Favorable pregnancy outcome in a patient with morbid obesity, type 2 diabetes mellitus and extremely high baseline proteinuria

The prevalence of type 2 diabetes mellitus (DM2) and obesity in pregnant women is increasing, particularly in those of advanced reproductive age. DM2, arterial hypertension (AH), proteinuria, and renal insufficiency significantly elevate the risk of pregnancy complications, including preeclampsia (PE), preterm birth, cesarean section (CS), congenital malformations, neonatal respiratory and metabolic disorders, and accelerated progression of chronic kidney disease in mothers. This article describes a case of unplanned pregnancy in a 45-year-old woman with morbid obesity (BMI 50.39), AH, DM2, extremely high proteinuria (12 g/day), and pregestational serum creatinine 210 μmol/L. The patient declined medical recommendations for pregnancy termination. She was prescribed insulin detemir and aspart, achieving a target HbA1C level below 6%. Acetylsalicylic acid and enoxaparin were administrated to prevent PE and thromboembolic complications. Antihypertensive therapy was adjusted multiple times based on 24-h blood pressure monitoring. By 26 weeks of gestation, the patient received methyldopa, extended-release nifedipine, and bisoprolol. No PE or fetal growth restrictions was observed. At 36 weeks 4 days of gestation, a planned CS was performed due to breech presentation. A female infant with diabetic fetopathy was delivered with weight 3290 g, height 51 cm, Apgar score – 7/8 points. The postpartum period was uneventful, and both mother and child were discharged at eighth day. The infant remains healthy and is developing normally. The mother was resumed nephroprotective therapy but, by her own decision, was lost to follow-up after six months. It is known she began regular hemodialysis 1.5 years postpartum. A favorable obstetric outcome was achieved through multidisciplinary pregnancy management, complication prevention, and strict glycemic and blood pressure control.