Delivery Method in Patients After Liver or Kidney Transplantation.

Pregnancy following renal or liver transplant is safe for the mother, fetus, and allograft if standard practice guidelines are strictly followed. Cesarean delivery is often required for the safety of the mother and child. The aim of this paper was the evaluation of delivery method in patients after liver (G1) and kidney transplantation (G2) in comparison with the population of healthy pregnant women (G0). MATERIALS: Retrospective analysis included 51 (G1) and 59 (G2) women who delivered between 2000 and 2016. Control group (G0) consisted of 170 nontransplanted patients, who delivered between 2014 and 2016. The results were compared using nonparametric and parametric tests (Fisher exact test, t test). The SAS 9.2 was used for the analysis. RESULTS: The rate of cesarean delivery was high in all pregnancies following kidney (G1 = 80.4%) or liver transplantation (G2 = 67.8%) compared with control group (G0 = 44.1%; P < .05). The most common indication for cesarean delivery in G1 was gestational hypertension/preeclampsia (n = 18; 43.9%), threatening intrauterine asphyxia (n = 12; 29.3%), and failure to progress (n = 2; 4.9%). The most common indications for cesarean delivery in G2 were threatening intrauterine asphyxia (n = 14; 35%), failure to progress (n = 9; 22.5%), and gestational hypertension/preeclampsia (n = 2; 5%). CONCLUSION: Cesarean delivery in patients after kidney or liver transplantation is performed mainly for obstetric reasons. The reported incidence of cesarean delivery in pregnancy following transplant is high, reflecting the high degree of clinical caution exercised in these patients.

In Vitro Fertilization and Pregnancy Outcomes Among Patients After Kidney Transplantation: Case Series and Single-Center Experience.

INTRODUCTION: Kidney transplantation (KTx) is the treatment of choice in patients with end-stage renal failure. Among various medical issues in female graft recipients, the need for maternity can become an overriding one. Gonadal dysfunction usually resolves within 6 months after transplantation; however, the prevalence of infertility is similar to this in the general population. MATERIALS AND METHODS: This case series describes the experience in infertility treatment and following perinatal care among KTx women who underwent successful in vitro fertilization (IVF). We followed three patients who previously received KTx and underwent IVF between 2014 and 2015. The 34-year-old (patient A) and 39-year-old (patient B) women received single KTx, and the 31-year-old (patient C) woman had received three previous transplantations. Patients A and C were diagnosed with primary tubal factor infertility, while patient B suffered from secondary idiopathic infertility. The stimulation protocols had no influence on their general condition nor graft function. Viable singleton pregnancies were confirmed in all cases. All newborns were born preterm, via cesarean section, as a consequence of severe preeclampsia. Patients A and C gave birth at 34th week of gestation (WG) (A: 1810 g and C: 2295 g), while patient B gave birth at 36th WG (2655 g). Other pregnancy complications were intrauterine growth restriction (patient A) and gestational diabetes mellitus (patient B). Although mild graft dysfunction was observed prior to delivery, all clinical measures and hypertension resolved during the puerperium. CONCLUSIONS: In these cases, pregnancy after KTx did not implicate persistent graft dysfunction. Regardless of the method of conception, pregnancy following KTx is associated with an increased incidence of complications, therefore it requires a multidisciplinary approach. IVF itself seems to be a safe procedure in KTx recipients if the pregnancy is advisable.

Congenital Infections in Neonates of Women With Liver or Kidney Transplants.

