Pregnancy in women on chronic dialysis: a review
Embarazo en mujeres en diálisis crónica: revisión
Karina Ruth Furaz Czerpaka, Karina R. Furaz-Czerpakb, Gema Fernández Juárezc, Gema Fernández-Juárezd, María Angeles Moreno de la Higueraa, M. Ángeles Moreno-de la Higuerab, Elena Corchete Pratsa, Elena Corchete-Pratsb, Adriana Puente Garcíaa, Adriana Puente-Garcíab, Roberto Martín Hernandeza, Roberto Martín-Hernándezb
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FRIAT, Móstoles, Madrid, Spain, " "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] 1 => array:3 [ "entidad" => " Centro Los Llanos. FRIAT, Móstoles, Madrid, " "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "affb" ] 2 => array:3 [ "entidad" => " Unidad de Nefrología, Fundación Hospital Alcorcón Alcorcón, Madrid, Spain, " "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "affc" ] 3 => array:3 [ "entidad" => "Unidad de Nefrología, Fundación Hospital Alcorcón, Alcorcón, Madrid, " "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "affd" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Embarazo en mujeres en diálisis crónica: revisión" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig1" "etiqueta" => "Tab. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "11319_16025_28449_en_t1_11319_ing.jpg" "Alto" => 617 "Ancho" => 2186 "Tamanyo" => 399884 ] ] "descripcion" => array:1 [ "en" => "Parameters for pregnancy and new-borns in women on chronic haemodialysis" ] ] ] "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">INTRODUCTION</span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">Pregnancies in dialysis patients are uncommon and difficult to study. These pregnancies occur in widely separated dialysis units, and so the majority of nephrologists encounter one or two pregnant patients during their time in practice.<span class="elsevierStyleSup">1</span> Fortunately, the percentage of successful pregnancies has increased consistently, but there is still a very high maternal/foetal mortality and morbidity rate as compared to the normal population.<span class="elsevierStyleSup">2,3</span> In order to achieve a successful birth, this situation requires the joint efforts of nephrologists, gynaecologists, nephrological nurses, and nutritionists.<span class="elsevierStyleSup">2</span></p><p class="elsevierStylePara">This article is a review of the existing medical literature regarding the management of this type of patient, the incidence of successful pregnancies, and the maternal and foetal complications involved.</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara"><span class="elsevierStyleBold">FREQUENCY AND DIAGNOSIS OF PREGNANCY IN WOMEN ON DIALYSIS</span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">Although not well documented, it is believed that the frequency of pregnancies in women on haemodialysis is on the rise, from 1% to 7%, according to the most recent publications, with different rates in different countries.<span class="elsevierStyleSup">2,4-7</span> Pregnancies are more common in women with preserved residual diuresis.<span class="elsevierStyleSup">8,9</span></p><p class="elsevierStylePara">The majority of patients on haemodialysis have sexual dysfunction as a result of physical and/or emotional problems.<span class="elsevierStyleSup">2</span></p><p class="elsevierStylePara">Fertility drops due mainly to anaemia and hyperprolactinaemia; this decrease in fertility is also associated with hypothalamic/pituitary dysfunction, which results in ovarian dysfunction and anovulatory cycles, multiple drug treatments, depression, and loss of sex drive.<span class="elsevierStyleSup">10,11</span></p><p class="elsevierStylePara">However, the improved efficacy of dialysis, along with corrections to anaemia due to the standardised application of erythropoietin, has improved general health in these patients, as well as their sexual function, which involves increased fertility and normal menstrual cycles.<span class="elsevierStyleSup">11,12</span></p><p class="elsevierStylePara">Pregnancy in these patients tends to be diagnosed late, since irregular cycles and abdominal pain are already common, and many doctors do not think immediately of pregnancy as a possible cause of the symptoms.<span class="elsevierStyleSup">13</span></p><p class="elsevierStylePara">Further deterioration of anaemia or apparent resistance to erythropoietin as well as hypotension episodes of unknown cause in premenopausal women should arouse suspicion of a possible pregnancy.