Overview of the problem: End stage renal disease (ESRD) during pregnancy is a rare occurrence.  The incidence in the early 1980s of pregnancy in women on dialysis was <1% (Holley and Reddy, 2003).  Today, the incidence is between 1-7% yet only half of infants born to these women survive. If well controlled with dialysis, fetal growth and maternal stabilization to delivery at term can be achieved.  Close observation of hemodynamic status, weight control and electrolyte balance in concert with fetal surveillance and maternal support, requires a coordinated team approach. Our patient, Ms R is a 33 year old Spanish speaking primnip with a three year history of dialysis due to vasculitis. She has limited resources and social support.  Her pregnancy was further complicated with depression, treatment for tuberculosis with INH exposure and positive Group B strep culture.

Discussion of interdisciplinary intervention: Interdisciplinary collaboration begins early in pregnancy.  Endocrinology, anesthesiology, and perinatology needed to monitor her multi system needs including psychosocial status.  Her hemodynamic status was closely monitored to adjust hypertension medications in relation to increased fluid volume of pregnancy and to identify the existence of superimposed pregnancy induced hypertension.  The dialysis nursing team coordinated with the perinatal nursing team to monitor patient education needs as the plan of care was altered in relation to her fluctuating hemodynamic and respiratory status in the third trimester.  Social Services and Translation Services were involved early and provided consistent coverage throughout the pregnancy to improve team communication with our patient and continuity of care.  Dialysis was increased post 16 weeks to improve fetal growth.  From 24 weeks gestation forward, dialysis occurred in the labor unit, to ensure proper fetal surveillance and continuous education and support on alterations of pregnancy.    

Patient outcomes:  At 34 weeks Ms R developed signs of pulmonary edema versus pneumonia with echocardiography findings of a decrease in ejection fraction.  She was admitted to the Cardiac Intensive Care Unit and once stable, was delivered by cesarean section.  Her infant weighed 1731 kg and had Apgars of 9 and 9.  The infant went from the NICU to the level II nursery and did well with a few episodes of apnea up till 36 weeks of life. Ms R resumed dialysis three times a week post partum and her hypertension medications were decreased appropriately. Ms R experienced some difficulty with mood adjustment related to demands of dialysis and caring for her hospitalized infant. Lessons learned implications for future practice: Early coordination of services with special attention to Ms R’s psychosocial and communication needs was imperative. Interdisciplinary ownership of total patient needs was paramount to ensuring complimentary and efficient care.  No discipline could work in a silo and all had to be concerned with the patient’s overall quality experience. Weekly updates on our patient’s status ensured that every member of the staff was well versed in the plan of care, systems needs and the availability of resources for problem solving as they arose.