Dr NEHA CHANDRASEKAR1, LUCY BIRTWISTLE1,2, RAVINDU WIJAYARATNE2, BRIONY BEAL2, AKSHAY ATHAVALE2,3,4
1Royal North Shore Hospital, , Australia, 2Department of Renal Medicine, Gosford Hospital, Australia, 3School of Medicine and Public Health, University of Newcastle, Australia, 4Faculty of Medicine and Health, Macquarie University, Australia
Biography:
Neha Chandrasekar is a Basic Physician Trainee with a strong interest in nephrology and public health. She is currently training in the Royal North Shore Hospital network. Her current research focuses on anaemia management in dialysis patients and the role of nutrition in multi-morbid populations. She has also published research in nutrition for enterally feed patients, gastroparesis management, and the expanding role of virtual care in medicine. Having completed her medical degree and Master of Public Health at the University of New South Wales, she has a strong interest in health equity and is passionate medical education.
Background:
Nephrotic-range proteinuria (> 3.5 g/day) in pregnancy presents a diagnostic challenge when distinguishing primary glomerular disease from preeclampsia-associated kidney dysfunction.
Kidney biopsy is often deferred during pregnancy due to maternal and foetal risks. Proteinuria in pregnancy and adverse outcomes including pre-term birth and intrauterine growth restriction demonstrate a near linear relationship. Management of nephrotic syndrome in pregnancy requires risk assessment and treatment of hypertension, oedema and thrombotic risk.
Key Words:
Pre-Eclampsia, Nephrotic Syndrome, Pregnancy, Hypertension
Case Report:
A 22-year-old primigravida with a history of three spontaneous early pregnancy miscarriages presented at 32+1 weeks gestation with new-onset hypertension (148/100 mmHg), worsening oedema and severe proteinuria (urine protein: creatinine ratio; uPCR 778 mg/mmol). Serum albumin was 14 g/L. Kidney function was normal (creatinine 59–70 µmol/L). Platelets were 190 x 109 and liver function normal. Neurologic examination was benign. Autoimmune testing was non-diagnostic. She was treated for preeclampsia and nephrotic syndrome with labetalol and prophylactic enoxaparin.
At 35+4 weeks gestation, emergency caesarean section was performed due to reduced foetal movements. Post-partum treatment included enalapril and therapeutic anticoagulation with enoxaparin. Six weeks post-partum, 24-hour urine protein was 2.17 g/day and serum albumin was 38 g/L. Anticoagulation was ceased and enalapril continued. Three months post-partum, uPCR was 56.9 mg/mmol with enalapril treatment. Six-months post-partum, blood pressure was normal, uPCR 8.2 mg/mmol and serum albumin 45 g/L. Enalapril was ceased.
Conclusions:
This case illustrates spontaneous resolution of nephrotic syndrome secondary to preeclampsia. Clinicians should be aware of significant maternal and foetal risks associated with proteinuria and consider the pros and cons of kidney biopsy in pregnancy.