Bronisława Pietrzak

Menstrual Function in Female Liver Transplant Recipients of Reproductive Age

BACKGROUND AND AIM End-stage liver failure is associated with severe abnormalities in menstrual and reproductive function. These abnormalities may be reversed by successful orthotopic liver transplantation (OLT). The aim of the study was to investigate menstrual patterns and sex hormone profiles among female liver transplant recipients of reproductive age. METHODS The study group consisted of 24 women of reproductive age with end-stage liver failure who underwent successful OLT. Menstrual patterns and sex hormone profiles were analyzed before as well as 3 and 12 months after OLT. Twenty-seven healthy women of reproductive age served as controls. Biochemical parameters of liver function were assessed before and after OLT. RESULTS Amenorrhea was the most commonly observed abnormality of menstrual cycle in women with end-stage liver failure (71% of patients). The recurrence of regular menstrual cycles was observed in 35% of patients 3 months after OLT. The percentage increased to 70% at 1 year after grafting and was clearly associated with stabilization of liver function. Similar levels of follicle stimulation hormone (FSH), luteinizing hormone (LH), prolactine (PRL), and testosterone (T) as well as lower levels of estradiol (E(2)), dehydroepiandrostendione sulphate (DHEA-S), and progesterone, (P) were observed in patients with liver failure compared with healthy women. We observed normalization of E(2) and DHEA-S levels after OLT. CONCLUSIONS Amenorrhea, the most common menstrual disturbance in women with end-stage liver failure, may be reversed by OLT. One year after OLT menstrual bleedings were noted in 74% of patients of reproductive age. The recurrence of reproductive function indicated the need for effective and safe family planning methods in that group of patients.

Successful Pregnancy Outcome after In Vitro Fertilization in a Kidney Graft Recipient: A Case Report and Literature Review

BACKGROUND Successful spontaneous pregnancy in a kidney graft recipient is regarded as a sign of full recovery. The crucial factors determining positive outcome are optimizing time of conception and multidisciplinary team care. However, there are only a few reports dealing with in vitro fertilization (IVF) outcomes in organ recipients. CASE REPORT A 34-year-old living donor kidney recipient with primary infertility due to bilateral tubal obstruction was referred to our clinic. Transfer of 2 embryos was conducted after a long stimulation protocol with GnRH and rFSH, and a viable singleton pregnancy was confirmed by subsequent ultrasound examination. Pregnancy complications were: chronic hypertension, fetal intrauterine growth restriction, and severe anemia requiring blood transfusions and erythropoietin treatment. In the 34th week of gestation the patient presented with worsening of blood pressure control. A male newborn, 1810 grams weight and 10 points Apgar score was delivered by cesarean section. Although our patient was qualified for the IVF program with signs of suboptimal graft function, it was stable during the ovarian stimulation protocol. Fortunately, in the second half of the pregnancy only mild creatinine rise and proteinuria <1 g/day were observed. CONCLUSIONS IVF may be a good treatment option in female kidney graft recipients. It does not necessarily lead to graft function deterioration and it provides multidisciplinary specialized care, allowing for delivery of a healthy newborn.

Prevalence of high-risk human papillomavirus cervical infection in female kidney graft recipients: an observational study

BackgroundImmunosuppressive therapy protects the transplanted organ but predisposes the recipient to chronic infections and malignancies. Transplant patients are at risk of cervical intraepithelial neoplasia (CIN) and cervical cancer resulting from an impaired immune response in the case of primary infection or of reactivation of a latent infection with human papillomavirus of high oncogenic potential (HR-HPV).MethodsThe aim of this study was to assess the prevalence of HR-HPV cervical infections and CIN in 60 female kidney graft recipients of reproductive age in comparison to that in healthy controls. Cervical swabs were analyzed for the presence of HR-HPV DNA. HR-HPV-positive women remained under strict observation and were re-examined after 24 months for the presence of transforming HR-HPV infection by testing for HR-HPV E6/E7 mRNA. All the HR-HPV-positive patients were scheduled for further diagnostic tests including exfoliative cytology, colposcopy and cervical biopsy.ResultsThe prevalence of HR-HPV did not differ significantly between the study group and the healthy controls (18% vs 25%, p = 0.37). There was no correlation between HR-HPV presence and the immunosuppresive regimen, underlying disease, graft function or time interval from transplantation. A higher prevalence of HR-HPV was observed in females who had had ≥2 sexual partners in the past. Among HR-HPV-positive patients, two cases of CIN2+ were diagnosed in each group. In the course of follow-up, transforming HR-HPV infections were detected in two kidney recipients and in one healthy female. Histologic examination confirmed another two cases of CIN2+ developing in the cervical canal.ConclusionsFemale kidney graft recipients of reproductive age are as exposed to HR-HPV infection as are healthy individuals. Tests detecting the presence of HR-HPV E6/E7 mRNA offer a novel diagnostic opportunity in those patients, especially in those cases where lesions have developed in the cervical canal.

