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

EDTNA|ERCA JOURNAL 2002 XXVIII 2 91

was not entirely supportive of her decision, and believed she care was maintaining Sue’s access point. A fistula was the only
should heed the advice of the doctors. access point in her left arm. In an attempt to preserve Sue’s
I asked Sue if she was aware that pregnancy could occur access point, the nurse used a single needle. There was no sub-
on dialysis. She replied that the information she received was stance based on the nurses’ theory. After 2-3 months we resort-
that pregnancy was impossible whilst on dialysis. However, ed back to double-needle dialysis. Sue tolerated double needle
it was documented that she was prescribed (microner) ‘The dialysis daily for the remaining duration of her pregnancy. No
Pill’, for menorrhagia – heavy monthly discharge. She was evidence of a clotted fistula, or signs of a breakdown in skin
clearly treated for anaemia, rather than the prevention of preg- turgidity, emerged once the needles were rotated to different
nancy. sites on the arterial and venous points.

History of disease Anaemia management

At 14 years old, Sue showed signs of a deteriorating renal func- Since the revolution of the drug Recombinant Human Erythro-
tion and was diagnosed with reflux nephropathy. When she was poietin (rHuEpo), the quality of patients’ lives has substantially
19 years old, she commenced peritoneal dialysis, and later that improved. Erythropoietin has been linked with improved
year had a cadaver transplant. Two years later, the transplant libido, fertility and subjective improvements in the sense of
failed, possibly due to contracting the measles virus. She then well-being and exercise tolerance (6).
started haemodialysis. 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
Clinical management required blood transfusions and iron to maintain her Hb greater
than 9 grams. The total amount of blood transfusions accumu-
In the first three months of Sue’s pregnancy the dialysis regime lated to 17 units. This was an enormous amount of antibodies
was normal, occurring 3 times a week. However, routine sud- introduced into her system, which would invariably increase
denly began to change in the second trimester. her rejection rate when she had a kidney transplant. Pregnancy
In the second trimester, the dialysis regime gradually alone increases antibodies.
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 Dietary management
system, therefore intensive dialysis was needed for the urea to
be kept on target as prescribed by the physicians (less than It is estimated that the minimal daily dietary protein intake
70 mg/dl in the second trimester, and less than 150 mg/dl in (DPI) in healthy individuals is approximately 0.6 g/kg. Adding
the third). the DPI for dialysis patients and the additional daily protein
This target is quite a tough regime to achieve. Most case requirements for pregnancy, a pregnant dialysis patient should
studies report haemodialysis anywhere from 4 hours thrice be ingesting 1.8 g/kg day of protein (7). This would mean
weekly to 4 hours 5 times per week. Aggressive dialysis appears that she should be ingesting just over 400 grams of protein
to increase the likelihood of a successful outcome. Studies show each day. Sue was advised to increase her protein and calcium
that patient’s dialysed more than 20 hours a week have better intake.
pregnancy outcomes. (1). Sue found it difficult to maintain a good nutritional level
Aggressive dialysis consisted of spending longer rigorous due to tiredness and financial circumstances. She required hos-
time on the machine, and having consistent gentle flows, rather pital transport. Her husband did not visually appear to offer
than spending a shorter time on the machine and having high enormous support, as he never accompanied her for dialysis
flux dialysis with a faster blood diffusion rate. We did experi- sessions, or for clinic appointments. Because of her personal
ment and change to a high flux dialyser, and quickly realised circumstances, the nurses arranged for a hot meal to be deliv-
Sue was filtering better than a normal person to the effect of ered every mid-day afternoon.
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. Weight management
Sue managed to tolerate 30 hours a week on dialysis and
kept urea to a reasonable level. Because of the long hours spent The fourth main problem apart from managing Sue’s dialysis
on dialysis, Sue found it difficult to maintain a normal potassi- regime, anaemia and nutrition, was controlling her weight. This
um level. Despite eating bananas and chocolate to compensate needed careful daily assessments. In the first trimester, her tar-
the low levels in her body, it was necessary to dialyse her against get weight remained static.
a high bath of potassium daily, to prevent bradycardia. The major influx of weight change occurred in the second
One of the main concerns of the nurse in charge of Sue’s trimester. Here the target weight increased by 7 kg. The target

