“A pregnant woman with end-stage chronic kidney disease undergoing dialysis 3 times a week wants to terminate the pregnancy. Can medication be used? What are the risks?”
A question from the RSA Northern volunteer medical network at a hospital. The story of this woman will be told by Uncle Doctor in the next episode, but for now, let’s talk about kidney disease and pregnancy. In Thailand, about 7 million people have chronic kidney disease. People aged 18 and over with chronic kidney disease stages 1-5 account for 4.6%-17.5% of the population, but only a small number, just 1.9%, know they have the disease.
Stage 1 No symptoms yet
Stage 2 Slight decrease in kidney waste filtration
Stage 3-5 Moderate to severe decrease in kidney filtration and kidney failure
End-stage chronic kidney disease has kidney function reduced to less than 15%
About 3% of women of childbearing age have stage 1-2 chronic kidney disease, and 1 in 750 women have stage 3-5 kidney disease. Chronic kidney disease involves the destruction of kidney tissue, leading to a continuous decline in kidney function over months or years. Most cases, about 2 out of 3, are caused by diabetes and high blood pressure, leading to permanent kidney deterioration that cannot return to normal function. Symptoms of kidney failure include anemia, swelling of the face and legs, shortness of breath, pulmonary edema, inability to lie flat, and seizures. Treatment includes dialysis with a dialysis machine to cleanse the blood of waste and peritoneal dialysis. The better option is kidney transplantation through surgery. Chronic kidney disease significantly reduces the chance of pregnancy to only 0.3 – 2.2%.
This disease interferes with the hormones that regulate ovulation and menstruation, causing irregular or absent periods and reduced sexual desire. It is quite difficult to know if one is pregnant. If there are symptoms of nausea, fatigue, or exhaustion, a urine test should be done to confirm pregnancy. If urine output is low, a blood test should be done instead. Be cautious, as pregnancy is often detected late, around the 3rd-4th month. Pregnancy before starting dialysis has better outcomes. Women who become pregnant while on dialysis for end-stage chronic kidney disease may experience discomfort known as “preeclampsia,” occurring in up to 19.4% of cases after 5 months of pregnancy. There may be uncontrollable high blood pressure, seizures, and liver failure. The mother may become significantly anemic, with about 35% of those on dialysis requiring blood transfusions before or during delivery. For the baby, there is a very high risk of premature birth, increasing from the normal 5% to 73% or even 100%, leading to breathing difficulties and a high risk of death if born before 24 weeks. Fetal growth retardation occurs in 57% of cases, and fetal death increases to 1 in 3. Miscarriage is also very common.
Pregnant women on dialysis are 10 times less likely to deliver a live baby compared to the general pregnant population. During pregnancy, there is an increased risk of kidney function loss, depending on the severity of kidney disease before pregnancy. For women not yet on dialysis, pregnancy can worsen symptoms, necessitating earlier dialysis. For those already on dialysis, pregnancy requires more intensive dialysis, with longer and daily sessions, which can be very challenging. However, this approach has been found to improve outcomes for both mother and child compared to traditional dialysis methods. It is well known that individuals with end-stage kidney disease often have a shorter lifespan. There are records of young women dying during follow-up treatment while their children are still young. In this stage of the disease, the body is not yet fit for childbearing, and the outcomes for pregnant women with end-stage chronic kidney disease undergoing dialysis, as summarized from a study by Okundaye and colleagues from 930 dialysis centers, show that 42% of newborns survive, 6% die at birth, 7.5% die after birth, 32% miscarry, with 38% miscarrying between 3-6 months of pregnancy, and 10.8% choose to terminate the pregnancy. Pregnancy can be prevented.
**Contraceptive methods should not include combined hormonal contraceptives as they increase blood pressure, cause vascular blockage, and affect blood vessels. Progestin-only hormonal contraceptives are better and safer. Intrauterine devices are not recommended for continuous dialysis patients as they may cause anemia due to bleeding. The 3-year contraceptive implant is safe and highly effective, but using condoms is easier. The most suitable choice is sterilization, which is more effective.
With love and care,
Uncle Doctor
Story by Dr. Ruangkit Sirikanchanakul