Case Study

Management of a pregnant woman

dependent on haemodialysis
Anna-Marie Walsh, BSc, RN,

Summary
This is a case study of a woman who became pregnant whilst receiving haemodialysis in a London teaching hospital. She
courageously disregarded the doctors’ advise to abort the fetus. The doctors advised her to wait until she had a kidney
transplant to become pregnant again, rather than increase maternal and fetal risk on dialysis. She was due to have a live-
related transplant from her father in the spring.
The case study describes a practical account in detailed measure to equip nurses with the knowledge to provide spe-
cialised care to high-risk dialysis expecting mothers. The main problems in this case study were trying to manage the
mother’s dialysis regime, control her anaemia, ensure good nutritional levels and gain accurate daily weights.

Incidence The main complication in pregnancy with end-stage renal

Conception is unusual in women treated with dialysis, occur-
ring approximately one in 200 women of childbearing age each
year (1). However, most of these pregnancies were said to end
in abortions, either spontaneous or induced. Overall, there is
better knowledge and expertise now in managing pregnancy
and dialysis ever since dialysis in pregnancy was first experi-
enced in 1961 by a pregnant woman, who overdosed on Di-
lantin (2).
Subject discussion
If a woman wants to plan parenthood during the dialysis stage
of her renal replacement therapy, or is pregnant and decides to
keep her child, the medical attitude insisting on abortions (esti-
mated at 30% of pregnancies in dialysis) can sometimes be
regarded as abusive (3).
Hou (1) believes that we have reached the point at which
physicians should regard childbearing as one of the goals of
treatment for renal disease, rather than as an accident to be
dealt with when it occurs. She believes that “. . . childbearing is
important to women with renal disease . . . for a woman with
renal insufficiency who conceives, the pregnancy may represent
the last opportunity for childbearing”.
Complications
There were two main medical concerns. Firstly, the financial
costs. This woman would need to dialyse at the cost of two peo-
ple. And secondly, what would be the outcome for mother and
child? In this case, the medics felt the cost would out weight the
benefit.
Anna-Marie Walsh at the time of submission of
this case study was working as a Renal Research
Nurse at the Churchill Hospital, Oxford. She has
spent the last 5 years working in nephrology.
Her future plan is to lecture in a nursing college.
disease is premature labour, resulting in a low birth weight, or
small for gestation age babies. This is usually caused by
hypotension during haemodialysis, due to a drop in proges-
terone levels following dialysis. It may also be caused by poly-
hydramnios. This is where a greater than normal amount of
amniotic fluid surrounds the fetus (4).
One of the major anticipated complications of a premature
labour is placental abruption.
This is where the placenta is prematurely detached from the
wall of the uterus. This can be caused by uncontrolled blood
pressure.
Anaemia too requires a constant need for vigilant monitor-
ing. Anaemia, like blood pressure control is a major problem in
renal patients, and is exacerbated by pregnancy (4).
Findings in practice
Patient (Sue) profile
A 31-year-old married ex-nursery nurse on haemodialysis
was diagnosed 8 weeks pregnant by ultrasound scan. In
November 1999, her haemoglobin dropped unexplainably.
She underwent rigorous tests, and was discovered to be 8 weeks
pregnant by ultrasound scan. The expected date of delivery
was 20.06.00.
Making the diagnosis of pregnancy requires a fair amount of
suspicion. Irregular menses and abdominal symptoms are com-
mon in dialysis patients. In women who are not anuric, urine
pregnancy tests are not interpretable because proteinuria may
cause false positive tests. It has been estimated that among
pre-menopausal women, 25% experience regular menses and
another 25% have irregular menses, and the remaining half
are amenorrheic (5).
Sue was delighted with her pregnancy. She was a Catholic
and did not believe in abortion. Unfortunately, Sue’s husband

