Pregnancy and IgAN One Woman’s Story

(This informative paper on pregnancy and IgAN was submitted by one of the subscribers to the IgAN Listserve.)

On request, I’m re-posting this information I’ve gathered with the caveats that I’m not a physician; I don’t study medicine; and I do not work in the medical field. However, this issue was very important to me, and I took time and effort to obtain the best advice available to me.

I have IgAN, and I considered pregnancy approximately 2 years ago. I decided against it at the time for non-medical reasons. However, in forming my decision, I visited a perinatal specialist (with a PhD as well as an MD) who provided me with some interesting materials on this subject.

I’ll quote the doctor’s report, as well as the sources he offered. Beware, this is a long-winded post, because of my attempt to present the information as I received it.

Although pregnancy is generally discouraged in patients with certain renal diseases and similar diseases such as lupus, the jury is still out on pregnancy and IgAN, particularly mild IgAN. It’s important to remember that blood volume increases during pregnancy, and that kidneys hyperfiltrate. Furthermore, anyone considering pregnancy should consult with an obstetrician. I’ll strive to present this information now, as forthright as possible. All comments, detractors are welcome.

From the Perinatal Specialist’s report to me.

“Regarding the effect of pregnancy on the natural history of IgA nephropathy, we discussed this point is controversial. Although some authors believe that pregnancy should not lead to permanent worsening of renal function. There have been reported cases of worsening renal function during and after pregnancy with this disorder.

What is unclear without large, well-controlled series is whether the progression was accelerated by the pregnancy per se. Therefore, it is not possible to state with certainty whether or not pregnancy should be contraindicated in women with IgA nephropathy. Although some authors feel that this is contraindicated, there is certainly no consensus in this regard. Therefore, the decision whether or not to pursue pregnancy is largely a matter of personal choice rather than one that can be based upon solid, scientific evidence.

“Regarding the effect of Iga nephropathy on pregnancy, the published data would indicate that women with IgA nephropathy, as with all chronic renal diseases, are at somewhat increased risk of a variety of adverse pregnancy outcomes. The most common outcomes of concern are intrauterine growth delay, accelerated hypertension, pre-eclampsia with resultant effects on fetal well being, a risk of preterm delivery and consequent neonatal morbidity and increased risk of stillbirth. Of the maternal factors that would predict a level of risk for those adverse outcomes, most studies would indicate that these risks are lowest in women who are normotensive before pregnancy and women who have negligible degrees of renal insufficiency as manifest by low serum creatinine and high creatinine clearance.

“Most authors feel that as long as GFR is greater than 70 mL/minute, serum creatinine less than 1.1 and blood pressure less than 140/90, pregnancy can be expected to have a reasonably good prognosis. In Abe’s series, 30 women with IgA nephropathy were followed through 38 pregnancies. 74% of these resulted in live births of normally-grown infants at term, 13% were “abnormal” pregnancies, meaning either growth-restricted, preterm, abruption or postpartum hemorrhage. 10 % are listed as fetal or neonatal deaths and one spontaneous abortion. This finding overall with IgA nephropathy should be encouraging to this patient.

Summary of Counseling and Recommendations:

1. Assuming that her renal function remains good and blood pressure remains normal, she has a reasonable prognosis for a normal pregnancy. 2. Pregnancy is not contraindicated for women with IgA nephropathy with the caveat that some authors have suggested that pregnancy may accelerate the progression of IgA nephropathy to end-stage renal disease. However, this point is controversial. 3. If she becomes pregnant, she will require close follow-up between her obstetrician and nephrologist. This will entail periodic assessment of renal function, fetal growth and fetal well being.”

From Davison and Lindheimer,

“…Pregnancy does not adversely affect the natural history of the renal disease; however, there are four entities that are controversial: IgA nephropathy .. Some believe that pregnancy adversely affects the course of these diseases. Others believe that the outcome is similar to most other renal disorders.

