A 28-year-old primigravid woman with systemic lupus erythematosus (SLE) was the St George Obstetric Medicine clinic following an unplanned but desired pregnancy occurring during a new lupus flare. Despite feeling well, investigations demonstrated markedly elevated anti-double stranded DNA antibodies (>3500 IU/mL), elevated inflammatory markers and new-onset proteinuria (98mg/mmol). Kidney biopsy performed in the first trimester confirmed .
The management dilemma was immediate. Although the patient was clinically asymptomatic with relatively mild proteinuria, serological and histological findings suggested active disease with known potential implications for both maternal and fetal outcomes.
Following extensive review of the available literature and expert consultation, a decision was made to administer pulse corticosteroids and two doses of rituximab in the first trimester. At 30 weeks’ gestation, maternal disease remains in remission with rapid improvement in serological markers and proteinuria, and foetal growth is appropriate.
This case highlights the uncertainty of balancing undertreatment versus overtreatment when managing asymptomatic lupus nephritis during pregnancy. Although the outcome has been favourable, it remains unclear whether aggressive treatment altered the disease trajectory or whether a more conservative approach would have achieved the same result. Therapeutic options in management of lupus nephritis are expanding, but evidence to guide the intensity of treatment during pregnancy remains limited. Sharing experiences such as these is critical to expanding the literature and guiding future clinicians faced with similar dilemmas.