EDTNA|ERCA JOURNAL 2002 XXVIII 2 91

was not entirely supportive of her decision, and believed she
should heed the advice of the doctors.
I asked Sue if she was aware that pregnancy could occur
on dialysis. She replied that the information she received was
that pregnancy was impossible whilst on dialysis. However,
it was documented that she was prescribed (microner) ‘The
Pill’, for menorrhagia – heavy monthly discharge. She was
clearly treated for anaemia, rather than the prevention of preg-
nancy.
History of disease
At 14 years old, Sue showed signs of a deteriorating renal func-
tion and was diagnosed with reflux nephropathy. When she was
19 years old, she commenced peritoneal dialysis, and later that
year had a cadaver transplant. Two years later, the transplant
failed, possibly due to contracting the measles virus. She then
started haemodialysis.
Clinical management
In the first three months of Sue’s pregnancy the dialysis regime
was normal, occurring 3 times a week. However, routine sud-
denly began to change in the second trimester.
In the second trimester, the dialysis regime gradually
increased to six days a week and the time span increased to five
hours per day. This was to compensate for the fetal growth.
There was a greater quality of toxic substance floating in the
system, therefore intensive dialysis was needed for the urea to
be kept on target as prescribed by the physicians (less than
70 mg/dl in the second trimester, and less than 150 mg/dl in
the third).
This target is quite a tough regime to achieve. Most case
studies report haemodialysis anywhere from 4 hours thrice
weekly to 4 hours 5 times per week. Aggressive dialysis appears
to increase the likelihood of a successful outcome. Studies show
that patient’s dialysed more than 20 hours a week have better
pregnancy outcomes. (1).
Aggressive dialysis consisted of spending longer rigorous
time on the machine, and having consistent gentle flows, rather
than spending a shorter time on the machine and having high
flux dialysis with a faster blood diffusion rate. We did experi-
ment and change to a high flux dialyser, and quickly realised
Sue was filtering better than a normal person to the effect of
recording less than normal urea levels. The doctors were keen
to return to a gentler dialysis session, so as to avoid any undue
cardiovascular adverse reaction.
Sue managed to tolerate 30 hours a week on dialysis and
kept urea to a reasonable level. Because of the long hours spent
on dialysis, Sue found it difficult to maintain a normal potassi-
um level. Despite eating bananas and chocolate to compensate
the low levels in her body, it was necessary to dialyse her against
a high bath of potassium daily, to prevent bradycardia.
One of the main concerns of the nurse in charge of Sue’s
92 EDTNA|ERCA JOURNAL 2002 XXVIII 2
care was maintaining Sue’s access point. A fistula was the only
access point in her left arm. In an attempt to preserve Sue’s
access point, the nurse used a single needle. There was no sub-
stance based on the nurses’ theory. After 2-3 months we resort-
ed back to double-needle dialysis. Sue tolerated double needle
dialysis daily for the remaining duration of her pregnancy. No
evidence of a clotted fistula, or signs of a breakdown in skin
turgidity, emerged once the needles were rotated to different
sites on the arterial and venous points.
Anaemia management
Since the revolution of the drug Recombinant Human Erythro-
poietin (rHuEpo), the quality of patients’ lives has substantially
improved. Erythropoietin has been linked with improved
libido, fertility and subjective improvements in the sense of
well-being and exercise tolerance (6).
The main problem with managing Sue on dialysis was to
control her anaemia. She required 60,000 units of erythropoi-
etin per week. Despite an enormous dose of EPO, Sue also
required blood transfusions and iron to maintain her Hb greater
than 9 grams. The total amount of blood transfusions accumu-
lated to 17 units. This was an enormous amount of antibodies
introduced into her system, which would invariably increase
her rejection rate when she had a kidney transplant. Pregnancy
alone increases antibodies.
Dietary management
It is estimated that the minimal daily dietary protein intake
(DPI) in healthy individuals is approximately 0.6 g/kg. Adding
the DPI for dialysis patients and the additional daily protein
requirements for pregnancy, a pregnant dialysis patient should
be ingesting 1.8 g/kg day of protein (7). This would mean
that she should be ingesting just over 400 grams of protein
each day. Sue was advised to increase her protein and calcium
intake.
Sue found it difficult to maintain a good nutritional level
due to tiredness and financial circumstances. She required hos-
pital transport. Her husband did not visually appear to offer
enormous support, as he never accompanied her for dialysis
sessions, or for clinic appointments. Because of her personal
circumstances, the nurses arranged for a hot meal to be deliv-
ered every mid-day afternoon.
Weight management
The fourth main problem apart from managing Sue’s dialysis
regime, anaemia and nutrition, was controlling her weight. This
needed careful daily assessments. In the first trimester, her tar-
get weight remained static.
The major influx of weight change occurred in the second
trimester. Here the target weight increased by 7 kg. The target
weight did not exceed the actual weight at any time throughout
Sue’s pregnancy – it was always a catching up job.
There are no rules to determine target weight, just recom-
mendations from previous studies. For instance, Nakabayashi
(8) suggests:
300 g/wk in 2nd trimester = 3.6 kg,
300g-500g/wk in 3rd trimester.
Here you can see there is no magic formula. The formula
suggests a 3.6 kg gain in the second trimester, where in reality
a 7 kg gain was made.
In another more realistic recommendation, Jungers (9) sug-
gests to increase the dry weight by 0.5 kg per week in the 3rd
and 4th month, and one kg per week in the 5th and 6th month.
Obviously every fetus is unique and grows rapidly at differ-
