We have a patient who had amenorrhea for 8 months before a living-related renal transplant about 3 months ago. She has come to us for advice regarding her pregnancy; the gestational age is 23 weeks. Since transplantation, she has been on cyclosporine, Imuran (azathioprine), and Deltacortil. She is normotensive, and her serum creatinine is 0.6 mg/dL. My question is, should we continue with the pregnancy or proceed with a therapeutic abortion?
Syed Mahmud, MD
This is certainly a difficult choice to make as there is much to consider. Assuming that the pregnancy was around 11-12 weeks at the time of transplantation, the effects of high-dose steroids and cyclosporine on the pregnancy at this stage is the critical issue. The main concern is congenital malformations and developmental problems. Prednisone has been used in pregnancy for a variety of reasons. While some animal studies suggest an increased incidence of cleft lip and palate, one of the concerns should be adrenal insufficiency, seen in some of the early pregnancy reports before recommendations were published for "safer" times of conception after transplantation.
There is very little in the literature to guide us to an answer for this question, but from my research on pregnancy after transplantation, my recommendations are as follows:
Ultrasound to evaluate for structural abnormalities.
Serum studies to evaluate for the presence of detectable defects.
Review of the early postoperative course to see if any complications of early viral infections such as cytomegalovirus or herpes virus could have resulted in intrauterine infections.
Review of all medications given at the time of transplantation to evaluate the drug effects during the developmental phase of the fetus.
Consultation with a high-risk obstetrician/gynecologist to assist in evaluating and recommending options for this patient.
We have had one patient who received a liver transplant at 23 weeks' gestation, but suffered fetal death due to an episode of hypotension during the case. Another patient was pregnant (unknowingly, 5-7 weeks' gestation) at the time of liver transplant and gave birth to a healthy child, small for gestational age, but otherwise normal.