妊娠を契機に血小板減少を来たし，子宮内胎児死亡に至った全身性エリテマトーデス及び抗リン脂質抗体症候群の一例

　抗リン脂質抗体症候群は，抗リン脂質抗体が産生されることで血栓症を主体とする病態を引き起こす自己免疫疾患である．動静脈血栓症に加え，習慣性流産，早産，妊娠高血圧症候群，胎児発育遅延，胎児機能不全などの妊娠合併症を高率に引き起こすとされている．また患者のうち約半数は全身性エリテマトーデスが併存していると言われている．我々は妊娠を契機に血小板減少を来たし，子宮内胎児死亡に至った全身性エリテマトーデス及び抗リン脂質抗体症候群の症例を経験した．　患者は20歳代女性，未経妊未経産．５年前に全身性エリテマトーデス及び抗リン脂質抗体症候群と診断された．プレドニゾロンとタクロリムス，アザチオプリンによる免疫抑制療法及び低用量アスピリン療法を開始され，数年間に渡りプレドニゾロン５mg/ 日＋タクロリムス３mg/ 日＋アザチオプリン50mg/ 日で病態は安定していた．妊娠を契機にプレドニゾロン10mg/ 日の単独治療に切り替えたが，徐々に血小板減少が進行してきたため入院し，プレドニゾロン30mg/ 日への増量及びタクロリムス３mg/ 日を再開した．また血栓予防治療として，低用量アスピリンに加えヘパリン療法を開始した．しかし妊娠16週５日で子宮内胎児死亡が判明したため，血栓予防治療を中止し児の娩出に至った．　抗リン脂質抗体症候群合併妊娠は，周産期管理に慎重を要する例も存在することを念頭に置き，特にハイリスク症例に対しては妊娠成立前から産婦人科と連携して治療にあたる必要がある．　Antiphospholipid syndrome is an autoimmune disease characterized by episodes of recurrent thrombosis. This syndrome is associated with not only recurrent arteriovenous thrombosis but also recurrent pregnancy loss, premature birth, pregnancyinduced hypertension, and fetal growth restriction. It has been reported that systemic lupus erythematosus coexists with antiphospholipid syndrome in as many as about 50% of patients. We report a case of intrauterine fetal death (IUFD) following thrombocytopenia in a patient with systemic lupus erythematosus and antiphospholipid syndrome. A woman in her 20s had difficulty conceiving and had been diagnosed as having systemic lupus erythematosus and antiphospholipid syndrome 5 years earlier. She was started on immunosuppressive therapy with prednisolone 5 mg/day, tacrolimus 3 mg/day, and azathioprine 50 mg/day, with low-dose aspirin therapy. Her disease was stable for several years. Thrombopenia gradually developed after treatment was changed to prednisolone 10 mg/day during pregnancy. She was admitted to hospital and treatment was started with prednisolone 30 mg/day, tacrolimus 3 mg/day, and heparin therapy in addition to low-dose aspirin therapy. However, IUFD was detected at a gestational age of 16 weeks 5 days, so we discontinued thromboprophylaxis treatment and administered a therapeutic abortion. In patients with antiphospholipid syndrome who need meticulous perinatal management, it is important to consult with the obstetrics and gynecology specialists before proceeding with a potentially high-risk pregnancy

Case reports of pregnancies complicated with kidney disease and their fetal prognosis

　The number of patients with chronic kidney disease (CKD) has been increasing every year, with a current prevalence of one in eight adults. Although the frequency of complications due to kidney disease before pregnancy is not high (0.02–0.12%), frequency of pregnancy with CKD, including cases receiving continuous dialysis therapy is expected to increase in the future. The fertility and birth rates among dialysis patients are low, and perinatal management in these patients is currently difficult. However, even under such circumstances, the probability of having a live-born baby in pregnant women on dialysis has increased due to improvements in dialysis technology, perinatal management, and neonatal care. There are some case reports written about them, and I think that it is possible to approach term delivery with careful care through the cases experienced this time.　In this study, we examined the pregnant patients, on dialysis or requiring postpartum dialysis, at Kawasaki Medical School Hospital between January 2005 and March 2018. Six patients (86%) had a live-born baby, while one had a miscarriage. One patient underwent two pregnancies on dialysis; one case gave a full-term birth, while the rest had a premature delivery. The modes of delivery were vaginal delivery (n = 1), elective cesarean section (n = 3), and emergency cesarean section (n = 2). Five patients delivered successfully and had a good prognosis, while in one case, the neonate died.　Over the years, owing to continuous improvement at our hospital, we have achieved better pregnancy prognosis and longer gestation periods in the patients. In particular, one case, which had a natural second pregnancy, 9 years after the beginning of dialysis, was worthy of note; we were able to manage her second pregnancy using the process followed during her first pregnancy as reference