For mothers with advanced kidney disease the outcome for the baby can be improved by dialysis. Dialysis may be started sooner if the mother is close to needing it anyway, or the amount of dialysis increased in those already on it regularly.
Fetal growth is monitored by ultrasound scans. Scans are repeated to see if the baby is growing normally. If growth slows down it becomes important to decide whether the baby is better off continuing to grow in the womb or being delivered early. In high risk cases or if the mother’s kidney function is getting worse, it is often safer both for mother and child for labour to be induced (started medically), particularly if gestation is around 38 weeks. This might need to be done earlier and the issues of prematurity taken into consideration. Earlier on in pregnancy medical induction of labour is less reliable and a caesarean section will then be needed.
Where there is a risk of early delivery the mother should be under the care of an obstetric unit with a neonatal intensive care to ensure rapid support for the newborn is available.
Some women with CKD can carry a pregnancy to term, and for them a normal delivery is often possible and to be encouraged.
Will medication harm the baby?
There are some medicines used in CKD which have to be stopped before getting pregnant. This is because they can cause abnormalities to the fetus. The most common drugs of concern to kidney patients are those used to suppress the immune system. Cyclophosphamide, Mycophenolate mofetil and Sirolimus should not be taken during or for some months before pregnancy. Patients would need to switch to safer medications such as azathioprine, cyclosporine, tacrolimus and prednisolone.
Some medicines used for the treatment of high blood pressure also need to be stopped in early pregnancy or before pregnancy. These include Angiotensin Converting Enzyme (ACE) inhibitors such as enalapril, ramipril, lisinopril; and Angiotensin Receptor Blockers (ARB) such as irbesartan, valsartan and losartan.
It is important that patients do not simply stop their medication on learning that they are pregnant. Many medicines are either safe or there are safe alternatives. Medicines that are safe and must not be stopped without medical advice include prednisolone, azathioprine, cyclosporine, tacrolimus, hydroxychloroquine, nifedipine, labetalol and methyl dopa.
Will the baby get kidney disease?
This depends on the nature of the mother’s kidney disease. Some conditions are directly inherited. If that is the case, parents can be told of the risks and whether there is a way to confirm or exclude the possibility of the baby being affected. Some conditions are partially inherited. For example, for women with vesico ureteric reflux or congential abnormalities of the urinary tract, there is a small increased chance overall that the child will have a similar problem, but it cannot be predicted accurately. Babies of these mothers should have their kidneys and bladders scanned in infancy to identify any abnormalities early.
Where should the birth take place?
It is perfectly reasonable for a woman with mild CKD, in generally good health and with well controlled blood pressure to remain under the care of her usual kidney specialists and local obstetric unit.
For those with more severe CKD, a kidney transplant, lupus nephritis, or other rare conditions, it is wise to be under a specialist unit. This will provide access to nephrologists experienced in managing advanced kidney disease in pregnancy, obstetricians and midwives trained in managing high risk pregnancies and paediatric neonatal support.
Is breast feeding safe?
In general yes! Some drugs are excreted into breast milk so that the baby is exposed to them. However, for several commonly used drugs it seems not to be a problem. Specific advice should be obtained from your obstetric team. A full list of drugs that should be avoided in breast feeding will shortly be provided on the Information for Clinicians page.