal transplantation.Transplant Proc. 1994; 26: 2117-2118PubMed Google Scholar The outcome in pancreatic-renal transplant recipients seems similar.2Castro LA Baltzer U Hillebrand G Landgraf R Kuhlmann H Land W Pregnancy in juvenile diabetes mellitus under cyclosporine treatment after combined kidney and pancreas transplantation.Transplant Proc. 1986; 18: 1780-1781Google Scholar, 3Tyden G Brattstrom C Bjorkman U Landgraf R Baltzer J Hillebrand G Pregnancy after combined pancreas-kidney transplantation.Diabetes. 1989; 38(Suppl l): 43-45Google Scholar, 4Carmona F Cararach V Bedini JL Mas E Deulofeu P Ricart MJ Successful pregnancy after combined pancreas-kidney transplantation.Eur J Obstet Gynecol Reprod Biol. 1993; 52: 143-145Abstract Full Text PDF PubMed Scopus (14) Google Scholar, 5Barrou B Baldi A Bitker MO Squifflet JP Gruessner RW Sutherland DER Pregnancy after pancreas transplantation: report of four new cases and review of the literature.Transplant Proc. 1995; 27: 3043-3044PubMed Google Scholar The fact that the transplanted pancreas empties its secretions into the urinary tract of the pregnant patient suggests the theoretic risk of pancreatitis associated with obstruction or infection of the urinary tract. Because of these risks, we recommend that the delivery occur at a tertiary-care center with a level-3 nursery (neonatal intensive-care unit). In addition to assessment of newborns for short-term effects such as adrenal suppression (it is unlikely that it is due to binding of maternal prednisolone to corticosteroid-binding globulin), they need careful long-term follow-up. Finally, breast-feeding is discouraged because cyclosporine levels are similar in maternal blood and breast milk.10Gilstrap III, LC Little BB Drugs and Pregnancy. Elsevier, New York1992Google Scholar, 14Davison JM Lindheimer MD Pregnancy in renal transplant recipients.J Reprod Med. 1982; 27: 613-621PubMed Google Scholar, 16Flechner SM Katz AR Rogers AJ Van Buren C Kahan BD The presence of cyclosporine in body tissues and fluids during pregnancy.Am J Kidney Dis. 1985; 5: 60-63PubMed Scopus (137) Google Scholar Pancreatic transplantation can reverse the need for exogenous insulin in patients with diabetes and perhaps decrease the risk of congenital defects in their offspring. To date, only minimal literature is available regarding the long-term outcome of pregnancy in patients and their infants after combined organ transplantation or single-organ transplantation other than renal.1Kirk EP Organ transplantation and pregnancy: a case report and review.Am J Obstet Gynecol. 1991; 164: 1629-1634Abstract Full Text PDF PubMed Scopus (47) Google Scholar, 12Hou S Pregnancy in organ transplant recipients.Med Clin North Am. 1989 May; 73: 667-683PubMed Google Scholar, 17Rizzoni G Ehrich JH Broyer M Brunner FP Brynger H Fassbinder W Successful pregnancies in women on renal replacement therapy: report from the EDTA Registry.Nephrol Dial Transplant. 1992; 7: 279-287PubMed Google Scholar, 18Laifer SA Guido RS Reproductive function and outcome of pregnancy after liver transplantation in women.Mayo Clin Proc. 1995; 70: 388-394Abstract Full Text Full Text PDF PubMed Scopus (81) Google Scholar, 19Kossoy LR Herbert III, CM Wentz AC Management of heart transplant recipients: guidelines for the obstetrician-gynecologist.Am J Obstet Gynecol. 1988; 159: 490-499Crossref PubMed Scopus (48) Google Scholar Our patient and most of the other patients described in Table 1 had viable infants without congenital defects and no short-term effect on allograft survival or function after pregnancy.2Castro LA Baltzer U Hillebrand G Landgraf R Kuhlmann H Land W Pregnancy in juvenile diabetes mellitus under cyclosporine treatment after combined kidney and pancreas transplantation.Transplant Proc. 1986; 18: 1780-1781Google Scholar, 3Tyden G Brattstrom C Bjorkman U Landgraf R Baltzer J Hillebrand G Pregnancy after combined pancreas-kidney transplantation.Diabetes. 