Pregnancy In Transplant Recipients Research Articles

#1844 Pregnancy outcome among kidney transplant recipients

Abstract Background and Aims Background The possibility of a term pregnancy is one of the benefits of solid organ transplantation for women. The gonadal dysfunction, caused by the failure of the kidney or another organ, is reverted within a few months after normal graft function. Unplanned pregnancies in transplant recipients, however, may compromise graft function and survival, and may also risk unnecessary fetal exposure to immunosuppressive medications. Aims To study the prevalence of pregnancy and pregnancy related complication after kidney transplantation (KT). Method Retrospective cohort study conducted on 236 patients out of 3000 kidney transplant recipient who underwent renal transplantation (RT) at Mansoura Urology and Nephrology Centre between March 1976 and December 2019. divided into group I; 118 kidney transplant female's recipient experienced pregnancy at any time after kidney transplant and group II; 118 kidney transplant female's recipients who didn`t experience pregnancy after renal transplantation, they were matched according to age and duration of renal transplantation and comparable in primary immunosuppressant drugs. all kidney recipients were reviewed for preoperative & operative and post-operative details also we record maternal and fetal complication. Results Prevalence of pregnancy in our center is 191 pregnancies in 118 women who had underwent kidney transplantation between 1976 and 2019. We have found that the mean age of pregnancy between (26.27 ± 4.37-29.89 ± 4.6), the mean gestational age between (33.69 ± 6.4 – 33 ± 7.5) weeks, the live birth rate is 126 (66%). Preterm delivery rate in our study is 85 (44.5%), neonatal death 8 (4.1%), miscarriage 59 (30.9%), intrauterine fetal death 6 (3.1%) and birth defect 4 (2%). The prevalence rates of gestational hypertension is 87 (45.5%), pre-eclampsia 48 (25.1%), gestational diabetes 19 (9.9%), urinary tract infection 36 (18.8%), and graft rejection 8 (4.1%) during pregnancy. caesarean section is the most common method of delivery in our study 133 (69.6%). Kidney transplant recipients who aged more than or equal to 30 years at time of pregnancy are at higher risk for having non live-birth outcome (OR: 3.2, p value: 0.05). Proteinuria more than or equal to 0.5 g/day before pregnancy is a significant risk factor for having non live-birth outcome (OR: 4.7, p value: 0.009). Also, proteinuria ≥0.5 g/day during pregnancy is associated with increases risk for non-live-birth (OR: 10.2, p value: 0.013). Gesatational hypertension is associated with increases risk for non-live-birth (OR: 8.3, p value: 0.010).Preeclampsia is associated with increases risk for non-live-birth (OR: 4.6, p value: 0.005). Conclusion Although the outcome of live births is favourable, the risks of maternal and fetal complications are high in kidney transplant recipients including pregnancy-induced hypertension, increased rates of preeclampsia, gestational diabetes, and caesarean section rates. The risk of miscarriage, prematurity, and low birth rate is also high.

