A 35 year old woman with diabetic nephropathy who wants a baby: case presentation
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《英国医生杂志》
1 Chair of Nephrology, Department of Internal Medicine, University of Turin, Corso Dogliotti, 14-10126 Turin, Italy, 2 Diabetic Care Unit, Department of Internal Medicine, University of Turin, 3 Department of Obstetrics and Gynaecology, University of Turin
Correspondence to: G B Piccoli gbpiccoli@hotmail.com
Maria Tomasa (Tommy) is a 35 year old woman with diabetic nephropathy. She has been diabetic since the age of 15 and has developed several complications, including retinopathy (requiring laser therapy) and mild hypertension. She desperately wants a baby despite being advised against it by her diabetologist. Indeed, she changed where she was referred for diabetic care until she found a group of care givers mildly tolerant of a pregnancy.
Five years ago she had a spontaneous abortion in the first trimester, complicated by hypertension and nephrotic proteinuria and was referred to an outpatient unit dedicated to diabetic patients with renal diseases. She had a renal biopsy after the miscarriage, which showed nodular and diffuse nephropathy with initial sclerosis (five glomeruli, two with global ischaemic sclerosis, the others with signs of nodular and diffuse diabetic glomerulopathy).
Despite the presence of renal damage, we decided not to discourage her wish; none of us was enthusiastic about the idea, but the attitude was "let nature decide." She was put on a strict nephrological and diabetological follow up and a low protein diet (0.8 g/kg/day) and was instructed to stop taking angiotensin converting enzyme inhibitors in case of pregnancy. One year later she had a tubal pregnancy and needed salpingectomy. The surgeon suspected obstruction of the residual salpinx.
Questions
What would you tell Tommy about the risks of assisted reproduction?
How would you search for evidence of the risks and what search strategy would you use?
How would you balance the risks against Tommy's determination to have treatment?
Please respond through bmj.com, remembering that Tommy is a real patient and that she and her doctors will read your response
Over the next two years, Tommy's attempts to become pregnant continued to be unsuccessful, as expected in the case of a mechanical fertility problem. At the age of 35, she asked for assisted fertilisation. The table gives her renal data. Control of her diabetes was good (glycated haemoglobin 6.7-8%), but she needed a further cycle of laser therapy to stabilise her retinopathy.
Patient's renal function
Competing interests: None declared.
This is the first of a three part case report where we invite readers to take part in considering the diagnosis and management of a case using the rapid response feature on bmj.com. Next week we will report the case progression and in four weeks' time we will report the outcome and summarise the responses.(Giorgina Barbara Piccoli,)
Correspondence to: G B Piccoli gbpiccoli@hotmail.com
Maria Tomasa (Tommy) is a 35 year old woman with diabetic nephropathy. She has been diabetic since the age of 15 and has developed several complications, including retinopathy (requiring laser therapy) and mild hypertension. She desperately wants a baby despite being advised against it by her diabetologist. Indeed, she changed where she was referred for diabetic care until she found a group of care givers mildly tolerant of a pregnancy.
Five years ago she had a spontaneous abortion in the first trimester, complicated by hypertension and nephrotic proteinuria and was referred to an outpatient unit dedicated to diabetic patients with renal diseases. She had a renal biopsy after the miscarriage, which showed nodular and diffuse nephropathy with initial sclerosis (five glomeruli, two with global ischaemic sclerosis, the others with signs of nodular and diffuse diabetic glomerulopathy).
Despite the presence of renal damage, we decided not to discourage her wish; none of us was enthusiastic about the idea, but the attitude was "let nature decide." She was put on a strict nephrological and diabetological follow up and a low protein diet (0.8 g/kg/day) and was instructed to stop taking angiotensin converting enzyme inhibitors in case of pregnancy. One year later she had a tubal pregnancy and needed salpingectomy. The surgeon suspected obstruction of the residual salpinx.
Questions
What would you tell Tommy about the risks of assisted reproduction?
How would you search for evidence of the risks and what search strategy would you use?
How would you balance the risks against Tommy's determination to have treatment?
Please respond through bmj.com, remembering that Tommy is a real patient and that she and her doctors will read your response
Over the next two years, Tommy's attempts to become pregnant continued to be unsuccessful, as expected in the case of a mechanical fertility problem. At the age of 35, she asked for assisted fertilisation. The table gives her renal data. Control of her diabetes was good (glycated haemoglobin 6.7-8%), but she needed a further cycle of laser therapy to stabilise her retinopathy.
Patient's renal function
Competing interests: None declared.
This is the first of a three part case report where we invite readers to take part in considering the diagnosis and management of a case using the rapid response feature on bmj.com. Next week we will report the case progression and in four weeks' time we will report the outcome and summarise the responses.(Giorgina Barbara Piccoli,)