The immediate answer is yes the patient should have her kidneys evaluated whether or not she is planning a new pregnancy. This is because her proteinuria appeared early and was in the nephritic range (more than 3 g/day), probably before mid pregnancy. This also because early (before 34 weeks gestation)preeclampsia is more apt to be superimposed on an underlying cardio-renal disease or may even be an exacerbation of a kidney disorder masquerading as preeclampsia. Furthermore, while protein in the urine can precede a rise in blood pressure during in women developing Ã¢â‚¬Å“pureÃ¢â‚¬Â preeclampsia it is rarely if ever of the magnitude seen here.
The appearance of proteinuria of this magnitude in the absence of hypertension in pregnancy is not an unusual occurrence in patients with underlying quiescent renal disease. This is because protein excretion normally increases in pregnancy. We all filter a lot of protein every day but our kidney tubules reabsorb most of it and very little comes out in the urine. In patients with an underlying disease showing minimal or even normal proteinuria the reabsorbing mechanism may be saturated and the normal increased filtration of protein results in a large rise in excretion. Thus there are studies that show that proteinuria increases to the nephrotic range in about 50% of pregnant women with underlying renal disease.
One should further note that some experts would have referred the patient described here for evaluation of underlying renal disease when her proteinuria was detected during gestation, an evaluation that would have included a series of tests (microscopic analysis of the urine, blood tests that screen for vasculitidies like systemic lupus erythematosus, renal specific disorders associated with low compliment levels. etc.) Although rarely performed there are indications for renal biopsy this early in pregnancy.
Finally, the blood pressure of 120/80 mm Hg early in pregnancy is really borderline. Blood pressure normally decreases in the first half of pregnancy, and thus some individuals with previously undetected hypertension before conception may be recorded as normal. However, there are already data that women with a systolic level of 120 mm Hg or greater (but still Ã¢â‚¬Å“normalÃ¢â‚¬Â) or diastolic levels of 75 mm Hg or higher may be at higher risk. These are not pressures to worry about but just a sign to watch patient more closely. In addition it took eight weeks for the blood pressure to normalize and one wonders at what levels.
In conclusion: Ileana should definitely have a renal evaluation prior to the next conception, and her next pregnancy should be managed by high-risk obstetric experts preferably at or near a tertiary center.
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