Pregnancy risk in female kidney and liver recipients: a retrospective comparative study.

Objective: To determine and compare maternal, neonatal and graft outcomes in pregnant women after kidney or liver transplantation, who had delivered from 1 January 2005 to 1 February 2010. Methods: A retrospective, single-center study provided in Warsaw, Poland. Results: Complete data were collected in 38 deliveries in 37 women. Preexisting hypertension was present in 15 of 19 (79%) pregnant kidney recipients and in 2 of 19 (10.5%) women after liver transplantation (p < 0.000). The incidence of preeclampsia was also more often in pregnant kidney recipients (p = 0.04). Mean gestational age at labor was lower in the kidney group (34.9 ± 3.56 vs. 37.5 ± 1.62, p = 0.000). A similar relation was observed in the frequency of preterm deliveries before 37 weeks of gestation (42% vs. 11%, respectively, p = 0.02) and neonates small for gestational age (47% vs. 11%, respectively, p = 0.008). Cesarean sections were performed in approximately 79% (15/19) and 95% (18/19) liver and kidney posttransplant pregnancies, respectively. Four of 38 infants presented structural malformations. Conclusions: Pregnancies after kidney transplantation are complicated with a higher prevalence of prematurity and worse neonatal prognosis, which depends mainly on the underlying condition.

Intrauterine Hypotrophy and Premature Births in Neonates Delivered by Female Renal and Liver Transplant Recipients

BACKGROUND Neonates born to mothers, who underwent organ transplantation require close medical monitoring. It is unknown how chronically diseased mothers organs or immunosuppressive drugs affect fetal growth and development; some immunosuppressants are teratogenic and contraindicated during pregnancy. The aim of this study was to determine the prevalence of prematurity and intrauterine growth restriction in neonates born to women who have undergone renal or liver transplantation. METHODS Our retrospective analysis identified 53 (25 renal and 28 liver) cases of neonates delivered by female graft recipients between January 2005 and December 2009. Hypotrophy was defined as a birth weight<10th percentile for gestational age. We excluded newborns diagnosed with severe hypotrophy (<5th percentile). RESULTS Neonates born prematurely were predominate in the renal (16/25, 64%), but less than half of the liver cohort (13/28, 46%). Hypotrophy less than the 10th percentile was noted significantly more often among renal than liver recipients; 36% versus 14% (P<.05). Severe hypotrophy was also observed significantly more often among renal than liver transplant neonates: 28% versus 3.6% (P<.001). CONCLUSIONS Compared with liver insufficiency, chronic kidney diseases have stronger effects on the fetus, leading to adverse neonatal complications. A greater prevalence of preterm births, as well as hypotrophic newborns, especially less than the 5th percentile, was observed among neonates delivered by mothers after kidney transplantation.

Use of fondaparinux in a pregnant woman with pulmonary embolism and heparin-induced thrombocytopenia.

Summary Background A serious complication of heparin treatment, heparin-induced thrombocytopenia (HIT) is rarely observed in pregnant women. Drug therapy during pregnancy should always be chosen to minimize fetal risk. The management of HIT in pregnancy represents a medical challenge. Unlike heparins, the anticoagulants used in patients with HIT do cross the placenta, with unknown fetal effects. Case Report We present a case of a 24-year-old female presenting for care at 34 weeks of gestation with acute pulmonary embolism treated initially with unfractionated heparin (UFH) and low molecular weight heparin (LMWH), who developed HIT. She was then successfully treated with fondaparinux. Conclusions To the best of our knowledge, this is one of the first case reports describing a successful use of fondaparinux in the treatment of HIT in a third-trimester pregnant woman, providing a novel approach for this subset of patients.

