Ниркова асоціація Клінічні настанови щодо вагітності The Renal Association Clinical Practice Guideline on Pregnancy аnd Renal Disease

Короткий зміст настанов клінічної практики Структура медичної допомоги Настанова 1.1 Ми рекомендуємо створювати мультидисциплінарні команди (включаючи лікаря-акушера, консультанта лікарянефролога/лікаря-експерта, а також акушерку чи акушерську групу) для надання консультацій і допомоги жінкам із ХХН, які вагітні або планують вагітність. Усі медичні працівники, які доглядають за жінками з ХХН, повинні мати доступ до цієї мультидисциплінарної команди (1D).


Guideline 2.4
We recommend mycophenolate mofetil, methotrexate and cyclophosphamide are not taken in pregnancy as they are teratogenic (1B).
Guideline 2. 5 We recommend mycophenolate mofetil is stopped before pregnancy, as use in pregnancy is associated with an increased risk of spontaneous miscarriage and fetal abnormality. A 3-month interval is advised before conception to allow conversion to a pregnancy-safe alternative and ensure stable disease/kidney function (1C).
Guideline 2. 6 We recommend that, when other treatment options exist, rituximab is avoided in pregnancy due to the risk of neonatal B cell depletion and unknown long-term outcomes (1D).
Guideline 2. 7 We recommend sirolimus and everolimus are avoided in pregnancy due to insufficient safety data (1D).
Guideline 2. 8 We suggest the benefits of eculizumab in pregnancy for organ threatening disease are likely to outweigh risk (2D).
Guideline 2. 9 We recommend metformin can be used in pregnancy for women with a pre-pregnancy eGFR > 30 mls/ min/1.73 m 2 and stable renal function during pregnancy (1D).
Guideline 2. 10 We recommend immunosuppressive treatment is not increased routinely in the peripartum period and that dose changes are based on clinical indications and blood concentrations (1D).

Pre-pregnancy care
Contraception Guideline 3.1.1 We recommend advice on safe and effective contraception is offered to all women of reproductive age with CKD (1D).
Guideline 3.1.2 We recommend safe and effective contraception is offered to women of reproductive age who are taking teratogenic medication, have active glomerulonephritis, are within one year of renal transplantation or acute graft rejection, and for any woman who does not wish to conceive (1D).

Fertility Guideline 3.2.1
We suggest fertility preservation is considered for women of reproductive age who require treatment with cyclophosphamide (2C).

2.2
We suggest women who have had previous treatment with cyclophosphamide have early investigation of infertility (2D).

Guideline 3.2.3
We recommend women with CKD are referred for pre-pregnancy counselling before receiving assisted reproduction (1D).

Guideline 3.2.4
We recommend single-embryo transfer is performed to reduce risk of complications associated with multifetal pregnancies in women with CKD (1C).
Pre-pregnancy counseling and optimization for pregnancy Guideline 3.3.1 We suggest women with CKD considering pregnancy are offered pre-pregnancy counselling by a multidisciplinary team including a consultant obstetrician and nephrologist or expert physician (2D).

Guideline 3.3.2
We recommend women with CKD are advised there is an increased risk of complications in pregnancy including pre-eclampsia, preterm birth, fetal growth restriction, and neonatal unit (NNU) admission, and that they are more likely to require caesarean delivery (1C).

Guideline 3.3.3
We recommend women with known or suspected inheritable renal diseases are offered genetic counselling including inheritance risk, prognosis, and intervention options including pre-implantation genetic diagnosis (1C).

Guideline 3.3.4
We recommend pre-pregnancy counselling for the optimisation of maternal and neonatal outcomes in women with CKD, which may include: -stabilising disease activity in advance of pregnancy on minimised doses of pregnancy-appropriate medications (1B); -optimising blood pressure control (< 140/90 mmHg) on pregnancy-appropriate medications (1B); -optimising glycaemic control in women with diabetes mellitus (1A) (see section 5.4); -minimising risk of exposure to teratogenic medications (1C) (see section 2); -making a treatment plan in the event of hyperemesis or disease exacerbation/relapse during pregnancy (1D).
Guideline 3.3.5 We recommend women with CKD who are taking angiotensin converting enzyme inhibitors have a plan for discontinuation/conversion guided by the strength of indication for renin-angiotensin blockade and the Vol. 8, No. 4, 2019 Настанови / Guidelines likelihood of pregnancy confirmation in the first trimester (1B). Guideline 3.3. 6 We recommend angiotensin receptor antagonists are discontinued in advance of pregnancy (1D).
Guideline 3.3.7 We suggest women with CKD stages 4 and 5 contemplating pregnancy are offered pre-dialysis education (2D).

