Introduction:
Chronic kidney disease associated with decrease chance of pregnancy. In patient with autoimmune disease involving kidney like systemic lupus erythematosus SLE with lupus nephritis there is also risk of disease flare up during pregnancy. however it is relatively not uncommon to get successful pregnancy in women with autoimmune disease particularly if the disease under control and patient in remission.
Methods:
We reported a 38 years old female patient who is known to have SLE diagnosed at age of 21 years and class 3 lupus nephritis a biopsy proven with stable renal function and low level proteinuria maintained on small dose prednisolone and mycophenolate mofetile.
At age of 32 she decided to get pregnancy with in vitro fertilizations IVF due to failed attempts with normal pregnancy. accordingly mycophenolate mofetil stopped and started on azathioprine .she had IVF procedure successfully with twin implantation .
At week 9th of pregnancy her blood pressure increased and methyl dopa was added to control BP. by 12 weeks of pregnancy noted worsening renal function , worsening proteinuria as well as low complements level and increased ds DNA antibodies with ANA titre. a picture suggestive of flare up of the disease .hence prednisolone was increase to 60 mg and tacrolimus was added .follow up showed the renal function and proteinuria improved and serological parameters of SLE improved.prednisolone was tapered gradually and maintained on 5 mg plus azathioprine and tacrolimus to keep the level at around 6 .the disease was stable along the pregnancy with stable renal function and proteinuria less than 0.5 g/g Cr. she delivered with caesarean section twins healthy two girls.
Results:
Autoimmune disorders are more common among females and incidence is higher during reproductive age period .in women with autoimmune diseases in the past treating physician may counsel them to avoid pregnancy to avoid and complications . However nowadays more and more women with different range of autoimmune conditions are achieving normal pregnancies.
In vitro fertilizations IVF is an option for pregnancy in infertile women .IVF in autoimmune disorder is relatively rare. obviously considered high risk pregnancy. In addition the pregnancy per see can trigger the autoimmune disease and cause flare up .thus there is several aspects should be taken in consideration prior to pregnancy in autoimmune women. first to select optimal time to perform the procedure in which the disease is stable preferably not less than 6 months after remission . Second ,to take in consideration during pregnancy from renal point of view the patient is at risk to develop worsening renal function, increase proteinuria, may develop uncontrolled hypertension and preeclampsia in mother .on other hand the foetus at risk to develop low birth weight, intrauterine growth restriction and prematurity. the causes of theses complications is multifactorial but one of theories is that the antibodies which the mother produces can enter the fetus’s system, affecting its overall growth.
In regards to immunosuppressive medication it depends on the autoimmune disease but in general should be closely monitored. Medication with teratogenic complications like Mycophenolate mofetil should be stopped and replaced by azathioprine preferably two months prior to the procedure. tacrolimus level should be monitored and optimised , prednisolone to be continued however stress dose may needed at time of delivery.
In general normal pregnancy is challenging in patient with autoimmune disorder and in certain cases reported to trigger and flare up the disease . although most of the autoimmune disorder worsening during the pregnancy
like Anti phospholipid antibody syndrome (APS) ,Systemic lupus erythematosus (SLE) ,Sjogren’s syndrome ,and Immune thrombocytopenia (ITP) . however some autoimmune disorder like Rheumatoid Arthritis ( RA) the symptoms may become less severe in about 50 % of mothers during pregnancy. And RA does not affect the foetus.
In regards to SLE and lupus nephritis it consider one of the higher-risk autoimmune diseases during pregnancy .SLE increases the risk and associated with worsening maternal renal function , hypertension ,proteinuria and
Preeclampsia. In regards to fetal complication includes cardiac complications for example slow heart rate and arrhythmias (irregular heartbeat), preterm birth ,still birth , and intrauterine growths retardation. as well as Miscarriage.
Treatment for lupus during pregnancy includes immunosuppressive like steroid, azathioprine and some time calcineurin inhibitors like tacrolimus may added as multi target immunosuppressive regimen.
Frequent medication monitoring/adjustments to control the disease as well as more frequent prenatal care and monitoring is needed. Despite the risks, but women with lupus often have good pregnancy outcomes .data on IVF in autoimmune/SLE relatively limited thus the decision to perform the procedure was challenging. However if closely followed and managed with multidisciplinary team including obstetrician, foetal and maternal medicine, rheumatologist and nephrologist ,then a successful outcome result is achievable.
Conclusions:
In vitro fertilizations is an procedure that potentially can be performed in women with autoimmune disorders .However risk and complications on the mother and foetus should be explained and both needs to be monitored closely .this procedure is challenging and considered very high risk pregnancy and needs multidisciplinary team approach.
I have no potential conflict of interest to disclose.
I did not use generative AI and AI-assisted technologies in the writing process.