Question:
27 year old obese lady with CKD 3 with stable creatinine of 1.7 and 1 gm of proteinuria referred to you for opinion regarding her pregnancy. Her etiology of CKD is FSGS thought to be secondary to obesity. This is her first pregnancy and She is in her first trimester of pregnancy. She was adviced not to plan pregnancy because of CKD and also because of ARBs(Angiotensin Receptor Blockers). Inspite of the caution she conceived. Her BP is well controlled and physical exam is unremarkable except obesity. What would be your recommendation?
1) Terminate pregnancy.
2) Continue pregnancy as well as ARBs
3) Explain the risks and leave upto the patient to decide.
4) Continue pregnancy but change ARBs to methydopa.
In the presence of CKD alone her chances of having preeclampsia are higher ( about 25%). Her being obese further increases the risk of preeclampsia.
ReplyDeleteCr more than 1.4 alone puts her at risk for deterioration of renal function and Presence of 1gm proteinuria increases the risk further. Not to mention increase risk of pre term delivery, still birth, neonatal and perinatal deaths.
Ideally ARBs should have been before conception but if patient gets pregnant while on A II drugs data is not strong enough to recommend pregnancy termination.
Personally i will go with OPTION 3 and leave it to the patient to decide if she is willing to proceed with pregnancy after explaining that pregnancy will be high risk. If she decide to proceed ARBs need to be changed to either Methyldopa, Hydralazine CCB (preferably Nifedipine) or Beta blocker (Labetalol) and she will need very close pre and perinatal care.
I agree with Pradeep's response, with a couple of additional comments If the pregnancy was intentional, then it is very unlikely the woman will elect termination, and though its appropriate to mention it as an option (and of course fully discuss all the risks), I don't spend much time on it - I usually assume women will chose to continue the pregnancy. The age of the woman also needs to be taken into account - for women with CKD pregnant in their 30s, this may be their only chance to have a child. Though the risks are real, if BP is well-controlled then the chances of a live birth are >90%.
ReplyDeleteI don't use methyldopa (fatigue, cumbersome TID dosing) or hydralazine (not very effective) as first-line in pregnancy. Nifedipine or labetalol are better.
Finally, first trimester exposure to ARB is not nearly as serious as second or third trimester exposure. Risks of birth defects are slightly (though significantly) increased over the general population. If the mid-trimester ultrasound is normal, then there are no worries.