International Journal of Case Reports and Images (IJCRI) is an international, peer reviewed, monthly, open access, online journal, publishing high-quality, articles in all areas of basic medical sciences and clinical specialties.Aim of IJCRI is to encourage the publication of new information by providing a platform for reporting of unique, unusual and rare cases which enhance understanding of disease process, its diagnosis, management and clinico-pathologic correlations. IJCRI publishes Review

Key Clinical Message Point‐of‐care ultrasonography by non‐radiology physicians has become a valuable bedside diagnostic tool. As urolithiasis is one of the commonest indications for sonographic examination, physicians need to be familiar with the characteristic features of stones, that is, acoustic shadowing on gray scale and twinkle artefact on color doppler imaging.

DESCRIPTIONThe physiological adaptations in pregnancy can unmask underlying occult proteinuric renal disease. However, the effect of multiple pregnancies on the course of the disease is variable. We report the clinical course of a case of idiopathic membranous nephropathy through multiple pregnancies.A 25-year-old Hispanic woman was referred to our institution for worsening generalised swelling of the body, uncontrolled hypertension and 21 g/day of proteinuria at 34 weeks' gestation during her third pregnancy. There were no stigmata suggestive of HELLP (Hemolysis, Elevated Liver enzymes, Low Platelet count) syndrome. She was previously seen at our institution 5 years ago during her 1st pregnancy when 13 g/day of proteinuria was recorded at 25 weeks of gestation. At that time, she was treated with oral steroids and delivery was induced at 35 weeks due to intrauterine growth restriction. Placental biopsy revealed focal, tightly adherent blood clot, consistent with possible abruption. Renal biopsy performed in the postpartum period was consistent with membranous nephropathy (figure 1).She was treated with ACE inhibitors (ACEI) and at 3-month follow-up, she was asymptomatic, without oedema and urine protein-creatinine ratio (UPCR) had decreased to 7 g/g. She was lost to follow-up for 5 years until this recent admission. In the interim, she apparently had a second successful pregnancy but no data was available. During current pregnancy, delivery was induced at 34 weeks and the placental biopsy showed that it was critically small for gestational age and had focal intervillous fibrin deposition together with focal calcifications in the areas of more significant ischaemia (figure 2). Serology for antinuclear antibody, anti-double-stranded DNA, antiphospholipid antibody, viral hepatitis and rapid plasma regain were negative. Serum complements were within normal limits. During both the pregnancies, she had hypertension with average blood pressures in the range of 140-150/80-90 mm Hg, which is higher than expected for a normal pregnancy but within acceptable range for patients with preexisting chronic hypertension. At 1-month postpartum, UPCR was 1.8 g/g, without any treatment. Interestingly, her serum creatinine ranged between 0.6 and 0.9 mg/dL during this 5-year period. The patient was once again lost to follow-up. Learning points▸ Although there is physiological increase in proteinuria during pregnancy, the presence of nephrotic range proteinuria with or without hypertension in any trimester is always pathological and may be associated with underlying renal disease and a poor prognosis.