Challenging pregnancy outcome in a primigravida with chronic kidney disease on maintenance hemodialysis: From hopeful continuation to spontaneous fetal expulsion

Jayasrimurugaiyan*

Physician Assistant, OBG OPD, Kauvery Hospital, Hosur, Tamil Nadu

*Correspondence

Abstract

Pregnancy in women with CKD stage 5 on maintenance hemodialysis is rare and carries substantial maternal and fetal risks. We present a case of a 22-year-old primigravida with CKD stage 5, chronic hypertension, and dialysis dependent who conceived spontaneously. Despite extensive counseling regarding the high risk adverse maternal and fetal outcomes and recommendation for pregnancy termination, the patient and her family chose to continue the pregnancy. She was managed with close multidisciplinary follow-up involving Obstetrics & Gynecology and Nephrology teams, regular hemodialysis (4 times per week), strict blood pressure control, and continuous maternal-fetal surveillance. At 16 weeks + 3 days of gestation, the patient experienced spontaneous expulsion of fetus followed by retained placenta requiring check evacuation. The post-expulsion period was complicated by pulmonary edema necessitating ventilatory support and intensive care management, from which subsequently recovered. Although the pregnancy ended in second-trimester fetal loss, this case highlights the immense challenges of pregnancy in advanced renal disease and reflects remarkable courage, informed decision-making ,and the unwavering dedication of the multidisciplinary team in Supporting the patient Hope and Loss

Key words: Chronic hypertension; CKD, Obstetrics and gynecology

Introduction

Pregnancy in women with CKD stage 5 requiring maintenance dialysis remains a major clinical challenge. Maternal compilations such as uncontrolled hypertension, anemia, fluid imbalance, and worsening renal function are common. Fetal complications include miscarriage, fetal growth restriction ,preterm delivery and perinatal mortality. Despite advancements in dialysis and obstetric care, successful pregnancy outcomes remain difficult to achieve.

Management requires a multidisciplinary approach involving Obstetrics and gynecology, Nephrology, General physician, critical care, Anesthesia, Nursing teams to optimize maternal and fetal wellbeing equally important is respecting patient autonomy when complex decision regarding pregnancy continuation are made

Case presentation

A 22 Years old, Primi gravida with CKD stage 5 secondary to presumed poly cystic kidney disease and chronic hypertension presented with spontaneous conception. She was receiving maintenance hemodialysis four times per week through an arteriovenous fistula.

Background story: At approximately 9 weeks of gestation, ultrasonography confirmed a single live intrauterine pregnancy with fetal cardiac activity .        The patient was counseled extensively regarding the significant maternal and fetal risks associated with continuing pregnancy in the setting of ESRD and chronic hypertension. However, after understanding all potential complications, the patient and her family elected to continue pregnancy.

  • Uncontrolled Hypertension requiring multiple Anti-hypertensive agents with daily Bp monitoring.
  • Chronic anemia is managed with Iron sucrose and Erythropoietin injection.
  • At 13 weeks and 2 days of gestation, she presented with vaginal bleeding and was diagnosed with threatened abortion. Ultrasound demonstrated a live fetus with a small subchorionic hemorrhage. Conservative management was undertaken, and the pregnancy continued under strict fetal maternal and fetal surveillance
  • Despite regular dialysis, anti-hypertensive therapy, supportive care and close multidisciplinary monitoring, the pregnancy remained high risk during the Double marker test revealed abnormal findings including increased beta Hcg levels, prompting further assessment. Probable reason for high Beta Hcg values due to poor renal clearance of Beta Hcg was explained to patients and attenders. Advised NIPT and Amniocentesis for further evaluation.
  • Menstrual H/O- Regular cycles, LMP-14/01/2026, EDD-21/10/2026
  • Obstetric H/O -Primigravida, Natural conception, Booked and immunized at kauvery hospital Hosur.
  • Marital H/O – Married for 3 1/2 years, NCM
  • Medical H/O – Stage 5 chronic kidney disease (End Stage Renal Disease) On maintenance hemo-dialysis 6 hours per session x 4 times per week.

Chronic hypertension and on regular medication (T.Labetalol 200mg QID, T.Apresol 25 mg BD, T.Nicardia retard 10mg BD ) with strict Bp monitoring at home.

Patient presented to ER with C/o Lower abdomen pain since morning, H/o Loose stools (5 episodes) & Generalized tiredness (+) Initially USG screening scan done – OS closed hence advised admitting under physician.

