Glomerular disease in pregnancy

Multiple glomerular diseases may affect women of childbearing age. The relationship between glomerular disease and pregnancy is complex and should be approached from two major standpoints: the effects of pregnancy on maternal disease activity and progression and effects of the disease and related medical therapy on the developing fetus. Glomerular disease may be active or quiescent at conception, may flare during pregnancy, or may occur de novo during pregnancy. Adverse fetal outcomes (spontaneous abortion, prematurity, intrauterine growth retardation) and maternal outcomes (preeclampsia, renal disease flare) are common, particularly in patients with active disease and those with advanced renal insufficiency. Consequently, irrespective of the underlying etiology, remission of renal disease for >6 months prior to conception is recommended. The risk for progression is increased for patients with established renal insufficiency with creatinine values >1.4 mg/dL. The differential diagnosis of worsening proteinuria, which commonly occurs during the third trimester in all proteinuric renal diseases, should include renal disease flare and preeclampsia, a pregnancy-specific condition clinically characterized by hypertension and proteinuria. If indicated, a renal biopsy can be safely performed prior to 32 weeks gestation in women with adequately controlled blood pressure and in the absence of coagulation abnormalities. The goal of therapy during pregnancy is control of disease activity, both renal and systemic, with medications that are relatively safe for a growing fetus. Consequently, the optimal management of these patients crosses specialties and should include a nephrologist, obstetrician, and, commonly, a rheumatologist.