Dr Shilpa Jesudason
Royal Adelaide Hospital
Dr Jesudason is a nephrologist in the Central and Northern Adelaide Renal and Transplantation Service (CNARTS) at the Royal Adelaide Hospital, visiting physician at the Women's and Children's Hospital and Clinical Senior Lecturer, University of Adelaide. She trained in Adelaide and London, and undertook her PhD in transplantation immunology.

Her current clinical interests are management of parenthood-related issues in women and men with renal disease (CKD, dialysis and transplant patients), and the impact of pregnancy and pre-eclampsia on future renal health. She oversees a broad program of clinical, epidemiological and laboratory research


Pregnancy Outcomes In Women With Renal Disease
Dr Shilpa Jesudason, Central and Northern Adelaide Renal and Transplantation Service, Royal Adelaide Hospital

The prevalence of chronic kidney disease (CKD) is rising, and may affect up to 3% of women in their childbearing years. Pre-existing CKD of any stage may impact upon maternal renal and perinatal outcomes and morbidity. Pregnancy in women with advanced kidney disease, women receiving dialysis, or those with a functioning kidney transplant poses a particularly challenging clinical scenario. Parenthood is a central focus for women with chronic kidney disease, but raises important fears and uncertainties about risks to their own and their baby’s health. Improvements in care over recent decades have led to a paradigm shift with cautious optimism and growing interest regarding pregnancies in women with chronic kidney disease. The challenging nature of these pregnancies underscores the need for careful pre-pregnancy planning in known CKD patients, early identification of new-onset maternal CKD, management of pregnancy with shared decision-making and a patient-centred approach, in an integrated specialised obstetric and nephrology service. 

Renal Transplantation and Pregnancy 
Dr Shilpa Jesudason, Central and Northern Adelaide Renal and Transplantation Service, Royal Adelaide Hospital

Fertility is significantly increased after kidney transplantation, and the chances of successful birth are markedly improved compared to the dialysis cohort. In recent years, there has been an explosion of data with numerous registry and cohort studies, systematic reviews and a meta-analysis describing kidney transplant pregnancy outcomes. The Australian and New Zealand Dialysis and Transplant (ANZDATA) registry reports the rate of elective termination has fallen from 25% in the 1970s to 3% in the recent era. The overall live birth rate is 76% (97.8% for pregnancies reaching >20 weeks gestation), with most pregnancy losses occurring in the first trimester. However, even in successfully transplanted women, substantial rates of important obstetric complications are observed. Pre-eclampsia occurs in 25-35% of pregnancies, with 30-50% of babies having growth restriction or pre-term birth. The ANZDATA registry analyses demonstrated a difference in mean gestational age of 3.5 weeks and birthweight of 873g for babies of transplanted women compared to the Australian birth cohort.

Issues specific to managing pregnancy in transplanted women include determining appropriate timing of conception post-transplant, adjustment of immunosuppression, surveillance of allograft function and vigilant monitoring for pre-eclampsia, rejection and infection in the immunocompromised recipient. Risk factors for inferior perinatal outcomes and decline in maternal graft function are similar to those observed in chronic kidney disease cohorts. Pre-conception graft function is a key determinant of pregnancy success. More data is required regarding longer-term graft and infant outcomes, and methods of risk stratification. Of particular concern are those women with borderline pre-conception allograft function; the longer-term impact of pregnancy is much less defined in this cohort. We are exploring these issues in ongoing research studies.

Pregnancy Outcomes in Women with Renal Disease in South Australia
A Fitzpatrick1, A Nguyen2, V Kamalesh2, W Scheil2, SP McDonald3,4, S Jesudason1,3,4,

1.     1Women’s and Babies’ Division, Women’s and Children’s Hospital, Adelaide, Australia
 SA Pregnancy Outcomes Unit, SA Health, Adelaide, Australia,
3Central and Northern Adelaide Renal and Transplantation Services (CNARTS), Royal Adelaide Hospital, Adelaide, Australia
4Department of Medicine, University of Adelaide, Australia

Aims. Renal disease in pregnancy is an important determinant of adverse maternal and perinatal outcomes. The impact on pregnancy outcomes depends on the nature and severity of underlying disease. The study aims to characterise the extent and impact of renal disease in Australian pregnant women.  

Methods. The South Australian Pregnancy Outcomes Unit dataset for singleton pregnancies, >20 weeks gestation (1990-2012) was analysed. ICD-9 codes for immunological renal conditions, cystic/genetic renal disease, vesicoureteral reflux, hypertensive nephropathy, urological conditions, pyelonephritis, and unspecified renal disease were identified. We undertook descriptive analysis, and determined odds ratios for maternal and neonatal outcomes, including multivariable logistic regression adjusted for covariates as per Table 1 footnotes.  

Results. Among 407,580 births, 1392 had maternal renal codes ascribed (0.3%). Women with renal codes were significantly more likely to be younger, smoke and from a lower socioeconomic background (p<0.001). Maternal renal disease was associated with adverse obstetric and perinatal outcomes (Table 1).  In sub-analyses of renal disease groups, women with immunological, cystic/genetic and vesicoureteric reflux conditions had the highest risk of adverse outcomes.

Table 1. Outcomes for women with ICD-9 codes for renal disease compared to women with no renal codes


Odds ratio (95% CI)

Univariable analyses

Pregnancy-induced hypertension

1.99 (1.72, 2.32)

Antepartum haemorrhage – abruption

1.60 (0.64, 2.91)

Caesarean section

1.24 (1.11, 1.39)

Preterm birth

2.95 (2.56, 3.40)

Low birth weight <2500g

2.65 (2.26, 3.10)

Intrauterine growth restriction

1.20 (1.02, 1.43)

Small for gestational age

1.18 (1.00, 1.39)

Multivariable analysesa

Preterm birth

2.60 (2.25, 3.01)

Caesarean section – primiparousb

1.12 (0.95, 1.33)

Caesarean section – multiparousb

1.76 (1.37, 2.27)

Small for gestational age

1.04 (0.88, 1.23)

aAdjusted for maternal age, ethnicity, socioeconomic status, induction of labour, hypertension and diabetes.

bNot adjusted for ethnicity. In multiparous women, adjustment made for previous Caesarean section. 

Conclusions. In the South Australian cohort, maternal renal diagnostic coding was associated with adverse maternal and perinatal outcomes.