Systemic lupus erythematosus (SLE) is an autoimmune disease with serious consequences affecting mostly women with darker skin at a rate of two to three times over white women. Management of lupus flares in pregnancy is challenging due to difficulty of the diagnosis and treatment limitations due to fetal effects.  Severe flares can damage to the maternal heart, lungs, brain and kidneys, requiring medications not acceptable in pregnancy due to teratogenic effects.  Her condition may deteriorate such that delivery is necessary despite the gestational age of the fetus as illustrated in this case report.

Case:

The advanced practice nurse (APN) met AK in the high-risk obstetrical (OB) clinic at seven weeks gestation.  She had a prior preterm delivery after a pregnancy complicated by SLE and pancreatitis.  Despite three years of good health, she had 4+ proteinuria on dipstick, but was otherwise asymptomatic for lupus flare.  By 11 weeks, she had three grams of proteinuria, pitting edema and suspected lupus nephritis.  By 14 weeks, she had seven grams of proteinuria and a renal biopsy confirmed Stage IV lupus nephritis.  At 15 weeks she had vaginal bleeding, hypertension, and a malar rash.  The fetus was growing well with a normal heart rate but maternal ascites was noted.  She began inpatient management, now had 13 grams of proteinuria, and on hospital day six elected for termination of pregnancy due to worsening renal disease unresponsive to medical management.  She was scheduled for surgery but delivered vaginally after one dose of misoprstol.  She initially declined all bereavement activities, but later asked to hold the baby.  She was discharged on hospital day seven with follow-up in the nephrology, rheumatology and high-risk OB clinics.  She was started on Lisinopril, Cellcept, Lasix and Coumadin, medications not compatible with pregnancy.  At four weeks postpartum she was coping well and elected for sterilization.

Conclusion:

Termination of pregnancy is a complex decision providing nurses a unique opportunity to help.  Women who terminate report feelings of guilt, anger and depression.  They value nurses who exhibit caring through acknowledgement of grief and individualized care.  Nurses in this case lent support throughout the pregnancy and puerperium, providing non-judgmental, empathetic care with continuous assessment of psychological health.  Collected mementos and time with the deceased baby were encouraged, both important activities in the grieving process.  At the postpartum visit, the APN listened as she described her experience, a vital intervention all nurses can participate in.                 

Keywords:

 Pregnancy, lupus, termination, grief