lupus nephritis in pregnancy

7/28/2019 Lupus Nephritis in Pregnancy

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Lupus Nephritis in Pregnancy

Journal case recordYovita Devi K

030.08.261


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CASE

A 29-year-old pregnant woman withsystemic lupus erythematosus was admitted

to the hospital because of renal failure at 20

weeks 6 days of gestation.


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HISTORY OF THE ILLNESS


4/28

21 years of age

Pain and swelling developed in the distal andproximal interphalangeal joints of both hands and

feet.

Diagnosis : systemic lupus erythematosus.

Therapy : Low-dose prednisone


5/28

Three years before admission

the nephrotic syndrome developed. Renal biopsy : class IV lupus nephritis.

Therapy : Prednisone (10 mg), azathioprine (25

mg), furosemide (20 mg), and enalapril (15 mg)were administered daily.


6/28

Eighteen months before admission

Renal biopsy : class IV lupus nephritis, diffuseproliferative type.


7/28

One year before admission

The blood pressure was 85/50 mm Hg and theweight 50.3 kg.

Therapy : patient declined the option of

cyclophosphamide therapy because of a desire to

preserve fertility. Azathioprine was discontinued,

and mycophenolate mofetil was added to

prednisone therapy.


8/28

Five months before admission

The patient reported that during the precedingmonth she had had unprotected intercourse.

The blood pressure was 92/48 mm Hg and the

pulse more than the 80 beats per minute.

Therapy : mycophenolate mofetil was discontinued

and enalapril was withheld temporarily.


9/28

Three months before admission

The patient still had not menstruated, testing forquantitative serum levels of the beta subunit of

human chorionic gonadotropin was positive at

162,000 U per liter.


10/28

Two months before admission

The patient was seen in the high-risk obstetricalclinic for prenatal care, at 11 weeks 6 days of

gestation.

The vital signs and physical examination were

normal.

Therapy : supplementary prenatal vitamins, folic

acid, and calcium were begun, and prednisone was

continued at 10 mg a day.


11/28

Six weeks before admission

The patients weight was 53.5 kg. Two weeks later, the weight was 60.3 kg, and 3+

pedal edema was noted.


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Three weeks before admission

The blood pressure was 132/74 mm Hg, the pulse 88 beatsper minute, and the weight 62.1 kg.

There was mild pallor, no icterus, 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. There was 2+ pitting edema of the ankles and

mild sacral edema.

Treatment non-pharmacology : patient was advised to wearantiembolic stockings and to restrict her intake of fluids to

1500 ml per day.


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The day of admission Patient had fatigue and weakness.

She had no allergies. She did not smoke cigarettes or drink alcohol. There was

no family history of systemic lupus erythematosus or kidney disease.

Physical examination : patients skin was pale.

The temperature was normal, the blood pressure 110/60 mm Hg, the pulse 96 beats

per minute, and the weight 62.1 kg.

the lungs revealed no abnormalities, and a 2/6 systolic ejection murmur was heard at

the upper left sternal border.

The abdomen was soft, nontender, and gravid, with a fundal height consistent with the

gestational age of 20 weeks. There was 3+ edema extending to the thighs. An

ultrasonogram of the uterus obtained on the second hospital day revealed a normal

fetus and normal volume of amniotic fluid.

Treatment non-pharmacology :

bed rest, Fluids were restricted to 1500 ml per day, and her vital signs were

monitored.

The option of pregnancy termination was discussed and declined by the patient.

Pharmacology : Methylprednisolone IV (250 mg per day) for three days, followed

by prednisone (60 mg per day). Epoetin alfa was begun, 3000 IU three times per

week.


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On the third hospital day, the blood pressure rangedfrom 107/59 to 138/78 mm Hg.

On the seventh hospital day, the weight was 64.1 kgand the blood pressure 140/80 mm Hg. Anultrasonogram ofthe patients kidneys revealed noevidence of renal-vein thrombosis.

On the eighth hospital day, the blood pressure ranged

from 120/60 to 150/70 mm Hg. Therapy : subcutaneous heparin, 5000 IU twice per day, was

begun.

On the ninth day, the blood pressure was 140/80 to

140/90 mm Hg, and the weight 65.0 kg. Treatment : azathioprine was again added. Two units of

packed red cells were transfused.


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On the 14th hospital day, the patients weight was

67.3 kg.

Ultrasonography of the uterus again showed a normalfetus and normal volume of the amniotic fluid.

