How should a woman with chronic kidney disease who is pregnant or planning pregnancy be managed regarding medication adjustments, monitoring, delivery planning, and postpartum care?

Management of Chronic Kidney Disease in Pregnancy

Women with CKD who are pregnant or planning pregnancy require immediate discontinuation of ACE inhibitors, ARBs, and SGLT2 inhibitors, strict blood pressure control to 110-140/80-85 mmHg using methyldopa or labetalol, and coordinated care by a multidisciplinary team including nephrologists and maternal-fetal medicine specialists throughout pregnancy and postpartum. 1

Preconception Counseling and Risk Stratification

All women with CKD contemplating pregnancy must undergo comprehensive preconception counseling with a nephrologist to assess maternal cardiac, obstetric, and fetal risks. 2 Women with advanced CKD face markedly elevated maternal and fetal morbidity even when baseline disease is mild. 1

Risk Assessment Framework

• Baseline renal function is the single most important prognostic factor for both maternal and fetal outcomes. 3, 4
• Women with serum creatinine <1.3 mg/dL generally have successful pregnancies without accelerated renal decline. 5
• Women with moderate-to-severe renal impairment (creatinine >1.3 mg/dL) face 40% risk of permanent worsening of kidney function during pregnancy. 1, 6
• Genetic counseling should be offered for hereditary conditions such as autosomal dominant polycystic kidney disease. 1

Immediate Medication Adjustments

Discontinue Teratogenic Medications Immediately

ACE inhibitors, ARBs, angiotensin receptor-neprilysin inhibitors (ARN-I), mineralocorticoid receptor antagonists (MRAs), and SGLT2 inhibitors must be stopped immediately upon pregnancy confirmation or ideally before conception because they cause fetal renal dysgenesis and severe harm in the second and third trimesters. 1 This is a Level A recommendation with absolute contraindication. 1, 6

Additional medications to discontinue:

• Ivabradine must be stopped in pregnant patients. 1
• All medications require review for teratogenic potential and dose adjustment based on estimated GFR for renally cleared agents. 1

Safe Antihypertensive Options

Methyldopa is the first-line antihypertensive agent in pregnancy with the longest safety record and no adverse maternal-fetal effects. 1 This represents Level B evidence from the European Society of Cardiology. 1

Labetalol is the preferred alternative, providing combined α- and β-blockade with vasodilatory properties. 1, 7 Level B evidence supports its use. 1

Long-acting nifedipine is safe throughout gestation and represents the strongest safety data with once-daily dosing convenience. 1, 7 Critical caveat: Never use sublingual or intravenous nifedipine due to risk of abrupt blood pressure fall causing fetal distress. 1

Hydralazine may be used as second- or third-line therapy when first-line agents fail to achieve target blood pressure. 1

Blood Pressure Management Protocol

Target Blood Pressure Goals

Maintain systolic blood pressure between 110-140 mmHg and diastolic blood pressure between 80-85 mmHg throughout pregnancy. 1, 7 This Level A recommendation balances maternal hypertension control with adequate placental perfusion. 1

The landmark CHIPS trial demonstrated that targeting diastolic blood pressure of 85 mmHg reduces accelerated maternal hypertension without adverse neonatal outcomes. 1 This represents the highest quality evidence (Level A) for blood pressure targets. 1

Management of Severe Hypertension

Treat severe hypertension urgently when blood pressure reaches ≥160/110 mmHg in a monitored setting using oral nifedipine or intravenous labetalol/hydralazine. 1 This is a Level A recommendation. 1

Intensive Monitoring Protocol

Maternal Monitoring Schedule

Perform serial assessment of eGFR, electrolytes, and proteinuria throughout pregnancy, with intensified frequency for women with pre-existing hypertension. 1

Obtain comprehensive laboratory panels (hemoglobin, platelets, liver enzymes, uric acid, creatinine) at ≥28 weeks and ≥34 weeks gestation. 1 This timing captures the critical third-trimester period when complications accelerate.

Screen for superimposed preeclampsia at every prenatal visit using urinalysis, clinical assessment, and laboratory testing. 1 Approximately 25% of women with gestational hypertension progress to preeclampsia, and rising proteinuria in CKD can mask this diagnosis. 1

Fetal Monitoring Schedule

Begin fetal ultrasound at 26 weeks gestation, then repeat every 2-4 weeks if biometry remains normal. 1 This represents expert consensus from the Hypertension Society. 1

Increase ultrasound frequency when fetal growth restriction is suspected, especially if maternal uric acid is elevated. 1

Perform routine third-trimester echocardiography to reassess maternal cardiac function before labor in high-risk patients. 1

Dialysis Management for Progressive Disease

Initiate early intensive hemodialysis at approximately 36 hours per week for pregnant women with deteriorating renal function, as this regimen yields the best maternal and fetal outcomes. 1 This is Level B evidence. 1

In the setting of volume overload, implement salt restriction, loop diuretics, or intensified dialysis to improve drug responsiveness. 1

Preeclampsia Prevention

Administer low-dose aspirin (75-162 mg daily) from the first trimester until 36 weeks gestation to reduce preeclampsia risk in high-risk women. 7

Provide calcium supplementation of 1.5-2 g/day for women with low dietary calcium intake (<600 mg/day). 7

Delivery Planning

Timing of Delivery

For gestational hypertension without preeclampsia, plan delivery at 39 weeks when blood pressure is controlled and fetal monitoring is reassuring. 1 This is Level A evidence. 1

Indications for earlier delivery include:

• Worsening maternal status
• Laboratory evidence of end-organ dysfunction
• Fetal distress 1

Mode of Delivery

Vaginal delivery with epidural analgesia and elective instrumental assistance is recommended for most CKD pregnancies, including those with severe hypertension. 1 This is Level B evidence from the European Society of Cardiology. 1

Administer antenatal corticosteroids ≥48 hours before planned delivery when gestational age is <34 weeks to promote fetal lung maturation. 1

Delivery remains the definitive treatment for preeclampsia. 1

Postpartum Management

Breastfeeding mothers should have medication regimens reviewed; ACE inhibitors (enalapril, captopril) and β-blockers (metoprolol) may be used with neonatal monitoring. 1

Systematically re-initiate all essential medications discontinued during pregnancy promptly after delivery. 1 Failure to restart postpartum medications can lead to maternal renal deterioration and adverse outcomes. 1

Women with CKD should be seen by a nephrologist within 6 months after delivery for postpartum kidney function review. 1, 6

Multidisciplinary Team Approach

Management requires coordinated care among nephrologists, maternal-fetal medicine specialists, high-risk obstetric nurses, dietitians, and pharmacists, preferably in specialized high-risk centers. 1 This represents expert consensus from multiple societies. 2, 1, 4

Critical Pitfalls to Avoid

Never continue ACE inhibitors or ARBs during pregnancy due to severe fetal toxicity causing renal dysgenesis. 1, 6 This is Level A evidence with absolute contraindication. 1

Avoid sublingual or intravenous nifedipine because of risk of abrupt blood pressure fall and fetal compromise. 1

Do not use prostaglandin F₂α agents for pregnancy termination in CKD patients, as they increase pulmonary artery pressure and reduce coronary perfusion. 1

Never fail to restart essential postpartum medications, as this leads to maternal renal deterioration. 1

Do not use diuretics as monotherapy; they should only be used in combination with other antihypertensive agents, particularly when vasodilators exacerbate fluid retention. 1