BACKGROUND: Immunosuppressive therapy is associated with an increased risk of pregnancy complications and may have adverse effects for the newborn. The aim of this study was to determine the frequency and the type of early congenital infections and to assess typical markers of infections in neonates of liver and kidney recipients. METHODS: A retrospective analysis of 71 neonates born to either liver (39 cases) or kidney transplanted women (32 cases) was conducted. The rate and the type of newborns' infections as well as laboratory and bacteriologic markers of infections were analyzed. RESULTS: There was no significant difference in the frequency of congenital infections between the LT and KT groups (8 vs 7 cases; P = .879).). The rate of infections was not significantly higher in both groups compared with the general population. Infections were detected in 23.9%, 13.6%, and 26.6% of neonates born to mothers using tacrolimus, cyclosporine, and azathioprine respectively. No significant differences in white blood count or levels of neutrocytes and lymphocytes were observed between the groups. No abnormalities in white blood smear, but 1 case of leukopenia in the kidney transplant group, were detected. CONCLUSIONS: The rate of congenital infections in neonates of allograft recipients is not significantly higher than in the general population. Immunosuppressive regimens with azathioprine seem to carry the greatest risk, it is a little lower in the tacrolimus group, and cyclosporine-based regimens have the lowest risk of congenital infections. Differences were not statistically significant. Prenatal exposure to immunosuppressive agents seems not to be associated with any hematologic disturbances in white blood count and white blood smear.

Hypertension in Pregnant Renal and Liver Transplant Recipients.

BACKGROUND: Pregnancies in transplant recipients involve risks for both grafts and the fetus, and need to be carefully managed. Hypertension is the most frequent complications in pregnant transplant recipients, especially in renal transplant recipients. Strict control of blood pressure is essential for a favorable obstetric outcome and long-term graft survival. The aim of the study was to evaluate the influence of hypertension on obstetric outcome and graft function in pregnant renal transplant recipients (RTR) or liver transplant recipients (LTR) in comparison with healthy pregnant women. PATIENTS AND METHODS: This retrospective analysis included 46 RTR and 55 LTR who delivered between the years 2000 and 2014. The control group consisted of 187 nontransplant patients aged 20-45 years who delivered between 2010 and 2013. The analyzed group was divided into 2 subgroups: patients with hypertension and patients without hypertension. Descriptive data analysis, Fisher Exact test, unpaired Student t test, and analysis of the variance were performed. RESULTS: Hypertension prevalence among the RTR, LTR, and control group was 73.5%, 34.5%, and 4.3% respectively. In the RTR group, the mean gestational age at delivery inp patients with hypertension vs without hypertension was 36 vs 34.5 weeks (P < .05); IUGR was diagnosed in 20% vs 8.5% pregnant women (P > .05). In the TRL group, the mean gestational age at delivery in group with hypertension vs without hypertension was 37 vs 3.9 weeks (P < .05); IUGR was diagnosed in 10.5% vs 5% of pregnant women (P > .05). Hypertension in RTR patients had a negative influence on graft function (P > .05). CONCLUSION: Hypertension is common in organ recipients, and is associated with adverse pregnancy outcomes and loss of graft function.

Pregnancy and delivery in women with esophageal varices due to hepatic vein thrombosis.

AIM: Retrospective analysis of the course of pregnancy, labor and mode of anesthesia in women with portal hypertension and esophageal varices induced by portal vein thrombosis. MATERIAL: From 2000 to 2012 seven pregnant were admitted. None had liver transplantation (Ltx), the varicose have been in the 1st stage. Each of them has been consulted by the obstetrician, transplant surgeon and anesthetist. The patient condition during pregnancy, labor and postpartum period was analyzed. RESULTS: Pregnancy in five cases proceeded physiologically. In one threatening miscarriage was diagnosed and treated with gestagens, two patients had tocolytic. One required variceal banding twice. In three thrombocytopenia worsened, with platelet count <70 g/L (up to 59 g/L). They received platelet transfusion before delivery. In one case, significant hipoproteinemia (4.7 g/L) occurred. In a case, GDM G1 and oligohydramnios were found. All women delivered at term (37-40 Hbd). In all general anesthesia with the use of remifentanil was done. There were no fluctuations in MAP and HR. Incision to delivery time was 2.5 min. Time from opioid administration to birth was <4 min. All children were born in good condition, weight 10-90 percentile. Regional anesthesia is contraindicated in patients with thrombocytopenia. In patients with esophageal varices sudden increase in heart rate and blood pressure can cause hemorrhage. CONCLUSION: Patients with portal hypertension can deliver at term. It is a high-risk pregnancy. In this group it is desirable to shorten the second stage of labor or complete it by c-section under general anesthesia with remifentanyl which allows getting desired analgesia without complications in the newborn. Surveillance of pregnant with portal hypertension must include monitoring of liver function and coagulation disorders.

