**8. Risks to fetus**

Published reports from UK, USA and European registries persistently highlighted risk of low birth weight of fetus and pre term delivery in renal transplant recipients. (Sibanda 2007, Ar‐ menti 2004) Willis et al from Australia reported 44% with low birth weight. (Willis 2000) In our experience we found mean birth weight infants born to transplant recipients was 2.4± 0.57 Kg, with 7 newborns <1.8 Kg. (Naqvi 2010)

Exposure to immunosuppressants: Adrenal insufficiency and thymic hypoplasia have occa‐ sionally been described in the infants of transplant recipients, but these problems are unlikely if the dose of prednisone has been decreased to 15 mg (Penn I, 1980). Prednisolone traverses the placenta but 90 % of maternal dose is metabolized within the placenta and not reaching to fetus (Blanford 1977). In addition if pregnancy is occurring after 2 years of transplant, recipient already on very small dose of Prednisolone. Steroids can also aggravate hypertension in moth‐ er; mothers are more prone to infections if steroid dose is still high at time of conception. Premature rupture of membrane is another complication reported in relation of steroids. Therefore, it is recommended to get conceive when steroid dose is reduced to minimal. Reports from azathiaprine era through cyclosporine era have not identified specific malformations among infants born to transplant recipients (Armenti 2000). Radioactive labeling studies in humans have shown that 64–93% of Azathioprine administered to mothers appears in fetal blood as inactive metabolites (Sarikoski S, 1973). Cyclosporine metabolism appears to be in‐ creased during pregnancy and higher doses may be required to maintain plasma levels in the therapeutic range (Muirhead N, 1992). Data concerning the effect of tacrolimus on pregnancy is scarce. A report of 100 pregnant women (which included all organ transplant recipients), among 84 treated with tacrolimus, 68 progressed to a live birth, with 60% of deliveries being premature (Kainz A, 2000). Teratogenecity of mycophenolate mofetil is not yet confirmed, therefore it is recommended to switch over to azathiaprine in female who are planning to conceive. A study has reported low number of T and B cells at birth in infants born to mothers who were on immunosuppressants, but these were normalized after few months. (Di Paolo 2000) Most published studies related to subject have not described clear cut congenital mal‐ formations or autoimmune disorders to children born to transplant recipients, though sporadic case reports which could be related to exposure risk of disease in general population.

**3.** stature compatible with good obstetric outcome

**5.** no hypertension or well controlled blood pressure on one agent

**6.** consider revising anti-hypertensive regimen when pregnant

**8.** stable graft function with serum creatinine less than 1.5 mg/dl

quency of 4 weeks during first trimester and 2 weeks later on.

mus to CyA and Prednisolone in minimal doses

**10.** switch immunosuppressants to milder, e.g. MMF should be converted to AZA, Tacroli‐

Pregnancy Post Transplant http://dx.doi.org/10.5772/54805 283

**11.** once pregnant, transplant recipient should be seen by multidisciplinary team with a fre‐

Nephrology Sindh Institute of Urology and Transplantation (SIUT), Karachi, Pakistan

[1] Armenti, V. T, Radomski, J. S, Moritz, M. J, Gaughan, W. J, Hecker, W. P, Lavelanet, A, & Mcgrory, C. H. Coscia LA: Report from the National Transplantation Pregnancy Registry (NTPR): Outcomes of pregnancy after transplantation. Clin.Trans, (2004). ,

[2] Bagon, J. A, Vernaeve, H, De Muylder, X, Lafontaine, J. J, Martens, J, & Van Roost, G. Pregnancy and dialysis. Am J Kidney Dis (1998). PubMed: 9590184], 31, 756-765. [3] Barua, M, Hladunewich, M, Keunen, J, Pierratos, A, Mcfarlane, P, Sood, M, & Chan, C. T. Successful pregnancies on nocturnal home hemodialysis. Clin J Am Soc Nephrol

[4] Badshah, S, Mason, L, Mckelvie, K, & Payne, R. Lisboa PJG; Risk factors for low birth weight in public hospitals at Peshawar, NWFP-Pakistan. BMC Public Health. (2008).

[5] Blanford, A. T, & Murphy, B. E. In vitro metabolism of prednisone, dexamethasone, and cortisol by the human placenta. Am J Obstet Gynecol (1977). , 127, 264-7.

[6] Cararach, V, Carmona, F, Monleon, F. J, & Andreu, J. Pregnancy after renal transplan‐

(2008). PMCID: PMC2390936] [PubMed: 18308997], 3, 392-396.

tation: 25 years experience in Spain. Br J Obstet Gynaecol. (1993).

**4.** no or minimal proteinuria

**Author details**

Rubina Naqvi\*

**References**

2004, 103-114.

**7.** no evidence of recent graft rejection

**9.** drug therapy at maintenance levels
