Report from the National Transplantation Pregnancy Registry (NTPR): outcomes of pregnancy after transplantation.

Experience in the field of pregnancy after transplantation has been gained through continued case reports, center reports, and registry data. The NTPR maintains an ongoing active database to study the safety of pregnancy and includes the outcomes of female transplant recipients as well as male recipients who father pregnancies. Analyses are ongoing and include long-term follow-up of recipients' graft status and of their offspring. For the most part, guidelines proposed in 1976 for counseling recipients remain applicable. While these counseling guidelines were formulated for kidney recipients, they may be extrapolated for other organ recipients as well. Organ-specific issues should also be considered in managing and counseling female transplant recipients. Recipients should be in general good health and graft function should be stable and ideally rejection free. They should have optimal control of comorbid conditions such as hypertension and diabetes prior to conception. While the shortest safe interval from transplant to conception has not been established, one year is a reasonable milestone, given the prerequisites of stable, adequate graft function and maintenance level immunosupression. During pregnancy, stable medication regimens should be changed as little as possible, and close maternal and fetal surveillance are required. These pregnancies are high-risk and require coordinated care among maternal fetal medicine specialists and transplant personnel. The pregnancy issues that face recipients and caretakers with the current adjunctive therapies and differing combinations of immunosuppressive regimens continue to require further study. The most pressing issue is the question of whether fetal exposure to mycophenolate mofetil or sirolimus confers additional risk, relative to the potential improvement in maternal survival and maternal graft function/survival conferred by these drugs. Given the multiplicity of immunosuppressive regimens, only broad-based registry participation can provide the data needed to analyze such complex questions. Future analyses are directed at potential effects of these newer immunosuppressive regimens, not only from immediate exposure, but also from potential long-term exposures such as may occur from breastfeeding. As the registry study design allows for continuing contact between registry staff and recipients and their health care providers, efforts are in progress to analyze long-term outcomes of parent and child. Continued close collaboration among specialists will help to better identify potential pregnancy risks in these populations, especially as new immunosuppressive agents are developed.