|Year : 2021 | Volume
| Issue : 2 | Page : 181-183
Case of renal transplant recipient with twin pregnancy - A case report
Atul Kumar Srivastava1, Md Rasheed2, Indranil Ghosh1, Sudhir Mansingh2
1 Department of Nephrology, Command Hospital, Lucknow, Uttar Pradesh, India
2 Department of Obstetrics and Gynecology, Command Hospital, Lucknow, Uttar Pradesh, India
|Date of Submission||21-Jun-2020|
|Date of Decision||22-Nov-2020|
|Date of Acceptance||30-Dec-2020|
|Date of Web Publication||30-Jun-2021|
Dr. Atul Kumar Srivastava
Department of Nephrology, Command Hospital, Lucknow - 226 002, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Kidney transplant can restore fertility in young recipients. Preconception counseling should be done for each kidney transplant recipient (KTR) of childbearing age; however, multiple gestations can occur in these patients spontaneously and with assisted reproduction. Pregnancy in KTR can have impact on graft functioning and has obstetrical and fetal implications. We report a 28-year-old KTR with twin pregnancy following intrauterine insemination and challenges associated with it during the pregnancy.
Keywords: Kidney transplantation, pregnancy, twins
|How to cite this article:|
Srivastava AK, Rasheed M, Ghosh I, Mansingh S. Case of renal transplant recipient with twin pregnancy - A case report. Indian J Transplant 2021;15:181-3
|How to cite this URL:|
Srivastava AK, Rasheed M, Ghosh I, Mansingh S. Case of renal transplant recipient with twin pregnancy - A case report. Indian J Transplant [serial online] 2021 [cited 2022 Oct 3];15:181-3. Available from: https://www.ijtonline.in/text.asp?2021/15/2/181/319888
| Introduction|| |
Restoration of fertility is an achievement of kidney transplant surgery in recipients of childbearing age. Kidney transplant recipient (KTR) should be counseled about need of contraception in posttransplant period for at least 12–24 months. However, unplanned pregnancy can occur with rates varying from 33% to 93% in KTRs. Unplanned pregnancy exposes the fetus to teratogenic drugs and increases the risk of congenital anomalies. Pregnancy in recipients can be spontaneous or due to assisted conception. Pregnancy in KTRs is associated with worsening of graft function if baseline serum creatinine is deranged, reduction in levels of immunosuppressants, and due to increased if there is risk of acute rejection. Obstetrical complications during pregnancy include risk of preeclampsia, gestational diabetes, preterm labor, and increase the use of cesarean sections for delivery. Fetal complications include prematurity and risk of intrauterine growth retardation. Multiple gestations in KTRs are associated with adverse outcomes. Currently, guidelines for the management of pregnancy in KTR exists, but experience with multiple gestation is less and conception by intrauterine insemination (IUI) is even lesser.,, We report a case of twin pregnancy in a KTR and challenges associated with the management of the case.
| Case Report|| |
We report a case of a 28 year old nulliparous female who presented 4 years back with fever, dysuria, and two episodes of generalize tonic clonic seizures of 2-day duration. She had urine output of 1100 ml/day. Clinically, she was pale, hypertensive (blood pressure [BP] 160/100 mmHg), and unremarkable systemic examination. On investigation, she had anemia (Hb: 5.5 g/dl), leukocytosis, serum creatinine was 8.2 mg/dl, urine routine and microscopic examination revealed numerous pus cells, urine culture grew Escherichia More Details coli, and ultrasound of the kidneys revealed bilateral small size kidneys and noncontrast computerized tomography of head was within normal limits. She was managed as a case of urinary tract infection and end-stage renal disease secondary to presumed chronic tubulointerstitial disease. Seizures were attributed to uremia. She remained dialysis dependent and received 100 hemodialysis before undergoing live-related ABO compatible kidney transplant with mother as donor 3 years back. She received basiliximab as induction agent and was started on tacrolimus, mycophenolate mofetil, and prednisolone. Her immediate postoperative period was uneventful, and she achieved baseline serum creatinine of 0.9 mg/dl at the time of discharge.
