mycophenolic-acid and Pre-Eclampsia

Thrombocytopenia develops in 5% to 10% of women during pregnancy or in the immediate postpartum period. A low platelet count is often an incidental feature, but it might also provide a biomarker of a coexisting systemic or gestational disorder and a potential reason for a maternal intervention or treatment that might pose harm to the fetus. This chapter reflects our approach to these issues with an emphasis on advances made over the past 5 to 10 years in understanding and managing the more common causes of thrombocytopenia in pregnancy. Recent trends in the management of immune thrombocytopenia translate into more women contemplating pregnancy while on treatment with thrombopoietin receptor agonists, rituximab, or mycophenylate, which pose known or unknown risks to the fetus. New criteria to diagnose preeclampsia, judicious reliance on measurement of ADAMTS13 to make management decisions in suspected thrombotic thrombocytopenic purpura, new evidence supporting the efficacy and safety of anticomplement therapy for atypical hemolytic uremic syndrome during pregnancy, and implications of thrombotic microangiopathies for subsequent pregnancies are evolving rapidly. The goals of the chapter are to help the hematology consultant work through the differential diagnosis of thrombocytopenia in pregnancy based on trimester of presentation, severity of thrombocytopenia, and coincident clinical and laboratory manifestations, and to provide guidance for dealing with some of the more common and difficult diagnostic and management decisions.

Topics: ADAMTS13 Protein; Female; Humans; Mycophenolic Acid; Postpartum Period; Pre-Eclampsia; Pregnancy; Pregnancy Complications, Hematologic; Purpura, Thrombotic Thrombocytopenic; Receptors, Thrombopoietin; Rituximab

Most pregnancies are successful in women with systemic lupus erythematosus, particularly if the disease is quiescent and there are no signs of active nephritis. There is no major impact of immunosuppression on maternal outcome. However, high doses of cyclosporine and glucocorticoids are used which may favor development of hypertension or preeclampsia. Some immunosuppressive drugs may exert toxic effects on the fetus. Glucocorticoids may cause small birth weight, and azathioprine and calcineurin inhibitors may be associated with lower birth weight, gestational age and prematurity. Cyclophosphamide may cause fetal malformation when given in the first trimester. Mycophenolate and leflunomide are teratogenic drugs and should be withdrawn before conception in case of programmed pregnancy or should be rapidly discontinued in case of unexpected pregnancy. Option counseling for pregnancy and correct use of immunosuppressive drugs are prerequisites for a successful pregnancy in women with lupus.

Topics: Contraindications; Cyclosporine; Female; Glucocorticoids; Humans; Hypertension; Immunosuppression Therapy; Isoxazoles; Leflunomide; Lupus Erythematosus, Systemic; Maternal Exposure; Mycophenolic Acid; Pre-Eclampsia; Pregnancy; Pregnancy Complications; Withholding Treatment

Few data are available on pregnancy in renal transplanted women for lupus nephritis (LN).. Among 38 women with LN who received a renal transplant in our Unit, three had nine pregnancies. During the pregnancies, patients were followed by a multidisciplinary team including gynecologists and nephrologists.. Two patients received a living related and one a deceased kidney transplant. The immunosuppressive therapy consisted of steroids calcinurin inhibithors and mycophenolate mofetil. The last drug was substituted with azathioprine in prevision of pregnancy. All patients had normal renal function and urinalysis. In two patients some signs of immunological activity persisted after transplantation. Five pregnancies ended in miscarriage and four in live births. Two pregnancies were uneventful. Pre-eclampsia occurred in a hypertensive patient in two pregnancies that ended in preterm delivery in one case and in a small for gestation age in both cases. And finally, follow-up graft function and urinalysis continued to be normal in all patients.. After renal transplantation our LN women continue to have frequent miscarriages. The other pregnancies ended in live births and, with the exception of pre-eclampsia in a hypertensive patient, no renal or extra-renal complications occurred during or after pregnancy, even in cases with active immunological tests.

