Systemic lupus erythematosus sle and pregnancy
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Systemic Lupus Erythematosus (SLE) and Pregnancy. . Mishelle M. Hernandez, M.D. Objectives. To discuss how pregnancy affects SLE in increasing lupus flare rates To discuss the effects of SLE on maternal and fetal outcome in pregnancy To discuss management of Lupus flare in pregnancy

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Systemic lupus erythematosus sle and pregnancy

Systemic Lupus Erythematosus(SLE) and Pregnancy

.

Mishelle M. Hernandez, M.D.


Objectives
Objectives

  • To discuss how pregnancy affects SLE in increasing lupus flare rates

  • To discuss the effects of SLE on maternal and fetal outcome in pregnancy

  • To discuss management of Lupus flare in pregnancy

  • To discuss ethical issues on the case


General data
General Data

  • K. G.

  • 18/F

  • Makati City

  • CC: bipedal edema

  • DOA: 3/18/08


Diagnosed case of Systemic Lupus Erythematosus since Aug. 2007

1997 Revised Classification Criteria for Systemic Lupus Erythematosus [1]

1 Kliegman, Robert, M.D., et al. Nelson’s Textbook of Pediatrics. 18th ed. USA: Sanders, 2007, pp. 1015-191


History of present illness
History of Present Illness 2007

1 yr PTA (+) alopecia, (+) malar rash

9 mo PTA (+) fever, (+) discoid rash, (+) oral ulcers

(+) R eyelid swelling

(+) joint pain and swelling of hands

RHEUMA CLINIC A> SLE

Labs: ANA (+4) homogenous 1:80

leukopenia (3,800), anemia (10),

lymphopenia (ALC 0.934)

BUN 2.3 mol/L (N), Crea (N),

Proteinuria(++), RBC 0-1


History of present illness1
History of Present Illness 2007

2 mo PTA Pregnant

discontinued Prednisone

No consult done

1 wk PTA (+) persistence of cough

(+) bipedal and periorbital

edema

4 d PTA (+) persistence of edema

(+) 2 pillow orthopnea

(-) PND, palpitations, chest

pain


History of present illness2
History of Present Illness 2007

2 d PTA (+) easy fatigability

(+) difficulty of breathing

(+) vomiting

(+) epigastric pain

(+) diarrhea

(+) tea-colored urine

(+) oliguria

Rheuma clinic consult

PAY


Review of systems
Review of Systems 2007

  • General: (-) generalized weakness, (-) weight loss, (-) anorexia

  • Neurologic: (-) seizure, (-) headache, (-) change in sensorium, (-) change in behavior

  • HEENT: (-) eye pain, blurring of vision, (-) sore throat

  • Hematologic: (-)epistaxis, (-)hematemesis, (-) hematochezia, (-) hemoptysis, (-) easy bruisability, (-) increased bleeding,

  • Dermatologic: (-) active skin lesions


Past medical history
Past Medical History 2007

Family History

Birth/Maternal History

Immunization History

Nutritional History

No intake of other Meds except Prednisone

(+) similar illness – grandmother, paternal side

noncontributory

Completed at Local health center

Unremarkable


Developmental History 2007

Obstetrics/Menstrual History

  • At par with age

  • G1P0, (+) pregnancy test in February,

  • (+) spotting in February, (-) vaginal discharge

  • LMP: Dec 3, 2007, 30 days interval, 4 days duration, 3 pads/day, (+) dysmenorrhea

  • 2nd child from a brood of 9

  • Mother is a 39 y/o,housewife.

  • Father is 45 y/o, nurse at PGH PICU.

Personal/Social History


Headss
HEADSS 2007

  • Home

    • living with parents and siblings

    • good relationship with them (closest to her older sister)

  • Education

    • incoming 1st year college student, taking up BS Psychology

    • She didn’t finished first year due to her illness

    • plans to finish her study and work to help her parents


Headss1
HEADSS 2007

  • Activity

    • hangs out with friends in the mall or in their house, go out preferably at night

    • love to talk about gossips

  • Drugs

    • Denies illicit drug use

    • occasional beverage drinker

    • doesn’t smoke


Headss2
HEADSS 2007

  • Sex

    • one relationship and sexually active, with a 15 y/o guy, who is also the father of her present pregnancy

