Background: Pregnancy after living kidney donation is increasingly common, but the dominant obstetric phenotype remains unclear. Prior work focused on hypertension, yet placental dysfunction and fetal growth impairment may be more informative. We investigated whether post-donation pregnancies are associated with increased risks of placental dysfunction and fetal growth restriction versus matched non-donor and pre-donation pregnancies. Methods: Nationwide Swedish registry-based cohort study (1995–2018) including women ≤45 years at living kidney donation. Singleton pre- and post-donation pregnancies were identified. Post-donation pregnancies were compared 1:10 with matched general obstetric controls (age, parity, year, region) and with pre-donation pregnancies. Primary outcome: placental dysfunction (pre-eclampsia or SGA <10th percentile). Co-primary: SGA as proxy for fetal growth restriction. Adjusted regression models accounted for maternal clustering. Results: 642 donors contributed 987 pre-donation and 1,013 post-donation pregnancies; 10,130 controls were included. Placental dysfunction occurred in 21.4% (post-donation) vs. 15.2% (pre-donation) vs. 16.8% (controls). Adjusted ORs: 1.38 (95% CI 1.19–1.60) vs. controls and 1.45 (1.21–1.74) vs. pre-donation. SGA occurred in 17.6%, 12.4%, and 13.7%, respectively (ORs 1.41 and 1.49). Mean birth weight was 92 g lower post-donation (95% CI –118 to –66). Pre-eclampsia alone showed modest association (OR 1.25, 1.04–1.50), suggesting a fetal growth phenotype. Conclusions: Post-donation pregnancies had higher risks of placental dysfunction and impaired fetal growth, with weaker association for pre-eclampsia alone. The absolute risk increase was modest ( 5 percentage points), supporting targeted antenatal surveillance focused on fetal growth alongside maternal hypertension.