Pregnancy after transplantation

Abstract

The first known posttransplant pregnancy occurred in 1958 in a renal transplant recipient who had received a graft from her identical twin sister. That delivery, and the events preceding it, although not reported until 1963, heralded the start of interdisciplinary cooperation that has now coped worldwide with thousands of pregnancies in women with all types of solid organ transplants. Important case reports and single center experiences appeared in the 1970s and intermittently thereafter, but over the last decade, registry data have proved crucial in providing clinicians with timely and relevant information. The National Transplantation Pregnancy Registry (NTPR) was established in 1991 at Thomas Jefferson University in Philadelphia to study the outcomes of pregnancies in transplant recipients, as well as pregnancies fathered by male transplant recipients. Since then, the NTPR has encouraged continued surveillance and reporting of pregnancies throughout the United States and stimulated the establishment of national registries in other countries. When prepregnancy recipient graft function is stable and adequate, recipients can be expected to tolerate pregnancy well. Each group of organ transplant recipients presents its own spectrum of issues and problems, specific to the type of transplanted organ as well as the original disease process. With the exception of monitoring organ-specific dysfunction parameters in renal allograft transplant recipients and to some extent in liver transplant recipients, it has proved difficult to identify specific prepregnancy markers or predictors of adverse events. Graft function can deteriorate unexpectedly, unpredictably, and occasionally, irreversibly in some women with or without the occurrence of rejection episodes. To date there is no evidence of specific structural malformations among the children, but there appears to be an ever-present risk of prematurity and/or low birth weight. Follow-up studies of these children provide an opportunity to investigate drug effects on germ cell lines as a result of immunosuppressive exposure during development. Thus, the overall consensus is that pregnancy can be safe and successful in women with a solid organ transplant. Data from the NTPR have done much to consolidate the reassurances from publications of smaller experiences. Important future issues include reassessment of prepregnancy guidelines, gestational and organ-specific problems, the role of new immunosuppressive drugs, and the remote effects of pregnancy on both graft prognosis and the children.