Reproductive health and outcomes following intestine transplantation
Beverly Kosmach-Park1, Dolly Martin1, Guillherme Costa2, George Mazariegos1
1Transplant Surgery, Children's Hospital of Pittsburgh, Pittsburgh, PA, United States; 2Transplant Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
Background: Pregnancy after transplantation has become a reality for female transplant recipients desiring parenthood, particularly after renal or liver transplantation. Women at 1-2 yrs post-transplant with good graft and kidney function, stable immunosuppression and in overall good health, may consider pregnancy after pre-conception counseling. With improved long-term survival following intestine transplant (ITx), pediatric recipients are reaching puberty and surviving into reproductive age. Adult recipients are resuming sexual activity and some are considering parenthood.
Objective: Describe reproductive outcomes of ITx recipients.
Methods: Database, chart review and patient reports were used to describe peripregnancy patient and infant outcomes.
Results: Three ITx recipients had 4 pregnancies at 3.4-13 yrs post-ITx. Maternal Outcomes: Indications for ITx : volvulus (n=2), pseudo-obstruction (n=1). Women’s ages at ITx= 13.2, 22.2 and 26.9 yrs; at delivery = 24.3, 26.4, 26.6 and 30.3 yrs. All women received tacrolimus (TAC), mean levels during pregnancy ranged from 2.5 to 6.5 ng/ml. One pt received daily prednisone. Two pts had 3 previous episodes of ACR, one moderate treated with OKT3; another had 2 mild episodes treated with steroids. There were no significant complications that affected maternal outcomes with pts maintaining stable graft and kidney function. Mean BUN and creatinine levels during pregnancy: 16.1 mg/dL , 1.13 mg/dL. Mean levels of nutritional markers and graft function: albumin 3.4 g/dL, protein 6.2 g/dL, magnesium 1.4 mg/dL. Pts were normotensive; there were no incidences of gestational diabetes. Polyhydraminos developed in one pregnancy and resolved without incident. There was fetal exposure to lithium during the first month of pregnancy in one pt being treated for depression and bipolar disorder. Ultrasounds revealed no structural abnormalities at 25 weeks gestation. Maternal outcomes were favorable with normal surveillance endoscopies at 1-6 mos post-partum, stable graft function, no rejection and stable TAC levels. One pt reported new onset migraines following the birth of her son. Infant Outcomes: 3 females and 1 male at 35-39 wks gestation (mean 37.7 wks). Normal fetal growth, activity and development were reported during each pregnancy. Three infants were delivered by Caesarean section (2 emergent, 1 planned). The infants’ Apgar scores at 1 minute were 5-8 , at 5 minutes was 9 for all. Birthweights = 2270-3885 grams (mean= 3105 gm). TAC levels were measured in 3 infants at 24 hrs after birth = 2.4, 3.7 and < 5 ng/ml. None of the infants were breastfed due to concerns for low levels of TAC in breast milk. Two infants were hospitalized for additional days after birth, one for temperature instability and the other for poor feeding. Infant outcomes were excellent with all currently healthy and achieving developmental milestones at 3-7 years of age per maternal report.
Conclusions: These outcomes suggest that healthy pregnancies are possible following ITx in pts who have stable graft function, good renal function, stable immunosuppression without recent evidence of rejection and general good health. It is also important that ITx recipients be under the care of a high-risk obstetrician and maintain close follow-up with the transplant center. The ability to conceive and have a successful delivery following ITx is an important outcome that may contribute to an improved quality of life.