Evaluation of selected markers of the immune system in children of renal transplant recipients.

OBJECTIVE: The aim of this study was to evaluate whether chronic use of immunosuppressive drugs during pregnancy in women after renal transplantation affects the concentration of immunoglobulin G (IgG) and IgM in the serum of their children. MATERIAL: Seventy-eight children aged 1 day to 15 years were enrolled. The study group consisted of 39 children born to renal transplant recipient mothers. The control group comprised 39 children whose mothers had not received immunosuppressive medications during pregnancy and were born at similar gestational age. METHODS: Serum concentrations of IgG and IgM were evaluated with the use of agglutination immunoassays on Siemens or Cobas device. Age-adjusted reference values for immunoglobulins formulated by Wolska-Kusnierz et al were used. Statistical analysis was performed with the use of Statistica 10.0 software with P value <.05 considered significant. RESULTS: Normal IgG concentrations were found in 82.05% (32) of children from the study group and 79.49% (31) of the control group. IgG concentrations below normal range were observed in 12.82% (5) of children from the study group and in 15.38% (6) of the control group. Normal concentrations of IgM were found in 53.85% (21) of children from the study group and in 61.54% (24) of the control group. Decreased levels of IgM were observed in 38.46% (15) of children from the study group and 35.9% (14) of the control group. There were no significant differences regarding the analyzed values between the groups. CONCLUSION: The exposure to chronic intrauterine immunosuppression had no significant effect on the concentration of IgG or IgM in children born to kidney transplant recipients.

Analysis of the selected biochemical parameters of liver and kidney function in children of mothers after liver transplantation.

INTRODUCTION: Children of mothers after liver transplantation (LT) are exposed during fetal life to the immunosuppressive agents. These drugs may have hepatotoxic and nephrotoxic effects. OBJECTIVES: The aim of the work was to assess liver and kidney parameters of children born from mothers who had LT. MATERIALS AND METHODS: The research included 51 children of mothers after LT and 51 children from a control group who were born in the First Department of Obstetrics and Gynecology in Warsaw between 2001 and 2013. The control group consisted of children born in the similar gestational age. Analysis concerned neonates, infants, and children older than 12 months. Two liver parameters (alanine transaminase [ALT] and aspartate transaminase [AST]) as well as two kidney parameters (urea and creatinine) were assessed. For statistical analysis we used Fisher's exact test and the Mann-Whitney test. RESULTS: All children from the LT group had correct ALT levels. In the control group, 5 of 51 cases (9.8 %) had levels that were greater than the norm, and those cases concerned only children younger than 12 months. The average concentration of ALT in the LT group was 15.14 U/L and the average for the control group was 22.6 U/L (P = .012699, Mann-Whitney test). Three of 51 children in the LT group (5.9%) and 8 of 51 (15.7%) in the control group had AST levels that were increased (P = .2003; Fisher's exact test). Incorrect AST levels were reported in all age groups. Incorrect values of kidney parameters concerned only neonates. Increased creatinine levels were reported in 3 of 51 cases (5.9%) in the LT group and in 1 of 51 cases (1.96%) in the control group (P = .6175; Fisher's exact test). The average concentration of creatinine in children of mothers after LT was 0.51 mg/dL, and the average of the control group was 0.44 mg/dL (P = .223698; Mann-Whitney test). Only 1 of 51 children in the LT group (1.96%) had an increased urea level. All children from both the LT and the control groups had normal ultrasound images of urinary tract and liver. CONCLUSION: Exposure to immunosuppressive drugs during fetal life does not result in the occurrence of serious disturbances of liver function and kidneys function in children of mothers after LT.

