A 31-Year-Old Lady with Post-Partum Systemic Lupus Erythematosus

Case Report

Austin J Nephrol Hypertens. 2019; 6(2): 1081.

A 31-Year-Old Lady with Post-Partum Systemic Lupus Erythematosus

Malaweera A1* and Huang LL2

1Department of Medicine, Eastern Health Clinical School, Monash University, Australia

2Department of Nephrology, Box Hill Hospital, Eastern Health, Australia

*Corresponding author: Malaweera A, Department of Medicine, Eastern Health Clinical School, Monash University, Australia

Received: May 02, 2019; Accepted: July 08, 2019; Published: July 15, 2019


Systemic lupus erythematosus (SLE) is an autoimmune systemic disease that is more common in women of child bearing age. Although the impact of pregnancy on SLE activity has been debated in the literature, majority of studies have noted increased SLE activity during pregnancy, causing peripartum complications like pre-eclampsia, pre-term labour and stillbirth. Our case is a 31-year-old woman who suffered pre-eclampsia during her pregnancy, presenting one month post-partum with haemolytic anaemia, decompensated cardiomyopathy with serositis and acute renal impairment. She was diagnosed with systemic lupus erythematosus with lupus nephritis and started on immunosuppressive therapy with hydroxychloroquine, corticosteroids and mycophenolate mofetil. This case highlights the importance of understanding the heterogeneous nature of SLE presentation with multiple organ involvement and the impact on SLE activity on pregnancy and its outcomes.


Systemic lupus erythematosus (SLE) is a chronic autoimmune disease affecting multiple organs. Its predominance in women, especially of child bearing age is characteristic for the disease. It is extremely heterogeneous with a wide range of clinical and serological manifestations and marked disease course in different individuals.

Although SLE can present commonly with constitutional symptoms like fatigue, weight loss and arthralgia, 25-50% patients can have serious organ involvement with lupus nephritis, pleural disease and myopericarditis. Additionally, SLE activity is associated with poor pregnancy and peri-partum outcomes with high risk of pre-eclampsia, pregnancy loss, pre-term birth, stillbirth and low birth weight1.

SLE is characterised by anaemia, hypocomplementemia and raised anti-nuclear antibody (ANA) and double stranded DNA antibody (dsDNA), the latter being diagnostic.

Today we present a challenging case of a 31-year-old presenting one month post-partum with anaemia, cardiomyopathy with a pericardial effusion, pleural effusions, arthralgia and acute renal failure.

Case Report

We present a 31-year-old Caucasian female (G1P1) who delivered twins through normal vaginal delivery 6 weeks prior to presenting to hospital with SLE. At 34 weeks, she was diagnosed as having preeclampsia with evidence of proteinuria, hypertension and deranged liver function tests. As a result, she underwent chemical induction and delivered twins via normal vaginal delivery without complications. She was hypertensive at >140/80 mmHg in the peri-partum period and was discharged with labetalol.

Her past medical history included Immune Thrombocytopenic Purpura (ITP) with previous steroid use and was currently in remission. She was in a family of four, with a history of SLE in both her brother and mother.

Two weeks after childbirth, she developed fatigue, shortness of breath on exertion and bilateral leg swelling and was diagnosed as having pleural effusions on chest x-ray. She received frusemide for this and her labetalol was changed to nifedipine. She was also found to have iron deficiency and anaemia with a haemoglobin of 68 g/L and was given an iron infusion. Other than mild vaginal bleeding post-delivery, she denied any other sources of bleeding.

Two weeks following this, she developed arthralgia in the small joints of the hands and a macular, blanching rash over her feet, knees, chest wall and hands but sparing the face.

She presented to a public hospital for further assessment and management of her anaemia and fluid overload. On clinical assessment, she had evidence of conjunctival pallor and a macular blanching rash over chest, hands and feet. She also had small joint synovitis with swelling and tenderness at proximal interphalangeal joints and pitting odema of the feet.

Her vital observations were stable throughout the admission with blood pressures of 120-130 mmHg systolic and 70-90 mmHg diastolic.

She had a normocytic anaemia of Hb 71 g/L, with a blood film consisting of mild anisocytosis with moderate normochromic normocytic anaemia with occasional tear drop and rare fragmented red cells. Her haemolysis screen revealed a positive coombs test, a low haptoglobin and high reticulocytes consistent with a haemolytic anaemia. Cross-matching studies also found that multiple positive antibodies making it difficult to find compatible blood for transfusion.

She also had acute kidney injury with a creatinine of 160 μmol/L, hyperkalaemia with a potassium of 6 mmol/L, metabolic acidosis with a bicarbonate of 16 mmol/L and a 24-hour urinary protein excretion of 0.64 g. Her kidney ultrasound revealed normal size kidneys without obstruction. Her urinalysis revealed 15 million/L erythrocytes without any cellular casts.

Additionally, she also had evidence of serositis. This was in the form of bi-basal (left>right) pleural effusions (Figures 1 & 2) and a moderate pericardial effusion with moderately-severe reduction in LV function on an Echocardiogram (Echo). She had a serum troponin 68 ng/L (‹14 ng/L) and a BNP was 3500 pmol/L (‹15.3 pmol/L) and her Electrocardiogram (ECG) revealed normal sinus rhythm.