Successful pregnancy outcomes are possible after solid organ transplantation and thousands of successful pregnancies in women with all types of solid organ transplants have been reported. As immunosuppressive therapy is required to maintain adequate graft and maternal survival, an ongoing concern for this population is the effect of the immunosuppressive therapy on the fetus and the effect
of pregnancy on the well being of mother and graft.
The general advice to any pregnant woman is to avoid unnecessary medications during pregnancy. Clinicians do worry about teratogens, those agents that cause abnormal development, whether this is an overt structural birth defect or more subtle derangements of embryonic or fetal development. There is the concern that any agent or combination of agents and maternal condition(s) may be teratogenic and that this risk is increased in the transplant recipient population. The goal of immunosuppressive therapy is to allow graft and patient survival by preventing rejection. Due to their toxicities, combinations of agents allow for synergistic effects while minimizing drug toxicities. Combinations of immunosuppressive agents may, however, potentially be teratogenic and it is difficult to derive accurate fetal risk assessments from animal studies alone.
Although there are known theoretical risks to mother and fetus, successful pregnancies are now the rule in transplant recipients. Most recipients appear to tolerate pregnancy well, while only a small percentage develop graft dysfunction and or irreversible deterioration either related to prepregnancy graft problems or unpredictable gestational factors.
A reasonable approach to management of the pregnant transplant recipient has been to maximize recipient, graft and fetal survival by using combinations of agents that will optimize graft outcome. Thus, what is best for the mother and her survival would hopefully provide the best outcomes for the fetus. As yet no specific combination of immunosuppressive agents has been deemed optimal for pregnancy. The effects of the newer combinations of agents, however, require further study. A balance of good maternal and graft outcome with the lowest risk of fetal toxicity must be the goal of management in this setting.