IMMUNOSUPPRESSIVE THERAPY, MANAGEMENT, AND OUTCOME OF HEART-TRANSPLANT RECIPIENTS DURING PREGNANCY

To evaluate challenges facing heart transplant recipients who become p regnant, we surveyed 194 heart transplantation centers and reviewed th e literature. Thirty-two known pregnancies in heart (n = 29) or heart- lung (n = 3) allograft recipients have resulted in 29 children, includ ing two sets of twins. The method of delivery was most often vaginal ( cesarean section rate was 33%), and premature delivery was common (41% ). The onset of pregnancy from the time of transplantation was 2.6 +/- 0.3 years, with the age at conception ranging from 19 to 35 years. Hy pertension (44%), premature labor (30%), and preeclampsia (22%) were t he most frequent maternal complications. Four patients experienced a w orsening of ongoing chronic renal insufficiency; four patients experie nced infections during pregnancy, and six patients (22%) were successf ully treated for rejection episodes during pregnancy by adjustments in standard immunosuppressive agents. No peripartum deaths were reported ; three late deaths occurred. Of the 29 children born of heart transpl ant recipients who became pregnant, no fetal anomalies or neonatal dea ths occurred. Prematurity (41%) and low birth weight (17%) were the mo st common complications. All children are reported in good health at 3 .4 +/- 0.4 years of age. Most transplant recipients (59%) were being t reated with triple-drug immunosuppression with azathioprine, corticost eroids, and cyclosporine during pregnancy. The most common alteration to immunosuppressive therapy during pregnancy (41%) involved increasin g cyclosporine doses caused by decreasing cyclosporine levels during p regnancy. Twenty-two percent of patients underwent empiric lowering of cyclosporine doses during pregnancy; four patients continued with cor ticosteroid tapering during pregnancy, and four patients increased cor ticosteroid doses. Three patients discontinued azathioprine, two becau se of drug-induced cholestatic jaundice and one for severe anemia. The specific immunosuppressive regimen used during pregnancy did not appe ar to affect the outcome of the pregnancy; however, the data suggest t hat immunosuppressive therapy must be monitored closely because of the metabolic and hemodynamic changes of pregnancy. Although these result s show increased complications in a high risk population, pregnancy ap pears to be fairly well tolerated in heart transplant recipients.