Vaginal delivery following combined pelvic renal and pancreatic transplant

Authors


Correspondence: Mr K. Allenby, William Harvey Hospital, Kennington Road, Willesborough, Ashford, Kent, TN24 OLZ, UK.

Case Report

A 28 year old nulliparous woman underwent a combined renal and pancreatic transplant in February 1993. She had been diabetic from the age of nine years, and for two years prior to transplant had been undergoing chronic ambulatory peritoneal dialysis for chronic renal failure secondary to diabetic nephropathy. Hypertensive disease was controlled with angiotensin converting enzyme inhibitors and calcium channel blockers. In addition, she had undergone photocoagulation for diabetic retinopathy.

The transplant procedure was uncomplicated and through a low midline incision an extraperitoneal approach to the right iliac vessels was made and the renal vein anastomosed to the external iliac vein. The renal artery on a small patch of aorta was anastomosed to the external iliac artery. An onlay ureteroneocystotomy was then performed. An intraperitoneal approach was made to the left common iliac vessels and the pancreas transplanted. The portal vein was used for drainage from the pancreas into the common iliac vein and using a donor common iliac graft (with donor internal and external iliac arteries anastomosed to the splenic and superior mesenteric arteries on the pancreatic graft) the pancreas was anastomosed to the common iliac artery of the recipient. The donor duodenum attached to the pancreas was anastomosed to the bladder. The anatomical result was that the kidney lay in the right side of the pelvis and the pancreas in the left side (Fig. 1).

Figure 1.

Diagram showing position of pelvic structures immediately after the transplant.

Post-operatively there was only a brief episode of rejection and immunosuppression was established using azathioprine, prednisolone and cyclosporin. Renal and pancreatic function remained normal with normal biochemical parameters.

Three months following transplantation the patient had recurrent haematuria which was investigated using cystoscopy (which showed haemorrhagic urethral mucosa) and was initially felt to be chemical urethritis due to pancreatic enzyme secretion. The haematuria persisted and repeat cystoscopy showed a much improved urethra but an area of duodenal ulceration in the donor duodenum. The duodenocystostomy was therefore disconnected and enteric drainage into the patients jejunum established without complication. Histology showed no evidence of rejection or cytomegalovirus infection (a common cause for haematuria in these patients) in the donor duodenum.

Four years following the transplant she presented with six weeks amenorrhoea and was confirmed to be pregnant. She booked for consultant-led care and an ultrasound scan confirmed a gestation of 10 weeks with an expected date of delivery of September 1997. She was counselled regarding the risk of intrauterine growth restriction in association with her immunosuppressive therapy and also the small risk of fetal anomaly associated with azathioprine. Tetracycline taken for treatment of acne was stopped. A triple test was performed at 14 weeks which gave a low risk result of 1 in 400 for Down's syndrome.‘Booking blood’ urea and electrolytes were normal.‘Booking’ cyclosporin level was 223 ng/ml.

Care was shared between the consultant obstetrician, transplant surgeons and consultants whose specialty is diabetes. The plan for delivery was for an elective caesarean section as the effect of labour upon the pelvic pancreas was unknown. The detailed ultrasound scan at 18–19 weeks was normal. From 22 weeks of gestation, growth and fetal uteroplacental Doppler measurements were undertaken twice weekly, these remained entirely normal throughout the pregnancy. Similarly, serum biochemistry remained normal, and she remained normotensive throughout the antenatal period. Serum cyclosporin levels were maintained by adjustment of the oral dose with levels between 109 and 122 ng/ml. Glucose tolerance tests at 22 and 28 weeks gestation were entirely normal.

At a gestational age of 34 weeks and five days the woman presented in labour and was found to be 6 cm dilated on admission with the fetal head engaged. Epidural analgesia was started in anticipation of a caesarean section, but after discussion with the trans-plant team it was decided to allow a vaginal delivery. Artificial rupture of membranes revealed clear amniotic fluid; the cardiotocograph remained normal throughout, and at full dilatation 90 minutes later she had an uncomplicated ventouse delivery of a live male infant weighing 2050 g with Apgar scores of 9 at 1 minute and 10 at 5 minutes. The third stage of labour was uncomplicated.

Transient postpartum hypertension was treated with a single additional dose of nifedipine. Post-partum serum biochemistry monitoring showed no deterioration in renal function; the serum amylase was normal. The woman and her infant were discharged after four days.

Discussion

Since 1986 when the first successful pregnancy following pancreatic transplantation was described1 there have been approximately 20 cases2–9 reported in the world literature. Transplantation of the pancreas is an accepted treatment for insulin-dependant diabetes mellitus and is commonly combined with renal transplantation for chronic renal failure secondary to diabetic nephropathy.

This patient had long-standing diabetes until the time of transplant when she became completely metabolically controlled with only one brief episode of rejection. Menses returned six weeks after the transplant, and she became pregnant three and a half years after the transplant.

Hypertension has been reported in up to 83% of cases9 following combined kidney and pancreas transplant, but our patient remained normotensive. Previous reports have suggested a high incidence of intrauterine growth restriction4 but fetal growth was normal in this woman.

In a number of reports the theoretical but unsubstantiated risk of a deleterious effect on the pelvic pancreatic graft caused by prolonged increased pressure by the presenting part was stated as reason for offering a caesarean section3. In addition, intrauterine growth restriction and hypertension were cited as reasons for caesarean section. In our patient, who was delivered vaginally with a pelvic pancreas graft, the initial decision had been to perform an elective caesarean section in conjunction with the transplant team as a precaution against unexpected intraoperative difficulties. When she presented in advanced preterm labour the plan was changed. The rationale for this was that there was likely to be a quick and straightforward delivery and no prolonged periods of pelvic compression, hence minimising the theoretical risk of pancreatitis. Once full dilatation was reached, an assisted delivery was undertaken to shorten the duration of increased pelvic pressure in the second stage.

Vaginal delivery appears to have been undertaken in four previous cases of renal-pancreas transplant9, all in the United States. These cases have not been separately reported. It appears to be safe to consider vaginal delivery in the presence of a pelvic pancreas transplant if the labour is progressing well and there is not prolonged pelvic compression. We suggest that each case should be taken on its own merits with close co-operation between the multidisciplinary team in reaching a final decision about the mode of delivery. Following delivery all patients should be registered with the National Transplantation Pregnancy Registry.

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