<span class="elsevierStyleSup">14</span></p><p class="elsevierStylePara">Urine pregnancy tests are not very useful in these situations, even if the patient has residual diuresis. The measurement of human chorionic gonadotrophin is inexact, since this molecule is produced by somatic cells and excreted by the kidney, and so ultrasound is the only reliable method to calculate gestational age.<span class="elsevierStyleSup">15</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold"> </span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">RESULTS OF PREGNANCIES IN WOMEN ON HAEMODIALYSIS</span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">The first pregnancy with a successful result in a patient on haemodialysis was described in 1971 by Confortini et al<span class="elsevierStyleSup">16</span>; the patient was 35 years old.</p><p class="elsevierStylePara">In 1980, a case series was published in the European Dialysis and Transplant Association (EDTA) register involving 1300 women of child-bearing age, reporting a 0.9% incidence rate of pregnancies in patients on chronic haemodialysis.<span class="elsevierStyleSup">17</span></p><p class="elsevierStylePara">In 1994, Hou published another case series from 206 North American dialysis units. The percentage of miscarriage was 70% before 1990 and under 40% in the following years.<span class="elsevierStyleSup">17</span></p><p class="elsevierStylePara">The majority of case series described since 2000 reported success rates for these pregnancies over 70%.<span class="elsevierStyleSup">5,18-24</span></p><p class="elsevierStylePara">As regards maternal mortality, few such cases have been registered in the literature. The prognosis for the mother is good; especially in patients that start dialysis after conception.<span class="elsevierStyleSup">2-7</span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara"><span class="elsevierStyleBold">MATERNAL AND FOETAL COMPLICATIONS</span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">Maternal complications include: miscarriage, placental detachment, anaemia, infection, premature rupture of membranes, polyhydramnios, pre-term birth, uncontrolled arterial hypertension, preeclampsia/eclampsia, haemorrhage, need for a caesarean, and maternal death.<span class="elsevierStyleSup">25,26</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">The incidence of polyhydramnios</span> has been estimated at 30%-70%. The increased production in foetal urine secondary to urea-induced osmotic diuresis is probably the cause of excess amniotic fluid.<span class="elsevierStyleSup">23,24</span> Several studies have suggested that treatment for this complication consists of increasing dialysis doses.<span class="elsevierStyleSup">24</span></p><p class="elsevierStylePara">As regards <span class="elsevierStyleBold">preeclampsia/eclampsia</span>, approximately 80% of women on haemodialysis that become pregnant have arterial hypertension or require anti-hypertensive medications at some point during pregnancy.<span class="elsevierStyleSup">3</span></p><p class="elsevierStylePara">Uncontrolled hypertension poses a serious risk to the mother, and must be quickly and adequately controlled, maintaining diastolic blood pressure below 80-90mm Hg.<span class="elsevierStyleSup">2,13,27</span> As in any other dialysis patient, the initial treatment consists of adjusting volume using ultrafiltration, but if the cause of hypertension is preeclampsia, fluid extraction could exacerbate hypoperfusion to the various organs.<span class="elsevierStyleSup">15</span></p><p class="elsevierStylePara">Several different types of medications are used to treat hypertension in pregnant women:</p><p class="elsevierStylePara">- <span class="elsevierStyleBold">Alpha-methyldopa</span> is commonly used; no adverse side effects have been observed in babies, and they are relatively few in the mother: fatigue, depression, and in a small percentage of patients, hepatitis.<span class="elsevierStyleSup">2</span></p><p class="elsevierStylePara">- <span class="elsevierStyleBold">Hydralazine</span> has been used both orally and intravenously with no problems. It is not effective as a monotherapy under oral administration, but can also be associated with first-line drugs if results are not sufficiently effective.