What is the recommended management plan for a woman of child‑bearing age with chronic kidney disease who becomes pregnant, including medication adjustments, blood pressure targets, monitoring, dialysis indications, and delivery timing?

Management of Chronic Kidney Disease in Pregnancy

Women with CKD who become pregnant require immediate medication adjustments (discontinuing ACE inhibitors, ARBs, and SGLT2 inhibitors), blood pressure control targeting 110-140/85 mmHg using methyldopa, labetalol, or nifedipine, intensive multidisciplinary monitoring for superimposed preeclampsia and fetal growth restriction, and consideration for early dialysis at approximately 36 hours per week if renal function deteriorates significantly. 1, 2

Preconception Counseling and Risk Stratification

• Counsel all women with CKD about pregnancy risks before conception, including the 40% risk of permanent worsening of renal function in those with incipient renal failure 2
• Perform baseline assessment of kidney function, blood pressure, and proteinuria before conception to establish a reference point for pregnancy monitoring 2
• Women with advanced CKD face substantially worse maternal and fetal outcomes compared to the general population, even when CKD is mild 1
• Provide genetic counseling for women with hereditary kidney diseases like autosomal dominant polycystic kidney disease 1, 3

Immediate Medication Adjustments

Discontinue Teratogenic Medications

• Stop ACE inhibitors, ARBs, ARNi, MRA, and SGLT2 inhibitors immediately upon pregnancy confirmation or ideally before conception, as these cause renal dysgenesis and fetal harm in the second and third trimesters 1, 2
• Review all medications for teratogenicity potential and adjust dosing based on GFR for renally cleared drugs 1
• Discontinue ivabradine if being used 1

Safe Antihypertensive Options

• Methyldopa remains the first-line agent (750 mg to 4 g daily in divided doses) due to the best long-term safety record with no adverse effects on mothers or babies 1, 4
• Labetalol (100 mg twice daily up to 2400 mg daily) is an acceptable alternative, offering alpha-beta blockade with vasodilation 1, 4
• Long-acting nifedipine is safe throughout pregnancy, though avoid sublingual or IV administration due to risk of excessive BP reduction causing myocardial infarction or fetal distress 1, 4
• Hydralazine should be reserved as a second or third-line agent when first-line medications fail to control severe hypertension 1, 4

Blood Pressure Management

Target Blood Pressure

• Maintain BP at 110-140/80-85 mmHg throughout pregnancy to reduce accelerated maternal hypertension without compromising placental perfusion 1, 2
• Treat BP urgently when ≥160/110 mmHg in a monitored setting using oral nifedipine or IV labetalol/hydralazine 1
• The CHIPS trial demonstrated that targeting diastolic BP of 85 mmHg reduced accelerated maternal hypertension without adverse neonatal outcomes 1

Monitoring Strategy

• Weekly home blood pressure monitoring is recommended, particularly with pre-existing hypertension 2
• Verify home BP device accuracy against a sphygmomanometer, as approximately 75% of devices are accurate 1
• Avoid excessive BP reduction, as meta-analysis shows a direct linear relationship between treatment-induced fall in mean arterial pressure and small-for-gestational-age infants 4

Intensive Monitoring Protocol

Maternal Monitoring

• Monitor eGFR, electrolytes, and proteinuria frequently throughout pregnancy, with more intensive monitoring for those with pre-existing hypertension 1, 2
• Perform clinical assessment and blood tests (hemoglobin, platelet count, liver transaminases, uric acid, creatinine) at minimum at 28 and 34 weeks 1
• Screen for superimposed preeclampsia at every visit using urinalysis, clinical assessment, and laboratory monitoring, as women with CKD face substantially higher risk 1, 2
• Perform monthly urinalysis and treat asymptomatic bacteriuria with appropriate antibiotics to prevent pyelonephritis 2

Fetal Monitoring

• Assess fetal well-being with ultrasound from 26 weeks' gestation, then at 2-4 week intervals if fetal biometry is normal 1
• Monitor more frequently if fetal growth restriction is suspected, particularly if maternal uric acid is elevated 1
• Consider routine echocardiographic screening in the third trimester for reassessment of maternal cardiac function before labor 1

Dialysis Management for Progressive Disease

• Initiate early dialysis with an aggressive prescription of approximately 36 hours per week for women with progressive renal disease in pregnancy, as this conveys the best maternal and fetal outcomes 1, 2
• Volume overload may increase and reduce drug responsiveness, requiring salt restriction, loop diuretics, or intensified dialysis 1
• Intensive hemodialysis regimens improve obstetric outcomes in women with end-stage kidney disease 3, 5

Prevention of Complications

Preeclampsia Prevention

• Administer low-dose aspirin from the first trimester until 36 weeks gestation to reduce preeclampsia risk 2
• Monitor closely for developing preeclampsia, as at least 25% of women with gestational hypertension progress to preeclampsia 1
• Increasing proteinuria in women with pre-existing kidney disease can mask superimposed preeclampsia, requiring heightened clinical vigilance 1

Other Preventive Measures

• Screen regularly for gestational diabetes, especially in women on glucocorticoid treatment 2
• Use diuretics cautiously and only in combination with other drugs, particularly when vasodilators exacerbate fluid retention, as they reduce plasma volume expansion and may promote preeclampsia 1, 2
• Diuretics are contraindicated when utero-placental perfusion is already reduced in preeclampsia with fetal growth retardation 1

Delivery Planning

Timing of Delivery

• Delivery timing should be determined based on maternal and fetal status, with consideration for preterm delivery if maternal condition worsens 2
• For women with gestational hypertension without preeclampsia features, delivery at 39 weeks appears optimal if BP is controlled and fetal monitoring is reassuring 1
• Indications for earlier delivery include worsening maternal condition, laboratory evidence of end-organ dysfunction, or fetal distress 1

Mode of Delivery and Peripartum Care

• Vaginal delivery with epidural analgesia and elective instrumental delivery is recommended for most patients, including those with severe hypertension 1
• Administer steroids 48 hours before delivery to accelerate lung maturation if gestation is <34 weeks 1, 2
• Delivery is the only definitive treatment for preeclampsia 1

Postpartum Management

• Women with CKD should be seen by a nephrologist within 6 months after delivery for postpartum kidney function review 2
• For women who choose to breastfeed, review medications with neonatology teams; ACE inhibitors (enalapril or captopril preferred) and beta blockers (metoprolol preferred) may be appropriate with neonatal monitoring 1
• Communicate clear plans for restarting medications discontinued during pregnancy or delivery 1

Multidisciplinary Team Approach

• All pregnancies in women with CKD require collaborative multidisciplinary care including nephrologists experienced in pregnancy management, maternal-fetal medicine specialists, high-risk pregnancy nursing staff, dieticians, and pharmacists 6, 7, 8
• Access to skilled neonatologists and neonatal intensive care unit support is essential given risks for preterm delivery 6
• High-risk patients should be managed in specialized centers with comprehensive support services 1, 6

Common Pitfalls to Avoid

• Never continue ACE inhibitors or ARBs during pregnancy despite their renal protective effects outside pregnancy, as they cause severe fetal harm 1, 2
• Avoid aggressive BP lowering that compromises placental perfusion, as this increases risk of small-for-gestational-age infants 4
• Do not use sublingual or IV nifedipine due to risk of excessive BP reduction 1
• Avoid prostaglandin F compounds if pregnancy termination is needed, as they increase pulmonary artery pressure and decrease coronary perfusion 1
• Do not fail to restart essential medications postpartum, as unintentional discontinuation leads to harm 1