Pregnancy Care
Assessment of renal function in pregnancy Guideline 4.1. 1 We recommend renal function in pregnancy is assessed using serum creatinine concentrations as estimated GFR (eGFR) is not valid for use in pregnancy (1C).
Guideline 4.1.2 We recommend women with CKD have formal quantification of proteinuria in pregnancy (1D).
Guideline 4.1. 3 We recommend quantification of proteinuria is undertaken by protein : creatinine ratio (uPCR) or albu min : creatinine ratio (uACR). Twenty-four hour urine collection for quantification of protein is not required (1B).

2.1
We suggest pregnant women with CKD who have not had pre-pregnancy counselling by the MDT are referred to the MDT and receive the same counselling and optimisation as for women attending pre-pregnancy (2D).

Guideline 4.2.2
We recommend pregnant women with CKD receive routine antenatal care, in addition to specialist input (1D).

Guideline 4.2.3
We recommend pregnant women with CKD be referred for assessment by a consultant obstetrician (1D).

Guideline 4.2.4
We recommend pregnant women with CKD have access to usual trisomy screening with specialist interpretation of high-risk results (1C).

Guideline 4.2.5
We recommend women with CKD exposed to teratogenic drugs in the first trimester are referred to a specialist fetal medicine unit (1D).

Guideline 4.2.6
We recommend pregnant women with CKD have scans to assess fetal growth and wellbeing in the third trimester (1C).

Guideline 4.2.7
We recommend pregnant women taking prednisolone and/or calcineurin inhibitors are screened for gestational diabetes (1C).

Guideline 4.3.2
We suggest kidney donors are offered low dose aspirin (75-150 mg) to reduce the risk of pre-eclampsia (2D).
Blood pressure management Guideline 4.4.1 We recommend that the target blood pressure during pregnancy for women with CKD is 135/85 mmHg or less, which should be documented in the woman's healthcare record (1D).

Guideline 4.4.2
We suggest antihypertensive treatment in women with CKD is continued in pregnancy unless systolic blood pressure is consistently < 110 mmHg systolic, or diastolic blood is pressure consistently < 70 mmHg diastolic BP, or there is symptomatic hypotension (2D).

Guideline 4.4.3
We recommend labetalol, nifedipine and methyldopa can be used to treat hypertension in pregnancy (1B).

Guideline 4.4.4
We recommend angiotensin converting enzyme inhibitors, angiotensin receptor antagonists and diuretics are not used to treat hypertension in pregnancy (1B).
Guideline 4.4.5 We recommend a diagnosis of superimposed preeclampsia is considered: -in a woman with non-proteinuric CKD, if she develops new hypertension (systolic BP > 140 mmHg and/or diastolic BP > 90 mmHg) and proteinuria (uPCR > 30 mg/mmol or uACR > 8 mg/mmol) or maternal organ dysfunction after 20 weeks' gestation (1B); -in a women with proteinuric CKD if she deve lops new hypertension (systolic BP > 140 mmHg and/or diastolic BP > 90 mmHg) or maternal organ dysfunction after 20 weeks' gestation (1B); -in a women with chronic hypertension and proteinuria, if she develops maternal organ dysfunction after 20 weeks' gestation (1B).
Guideline 4.4. 6 We suggest in women with chronic hypertension and proteinuria that the development of sustained severe hypertension (systolic BP > 160 mmHg and/or diastolic BP > 110 mmHg or doubling of antihypertensive agents) and/or a substantial rise in proteinuria (doubling of uPCR or uACR compared to early pregnancy) should prompt clinical assessment for superimposed pre-eclampsia (2D).
Guideline 4.4.7 We suggest a role for angiogenic markers (PlGF ± sFlt-1) is considered as an adjunct to diagnose superimposed pre-eclampsia, dependent upon on-going research in women with CKD (2C).
Venous thromboembolism Guideline 4.5.1 We recommend that women with nephrotic-range proteinuria (uPCR > 300 mg/mmol or ACR > 250 mg/mmol) be offered thromboprophylaxis with low molecular weight heparin in pregnancy and the post-partum period Vol. 8, No. 4, 2019 Настанови / Guidelines unless there is a specific contraindication including risk of labour or active bleeding (1D).