#2252 Outcome of pregnancy after kidney transplantation

Abstract Background and Aims Background The possibility of a term pregnancy is one of the benefits of solid organ transplantation for women. The gonadal dysfunction, caused by the failure of the kidney or another organ, is reverted within a few months after normal graft function. Unplanned pregnancies in transplant recipients, however, may compromise graft function and survival, and may also risk unnecessary fetal exposure to immunosuppressive medications. Aims To study the prevalence of pregnancy and pregnancy related complication after kidney transplantation (KT). Method Retrospective cohort study conducted on 236 patients out of 3000 kidney transplant recipient who underwent renal transplantation (RT) at Mansoura Urology and Nephrology Centre between March 1976 and December 2019. divided into group I; 118 kidney transplant female's recipient experienced pregnancy at any time after kidney transplant and group II; 118 kidney transplant female's recipients who didn't experience pregnancy after renal transplantation, they were matched according to age and duration of renal transplantation and comparable in primary immunosuppressant drugs. all kidney recipients were reviewed for preoperative & operative and post-operative details also we record maternal and fetal complication. Results Prevalence of pregnancy in our center is 191 pregnancies in 118 women who had underwent kidney transplantation between 1976 and 2019. We have found that the mean age of pregnancy between (26.27 ± 4.37 - 29.89 ± 4.6), the mean gestational age between (33.69 ± 6.4 - 33 ± 7.5) weeks, the live birth rate is 126 (66%). Preterm delivery rate in our study is 85 (44.5%), neonatal death 8 (4.1%), miscarriage 59 (30.9%), intrauterine fetal death 6 (3.1%) and birth defect 4 (2%). The prevalence rates of gestational hypertension is 87 (45.5%), pre-eclampsia 48 (25.1%), gestational diabetes 19 (9.9%), urinary tract infection 36 (18.8%), and graft rejection 8 (4.1%) during pregnancy. caesarean section is the most common method of delivery in our study 133 (69.6%). Kidney transplant recipients who aged more than or equal to 30 years at time of pregnancy are at higher risk for having non live-birth outcome (OR: 3.2, p value: 0.05). Proteinuria more than or equal to 0.5 g/day before pregnancy is a significant risk factor for having non live-birth outcome (OR: 4.7, p value: 0.009). Also, proteinuria ≥0.5 g/day during pregnancy is associated with increases risk for non-live-birth (OR: 10.2, p value: 0.013). Gestational hypertension is associated with increases risk for non-live-birth (OR: 8.3, p value: 0.010).Preeclampsia is associated with increases risk for non-live-birth ( OR: 4.6, p value: 0.005). Conclusion Although the outcome of live births is favourable, the risks of maternal and fetal complications are high in kidney transplant recipients including pregnancy-induced hypertension, increased rates of preeclampsia, gestational diabetes, and caesarean section rates. The risk of miscarriage, prematurity, and low birth rate is also high.

Pregnancy after kidney and liver transplantation.

Pregnancy in kidney and liver transplant recipients presents unique challenges and risks for both maternal and fetal health. This article examines the management of pregnancy in kidney and liver transplant recipients, focusing on pre-pregnancy counselling, trimester-specific care, the teratogenic effects of immunosuppressive drugs, and the role of the multidisciplinary team. While South African (SA) data on this topic are limited, the Transplant Pregnancy Registry International has provided valuable insights. Despite the increased risk of maternal and fetal complications, the overall risk of graft loss during pregnancy is low. Graft survival rates are comparable between pregnant and non- pregnant transplant recipients, except for pregnancies occurring within 1 year of transplantation. By addressing the complexities of managing pregnant women with kidney or liver transplants, this article underscores the importance of tailored care and the involvement of various medical specialists. It also explores the safety of and potential complications associated with specific immunosuppressive therapies during pregnancy. Further research is needed to enhance our understanding and optimise the management of these high-risk pregnancies in SA.

Outcomes of Children with Fetal and Lactation Immunosuppression Exposure Born to Female Transplant Recipients.

Solid organ transplantation (SOT) is a lifesaving procedure for those with end-stage kidney, liver, heart, lung, and intestinal diseases, including females of childbearing age who wish to proceed with pregnancy following transplantation. While there is clear risk associated with use of mycophenolate during pregnancy, the risks associated with use of other immunosuppressant agents are less well understood, and the timing of use in pregnancy may be pertinent when considering the risk versus benefit for individual patients. In addition to overall fetal outcomes, including gestational age, birth weight, and mortality, this review summarizes published literature on additional complications that have been examined in association with maternal use during pregnancy and postpartum while breastfeeding. Compared with non-transplant pregnancies, pregnancies in transplant recipients are associated with lower birth weight and earlier gestational age. Effects associated with particular immunosuppressant agents in the infant include renal dysfunction from calcineurin inhibitors, myelosuppression from azathioprine, and decreased circulating immune cells with several agents. However, these effects are noted to primarily be transient, though the decrease in immune cells may predispose the infant to increased infectious complications in the first year of life. Utilizing relative infant dose estimations, nearly all commonly utilized immunosuppressants are likely safe during breastfeeding given the limited exposure to the infant.

Pregnancy Following Heart Transplantation: A Single Centre Case Series and Review of the Literature

