Successful management of six pregnancies resulting in live births after simultaneous pancreas kidney transplantation: a single‐center experience

Apart from improving quality of life and long-term cardiovascular function, a successful simultaneous kidney pancreas transplantation (SPK) also contributes to restoration of fertility in female patients [1–4]. In contrast to multiple reported successful births following kidney transplantation, only few registry analyses and case reports regarding childbirth after SPK have been published to date [5–8]. We report on our single-center experience regarding the obstetric, maternal, and graft outcome in total six successful deliveries in four female SPK patients: Of total 442 SPKs performed between 1979 and 2011, 166 (37.6%) were in females. Four of them (mean age of 32 at transplant) became pregnant for the first time at mean 55 months post-transplant and two of them again at mean 97 months. No in vitro fertilization was performed (Table 1). Transplantation was performed according to standard techniques: The kidney was implanted into the left side (vascular anastomosis to the common/external iliac vessels), the pancreas through transperitoneal access with arterial anastomosis to the recipient common iliac artery and venous anastomosis to the external iliac vein, and in one patient each to the V. cava inferior and the V. mesenterica superior. The exocrine pancreas was drained by either duodenojejunostomy (three patients) or duodenocystostomy (one patient). Secondary diabetic complications included one case of severe proliferative retinopathy with bilateral amaurosis, one case of successful laser coagulation controlled by split lamp, one severe peripheral angiopathy requiring amputation of one toe, and one asymptomatic noncritical coronary artery stenosis. Maintenance immunosuppression consisted of tacrolimus and mycophenolate mofetil (MMF) after induction therapy with antithymocyte globulin. Steroids were discontinued during the first post-transplant year. In one patient, sirolimus was administered on a study protocol. In all prospectively planned pregnancies, immunosuppression was adapted preconception by converting MMF/ sirolimus to azathioprine following reports of MMF being associated with a higher incidence of spontaneous abortion and congenital malformation in contrast to azathioprine being favorable in deliveries after kidney transplantation [1]. Tacrolimus (mean level 5.9 ng/ml) and azathioprine 1.0 mg/kg (rounded according to pills of 50 mg) remained unmodified during pregnancy. All kidney and pancreas grafts were at stable function prior to conception (Table 1). Three patients had no history of pregnancy, miscarriage or abortion, and one patient had one early abortion each before and post-transplant. Study data were recorded in an electronic database. Permission for analysis was given by the local ethics board. Statistics were performed using SPSS 15.0 IBM Deutschland GmbH, Ehningen, Germany. Cesarean section was performed in all pregnancies at mean gestational week 32.8. Concerning pediatric course, all six babies were born without any congenital malformation corresponding to the report by Bar et al. [9], who found no statistically significant differences in neonatal malformations when comparing babies from untransplanted mothers and from renal-transplanted mothers. Our study group had a low birth weight (mean 1851 g) in coincidence with lower gestational age (according to the reports by Coscia et al.); two babies required respiratory support without subsequent pulmonary disorder or hypoxic damage ([8], Table 1). No gynecological complications in maternal course were observed. Three women remained physically stable without deterioration of blood pressure, peripheral angiopathy, or retinopathy. No severe urinary tract infection or other bacterial/serious viral infection occurred, probably due to the relatively low-dosed immunosuppression, exact attention to hygiene standards and controlled fluid balances avoiding cystitis. The patient with a graft pancreaticocystostomy developed leukocyturia (within sterile bacterial