    • Her boyfriend impregnated another woman prior to her

    • no plans of getting married now

  • Suicidal ideations

    • when scolded by parents

    • felt very sad when she was diagnosed with SLE


Physical examination on admission
Physical Examination on Admission 2007

  • General exam: conscious, coherent, not in cardiorespiratory distress

  • Vital signs: BP 140/80, PR 110, RR 24, T 38C, wt 47 kg, ht 151 cm

  • HEENT: slightly pale conjunctivae, anicteric sclera, (+) periorbital edema, bilateral

  • (-) cervical lymphadenopathy, (-) anterior neck mass, (-)neck vein engorgement, (-) tonsillopharyngeal congestion


Physical examination on admission1
Physical Examination on Admission 2007

  • Chest and Lungs: Equal chest expansion, no retractions, (+) clear breath sounds, (-) crackles/wheeze

  • Cardiovascular: adynamicprecordium, distinct HS, tachycardic, normal regular rhythm, AB at 5th LICS MCL, (-) murmur

  • Abdomen: globular abdomen, (+) NABS, soft, (+) epigastric tenderness, (-) organomegaly, abdominal girth = 76 cm, fundic height = 20 cm, fetal heart tone not appreciated by stethoscope


Physical examination on admission2
Physical Examination on Admission 2007

  • Internal examination: (+) vulvar edema, nulliparous vagina, corpus enlarged to AOG, cervix soft closed, (-) abnormal discharge or masses

  • Extremities: Pink nailbeds, FEP, (-) cyanosis, (+) bipedal edema, pitting, grade 1

  • External genitalia: grossly female, SMR 4

  • Skin: (-) active dermatoses

  • Neurologic exam: essentially normal


Initial impression
Initial Impression 2007

SLE in activity

Pregnancy Uterine 17 2/7 weeks by early UTZ, NIL

UTI


Problem list
Problem List 2007

Pregnancy

SLE

Nephritis, Hypertension

Pericarditis

Anemia

Pulmonary edema, noncardiogenic Pleural Effusion, B

Infection


Pregnancy
Pregnancy 2007



Lupus pericarditis
Lupus 2007Pericarditis





  • Ward stay – 17 days 2007

  • PICU stay – 10 days

  • Discharged – on April 15, 2008

    • Home Meds

      • Prednisone

      • Aspirin

      • Azathioprine

      • Nifedipine

      • Methyldopa

      • Hydralazine

      • Multivitamins

      • Folic acid

      • MgSO4

      • Fe


Whether pregnancy exacerbates lupus
Whether pregnancy exacerbates lupus? 2007

  • Among retrospective and prospective studies [2]

    • Lupus flare rates ranges from approximately 20% – 60%

  • Lupus that is active at the onset of pregnancy is activated further during pregnancy

2 Singh, Ajay K. Lupus nephritis and anti-phospholipid activity syndrome in pregnancy. Kidney International. Vol 58. (2000), pp 2240-2254.


Table 1 distribution of sle flares occurring during pregnancy a 3
Table 1. Distribution of SLE flares occurring during pregnancy a [3]

3 Cortez-Hernandez, J., et al. Clinical Predictors of Fetal and Maternal Outcome in Systemic Lupus Erythematosus, a Prospective Study. Rheumatology. 2002; 41: 643-50.


How to treat sle flare during pregnancy
How to treat SLE flare during pregnancy? pregnancy

  • Prednisone (1-2 mg/kg/day) – drug of choice for most SLE manifestation

  • Methylprednisone pulse 1g/day fowllowed by oral Prednisone at 0.5-1.0 mg/kg/day – severe systemic disease

  • Azathioprine (2 mg/kg/day) – for initial mild flare

  • Stress doses of Hydrocortisone – for emergency surgery, cesarean section, prolonged labor and delivery

5 Obstetric Emergencies: Management of Lupus Flare. www.obgmanagement.com. May 2006.



Table 2 evidence for adverse effects of immunosuppressant used in pregnancy and breastfeeding 6
Table 2. Evidence for adverse effects of immunosuppressant used in pregnancy and breastfeeding[6]

6 Mackillop, Lucy H., et al. Pregnancy plus Systemic Lupus Erythematosus. BMJ.2007; 335: 93336.


Refractory cases
Refractory cases used in pregnancy and breastfeeding

  • Rule: To treat the lupus flare before irreparable maternal harm occurs

  • Use of other new line immunosuppressive drugs

    • Benefits must be outweighed by potential risks

  • No conclusive data suggest pregnancy termination will ameliorate lupus flare.

