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Background and objectives: There is an increasing incidence and interest in pregnancy on hemodialysis (HD), as shown by the increasing number of reported cases, but woman that start dialysis during early pregnancy is rare. Fetal death is still a likely outcome without a multidisciplinary approach and adequate team communication, so accurate maternal and fetal monitoring from an early stage is required. Multiple pregnancies carry a higher-risk of fetal and maternal complications. We report the management of a twin pregnancy in a hemodialysis patient, in a woman with three previous cesareans. We have not found similar reports in the literature.
Case report: A 32-year-old woman started urgent hemodialysis when diagnosed hypertensive crisis with uremic syndrome and end-stage renal disease. An ultrasound 15 weeks later detected a 19 weeks twin pregnancy; gravida 4 para 3. Therapeutic adjustments were made with multidisciplinary management. She developed hypertension, gestational diabetes and anemia. Cesarean was planned for 35 weeks of gestation but labour started two days before during a hemodialysis session, heparin was used, and urgent cesarean was needed. Under general anesthesia both babies were extracted without major complications.
Conclusions: Successful pregnancy outcome in patients in hemodialysis is uncommon, but not an impossible event. Neuroaxial anesthesia can be safely performed in patients in hemodialysis. Use of heparin derivatives may preclude that approach since the unpredictability of the onset of labour or an eventual obstetric emergency makes the delivery schedule uncertain. An interdisciplinary team and cooperation between nephrologists, obstetricians, neonatologists and anesthesiologists proved essential to this good outcome.