Transcript Background, SOME TERMINOLOGIES, predictive factors

This lecture was conducted during the Nephrology Unit Grand
Ground by Medical Student rotated under Nephrology Division
under the supervision and administration of Prof. Jamal Al
Wakeel, Head of Nephrology Unit, Department of Medicine and
Dr. Abdulkareem Al Suwaida, Chairman of the Department of
Medicine. Nephrology Division is not responsible for the
content of the presentation for it is intended for learning and
/or education purpose only.
Presented by:
Nora Al Kheraiji
Medical Student
December 24, 2008
Systemic lupus erythromatosus(SLE) is
one of the most common
autoimmune disorders that affect
women during their childbearing
years (ages 15 and 45 years).
Gravida--(number of pregnancies)
para --(number of births >24 W)
Abortions--(<24 W)
Full Term--(38-42W)
Preterm--(24-37)
IUGR--(snography parameters are decreased)
Still birth=IUFD--(fetal death >20 but befor labor)
50% (active/inactive lupus)
have a normal
outcome.
25%
deliver healthy babies prematurely.
The foetal outcome in lupus pregnancy:
• abortions
•
still-births
• intra-uterine growth retardation (IUGR).
Lupus patients have an increased risk of pre-eclampsia
(5-38%) as compared to women without SLE.
for foetal
wastage
• active lupus nephritis
• previous history of
foetal death
• Maternal
for
prematurity hypertension
and IUGR • high dose steroids
The pathophysiology of disease activity during
pregnancy remains unknown. Increased SLE
disease activity is expected during pregnancy
because of increased levels of estrogen,
prolactin(ie, proinflammatory hormone), and
T–helper cell 2 cytokines.
Nausea, vomiting, and morning sickness can occur during the first
trimester
absorption of medications.
Most patients with lupus report fatigue during pregnancy.
(fatigue
Lupus/pregnancy ? )
Differentiate malar rash from chloasma.
Pedal edema and fluid accumulation in joints, especially the
knees, can occur in the late stages of pregnancy and should be
differentiated from the arthritis of systemic lupus erythematosus
(SLE).
Differentiate proteinuria secondary to preeclampsia from
proteinuria due to lupus nephritis.
** The likelihood of developing renal disease
during pregnancy is not increased if the
patient was in remission at the time of
conception.
Pregnancy + active lupus
risk of fetal loss
and worsening of the renal and extrarenal
manifestations.
women with lupus nephritis should be
encouraged to delay pregnancy
until the disease can be rendered
inactive for at least 6 months.
In a retrospective study from 2000–2005
done on 84 pregnancies in 84 SLE
patients to evaluate the influence of LN
on maternal and fetal outcome in
patients with histologically proven LN
compared with patients without LN
(Pacheco-Reyes.H et al; 2006).
Conclusion:
Pregnant women with LN have poor outcome than
pregnant patients without LN. These patients
require close follow-up for the best pregnancy
outcome.
Proteinuria
Lupus nephritis
Preeclampsia
active urine
sediment (RBCs,
WBCs, and cellular
casts)
NO
complement
levels + antiDNA antibodies
Lupus nephritis
Preeclampsia
anti-DNA
complement
anti-DNA
(No)
complement
In pregnant + renal disease
nephritis
preeclampsia or active lupus
differentiation on clinical grounds
is not possible
renal biopsy
Platelet + liver enzymes/uric acid + urinary excretion of
calcium ,these are more prominent in preeclampsia than in
lupus nephritis.
Note : thrombocytopenia may also be
associated with :
antiphospholipid antibodies
thrombotic thrombocytopenic purpura
(TTP)
immune thrombocytopenia
each of which may complicate pregnancy
in women with SLE.
Pregnancy + postpartum period (especially) the thrombotic
risk in SLE patients who have antiphospholipid antibodies.
Patients on warfarin (because of a past venous or arterial
thrombotic event) switch to heparin as soon as the
pregnancy is recognized.
Patients who had fetal losses or other pregnancy morbidity
due to antiphospholipid antibody syndrome are treated with
prophylactic doses of heparin and low-dose aspirin (81 mg)
during subsequent pregnancies (no past morbidity, many
consider the use of low-dose aspirin) .
Neonatal lupus (3.5%)
associated with
congenital heart block /lupus rash, it is
+ve maternal anti-Ro (usually anti-La)
(rash may occur with anti-RNP antibodies.)
In rare cases
hepatic or hematologic involvement.
So what should be done?
fetal 4-chamber cardiac
echocardiography performed at
16-28 weeks' gestation is
recommended.
If heart block of any degree is found,
dexamethasone 4 mg/day is
given to the mother because it
crosses the placenta.
pregnancy loss
in SLE compared with control groups.
Fetal loss is possible in any trimester.
First-trimester losses
antiphospholipid antibodies and with
lupus activity (eg, low complement concentrations and increased
anti–double-stranded DNA [anti-dsDNA] antibodies).
Late losses
antiphospholipid antibodies.
Note : hypercoagulable states other than antiphospholipid
antibody syndrome are also associated with increased fetal loss.
SLE is not associated with infertility unless the
woman has been treated with cyclophosphamide ,
which leads to premature ovarian failure.
Patients may need to be reminded about the
importance of using contraception while they are
taking methotrexate, cyclophosphamide, and
mycophenolate.
Counsel patients about the teratogenicity of
medications used to treat systemic lupus
erythematosus (SLE) before therapy is initiated.
Educate patients that, because of prolonged
half-lives, some medications may need to be
discontinued several months before the
planned conception.
Women with lupus and the antiphospholipid
antibody syndrome require more frequent
monitoring than those with SLE alone.
AZATHIOPRINE(2.5
mg/kg/d) and
STEROIDS(Prednisone, 5-60
mg/d PO) (safe in
pregnancy)
anti-phospholipid antibody
syndrome add aspirin
and/or low-molecular
weight heparin
CYCLOPHOSPHAMIDE :
causes birth defects, especially
during the 1st trimester
MYCOPHENOLATE MOFETIL :
recently has been shown to
result in ear and other facial
malformations such as cleft lip
and cleft palate.
PACHECO-REYES, H; MEDINA, G; ANGELES, U; CRUZ, P; JARA, L J. THE IMPACT OF
LUPUS NEPHRITIS ON PREGNANCY OUTCOME.JOURNAL OF CLINICAL
RHEUMATOLOGY. VOLUME 12(4) SUPPLEMENT, AUGUST 2006, PP S64-S65.
KHURANA.R, WOLF.R. SYSTEMIC LUPUS ERYTHEMATOSUS AND PREGNANCY.
EMEDICINE FROM WEB MD. UPDATED: FEB 14, 2008
TREATING LUPUS NEPHRITIS DURING PREGNANCY .RENAL FELLOW NETWORK.
OCTOBER 14, 2008
HANDA .R, KUMAR.U, WALI.J. SYSTEMIC LUPUS ERYTHEMATOSUS AND
PREGNANCY. SUPPLIMENT TO JAPI . New Delhi. JUNE 2006. VOL. 54. P 19