Reproductive health and pregnancy in women with chronic kidney disease

Chronic kidney disease (CKD) is associated with reduced fertility and an increased risk of adverse pregnancy outcomes. Rates of pre-eclampsia, fetal growth restriction and preterm delivery increase incrementally with the severity of CKD and proteinuria. Pre-pregnancy counselling can facilitate informed decision-making. Safe and effective contraception is required for women who wish to delay or avoid pregnancy. Pregnancy planning for women who wish to conceive involves appropriate substitution of known teratogens - including mycophenolate mofetil, angiotensin blockers and cyclophosphamide - and can aid optimization of disease control. However, pregnancy, which can occur in women with any stage of CKD, can exacerbate comorbidities such as anaemia, vitamin D deficiency and hypertension. Increased haemodialysis provision is associated with improved pregnancy outcomes for women on dialysis. Diagnosis of pre-eclampsia in women with CKD is complicated in patients with pre-existing hypertension and proteinuria but can be improved by the use of vasoactive biomarkers as well as placental and fetal Doppler ultrasound. Pregnancy data for newer drugs used in CKD are limited as pregnancy and CKD are common exclusion criteria for drug and intervention trials. Although prospective data may be available for older drugs, the use of most drugs in pregnancy is based on retrospective data and expert consensus.