A woman 38-year-old Lupus Nephritis with Ro-60 and Scl-70 positive During Pregnancy

Pregnancy in Systemic Lupus Erythematosus (SLE) patients poses a high risk of impact on maternal and fetal outcomes. SLE is a chronic autoimmune disease that often affects women of childbearing age. Lupus nephritis (LN), a severe complication of systemic lupus erythematosus (SLE), leads to significant kidney inflammation and damage and drastically increases mortality risk. LN associated with higher mortality compared to the general population. Protein urine excretion increases from 60–90 mg/day to 180–250 mg/day, as measured by a 24-hour urine collection. As a consequence of this physiologic increase in proteinuria, the threshold for elevated proteinuria in pregnancy has been set at a higher level of 300 mg/day. Indications for renal biopsy are proteinuria greater than 1-2 g /24 hours with or without renal involvement associated with hypertension, impaired renal function of unknown cause (especially when an active urine sediment indicates possible crescentic glomerulonephritis), and if renal involvement is suspected in association with an immunological or paraneoplastic systemic disease (e.g., antineutrophil cytoplasmatic antibody (ANCA)-associated vasculitis, SLE, monoclonal gammopathy or amyloidosis). Patients who tested positive for anti-Ro/SSA and/or anti-La/SSB antibodies undergo vigilant screening for congenital heart block. Women with anti-Ro antibodies linked to neonatal lupus and risk of congenital heart block (ranging from 0.7% to 2%), especially when antibody levels are high, require additional fetal surveillance. The EULAR guidelines recommend fetal echocardiography for suspected cases of fetal dysrhythmia or myocarditis, particularly in those who are positive for Ro/SSA or La/SSB autoantibodies.

Case Report

A women 38-year-old pregnant with her fourth child at 17 weeks of gestation was consulted to the nephrology department due to increased kidney function. The patient have a kidney biopsy at 20 weeks of gestation and the results showed Lupus Nephritis class IV. The results of the ANA IF examination is 1/100 with Ro-60 and Scl-70 borderline results and ANA profile results were RPN/Sm (+) and AMA-M2 (++). History of the first pregnancy, the baby died at 6 months of gestation. During pregnancy, the patient often complained of headaches and dizziness. At 19 weeks and 26 weeks of pregnancy, there was a history of threatened abortion. At 28 weeks of gestation, she experienced IUFD. The patient received therapy with aspirin 80 mg once a day, folic acid 400 mcg twice a day, ferrous sulfate twice a day, calc once a day, nifedipine 10 mg 3 times a day, azathioprine 50 mg twice a day, hydroxychloroquine 200 mg once a day, methylprednisolone 16 mg twice a day.

Pregnant women with LN are at increased risk for complications like pre-eclampsia, intrauterine growth restriction, stillbirth, and preterm delivery. The risk is further amplified by factors such as lupus activity, the presence of specific antibodies (like Antiphospholipid antibody (APA), anti-SSA/Ro, and anti-SSB/La), and pre-existing conditions like hypertension. The differentiation between an LN flare and pregnancy-induced hypertension or proteinuria can be challenging but is crucial for appropriate management.

Management of LN patients during pregnancy is a diagnostic challenge (differentiating LN from preeclampsia and determining the role of renal biopsy). During pregnancy, LN patients are managed by a multidisciplinary team (rheumatology, gynecology, obstetrics, and neonatology). Routine assessment involving close clinical and laboratory monitoring every 4-6 weeks to detect early signs of disease activity.