<span class="elsevierStyleSup">3-28</span></p><p class="elsevierStylePara">- <span class="elsevierStyleBold">Beta-blockers</span> are not used due to their adverse effects on new-borns; labetalol does not produce these effects, so it is widely used.<span class="elsevierStyleSup">3-29</span></p><p class="elsevierStylePara">- The experience with <span class="elsevierStyleBold">clonidine</span> and <span class="elsevierStyleBold">prazosin</span> is limited, and these drugs do not appear to provide any serious benefit.<span class="elsevierStyleSup">3-30</span></p><p class="elsevierStylePara">- <span class="elsevierStyleBold">Calcium channel blockers</span> that can be used include: nifedipine, nicardipine, and verapamil. These have been used in cases of severe hypertension, and do not appear to be associated with congenital defects when used during the first trimester. Only limited experience has been gained using diltiazem. We must remember that combined therapy with magnesium can lead to severe episodes of hypotension.<span class="elsevierStyleSup">15,28,31</span></p><p class="elsevierStylePara">- <span class="elsevierStyleBold">Diuretics</span> can be used when no other alternative exists, but must be suspended in the event of suspected preeclampsia.<span class="elsevierStyleSup">3</span> Some publications have described neonatal thrombocytopenia, haemolytic anaemia, electrolyte imbalances, and jaundice with the use of thiazides.<span class="elsevierStyleSup">32</span></p><p class="elsevierStylePara">- <span class="elsevierStyleBold">Angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARB) and minoxidil</span> are contraindicated due to their adverse effects on the new born.<span class="elsevierStyleSup">2,33-35</span></p><p class="elsevierStylePara">As regards drugs used in hypertensive emergencies, labetalol and hydralazine are prescribed intravenously.<span class="elsevierStyleSup">3,36</span></p><p class="elsevierStylePara">The most common <span class="elsevierStyleBold">foetal complications</span> are: restricted intra-uterine growth, acute and chronic foetal suffering, pre-term birth, respiratory difficulty in the new-born, growth in neonatal intensive care units, and uterine or neonatal death.<span class="elsevierStyleSup">25</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Pre-term births</span> occur in 83% of live births; the new-borns have a low weight and the gestational age is approximately 32 weeks or even less (Table 1).<span class="elsevierStyleSup">5,19-24,37</span></p><p class="elsevierStylePara">Table 2 describes the primary recommendations for managing these patients.</p><p class="elsevierStylePara"><span class="elsevierStyleBold"> </span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">INTENSIVE DIALYSIS</span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">It is well established that a longer duration of dialysis treatment prolongs the gestation period, resulting in babies with a higher weight at birth, improved life expectancy, and reduced long-term complications.<span class="elsevierStyleSup">3</span></p><p class="elsevierStylePara">The weekly time that patients should be on dialysis varies according to study (Table 3), but regardless of the criteria followed, the prescription of haemodialysis must be sufficient to maintain stable conditions in the mother in terms of volaemia, blood pressure, and weight gain between sessions.<span class="elsevierStyleSup">10</span></p><p class="elsevierStylePara">The results from the study by Hou showed that pregnant women that receive over 20 hours of dialysis per week gave birth to babies with higher weight and gestational age.<span class="elsevierStyleSup">3</span> Two studies have also shown that pregnant patients should receive the maximum possible amount of time on dialysis, at least 24 hours per week.<span class="elsevierStyleSup">23,38</span></p><p class="elsevierStylePara">Nocturnal haemodialysis provides greater clearance of small and medium molecular weight molecules and improves the control of metabolic, electrolyte, phosphorous, volaemia, and blood pressure profiles.<span class="elsevierStyleSup">21,39-42</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold"> </span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">MATERNAL UREA NITROGEN</span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">Several retrospective studies and isolated clinical cases have reported increased new-born survival in women with blood urea nitrogen (BUN) levels <50mg/100ml, but Asayima et al, in a retrospective study involving 28 pregnant patients on haemodialysis, demonstrated for the first time that lower maternal BUN levels are associated with higher weight and gestational age at birth.