ent stages of the pregnancy. The patient was compliant with her
fluid restriction. We tried not to take off more than 1.5 kg/day.
However, this was not always possible, as some nurses removed
up to 2 even 2.5 litres a day to compensate for blood transfu-
sions etc as far advanced as 26 weeks into Sue’s pregnancy.
The dangers of removing too much fluid without adequate
planning could result in a hypotensive attack, causing fetal dis-
tress and a spontaneous abortion.
Alternatively the nurses could decide to increase her target
weight too much too quickly, and there was a real risk that the
patient would become hypertensive and fluid overloaded
putting undue stress on the heart.
Sue did not have any one identified primary nurse. We rely
on agency nurses, which may have hampered consistent knowl-
edge based care. The lack of an appreciation in knowledge of
daily coherent fluid assessment and vigilant fluid monitoring,
availing of the tools and using them effectively such as on-line
blood monitoring and the use of a dynamap to check blood
pressures periodically may have arguably to some extent com-
promised Sue’s care.
Fetal outcome
Unexpectantly at 29 weeks gestation, on the 3rd April 2000,
Sue was at home on weekend leave from a hospital admission,
when early signs of fetal distress emerged due to cord prolapse
or placental abruption. This is a known complication with
advanced pregnancy in haemodialysis patients. After a speedy
admission to a nearby Casualty department, an emergency Cae-
sarean was performed. It was a traumatic delivery, and a baby
boy was born severely bruised with poor respiratory function.
He weighted 1.8 kg. The baby had to be intubated at 3 minutes
old, and was transferred to the neonate intensive care unit.
Mother made a good recovery with no further complications
and the dialysis regime returned to normal.
Sue had not received any drugs that would enhance fetal
lung maturity. Although the treating obstetricians recognized
lung immaturity as a major complication of fetal survival, no
such treatment was instigated. Cohen (10) describes two case
studies where the patients received 6 weekly courses of
betamethasone (disodiumphosphate and acetate forms). In the
first case, the steroids were given between the 27th and 33rd
weeks of gestation. In the second case, the steroid drug treat-
ment was given between the 31st and 34th weeks of pregnan-
cy. Cowley et al (11) recommend that glucocorticoid adminis-
tration be considered at least 48 hours prior to delivery for
patients at risk of delivering prematurely.
There were no abnormalities observed in the initial assess-
ment of Sue’s infant. Children born to women with renal failure
are initially small for gestation age, but manage to catch up with
peers in physical and mental development. Congruently it has
been estimated that the incidence of major neurological handi-
caps in premature small for-gestational-age infants (those who
experienced intrauterine growth restriction) may be as high as
35% (12).
Congenital abnormalities were reported to be more frequent
in uraemia women than in the general population (10). In the
EDTNA series (13) two of 35 babies born to mothers on hae-
modialysis manifested congenital malformations.
Sue’s baby had a high urea and creatinine in the first 24
hours of delivery. This was anticipated, as shown from other
case studies; after a few diuresis the baby’s kidney function
began to kick in. The sodium, potassium and calcium elec-
trolytes were all within normal limits when the kidneys started
to function.
The main problem the infant experienced was an inability to
maintain his own oxygen supply. He was dependent on oxygen
for five months throughout his admission in the Special Care
Baby Unit. He developed pneumonia, and nearly died when
attempts were made to extubate too early. But this little tiger
surprised all staff in his determination to survive.
At 11 weeks old, 4 weeks post discharge, the infant weight-
ed 4.54 kg, putting an impressive 2.8 kg on since birth. He fed
well on formula milk, and began to tolerate 2 meals of early
solids. His current medication contained a combination of vita-
mins. At the infant’s first follow-up visit, he was able to put his
hand to his mouth and to the midline. He could turn his head
to sounds, and smiled a lot! There were no signs of respiratory
disease; his heart sounds were normal with no added sound or
murmurs. He had normal trunk tone and increased tone in
both legs with brisk reflexes and a few beats of muscle spas-
modically.
Summary
Six months following the event, Sue received the long awaited
live-related transplant from her father. Both mother and baby
have been reported to be doing fine.
Managing pregnancy whilst dependent on dialysis is a safe
procedure, once the patient is adequately informed, and sup-
ported by the nephrology, gynaecology and perinatology team,
and is carefully monitored by confident nursing staff. There are
certainly better fetal survival rates now than those initially
reported in the 1970’s/80’s. The pregnancy outcome is similar
whether the woman is on haemodialysis or CAPD. However
there is a greater frequency of conception in haemodialysis
EDTNA|ERCA JOURNAL 2002 XXVIII 2 93
patients than peritoneal dialysis. It is important that all child-
bearing women on dialysis are educated on the use of contra-
ceptives and childbearing women are not hoaxed into the false
pretence that dialysis or renal failure is an adequate form of
protection.
There is an uncertainty in the relationship between the use
of erythropoietin and conception, although links have been
suggested to increased fertility with the use of EPO. Hyperpro-
lactinemia is improved by use of erythropoietin therapy. Among
women with end-stage renal disease, the presence of hyperpro-
lactinemia has been associated with a lower rate of sexual inter-
course and percentage of orgasm compared with those with a
normal prolactin level. Prolactin normalization and hormonal
replacement therapy should now also be part of the therapeutic
care.
Address for correspondence
email: annamarie60@hotmail.com