Intrauterine growth restriction in pregnant renal and liver transplant recipients: risk factors assessment.

BACKGROUND: Nowadays pregnancy after organ transplantation is possible due to advances in surgical and immunosuppressive therapies. One of the possible complications in pregnancy after organ transplantation is intrauterine growth restriction (IUGR). This may lead to various adverse perinatal outcomes. Prevalence of IUGR in the general population is estimated at 3%-10% with smoking being the most frequent maternal risk factor. The aim of this study was to determine the risk factors of IUGR in pregnant renal transplant recipients (RTR) or liver transplant recipients (LTR) in comparison with healthy pregnant women. METHODS: Retrospective analysis included 48 RTR and 52 LTR. IUGR was defined as estimated fetal weight less than the 10th percentile for gestational age. IUGR was diagnosed in 15 (31.3%) pregnant RTR and in 10 (19.2%) LTR. The control group consisted of 60 healthy pregnant women diagnosed with IUGR. Fisher exact test and Student t test were used to assess the differences in fractions and means, respectively, between distinguished groups of patients. Test for fractions based on asymptotic normal distribution was used to compare the proportion of patients with IUGR with the proportion of 10% in the general population. The logistic regression model was used to assess the statistical significance of correlations between the assumed risk factors and the prevalence of IUGR in multivariate settings. RESULTS: Hypertension, anemia, and proteinuria were the most frequent complications in the study group. They were more prominent in RTR than in LTR. Hypertension was diagnosed in all RTR, whereas severe anemia requiring erythropoietin treatment or blood transfusion was found in 4 RTR and in 1 LTR. CONCLUSION: IUGR is more common in organ recipients. Therefore, vigilant obstetric care is highly recommended in pregnant patients after renal or liver transplantation. Hypertension, severe anemia, and proteinuria proved not to be statistically significantly correlated with the prevalence of IUGR among patients after transplantation.

Neurological development of children born to liver transplant recipients.

INTRODUCTION: Immunosuppressive treatment used in pregnant liver recipients may have a negative impact on fetal development and successively a child. AIM: The aim of the study was to make a neurological assessment of infants and children born to liver transplant recipients (LTRs) born between December 4, 2001, and February 11, 2013, in the 1(st) Department of Obstetrics and Gynecology, Medical University of Warsaw. METHODS AND MATERIALS: The study involved 88 children, of whom 44 children were born to LTR mothers, and 44 children born to women who were not organ recipients and delivered at a similar gestational age. The gestational age of neonates ranged from 33 to 41 weeks, and the birth weight ranged from 1420 g to 4100 g. The neurological examination was performed in children from 7 weeks to 10 years of age. The neurological development was assessed by a specialist in pediatric neurology. The results of the examination were divided according to the following criteria: 1) normal development, 2) slight disorders, 3) moderate disorders, and 4) severe disorders. The Fisher's exact test was used for statistical analysis. RESULTS: Normal development was found in 35 of 44 (79.54%) children in the LTR group and 39 of 44 (88.63%) children in the control group (P = .3827). Slight disorders were observed in 6 of 44 (13.63%) children in LTR group and 5 of 44 (11.36%) children in the control group. Moderate disorders were found only in 3 of 44 (6.81%) children in the LTR group. No severe disorders were observed in both groups. CONCLUSIONS: Neurological development of children born to the liver recipients who were exposed to chronic immunosuppressive treatment in their fetal lives is the same as that of children whose mothers have not undergone organ transplantation.

Anemia treatment with erythropoietin in pregnant renal recipients.

Pregnancies in renal transplant patients are considered to be high risk. Anemia is one of the major complications of pregnancy occurring among 65% to 85% of cases in this setting, especially since these patients carry additional risk factors. Herein we have presented five renal transplant recipients who were women who were treated with human recombinant erythropoietin due to severe anemia that developed during pregnancy. Hemoglobin levels below 9 g/dL after 3 weeks of oral iron administration were assumed to be qualifying criteria for erythropoietin treatment. No complication was observed to be associated with the treatment. Two of the five patients required blood transfusions despite erythropoietin administration. Two cases delivered small for gestational fetus age. Erythropoietin therapy in pregnant kidney transplant recipients should be considered to be a safe method to reduce the need for blood transfusions.

