Intensified hemodialysis for complicated pregnancy in a primigravida with advanced maternal age: a case report with literature review focusing on appropriate hemodialysis management during pregnancy

Renal Replacement Therapy

Ko Suginami¹  Jumpei Ogura²  Tatsuo Tsukamoto³  Tomomi Endo³  Motoko Yanagita⁴  Takeshi Matsubara⁴  Hiroyuki Arai⁴  Hideki Yokoi⁴  Ken Mizuta⁵  Keita P. Mori⁶  Yoshihiro Ikeda⁷ 

[1] Department of Gynecology and Obstetrics, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, 606-8507, Kyoto, Japan;Department of Gynecology and Obstetrics, Mitsubishi Kyoto Hospital, 1 Katsuragosho-cho, Nishikyo-ku, 615-8087, Kyoto, Japan;Department of Gynecology and Obstetrics, Saiseikai-Noe Hospital, 1-3-25 Furuichi, Joto-ku, 536-0001, Osaka, Japan;Department of Gynecology and Obstetrics, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, 606-8507, Kyoto, Japan;Department of Nephrology and Dialysis, Tazuke Kofukai Medical Research Institute, Kitano Hospital, 2-4-20 Ohgimachi, Kita-ku, 530-8480, Osaka, Japan;Department of Nephrology, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, 606-8507, Kyoto, Japan;Department of Nephrology, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, 606-8507, Kyoto, Japan;Institute for the Advanced Study of Human Biology (ASHBi), Kyoto University, Yoshida-Konoe-cho, Sakyo-ku, 606-8501, Kyoto, Japan;Department of Nephrology, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, 606-8507, Kyoto, Japan;TMK Project, Medical Innovation Center, Graduate School of Medicine, Kyoto University, 53 Shogoin Kawahara-cho, Sakyo-ku, 606-8507, Kyoto, Japan;Ikeda Clinic, 579 Kakimoto-cho, Gojyo-Horikawa-Nishiiru, Shimogyo-ku, 600-8357, Kyoto, Japan;

关键词: Hemodialysis;    Pregnancy;    Dry weight;    Atrial natriuretic peptide;    Hypertension;    Polyhydramnios, Fetal development;   

DOI  :  10.1186/s41100-020-00296-7

来源: Springer

【 摘 要 】

BackgroundPregnancy in dialysis patients is rare but challenging both for nephrologists and obstetricians. Although intensified hemodialysis is effective to achieve favorable clinical outcomes in this clinical setting, the evidence concerning reliable parameters for the optimal dialysis prescription is scarce. Herein, we report a case of a primigravida with advanced maternal age who underwent a normal spontaneous vaginal delivery at full term managed by intensified hemodialysis, and discuss reliable indicators of the appropriate dialysis prescription.Case presentationA 39-year-old primigravida with end-stage renal disease was referred to our department for hemodialysis management during pregnancy. She had a history of multiple gynecologic disorders, including cervical dysplasia, right tubal ectopic pregnancy and spontaneous abortion; consequently, she conceived through in vitro fertilization and embryo transfer. After pregnancy was confirmed, an intensified hemodialysis schedule with weekly duration of 36 hours was employed to prevent volume overload and the accumulation of hyperosmotic substances. Utilizing maternal blood pressure, plasma atrial natriuretic peptide levels and fetal development as indicators of volume status, we incremented her dry weight by 300–400 g per week in the first and second trimester and 100–200 g per week in the third trimester, respectively. Serum urea nitrogen levels were persistently maintained below 50 mg/dL. Throughout pregnancy, fetal growth and development were within normal limits. At 38 weeks and 3 days of gestation, she delivered a healthy child vaginally without complications. To date, the child’s development has been normal, both physically and mentally.ConclusionsPregnancy in dialysis patients with advanced age that leads to a normal childbirth is exceptionally rare. Our case is the hemodialysis patient with the most advanced age who achieves a normal spontaneous vaginal delivery at full term. Considering that cardiovascular system and endogenous metabolism dynamically alter during pregnancy, various clinical parameters should be closely monitored to modify dialysis settings accordingly. Of note, our case suggests that plasma atrial natriuretic peptide level is a useful parameter for the appropriate dry weight. Intensified hemodialysis is an effective and reliable measure that can achieve normal pregnancy in dialysis patients, even in a primigravida with advanced maternal age.

【 授权许可】

CC BY