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

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

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.

Eighteen months before admission

Renal biopsy : class IV lupus nephritis, diffuse proliferative type.

One year before admission

The blood pressure was 85/50 mm Hg and the weight 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.

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. Therapy : mycophenolate mofetil was discontinued and enalapril was withheld temporarily.

Three months before admission

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

Two months before admission

The patient was seen in the high-risk obstetrical clinic 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.

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.

Three weeks before admission

The blood pressure was 132/74 mm Hg, the pulse 88 beats per 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 wear antiembolic stockings and to restrict her intake of fluids to 1500 ml per day.

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.

 On the third hospital day, the blood pressure ranged from 107/59 to 138/78 mm Hg. On the seventh hospital day, the weight was 64.1 kg and the blood pressure 140/80 mm Hg. An ultrasonogram of the patients kidneys revealed no evidence 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.

 On the 14th hospital day, the patients weight was 67.3 kg.
Ultrasonography of the uterus again showed a normal fetus 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.

Hematologic Laboratory Data

Variable 33 mo Hb Ht Leuko Trombo
Antiphospholipid ab
Lupus anticoagulant

Before Admission 18 mo 11,2 31,3 4.800 1 yr 9,8 26,8 8.300 277jt 3 mo 8,8 25,3 8.800 209jt 2 mo 8,1 22,9 10.200 244jt
Negative Negative

Hospital Day 2 days 7,1 20,1 14.300 282jt 7,7 22,4 11.000 295jt 1 7,3 20,4 16.700 326jt 3 10 6,9 19,5 21.200 271jt 24 8,0 23,3 18.600 106jt 25 7,9 22,8 15.800 84jt

13,5 38,8 13.800 347jt

Negative 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

Urine Chemical Value

Variable 38 mo Urine creatinine Urine protein Protein to creatinine ratio Albumin
Albumin to creatinine ratio

Before admission 33 mo 0,59 1660 18 mo 0,84 1590 1 yr 1,61 2740 1,70 4 mo 1,13 2530 2,24 2 mo 0,21 2390 11,38 4340 6 wk 1 wk 0,82

Hospital day 10 1,24 18.200 14,68

712,8 8692,7

24-h urine specimen

-Protein -Creatinine -volume

6700

2656 944 1600

2465 1302 1550

8289 1910

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

<0,518 86-184 20-58 63-145 134 37 33 55 65 15 50

1,884 54 12 116 71 14

Blood Chemical Value

Variable 33 mo Urea nitrogen Creatinine 23 0.8 Before Admission 18 mo 18 0.8 1 yr 24 0.8 2 mo 18 0.7 2 days 18 1.5 25 1.4 1 36 1.8 3 34 1.8 Hospital Day 10 39 2.3 23 44 2.0 24

Protein -Total -Albumin -Globulin

Lactate dehydrogenase

3.1

2.9

7.0 3.0

1.8

1.1 154

4.7 1.2

4.1

3.7 1.1 2.6

3.7 1.1 2.6 399

Cholesterol -HDL -LDL -TG

283 45 179 295

339 60
562 490

325 51
845

Differential Diagnosis
Pregnancy-induced flare of systemic lupus erythematosus. Preeclampsia, with the nephrotic syndrome, thrombocytopenia, 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.

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

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.

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.

 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 bloodstream that induce generalized endothelial dysfunction and the syndrome of preeclampsia.

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