Lupus Nephritis in Pregnancy

Journal – case record
Yovita Devi K 030.08.261

CASE

A 29-year-old pregnant woman with systemic lupus erythematosus was admitted to the hospital because of renal failure at 20 weeks 6 days of gestation.

HISTORY OF THE ILLNESS .

• Therapy : Low-dose prednisone . • Diagnosis : systemic lupus erythematosus.21 years of age • Pain and swelling developed in the distal and proximal interphalangeal joints of both hands and feet.

• Renal biopsy : class IV lupus nephritis. and enalapril (15 mg) were administered daily. furosemide (20 mg). • Therapy : Prednisone (10 mg). azathioprine (25 mg).Three years before admission • the nephrotic syndrome developed. .

diffuse proliferative type. .Eighteen months before admission • Renal biopsy : class IV lupus nephritis.

One year before admission • The blood pressure was 85/50 mm Hg and the weight 50. . Azathioprine was discontinued. and mycophenolate mofetil was added to prednisone therapy. • Therapy : patient declined the option of cyclophosphamide therapy because of a desire to preserve fertility.3 kg.

• Therapy : mycophenolate mofetil was discontinued and enalapril was withheld temporarily.Five months before admission • The patient reported that during the preceding month she had had unprotected intercourse. . • The blood pressure was 92/48 mm Hg and the pulse more than the 80 beats per minute.

Three months before admission • The patient still had not menstruated. .000 U per liter. testing for quantitative serum levels of the beta subunit of human chorionic gonadotropin was positive at 162.

and prednisone was continued at 10 mg a day. • Therapy : supplementary prenatal vitamins. . folic acid. and calcium were begun. • The vital signs and physical examination were normal.Two months before admission • The patient was seen in the high-risk obstetrical clinic for prenatal care. at 11 weeks 6 days of gestation.

and 3+ pedal edema was noted.5 kg.3 kg.Six weeks before admission • The patient’s weight was 53. . • Two weeks later. the weight was 60.

. • There was mild pallor. no icterus.Three weeks before admission • The blood pressure was 132/74 mm Hg. • Treatment non-pharmacology : patient was advised to wear antiembolic stockings and to restrict her intake of fluids to 1500 ml per day. and the weight 62. There was 2+ pitting edema of the ankles and mild sacral edema. and no jugulovenous distention. The results of an examination of the heart and lungs were normal • The uterine fundus was compatible with a gestational age of five months.1 kg. the pulse 88 beats per minute.

There was no family history of systemic lupus erythematosus or kidney disease. – the lungs revealed no abnormalities. She had no allergies. and gravid. Physical examination : – patient’s skin was pale. the blood pressure 110/60 mm Hg. An ultrasonogram of the uterus obtained on the second hospital day revealed a normal fetus and normal volume of amniotic fluid.1 kg.The day of admission • • • Patient had fatigue and weakness. with a fundal height consistent with the gestational age of 20 weeks. – The temperature was normal. and her vital signs were monitored. followed by prednisone (60 mg per day). 3000 IU three times per week. She did not smoke cigarettes or drink alcohol. and a 2/6 systolic ejection murmur was heard at the upper left sternal border. There was 3+ edema extending to the thighs. – The option of pregnancy termination was discussed and declined by the patient. • Pharmacology : Methylprednisolone IV (250 mg per day) for three days. the pulse 96 beats per minute. . and the weight 62. nontender. • Treatment non-pharmacology : – bed rest. Fluids were restricted to 1500 ml per day. – The abdomen was soft. Epoetin alfa was begun.

Two units of packed red cells were transfused. was begun. and the weight 65. • On the ninth day.1 kg and the blood pressure 140/80 mm Hg. the weight was 64. An ultrasonogram of the patient’s kidneys revealed no evidence of renal-vein thrombosis. the blood pressure was 140/80 to 140/90 mm Hg. .• On the third hospital day. • On the eighth hospital day. the blood pressure ranged from 107/59 to 138/78 mm Hg. the blood pressure ranged from 120/60 to 150/70 mm Hg. – Therapy : subcutaneous heparin. 5000 IU twice per day.0 kg. – Treatment : azathioprine was again added. • On the seventh hospital day.

• On the 25th hospital day (24 weeks 2 days of gestation). a diagnostic procedure was performed. the patient’s weight was 67. the blood pressure had risen to 174/100 mm Hg. was given daily for two days. and the patient was dizzy. 30 minutes later the blood pressure was 140/80 and remained stable.3 kg. • On the 24th day. – Ultrasonography of the uterus again showed a normal fetus and normal volume of the amniotic fluid. 12 mg intramuscularly. – The blood pressure rose transiently to 170/98 mm Hg. – Therapy : betamethasone. .• On the 14th hospital day.