Guideline 4.5.2
We suggest that non-nephrotic range proteinuria in pregnancy is a risk factor for thrombosis and thromboprophylaxis with low molecular weight heparin should be considered in the presence of additional risk factors (2D).
Anaemia Guideline 4.6.1 We recommend pregnant women with CKD are given parenteral iron if indicated (1C).
Guideline 4.6.2 We recommend erythropoietin stimulating agents are given if indicated in pregnancy (1C).
Bone health Guideline 4.7.1 We recommend women with CKD who are vitamin D deficient be given vitamin D supplementation in pregnancy (1B).
Guideline 4.7. 3 We recommend non-calcium based phosphate binders are discontinued in pregnancy (1D).
Renal biopsy Guideline 4.8.1 We recommend if a histological diagnosis will change management in pregnancy then renal biopsy can be performed in the first and early second trimester of pregnancy (1C).
Peripartum care Guideline 4.9.1 We recommend women with CKD receive routine peripartum care, with additional specialist input (1D).
Guideline 4.9.2 We recommend women with CKD have observations taken and documented during any hospital admission. This includes temperature, heart rate, blood pressure, respiratory rate, and oxygen saturation. An early warning score should be calculated and actioned appropriately (1D).
Guideline 4.9.3 We recommend additional assessment for women with an elevated early warning score, for women considered to be high-risk, and for any women in whom there is any clinical concern. This includes examination of jugular venous pressure, lung auscultation and urine output monitoring (in-dwelling catheter not usually required) in addition to routine parameters (1D).
Guideline 4.9.4 We recommend women with CKD at risk of volume depletion or volume overload are highlighted by the MDT in advance of delivery (1D).
Guideline 4.9.7 We recommend the timing of birth for women with CKD is determined by obstetric indications, with consideration of renal factors including deteriorating renal function, symptomatic hypoalbuminaemia, pulmonary oedema, and refractory hypertension (1D).
Postnatal care Guideline 4.10.1 We recommend that non-steroidal anti-inflammatories should not be given (1C).
Guideline 4.10.2 We recommend women with CKD have a planned early postpartum renal review (1D).
Guideline 4.10.3 We recommend that women with CKD are prescribed medications that are compatible with breastfeeding whenever possible (1D).
Guideline 4.10.4 We recommend that women with CKD are offered safe and effective contraception postpartum and receive updated pre-pregnancy counselling before future pregnancies (1D).

Specific conditions
Renal transplantation Guideline 5.1.1 We recommend women with renal transplants wait until their kidney function is stable on medications that are safe in pregnancy before conceiving, which is usually more than one year after transplantation (1D).
Guideline 5.1.2 We recommend that plans for delivery in a woman with a renal transplant are discussed with the local surgical transplant team (1D).
Guideline 5.1. 3 We recommend that mode of delivery in women with renal transplants is based on obstetric indications and maternal preference (1D).
Guideline 5.1.4 We recommend that caesarean delivery in a woman with a renal transplant patient is performed by the most senior obstetrician available, ideally a consultant (1D).
Guideline 5.1.5 We recommend that women with kidney-pancreas transplants, kidney-liver transplants, and dual kidney transplants are managed during pregnancy and delivery by a multidisciplinary team including transplant physicians and surgeons, at a transplant centre (1D).
Dialysis Women receiving maintenance dialysis before pregnancy Guideline 5.2. 1 We recommend women established on dialysis prior to pregnancy receive pre-pregnancy counselling including the options of postponing pregnancy until