Classification of aspects
Aspects of management
Medications
• Selection and adjustment of immunosuppressant and other medications for CKD (Table 5.2)
• Low-molecular-weight heparin, which is recommended to prevent thrombosis in patients with nephrotic syndrome and high risk of thrombus formation
• Low-dose aspirin (50–100 mg/day) until 28 weeks of gestation
• Calcium monitoring and supplementation
• Folic acid (5 mg/day)
Blood pressure
• Use of antihypertensive drugs considered safe in pregnancy to enhance blood pressure control (Table 5.2)
• Blood pressure target of 130–140/80–90 mmHg
• Use of family self-test sphygmomanometer and recording of daily blood pressure at home
• Recording of blood pressure at each follow-up
Laboratory examination
• Renal function (including SCr and serum urea levels, CCr rate, and proteinuria) should be examined at least once a month, depending on the severity and progression of kidney disease
• Recording of baseline serum uric acid and liver enzyme levels, platelet count, and proteinuria, which is useful for the differential diagnosis of suspected PE after pregnancy
• Glucose tolerance test, especially for pregnant women treated with glucocorticoid or calcineurin inhibitors
Fetal monitoring
• Biophysical profile
• Assessment of fetal growth and development
• Evaluation of placental function once a month in the first trimester of pregnancy, once every 2 weeks in the second trimester of pregnancy, and once a week in the third trimester of pregnancy
Delivery
• If the condition is stable and no obstetric-related indication for cesarean section exists, vaginal delivery is performed as much as possible
• Termination of pregnancy if the condition is aggravated, endangering the lives of both the fetus and pregnant woman
• If delivery is expected to be less than 34 weeks, glucocorticoid is administered prior to delivery to promote fetal lung maturation
• Intermittent oxygen therapy, if necessary
• Stress dose of hydrocortisone may be administered, if necessary
Drugs | Permeability of the placenta | Teratogenic effects | Effects on the fetus and newborn | Safety in pregnancy | Safety in lactation |
|---|---|---|---|---|---|
Immunosuppressant | |||||
Prednisone | Limited | The incidence of cleft palate may be increased | Infrequent; large dosage can lead to cataract, infection, and adrenal insufficiency | Maternal side effects include bone loss and osteonecrosis, gestational diabetes, hypertension, cataract, and adrenal insufficiency | Yes; breastfeeding is not recommended at doses greater than 60 mg/day |
Azathioprine | Yes | No | Transient immune changes in newborns | Yes | Yes |
Tacrolimus/Cyclosporine A | Yes | No | Hypokalemia and renal insufficiency | Yes; increasing the dose is often required | Yes; 0.23–0.50% of dose adjusted for maternal body weight is secreted into breast milk |
Mycophenolate mofetil | Yes | The incidence rate of congenital malformations is 22.9%, which include cleft lip and palate; absence of the ear canal; considerable distance between organs; small ear, fifth finger, and limb deformities; and toe hypoplasia | No | No; should be stopped before conception | No |
Cyclophosphamide | Yes | Yes | Chromosomal abnormalities and leukopenia | No; should be stopped before conception | No |
Antihypertensive agents | |||||
Methyldopa | Yes | No | No | Top choice; restrict use when adverse events such as lethargy occur | Yes |
Beta blocker | Yes | No | Some studies indicate limited fetal growth; the use of atenolol in the first trimester of pregnancy leads to bradycardia | Labetalol is preferred | It can be secreted to breast milk, but no adverse reactions have been reported |
Calcium channel blocker (nifedipine, amlodipine) | Yes | No | No | Second-line drugs commonly used in combination with methyldopa and labetalol | It can be secreted to breast milk (<5% therapeutic dose), but no adverse reactions have been reported |
Diuretic (furosemide, hydrochlorothiazide) | Yes | No | Can cause fetal diuresis | In theory, it can reduce intravascular volume and placental perfusion. It can be carefully used in patients with excess fluid or refractory hypertension | Mother will exhibit polydipsia, and large doses can inhibit lactation |
Hydralazine hydrochloride | Yes | No | No | Often combined with sympathetic nerve blockers to prevent reflex tachycardia | It can be secreted to breast milk, but no adverse reactions have been reported |
ACEI/ARB | Yes | Teratogenic effects include neonatal anuria and renal insufficiency, limb contracture, craniofacial deformity, pulmonary dysplasia, and patent ductus arteriosus | Owing to renal papillary atrophy and disorders that prevent the establishment of renal medullary concentration gradients, long-term application can lead to renal insufficiency and impaired kidney function with regard to the concentration of urine | No; should be stopped before conception | A small amount of enalapril, captopril, and quinapril is secreted to breast milk, and no adverse reactions have been reported |
Other drugs | |||||
Recombinant EPO | No | No reports | No reports | Yes; increase the dose according to the need, which may cause hypertension | May be safe; protein may be damaged in the gastrointestinal tract of the infant |
Intravenous iron | Yes | No reports | No reports | Yes | May be safe |
Calcium-containing phosphate binder (calcium carbonate) | Yes | No reports | No reports | Yes | May be safe |
Calcium-free phosphate binder (sevelamer, lanthanum carbonate) | NA | Animal studies show reduction in osteogenesis or osteogenic irregularity | NA | No; should be stopped before conception | No |
Calcimimetics (cinacalcet) | NA | Animal studies show low risk | NA | Its use in patients with hypercalcemia can be continued | No |
Sodium hydrogen carbonate | Yes | No reports | No reports | Yes | May be safe |
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