Multiple types of high-risk human papilloma virus in the lower genital tract of a female kidney recipient: a case report.

We present a case of a female kidney recipient who was infected with 3 types of high-risk human papilloma viruses. An infection in the lower genital tract led to the development of both neoplastic cervical lesions and vulvar cancer.

Pregnancy outcomes among female recipients after liver transplantation: further experience.

INTRODUCTION: Liver transplantations give female recipients an ability to carry pregnancies successfully. However, solid organ transplantations exacerbate the pregnancy including maternal and neonatal outcomes. The aim of our study was to evaluate and identify the obstetric outcomes in women with a prior liver transplantation. METHODS: We analyzed all pregnant woman who had undergone a prior liver transplantation and afterward delivered from 2001 to 2011. Complete data were assessed in 39 deliveries and 40 live births. Three women were pregnant twice after liver transplantation. RESULTS: The mean gestational age at birth measured 37.2±2.2 weeks. The most common obstetric complications were premature labor (12/39,30.8%), hypertension (10/39, 25.6%), and symptomatic urinary tract infections (7/39, 18%). Other complications were pregestational diabetes (n=1), cholestasis (n=3), and of severe anemia treated with blood transfusions (n=2). The mean time from organ transplantation to delivery was 67.6±47.2 months. Acute graft rejections occurred among pregnant women 7.7% (3/39) of studied. Only 8 (20.5%) deliveries were finished vaginally. Infants small for gestational age were diagnosed in 20% (8/40). One case displayed a congenital urinary tract malformation. None of the neonates died neonatally. CONCLUSIONS: Pregnancies are possible after liver transplantation and likely end with successful maternal and newborn outcomes. Some cases experience an increased risk of obstetric complications. Therefore, posttransplant pregnancies must be regularly monitored with a multidisciplinary approach.

Intrauterine hypotrophy and premature births in neonates delivered by female renal and liver transplant recipients.

BACKGROUND: Neonates born to mothers, who underwent organ transplantation require close medical monitoring. It is unknown how chronically diseased mother's organs or immunosuppressive drugs affect fetal growth and development; some immunosuppressants are teratogenic and contraindicated during pregnancy. The aim of this study was to determine the prevalence of prematurity and intrauterine growth restriction in neonates born to women who have undergone renal or liver transplantation. METHODS: Our retrospective analysis identified 53 (25 renal and 28 liver) cases of neonates delivered by female graft recipients between January 2005 and December 2009. Hypotrophy was defined as a birth weight<10th percentile for gestational age. We excluded newborns diagnosed with severe hypotrophy (<5th percentile). RESULTS: Neonates born prematurely were predominate in the renal (16/25, 64%), but less than half of the liver cohort (13/28, 46%). Hypotrophy less than the 10th percentile was noted significantly more often among renal than liver recipients; 36% versus 14% (P<.05). Severe hypotrophy was also observed significantly more often among renal than liver transplant neonates: 28% versus 3.6% (P<.001). CONCLUSIONS: Compared with liver insufficiency, chronic kidney diseases have stronger effects on the fetus, leading to adverse neonatal complications. A greater prevalence of preterm births, as well as hypotrophic newborns, especially less than the 5th percentile, was observed among neonates delivered by mothers after kidney transplantation.

[The postnatal condition evaluation of preterm infants]. / Ocena stanu noworodków urodzonych przedwczesnie.

