Transcript Systemic Lupus Erythematosus and Pregnancy

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.
• 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 preeclampsia.
• 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.