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Nephrotic syndrome secondary to a new diagnosis of minimal change disease in late pregnancy
Abstract Number: T4C-5
Abstract Type: Case Report/Case Series
Proteinuria in pregnancy is a common occurrence.Nephrotic syndrome is a non-specific disease of the kidneys characterized by a triad of proteinuria, hypoalbuminemia and oedema.It has been reported to affect 0.012-0.025% of all pregnancies posing both maternal and fetal complications.
In this case, we describe the management of a multiparous 38 year old, with no previous history of renal disease.The patient presented at 29weeks gestation with pitting oedema to the knees bilaterally.Her urinalysis demonstrated gross proteinuria of 11.2grams.Her renal indices were mildly elevated and she had an unrecordable albumin.She was also normotensive.The Nephrology service was consulted at the time of admission.
By 32weeks gestation the oedema had progressed to the umbilicus.The patient was admitted to the high dependency unit (HDU) for monitoring.Over the coming days her renal function started to deteriorate.Despite no definitive diagnosis, this prompted a multidisciplinary team decision to perform a caesarean section.
Our goals were to perform a well titrated spinal anaesthetic and to cautiously manage fluid administration.We decided to use 20% Albumin and avoid crystalloids.This strategy would help increase the intravascular oncotic pressure thereby increasing intravascular volume whilst avoiding worsening of peripheral oedema through extra vascular crystalloid accumulation.
She was prehydrated with 100ml of 20% albumin.A standard spinal anaesthetic was administered and she was co-loaded with a 100ml of 20% albumin.Intra-operatively she received a further 100ml of 20% albumin and no additional fluids.The patient was haemodynamically stable throughout.Surgery was uncomplicated with 300mls blood loss. Intraoperatively, 1.3litres of peritoneal free fluid was noted.
Post operatively the patient was placed on cyclophosphamide, steroids and remained in HDU for 24 hours.
A renal biopsy was performed one month later.This biopsy demonstrated ‘minimal change disease’, which is responsible for 10-25% (2) of nephrotic syndrome in adults.There is only one case in pregnancy documented in the literature.
Discussion:This case highlights the challenges of fluid administration in nephrotic syndrome in the parturient.The development of nephrotic syndrome secondary to a new diagnosis of minimal change disease occurring in pregnancy is rare.The differential diagnosis of new onset of nephrotic syndrome in pregnancy should include minimal change disease.In selected cases a renal biopsy may need to be performed to help establish an early diagnosis and treatment plan in order to prevent progression of disease.
1. Cohen AW, Burton HG.Nephrotic syndrome due to preeclamptic nephropathy in a hydatidiform mole and coexistent fetus.Obstet Gynaecol 1979; 53: 130–134
2. Haas M, Meehan SM, Karrison TG, Spargo BH:Changing etiologies of unexplained adult nephrotic syndrome:A comparison of renal biopsy findings from1976-1979 & 1995-1997.Am J Kidney Dis30:621-631