<span class="elsevierStyleSup">37,39,43,44</span></p><p class="elsevierStylePara">Predialysis BUN levels are recommended to be kept below 50mg/100ml.<span class="elsevierStyleSup">2,11</span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara"><span class="elsevierStyleBold">TECHNIQUE</span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">The experience with peritoneal dialysis has been limited to a very few number of patients; in fact, the incidence of pregnancies in these patients is even lower than the rates for haemodialysis patients. This could be due to the presence of hypertonic solutions in the peritoneum, previous episodes of peritonitis, or physical factors that could interfere with foetal implantation. Most of the authors do not recommend changing the dialysis technique after conception.<span class="elsevierStyleSup">45,46</span></p><p class="elsevierStylePara">More data are needed on the results of pregnant patients on peritoneal dialysis and the possible associated complications.<span class="elsevierStyleSup">46</span></p><p class="elsevierStylePara">Data from the register of pregnant patients on dialysis and several reports showed no differences in the maternal and foetal results between haemodialysis and peritoneal dialysis.<span class="elsevierStyleSup">27,43,47</span></p><p class="elsevierStylePara">Peritoneal dialysis has the advantage of not inducing sudden metabolic changes, and allows for a gradual control of volaemia, thus avoiding episodes of hypotension. The main disadvantage would be difficulty in maintaining proper nutrition.<span class="elsevierStyleSup">3</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold"> </span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">MEMBRANE TYPE AND FLOW</span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">New dialysers, not recycled ones, with high biocompatibility and functionality are recommended in these patients.<span class="elsevierStyleSup">25,48</span></p><p class="elsevierStylePara">It is best to use membranes with a lower surface area combined with increased time on dialysis so as to minimise excessive fluid losses and avoid episodes of hypotension and sudden changes in osmolarity.<span class="elsevierStyleSup">2</span></p><p class="elsevierStylePara">Five different studies used dialysis fluid flow rates between 500ml/min and 700ml/min, and only one used low flow rates.<span class="elsevierStyleSup">21-23,40,49</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold"> </span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">WEIGHT GAIN</span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">Maternal dry weight and weight gain should be regularly evaluated and adjusted according to the estimated weight of the foetus. In the first trimester, the mother should gain a minimum of 1kg -1.5kg. After this, weight should increase by 0.45kg to 1kg per week. In the third trimester, foetal weight and growth can also be directly evaluated using ultrasound.<span class="elsevierStyleSup">44</span></p><p class="elsevierStylePara">Maternal blood pressure and heart rate must be closely monitored before, during, and after each dialysis session.<span class="elsevierStyleSup">44</span></p><p class="elsevierStylePara">Ultrafiltration doses should be administered on an individual basis so as to avoid episodes of arterial hypotension, hypovolaemia, and arrhythmia; and maternal blood volume expansion and weight gain should be proportional to the gestation stage. Severe maternal weight loss due to rapid and excessive ultrafiltration can reduce the foetal-placental blood flow, which could be very harmful for the foetus. As such, these factors must be considered in ultrafiltration prescription.<span class="elsevierStyleSup">25</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold"> </span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">DIALYSATE</span>  </p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">Potassium levels in the dialysate must be increased to 3-3.5mmol/l in order to avoid hypokalemia.<span class="elsevierStyleSup">2,3</span> Electrolyte levels must be checked weekly.