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.2001157-165.

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.2001157-165.

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.2001157-165.

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.2001157-165.

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.2001157-165.

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.2001157-165.