Lupus nephritis and the anti-phospholipid antibody syndrome in pregnancy

tite. One day prior to admission, the patient saw her primary physician, who noted that she was moderately hypertensive, with a blood pressure of 140/80 mm Hg as compared to a blood pressure of 110/70 mm Hg at six weeks of gestation. He also noted 31 proteinuria on dipstick. A 24-hour urine collection contained 9 g of protein; the creatinine clearance was 102 mL/ min. Serum creatinine had risen to 1.6 mg/dL from 1.0 mg/dL earlier in the pregnancy. ANA was positive at 1:320. Following this visit, the patient developed vaginal bleeding and presented the next day to the emergency department at the Brigham and Women’s Hospital. In the emergency room, the patient had no active vaginal bleeding. The medical history was noteworthy for a diagnosis of rheumatoid arthritis, hypothyroidism with a multinodular goiter, and mitral valve prolapse. She was taking levothyroxine sodium (Synthroid), 0.05 mg daily. She reported having one CASE PRESENTATION sister with an unspecified autoimmune disorder. A 32-year-old woman was gravida 2, para 0, and had had Physical examination revealed a patient comfortable at rest. one spontaneous abortion. When she was 12 weeks pregnant, Her blood pressure was 138/78 mm Hg and she was afebrile. she presented to the emergency department at the Brigham Her weight was 182 pounds. Head and neck examination was and Women’s Hospital with new-onset nephrotic syndrome remarkable for facial edema. No lymphadenopathy was apparand systemic lupus erythematosus. Seven years earlier, she ent, and the joints and skin were normal. Cardiac examination had had swelling in the small joints of her upper and lower was normal. Lung examination revealed decreased breath extremities. At that time she was told that she had rheumatoid sounds one-half way up with dullness to percussion in the right arthritis. Hydroxychloroquine sulfate (Plaquenil) relieved her hemithorax. The abdominal examination revealed distension symptoms. After five years of treatment, the patient discontinued consistent with ascites. The uterus was not palpable. The extaking the Plaquenil, as she was concerned about becoming tremities showed 21 pitting edema bilaterally. Her calves were pregnant. She did very well after the medication was stopped. not tender. A pelvic examination did not reveal bleeding. Approximately two years before this admission, she became The O2 saturation was 98% while breathing room air. A pregnant. Other than a positive rapid plasma reagin, all antenachest radiograph revealed a right pleural effusion and right tal tests were in the normal range. At approximately eight chest wall subcutaneous emphysema. An ultrasound study weeks gestation, the patient had a spontaneous abortion. She demonstrated an intrauterine pregnancy at 12.5 weeks, ascites, underwent a dilatation and curettage because of hemorrhage and a right pleural effusion. A urinalysis showed a specific and was diagnosed with a septate uterus. The septum was hystergravity of 1.025; pH, 6.0; 31 protein; and 31 blood; the rest oscopically resected one year prior to the current admission. of the parameters were negative. Sediment examination The patient had been well until approximately eight weeks showed 25 to 30 white blood cells/high-power field and toointo her current pregnancy, when she developed facial, hand, numerous-to-count red blood cells/high-power field with 5 to and leg edema. The edema gradually worsened, with a 12 pound 7 coarse granular/degenerating cellular casts. The blood urea weight gain over the next four weeks. She also noted increasing nitrogen was 35 mg/dL and the serum creatinine was 1.6 mg/dL. shortness of breath, abdominal distension, and decreased appeElectrolytes were in the normal range. A complete blood count showed a hematocrit of 25.8%, white cell count of 1536/mm (normal, 4000–10,000/mm), and platelet count of 128,000/mm The Nephrology Forum is funded in part by grants from Amgen, (normal, 150,000–450,000/mm). Liver function tests were norIncorporated; Merck & Co. Incorporated; AstraZeneca LP; Dialysis mal. Her total protein was 3.3 g/dL (normal, 6.0 to 8.0 g/dL); Clinic, Incorporated; and R & D Laboratories. albumin, 1.4 g/dL (normal, 3.7 to 5.4 g/dL); calcium, 6.8 mg/dL