<span class="elsevierStyleSup">2,3</span></p><p class="elsevierStylePara">For bicarbonate levels, Hou recommends low concentrations (25mEq/l). Based on collective experience, frequent haemodialysis can result in excessive alkali transfer to the mother, producing alkalemia.<span class="elsevierStyleSup">3,27,42</span></p><p class="elsevierStylePara">Frequent haemodialysis can also lead to hypophosphataemia. Given that added phosphorous in the dialysate can be a complicated issue, oral supplements are recommended, or increased dietary intake.<span class="elsevierStyleSup">50</span></p><p class="elsevierStylePara">With daily haemodialysis and a 3.5mEq/l dialysate calcium concentration, hypercalcaemia can develop, and so a 2.5mEq/l dialysate calcium concentration is preferred.<span class="elsevierStyleSup">3</span></p><p class="elsevierStylePara"><span class="elsevierStyleSup"> </span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">ANAEMIA</span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">In order to achieve the desired haemoglobin levels of 10-11g/100ml in these women (haematocrit: 30%-35%), erythropoietin doses must be increased by 50%-100%.<span class="elsevierStyleSup">25-27</span></p><p class="elsevierStylePara">In addition, anaemia during pregnancy is associated with increased incidence of pre-term births, which results in greater infant mortality rates.<span class="elsevierStyleSup">51</span></p><p class="elsevierStylePara">Asamiya et al analysed 24 pregnant patients on haemodialysis and demonstrated a positive correlation between maternal haemoglobin and a successful pregnancy.<span class="elsevierStyleSup">43</span></p><p class="elsevierStylePara">The use of erythropoietin during pregnancy has proven safe, with no documented increases in blood pressure or teratogenicity.<span class="elsevierStyleSup">25,52</span></p><p class="elsevierStylePara">During pregnancy, the mother and foetus need 800-1000mg of iron. Oral supplements would be insufficient, so it can be administered intravenously, without adverse effects. Frequent checks of haemoglobin and ferritin values should be performed.<span class="elsevierStyleSup">2</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold"> </span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">ANTICOAGULATION</span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">Heparin does not cross the placenta and is not teratogenic. It must be used in order to avoid coagulation of the vascular accesses.<span class="elsevierStyleSup">3,53</span> This treatment should be administered to all patients, except for those with active bleeding.<span class="elsevierStyleSup">25</span></p><p class="elsevierStylePara">Coumarin is contraindicated in these patients.<span class="elsevierStyleSup">25</span></p><p class="elsevierStylePara"><span class="elsevierStyleSup"> </span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">CALCIUM AND VITAMIN D</span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">Physicians must take into account both the calcium provided by the dialysate and calcium intake in the form of calcium chelating agents. Daily haemodialysis with a 3.5mEq/l dialysate calcium concentration could induce hypercalcaemia, and so 2.5mEq/l concentrations are preferred, along with oral supplements of 1g-2g calcium carbonate.<span class="elsevierStyleSup">2</span></p><p class="elsevierStylePara">Since maternal hypercalcaemia can cause hypocalcaemia and hyperphosphataemia in the newborn and affect its skeletal development, both calcium and phosphorous levels must be monitored weekly.<span class="elsevierStyleSup">2,44</span></p><p class="elsevierStylePara">The placenta converts 25-OH D3 (calcidiol) into 1,25-OH2 D3 (calcitriol), and so 25-OH vitamin D must be measured every trimester, administering supplements if levels are low.<span class="elsevierStyleSup">3</span></p><p class="elsevierStylePara">Although primary hyperparathyroidism is known to increase the frequency of pre-term births by 10%-20%, the effects of hyperparathyroidism on the foetus are unknown. The use of 1,25-dihydroxy-vitamin D is indicated in these cases: this molecule can be used to control both hyperparathyroidism and 1,25-hydroxy-vitamin D deficiency. Calciferol does not appear to be toxic at reasonable doses. Dosage adjustments must be based on weekly calcium and phosphorous measurements.<span class="elsevierStyleSup">2</span></p><p class="elsevierStylePara">Sevelamer, lanthanum carbonate, aluminium hydroxide, cinacalcet, and paricalcitol have not been tested or established for use during pregnancy/lactation.