Her graft function remained stable during follow-up and she desired for pregnancy after 1-year posttransplant. Serum creatinine at that time was 1.1 mg/dl; 24 h urine protein and creatinine were 180 mg and 900 mg, respectively. She was not requiring antihypertensives. Mycophenolate mofetil was stopped, and she was started on azathioprine (2 mg/kg) 2 years back. She could not conceive spontaneously and underwent IUI 10 months back following which she conceived quadruplets. Evaluation at the time of conception revealed normal renal functions, hepatitis B surface antigen, anti-hepatitis C virus, and HIV were negative. Thyroid profile was within normal limits. Fetal reduction was done at 12 weeks after nuchal translucency-nasal bone scan following which quadruplets were reduced to dichorionic diamniotic twins. Aspirin was started at 13-week period of gestation (POG) as per the American Colleges of Obstetrics and Gynecology guidelines. She underwent cervical encirclage at 16 weeks for clinically observed short cervix which was confirmed by ultrasound along with progesterone support. The patient was followed fortnightly till 24 weeks and weekly thereafter in nephrology and obstetrics OPD. Tacrolimus levels were monitored on monthly basis and dose of tacrolimus was adjusted to keep the trough levels between 3 and 5 ng/ml. She had Low Tacrolimus level (Tac level 1.5 ng/ml) in the second trimester, for which dose of tacrolimus was modified. She had rise in BP (146/96 mmHg) at 25-week POG. Patient had normal uric acid with no evidence of preeclampsia and blood pressure normalized with conservative management. She received four doses of injection dexamethasone at 28 weeks for fetal lung maturity. The patient had premature rupture of membrane and developed labor pains at 29 weeks and 3 days POG. The patient delivered twins (one male and one female baby) by spontaneous vaginal delivery with APGAR Score of 5 and 9 at 1 and 5 min, respectively. The birth weight of male and female babies was 1.1 kg and 1.0 kg, respectively. Puerperal period was uneventful. Three months postdelivery, the twin babies are fine with normal developmental milestones. She has serum creatinine of 1.1 mg/dl and has no evidence of proteinuria with normal tacrolimus level.
| Discussion|| |
Fertility improves in recipients of childbearing age following kidney transplant. Only 2%–5% of recipients of kidney transplant conceive despite half of such patients in the childbearing age. Predictors of successful pregnancy in KTR include age <35 years, stable graft function with glomerular filtration rate >60 ml/min, proteinuria <500 mg, no hypertension, or well-controlled hypertension. Various guidelines advise delaying conception 1–2 years posttransplant., Our patient had all of the abovementioned features to suggest favorable outcome. Assisted reproduction leads to increased risk of multiple pregnancies. In general population, multiple gestation is associated with higher risk of adverse outcomes such as preeclampsia, gestational diabetes mellitus, fetal growth restriction, and preterm delivery which holds true for recipients of kidney transplant. Our patient conceived by IUI which was the cause of quadruplets. Patient's renal functions were monitored monthly in the first trimester, fortnightly in second trimester, and weekly thereafter. Tacrolimus levels were done monthly during antenatal period and puerperal period. During pregnancy, increase in extracellular volume can reduce the drug levels and precipitate acute rejection. Hence, there is a need to do frequent drug monitoring in these patients. Our patient had low tacrolimus levels in the second trimester and the dose of tacrolimus was modified.
This patient had short cervix length, for which she underwent cervical encirclage at 16 weeks to prevent preterm birth. Short cervical length (<20 mm) diagnosed before 20-week POG increases the risk of preterm birth before 32 weeks from 6.8% to 42.4%. Selective reduction of high order multiple pregnancy is associated with favorable impact on gestational length but may increase the risk of miscarriage. Our patient also underwent fetal reduction at 16 weeks.
Risk of preeclampsia is high in recipients of kidney transplant as compared to general population, as most of these patients are on antihypertensives., Multiple gestations in KTR are also associated with increased risk of gestational diabetes due to influence of immunosuppressive drugs (e.g., prednisolone and tacrolimus). Our patient had transient rise of blood pressure in second trimester which was managed conservatively but had no derangement in blood sugar level.
KTR with pregnancy has 13-fold higher risk of preterm deliveries and 5-fold risk of small for gestational babies as compared to the general population. The rates of prematurity in KTR with pregnancy vary from 45% to 56%. The rate of cesarean section varies for 30%–73%., Our patient had preterm spontaneous vaginal delivery at 29 weeks and 3 days POG and had low birth weight twins.
Adaptation to pregnancy occurs in graft kidney, and most of the recipients maintain normal graft function postdelivery. Overall risk of acute rejection during pregnancy is similar to general transplant population. Rate of graft loss 2 years postpregnancy may vary from 5% to 9%. Data from the National Transplant Pregnancy Registry of USA suggest graft loss in those patients postpregnancy who had higher preconception serum creatinine.
| Conclusion|| |
Thus, KTR with twin pregnancies is associated with complications which have impact on graft function, mother and fetus. A close multidisciplinary approach between nephrologist and obstetrician is required for individualized assessment of patient risk and decide the optimal time of delivery to improve maternal and fetal outcome. This case highlights the successful management of pregnancy with multiple adverse factors such as patient being KTR, conception by assisted reproduction, short cervical length, and delivery of twins by vaginalroute.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given her consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Guazzelli CA, Torloni MR, Sanches TF, Barbieri M, Pestana JO. Contraceptive counseling and use among 197 female kidney transplant recipients. Transplantation 2008;86:669-72.