“…As renal function declines, the ability to conceive, let alone sustain a viable pregnancy decreases. Degrees of functional impairment that do not cause symptoms or do not appear to disrupt homeostasis in non-pregnant individuals can jeopardize pregnancy.”

“Normal pregnancy is very unusual when renal function decreases to a degree that non-pregnant creatinine and urea nitrogen levels are 3 mg/dl and 30 mg/dl, respectively. These increments above non-pregnant levels are moderate but represent considerable loss of function. The basic question for a woman with renal disease is whether pregnancy is advisable. If it is, the sooner she starts to plan a family, the better, since in many cases renal function will continue to decline with time.”

“… Most women with mild underlying renal disease show increments in GFR during pregnancy, although the magnitude is less than seen in normal pregnant women. Increased proteinuria is common, occurring in 50 percent of pregnancies … The prevalence of hypertension, renal functional abnormality and proteinuria, as well as their severity,” are considerably lower between pregnancies and during long-term follow up. When renal failure occurs, it usually reflects the inexorable course of a particular renal disease.”

“Moderate Renal Insufficiency: Prognosis is poorer when renal function is moderately impaired before pregnancy (plasma creatinine >= 1.5-2.5 mg/dl) … It is difficult to draw conclusions about pregnancy in these women, chiefly because the number of cases surveyed is still relatively small. Reviews have appeared elsewhere outlining the major problems in this condition as accelerated renal deterioration, uncontrolled hypertension, variable obstetric outcome, and accelerated post-delivery decline in renal function.

Severe Renal Insufficiency: … (plasma creatinine >= 3 mg/dl) … The likelihood of contraception and having a normal pregnancy and delivery are decreased, but are not, as some have thought, impossible. The risk of severe maternal complications is much greater than the probability of successful obstetric outcome … pregnancy should be vigorously discouraged. The aim should be to preserve what little renal function remains.

Is Pregnancy Advisable? … We prefer to restrict pregnancy to women whose plasma creatinine levels are 2 mg/dl … or less and who have a diastolic blood press of 90 mm Hg or lower (preferably below 80 mg Hg). Others are more strict, recommending that pregnancy should not be undertaken in patients when plasma creatinine concentrations exceed 1.5 mg/100 ml/dl.

Antenatal Care: Patients with known renal disease should be seen every 2 weeks until 32 weeks’ gestation, after which assessment should be weekly.

Consequently, a balance must be struck between pregnancy outcome and the long-term impact of the pregnancy on the patient. The crucial determinants are pre-pregnancy renal function, presence of hypertension (and its management), and the renal disease itself. Other factors are optimal fetal surveillance, more timely delivery, and recent neonatology advances.”

For those still reading, from Abe (a medical reference)

“Clinically normotensive women, as well as those having preserved renal function, experienced a favorable outcome in delivery … patients with normal blood pressure (<140/90 mm Hg) had statistically higher rates of normal delivery 97%) and of live births (88%) when compared with those of hypertensive cases (50% and 71% respectively). With regard to renal function, the rate of normal delivery was 76% in the cases with good renal function (that is, glomerular filtration rate of > 70 ml/min or serum creatinine level of

From a table on
“Relationship between antecedent renal disease and outcome of pregnancy – Iga Nephropathy”

No. of Pregnant women with IgAN:________ 30
No. of pregnancies: ____________________ 38
Deliveries: Normal: _____________________28 (74%)
Abnormal: ____________________________ 5 (13%)
Fetal or neonatal deaths: _________________ 4 (10%)
Spontaneous abortions: __________________ 1 (3%)

I hope this information, in spite of the lack of presentation, proves useful. I apologize for the lack of presentation, as well as any typos. Don’t let the errors reflect on the authors!

Sources:

Consultation report with Perinatal Specialist, 03/02/95, San Jose, Calif.

Abe, Shinichi, MD, “American Journal of Obstetrics and Gynecology,” vol. 153 pp 508, 1985.

Davison and Lindheimer, “Chronic Renal Disease,” published in Norbert Cleicher’s textbook, “Principles and Practice of Medical Therapy in Pregnancy,” second edition.