<span class="elsevierStyleSup">54,55</span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara"><span class="elsevierStyleBold">NUTRITION</span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">We recommend to:</p><p class="elsevierStylePara">- Increase calorie intake by 30-35kcal/day.<span class="elsevierStyleSup">3</span></p><p class="elsevierStylePara">- Consume 1-1.5g/kg of weight (haemodialysis) or 1.8g/kg of weight (peritoneal dialysis) of additional protein daily in order to ensure foetal development.<span class="elsevierStyleSup">3,8</span></p><p class="elsevierStylePara">- Take 1mg/day of folic acid starting from the first trimester.<span class="elsevierStyleSup">3</span></p><p class="elsevierStylePara">- Consume 1500mg/day of calcium.<span class="elsevierStyleSup">2</span></p><p class="elsevierStylePara">- Take water-soluble vitamins throughout the pregnancy, since the requirements for these molecules increase and intensive dialysis promotes their elimination.<span class="elsevierStyleSup">44</span></p><p class="elsevierStylePara">- Supplements for vitamins that can be dialysed (vitamin C, thiamine, riboflavin, niacin, vitamin B6).<span class="elsevierStyleSup">45</span></p><p class="elsevierStylePara">- Many patients also need increased potassium and phosphorous uptake in order to maintain adequate levels.<span class="elsevierStyleSup">3</span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara"><span class="elsevierStyleBold">OBSTETRIC MANAGEMENT</span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">As regards tocolytic agents, intravenous magnesium must be administered with caution in these patients in order to avoid toxicity, keeping levels below 5-7mg/dl. Calcium channel blockers are also administered for this purpose.<span class="elsevierStyleSup">2,3,56</span></p><p class="elsevierStylePara">Indomethacin has been used successfully, especially in women with polyhydramnios. However, in women with residual renal function, this effect can be lost. Additionally, prolonged use for more than 72 hours has been correlated with severe side effects on the newborn, so it should only be used for short periods.<span class="elsevierStyleSup">3,57</span></p><p class="elsevierStylePara">Progesterone supplements in their various presentations have not been evaluated in haemodialysis patients or women with chronic kidney disease.<span class="elsevierStyleSup">58</span></p><p class="elsevierStylePara">As regards the length of the gestation period, some authors recommend inducing labour after 34-36 weeks if the baby’s lungs have developed sufficiently, but the majority prefers to prolong the gestation period to 38 weeks.<span class="elsevierStyleSup">3</span></p><p class="elsevierStylePara">Caesarean sections should only be undertaken under the same indications as for women not being treated with haemodialysis.<span class="elsevierStyleSup">3</span></p><p class="elsevierStylePara">Newborns should be monitored in high-risk units, since they are usually born with similar urea and creatinine levels to their mothers, and may suffer osmotic diuresis.<span class="elsevierStyleSup">2,3</span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conflicts of Interest</span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">The authors affirm that they have no conflicts of interest related to the content of this article.</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara"><span class="elsevierStyleBold">KEY CONCEPTS</span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">1. Gestation in patients on renal replacement therapy involves a risk both to the mother and the foetus, even though new-born survival has improved in recent decades; various studies and registries report survival rates of 40%-85%.<span class="elsevierStyleSup">59</span></p><p class="elsevierStylePara">2. We currently have no literature reference for systematic nephrological/gynaecological treatment of these patients.<span class="elsevierStyleSup">30,59</span></p><p class="elsevierStylePara">3. According to the available literature on the subject, the measures to be taken in order to achieve successful pregnancies in these patients include: multidisciplinary approach, increased time on dialysis, maintain low levels of predialysis urea, prevention of pre-term birth, strict control of blood pressure and electrolyte levels, prevention of urinary infections, and adequate foetal monitoring.