Wyld ML, Clayton PA, Jesudason S, Chadban SJ, Alexander SI. Pregnancy outcomes for kidney transplant recipients. Am J Transplant 2013;13:3173-82.
Gizzo S, Noventa M, Saccardi C, Paccagnella G, Patrelli TS, Cosmi E, et al
. Twin pregnancy after kidney transplantation: What's on? A case report and review of literature. J Matern Fetal Neonatal Med 2014;27:1816-9.
Korpraphong S, Tanawattanacharoen S, Avihingsanon Y. Twin pregnancy after renal transplant: The first case report in Thailand. Asian Biomed 2011;4:931-4.
Pezeshki M, Taherian AA, Gharavy M, Ledger WL. Menstrual characteristics and pregnancy in women after renal transplantation. Int J Gynaecol Obstet 2004;85:119-25.
McKay DB, Josephson MA. Pregnancy in recipients of solid organs – Effects on mother and child. N Engl J Med 2006;354:1281-93.
Kidney Disease: Improving Global Outcomes (KDIGO) Transplant Work Group. Kdigo clinical practice guideline for the care of kidney transplant recipients. Am J Transplant 2009;9 Suppl 3:S1-155.
EBPG Expert Group on Renal Transplantation. European best practice guidelines for renal transplantation. Section IV: Long-term management of the transplant recipient. IV.10. Pregnancy in renal transplant recipients. Nephrol Dial Transplant 2002;17 Suppl 4:50-5.
Blickstein I, Keith LG. The decreased rates of triplet births: Temporal trends and biologic speculations. Am J Obstet Gynecol 2005;193:327-31.
Savasi VM, Mandia L, Laoreti A, Cetin I. Maternal and fetal outcomes in oocyte donation pregnancies. Hum Reprod Update 2016;22:620-33.
Conde-Agudelo A, Romero R, Hassan SS, Yeo L. Transvaginal sonographic cervical length for the prediction of spontaneous preterm birth in twin pregnancies: A systematic review and metaanalysis. Am J Obstet Gynecol 2010;203:128.e1-12.
Wimalasundera RC. Selective reduction and termination of multiple pregnancies. Semin Fetal Neonatal Med 2010;15:327-35.
Deshpande NA, James NT, Kucirka LM, Boyarsky BJ, Garonzik-Wang JM, Montgomery RA, et al
. Pregnancy outcomes in kidney transplant recipients: A systematic review and meta-analysis. Am J Transplant 2011;11:2388-404.
Coscia LA, Constantinescu S, Moritz MJ, Frank A, Ramirez CB, Maley WL, et al
. Report from the National Transplantation Pregnancy Registry (NTPR): Outcomes of pregnancy after transplantation. Clin Transpl. 2009;103-22.
Bramham K, Nelson-Piercy C, Gao H, Pierce M, Bush N, Spark P, et al
. Pregnancy in renal transplant recipients: A UK national cohort study. Clin J Am Soc Nephrol 2013;8:290-8.
You JY, Kim MK, Choi SJ, Oh SY, Kim SJ, Kim JH, et al
. Predictive factors for adverse pregnancy outcomes after renal transplantation. Clin Transplant 2014;28:699-706.
Sibanda N, Briggs JD, Davison JM, Johnson RJ, Rudge CJ. Pregnancy after organ transplantation: A report from the UK Transplant pregnancy registry. Transplantation 2007;83:1301-7.
American College of Obstetricians and Gynecologists, Task Force on Hypertension in Pregnancy. Hypertension in pregnancy. Report of the American College of Obstetricians and Gynecologists' Task Force on Hypertension in Pregnancy. Obstet Gynecol 2013;122:1122-31.
Smith MC, Ward MK, Sturgiss SN, Milne JE, Davison JM. Sex and the pregnant kidney: Does renal allograft gender influence gestational renal adaptation in renal transplant recipients? Transplant Proc 2004;36:2639-42.
Shah S, Venkatesan RL, Gupta A, Sanghavi MK, Welge J, Johansen R, et al
. Pregnancy outcomes in women with kidney transplant: Metaanalysis and systematic review. BMC Nephrol 2019;20:24.