November 2023

RHEUMATOLOGY

CASE REPORT: PREGNANCY WITH LUPUS AND LUPUS NEPHRITIS

A 25-year-old woman with a five-year history of lupus transferred her care to Northwestern Medicine in the hopes of having a successful pregnancy.  
 
Her past medical history related to lupus included the following manifestations:
  • Malar rash
  • Inflammatory arthritis
  • Unexplained fever
  • Pericarditis
  • Lupus nephritis
  • Abnormal blood tests consistent with a diagnosis of lupus

​She was treated initially with prednisone, hydroxychloroquine and cyclophosphamide. She improved with this treatment and was transitioned to mycophenolate. Prednisone was tapered, and hydroxychloroquine was continued.
 
A Pregnancy Journey
Two years later, the patient wanted to become pregnant. Her medications were adjusted to: a higher dose of prednisone, the discontinuation of mycophenolate mofetil and a continuation of hydroxychloroquine at the current dose.

The patient became pregnant but developed pre-eclampsia at the 21st week of gestation. Due to the increasing severity of the pre-eclampsia, she developed thrombotic microangiopathy which required urgent hemodialysis, and her care team performed an emergency cesarean section at 24 weeks gestation. The infant did not survive, and the patient sustained kidney damage.
 
Although the patient’s renal function recovered partially so she could go off dialysis in the short-term, she would likely need dialysis or a kidney transplant in the near future. She transferred her care to Northwestern Medicine for optimal management of lupus and lupus nephritis because she wanted to try for another pregnancy in the future.   
 
The Care Plan
At Northwestern Medicine, her team included rheumatologists, nephrologists, maternal-fetal medicine specialists and other specialists. They developed a two-year plan to support a future pregnancy in high-risk patients with lupus.

​Counseling: The care team will use contraceptive counseling to plan a pregnancy when the patient’s kidney function is stable, lupus disease is inactive using medications that are safe during pregnancy and after a transplant. In addition, the rheumatologist, nephrologist and maternal-fetal medicine physicians will provide general counseling about a high-risk pregnancy’s potential impact on the patient and a baby. The key principle is that a healthy mother with controlled disease and organ function sustain the stress of pregnancy is preferred for a future pregnancy.
 
Transplant: Since the current kidney function is suboptimal, the patient will be evaluated for a pre-emptive kidney transplant. The nephrologist and transplant surgeon will identify a matching living kidney donor. The goal here is to have a functioning kidney that supports the patient’s needs and can withstand the extra work the kidney needs to do during pregnancy.
 
Managing lupus: A rheumatologist will manage the patient’s lupus before transplantation. They will work with the transplant surgeon to control lupus before, during and after transplantation. The treating physicians will aim to prevent kidney rejection and to prevent lupus flares that required medications (Mycophenolate mofetil, tacrolimus and tapering doses of prednisone are needed early on to accomplish these goals.). The nephrologist will tell the patient to monitor her blood pressure at home and to report elevated findings.  
 
Medication: After the patient’s condition stabilizes in the year after surgery, the team will adjust medications to protect the kidney and control lupus. They will monitor the disease and review medications throughout the pregnancy to manage lupus while minimizing harm to the fetus. Then, the patient will transition from mycophenolate (teratogen) to:

  • Azathioprine
  • Monitoring lab tests and drug levels for toxicity
  • Adding a low dose aspirin
  • Using labetalol or nifedipine if blood pressure becomes an issue

After the patient is stabilized on the adjusted medication program for three months, she will discontinue contraception. All specialists are involved in these treatment decisions.  
 
A Success Story
The complex planning worked -- though not without challenges. This patient had two pregnancies. During both, monitoring detected pre-eclampsia at the 32nd week, requiring urgent delivery.
 
Both babies had to stay in the NICU and went home after several weeks. The family of four now includes two boys, now 3 and 5 years old.    

Related:
Letter to the Editor: The impact of U.S. abortion policy on rheumatology clinical practice: a cross-sectional survey of rheumatologists.
Bermas BL, Blanco I, Blazer AD, Clowse ME, Edens C, Ramsey-Goldman R, Donley G, Pierce L, Wright C, Birru Talabi M. Arthritis Rheumatol. 2023 Sep 14. doi: 10.1002/art.42699. Online ahead of print. PMID: 37706661
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Rosalind Ramsey-Goldman, MD, is the Gallagher Research Professor of Rheumatology at Northwestern Medicine. 

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