2. Patient education and counselling sessions
Pre-dialysis and dialysis education program
Education elements:
Conception rates: 40% of dialysis women under the age of 55 being able
to continue to menstruate.
Contraception options: contraception should be encouraged for women
who do not want to conceive. However, Intrauterine devices are discouraged as
they can increase bleeding during heparin use on dialysis and oral contraceptives
are contraindicated for women with a history thrombophlebitis or lupus.
Pregnancy complications: spontaneous abortion, Fetal death, distress and preterm delivery; Hypertension;
Preeclampsia, Polyhydramnios or oligohydramnios.
3. Statistics of a live baby:
Urea has been shown to be directly proportional to fetal mortality
Live birth rates were significantly higher in women who received more than 36
hours of dialysis per week than in those who received 20 hours or fewer per
week (85% vs 48%; P = .02).
Fetal survival rates for pregnant women on haemodialysis have also increased
to 87%, with an average gestational age of 32.7 +- 3.1 weeks.
Additional haemodialysis requirements during pregnancy.
Tests involved in caring for a pregnant woman on Haemodialysis
Patient education and counselling sessions
4. Staff managing patient
Dialysis unit head nurse should assign a core group of highly
trained senior nurses to dialyse the pregnant woman to
ensure continuity and advanced care is achieved.
5. Multidisciplinary team work
The pregnant hemodialysis patient should be cared
with team work including nephrologist, dialysis
nurse, obstetrician, social worker and dietician.
Frequent meetings and communications between
team members should be planned and arranged.
6. Hemodialysis Prescription
Duration and frequency: duration should be at least
20 hours per week; 4hx5sessions/week (e.g. Sat, Sun,
Tue, Wed, and Thursday).
More intensive HD prescription (36hours) showed better
outcomes: 6hX6 days/week.
7. Dialyzer: Biocompatible high flux dialyzer.
Blood flow rate: 200-300 ml/min. it is better to
increase BFR gradually during the first 30 min of
dialysis.
Hemodialysis Prescription
8. Anticoagulation
Use the minimal possible dose of heparin (Heparin is
safe unless there vaginal bleeding).
Tinzaparine sodium (innohep) can be used as a bollus
of 1500-2500 IU subcutaneousely.
Coumarin should be avoided.
Hemodialysis Prescription
9. Vitals: Blood pressure should be monitored every 15
min with target diastolic pressure 80-90mm/Hg.
Hemodialysis Prescription
10. Dry weight
Ultrafiltration goal should be adjusted based on
expected pregnancy induced weight gain, but slow
rate ultrafiltration is recommended as it is preferred to
leave “wet” as opposed to dry to avoid hypotension.
Rapid and excessive UF should be avoided.
Hemodialysis Prescription
11. Dry weight
Dry weight should be assessed at each dialysis and
reviewed weekly and as required due to:
Fetal and placental growth and 30% increase in plasma
volume during pregnancy.
The expected increase of body weight is 250gm/week till
20th week of pregnancy and 300-500gm/week afterwards.
Hemodialysis Prescription
13. Hyperension
BP should be kept ≤ 140/90 mm/Hg.
Recommended antihypertensive drugs in the following order: alpha
methyldopa, BB (labetalol and not atenolol), hydralazine and calcium
channel blocker (nifedipine, nicardipine, and verapamil).
Avoid diuretics, ACE inhibitors, and ARB.
Avoid hypotension and volume depletion.
Drugs for hypertensive emergency are intravenous labetalol and
hydralazine.
14. Anemia Management
Erythropoietin dose should be increased 50-100% to
keep Hb 10-11g/l.
Iron:
It should not be given in the 1st trimester.
Iron requirements should be increased to 200 mg IV
weekly
Mentain TSAT > 25 %.
15. Bone Disease
Calcium supplements and phosphate binder should be
adjusted according to weekly blood level.
Avoid post dialysis hypercalcemia which may be caused due
to frequent dialysis (maternal hypercalcemia will cause
hypocalcemia and hyperphosphatemia in the newborn and
affect skeletal development).
Avoid hyperphosphatemia and hypocalcemia.
16. Bone Disease
Hypophosphatemia may result from frequent dialysis, so, oral
supplement is recommended or increase dietary intake.
Vitamin D supplement should be adjusted according to
blood level of Vitamin D, calcium, phosphorus.
Sevelamer, lanthanum carbonate, aluminium hydroxide,
cinacalcet, and paricalcitol are not recommended.
17. Nutrition
Dietician should regularly visit the patient and
modify the nutritional plan according to the
coordinated team work meetings.