1989; 38(Suppl l): 43-45Google Scholar, 4Carmona F Cararach V Bedini JL Mas E Deulofeu P Ricart MJ Successful pregnancy after combined pancreas-kidney transplantation.Eur J Obstet Gynecol Reprod Biol. 1993; 52: 143-145Abstract Full Text PDF PubMed Scopus (14) Google Scholar, 5Barrou B Baldi A Bitker MO Squifflet JP Gruessner RW Sutherland DER Pregnancy after pancreas transplantation: report of four new cases and review of the literature.Transplant Proc. 1995; 27: 3043-3044PubMed Google ScholarTable 1Clinical Data on Pregnant Patients With Pancreatic-Renal Transplants*In Barrou and associates,5 four more cases of successful pregnancies were reported. Details of those cases are not listed in this table because not all data were provided.ComplicationsReferenceAge at conception (yr)Duration of diabetes (yr)Immuno- suppressive medicationGestational age at delivery (wk)†Mode of delivery of all neonates was by cesarean section.Maternal complications during pregnancy‡HT = hypertension.Intrauterine growth retardationNeonatalPostpartumCastro et al2Castro LA Baltzer U Hillebrand G Landgraf R Kuhlmann H Land W Pregnancy in juvenile diabetes mellitus under cyclosporine treatment after combined kidney and pancreas transplantation.Transplant Proc. 1986; 18: 1780-1781Google Scholar§The neonate in this case was the only one born with a congenital defect (bilateral cataracts).3324Cyclosporine35Increased serum creatinine, proteinuria, HT at 34 wkNoNoneNoneTydén et al3Tyden G Brattstrom C Bjorkman U Landgraf R Baltzer J Hillebrand G Pregnancy after combined pancreas-kidney transplantation.Diabetes. 1989; 38(Suppl l): 43-45Google Scholar2417Cyclosporine, prednisone35NoneYesNoneNone2923Cyclosporine, prednisone, azathioprine37Proteinuria at 33 wkNoNoneNone3021Cyclosporine, prednisone"Term"NoneYesNoneNoneCarmona et al4Carmona F Cararach V Bedini JL Mas E Deulofeu P Ricart MJ Successful pregnancy after combined pancreas-kidney transplantation.Eur J Obstet Gynecol Reprod Biol. 1993; 52: 143-145Abstract Full Text PDF PubMed Scopus (14) Google Scholar3819Cyclosporine36HT at 28 wkYesNoneAcute pancreatic graft rejectionCurrent case1st pregnancy3221Cyclosporine,35Herpes zosterNoNoneNoneprednisone,infection at 28 wk;azathioprinesevere HT at 35 wk2nd pregnancy3322Cyclosporine, prednisone, azathioprine30Severe HT and renal graft obstruction associated with increased serum creatinine at 30 wkNoPre- maturityNone* In Barrou and associates,5Barrou B Baldi A Bitker MO Squifflet JP Gruessner RW Sutherland DER Pregnancy after pancreas transplantation: report of four new cases and review of the literature.Transplant Proc. 1995; 27: 3043-3044PubMed Google Scholar four more cases of successful pregnancies were reported. Details of those cases are not listed in this table because not all data were provided.† Mode of delivery of all neonates was by cesarean section.‡ HT = hypertension.§ The neonate in this case was the only one born with a congenital defect (bilateral cataracts). Open table in a new tab Additional case reports and other contributions to the literature are needed for adequate discussion of the potential risks of pregnancy and long-term maternal and fetal outcome after pancreatic-renal transplantation. The earlier onset of complications during our patient's second pregnancy is evidence that a successful pregnancy does not guarantee the success of subsequent pregnancies.