No H/o Fever /bleeding

Clinical examination

Conscious and oriented ,afebrile

Vitals

BP160/90 mmHg
PR96 beats per minute
RR22 breaths per minute
AbdomenSoft, Uterus ~Just palpable
VaginalOS Open, BOM (+)
CVSS1, S2 heard
RSNormal Vesicular Breath Sound (+)

Investigations

TestResult
Hb7.7 g/dl
Total Count8320/cumm
Platelet Count183000/cumm
Sodium134 mmol/L
Potassium3.5 mmol/L
Urea14.9 mg/dl
Creatinine2.4 mg/dl
PTT11.7 sec
Control (PT)11.3 sec
INR 1.04
pH7.53
PCO233mmHg
PO2 158 mmHg
HCO327
Lac0.6 mmol/L

Echocardiogram

Concentric left ventricular hypertrophy, no regional wall motion abnormality, good LV function(LVEF-60%), Dilated LA /RA, mild mitral regurgitation, mild tricuspid regurgitation, mild aortic regurgitation, no pulmonary artery hypertension, RV function good, IVC -2.1 cm , trace B/L pleural effusion (+), no pericardial effusion , clot /vegetation.

Final diagnosis

Primigravida at 16 weeks +3 days of POG with Spontaneous expulsion of fetus

CKD – Stage -5 on maintenance hemodialysis (Presumed poly cystic kidney disease) with Chronic hypertension with anemia

Post procedure Pulmonary Edema

Management

Antenatal management

  • Detailed counseling regarding maternal and fetal risks associated with CKD Stage -5 maintenance hemodialysis ,and chronic hypertension
  • Shared decision making after the patient and family opted to continue the pregnancy despite understanding risks
  • Regular antenatal follow-up with serial clinical laboratory assessments
  • Strict blood pressure monitoring and anti-hypertensive therapy
  • Maintenance hemodialysis 4 times per week
  • Close fetal surveillance with serial Ultrasonography and fetal viability assessment
  • Treatment of anemia and nutritional support
  • Regular multidisciplinary review and warning signs &repeated risk counseling
  • Regular follow-up with Nephrologist relevant investigation has been done

Management during threatened abortion at 13 weeks of gestation

  • Patient admitted for close observation following vaginal bleeding
  • Maternal vital signs and bleeding pattern were monitored regularly
  • Ultrasound performed, conforming to a fetal well being
  • Conservative management done with bed rest support
  • Maintenance hemodialysis and anti-hypertensive medication were continued
  • Hence bleeding per vagina settled after 48 hours of observation, patient discharged.

Management at Spontaneous expulsion of fetus

  • Relevant investigations have been carried out. She was observed in ward,
  • At 10.30 AM Patient c/o Severe abdomen pain associated with lower back pain. Hence, she was shifted to labor room.
  • O/E -PV -OS open, BOM (+), Fetal parts felt, Bed side USG -Spontaneous expulsion of fetus.
  • Explained to patients and attenders about expulsion of fetus may need for D&C if placenta not expelled.
  • After getting informed, written and high-risk consent patient was monitored.
  • During the process persistent High blood pressure was noted and RS-Mild crepts (+) Anti Hypersensitive medications are given. Anesthetist review taken.
  • Patient C/O Breathlessness (+) At 1.40 pm- Patient expelled the male fetus, Weight -200g,
  • Patient developed acute Pulmonary edema, retained placenta (+), Explained to patient and attenders need for Check evacuation.
  • C/o Severe Breathlessness (+) explained need for NIV mask ventilation.
  • After getting informed written consent and high-risk consent following Nephrology and pre anesthetist checkup she underwent Check evacuation for retained placenta under general anesthesia. Post operatively she was shifted to ICU with NIV Mask ventilation and 2 LDPRBC transfused for anemia. Strict vitals monitoring is done. Physician and Nephrologist review taken.
  • Hemodialysis is done as per advice. With gradual clinical improvement, NIV support was progressively tapered, transitioned to supplemental oxygen, and subsequently weaned off to room air under anesthetist supervision. Milk suppressant given.
  • She was shifted to the ward. The patient showed gradual clinical improvement, PV bleeding Vitals were stable.
  • Following intensive multidisciplinary care, the patient condition improved significantly, and she was discharged symptomatically better and hemodynamically stable with appropriate medication and follow-up advice on POD -3

Discussion

Pregnancy in women receiving maintenance dialysis is associated with significantly increased risks of miscarriage, pre-term labor, fetal loss, and maternal complications, Pre-eclampsia, Eclampsia and pulmonary edema, renal dysfunction further worsen pregnancy outcomes. Although modern dialysis protocols have improved fetal survival rates, spontaneous pregnancy loss remains common ,particularly in second trimester. The case demonstrates the complex between medical recommendations and patient autonomy. Despite awareness of the risks, the patient determination to continue her pregnancy was respected and comprehensive multidisciplinary care was provided throughout the course of gestation. Obstetrics and Gynecology is often associated with the joy of welcoming new life .However there is another side of the coin-walking alongside women and families through loss, uncertainty and difficult decision. This case proves that our department is not only about celebrating happy outcomes but also about providing compassionate care, unwavering support and preserving maternal well-being when outcomes are not as hoped.

“Her hope becomes our hope, and her loss becomes our sorrow, because every heartbeat matters to us and every life deserves a chance”

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