dr. anupama kumar consultant rheumatologist sagar hospital, bangalore
TRANSCRIPT
Dr. Anupama Kumar Consultant
Rheumatologist Sagar Hospital, Bangalore
Biological prerogative of every woman
Pregnancy in lupus is not contraindicated
Many lupus patients deliver healthy babies
Many families at least want one child Fertility is not affected in patients with lupus
SLE is the most common autoimmune multisystemic disease to affect women in child-bearing years
Prognosis for both mother and baby have important implications during pregnancy
Marriage, pregnancy and childbirth are burning issues for most patients
Characterized by production of antibodies to cell nucleus called ANAs
Who is affected - 90% are young women 90% of them are in 20 to 40 years age group
More patients plan for pregnancy because of improved prognosis
Pregnancy outcomes are good when lupus is in remission
Ideally lupus should be inactive for six months
Serious disease such as active lupus nephritis, myocarditis, seizures is a contra-indication
Teratogenic drugs like cyclophosphamide, methotrexate should be stopped six months
before conception
Lupus patients for pregnancy counseling Known lupus cases coming for antenatal
care Undiagnosed or misdiagnosed lupus in
pregnancy Asymptomatic pregnant patients who have
history of neonatal lupus or concerned antibodies
Fatigue and fevers Arthritis or arthralgias Malar rash Serositis Raynaud’s phenomenon Proteinuria Vasculitis Leukopenia Thrombocytopenia Seizures
Complete blood count Anti Nuclear Antibodies by IF or HEP2
Anti double stranded DNA antibodies Anti Ro and Anti La antibodies Complement studies-C3 AND C4 Urine analysis Renal function tests Lupus anticoagulant and Anti cardiolipin antibodies
Mild risk cases-Mild disease, those who are in remission, on no medication except mild ones
High risk cases-Severe active disease. Major organ involvement,those with Anti Ro or APL antibodies
Moderate risk cases-Majority are in this group
H/O Previous pregnancy with complication Underlying kidney, heart or lung disease Active phase of the disease Presence of Anti Ro and Anti La antibodies
A history of previous thrombotic event APLA Additional factors like maternal age>40 years
and pregnancy with twins or triplets
Risks of Lupus to pregnancy
Pregnancy loss Preterm delivery Eclampsia Neonatal lupus due to
Ro and La antibodies
Risks of pregnancy to lupus
Lupus flares Progressive renal
disease Maternal
thromboembolism
Miscarriages(before 20 weeks) is the most common form, averaging about 20%
Stillbirths are especially increased in Lupus -11%
Neonatal lupus and death due to CHB because of Anti Ro and Anti La antibodies
APS related repeated pregnancy failures
Increased lupus activity at conception or during pregnancy
Hypertension Hypocomplementaemia
Renal disease Gestational Lupus
Spontaneous abortions IUGR Preterm delivery postpartum haemorrhage maternal venous thromboembolism Neonatal death due to fetal heart block
High blood pressure in the mother after 20 weeks of pregnancy
Occurs in ~13% of women w/ SLE Tx: DELIVERY Delivery may be delayed in some women
who are less than 34 weeks to give steroids for lung maturity
Occurs in about 2% of babies born to mothers with anti-Ro/SSA and or anti-La/SSB antibodies
Caused by passage of the antibodies from the mother’s bloodstream across the placenta to the developing baby after about 20 weeks
Signs of neonatal lupus includes red, raised rash on the scalp and around the eyes that resolves by 6-8 months (because the antibodies clear the blood stream)
SLE complications in babies: complete heart block and learning disabilities
Risk of neonatal lupus in subsequent pregnancy is 17%
Fetal bradycardia should be investigated looking for maternal Anti Ro antibodies as mothers may be asymptomatic or may develop lupus later
All suspected neonates should have an ECG as CHB recquires permanent pacing
Subsequent pregnancies have more risk of neonatal lupus
Lupus flares are seen in all trimesters
In mild to moderate lupus, 40% show no change, 40% flare and 20% improve
Flares are more common when disease is active at conception
Renal flares are most feared Postpartum flares are common as beneficial
effect of steroid produced by placenta wears off The pattern of the diseases activity is usually
repeated in subsequent pregnancies
Musculoskeletal and cutaneous flares are common and easier to manage by increasing the dose of prednisolone
IV Methylprednisolone may be required for severe flares
Use or continuation of Azathioprine is allowed
HCQ not to be discontinued as it is seen to cause flares
Low, but higher than general population Lupus related deaths are due to
HELLP Syndrome Thromboembolism associated with APS Pulmonary hypertension Infection following severe lupus flare
Chloasma or malar rash
Proteinuria of pre-eclampsia or worsening lupus nephritis
Thrombocytopenia in pregnancy (HELLP) or that of lupus exacerbation
oedema and fluid accumulation in joints in late pregnancy or arthritis of SLE
Prenatal counseling Frequent antenatal check up Monitoring of disease activity-CBC, monthly urine
analysis, monthly complements Fetal surveillance by frequent ultrasound
Patients may need anticoagulation Combined care: Rheumatologist, Obstretitian and
Nephrologist if required
Lupus patients are normally fertile Lupus pregnancies are successful two thirds of
the time Mild to moderate lupus does quite well in
pregnancy
Steroids are safe for exacerbation of lupus in pregnancy
Hydroxychloroquine should not be stopped in pregnancy