References
1. Hou S, Firanek C. Management of the Pregnant Dialysis Patient. Advances in Renal Replacement Therapy 1998; 5(1): 24-30.
2. Theil G et al. Acute Dilantin Poisoning. Neurology 1961; 11: 138.
3. Bagon J et al. Pregnancy and Dialysis. American Journal of Kidney Diseases 1998; 31(5): 756-765.
4. Perry L. A Multidisciplinary Approach to the Management of Pregnant Patients with end-stage stage disease. Journal of Perinatology Neonatal Nursing 1994;
8(1): 12-19.
5. Rockafellow R. A Guide to Nursing Care for Women Dialysis Patients of Childbearing Age. Dialysis & Transplantation 1999; 28(4): 184-199.
6. Orsini-Negroni J et al. Nursing Management of the Pregnant Haemodialysis Patient. ANNA Journal 1990; 17(6): 451-455.
7. Jungers P et al. Pregnancy and end-stage renal disease – past experience and new insights. Nephrology Dialysis Transplantation 1998; 13: 3005-3007.
8. Nakabayashi M et al. Perinatal and Infant Outcome of Pregnant Patients Undergoing Chronic Haemodialysis. Nephron 1999; 82: 27-31.
9. Jungers P et al. Pregnancy during Dialysis: case report and management guidelines. Nephrology Dialysis Transplantation 1998; 13: 3266-3272.
10. Cohen D et al. Dialysis during Pregnancy in Advanced Chronic Renal Failure Patients. Outcome and Progression. Clinical Nephrology 1998; 29(3): 144-148.
11. Cowley P et al. The effects of Corticosteroid Administration before Preterm Delivery: An Overview of the Evidence from Controlled Trials. Ballieres Clinical
Obstetric Gynaecology 1990; 97: 11-26.
12. Hussey M, Pombar X. Obstetric Care for Renal Allograft Recipients or for women treated with Haemodialysis or Peritoneal Dialysis during Pregnany. Advances
in Renal Replacement Therapy 1998; 5(1): 3-13.
13. EDTNA Registry Report. Successful Pregnancies in Women on Renal Replacement Therapy. Nephrology Dialysis Transplantation 1992; 7: 279-287.

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