Topics: Abortion, Spontaneous; Adult; Anti-Inflammatory Agents; Antibodies, Antinuclear; Antihypertensive Agents; Azathioprine; Female; Humans; Immunosuppression Therapy; Immunosuppressive Agents; Kidney Failure, Chronic; Kidney Transplantation; Lupus Nephritis; Mycophenolic Acid; Pre-Eclampsia; Prednisone; Pregnancy; Pregnancy Complications; Pregnancy Outcome

Kidney transplantation (KT) restores the fertility of women with end-stage kidney disease (ESKD), thus offering them the possibility of having children. However, pregnancy after kidney transplantation is associated with high maternal-fetal morbidity. The purpose of this work is to report the experience of our service in pregnancies in kidney transplant recipients.. We retrospectively studied the records of transplant recipients who had one or more pregnancies after KT. We analyzed clinical (blood pressure, weight gain, oedema, duration of pregnancy, obstetric complication) and biological (creatinine, urinary albumin excretion) parameters.. Between 1998 and 2020, twenty-one pregnancies occurred in 12 transplant recipients. The average age of patients at the time of conception was 29 ± 5 years with a delay between KT and pregnancy of 43 ± 29 months. Seven pregnancies began with arterial hypertension (HTA) controlled under treatment, proteinuria before conception was negative in all pregnancies and renal function was normal with an average creatinine level of 10.1 ± 1,27 mg/L. Prior to pregnancy, immunosuppression regimens were based on anticalcineurin (n = 21) combined either with mycophenolate mofetil (MMF) (n = 10) or azathioprine (n = 8) or alone (n = 3). Immunosuppression regimens were all associated with corticosteroid therapy. Three months before conception, MMF was relayed by azathioprine in seven pregnancies, on the other hand three other unplanned pregnancies, started under MMF. During pregnancy, the appearance of proteinuria greater than 0,5 g/24 h was noted in three pregnancies in the third trimester. Pregnancy hypertension was found in three pregnancies, one of which progressed to pre-eclampsia. As for renal function, it remained stable with an average creatinine level of 10,3 mg/l in the 3rd trimester. Two cases of acute pyelonephritis were noted. No episode of acute rejection was noted during and 3 months after pregnancy. The delivery was performed by caesarean section in 44.4 %, after an average term of 37 week of amenorrhea ± 2.04 with three cases of prematurity. The average birth weight was 3 110 g ± 450 g. There was one case of spontaneous abortion and two cases of fetal death in utero. After post-partum, renal function remained stable in five patients. In six cases, there was impaired renal function either by acute rejection or secondary to chronic allograft nephropathy.. In our department, a quarter of transplant recipients were able to carry a pregnancy with a rate of 89 % of successful pregnancies. Pregnancy after KT requires special planning and monitoring. A multidisciplinary collaboration between transplant nephrologist, gynecologist and pediatrician is necessary by referring to the recommendations.. La transplantation rénale (TR) permet de restaurer la fertilité des femmes en insuffisance rénale chronique terminale (IRCT), leur offrant ainsi la possibilité d’avoir des enfants. Toutefois, la grossesse après greffe rénale est associée à une morbidité materno-fœtale élevée. Le but de ce travail est de rapporter l’expérience de notre service dans les grossesses chez les transplantées rénales.. Nous avons étudié rétrospectivement les dossiers de transplantées ayant eu une ou plusieurs grossesses après TR. Nous avons analysé des paramètres cliniques (tension artérielle, prise de poids, œdèmes, durée de grossesse, complications obstétricales) et biologiques (créatininémie, excrétion urinaire d’albumine).. Entre 1998 et 2020, 21 grossesses ont eu lieu chez 12 transplantées. L’âge moyen des patientes au moment de la conception était de 29 ± 5 ans avec un délai entre la TR et la grossesse de 43 ± 29 mois. Sept grossesses ont débuté avec une hypertension artérielle (HTA) contrôlée sous traitement, la protéinurie avant conception était négative dans toutes les grossesses et la fonction rénale était normale avec une créatininémie moyenne de 10,1 ± 1,27 mg/L. Avant les grossesses, les régimes d’immunosuppression étaient à base d’anticalcineurine (n = 21), associé soit à du mycophénolate mofétil (MMF) (n = 10) soit à de l’azathioprine (n = 8), ou seul (n = 3). Les régimes d’immunosuppression ont tous été associés à une corticothérapie. Trois mois avant la conception, le MMF a été relayé par l’azathioprine dans sept grossesses, et trois autres grossesses non programmées ont débuté sous MMF. Au cours des grossesses, on a noté l’apparition d’une protéinurie supérieure à 0,5 g/24 h dans trois grossesses au troisième trimestre. L’HTA gravidique a été retrouvée dans trois grossesses, dont une a évolué vers une pré-éclampsie. Quant à la fonction rénale, elle est restée stable avec une créatininémie moyenne de 10,3 mg/L au troisième trimestre. Deux cas de pyélonéphrite aiguë ont été notés. Aucun épisode de rejet aigu n’a été noté au cours et trois mois après la grossesse. L’accouchement a été réalisé par césarienne dans 44,4 %, après un terme moyen de 37 semaines d’aménorrhée, ± 2,04 avec trois cas de prématurité. Le poids de naissance moyen était de 3 110 g ± 450 g. On a noté un cas d’avortement spontané et deux cas de mort fœtale in utero. Après le post-partum, la fonction rénale est restée stable chez cinq patientes. Dans six cas, on a assisté à une altération de la fonction rénale par un rejet aigu ou secondaire à une néphropathie chronique d’allogreffe.. Dans notre service, un quart des transplantées a pu mener une grossesse avec une productivité de 89 % de ces grossesses. La grossesse après la TR nécessite une planification et une surveillance particulière. Une collaboration multidisciplinaire entre néphrologue transplanteur, gynécologue et pédiatre est nécessaire en se référant aux recommandations.