<span class="elsevierStyleSup">2,3,23,24</span></p><p class="elsevierStylePara"><a href="grande/11319_16025_28449_en_t1_11319_ing.jpg" class="elsevierStyleCrossRefs"><img src="11319_16025_28449_en_t1_11319_ing.jpg" alt="Parameters for pregnancy and new-borns in women on chronic haemodialysis"></img></a></p><p class="elsevierStylePara">Table 1. Parameters for pregnancy and new-borns in women on chronic haemodialysis</p><p class="elsevierStylePara"><a href="grande/11319_16025_28451_en_t3_11319_ing3.jpg" class="elsevierStyleCrossRefs"><img src="11319_16025_28451_en_t3_11319_ing3.jpg" alt="Parameters for dialysis and foetal survival"></img></a></p><p class="elsevierStylePara">Table 3. Parameters for dialysis and foetal survival</p><p class="elsevierStylePara"><a href="11319_19157_28450_en_ref.1131912388_11319_19115_25239_es_11319_tabla_2_en.doc" class="elsevierStyleCrossRefs">11319_19157_28450_en_ref.1131912388_11319_19115_25239_es_11319_tabla_2_en.doc</a></p><p class="elsevierStylePara">Table 2. Recommendations for optimising the treatment of pregnant women on haemodialysis</p>" "pdfFichero" => "P1-E536-S3496-A11319-EN.pdf" "tienePdf" => true "PalabrasClave" => array:2 [ "es" => array:3 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec438251" "palabras" => array:1 [ 0 => "Hemodiálisis" ] ] 1 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec438253" "palabras" => array:1 [ 0 => "Insuficiencia renal crónica" ] ] 2 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec438255" "palabras" => array:1 [ 0 => "Embarazo" ] ] ] "en" => array:3 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec438252" "palabras" => array:1 [ 0 => "Haemodialysis" ] ] 1 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec438254" "palabras" => array:1 [ 0 => "Chronic renal failure" ] ] 2 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec438256" "palabras" => array:1 [ 0 => "Pregnancy" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "es" => array:1 [ "resumen" => "<p class="elsevierStylePara">La frecuencia de embarazos en mujeres en diálisis es extremadamente baja, aunque el porcentaje de gestaciones con éxito ha aumentado a lo largo de los años, siendo, según distintas series, superior al 70%. Estos embarazos no están exentos de complicaciones tanto para la madre como para el feto, el manejo de las cuales requiere el trabajo conjunto del nefrólogo, el ginecólogo, el enfermero y el nutricionista. A día de hoy no es posible encontrar un tratamiento sistemático nefrológico y ginecológico en este tipo de pacientes. Las principales medidas que se deberían adoptar incluirían: aumento del tiempo de diálisis, mantener bajos niveles de urea prediálisis, evitar hipotensiones e hipertensión materna, así como infecciones urinarias y fluctuaciones electrolíticas. Se requiere, además, una adecuada monitorización fetal.</p>" ] "en" => array:1 [ "resumen" => "<p class="elsevierStylePara">The frequency of pregnancy in women on dialysis is extremely low, but the percentage of successful pregnancies in this context has increased over the years, with some studies placing the survival rate above 70%. These pregnancies are not exempt from both maternal and foetal complications, and so their management requires the joint efforts of nephrologists, gynaecologists, nurses, and nutritionists. Currently, we have been unable to establish consistent systematic treatment from both nephrological and gynaecological specialists in these patients. The main changes that need to be made are: increased time on dialysis, maintaining low levels of pre-dialysis urea, avoiding: maternal hypertension and hypotension, anaemia, urinary tract infections, and fluctuations in electrolytes. Adequate foetal monitoring is also necessary.</p>" ] ] "multimedia" => array:3 [ 0 => array:8 [ "identificador" => "fig1" "etiqueta" => "Tab. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "11319_16025_28449_en_t1_11319_ing.jpg" "Alto" => 617 "Ancho" => 2186 "Tamanyo" => 399884 ] ] "descripcion" => array:1 [ "en" => "Parameters for pregnancy and new-borns in women on chronic haemodialysis" ] ] 1 => array:8 [ "identificador" => "fig2" "etiqueta" => "Tab. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "11319_16025_28451_en_t3_11319_ing3.jpg" "Alto" => 667 "Ancho" => 2168 "Tamanyo" => 426234 ] ] "descripcion" => array:1 [ "en" => "Parameters for dialysis and foetal survival" ] ] 2 => array:8 [ "identificador" => "mmc1" "etiqueta" => "Tab. 2" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "Ecomponente" => array:2 [ "fichero" => "11319_19157_28450_en_ref.1131912388_11319_19115_25239_es_11319_tabla_2_en.doc" "ficheroTamanyo" => 26112 ] "descripcion" => array:1 [ "en" => "Recommendations for optimising the treatment of pregnant women on haemodialysis" ] ] ] "bibliografia" => array:2 [ "titulo" => "Bibliography" "seccion" => array:1 [ 0 => array:1 [ "bibliografiaReferencia" => array:59 [ 0 => array:3 [ "identificador" => "bib1" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "1.\u{A0} \u{A0}\u{A0} Hou S. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 15 | 10 | 25 |
| 2024 October | 53 | 49 | 102 |
| 2024 September | 10 | 6 | 16 |
| 2024 August | 110 | 88 | 198 |
| 2024 July | 91 | 56 | 147 |
| 2024 June | 91 | 51 | 142 |
| 2024 May | 113 | 60 | 173 |
| 2024 April | 95 | 56 | 151 |
| 2024 March | 91 | 32 | 123 |
| 2024 February | 73 | 52 | 125 |
| 2024 January | 56 | 35 | 91 |
| 2023 December | 47 | 35 | 82 |
| 2023 November | 68 | 41 | 109 |
| 2023 October | 79 | 37 | 116 |
| 2023 September | 71 | 45 | 116 |
| 2023 August | 52 | 24 | 76 |
| 2023 July | 109 | 53 | 162 |
| 2023 June | 99 | 47 | 146 |
| 2023 May | 83 | 49 | 132 |
| 2023 April | 121 | 68 | 189 |
| 2023 March | 116 | 37 | 153 |
| 2023 February | 101 | 33 | 134 |
| 2023 January | 73 | 37 | 110 |
| 2022 December | 97 | 33 | 130 |
| 2022 November | 100 | 58 | 158 |
| 2022 October | 104 | 64 | 168 |
| 2022 September | 108 | 42 | 150 |
| 2022 August | 95 | 55 | 150 |
| 2022 July | 98 | 48 | 146 |
| 2022 June | 86 | 49 | 135 |
| 2022 May | 73 | 72 | 145 |
| 2022 April | 81 | 75 | 156 |
| 2022 March | 101 | 63 | 164 |
| 2022 February | 102 | 60 | 162 |
| 2022 January | 54 | 44 | 98 |
| 2021 December | 59 | 47 | 106 |
| 2021 November | 54 | 51 | 105 |
| 2021 October | 87 | 49 | 136 |
| 2021 September | 94 | 55 | 149 |
| 2021 August | 54 | 48 | 102 |
| 2021 July | 80 | 44 | 124 |
| 2021 June | 90 | 39 | 129 |
| 2021 May | 102 | 48 | 150 |
| 2021 April | 233 | 127 | 360 |
| 2021 March | 158 | 94 | 252 |
| 2021 February | 170 | 38 | 208 |
| 2021 January | 118 | 37 | 155 |
| 2020 December | 133 | 41 | 174 |
| 2020 November | 85 | 40 | 125 |
| 2020 October | 85 | 26 | 111 |
| 2020 September | 102 | 50 | 152 |
| 2020 August | 81 | 49 | 130 |
| 2020 July | 104 | 37 | 141 |
| 2020 June | 97 | 58 | 155 |
| 2020 May | 94 | 24 | 118 |
| 2020 April | 144 | 40 | 184 |
| 2020 March | 129 | 28 | 157 |
| 2020 February | 157 | 35 | 192 |
| 2020 January | 183 | 46 | 229 |
| 2019 December | 216 | 45 | 261 |
| 2019 November | 188 | 40 | 228 |
| 2019 October | 145 | 41 | 186 |
| 2019 September | 249 | 50 | 299 |
| 2019 August | 179 | 26 | 205 |
| 2019 July | 171 | 46 | 217 |
| 2019 June | 142 | 42 | 184 |
| 2019 May | 139 | 35 | 174 |
| 2019 April | 186 | 61 | 247 |
| 2019 March | 132 | 51 | 183 |
| 2019 February | 74 | 21 | 95 |
| 2019 January | 89 | 58 | 147 |
| 2018 December | 174 | 55 | 229 |
| 2018 November | 173 | 41 | 214 |
| 2018 October | 210 | 24 | 234 |
| 2018 September | 160 | 27 | 187 |
| 2018 August | 132 | 50 | 182 |
| 2018 July | 110 | 21 | 131 |
| 2018 June | 108 | 21 | 129 |
| 2018 May | 112 | 10 | 122 |
| 2018 April | 123 | 16 | 139 |
| 2018 March | 129 | 14 | 143 |
| 2018 February | 93 | 13 | 106 |
| 2018 January | 99 | 10 | 109 |
| 2017 December | 99 | 10 | 109 |
| 2017 November | 139 | 21 | 160 |
| 2017 October | 113 | 21 | 134 |
| 2017 September | 99 | 16 | 115 |
| 2017 August | 83 | 24 | 107 |
| 2017 July | 100 | 15 | 115 |
| 2017 June | 97 | 28 | 125 |
| 2017 May | 121 | 20 | 141 |
| 2017 April | 101 | 27 | 128 |
| 2017 March | 79 | 33 | 112 |
| 2017 February | 177 | 44 | 221 |
| 2017 January | 73 | 21 | 94 |
| 2016 December | 126 | 18 | 144 |
| 2016 November | 139 | 26 | 165 |
| 2016 October | 211 | 27 | 238 |
| 2016 September | 324 | 12 | 336 |
| 2016 August | 342 | 16 | 358 |
| 2016 July | 321 | 20 | 341 |
| 2016 June | 225 | 0 | 225 |
| 2016 May | 212 | 0 | 212 |
| 2016 April | 175 | 0 | 175 |
| 2016 March | 143 | 0 | 143 |
| 2016 February | 201 | 0 | 201 |
| 2016 January | 167 | 0 | 167 |
| 2015 December | 194 | 0 | 194 |
| 2015 November | 150 | 0 | 150 |
| 2015 October | 120 | 0 | 120 |
| 2015 September | 109 | 0 | 109 |
| 2015 August | 113 | 0 | 113 |
| 2015 July | 125 | 0 | 125 |
| 2015 June | 84 | 0 | 84 |
| 2015 May | 121 | 0 | 121 |
| 2015 April | 22 | 0 | 22 |
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