What are the current guidelines for pre‑conception assessment and obstetric management of a woman with chronic kidney disease planning pregnancy?

CKD in Pregnancy: Pre-Conception Assessment and Obstetric Management Guidelines

All women with chronic kidney disease planning pregnancy must receive comprehensive pre-pregnancy counseling with multidisciplinary team involvement, including nephrology and maternal-fetal medicine specialists, to assess and mitigate the substantial risks of maternal renal deterioration, pre-eclampsia, preterm delivery, and fetal complications. 1, 2

Pre-Conception Assessment

Risk Stratification

• Assess baseline renal function with serum creatinine, estimated GFR, and quantify proteinuria using urinary albumin-to-creatinine ratio before conception 1, 3
• Counsel women that pregnancy carries a 40% risk of permanent worsening of renal function in those with incipient renal failure, making pre-pregnancy assessment critical 1, 3
• Evaluate blood pressure control and document presence of pre-existing hypertension, as this significantly impacts maternal and fetal outcomes 1, 4
• Review underlying kidney disease etiology including lupus nephritis, diabetic nephropathy, or other conditions that may require specific management adjustments 5, 2

Medication Review and Optimization

• Discontinue all teratogenic medications prior to conception, particularly ACE inhibitors, ARBs, mycophenolate mofetil, and cyclophosphamide 1, 3, 6
• Substitute safe alternatives for blood pressure control including labetalol, methyldopa, or nifedipine long-release as first-line agents 1, 3
• Review all medications for renal dosing adjustments based on current GFR, as kidney clearance affects drug levels 1
• Do not restart teratogenic medications until breastfeeding is completed postpartum 1

Metabolic and Comorbidity Assessment

• Screen for metabolic abnormalities with fasting glucose, 2-hour glucose tolerance test, and lipid profile before conception 7
• Assess and optimize anemia, vitamin D deficiency, and bone mineral disease as pregnancy exacerbates these conditions 6
• Evaluate cardiovascular risk factors including hypertension severity and proteinuria level, which predict adverse outcomes 4, 2

Obstetric Management During Pregnancy

Monitoring Intensity

• Follow renal function at regular intervals throughout pregnancy with more frequent monitoring as disease severity increases 1, 2
• Monitor blood pressure, kidney function, and proteinuria frequently, with weekly home blood pressure monitoring recommended for those with pre-existing hypertension 1
• Screen regularly for pre-eclampsia, recognizing that diagnosis is complicated by pre-existing hypertension and proteinuria but can be improved with vasoactive biomarkers and placental/fetal Doppler ultrasound 1, 6

Blood Pressure Management

• Target blood pressure of 110-140/85 mmHg throughout pregnancy 1, 3
• Use labetalol, methyldopa, or nifedipine long-release as first-line agents for hypertension control 1, 3
• Use diuretics cautiously and only in combination with other drugs, particularly when vasodilators exacerbate fluid retention 1

Prevention of Complications

• Administer low-dose aspirin from the first trimester (week 12) until 36 weeks gestation to reduce pre-eclampsia risk 1, 7
• Perform monthly urinalysis and treat asymptomatic bacteriuria with appropriate antibiotics to prevent pyelonephritis 1
• Monitor for gestational diabetes, especially in women on glucocorticoid treatment 1

Management of Progressive Renal Dysfunction

• Initiate early dialysis with aggressive prescription of approximately 36 hours per week for those with progressive renal disease during pregnancy, as this conveys the best maternal and fetal outcomes 1, 8
• Consider intensified hemodialysis through longer and/or more frequent sessions, most conveniently offered in the patient's home when possible 8

Delivery Planning

• Determine timing of delivery based on maternal and fetal status, with consideration for preterm delivery if maternal condition worsens 1
• Administer steroids 48 hours before delivery to accelerate lung maturation if gestation is <34 weeks 1

Multidisciplinary Team Composition

Assemble a collaborative team including:

• Nephrologists experienced in managing kidney disease in pregnancy 2
• Maternal-fetal medicine specialists 1, 2
• High-risk pregnancy nursing staff 2
• Anesthesiologists experienced in high-risk obstetrics 2
• Dieticians and pharmacists 2
• Neonatologists with neonatal intensive care unit support given high preterm delivery risk 2

Expected Adverse Outcomes

Women with CKD face significantly elevated risks compared to controls:

• Pre-eclampsia occurs in 20% (vs 4% in controls) 4
• Small for gestational age infants in 23% (vs 10% in controls) 4
• Preterm delivery (<37 weeks) in 31% (vs 8% in controls) 4
• Pregnancy loss in 14% (vs 3% in controls) 4
• These risks increase incrementally with severity of CKD and degree of proteinuria 6

Postpartum Care

• Arrange nephrologist follow-up early and within 6 months after delivery for postpartum kidney function review 1, 3
• Monitor for progression to chronic kidney disease or end-stage renal disease, as pregnancy-related acute kidney injury increases this risk 3

Critical Pitfalls to Avoid

• Do not underestimate pregnancy risks in women with moderate CKD, as even stage 2-3 disease carries substantial maternal and fetal complications 2, 6
• Do not delay dialysis initiation in women with progressive azotemia during pregnancy, as early aggressive dialysis improves outcomes 1, 8
• Do not continue ACE inhibitors or ARBs even briefly into pregnancy, as teratogenic effects occur early 1, 3
• Do not assume pre-eclampsia cannot occur in women with pre-existing proteinuria and hypertension; use additional diagnostic tools including biomarkers and Doppler studies 6