Clinical Pathway Development for pregnancy post renal transplant to guide nursing and allied health practices

Clinical Pathway Development for

pregnancy post renal transplant to guide

nursing and allied health practices

Prepared by

Linh Pham Renal Social Worker

Katrina Drabsch CNC OPD Clinical Care Coordinator Margaret Jacks Transplant Coordinator

Content

• Management plan throughout stages: Pre-pregnancy and pre-transplant Pre – pregnancy and post transplant Pregnancy Post Partum Recommendations Conclusion References Acknowledgement

“ I kind of do want kids, but then I wonder if I want them enough to put my kidney, me and/ or the child at risk.”

Case Studies

AMANDA

• 25 years old

• End Stage Kidney Disease due to Systemic Lupus Erythematosus (SLE)

• Renal transplant 2 years ago – deceased donor

• Two children prior to commencing dialysis 5 years ago

ABIGAIL

• 24 years old

• End Stage Kidney Disease due to IgA Nephropathy

• Pre-emptive live donor transplant from father performed in United Kingdom 2 years ago

• Presented as a new patient to Transplant clinic as she had relocated to Australia

Literature Review

• Relevance of counselling pre and post pregnancy including

exploration of ethical concerns and psychosocial factors that may impact on successful outcome

• Importance of multidisciplinary approach to the management of the pregnancy and the monitoring of renal function

• Recommendations for the clinical management of renal transplant recipients including management plan pregnancy and pre-transplant, pre-pregnancy and post pre-transplant, during pregnancy and post partum. The management plan involves counselling throughout the process and involvement of the multidisciplinary team 1,2,3

1. Chowdhury et al, Journal of renal nursing, Vol 4 ( July), 2012: pp 170 -174

2. Colon et al, Advances in Chronic Kidney Disease, Vol 14, No 2 ( April), 2007: pp 168 – 177 3. Concepcion et al, Clinical transplantation, Vol 25, 2011: pp 821 -829

Pre Pregnancy and Pre-transplant

• Exploration of patient’s desire to have children

• Risk of conception is high immediately after transplantation

• Discuss effective contraception prior to transplant

• Genetic counselling regarding risk of offspring acquiring

maternal primary organ disease

• Discuss immunosuppressive protocol with transplantation

nephrologists in advance of transplant procedure

3. Concepcion et al, Clinical transplantation, Vol 25, 2011: pp 821 -829 6. Fuchs et al, Seminars in Perinatology, 2007:pp 339-342

7. Josephson et al, American Journal of Transplantation, 2005: pp 1592 – 1599 3,6,7

Case Studies

• At RBWH, there has not been a strong focus on formal pre- transplant counselling in regards to pregnancy.

• With Amanda, although the opportunity was there, it was not part of our transplant workup.

• With Abigail, as she entered our service post transplant, we were only able to provide her with her post transplant care and

Guidelines

Patients should defer conception until at least two years post deceased donor transplant and 1 year post live donor as long as: • no rejection in the past year,

• adequate and stable graft function,

• no acute infections that might impact on foetus

• immunosuppression is maintained at stable dosing

7. Josephson et al, American Journal of Transplantation, Vol 5, 2005: pp 1592 – 1599 7

Management

• Ensure well functioning stable graft

• Potential maternal and foetal risk: hypertension, gestational diabetes, preeclampsia, premature delivery, graft loss

• Co-morbid factors impacting on pregnancy and if there are already established medical non adherence

• Inform of the impact of immunosuppression and any other

required medication on the developing foetus as well as during breast feeding

1. Chowdhury et al, Journal of renal nursing, Vol 4 ( July), 2012: pp 170 -174 6. Fuchs et al, Seminars in Perinatology, 2007:pp 339-342

7. Josephson et al: , American Journal of Transplantation, Vol 5, 2005: pp 1592 – 1599 9. Neyhart, ANA Journal, Vol 25 ( June), 1998: pp 345 – 348

Case Studies

• Amanda and Abigail post two years and post one year respectively with stable graft function.

• Advised becoming pregnant would be a high risk.

• Discussed risks of Pneumocystis Pneumonia Prophylaxis and

Prophylaxis was withdrawn from the period of the pregnancy.

Case studies cont…

Amanda:

• Concerned Amanda only considering pregnancy and the ‘now’ but not the impact of three children post transplant and the ‘future’

• New partner, had never attended clinic and uncertain in regards to his support

Abigail:

• No concerns in regards to Abigail understanding of the process and the risks.