Maternal and fetal outcomes of pregnancy amongst cardiac transplant recipients are limited in the current literature. We describe five pregnancies in three cardiac transplant recipients managed between a tertiary centre for obstetric medicine and an associated state-wide transplant centre between 2014-2018, and provide a narrative review of the literature. Pre-conception counselling was undertaken. There were no recent rejection episodes and all women demonstrated good baseline cardiac function. Median maternal age was 27 years (range 23-38 yrs.). Median time from transplantation to pregnancy was 5 years (range 2-14 yrs.). All women were managed with modified immunosuppressant regimens and multidisciplinary care. Cardiac function, tacrolimus levels and renal function were closely monitored with frequent monitoring for common complications of pregnancy. There were no maternal or fetal deaths. There was no evidence of graft rejection and no deterioration in cardiac function. Tacrolimus doses were increased to maintain therapeutic targets. Gestational diabetes occurred in three women and cholestasis of pregnancy occurred in one. Each infant was delivered by vaginal delivery. One mother had postpartum haemorrhage in both pregnancies. Pre-eclampsia did not occur. Median gestation at delivery was 37 weeks (range 35+4-40+5 days) with two preterm deliveries. One (1) infant was born with low birth weight. One (1) infant had jaundice requiring phototherapy. All infants were breastfed. Pregnancy in transplant recipients confers risk to the mother and fetus. Pre-conception counselling, immunosuppressant tailoring and regular monitoring are paramount to avoid rejection and possible teratogenic complications. Favourable pregnancy outcomes are achievable with specialist multidisciplinary care.

A Single Center Analysis of Graft Vasculopathy Post Pregnancy in the Heart Transplant Recipient

Purpose Pregnancy in transplant recipients is becoming more common with improved medication regimens. Pregnancy may increase antibody production and cause stress within the mother's body leading to increase immune system response inducing changes in coronary lumen. This is a single center analysis of transplant graft vasculopathy post pregnancy at our center. No data from the transplant pregnancy registry is available on LHC and vasculopathy data. Per ISHLT report 2017 42% of all heart transplant recipients may experience graft vasculopathy within the first year post transplant. Methods A retrospective study was compiled of all female transplant recipients from 2012-2018 who experienced pregnancy post heart transplant. There were a total of 8 recipients with a total of 12 combined pregnancies. All charts and left heart catherization results post-delivery were reviewed after to one to three months when pre-pregnancy immunosuppression was resumed Results Pre-pregnancy left heart catherization reports in all 8 recipients showed normal coronaries.4 left heart catherization results post pregnancy showed normal coronaries. 2 left heart catherization results showed luminal irregularities. 1 left heart catherization result showed CAV2. One patient did not have a LHC post pregnancy as patient died 6 hours after birth, but left heart catherization results during pregnancy did show luminal irregularities Conclusion Our analysis reflected that 37.5% of patients experienced increased changes in coronary artery lumen post pregnancy (only one confirmed diagnosis of graft vasculopathy (CAV 2) Pregnancy has been shown to influence immune response and B & T cell formation leading to increased chances changes in coronary artery lumen leading to graft vasculopathy. It remains imperative to have a clear and concise plan for pregnancy planning and monitoring pre and post event to prevent luminal changes/graft vasculopathy.

Hypertension in Pregnant Renal and Liver Transplant Recipients

BackgroundPregnancies in transplant recipients involve risks for both grafts and the fetus, and need to be carefully managed. Hypertension is the most frequent complications in pregnant transplant recipients, especially in renal transplant recipients. Strict control of blood pressure is essential for a favorable obstetric outcome and long-term graft survival. The aim of the study was to evaluate the influence of hypertension on obstetric outcome and graft function in pregnant renal transplant recipients (RTR) or liver transplant recipients (LTR) in comparison with healthy pregnant women. Patients and MethodsThis retrospective analysis included 46 RTR and 55 LTR who delivered between the years 2000 and 2014. The control group consisted of 187 nontransplant patients aged 20–45 years who delivered between 2010 and 2013. The analyzed group was divided into 2 subgroups: patients with hypertension and patients without hypertension. Descriptive data analysis, Fisher Exact test, unpaired Student t test, and analysis of the variance were performed. ResultsHypertension prevalence among the RTR, LTR, and control group was 73.5%, 34.5%, and 4.3% respectively. In the RTR group, the mean gestational age at delivery inp patients with hypertension vs without hypertension was 36 vs 34.5 weeks (P < .05); IUGR was diagnosed in 20% vs 8.5% pregnant women (P > .05). In the TRL group, the mean gestational age at delivery in group with hypertension vs without hypertension was 37 vs 3.9 weeks (P < .05); IUGR was diagnosed in 10.5% vs 5% of pregnant women (P > .05). Hypertension in RTR patients had a negative influence on graft function (P > .05). ConclusionHypertension is common in organ recipients, and is associated with adverse pregnancy outcomes and loss of graft function.

Timing of Pregnancy After Kidney Transplantation and Risk of Allograft Failure.

