Moreover, the ischemic placental tissue showed no specific findings to confirm the diagnosis. course after delivery. Compared to previous reports, this case describes the earliest onset of HDP. Thus, HDP should be considered as a differential diagnosis in pregnant women with hypertension or proteinuria presenting with symptoms before 20?weeks of gestation. white blood cell, hemoglobin, platelet, total protein, albumin, total bilirubin, aspartate aminotransferase, alanine aminotransferase, lactate dehydrogenase, alkaline phosphatase, -glutamyl transpeptidase, blood urea nitrogen, creatinine, uric acid, estimated glomerular filtrationn rate, C-reactive protein, Puromycin 2HCl complement Puromycin 2HCl activity, prothrombin time, International Normalized Ratio, activated partial thromboplastin time, antithrombin, a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13, thyroid stimulating hormone, free thyroxine 3, free thyroxine 4, creatinine clearance, microglobulin We performed a kidney biopsy at 18?weeks of gestation to clarify the underlying renal disease as the renal manifestations were abnormal for HDP. Light microscopic examination showed 20 enlarged glomeruli. The narrowing of capillary lumens associated with endothelial cell swelling (known as endotheliosis) was prominent (Fig.?1a). In addition, three glomeruli showed glomerular epithelial hypercellularity and sclerosing change with the adhesion of the glomerular capillaries to Bowmans capsule at the tubular store, the so-called tip lesion of focal segmental glomerulosclerosis (FSGS) caused by the glomerular epithelial cell injury (Fig.?1b). A double contour of the capillary wall was also observed (Fig.?1c). While slight thickening of the endothelium and partial hyaline degeneration were observed in the small vessels, no fibrinoid Puromycin 2HCl necrosis or chronic changes like onion skin lesions were observed. The tubulointerstitial lesions were not injured. Immunofluorescence examination showed level 2?+?staining for immunoglobulin G (IgG), immunoglobulin M (IgM), and C4 and level 1?+?staining for immunoglobulin A (IgA) and fibrinogen at the capillary walls and mesangial areas (Fig.?1d). In contrast, the samples were unfavorable for C1q and C3. Electron microscopy showed endothelial cell swelling and the disappearance of the endothelial fenestra (Fig.?1e). Although effacement was not evident, slight villous changes of the foot process were observed. Diffuse double contour was present due to mesangial interposition (data not shown). Moreover, electron-dense deposits (EDD) were also detected in the subendothelial lesions (Fig.?1f). Although the presence of EDD and antinuclear antibody positivity suggested immunocomplex deposition, we concluded by mass spectrometry that this EDD was non-specific plasma exudation. Thrombotic microangiopathy (TMA) was provided as the pathological definitive diagnosis of the renal biopsy, with findings coincident with cases of HDP as described later. Open Puromycin 2HCl in a separate window Fig. 1 Renal biopsy findings. a Most of the capillary lumens are narrowed due to endothelial cell swelling (periodic acid-Schiff stain;??400). b Glomerular epithelial hypercellularity and sclerosing change and adhesion of glomerular capillaries to Bowmanss capsule are observed (indicated by an asterisk) (periodic acid-Schiff stain;??400). c The glomerular basement membranes show partial double contours (indicated by arrows) (periodic acid-silver methenamine stain;??1000). d Immunofluorescence staining showing positive immunoglobulin G (IgG) staining of mesangial and capillary areas (?400). e Electron microscopic examination showing endothelial cell swelling with disappearance of the fenestra (arrows) and subendothelial edema (asterisk). f Electron microscopic examination showing narrowing of the capillary lumens due to endothelial cell swelling with electron-dense deposits (EDD) (asterisk) Constantly, her BP was well controlled and the levels of liver enzyme and LDH were decreased (T.Bil 0.4?mg/dL; AST 26?IU/L; ALT 27?IU/L; and LDH 348?IU/L) and platelet count was increased (46.9??104 /L). However, congestive symptoms due to nephrotic syndrome worsened and fetal echo examination revealed asymmetric-type fetal growth restriction. The fetal estimated weight was 185?g, which was -1.8 SD; moreover, the resistance index (RI) of the umbilical artery was 0.9, which was higher than the 90% tile of the RI at 19?weeks of gestation. We had to judge quickly whether the patient could continue her pregnancy because she was nearing 22?weeks of gestation, the period allowed for abortion, when the renal biopsy results were obtained. Although she strongly hoped to continue the pregnancy, we recommended termination because she did Mouse monoclonal to SNAI2 not have any specific nephritis or causative TMA diseases that could Puromycin 2HCl be treated; for example, lupus nephritis. Moreover, her maternal risk was high and the fetal growth restriction was already.