Successful twin pregnancy in a patient on long-term hemodialysis

Chiz-Tzuang Chang,
Mai-Szu Wu and
Hong-Chiz Chien
+Author Affiliations
Introduction
Pregnancies in end-stage renal disease (ESRD) are uncommon, and a successful
outcome is rare. Pregnancy in uraemic patients puts the mother at risk of
hypertension and fluid overload. On the other hand, there is an increased risk for
the fetus of neonatal mortality, prematurity, and small-for-gestational-age. Twin
pregnancies are regarded as high-risk pregnancies even in healthy women and must
be even more risky in dialysed women. We report on a 30-year-old female on
chronic haemodialysis for 7 years who conceived after induced ovulation and had a
twin pregnancy.
Case
A 30-year-old female, without a previous pregnancy suffered from chronic
glomerulonephritis since childhood. She had started maintenance haemodialysis
(thrice weekly) 7 years ago. She was a hepatitis virus B and hepatitis virus C carrier.
For this reason, she was not considered for kidney transplantation. She married a
renal transplant recipient 4 years after initiation of haemodialysis. She could not
conceive after 3 years of unprotected intercourse. As she was eager to have a child
of her own, she underwent hormone-stimulated ovulation with timed intercourse.
She conceived and had a twin pregnancy within 3 months of hormone therapy,
including clomiphen and human chorionic gonadotrophin (HCG). Pregnancy was
diagnosed from the elevation of HCG at the 3rd week of pregnancy.
The dosage of haemodialysis was increased to six times per week and 4.5 h/session.
The weekly dialysis time was extended to 27 h from the 3rd week of pregnancy. The
dialysate was changed to high calcium concentration (3.5 mmol/l) dialysate
containing glucose (200 mg/dl) to meet the increased calcium need of the mother
and prevent hypoglycaemia during haemodialysis. The dose of erythropoietin (Epo)
was increased from 4000 U to 12000 U weekly to counteract the Epo
hyporesponsiveness during pregnancy. Folic acid supplement was increased from 5
to 35 mg per week to avoid folate deficiency [6]. An oral (100 mg elemental
iron/day) and intravenous iron supplement (40 mg elemental iron/week) were given
to keep serum ferritin above 500 ng/ml. The haematocrit was maintained between
29 and 33%. The patient had regular obstetric follow-up with fetal sonography every
3 weeks after the 21st week of pregnancy.
The course of the patient's pregnancy was smooth except for an episode of vaginal
spotting at the 29th week. The bleeding ceased under conservative therapy.
Preterm labour pain developed at the 32nd week of gestation. Tocolysis failed to
relieve the persistent uterine contraction. She underwent Caesarean section and
delivered a pair of male twins. The first baby weighed 1292 g with an Apgar score of
9 at 5th minute. The second twin was delivered 1 min later, weighing 958 g, and
with the same Apgar score. The mother had persistent post-partum haemorrhage
caused by a retained placenta. She underwent hysterectomy and was discharged 1
week later. The two babies were transferred to the neonatal ICU because of their

prematurity. They were discharged uneventfully after their body weight had risen to
2000 g 2 months later.
Discussion
Fertility is markedly decreased in women on chronic haemodialysis. Souqiyyeh et
al. reported a rate of conception of 1.2% among female chronic dialysis patients of
childbearing age in Saudi Arabia, where contraception is restricted by religious
tenet. The National Registry for Pregnancy in Dialysis Patients (NPDR) reported that
over a 4-year period 2.4% of 4531 female haemodialysis patients of childbearing
age became pregnant in the United States. Successful pregnancies are seen in only
a small fraction of pregnancies of haemodialysis patients, e.g. 25% in Europe before
the introduction of erythropoietin. The success rate increased to 39.5% recently.
Transplantation restores fertility and improves the likelihood of a successful
pregnancy. It offers the best chance of a child for women with end-stage renal
disease.
Previous studies had indicated that adequate dialysis, haemodynamic stability,
anaemia and nutrition are the most important factors for a successful pregnancy in
chronic haemodialysis patients. The report of the registry of pregnancy in dialysis
patients suggested that there was a trend toward better pregnancy outcome and
reduced fetal prematurity in patients with weekly dialysis exceeding 20 h. There
was also a positive correlation between birth weight and dialysis time.
After gestation had been diagnosed promptly, we increased our patient's usual
weekly 12-h haemodialysis to 27 h from the 3rd week of gestation. We used highflux dialysers (FB210U, urea clearance 198 ml/min, Nipro TM, Japan) to keep her predialysis urea concentration lower than 60 mg/dl as suggested by Maruyama et al.to
reduce the incidence of polyhydramnion. Reducing interdialytic body-weight gain by
daily intensive haemodialysis prevented haemodialysis-related hypotension, which
is detrimental for the fetus. Hypertension is common among pregnant
haemodialysis patients. Hypertension or hypotension were avoided throughout the
entire pregnancy in our patient. Her monthly blood sugar check-up was normal and
iPTH levels were kept between 130 and 180 ng/ml during the pregnancy, even with
high-calcium dialysate containing glucose.
Correction of anaemia possibly increases the success rate of pregnancy and
prevents hypoxaemic stress in the fetus, but increased doses of Epo should be given
to counteract the Epo hyporesponsiveness of pregnancy. Epo does not pass through
the human placenta. No Epo-related teratogenicity has been reported. Our
observation indicates that Epo is an effective and safe therapy for the pregnant
haemodialysis patient.
An adequate dietary prescription is mandatory for maternal health and fetal
development. With intensive haemodialysis, dietary restrictions could be liberalized
without running the risk of azotaemia and hyperkalaemia. In our patient, the serum
albumin level was kept between 3.5 and 4.2 g/dl, although there is a physiological
decrease in serum albumin concentration in normal pregnancy.
Our observation illustrates that intensified dialysis regimens and attentive medical
care permit a successful outcome even in high-risk twin pregnancies of dialysed
women.
1999 European Renal Association-European Dialysis and Transplant Association
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Nephrol. Dial. Transplant. (1999)14 (10): 2487-2488.doi: 10.1093/ndt/14.10.2487
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