The optimal timing of pregnancy after kidney transplantation remains uncertain. We determined the risk of allograft failure among women who became pregnant within the first 3 posttransplant years. Among 21 814 women aged 15-45 years who received a first kidney-only transplant between 1990 and 2010 captured in the United States Renal Data System, n = 729 pregnancies were identified using Medicare claims. The probability of allograft failure from any cause including death (ACGL) at 1, 3, and 5 years after pregnancy was 9.6%, 25.9%, and 36.6%. In multivariate analyses, pregnancy in the first posttransplant year was associated with an increased risk of ACGL (hazard ratio [HR]: 1.18; 95% confidence interval [CI] 1.00, 1.40) and death censored graft loss (DCGL) (HR:1.25; 95% CI 1.04, 1.50), while pregnancy in the second posttransplant year was associated with an increased risk of DCGL (HR: 1.26; 95% CI 1.06, 1.50). Pregnancy in the third posttransplant year was not associated with an increased risk of ACGL or DCGL. These findings demonstrate a higher incidence of allograft failure after pregnancy than previously reported and that the increased risk of allograft failure extends to pregnancies in the second posttransplant year.

Indoleamine 2,3-dioxygenase (IDO) Activity in Placental Compartments of Renal-Transplanted Pregnant Women

Immunosuppressive drugs change gestational IDO activity at the maternal-fetal interface. Analysis of placental IDO expression and activity, interferon gamma (IFN-γ), and IL-10 expression and NFkB activity in renal transplant recipient women under immunosuppressive treatment. We demonstrated a significant reduction in IDO activity (P = 0.0275) and expression (P = 0.026) and in NFkB activity (P = 0.0176) in the villous region of renal transplanted mother. These findings did not correlate with the higher serum levels of kynurenine (P = 0.002). In the decidual compartment, IDO was immunolocalized mainly on the extravillous cytotrophoblast but did not show significant differences among the experimental groups; kynurenine was significantly higher (P = 0.036) and was inversely proportional to the decidual IFN-γ profile (P = 0.0433). No change was seen in IL-10 levels. NFkB activity was significantly higher in decidual compartment correlating with the higher IDO activity and suggesting that in immunosuppressant pregnancy, IDO activity and expression remain regulated by NFkB. The increased IDO activity in decidua may indicate an attempt to offset the low expression. These findings call attention to the relevance of IDO activity at the maternal interface in pregnant transplant recipients, likely modulated by immunosuppressive agents and associated with a high risk of associated gestational disorders.

Pregnancy Outcomes in Liver and Cardiothoracic Transplant Recipients: A UK National Cohort Study

IntroductionThere are an increasing number of reports of pregnancy in transplant recipients but many questions remain regarding the effect of the transplant on pregnancy outcome, the pregnancy on the graft and the medication on the fetus. The majority of studies reporting outcomes in transplant recipients have focused on women with kidney transplants, and have included retrospective, voluntary registries or single centre studies.MethodsThe UK Obstetric Surveillance System (UKOSS) was used to prospectively identify all pregnant women with a liver or cardiothoracic transplant in the United Kingdom, between January 2007 and January 2012. Data were collected on demographics, transplant characteristics, immunosuppression regimens, antenatal care, maternal, graft and neonatal outcomes. In an exploratory analysis, we tested for associations between “poor fetal outcome” and medications used before or during pregnancy.Results and conclusionsWe report 62 pregnancies in 56 liver transplant recipients and 14 pregnancies in 14 cardiothoracic transplant recipients (including 10 heart, three lung and one heart-lung recipient). Liver transplant recipients, in comparison to cardiothoracic, had similar livebirth rates (92% vs. 87%) but better fetal outcomes (median gestational age 38 weeks vs. 35 weeks; median birthweight 2698 g vs. 2365 g), fewer caesarean deliveries (47% vs. 62%), fewer maternal intensive care (ICU) admissions (19% vs. 29%) and fewer neonatal ICU admissions (25% vs. 54%). Nine women (12%) were taking mycophenolate mofetil at conception, which was associated with adverse fetal outcomes. Pregnancy in transplant recipients may have successful outcomes, but complication rates are high, emphasising the role of pre-conception counselling and further research into the long-term effect on maternal and graft survival rates.

