3 - Chronic kidney disease in pregnancy: patterns of care and general principles of management

Summary

Basic principles of antenatal care

Management of the pregnant woman with chronic kidney disease (CKD) ideally begins prior to pregnancy to allow time for appropriate counselling regarding the potential risks and likely outcomes not only of the pregnancy but for the woman postpartum. Attitudes have changed over the past 20—30 years and CKD is no longer seen as an automatic contraindication to pregnancy. Nevertheless, the data used to counsel women today are generally those derived from a few key studies published more than 10 years ago, summarised clearly in two key reviews.

Controversy remains as to whether the primary underlying renal disorder affects the pregnancy outcome or, more likely, the outcome is dependent upon the baseline level of renal function, with the possible exception of systemic lupus erythematosus (SLE). In either case, maternal hypertension is a significant adverse factor; live births now occur in 64—98% of pregnancies depending upon the degree of renal impairment and the presence or absence of hypertension.

On occasion, women with CKD have an accelerated course towards dialysis, either during pregnancy or postpartum. In women with advanced renal failure, this possibility should be discussed before conception in the context of possible pre-emptive transplantation, which is usually associated with a better chance of having a successful pregnancy.