Table 1.

Commonly used medications in dialysis patients and safety in pregnancy and lactation

	Pregnancy Safety	Considerations for pregnant women with ESKD	Lactation Considerations
Anti-hypertensives
ACE-Inhibitors	Fetotoxic in second and third trimesters	No apparent increased risk in first trimester.	Enalapril and captopril safely used in lactation
		However, given potential for delayed diagnosis of pregnancy in women with ESKD, stop prior to attempting to conceive
Angiotensin Receptor Blockers	Fetotoxic in second and third trimesters with limited data in first trimester	Stop prior to pregnancy	No sufficient data; avoid use
Beta-blockers	Labetalol considered a preferred agent and licensed for use in pregnancy	Can cause fetal bradycardia Atenolol is contraindicated due to increased risk of intrauterine growth restriction	Considered safe in lactation
Calcium Channel Blockers	Nifedipine (long-acting) considered a preferred agent in pregnancy	Nifedipine has also been evaluated as a short term tocolytic	Considered safe in lactation
Methyldopa	Considered a preferred agent in pregnancy	Side effects include: fatigue, nausea, vomiting	May worsen post-partum depression; monitor closely
Loop diuretics	Can be used safely in pregnancy	In pregnant women on dialysis, favor increasing dialysis time and ultrafiltration if volume control is suboptimal	Use judiciously, may hinder breastmilk production
Hydralazine	Considered safe in pregnancy	Increased risk of neonatal thrombocytopenia, lupus-like syndrome, fetal tachycardia	Considered safe in lactation
Erythropoeitin stimulating agents	Considered safe in pregnancy, large molecule which is unlikely to cross the placenta	May need twice the typical dose to meet goal Hgb 10–11 mg/dL	Considered safe in lactation
Iron sucrose	Considered safe in pregnancy		Considered safe in lactation
Heparin	Considered safe in pregnancy	Stop heparin use with dialysis prior to delivery to allow for placement of epidural	Preservative-free preferred post-partum to minimize potential infant exposure and toxicity to benzyl alcohol
Bone mineral metabolism
Calcium based binders	Considered safe in pregnancy	Adjust to maintain maternal calcium and phosphorous levels in the normal range; Not often needed in women undergoing intensive hemodialysis	Considered safe in lactation
Sevelamer	Associated with fetal bone ossification abnormalities in animal studies; avoid	Use calcium-based binders if needed	Limited data though not expected to be present in large quantities in breastmilk; avoid in lactation
Calcitriol	Considered safe in pregnancy	Adjust to maintain target parathyroid hormone levels	Considered safe in lactation
Cinacalcet	Limited though successful case reports; avoid in pregnancy		Limited data; avoid in lactation