Nephrotic Syndrome,. Hypertension, and Hemolytic. Anemia Early in Pregnancy in Patients With IDDM. Ruth S. Weinstock, MD, PhD. Richard T. Kopecky, MD.
Rapid Development of Nephrotic Syndrome, Hypertension, and Hemolytic Anemia Early in Pregnancy in Patients With IDDM
In recent years, the prognosis for a successful pregnancy has greatly improved for women with insulindependent diabetes mellitus (IDDM) who are under good glycemic control and free of complications such as vascular disease and nephropathy. We report the rapid development of severe nephrotic syndrome, malignant hypertension, and microangiopathic hemolytic anemia during the first trimester of pregnancy in a 29-yr-old woman with IDDM of 18 yr duration. Our patient had no pregestational history of retinopathy or hypertension and only minimal proteinuria. Significant improvement in blood glucose levels had been achieved over the 6 mo before conception. Kidney biopsy performed before the termination of pregnancy at 10 wk gestation revealed diabetic nephropathy. No other etiology for her renal disease could be found. An arteriole was noted to have entrapped red blood cell fragments and platelet thrombi, revealing the probable source of her hemolytic process. By 8 wk postpartum, her nephrotic syndrome and hemolysis had completely resolved. At 3 mo postgestation, the patient's hypertension was still present but less severe. Her serum creatinine has continued to decrease toward normal. This is the first report of a woman with IDDM in White's classification C who developed a toxemia-like syndrome during the first trimester of pregnancy, attributable to the underlying diabetic state. Diabetes Care 11:416-21, 1988
From the Departments of Medicine, Pathology, and Obstetrics and Gynecology, the State University of New York Health Science Center, and the Department of Medicine, Veterans Administration Medical Center, Syracuse, New York. Address correspondence and reprints requests to Ruth S. Weinstock, MD, PhD, Department of Medicine, SUNY Health Science Center, 750 E. Adams Street, Syracuse, NY 13210.
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Ruth S. Weinstock, MD, PhD Richard T. Kopecky, MD David B. Jones, MD Shiraz Sunderji, MD
ew studies carefully document the effects of pregnancy on diabetic renal and ocular disease. Recent reports suggest that diabetic patients without significant pregestational renal disease or hypertension do not develop renal-function deterioration during pregnancy (1). We describe a patient with White's classification C diabetes who rapidly developed symptomatic diabetic nephropathy complicated by the nephrotic syndrome, malignant hypertension, and microangiopathic hemolytic anemia during the first trimester of pregnancy.
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CASE REPORT
A 29-yr-old woman was hospitalized because of hypertension and the nephrotic syndrome during the first trimester of pregnancy. The patient had a history of insulin-dependent diabetes mellitus (IDDM) for 18 yr. There was no history of cardiac disease, hypertension, peripheral vascular disease, or neuropathy. She smoked half a pack of cigarettes each day and had never used oral contraceptives. A single previous pregnancy, 6 yr earlier, was not associated with hypertension or renal disease. During that gestation, glycemic control was monitored by urine testing only. A 3097-g baby with Mobius syndrome was delivered by cesarean section at 37 wk. After the baby was delivered, the patient's diabetes mellitus was not well controlled. Glycosylated hemoglobin level 7 mo before the second conception was 16.9% (normal, 5.5-8.5%). Six months before conception, she received extensive diabetes teaching and began self-monitoring of blood glucose. Her blood pressure, hematological, and renal-function parameters at that time and throughout her subsequent clinical
DIABETES CARE, VOL. 11, NO. 5, MAY 1988
R.S. WEINSTOCK AND ASSOCIATES
course are shown in Fig. 1. Four months before conception, an ophthalmological consultant detected no diabetic retinopathy. One month later, the glycosylated hemoglobin was 11.8% (normal, 5.5-9.0%). Beginning 3 wk before conception, the patient's insulin regimen was intensified from two to three injections per day. She was seen for the first time at the State University of New York (SUNY) Health Science Center during the 7th wk of pregnancy. She noted a sore throat and a 3.6-kg weight gain since her last menstrual period. The patient's height was 169.5 cm, weight 69 kg, and blood pressure 150/80 mmHg. She was afebrile. The pharynx was normal, no retinopathy was seen, and 2 + pitting edema extended bilaterally to the midcalf. Laboratory evaluation revealed a normochromic normocytic anemia, 135 mM sodium, 4.4 mM potassium, 111 mM chloride, 25 mM bicarbonate, and 106 mg/dl glucose. Liver-function studies were normal. Glycosylated hemoglobin was 6.3% (normal, 3.4-6.1%). Urinalysis revealed specific gravity 1.020, pH 5, protein 4 + , glucose negative, hemoglobin trace, with two white blood cells and eight red blood cells per high-power field. Urine and throat cultures were negative. Self-mon-
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itoring showed the following blood glucose ranges: fasting, 83-163 mg/dl; prelunch, 83-145 mg/dl; predinner, 122-210 mg/dl; and bedtime 128-180 mg/dl. The patient's insulin regimen and diet were extensively modified, and she began doing fingerstick blood glucose determinations seven times per day. One week later, she had fasting blood glucose values
