What is the management approach for a pregnant woman with IgA (Immunoglobulin A) nephropathy?

Management of IgA Nephropathy in Pregnancy

Pregnant women with IgA nephropathy require coordinated nephrology-obstetrics care with strict blood pressure control using pregnancy-safe antihypertensives (avoiding ACE inhibitors/ARBs), close monitoring of proteinuria and renal function, and consideration of thromboprophylaxis if nephrotic-range proteinuria develops. 1, 2

Pre-Conception Counseling and Risk Assessment

Optimal timing for pregnancy is when patients are normotensive with preserved kidney function (eGFR >70 mL/min) and proteinuria <1 g/day. 3 Women requiring antihypertensive medications beyond RAS inhibitors before conception face significantly higher risks, with 5-fold increased odds of severe hypertensive disorders requiring IV nicardipine (aOR 5.01) and 6.5-fold increased odds of preterm delivery (aOR 6.45). 4

Key pre-conception parameters to assess:

• Baseline eGFR: Women with eGFR <70 mL/min have 14% perinatal mortality versus 3% with preserved function 3
• Blood pressure control: Pre-pregnancy hypertension (>140/90 mmHg) increases perinatal mortality to 33% versus 1% in normotensive women 3
• Proteinuria level: Higher baseline proteinuria correlates with adverse pregnancy outcomes 5

Medication Management During Pregnancy

Discontinue Teratogenic Agents

Immediately stop ACE inhibitors and ARBs before conception or as soon as pregnancy is confirmed, as these are contraindicated throughout pregnancy. 2 This is critical since RAS blockade is first-line therapy for IgAN outside pregnancy. 1, 6

Pregnancy-Safe Antihypertensives

Switch to pregnancy-compatible agents:

• Methyldopa, labetalol, or nifedipine are preferred options for blood pressure control 7
• Target blood pressure <140/90 mmHg to minimize preeclampsia risk 4

Immunosuppression Considerations

If immunosuppression is required during pregnancy, safe options include prednisone, azathioprine, tacrolimus, and cyclosporine. 2 However, glucocorticoids should be used with extreme caution given the lack of established benefit in IgAN and risks in pregnancy. 1 The decision to use immunosuppression should only occur if disease activity threatens maternal or fetal outcomes.

Monitoring Protocol Throughout Pregnancy

Renal Function Surveillance

• Monthly assessment of serum creatinine and eGFR to detect accelerated decline 5
• While pregnancy typically does not accelerate IgAN progression in women with preserved baseline function 8, rare cases show rapid deterioration to end-stage renal disease 3

Proteinuria Monitoring

• Serial urine protein quantification (24-hour collection or protein-to-creatinine ratio) 5
• Proteinuria during pregnancy is a borderline predictor of adverse outcomes (OR 1.39) 5
• Distinguish physiologic pregnancy-related proteinuria from disease progression

Blood Pressure Control

• Weekly to biweekly blood pressure checks, increasing frequency in third trimester 7
• Maintain strict control to prevent preeclampsia, which occurs at higher rates in IgAN patients 7

Thromboprophylaxis Decision-Making

If nephrotic syndrome develops (albumin <20-25 g/L), initiate prophylactic anticoagulation with low-molecular-weight heparin, as pregnancy increases thrombotic risk 5-fold and nephrotic syndrome compounds this dramatically. 2 This is particularly important given that full anticoagulation is indicated for thromboembolic events in nephrotic syndrome. 1

Supportive Care Measures

Dietary Modifications

• Sodium restriction to <2-3 g/day for edema control 2
• Low-protein diet may help preserve renal function, though protein replacement for nephrotic losses is necessary 1, 7

Infection Prevention

• Administer pneumococcal and influenza vaccines before or during pregnancy 1, 6
• Maintain high suspicion for bacterial infections; obtain blood cultures and start empirical broad-spectrum antibiotics immediately if fever develops, as infections are a primary cause of maternal death in nephrotic syndrome 2

Edema Management

If significant edema develops:

• Furosemide 0.5-2 mg/kg per dose orally, up to six times daily based on severity 2
• Avoid doses >6 mg/kg/day for >1 week due to ototoxicity risk 2

Delivery Planning

Plan delivery at a tertiary center with maternal-fetal medicine and nephrology expertise. 1 Women with declining renal function or uncontrolled hypertension may require early delivery, as demonstrated in the case report where delivery occurred at 34 weeks due to rupture of membranes with acceptable outcomes. 7

Critical Pitfalls to Avoid

• Never continue ACE inhibitors or ARBs during pregnancy - these are absolutely contraindicated 2
• Do not delay antibiotic therapy if infection is suspected - infections carry high maternal mortality risk in nephrotic patients 2
• Avoid assuming pregnancy will not affect disease progression - while most women maintain stable function 8, approximately 5 cases in historical cohorts showed rapid deterioration 3
• Do not use pre-pregnancy proteinuria alone to counsel patients - contemporary management has dramatically improved outcomes, with perinatal mortality dropping from 9% in the 1970s to 0% in the 1980s 3