THU0264 Efficacy and Safety of Cyclosporine-A During Pregnancy in Autoimmune Diseases

BackgroundCyclosporin-A (CYS-A) is an immunosuppressant agent widely used in the context of anti-rejection therapy. In Rheumatology it’s indicated for Rheumatoid Arthritis (RA) and Psoriasic Arthritis (PA), but it’s also administered...

Pregnancy and delivery after liver transplantation

⁎ Corresponding author at: Merkur University Hospital, Zajceva 19, 10000 Zagreb, Croatia. Tel.: +385 994888617. E-mail address: zanazegarac@yahoo.com (Ž. Žegarac). Pregnancy in liver transplant patients is associated with an increased risk of hypertension, pre-eclampsia, preterm delivery, and neonates of low birth weight due to immunosuppressive therapy [1]. Pregnant liver transplant recipients experience a higher incidence of hypertension (34% vs 4%–10%) and preeclampsia (22% vs 6%–8%) compared with the general pregnant population [2,3]. The most common fetal complications in pregnant transplant recipients compared with the general population include prematurity, low birth weight (less than 2500 g), and intrauterine growth restriction [2,4]. The incidence of fetal malformations does not appear to be increased in posttransplant pregnant women compared with the general population, and is approximately 3% [2]. Pregnancies that occur within 12 months of transplantation have a higher incidence of preterm delivery (58% vs 29%), acute rejection of the graft or transplanted liver (50% vs 29%), and cesarean delivery (50% vs 24%) compared with those that occur after 1 year. Cesarean delivery is not indicated for women who have undergone a liver transplant [2]. The present paper reports a successful pregnancy and delivery in a 30-year-old liver transplant recipient who conceived spontaneously 2 years after transplantation. The patient was born in 1976 and received a diagnosis of Wilson disease in 1991. She delivered a male infant in 2001. In 2003, the patient had a therapeutic abortion at 12 weeks of pregnancy owing to portal hypertension. The patient underwent liver transplantation in October 2003 because of advanced liver cirrhosis secondary to a hepatic form of Wilson disease. In 2005, she conceived spontaneously for a third time. Cyclosporine was administered during pregnancy for immunosuppression and whole-blood concentration levels were monitored regularly. The results of all biochemical tests during pregnancy were normal, except platelet count, which ranged from 49–85×10/L. Thrombocytopenia was present before pregnancy, probably as a consequence of spleen enlargement. Fetal ultrasound findings were normal, with fetal growth and development appropriate for gestational age. The patient delivered a male neonate vaginally at 40 weeks of pregnancy. The neonate weighed 4110 g at birth, measured 52 cm in length, and had an Apgar score of 10 at 1, 5, and 10 minutes. Cyclosporine is a potent immunosuppressive medication that may induce vascular endothelial cell dysfunction and reduce nitric oxide production, which may be linked to the development of hypertension [3]. Pregnancy in a patient with previous liver transplantation should be monitored closely. A multidisciplinary approach in pregnancy care is recommended and requires high compliance and motivation of the pregnant patient.

Use of cyclosporine in uterine transplantation.

Uterine transplantation has been proposed as a possible solution to absolute uterine factor infertility untreatable by any other option. Since the first human attempt in 2000, various teams have tried to clarify which immunosuppressant would be most suitable for protecting the allogeneic uterine graft while posing a minimal risk to the fetus. Cyclosporine A (CsA) is an immunosuppressant widely used by transplant recipients. It is currently being tested as a potential immunosuppressant to be used during UTn. Its effect on the mother and fetus and its influence upon the graft during pregnancy have been of major concern. We review the role of CsA in UTn and its effect on pregnant transplant recipients and their offspring.

Novel Influenza A (H1N1/09) Virus Infection during Pregnancy in a Kidney Transplant Recipient

We report the first case of a pregnant renal transplant patient with H1N1/09 infection. The woman showed a mild clinical course after diagnosis of H1N1/09 infection and therapy with oseltamivir (2 × 45 mg per day). After delivery by cesarean section, the neonate exhibited moderate respiratory and circulatory dysregulation, which spontaneously normalised a few days postpartum. In conclusion, rapid diagnosis of H1N1/09 and dose-adapted therapy with oseltamivir resulted in successful delivery of a healthy infant in our renal transplanted patient but emphasized the need for consequent vaccination strategies in pregnant transplant recipients for new influenza A pandemics in the future.