The blood pressure rose transiently to 170/98 mm Hg,

and the patient was dizzy, 30 minutes later the blood

pressure was 140/80 and remained stable.

On the 24th day, the blood pressure had risen to

174/100 mm Hg.

Therapy : betamethasone, 12 mg intramuscularly, was

given daily for two days.

On the 25th hospital day (24 weeks 2 days of

gestation), a diagnostic procedure was performed.


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Hematologic Laboratory Data

Variable Before Admission Hospital Day

33 mo 18 mo 1 yr 3 mo 2 mo 2 days 1 3 10 24 25

Hb 13,5 11,2 9,8 8,8 8,1 7,1 7,7 7,3 6,9 8,0 7,9

Ht 38,8 31,3 26,8 25,3 22,9 20,1 22,4 20,4 19,5 23,3 22,8

Leuko 13.800 4.800 8.300 8.800 10.200 14.300 11.000 16.700 21.200 18.600 15.800

Trombo 347jt 277jt 209jt 244jt 282jt 295jt 326jt 271jt 106jt 84jt

Antiphos-

pholipid ab

Negative Negative

Lupus

anticoagulantNegative Negative

Urinalysis

-Occult

blood

- albumin

- red cells

- 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


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Urine Chemical Value

Variable Before admission Hospital

day

38 mo 33 mo 18 mo 1 yr 4 mo 2 mo 6 wk 1 wk 10

Urine

creatinine

0,59 0,84 1,61 1,13 0,21 0,82 1,24

Urine

protein

1660 1590 2740 2530 2390 4340 18.200

Protein tocreatinine

ratio

1,70 2,24 11,38 14,68

Albumin 712,8

Albumin to

creatinine

ratio

8692,7

24-h urinespecimen-Protein

-Creatinine

-volume

6700 2656

944

1600

2465

1302

1550

8289

1910


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Immunologic Laboratory Data

Variable Normal

range

Before admission Hospital day

33 mo 1 yr 5 mo 2 mo 10

Antinuclear

antibody titer

Negative 1:640

Speckled

>1:5120

Speckled

1:640

Speckled

>1:5120

Speckled

>1:2560

Speckled

Anto-double-

stranded DNA

antibody titer

Negative 1:640 1:160 1:80 1:40

Anti Ro SS-A

antibody


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Blood Chemical Value

Variable Before Admission Hospital Day

33 mo 18 mo 1 yr 2 mo 2 days 1 3 10 23 24

Urea

nitrogen

23 18 24 18 18 25 36 34 39 44

Creatinine 0.8 0.8 0.8 0.7 1.5 1.4 1.8 1.8 2.3 2.0

Protein-Total

-Albumin

-Globulin

3.1 2.9

7.0

3.0 1.8 1.1

4.7

1.2

4.1 3.7

1.1

2.6

3.7

1.1

2.6

Lactate

dehydrogen-

ase

154 399

Cholesterol

-HDL-LDL

-TG

283

45179

295 562

339

60

490

325

51

845


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Differential Diagnosis

Pregnancy-induced flare of systemic lupuserythematosus.

Preeclampsia, with the nephrotic syndrome,

thrombocytopenia, and hemolytic anemia.


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Clinical Diagnosis

Pregnancy-induced flare of systemic lupuserythematosus.

Preeclampsia.


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Discussion of Management

received azathioprine and corticosteroids but notcyclophosphamide.

This patient underwent cesarean delivery because

the fetus was in the breech presentation.


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Pathological Discussion

The renal biopsy performed 18 months beforeadmission, showed findings that were diagnostic of

glomerulonephritis related to systemic lupus

erythematosus


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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.


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v

These findings a small placenta, decidual vasculopathy with or without

acute atherosis, sheets of intermediate trophoblast cells, and hypermature

villi as well as acute and chronic infarcts and a small-diameter umbilical

cord.


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Because the placental findings in pregnancies affected by

preeclampsia and lupus are similar, it is difficult to

distinguish between the two on the basis of placental

pathology alone.

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.

To explain the systemic findings of proteinuria,

hypertension, and coagulation abnormalities in the mother, it

has been hypothesized that the ischemic placenta secretes

one or more soluble factors into the maternal bloodstreamthat induce generalized endothelial dysfunction and the

syndrome of preeclampsia.


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Anatomical Diagnosis

Combined membranous (class V) and diffusesegmental proliferative and sclerosing (class IV-S

[A/C]) lupus nephritis.

Small, hypermature placenta with severe decidual

vasculopathy and acute atherosis, consistent with

preeclampsia


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lupus nephritis in pregnancy

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