Systemic lupus erythematosus (SLE) is an autoimmune disease with serious consequences affecting mostly women with darker skin at a rate 2 to 3 times greater than 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 cause damage to the maternal heart, lungs, brain, and kidneys, requiring medications not acceptable in pregnancy due to teratogenic effects. The mother's condition may deteriorate such that birth is necessary despite the gestational age of the fetus as illustrated in this case report.
The advanced practice nurse met Ms. AK in the high-risk obstetric clinic at 7 weeks gestation. She had a prior preterm delivery after a pregnancy complicated by SLE and pancreatitis. Despite 3 years of good health, she had 4+ proteinuria on dipstick but was otherwise asymptomatic for lupus flare. By 11 weeks, she had 3 grams of proteinuria, pitting edema, and suspected lupus nephritis. By 14 weeks, she had 7 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, had 13 grams of proteinuria, and on hospital day 6 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 misoprostol. She initially declined all bereavement activities but later asked to hold the infant. She was discharged on hospital day 7 with follow-up in the nephrology, rheumatology, and high-risk obstetric clinics. She was started on lisinopril, mycophenolate, furosemide, and warfarin, medications not compatible with pregnancy. At 4 weeks postpartum she was coping well and elected for sterilization.
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 nonjudgmental, empathetic care with continuous assessment of psychological health. Collected mementos and time with the deceased infant were encouraged as important activities in the grieving process. At the postpartum visit, the advanced practice nurse listened as the patient described her experience, a vital intervention all nurses can participate in.