92 EDTNA|ERCA JOURNAL 2002 XXVIII 2

weight did not exceed the actual weight at any time throughout first case, the steroids were given between the 27th and 33rd
Sue’s pregnancy – it was always a catching up job. weeks of gestation. In the second case, the steroid drug treat-
There are no rules to determine target weight, just recom- ment was given between the 31st and 34th weeks of pregnan-
mendations from previous studies. For instance, Nakabayashi cy. Cowley et al (11) recommend that glucocorticoid adminis-
(8) suggests: tration be considered at least 48 hours prior to delivery for
300 g/wk in 2nd trimester = 3.6 kg, patients at risk of delivering prematurely.
300g-500g/wk in 3rd trimester. There were no abnormalities observed in the initial assess-
Here you can see there is no magic formula. The formula ment of Sue’s infant. Children born to women with renal failure
suggests a 3.6 kg gain in the second trimester, where in reality are initially small for gestation age, but manage to catch up with
a 7 kg gain was made. peers in physical and mental development. Congruently it has
In another more realistic recommendation, Jungers (9) sug- been estimated that the incidence of major neurological handi-
gests to increase the dry weight by 0.5 kg per week in the 3rd caps in premature small for-gestational-age infants (those who
and 4th month, and one kg per week in the 5th and 6th month. experienced intrauterine growth restriction) may be as high as
Obviously every fetus is unique and grows rapidly at differ- 35% (12).
ent stages of the pregnancy. The patient was compliant with her Congenital abnormalities were reported to be more frequent
fluid restriction. We tried not to take off more than 1.5 kg/day. in uraemia women than in the general population (10). In the
However, this was not always possible, as some nurses removed EDTNA series (13) two of 35 babies born to mothers on hae-
up to 2 even 2.5 litres a day to compensate for blood transfu- modialysis manifested congenital malformations.
sions etc as far advanced as 26 weeks into Sue’s pregnancy. Sue’s baby had a high urea and creatinine in the first 24
The dangers of removing too much fluid without adequate hours of delivery. This was anticipated, as shown from other
planning could result in a hypotensive attack, causing fetal dis- case studies; after a few diuresis the baby’s kidney function
tress and a spontaneous abortion. began to kick in. The sodium, potassium and calcium elec-
Alternatively the nurses could decide to increase her target trolytes were all within normal limits when the kidneys started
weight too much too quickly, and there was a real risk that the to function.
patient would become hypertensive and fluid overloaded The main problem the infant experienced was an inability to
putting undue stress on the heart. maintain his own oxygen supply. He was dependent on oxygen
Sue did not have any one identified primary nurse. We rely for five months throughout his admission in the Special Care
on agency nurses, which may have hampered consistent knowl- Baby Unit. He developed pneumonia, and nearly died when
edge based care. The lack of an appreciation in knowledge of attempts were made to extubate too early. But this little tiger
daily coherent fluid assessment and vigilant fluid monitoring, surprised all staff in his determination to survive.
availing of the tools and using them effectively such as on-line At 11 weeks old, 4 weeks post discharge, the infant weight-
blood monitoring and the use of a dynamap to check blood ed 4.54 kg, putting an impressive 2.8 kg on since birth. He fed
pressures periodically may have arguably to some extent com- well on formula milk, and began to tolerate 2 meals of early
promised Sue’s care. 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
Fetal outcome to sounds, and smiled a lot! There were no signs of respiratory
disease; his heart sounds were normal with no added sound or
Unexpectantly at 29 weeks gestation, on the 3rd April 2000, murmurs. He had normal trunk tone and increased tone in
Sue was at home on weekend leave from a hospital admission, both legs with brisk reflexes and a few beats of muscle spas-
when early signs of fetal distress emerged due to cord prolapse modically.
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- Summary
sarean was performed. It was a traumatic delivery, and a baby
boy was born severely bruised with poor respiratory function. Six months following the event, Sue received the long awaited
He weighted 1.8 kg. The baby had to be intubated at 3 minutes live-related transplant from her father. Both mother and baby
old, and was transferred to the neonate intensive care unit. have been reported to be doing fine.
Mother made a good recovery with no further complications Managing pregnancy whilst dependent on dialysis is a safe
and the dialysis regime returned to normal. procedure, once the patient is adequately informed, and sup-
Sue had not received any drugs that would enhance fetal ported by the nephrology, gynaecology and perinatology team,
lung maturity. Although the treating obstetricians recognized and is carefully monitored by confident nursing staff. There are
lung immaturity as a major complication of fetal survival, no certainly better fetal survival rates now than those initially
such treatment was instigated. Cohen (10) describes two case reported in the 1970’s/80’s. The pregnancy outcome is similar
studies where the patients received 6 weekly courses of whether the woman is on haemodialysis or CAPD. However
betamethasone (disodiumphosphate and acetate forms). In the 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- women with end-stage renal disease, the presence of hyperpro-
bearing women on dialysis are educated on the use of contra- lactinemia has been associated with a lower rate of sexual inter-
ceptives and childbearing women are not hoaxed into the false course and percentage of orgasm compared with those with a
pretence that dialysis or renal failure is an adequate form of normal prolactin level. Prolactin normalization and hormonal
protection. replacement therapy should now also be part of the therapeutic
There is an uncertainty in the relationship between the use care.
of erythropoietin and conception, although links have been
suggested to increased fertility with the use of EPO. Hyperpro- Address for correspondence
lactinemia is improved by use of erythropoietin therapy. Among email: annamarie60@hotmail.com

References
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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.
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12. Hussey M, Pombar X. Obstetric Care for Renal Allograft Recipients or for women treated with Haemodialysis or Peritoneal Dialysis during Pregnany. Advances
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