Pregnancy and Reproductive Planning in Transplanted Women

Surita, Fernanda Garanhani; Guida, José Paulo Siqueira; Juliato, Cássia Raquel Teatin; Boin, Ilka de Fátima Santana Ferreira

doi:10.53855/bjt.v26i1.542_ENG

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Brazilian Journal of Transplantation

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REVIEW ARTICLE • Braz. J. Transplant. 26 • 2023 • https://doi.org/10.53855/bjt.v26i1.542_ENG copy

Pregnancy and Reproductive Planning in Transplanted Women

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

The objective of this literature review is to provide some pregnancy results in transplanted women, proposals for preconception, prenatal and postpartum evaluation, including postpartum contraception, and therapeutic guidance during pregnancy and lactation. Based on the results found in research on PubMed without date or language limitations, we discuss the importance of reproductive planning for women with solid organ transplants and what should be done before the transplant. There are formal contraindications to pregnancy; however, when planned, within clinical and laboratory criteria, and with adequate immunosuppression and specialized prenatal care, pregnancy is possible with good perinatal results. We also highlight the importance of psychological support among pregnant women with solid organ transplants.

Keywords
Hyperbaric oxygenation; Hyperbaric Oxygenation; Liver transplantation

Immunosuppressant	Mechanism of action	Adverse effects	Use during pregnancy	Use in breastfeeding
Corticosteroids	Multiple effects	palate defects (conflicting and scarce data), FGR, GDM,	Low risk	Compatible
Azathioprine	Inhibits purine synthesis, DNA replication, and B and T cells	No evidence of FD, FGR, Prematurity	Low risk	Compatible
Ciclosporin Tacrolimus	Inhibitors of interleukin II and T cell activation	No evidence of FD, FGR, Prematurity Dose-dependent maternal reactions	Low risk	Compatible
Mycophenolate	Purine synthesis inhibitor	1st-trimester abortion Teratogenic (facial, cardiac, CNS defects, esophageal atresia	Contraindicated Discontinue six weeks before pregnancy	No data; should be discouraged
Sirolimus Everolimus	B and T cell inhibitors	Scarce data, there are descriptions of congenital disabilities	Contraindicated Discontinue 12 weeks before pregnancy	No data
Betacept	T-selective cell inhibitors	No data	No data	No data

N°	Recommendation for receivers	Degree
1	People with SOT who are capable of becoming pregnant should receive preconception counseling as part of the pretransplant evaluation and before posttransplant pregnancy.	Good habits
2	Delay pregnancy for at least 1 year after SOT (except for lung transplant, in which case the recommended delay is 2 years) or any episode of acute cellular rejection.	1B
3	Stable allograft function and optimal control of chronic diseases before pregnancy.	1B
4	SOT recipients of reproductive age should use highly effective contraceptive methods when using mycophenolate or other immunosuppressive agents with a known teratogenic risk.	1A
5	SOT recipients who wish to become pregnant must first transition to an immunosuppressive regimen that can be maintained throughout pregnancy and establish stable medication dosage and allograft function.	1C
6	Close monitoring of serum drug levels during pregnancy and postpartum to guide dosing of immunosuppressive therapy.	1C
7	Pregnant women or those intending to become pregnant must receive all recommended vaccines before and during pregnancy	1C
8	Due to the fetal and neonatal risk of vertical CMV infection, treatment or prevention with antivirals must be carried out before pregnancy, in addition to screening during pregnancy.	2B
9	Use of ASA for Preeclampsia Prevention	1C
10	Access to mental health care with specialists and depression screening during pregnancy and the postpartum period	Good habits
11	Systematic ultrasound assessment for the risk of fetal growth restriction (every 4 to 6 weeks)	1C
12	Assessment of fetal vitality based on fetal viability	2C
13	Pre-pregnancy or early pregnancy renal function assessment for any SOT	1C
14	Elective termination of uncomplicated pregnancies at term (37 – 39+6 weeks)	2B
15	Spontaneous or induced vaginal birth is the most indicated, with less risk for the graft and cesarean section must follow obstetric indications	1C
16	Kidney transplant recipients with AH should follow the recommendations for any pregnant woman with chronic CAH (<130/80mmHg)	1C
17	Screening for asymptomatic bacteriuria with monthly urine culture for kidney transplant recipients and treatment whenever urine culture is positive to protect the graft	1C
18	Pancreas-kidney transplant cases must follow the recommendations for kidney transplant	1C
19	Characterize the condition that led to liver transplantation and evaluate renal function in all cases	1C
20	Due to the cardiovascular changes during pregnancy, heart transplant cases require multidisciplinary care with cardiologists and anesthesiologists.	Good habits
21	Birth planning to minimize hemodynamic stress and continuous intrapartum or intraoperative electrocardiographic monitoring in cases of heart transplantation.	1C

Associação Brasileira de Transplante de Órgãos Avenida Paulista, 2.001 - 17° andar Conj. 1.704/1.707, Cerqueira César - CEP: 01311-300, Tel: (55) 11 98243 - 3901 - São Paulo - SP - Brazil
E-mail: abto@abto.org.br

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[1] * Corresponding author: surita@unicamp.br