Pregnancy and liver transplantation

Since the first pregnancy in a transplant recipient in 1958, pregnancy in recipients of solid organ transplants has become increasingly common. Although previously considered a hazardous event, data collected over the last 50 years demonstrate that despite an increased risk of maternal and fetal complications, pregnancy in transplant recipients can have a successful outcome. As of 2006, there were over 3000 female liver transplant recipients of childbearing age in the USA. Two hundred and two pregnancies and 205 outcomes were reported in 121 liver transplant recipients in the National Transplantation Pregnancy Registry. Children born to female liver recipients have a greater risk of prematurity and low birth weight than the general population, but no malformation patterns have been observed. Mothers are more likely to experience pregnancy-induced hypertension, pre-eclampsia and caesarian section, but overall mortality is not worse. Rates of acute rejection and graft loss are similar to nonpregnant liver recipients. The optimal timing of conception post-transplant is controversial, but current recommendations suggest waiting for at least 1 year after transplantation. Choice of contraception is also debatable, although barrier methods have traditionally been preferred. Many medications used for post-transplant immunosuppression have potential effects during pregnancy and breast-feeding. The risks and benefits of each medication should be reviewed with patients contemplating pregnancy, and regimens should be tailored accordingly.

Pregnancy after Kidney Transplantation

Reproductive success is a common, expected outcome for male and female recipients of solid-organ transplants. Men can father children, and women can become pregnant and carry the fetus to delivery. There are, however, important maternal and fetal complications that need to be considered to provide optimal care to the mother and her infant. Although pregnancy is common after the transplantation of all solid organs, guidelines for optimal counseling and clinical management are limited. This review discusses information to help the physician counsel the kidney transplant recipient about risks of pregnancy for the mother and the fetus and provides information to help guide treatment of the pregnant transplant recipient.

Nutrition, Pregnancy, and Transplantation

One benefit of transplantation, along with the restoration of health, is the opportunity for successful pregnancies. A growing number of pregnancies have been reported among all types of solid-organ recipients. There is an increasing need for practice guidelines that include nutrition information in order to assist practitioners caring for and counseling these high-risk patients. In the transplant community, guidelines for managing pregnancies in transplant recipients have been evolving but lack specific nutrition recommendations. As for all pregnancies, there is a need to optimize nutrition for the mother and her infant, with additional consideration given to the transplant recipient's graft. This article reviews outcomes of posttransplant pregnancies and management guidelines, with special emphasis on nutrition in this unique population.

Considerations in the Medical Management of Pregnancy in Transplant Recipients

Pregnancy, although rare in the patient with end-stage renal disease, is not uncommon in the transplant recipient. Physicians taking care of transplant recipients must be able to inform patients about the potential risks of pregnancy in this setting. The patient and her partner must know that the risks associated with pregnancy increase with worsening kidney function and hypertension. Current consensus opinion is that pregnancy can be relatively safely undertaken by 1 year after transplant if the patient has had no rejections during the year, allograft function is adequate, there are no infections that could affect the fetus, the patient is not taking teratogenic medications, and immunosuppressive medication dosing is stable. Consideration must be given to immunosuppression during pregnancy both with respect to the specific agents as well as the level of dosing. None of the medications are FDA category A; all are B or higher. Part of planning for pregnancy should include an evaluation of immunosuppression medication and a plan to modify the regimen prior to conception if its use may be risky for the developing fetus. Rejection can occur during a kidney transplant, so maintaining adequate immunosuppression is important. Other issues that need to be managed when caring for a pregnant transplant patient include: potential for infection (urinary tract infections are very common), hypertension, and anemia. The type of delivery, posttransplant contraception, and breast-feeding also need to be addressed.

Medications During Pregnancy: Antihypertensives and Immunosuppressives

Use of prescription and nonprescription medications is common during pregnancy and is required in many women with underlying kidney disease or hypertension and in all with solid-organ allografts. Systematic assessment of drug safety during pregnancy is lacking, as are rigorous and comprehensive studies of pharmacokinetics and pharmacodynamics to guide drug selection and dosing across pregnancy. Renal and hepatic clearances of many drugs change markedly during pregnancy and pitfalls may complicate routine therapeutic monitoring of some drugs during pregnancy. However, available data and clinical experience allow reasonable strategies for selection and dosing of immunosuppressive agents in pregnant transplant recipients and of antihypertensive agents in women with mild or more severe hypertension complicating their pregnancies.

Ethical Considerations Related to Pregnancy in Transplant Recipients

Ethical Considerations Related to Pregnancy in Transplant Recipients