Minimum daily intake of protein should be 1.8g/kg.
Calorie intake of 35kcal/kg/ pregnant weight/day
+300kcal/day.
18. Nutrition
Supplements
Folic acid 2mg/day.
Calcium carbonate 1500mg/day.
Vitamin D: 1000 iu daily.
Calcitriol: adjust according to level of calcium and phosphorus level.
Supplements of water soluble vitamins that can be dialyzed (Vitamin C, thiamine,
riboflavin, niacin, vitamin B6 and vitamin B12).
Zinc 15 mg daily.
Potassium, Calcium, Phosphorus and bicarbonate: Values for these parameters should
be monitored closely in pregnant patients so that treatment can be individualized.
19. Blood Investigations
Weekly and PRN blood result for U&Es, bone profile, vitamin D, LFT and
CBC.
Pre-dialysis urea should be kept < 15 mmol/l.
Pre-dialysis creatinine should be kept < 550 umol/l.
PH should be maintained >7.2.
Vitamin D and iPTH level should be checked every trimester.
Calcium supplements should be adjusted according to the weekly blood
level (Production of calcitriol by the placenta may increase the patients
calcium).
20. Positioning
The pregnant woman should be positioned semi reclined or
on a bed with a left lateral tilt from 20 weeks, to ensure
decompression of vena cava.
22. Delivery
Delivery is recommended between 34-36 weeks and
no later than 38 weeks.
Neonatal intensive care management is mandatory
as even babies born “close to term should be
monitored closely, as they generally have solute
diuresis and may become seriously volume
contracted.
23. References
Baha di, A., El Kabbaj, D., Guelzim, K., Kouach, J., Hassani, M., Maoujoud, O., Aattif, M.,
Kadiri, M., Montassir, D., Zajjari, Y., Alayoud, A., Benyahia, M., Elallam, M. & Oualim, Z.
(2010). Pregnancy during hemodialysis: A single Center experience. Saudi Journal of
Kidney Diseases and Transplantation, 21 (4), 646-651.
Bamberg, C., Diekmann, F., Haase, M., Budde, K., Hocher, B., Halle, H. & Hartung, J.
(2007). Pregnancy on Intensified Haemodialysis: Fetal surveillance and perinatal
outcome. Fetal Diagnosis and Therapy, (22), 289-293.
Barua, M., Hladunewich, M., Keunen, J., Perratos, A., McFarlane, P., Sood, M. & Chan, C.
T. (2008). Successful pregnancies on nocturnal home haemodialysis. Clinical Journal of
the American Society of Nephrology, 3, 392-396. Coyle, M., Sulger, E., Fletcher, C. &
Rouse, D. (2008). A successful 39-week pregnancy on hemodialysis: A case report.
Nephrology Nursing Journal, 35 (4), 348-402.
24. Daugirdas, J. T., Blake, P. G. & Ing, T. S. (2007). Handbook of Dialysis. 4th Ed. Lippincott Williams &
Wilkins, Philadelphia, 673-677.
Dhir, S. & Fuller, J. (2007). Case report: Pregnancy in hemodialysis-dependent end-stage renal
disease: anaesthetic considerations. Canadian Journal of Anaesthesia, 54 (7), 556- 560.
Hladunewich MA, Hou S, Odutayo A, et al: Intensive hemodialysis associates with improved
pregnancy outcomes: a Canadian and United States cohort comparison. J Am Soc Nephrol. 2014
May;25(5):1103-9.
Ind, D. (2007). Pregnancy and renal function. Renal Society of Australasia Journal, 3 (2) 47- 49.
Renal Department 2013 Page 6
Luders, C., Castro, M. C, M., Titan, S. M., De Castro, I., Elias, R. M., Abensur, H. & Romao,
J. E. (2010). Obstetric outcome in pregnant women on long-term dialysis: A case series. American
Journal of Kidney diseases, 56 (1), 77-85.
References
25. Piccoli, G. B., Conijn, A., Consiglio, V., Vasario, E., Attini, R., Deagostini, M. C.,
Bontempo, S. & Tudros, T. (2010). Pregnancy in Dialysis Patients: Is Evidence
strong enough to lead us to change our counselling policy? Clinical Journal of the
American Society of Nephrology, (5), 62-71.
Vidaeff, A. C., Yeomans, E. R. & Ramin, S. M. (2008). Pregnancy in women with
renal disease. Part I: General principles. American Journal of Perinatology, 25 (7),
385-397.
Wilkinson, J. (2007). Motherhood becomes a reality. Renal Society of Australasia
Journal, 3 (2) 39-46.
References