Topics: Azathioprine; Cesarean Section; Child; Child, Preschool; Creatinine; Female; Graft Rejection; Hospitals; Humans; Hypertension; Immunosuppressive Agents; Kidney Transplantation; Mycophenolic Acid; Pre-Eclampsia; Pregnancy; Pregnancy Complications; Pregnancy Outcome; Retrospective Studies

Kidney transplantation (KT) restores the fertility of women with end-stage kidney disease (ESKD), thus offering them the possibility of having children. However, pregnancy after kidney transplantation is associated with high maternal-fetal morbidity. The purpose of this work is to report the experience of our service in pregnancies in kidney transplant recipients.. We retrospectively studied the records of transplant recipients who had one or more pregnancies after KT. We analyzed clinical (blood pressure, weight gain, oedema, duration of pregnancy, obstetric complication) and biological (creatinine, urinary albumin excretion) parameters.. Between 1998 and 2020, twenty-one pregnancies occurred in 12 transplant recipients. The average age of patients at the time of conception was 29 ± 5 years with a delay between KT and pregnancy of 43 ± 29 months. Seven pregnancies began with arterial hypertension (HTA) controlled under treatment, proteinuria before conception was negative in all pregnancies and renal function was normal with an average creatinine level of 10.1 ± 1,27 mg/L. Prior to pregnancy, immunosuppression regimens were based on anticalcineurin (n = 21) combined either with mycophenolate mofetil (MMF) (n = 10) or azathioprine (n = 8) or alone (n = 3). Immunosuppression regimens were all associated with corticosteroid therapy. Three months before conception, MMF was relayed by azathioprine in seven pregnancies, on the other hand three other unplanned pregnancies, started under MMF. During pregnancy, the appearance of proteinuria greater than 0,5 g/24 h was noted in three pregnancies in the third trimester. Pregnancy hypertension was found in three pregnancies, one of which progressed to pre-eclampsia. As for renal function, it remained stable with an average creatinine level of 10,3 mg/l in the 3rd trimester. Two cases of acute pyelonephritis were noted. No episode of acute rejection was noted during and 3 months after pregnancy. The delivery was performed by caesarean section in 44.4 %, after an average term of 37 week of amenorrhea ± 2.04 with three cases of prematurity. The average birth weight was 3 110 g ± 450 g. There was one case of spontaneous abortion and two cases of fetal death in utero. After post--partum, renal function remained stable in five patients. In six cases, there was impaired renal function either by acute rejection or secondary to chronic allograft nephropathy.. In our department, a quarter of transplant recipients were able to carry a pregnancy with a rate of 89 % of successful pregnancies. Pregnancy after KT requires special planning and monitoring. A multidisciplinary collaboration between transplant nephrologist, gynecologist and pediatrician is necessary by referring to the recommendations.. La transplantation rénale (TR) permet de restaurer la fertilité des femmes en