Planning pregnancy after CF-linked lung transplant tied to better results
Study: Positive outcomes include lower risk of maternal death after pregnancy
Women with conditions such as cystic fibrosis (CF) who planned their pregnancies after a lung transplant experienced better outcomes compared with those who did not plan their pregnancies, according to a recent study.
Those positive outcomes included longer gestation periods, higher birth weights of their babies, and a lower risk of maternal death following pregnancy.
Pregnancies in women receiving a transplant are particularly complex due to potential complications for both mother and baby. However, “successful pregnancy outcomes after lung transplantation are possible. Planning the pregnancy is the most positive modifiable risk factor,” researchers wrote.
The study, “Pregnancy Outcomes in 53 Female Lung Transplant Recipients,” was published in CHEST journal.
Lung transplant can be lifesaver for CF patients
Depending on the severity of lung disease progression, a lung transplant may become a lifesaving intervention for people living with CF, particularly as common symptoms such as persistent respiratory infections, breathlessness, and declining lung function worsen.
In the past, pregnancy was often discouraged for women who had received a lung transplant due to potential graft loss, organ rejection, increased vulnerability to infections, and complications from immunosuppressive medications like mycophenolic acid (MPA). While MPA is crucial in preventing the body from rejecting the transplanted organ, it can be harmful to the fetus.
While a few small studies have documented pregnancies following lung transplant and guidelines have been recently published on the management of pregnancy in organ transplant recipients, “limited data exist to inform and appropriately counsel female [lung transplant] recipients regarding pregnancy after transplantation,” the researchers wrote.
In this study, the researchers retrospectively analyzed data from 53 women who became pregnant after lung transplant, with a total of 72 pregnancies reported to the Transplant Pregnancy Registry International between 1991 and 2021. These women received their transplants at 36 different centers across six countries, most commonly due to CF (60%) or pulmonary hypertension (19%).
By the end of the study period, 38% of transplant recipients had died, and 13% were lost to follow-up. The leading cause of death, accounting for half of the cases, was chronic rejection and graft failure.
The median age at the time of transplant was 27.5 years, and women were, on average, 31.2 years old at the time of the first pregnancy. More than half (54%) of the pregnancies were unplanned, and 36% reported using birth control after transplant.
Babies from planned pregnancies had significantly higher birth weights
Out of these pregnancies, 46 resulted in live births, while 22 ended in miscarriages, five were terminated due to complications, and one was ectopic, where the fetus develops outside the uterus. Median gestational age — how far along the pregnancy is from the first day of the woman’s last menstrual cycle — was 36 weeks. Three newborns, the most premature, died shortly after birth.
Premature birth, defined as delivery before 37 weeks of pregnancy, occurred in 61% of pregnancies, and 59% of the babies weighed less than 2,500 grams (about 5.5 lbs), a threshold used to define low birth weight. Birth defects were reported in 16% of children, including heart and bladder anomalies, but none were linked to MPA exposure.
Babies from planned pregnancies had significantly higher birth weights, averaging 2,639 grams (about 5.82 lbs), compared with 2,155 grams (about 4.75 lbs) for babies from unplanned pregnancies. These babies were born after a significantly longer gestational period, with an average of 36.9 weeks versus 34 weeks for those from unplanned pregnancies.
Unplanned pregnancy increases the risk of adverse outcomes for recipients and is an indicator of either a lack of sufficient coordination of care with the health care team or recipient nonadherence, with poorer outcomes the result.
When looking at the time between lung transplant and conception, the researchers found that women who died during the study became pregnant sooner after their transplant, a median of 2.3 years later, compared with 4.1 years in those who were still alive.
Women who did not plan their pregnancies had a significantly higher rate of mortality after pregnancy, 61% compared with just 8% in planned pregnancies. These unplanned pregnancies also occurred sooner after transplant, a median of 2.8 years, compared to 5 years in planned pregnancies.
After adjusting for other factors, unplanned pregnancy remained the only factor significantly associated with maternal mortality.
“A causal relationship between pregnancy planning and recipient survival cannot be inferred; however, unplanned pregnancy increases the risk of adverse outcomes for recipients and is an indicator of either a lack of sufficient coordination of care with the health care team or recipient nonadherence, with poorer outcomes the result,” the researchers wrote.
Researchers stress importance of pregnancy planning
Nearly all women were on immunosuppressive therapy throughout pregnancy, with tacrolimus or cyclosporine combined with prednisone, a corticosteroid, used in 91% of cases. Before becoming pregnant, 39% of women were on MPA.
Among the 18 women taking MPA at the time of conception, half discontinued without introducing an alternative immunosuppressive drug, while 44% switched to azathioprine.
MPA exposure occurred in 11 pregnancies, all of which were the first pregnancy post-transplant. Exposure ranged from a few days to as long as 85 days into the pregnancy. Six of these pregnancies ended in miscarriage, and five resulted in live births. One baby, who had the longest exposure to MPA, died after birth due to severe prematurity. About 72% of MPA-exposed pregnancies were unplanned.
Importantly, none of the women who discontinued MPA during pregnancy experienced organ rejection.
“A survey of female recipients of all [solid organ transplant] types shows 39% desire pregnancy, and 75% disagreed with the recommendation that they should be advised to avoid pregnancy,” the researchers wrote. “It is incumbent on providers to discuss the potential for pregnancy, pregnancy-associated risks, contraception, and the advantages to the mother and potential offspring of planning pregnancy.”
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