• This was Abigail’s first child, she was in a stable relationship with extensive family support

Management

• Refer prenatal care to maternal foetal medicine specialist or if not available, Obstetrician

• Clinical and laboratory monitoring of the functional

status of transplanted organs and immunosuppressive drug levels; every 4 weeks until 32 weeks, then every 2 weeks until 36 weeks, then weekly until delivery

• Rigorous monitoring during pregnancy by management team of allograft function, emotional coping,

immunosuppressant levels, diet, foetal health risks of

breast feeding 1,2

1. Chowdhury et al, Journal of renal nursing, Vol 4 ( July), 2012: pp 170 -174

Case Studies

• Both Amanda and Abigail

determined to proceed with a plan to become pregnant so all

teratogenic medications were changed to pregnancy safe drugs. • Subsequently pregnancy was

achieved within few months, both Amanda and Abigail extremely happy!

• Referred to high risk obstetric care.

Management

• Monitor for allograft function and maternal disease activity

• Monitor for changes in immunosuppressant drug levels

• Advice resuming contraception

• Counselling in regards to Post Natal Depression and provide

education

6. Fuchs et al, Seminars in Perinatology, 2007:pp 339-342

7. Josephson et al, American Journal of Transplantation, Vol 5, 2005: pp 1592 – 1599 6,7

Case Studies

• Amanda’s baby delivered at 32 weeks by semi-elective

caesarean section due to pre-eclampsia.

• Infant in Neonatal Intensive Care Unit for 5 weeks and

discharged with no anticipated long term complications.

• Amanda’s pre-pregnancy renal function was compromised • Amanda, her partner and

extended family were very happy

Case Studies

• Abigail had a problem free pregnancy until last trimester. Elective caesarean section at 36 weeks gestation as renal function declining.

• Baby in Neonatal Special care Unit for two days and

discharged with no complications.

• Abigail’s pre-pregnancy renal function returned to baseline within one week.

Recommendations

•Utilising the literature review to guide our clinical pathways, local protocols/ standards

•Guidelines for reproductive health.

•To build stronger relationships and more effective and open communication between the renal

transplant team and the Obstetrics team

Conclusion

• The way into the future is to provide safe and

comprehensive care for our patients.

• Our philosophy is for

mums to simply enjoy and focus on their

pregnancy and not on their kidney transplant!

References

1. Chowdhury P, Harding K, Nelson-Piercy C: Pregnancy after Renal

Transplantation, Journal of renal nursing, Vol 4 ( July), 2012: pp 170 -174

2. Colon MM, Hibbard JU: Obstetric Considerations in the Management of pregnancy in Kidney Transplant recipients, Advances in Chronic Kidney

Disease, Vol 14, No 2 ( April), 2007: pp 168 – 177

3. Concepcion BP, Schaefer HM: Caring for the pregnant Kidney Transplant recipient, Clinical transplantation, Vol 25, 2011: pp 821 -829

4. Crowe AV, Rustom R, Gradden C, Sells RA, Bakran A, Bone JM, Walkinshaw S, Bell GM: Pregnancy does not adversely affect renal transplant function, Q J Med, Vol 92, 1999: pp 631 -635

5. Deshpande NA, James NT, Kucirka LM, Boyarsky BJ, Garonzik- Wang JM, Montgomery RA, Segev DL: Pregnancy Outcomes in Kidney Transplant Recipients: A systematic review and Meta – Analysis, American Journal of

References - cont…

6. Fuchs KM, Wu D, Ebicoglu Z: Pregnancy in Renal Transplant Recipients,

Seminars in Perinatology, 2007:pp 339-342

7. Josephson MA, McKay DB: Reproduction and Transplantation: Report on the AST Consensus Conference on Reproductive issues and

Transplantation, American Journal of Transplantation, Vol 5, 2005: pp

1592 – 1599

8. Mastrobattista JM, Gomez-Lobo V : Pregnancy after Solid Organ

Transplantation, Obstetrics and Gynaecology, Vol 112, No 4 ( October)

2008: pp 919 – 932

9. Neyhart CD: Contraception in ESRD and Immunosuppression for the Pregnant Transplant Patient, ANA Journal, Vol 25 ( June), 1998: pp 345 –

348

10. Watnick S, Rueda J: Reproduction and Contraception after Kidney

Transplantation, Current Opinion in Obstetrics and Gynaecology, Vol 20,

Acknowledgments

We would like to thank our two lovely ladies Amanda and Abigail,

and Dr. George John, RBWH

Nephrologist for their contributions.