Background:
Diagnosis of systemic lupus erythematosus (SLE) during pregnancy is challenging due to overlapping features with pregnancy-related conditions. Prompt diagnosis and management can minimise adverse maternal and fetal outcomes.
Case Report:
A 31-year-old nulliparous Tongan female at 25 weeks gestation presented with one week of dyspnoea and chest pain. She had a prior miscarriage at 13 weeks and no known medical or autoimmune history. Investigations revealed renal impairment (urea 7.3mmol/L, creatinine 101umol/L), haematoproteinuria (uPCR 298.9mg/mmol), liver dysfunction, haemolytic anaemia, positive anticardiolipin IgG, bilateral pleural effusions and a 20-25mm posterior pericardial effusion without tamponade. Autoimmune screen showed ANA 1:1280, dsDNA>799IU/ml and hypocomplementaemia. Renal biopsy confirmed class IV lupus nephritis. She was diagnosed with multi-system SLE and commenced on IV methylprednisone followed by oral prednisone, hydroxychloroquine and azathioprine.
Two weeks later, she developed suspected lupus myocarditis with tachycardia, elevated troponin (28ng/L) and ventricular thickening, where cardiac MRI without gadolinium was negative. IVIG and IV cyclophosphamide was given after multidisciplinary input. Her pregnancy was further complicated by early-onset pre-eclampsia and delivered a healthy girl via emergency caesarean at 33+4 weeks. On discharge, renal function had normalised with improved serological markers.
Six months postpartum, she developed pulmonary embolism secondary to antiphospholipid syndrome and pulmonary hypertension. Management included cyclophosphamide, mycophenolate, belimumab and tapering prednisone as she did not breastfeed. Medication non-compliance and financial strain led to SLE relapse and progression to stage IV chronic kidney disease within a year.
Conclusion
SLE in pregnancy requires early diagnosis, multidisciplinary care and long-term treatment adherence for optimal outcomes.