Solid Organ Transplantation In Preg TOG 2016

Question 1

The most common organ transplant in UK

Answer 1

Kidney (30-40)
All transplant : 50-60 pregnancies

Question 2

Associated with what Higher maternal/fetal outcome?

Answer 2

PET
FGR
Preterm delivery

Question 3

Prevalence of renal transplant in UK

Answer 3

2-6/10,000
30-40 pregnancies annually

Question 4

What is the risk of rejection of renal transplant ?

Answer 4

10-15% in first year in people <45 years

Avoid pregnancy in 1st year

Question 5

What commonly used medications in transplant have high risk of teratogenicity

Answer 5

Mycophenolate mofetil
ACE inhibitor
Angiotensin receptor antagonists
Warfarin

Question 6

What is the “washout period” before conception after stopping mycophenolate mofetil?

Answer 6

90 days( 3 months) if male patient (BNF)
6 weeks for female patients
Use 2 reliable forms of contraception

Question 7

What dose of pre pregnancy folic acid

Answer 7

400mcg / day

Question 8

What % of pregnancy renal transplant patient are hypertensive

Answer 8

> 50%

Question 9

What are the diabetogenic immunosuppressants

Answer 9

Tacroclimus
Ciclosporins
Prednisolone

Question 10

What is the incidence of new onset diabetes in renal transplant patients ?

Answer 10

4-25%

Question 11

What is the rate of acute Graf rejection in pregnant recipients in UK?

Answer 11

<2%

Question 12

What’s the next step in management if graft rejection is suspected?

Answer 12

Renal biopsy

Question 13

What vaccines must be avoided in babies of mother exposed to biologics in utero?

Answer 13

Live vaccines : BCG, rotavirus , live attenuated influenza, oral polio, typhoid, yellow fever , varicella, MMR)

Question 14

When should VTE prophylaxis be considered in relation to proteinuria?

Answer 14

Urine PCR of >300mg/mmol
Or ACR of 180mg/mmol

Question 15

What component of combined testing will lead to a high false positive result

Answer 15

Raised Bhcg due to reduced clearance by the kidneys

Question 16

How often should pre-dose tacrolimus/ciclosporin levels be checked antenatally?

Answer 16

No less than monthly

Question 17

What antibiotics levels should be avoided in pregnant patients on calcineurin inhibitors(Tac/Cic)

Answer 17

Cytochrome P450 inhibitors: erythromycin and clarithromycin

Question 18

How should iron replete anemia in pregnancy be treated?

Answer 18

Erythropoietin stimulating agents

Question 19

How should super imposed pre eclampsia be diagnosed in renal transplant pregnant patients?

Answer 19

BP >160/100
Increase treatment to maintain BP below 160/110
100% rise in proteinuria
Low levels of placental growth factor
Elevated transaminases
Thrombocytopenia
FGR

Question 20

Is Mag sulpahate contraindicated in renal transplant?

Answer 20

No
Give 4g loading dose
Half the maintenance
Check magnesium levels every 4-6 hours ( <3.5 mmol/L)

Question 21

What’s the preferred mode of delivery

Answer 21

Vaginal delivery is not contraindicated

Question 22

Can renal transplant patients be induced

Answer 22

Yes
Prostaglandins and oxytocin are safe to use in renal patients

Question 23

Risk of trauma to renal graft at CS

Answer 23

1-2%

Question 24

Preferred mode of entry at CS in renal transplant patients

Answer 24

Midline incision to reduce trauma to allograft
Locate kidneys first with ultrasound

Question 25

What additional management in women on prednisolone or >2 weeks in labour

Answer 25

Give stress dose hydrocortisone 50-100mg 6-8 hourly in labour

Question 26

What’s safe and effective contraception in renal transplant patients

Answer 26

POP( Desogestrel preparations) LNG-IUS Progesterone implants

Question 27

What’s antenatal management of kidney donors?

Answer 27

Aspirin prophylaxis due to double risk of PET and gestational hypertension

Question 28

What organ has the overall highest pregnancy related risk?

Answer 28

Lungs Lower live birth rate Higher graft rejection Increased GDM rate