Dialyse und Schwangerschaft – Eine Fallserie von fünf Schwangeren unter intensivierter Dialyse

Dialysepflichtige Frauen werden selten schwanger. Fallberichte geben das fetale Outcome mit einer Lebendgeburtenrate zwischen 40 und 85 % an. Wir berichten von fünf dialysepflichtigen Schwangeren, die an unserem Perinatalzentrum betreut wurden. Alle Patientinnen erhielten ein standardisiertes, intensiviertes Dialyseprotokoll mit bis zu 7 Hämodiafiltrationen pro Woche mit einer mittleren Behandlungszeit von 28,6 ± 6,3 Stunden pro Woche. Der Behandlung lag ein multidisziplinärer Betreuungsansatz in Kooperation mit den Nephrologen und Neonatologen zugrunde. Supportiv erhielten die Patientinnen Erythropoetin, Vitamine und Spurenelemente. Ab der 26. Schwangerschaftswoche wurden alle Patientinnen stationär überwacht. Das mittlere Gestationsalter bei der Entbindung betrug 32,8 ± 3,3 Schwangerschaftswochen und die Neugeborenen waren im Mittel 1765 ± 554 g schwer. Die Lebendgeburtenrate betrug 100 %. Das fetale Outcome profitiert von einer qualifizierten, multidisziplinären Betreuung am Perinatalzentrum. Bei dialysepflichtigen Schwangeren sollte die Dialysedauer intensiviert werden und eine stationäre Betreuung im 2. Trimenon stattfinden.

Women subject to dialysis are rarely pregnant. Case reports have registered a fetal outcome of between 40 and 85 per cent live births. This is a report on five pregnant women subject to dialysis treated in our perinatal center. All these patients were subjected to a standardized intensified dialysis procedure with up to seven hemodiafiltrations weekly with an average treatment period of 28.6 +/– 6.3 hours weekly. A multidisciplinary care program was initiated in co–operation with the nephrologists and neonatologists. The patients supportingly received erythropoietin, vitamins and trace elements. Starting with the 26th week of pregnancy all patients were closely watched on an in–patient basis. The average gestation age at birth was +/– 3.3 pregnancy weeks and the average newborn weight was 1765 +/– 554 g. The live birth rate was 100 %. The fetal outcome benefited from a qualified multidisciplinary care program of the perinatal center. Pregnant women who are subjected to dialysis should be dialysed for a longer time and subjected to inpatient supervision from the second three–month term of pregnancy.

Key words

pregnancy - intensified hemodialysis - fetal surveillance - perinatal outcome

Literatur

• 1 Bagon JA, Vernaeve H, De Muylder X. et al. . Pregnancy and dialysis.  Am J Kidney Dis. 1998;  31 756-765
• 2 Bamberg C, Diekmann F, Haase M. et al. . Pregnancy on intensified hemodialysis: Fetal surveillance and perinatal outcome.  Fetal Diagn Ther. 2007;  22 289-293
• 3 Berkenstadt M, Weisz B, Cuckle H. et al. . Chromosoma abnormalities and birth defects among couples with colchicine treated familial Mediterran fever.  Am J Obstet Gynecol. 2005;  193 1513-1516
• 4 Chan WS, Okun N, Kjellstrand CM. Pregnancy in chronic dialysis: a review and analysis of the literature.  Int J Artif Organs. 1998;  21 259-268
• 5 Da Fonseca EB, Bittar RE, Carvalho MH, Zugaib M.. Prophylactic administration of progesterone by vaginal suppository to reduce the incidence of spontaneous preterm birth in women at increased risk: a randomized placebo–controlled double–blind study.  Am J Obstet Gynecol. 2003;  188 419-424
• 6 Gahl WA, Thoene JG, Schneider JA.. Cystinosis.  N Engl J Med. 2002;  347 111-121
• 7 Giatras I, Levy DP, Malone FD. et al. . Pregnancy during dialysis: case report and management guidelines.  Nephrol Dial Transplant. 1998;  13 3266-3272
• 8 Haase M, Mogera S, Bamberg C. et al. . A systematic approach to managing pregnant dialysis patients–the importance of an intensified haemodialfiltration protocol.  Nephrol Dial Transplant. 2005;  20 2537-2542
• 9 Haase M, Mogera S, Budde K.. A systematic approach to managing pregnant dialysis patients – the importance of an intensified haemodiafiltration protocol.  Nephrol Dial Transplant. 2006;  21 1443-1457
• 10 Holley JL, Reddy SS.. Pregnancy in dialysis patients: a review of outcomes, complications, and management.  Semin Dial. 2003;  16 384-388
• 11 Holley JL, Schmidt RJ, Bender FH. et al. . Gynecologic and reproductive issues in women on dialysis.  Am J Kidney Dis. 1997;  29 685-690
• 12 Hou S.. Pregnancy in chronic renal insufficiency and end–stage renal disease.  Am J Kidney Dis. 1999;  33 235-252
• 13 Hou SH.. Frequency and outcome of pregnancy in women on dialysis.  Am J Kidney Dis. 1994;  23 60-63
• 14 Hou SH.. Pregnancy in women on haemodialysis and peritoneal dialysis.  Baillieres Clin Obstet Gynaecol. 1994;  8 481-500
• 15 Jones DC, Hayslett JP.. Outcome of pregnancy in women with moderate or severe renal insufficiency.  N Engl J Med. 1996;  335 226-232
• 16 Levy DP, Giatras I, Jungers P.. Pregnancy and end–stage renal disease – past experience and new insights.  Nephrol Dial Transplant. 1998;  13 3005-3007
• 17 Nakabayashi M, Adachi T, Itoh S. et al. . Perinatal and infant outcome of pregnant patients undergoing chronic hemodialysis.  Nephron. 1999;  82 27-31
• 18 Okundaye I, Abrinko P, Hou S.. Registry of pregnancy in dialysis patients.  Am J Kidney Dis. 1998;  31 766-773
• 19 Palmer BF.. Sexual dysfunction in uremia.  J Am Soc Nephrol. 1999;  10 1381-1388
• 20 Pitkin RM.. Folate and neural tube defects.  Am J Clin Nutr. 2007;  85
• 21 Reddy SS, Holley JL.. Management of the pregnant chronic dialysis patient.  Adv Chronic Kidney Dis. 2007;  14 146-155
• 22 Registration Committee of the European Dialysis and Transplant Association. . Successful pregnancy in women treated by dialysis and transplantation.  Br J Obstet Gynecol. 1980;  87 839-845
• 23 Rizzoni G, Ehrich JH, Broyer M. et al. . Successful pregnancies in women on renal replacement therapy: report from the EDTA Registry.  Nephrol Dial Transplant. 1992;  7 279-287
• 24 Romao Jr JE, Luders C, Kahhale S. et al. . Pregnancy in women on chronic dialysis. A single–center experience with 17 cases.  Nephron. 1998;  78 416-422
• 25 Toma H, Tanabe K, Tokumoto T. et al. . Pregnancy in women receiving renal dialysis or transplantation in Japan: a nationwide survey.  Nephrol Dial Transplant. 1999;  14 1511-1516
• 26 Wilcox AJ, Lie RV, Solvoll K. et al. . Folic acid supplement and risk of facial clefts: national population based case–conrol study.  BMJ. 2007;  334 464

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