Systemic Lupus Erythematosus and Pregnancy

1. Systemic Lupus Erythematosus and Pregnancy Andres Quiceno, MD Rheumatology

2. 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.

3. 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.

4. 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.

5. 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.

6. 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.

7. 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.

8. 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.

9. 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.

10. 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.

11. 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.

12. 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.