OBJECTIVE: The aim of the study was to compare general postnatal condition of preterm infants delivered by caesarean section or born vaginally. MATERIAL AND METHODS: The study group consisted of 605 premature newborns delivered in Obstetrics and Gynaecology Clinic of Medical University of Warsaw in 1995-2000. The newborns were divided into two groups. There were 280 prematures delivered by caesarean section in the first group and 325 ones were born vaginally in the second group. RESULTS: The first day mortality rate in infants born vaginally was 6.8% comparing with 2.8% in ones delivered by caesarean section. CONCLUSIONS: In the study group the percentage of neonatal severe condition was similar in both groups but mortality rate in the first day of life was slightly higher in infants born vaginally.

[Analysis of the postnatal condition and mortality of neonates with extremely low birth weight]. / Analiza umieralnosci poporodowej, stanu pourodzeniowego oraz przyczyny zgonów noworodków z ekstremalnie niska urodzeniowa masa ciala.

OBJECTIVE: The aim of this study was to analyze the postnatal condition and mortality of neonates with extremely low birth weight. MATERIALS AND METHODS: The study group consisted of 35 neonates delivered in the 1st Dept of Ob/Gyn. Medical University of Warsaw in the period of 1996-2000. The group was divided into two classes depending on the birth weight. There were newborns weighted 500-750 g in the first class and 751-1000 g in the second one. Newborns condition in the 1st minute of life was assessed with Apgar score. The rate of mortality up to the 7th day of life as well as the causes of deaths was analyzed. CONCLUSIONS: Postnatal mortality rate of premature newborns extremely low birth weight is still very high, especially in case of newborns below 750 g. Respiratory distress syndrome and intracranial hemorrhage are the most common causes of demise of those newborns.

[Preterm deliveries of extremely low birth babies--analysis of the course of pregnancy, labour and neonatal outcome]. / Porody przedwczesne noworodków ze skrajnie niska masa urodzeniowa ciala--analiza przebiegu ciazy, porodu oraz stanu pourodzeniowego noworodka.

OBJECTIVE: Preterm delivery of baby with extremely low birth weight (ELBW) is an important problem in contemporary perinatology and a major reason of perinatal mortality. A great development of neonatal intensive care that has occurred over the last few years has resulted in the decrease of perinatal mortality rate. The aim of the study is to analyse the course of pregnancy, labour and neonatal outcome in the group of patients who delivered ELBW children. MATERIALS AND METHODS: In 1st Obstetric and Gynaecology Department Clinic of Medical University of Warsaw, 6982 deliveries were conducted from 1996 to 2000. Among them there were 589 preterm ones. As a result 44 women delivered ELBW children. These 44 deliveries were divided into three groups according to the reasons: Idiopathic preterm contractility-24 patients PROM with intrauterine infection or threatening infection-14 Induction of delivery because of lethal foetal defects and direct foetal distress-6. RESULTS: The most common reasons for deliveries of ELBW children were hypertension and ascending infections. CONCLUSIONS: A great number of mothers who delivered ELBW children had low socioeconomic status. In most cases pregnancy was unplanned and body mass index of the mothers was below 19. Almost all these newborns were severely depressed and delivery was often complicated. It is important to conduct labour in a careful way to avoid tissue injuries.

[The effectiveness of prenatal steroid and ambroxol therapy for the prevention of respiratory distress syndrome in newborns of diabetic mothers]. / Profilaktyka zaburzen oddychania noworodków u ciezarnych z przedciazowa cukrzyca insulinozalezna.

The aim of the study was to determine the effectiveness of antenatal steroids and ambroxol in reduction of respiratory distress syndrome (RDS) in newborns of diabetic mothers. A retrospective chart review was done on 101 diabetic gravidas who were hospitalised at 1st Department of Obstetrics and Gynaecology Medical University in Warsaw between January 1989 and December 1999. We studied the neonatal outcomes for women with diabetes mellitus who delivered before 37 gestational weeks depend on exposition to antenatal steroids or ambroxol. Both groups were compared with unexposed neonates for respiratory distress syndrome. Frequency of occurrence and severity of RDS were similar in all study subgroups. We did not found reduction of respiratory distress syndrome in newborns of diabetic mothers exposed to antenatal steroids or ambroxol.