Natalia Mazanowska

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.

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.

The observational study of selected sexual behaviour issues in female organ transplant recipients

OBJECTIVE To investigate sexual behaviour in women following solid organ transplantation. STUDY DESIGN A cross-sectional single-centre survey study of 230 female organ transplant recipients, aged 18-45years. MAIN OUTCOME MEASURES Sexual behaviour, contraceptive awareness and methods of birth control. RESULTS 205 females declared to be post their sexual initiation. The mean age at sexual initiation in our study population was 20.3±3.3years (range: 14-32). Fifty-three percent (122/230) of the patients declared that they had only one sexual partner at enrolment. After transplantation female organ recipients became more sexually active (71% vs. 83%; p=0.018). The frequency of sexual intercourse decreased significantly in the post-transplant period (p=0.004). In the group of sexually active females before transplantation the frequency of sexual intercourses decreased significantly in the post-transplant period (mean Δ -0.16±0.79; p=0.004). An increase or lack of change in the frequency of sexual intercourse was noted amongst younger transplant-recipients (OR: 0.91; 95%CI 0.86-0.97) and women with effective birth control methods post-transplantation (OR: 3.68; 95%CI 1.60-8.49). CONCLUSION Sexual education of organ transplant recipients is necessary, mainly in younger patients, who present to be more sexually active, thus they need to be taught about effective family planning.

Pregnancy after living related liver transplantation – a report of two cases

BACKGROUND Living related liver transplantation (LRLT) is currently the only available alternative to orthotopic liver transplantation that is of use in children with acute liver failure. There are reports of long-term survival in liver graft recipients who had been transplanted in childhood. In female patients of reproductive age it may also mean ability to conceive. CASE REPORT We report 2 cases of successful pregnancies in women after living related liver transplantation. During the 6-month follow-up, no obstetric complications during pregnancy, delivery and postpartum period, and no deterioration of graft function were noted. The neonates were delivered full-term in good general condition, with no signs of intrauterine hypotrophy, congenital malformations or infection, and their psycho-motor development is perfectly normal. CONCLUSIONS These 2 cases of pregnancies with favorable perinatal outcomes in women after living related liver transplantation, who delivered in our Department with no deterioration of graft function, may be regarded as evidence of full recovery in women after the LRTL procedure.

Low Transfer of Tacrolimus and Its Metabolites into Colostrum of Graft Recipient Mothers

Currently, the majority of neonates born to organ recipient mothers on chronic immunosuppressive therapy are formula fed. However, over the past few years, evidence has grown, suggesting that breastfeeding might be possible and beneficial. We designed a study assessing the transfer of tacrolimus into the colostrum of posttransplant mothers. We assessed the amount of tacrolimus and its metabolites, M-1 and M-3, that would be ingested by the breastfed neonates. Concentrations of tacrolimus and its metabolites were measured in colostrum from 14 posttransplant mothers as well as in venous cord blood and venous blood of the neonates. Test material analysis was performed by liquid chromatography coupled with mass spectrometry (LC/MS). The amount of ingested formula was registered, which allowed for estimation of the amount of tacrolimus and its metabolites that would be ingested by breastfed infants. The mean amount of tacrolimus that would be ingested by the neonates in maternal milk was 151.4 ng/kg/24 h (standard deviation SD ± 74.39); metabolite M-1: 23.80 ng/kg/24 h (SD ± 14.53); and metabolite M-3: 13.25 ng/kg/24 h (SD ± 9.05). The peak level of tacrolimus and metabolite M-1 in colostrum was noted 8 h after an oral dose (3.219 ng/mL SD ± 2.22 and 0.56 ng/mL SD ± 0.60, respectively) and metabolite M-3 after 6 h (0.29 ng/mL SD ± 0.22). Low concentrations of tacrolimus and its metabolites, M-1 and M-3, in colostrum show that neonates will ingest trace amounts of the drug. Further studies are required to fully assess the safety of breastfeeding by posttransplant mothers.

Unintended pregnancies and family planning among women after kidney or liver transplantation

Abstract Background: To evaluate the incidence of unplanned pregnancies in female organ transplant recipients. Methods: In a single-center cross-sectional study 252 women aged 18–45 years who underwent kidney or liver transplantation were asked to fill in a survey form. Results: 217 (86%) women were enrolled in the study. Fifty-three percent of women declared 181 pregnancies, of which 30% (54/181) were unplanned. Women more frequently consulted their conception with a doctor post-transplantation (74 versus 88%, p = .064). The number of unplanned pregnancies decreased post-transplantation (34 versus 20%, p = .051). The mean time elapsed from an organ transplant to unintended conception was 27.0 ± 12.5 (3.0–63.0) months. Women with longer (>24 months) rather than shorter (≤24 months) time elapsed from the transplant became pregnant less frequently (38 versus 15%, p = .060). In 70% (38/54) of unplanned pregnancies women did not use any birth control. All cases of conceptions within the post-transplant year were unintentional. Every third woman, who underwent the transplantation up to 1 year before the study enrolment, was unaware of the necessity to prevent the pregnancy. Conclusions: Although unwanted pregnancies occur more frequently in the early post-transplant period, it seems that women after kidney or liver transplantation seem to plan their pregnancies more carefully.

The comparison of intelligence levels of children born to kidney or liver transplant women with children of healthy mothers

Abstract Background: Pregnancy after transplantation is associated with high risk of complications and prenatal exposure to immunosuppressants. The purpose of the study was to evaluate the intellectual development of children born to women after organ transplantation. Aims: A comparison of intelligence levels in 78 children of kidney or liver transplant women of 78 children born to healthy mothers. The assessment of intellectual level in children was conducted by psychologists and evaluated using age-adjusted intelligence tests (Psyche Cattell Infant Intelligence Scale, Terman–Merril Intelligence Scale or the Scales of Raven’s Progressive Matrices). Results: No significant differences in the distribution of the quotient of intelligence between children born to kidney and liver transplant women were noted (Chi2 = 5.037; p = .284). Also no differences in the distribution of intelligence levels were noted between the children of transplanted and healthy mothers in infants and toddlers (Chi2 = 3.125; p = .537); preschool (Chi2 = 1.440; p = .692), and school age children (Chi2 = 4.079; p = .395). Conclusions: The intellectual development of children of post-transplant women is similar to the general population. These results provide information on the low risk of intellectual disability in children of transplanted mothers and may improve counseling on the planning of pregnancy in this group of women.