insuffisance rénale chronique terminale (IRCT), leur offrant ainsi la possibilité d’avoir des enfants. Toutefois, la grossesse après greffe rénale est associée à une morbidité materno-fœtale élevée. Le but de ce travail est de rapporter l’expérience de notre service dans les grossesses chez les transplantées rénales.. Nous avons étudié rétrospectivement les dossiers de transplantées ayant eu une ou plusieurs grossesses après TR. Nous avons analysé des paramètres cliniques (tension artérielle, prise de poids, œdèmes, durée de grossesse, complications obstétricales) et biologiques (créatininémie, excrétion urinaire d’albumine).. Entre 1998 et 2020, 21 grossesses ont eu lieu chez 12 transplantées. L’âge moyen des patientes au moment de la conception était de 29 ± 5 ans avec un délai entre la TR et la grossesse de 43 ± 29 mois. Sept grossesses ont débuté avec une hypertension artérielle (HTA) contrôlée sous traitement, la protéinurie avant conception était négative dans toutes les grossesses et la fonction rénale était normale avec une créatininémie moyenne de 10,1 ± 1,27 mg/L. Avant les grossesses, les régimes d’immunosuppression étaient à base d’anticalcineurine (n = 21), associé soit à du mycophénolate mofétil (MMF) (n = 10) soit à de l’azathioprine (n = 8), ou seul (n = 3). Les régimes d’immunosuppression ont tous été associés à une corticothérapie. Trois mois avant la conception, le MMF a été ­relayé par l’azathioprine dans sept grossesses, et trois autres grossesses non programmées ont débuté sous MMF. Au cours des grossesses, on a noté l’apparition d’une protéinurie supérieure à 0,5 g/24 h dans trois grossesses au troisième trimestre. L’HTA gravidique a été retrouvée dans trois grossesses, dont une a évolué vers une pré-éclampsie. Quant à la fonction rénale, elle est restée stable avec une créatininémie moyenne de 10,3 mg/L au troisième trimestre. Deux cas de pyélonéphrite aiguë ont été notés. Aucun épisode de rejet aigu n’a été noté au cours et trois mois après la grossesse. L’accouchement a été réalisé par césarienne dans 44,4 %, après un terme moyen de 37 semaines d’aménorrhée, ± 2,04 avec trois cas de prématurité. Le poids de naissance moyen était de 3 110 g ± 450 g. On a noté un cas d’avortement spontané et deux cas de mort fœtale in utero. Après le post-partum, la fonction rénale est restée stable chez cinq patientes. Dans six cas, on a assisté à une altération de la fonction rénale par un rejet aigu ou secondaire à une néphropathie chronique d’allogreffe.. Dans notre service, un quart des transplantées a pu mener une grossesse avec une productivité de 89 % de ces grossesses. La grossesse après la TR nécessite une planification et une surveillance particulière. Une collaboration multidisciplinaire entre néphrologue transplanteur, gynécologue et pédiatre est nécessaire en se référant aux recommandations.

Topics: Azathioprine; Cesarean Section; Child; Child, Preschool; Creatinine; Female; Graft Rejection; Hospitals; Humans; Hypertension; Immunosuppressive Agents; Kidney Transplantation; Mycophenolic Acid; Pre-Eclampsia; Pregnancy; Pregnancy Complications; Pregnancy Outcome; Retrospective Studies