A case report from Japan described systemic lupus erythematosus (SLE) first manifesting as preeclampsia during pregnancy, highlighting the difficulties of distinguishing SLE during the third trimester. The findings of the case study were published in the American Journal of Perinatology Reports..1

A 32-year-old primigravid Japanese woman was diagnosed with severe preeclampsia at 29 weeks of gestation. She had become pregnant by in vitro fertilization and egg transfer.  Laboratory testing during the first trimester revealed anemia, with a hemoglobin level of 9.0 g/dL, thrombocytopenia, and proteinuria, although no further assessment was performed.

At 29 weeks, the patient presented with leg edema, hypertension, intrauterine growth reduction, and a high umbilical artery resistance index. She was diagnosed with severe preeclampsia and underwent emergent cesarean section.

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Hypertension and renal disorder improved after the operation, but her thrombocytopenia and anemia worsened. A comprehensive autoimmune workup was performed, and SLE was diagnosed on postoperative day 5.

Her proteinuria improved from 4g/d on postoperative day 4 to 1 g/d on postoperative day 18, and her blood pressure normalized on day 7. SLE was controlled with oral prednisone, and she was discharged from the hospital on postoperative day 34 with normal blood pressure, normal laboratory data, and no recurrence of seizures. Her newborn also showed no evidence of neonatal lupus.

“New-onset SLE during pregnancy is rare and difficult to quickly diagnose, especially in cases that manifest as preeclampsia in the third trimester,” the authors concluded. “New-onset SLE should be suspected and an autoimmune workup should be performed as soon as possible when symptoms of preeclampsia persist or new atypical symptoms of preeclampsia develop after delivery.”

Summary and Clinical Applicability

SLE during pregnancy is rare and difficult to detect as cases that manifest as preeclampsia. However, preexisting renal disease and any SLE activity during the first 6 months before conception are known potential risk factors for lupus flares during pregnancy. The study authors  noted that there is a greater prevalence of preeclampsia, fetal loss, intrauterine growth retardation, and preterm birth among women with active lupus during pregnancy.

The researchers concluded that new-onset SLE during the third trimester of pregnancy is difficult to diagnose, although it should be suspected when symptoms of preeclampsia persist after delivery.

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Miyamoto T, Hoshino T, Hayashi N, et al. Preeclampsia as a manifestation of new-onset systemic lupus erythematosus during pregnancy: a case-based literature review. AJPRep. 2016;6(1):e62-67.