5 Obstetric Emergencies: Management of Lupus Flare. www.obgmanagement.com. May 2006.


Management preconception visit
Management Preconception Visit used in pregnancy and breastfeeding

  • counseled on appropriate timing of planned pregnancy

    • remission of at least 6 months and preferably more than 12 months and minimal or no need of immunosuppressives

  • Risks to patient and fetus are discussed in detail

  • The following baseline investigations are obtained at the start

    • CBC

    • Urea, creatinine, electrolytes

    • Liver function tests

    • ANA, anti dsDNA, aPL, anti-Ro/anti-La

Mackillop, Lucy H., et al. Pregnancy plus Systemic Lupus Erythematosus. BMJ.2007; 335: 93336.


Management after conception
Management after conception used in pregnancy and breastfeeding

  • follow-up frequency is dependent on disease activity

  • hydroxychloroquine is given to prevent flares

  • Low dose aspirin is administered to prevent preeclampsia

  • If APLS positive or history of thrombosis or fetal loss, treatment with heparin or LMWH and low dose aspirin

Mackillop, Lucy H., et al. Pregnancy plus Systemic Lupus Erythematosus. BMJ.2007; 335: 93336.


Management after conception1
Management after conception used in pregnancy and breastfeeding

  • fetus is regularly monitored by obstetrician using Doppler UTZ

    • 20 weeks, a detailed morphology scan is done

    • Regular growth scans at 28, 32 and 36 weeks is done

    • If with anti-Ro and anti-La, fetal heart pulsed Doppler echocardiography at 18 weeks and 3rd trimester

  • Delivery method and timing depends on obstetric indications

Mackillop, Lucy H., et al. Pregnancy plus Systemic Lupus Erythematosus. BMJ.2007; 335: 93336.


Management after conception2
Management after conception used in pregnancy and breastfeeding

  • Nutrition management

    • Megavitamin therapy

    • adequate dietary intake

    • Breastfeeding is contraindicated when taking the following drugs: mycophenolate, cyclophosphamide, methotrexate and leflunomide

    • Breastfeeding is appropriate if the maternal dose of prednisone is <30 mg/d, to take her medications just after breast-feeding

Ferris, Ann M., et al. Nutritional consequences of chronic maternal conditions during pregnancy and lactation: lupus and diabetes. American Journal of Clinical Nutrition. 1994; 59 (suppl): 465S-73S.


How sle affects pregnancy
How SLE affects pregnancy? used in pregnancy and breastfeeding

  • Spontaneous abortion

  • Preeclampsia

  • IUGR

  • Fetal death rate

  • Preterm delivery

  • Thromboembolism

  • Lupus nephritis

  • Renal failure

  • Antiphospholipid syndrome

  • Active disease at conception

  • First presentation of SLE at pregnancy

7 Molad, Yair. Sytemic Lupus in Pregnancy. Current Opinion in Obstetrics and Gynecology.2006; 18: 613-617.


Table 4 fetal outcome 8
Table 4. Fetal Outcome [8] used in pregnancy and breastfeeding

8 Valdez, Corazon, et al. Systemic Lupus Erythematosus in Pregnancy: a 23-year review. Acta Medica Philippina


Updates on the patient
Updates on the Patient used in pregnancy and breastfeeding

  • On regular follow up to Rheuma, Renal, Perinatology

  • Maintained on Prednisone, Azathioprine, Aspirin, megavitamin

  • Controlled hypertension

  • Normal fetus on serial scans

  • EDC: Aug. 26, 2008the

  • Awaiting APAS

  • Father is alienating the patient.


Conclusion
Conclusion used in pregnancy and breastfeeding

  • Whether pregnancy does exacerbate SLE is a controversial issue.

  • Women with SLE can have successful pregnancies.

  • In the care of lupus pregnant patient, the most diffiucult dilemma is saving both the mother and the unborn child.


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