Prevalence of cervical high-risk human papillomavirus infections in kidney graft recipients

BACKGROUND Female kidney graft recipients are regarded as a group at risk of cervical cancer development. The objective of this study was to assess the prevalence of cervical high-risk human papilloma virus (HR-HPV) infection and cervical intraepithelial neoplasia (CIN) in female kidney graft recipients in comparison to healthy controls. MATERIAL AND METHODS We assessed the prevalence of HR-HPV and CIN in 60 female kidney graft recipients of reproductive age in outpatient care of the First Department of Obstetrics and Gynecology, Medical University of Warsaw. The control group consisted of 60 healthy women. Cervical swabs were analyzed with use of Amplicor HPV Roche Molecular Systems test, detecting DNA of 13 types of high-risk HPV: 6, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, and 68. RESULTS HR-HPV was detected in 11/60 kidney recipients and 15/60 healthy women (p=0.37). There was no correlation between HR-HPV presence and immunosuppressive regimen, underlying disease, graft function, or time interval from transplantation. In both groups, higher prevalence of HR-HPV was observed in females with ≥2 lifetime sexual partners. Abnormal Pap test results in 2 kidney recipients (2 cases of HSIL) and 2 healthy women (LSIL and HSIL) required colposcopy-guided cervical biopsy, which in all cases revealed CIN2+. CONCLUSIONS Female kidney graft recipients seem to be equally exposed to cervical infection with HPV of high oncogenic potential as the healthy population.

Prevalence of urogenital mycoplasmas and ureaplasmas in women after kidney transplantation.

Background. The prevalence of urogenital mycoplasmas and ureaplasmas in kidney transplant and hemodialyzed patients was studied. Methods. Vaginal and cervical swabs taken from 40 women of the study group and 40 women of the control group were investigated. Identification of ureaplasmas, Mycoplasma genitalium, and human papillomavirus was performed by polymerase chain reaction. Each vaginal slide was evaluated for bacterial vaginosis. Results. Urogenital mycoplasmas and ureaplasmas were significantly more common in patients from the study group (40%) compared with the control group (27.5%). Mycoplasma hominis and M. genitalium were demonstrated only in a few cases. Ureaplasma parvum was isolated predominantly, but Ureaplasma urealyticum was more common in patients from study group (10%) compared with control group (2.5%). In all U. urealyticum-positive women from the study group, human papillomavirus DNA was detected. Conclusion. Our observation showed the necessity of careful examination of possible atypical pathogens in diagnostic materials from hemodialyzed and kidney transplant patients.

Pregnancy complications after liver transplantation

To review complications in pregnancy after liver transplantation and assess the time interval since transplantation on fetal development and preterm birth rate.

Contraceptive awareness and birth control selection in female kidney and liver transplant recipients

OBJECTIVE(S) Interest has increased regarding the issue of contraception in transplant recipients. The purpose of this study was to assess birth control selection and the role of contraceptive counseling sessions in female kidney transplant (KT) and liver transplant (LT) recipients. STUDY DESIGN A cross-sectional single-center survey study of 217 female organ recipients (KT, 137 and LT, 80), aged 18-45 years, met the study criteria. Patients were asked 43 questions regarding their pre- and posttransplantation use of contraceptive methods, birth control awareness, contraception counseling and the factors determining the selection of effective contraception (hormonal contraception, intrauterine devices and female sterilization). RESULTS Thirty-three percent (5/15) of patients who had undergone the transplantation within 1 year prior to study inclusion were unaware of the necessity to use contraception. Both of the groups studied did not differ significantly in terms of the rates of pre- and posttransplantation consultations on effective contraception (KT: 26% vs. 34%; p=0.153 and LT 38% vs. 35%; p=0.729). Effective posttransplantation contraception was used by one in three patients, as indicated by posttransplantation consultations (KT: 30% vs. LT: 29%; p=0.910). The following factors affected the posttransplantation use of effective contraception: the presence of posttransplantation counseling on effective contraception [odds ratio (OR): 6.67; 95% confidence interval (CI): 2.12-20.1] and infrequent sexual activity prior to transplantation (OR: 0.56; 95% CI: 0.35-0.89). CONCLUSION(S) The selection of effective contraception in KT and LT recipients remain suboptimal. Despite the low numbers of women who received contraceptive counseling in this study, consultation was nonetheless associated with choosing an effective method of contraception. IMPLICATION Current literature and data regarding contraception among female organ transplant recipients remain limited and are predominantly limited to a single population. The purpose of the study was to assess the level of satisfaction and the reasons underlying birth control selection in female kidney and LT recipients.