Many renal transplant patients have coexisting comorbid conditions that could influence the outcome of a pregnancy. It is essential that each comorbid condition is recognised and a management plan made for each of these at every stage of pregnancy – from the time of prepregnancy counselling to postpartum care. An overall integrated management plan for the pregnancy can then be developed and followed by the patient and the multidisciplinary team (Table 19.1).

Some of the more common comorbid conditions found in renal transplant patients are considered below.

Hypertension

A high proportion of renal transplant recipients are hypertensive before pregnancy (47–73%). A further 25% will become hypertensive during pregnancy and indeed, in the later stages of pregnancy, superimposed pre-eclampsia develops in 15—37% of renal transplant recipients. Ciclosporin is associated with an increased incidence of hypertension during pregnancy.

The presence of hypertension is one of the most important factors contributing to fetal growth restriction and/or preterm delivery in renal transplant patients.

In pregnancy, mild to moderately raised blood pressure requires treatment with one or more antihypertensive medications. The aim is to maintain a safe level of blood pressure for mother, graft and fetus. However, lowering of blood pressure has been reported by some, but not all, authors to have an adverse impact upon fetal growth. One meta-analysis demonstrated that lowering maternal blood pressure resulted in increased incidence of small-for-gestational age infants but another analysis showed no overall risk of a small baby in women taking antihypertensive medication.