200 271jt 24 8.000 295jt 1 7.800 1 yr 9.8 8.7 22.800 84jt 13.0 23.700 326jt 3 10 6.8 26.3 4.9 10.red cells .4 11.200 244jt Negative Negative Hospital Day 2 days 7.1 22.8 13.1 14.white cells -Bacteria -Hyaline casts -Granular casts -Waxy cast Negative 2+ 3-5 - +2 +3 0-2 10-20 Few +3 +3 10-20 50-100 moderate 10-20 0-2 +2 +3 20-50 20-50 Few 3-5 3-5 +3 +3 >100 >100 Many >29 3-5 .3 18.3 20.9 19.800 209jt 2 mo 8.5 38.4 16.600 106jt 25 7.8 15.2 31.300 277jt 3 mo 8.1 20.300 282jt 7.albumin .8 25.5 21.3 8.9 22.Hematologic Laboratory Data Variable 33 mo Hb Ht Leuko Trombo Antiphospholipid ab Lupus anticoagulant Before Admission 18 mo 11.800 347jt Negative Negative Urinalysis -Occult blood .

7 24-h urine specimen -Protein -Creatinine -volume 6700 2656 944 1600 2465 1302 1550 8289 1910 .82 Hospital day 10 1.8 8692.61 2740 1.24 2 mo 0.68 712.200 14.24 18.Urine Chemical Value Variable 38 mo Urine creatinine Urine protein Protein to creatinine ratio Albumin Albumin to creatinine ratio Before admission 33 mo 0.70 4 mo 1.59 1660 18 mo 0.21 2390 11.38 4340 6 wk 1 wk 0.84 1590 1 yr 1.13 2530 2.

518 86-184 20-58 63-145 134 37 33 55 65 15 50 1.884 54 12 116 71 14 .Immunologic Laboratory Data Variable Normal range 33 mo Antinuclear – antibody titer Anto-doublestranded DNA antibody titer Anti Ro SS-A antibody C3 C4 Total complement Negative Negative 1:640 Speckled Before admission 1 yr >1:5120 Speckled 1:640 5 mo 1:640 Speckled 1:160 2 mo >1:5120 Speckled 1:80 Hospital day 10 >1:2560 Speckled 1:40 <0.

8 1 yr 24 0.0 3.5 25 1.8 3 34 1.8 Hospital Day 10 39 2.1 154 4.7 1.6 3.6 399 Cholesterol -HDL -LDL -TG 283 45 179 295 339 60 562 490 325 51 845 .7 1.8 Before Admission 18 mo 18 0.0 1.1 3.1 2.1 2.0 24 Protein -Total -Albumin -Globulin Lactate dehydrogenase 3.8 1.7 1.Blood Chemical Value Variable 33 mo Urea nitrogen Creatinine 23 0.7 2 days 18 1.1 2.9 7.3 23 44 2.4 1 36 1.2 4.8 2 mo 18 0.

• Preeclampsia. with the nephrotic syndrome. . • thrombocytopenia.Differential Diagnosis • Pregnancy-induced flare of systemic lupus erythematosus. and hemolytic anemia.

Clinical Diagnosis • Pregnancy-induced flare of systemic lupus erythematosus. . • Preeclampsia.

Discussion of Management • received azathioprine and corticosteroids but not cyclophosphamide. . • This patient underwent cesarean delivery because the fetus was in the breech presentation.

showed findings that were diagnostic of glomerulonephritis related to systemic lupus erythematosus .Pathological Discussion • The renal biopsy performed 18 months before admission.

v the findings on renal biopsy satisfy the criteria for both membranous lupus nephritis (class V) and diffuse segmental proliferative and sclerosing (class IV-S [A/C]) disease. .

sheets of intermediate trophoblast cells. .v These findings a small placenta. decidual vasculopathy with or without acute atherosis. and hypermature villi as well as acute and chronic infarcts and a small-diameter umbilical cord.

• Because the placental findings in pregnancies affected by preeclampsia and lupus are similar. it has been hypothesized that the ischemic placenta secretes one or more soluble factors into the maternal bloodstream that induce generalized endothelial dysfunction and the syndrome of preeclampsia. . it is difficult to distinguish between the two on the basis of placental pathology alone. • To explain the systemic findings of proteinuria. and coagulation abnormalities in the mother. • A cardinal pathological feature of preeclampsia is that the spiral arteries of the mother do not undergo the normal spectrum of changes necessary for adequate oxygen and nutrient delivery to the placenta and fetus. hypertension.

consistent with preeclampsia . • Small.Anatomical Diagnosis • Combined membranous (class V) and diffuse segmental proliferative and sclerosing (class IV-S [A/C]) lupus nephritis. hypermature placenta with severe decidual vasculopathy and acute atherosis.

Sign up to vote on this title
UsefulNot useful