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Systemic Lupus Erythematosus and Pregnancy. Andres Quiceno, MD Rheumatology. Case Presentation 28 y/o WF with PMHx of SLE diagnosed in 1993 when presented with thrombocytopenia, arthritis, malar rash and +ANA. Patient was clinically in remission for the last 2 years on Plaquenil.

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systemic lupus erythematosus and pregnancy

Systemic Lupus Erythematosus and Pregnancy

Andres Quiceno, MD


Case Presentation
  • 28 y/o WF with PMHx of SLE diagnosed in 1993 when presented with thrombocytopenia, arthritis, malar rash and +ANA.
  • Patient was clinically in remission for the last 2 years on Plaquenil.
  • On 9/30/2004 she was evaluated in a routine visit and petechiae were noted in her lower extremities. Patient stated at that time that she was trying to become pregnant.
CBC done that day revealed a platelet count of 62K.
  • PMHx: G1 P1C1. Pregnancy was ended at week 36 because pre-eclampsia. During the pregnancy patient received treatment with prednisone 10 mg PO QD.
  • Family Hx: maternal aunt with SLE.
Clinical Course
  • 10/4/04 Platelet count 317K, prednisone decreased to 20 mg PO QD.
  • 10/13/04 Platelet count 10K, patient admitted to the hospital, treated with methyl-prednisolone 1 gr IV x 3 and IVIG 1gr/kg/day x 2. Patient was started on azathioprine 50 mg a day. Urine pregnancy test was negative. Instructed to avoid pregnancy because SLE flare.
11/2/04 Patient evaluated because 24 hrs nausea, vomiting and abdominal pain.
  • Patient no missing her period and she denied any sexual encounter since her last admission.
  • Patient sent to the ER for hydration.
  • Pregnancy test ordered there was positive.
  • Beta HCG 11824 U (7-12 weeks pregnancy). Platelet count 32K.
  • Prednisone increased to 100 mg a day.
12/16/04 Admitted to high risk pregnancy service because BP 160/100 and +2 protein in U/A. 14 weeks pregnancy.
  • 24 hrs urine collection 1700 mg. Creat 0.5. Platelet 342K. SSA/SSB negative.
  • dsDNA 130, C3 and C4 within normal limits.
  • Patient received treatment with azathioprine 200 mg a day, labetalol 100 mg BID and prednisone 80 mg a day.
Pregnancy and flares of SLE
  • It is not clear if flares of SLE are more frequent during pregnancy.
  • Lupus flares during pregnancy do not seem to be more serious than those occurring in non-pregnant patients.
  • Lupus may flare at any trimester and the postpartum period.
  • Postgrad Med J.2001:157-165.
Obstetric and fetal outcome in lupus prengancy
  • The incidence of pre-eclampsia is increased.
  • Pre-existing hypertension, nephritis and presence of aPL are risk factors for pre-eclampsia.
  • Fetal wastage, prematurity and intrauterine growth retardation are more common.
  • Active nephritis at conception and the presence of aPL are predictors of fetal loss.
  • Postgrad Med J.2001:157-165.
Congenital heart block
  • Having SLE per se is not an independent risk factor.
  • The risk depends solely in the presence of anti-SSA/Ro or SSB/La.
  • The risk is approximately 7% in SLE mothers with positive anti-SSA/Ro.
  • Postgrad Med J.2001:157-165.
Use of medications in lupus pregnancies
  • NSAIDs should be avoided in the last few weeks of pregnancy.
  • Corticosteroids and hydroxychloroquine have not been shown to be teratogenic.
  • Azathioprine and cyclosporine can be used in pregnancy when intense immunosupression is necessary.
  • Cyclophosphamide is teratogenic and should be avoided.
  • Postgrad Med J.2001:157-165.
Lupus and Lactation
  • Big doses of aspirin should be avoided in nursing mothers.
  • NSAIDs are contraindicated in nursing mothers with jaundiced neonates.
  • Prednisone, prednisolone and hydroxychloroquine are compatible with breast feeding.
  • Breast feeding should be avoided by mothers on cytotoxic medications.
  • Postgrad Med J.2001:157-165.
Contraception in SLE patients.
  • Low dose estrogen contraceptives can be used in patients with stable disease and no history of thromboembolism.
  • Barrier methods or progestogens are alternatives in patients with contraindications to steroids.
  • Intrauterine contraceptive device is associated with an increase risk of infections.
  • Postgrad Med J.2001:157-165.