Nephrotic syndrome is estimated to occur in around 0.012–0.025 % of all pregnancies.
A 33-year-old woman G3P2, presented to the Obstetric Day Assessment Unit at 24 weeks gestation with non-specific lower abdominal pain of one week duration and generalized body swelling for the past month. She also reported shortness of breath, chest pain and significant weight gain of 30 kg in 7 weeks. This was a high risk pregnancy in view of: high Body Mass Index (BMI) 48 (body weight 176Kg), overt hypothyroidism on Thyroxine 150 microgram daily. Additionally, in her previous pregnancies she had Insulin required gestational diabetes, macrocosmic baby with 3rd degree perineal tear, pre-eclampsia and primary postpartum haemorrhage. During the current pregnancy, she was booked to antenatal clinic and was commenced on low dose aspirin from early pregnancy. Morphology scan at 20 weeks was normal.
She was admitted for further evaluation. She had anasarca but remained normotensive. The 24 weeks fetal growth ultrasound was normal. Investigations revealed elevated creatinine of 83 mg/dl, urine protein creatinine ratio of 945.3, low serum albumin of 5g/dl, and normal SFLT/PLGF ratio of 8. Anti GBM <2, ANA >1280, both AntiRo, Anti-ribonuclear antibodies were positive, SSA positive, PLAR2 Ab negative, normal complements.
The impression by renal medicine team was first onset of Nephrotic Syndrome in pregnancy. She was commenced on pulsed IV Methylprednisolone for 3 days then 80 mg daily for 4 weeks. Along with fluid restriction to 1.5 L daily, low salt diet, daily weight measurement, Frusemide 80 mg IV with 20% Albumin twice daily. Aspirin was ceased and she was commenced on prophylactic dose of Enoxaparin. Insulin had to be initiated because of steroid induced hyperglycemia. She was transferred to a tertiary care hospital for a renal biopsy and was managed under a multidisciplinary team, including renal medicine, endocrine, obstetrics, and dietitian. During the hospitalization, she developed E. Coli UTI and was treated with Nitrofurantoin. She had 2 renal biopsies which were indeterminate, the first one revealed skeletal muscle only with no renal tissues, the second one showed sclerosed glomerulus sub capsular in location, not able to perform further testing. She was commenced on Tacrolimus daily and Plaquenil 200 mg daily. The Enoxaparine was converted from prophylactic to therapeutic dose. She is currently 28 weeks gestation undergoing regular close antenatal care and fetal monitoring with serial fetal growth ultrasound.