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MRCOG PART 2 SBAs and EMQs

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Essay 288 - SLE

SLE Posted by NAZIA H.

 

SLE

 

A)     The patient is asked about duration of her SLE and the clinical manifestations like malar rash, symmetrical polyarthritis, urine problems, previous history of venous thromboembolism, respiratory symptoms and any cardiac problem, any history of seizures or migraine. She is asked about medication she’s taking because some medication such as NSAID and warfarin needs to be discontinued during pregnancy, patient is assessed whether the disease is in remission or relapsing phase as there is increase risk of miscarriage and pregnancy complications if in relapsing phase. She is counselled about increase risk of foetal growth retardation, preterm birth and still birth during this pregnancy. Her antibodies level may remain unaltered but she can have an acute flare of SLE during this pregnancy. Routine antenatal investigations like blood grouping, Rh factor, Hb, BSR, urine examination, HIV/HCV, syphilis status  is assessed and viability scan is advised.

 

B)     Full blood count for haemoglobin, platelets as SLE is associated with anaemia, thrombocytopenia, and leucopoenia. Antiphospholipid antibodies are checked by assessing anticardiolipin antibodies and lupus anti coagulant because the increase level are associated with adverse pregnancy outcome. Anti Ro antibodies are checked, as these are associated with congenital heart block in the foetus or neonate. This needs regular monitoring and treatment by cardiac scan of the foetus and treatment in the neonatal period. Liver function test, clotting profile (PT, APTT) are checked as anti phospholipid syndrome is a form of acquired thrombophilia. Renal assessment with renal function tests like serum urea, creatinine is done. Urine for protein urea RBC, RBC casts is checked, as pregnancy can be associated with renal flare.

 

C)     To optimise the maternal and perinatal outcome the patient should be offered multidisciplinary care involving obstetrician, physician, anaesthetist, neonatologist and midwife. She is started on aspirin daily during pregnancy and upto 36 weeks. Low molecular weight heparin in prophylactic dose during the antenatal period and discontinued up to the labour starting and is discontinued in the peripartum period. LMWH is given to optimise the foetal outcome as the RCOG guideline recommend it although there is growing evidence that antenatal LMWH in the presence of recurrent miscarriages does not provide additional benefit. She is monitored for early onset preeclampsia with blood pressure monitoring and urine for protein. SLE is associated with vascular thromboembolism, which can be arterial, arteriolar or venous and can be at unusual sites like retinal artery or axillary vain. She should be monitored for the signs of VTE like pulmonary embolism, stroke or DVT. She is offered anomaly scan at 18-20 weeks and foetal cardiac scan at 22 weeks for the foetal cardiac status. She is offered serial foetal growth monitoring scans 4 weekly for 28 weeks to 36 weeks, as there is a risk of IUGR. Delivery plan depends upon individual clinical assessment and agreed between woman and obstetrician. Patient should be assessed before deliver by anaesthetist as she is taking LMWH, which should be discontinued in the peripartum 

Essay 288 - SLE Posted by k H.

A) history taking from the woman as well as reviewing her notes regarding disease control and the last episode of flare since a flare in the 6 month preceeding pregnancy is associated with more complications.reviewing her medications,azathioprine and steroids do not need to be stopped, ACEI and ARBs for hypertension need to be replaced by oral labetalol,if on anticoagulation by warfarin,it should be substituted by LMWH for the rest of the pregnancy.assessing disease complications,pulmonary hypertension is associated with high mortality rate that should be discussed and TOP offered,though unlikely to be accepted by the woman.hypertension will further increase the risk of PET,previous VTE will need anticoagulation by LMWH for the rest of the pregnancy.assessment of associated comorbidities since SLE is commonly associated with other autoimmune disorders and their severity and degree of control and medications that might need adjustment in liase with physicians.general examination for BMI, blood pressure and proteinurea for baseline levels.cardiovascular examination for pulmonary hypertension.abdominal examination and pelvic examination are unlikely to be relevant.

B) A FBC for anaemia and thrombocytopenia frequently associated with SLE.coagulation profile if already on anticoagulation to assess control.base line renal functions and 24 hour urinary protein to help differentiate a flare up of the disease from PET later on in pregnancy and monitoring for lupus nephritis.base line liver functions to monitor for PET later in pregnancy.echocardiography should be arranged for excluding or assessing pulmonary hypertension.anti RO/LA antibodies should be checked as these are associated with increased risk of congenital hear block and neonatal cutaneous lupus.anti RBC autoantibodies should be checked as if present blood should be cross matched during labour.levels of C3,C4,Anti DNA and ANA should be checked to provide a baseline that can be used to differentiate a flare up of the disease from PET.

C) care will be under a MDT formed of an obstetrician,experienced midwife,physician,haematologist and possible input from cardiologists and later on involving neonatologists and aneasthetists.maternal monitoring for the increased risk of PET by checking blood pressure and proteinurea at each antenatal visit,as well as adding aspirin 75 mg daily from 12 weeks untill delivery.increased risk of VTE can be minimised by starting LMWH thromboprophylaxis as soon as possible if not already on it which will also help to minimise the risk of miscarriage.monitoring renal functions to early detect flare ups and measuring C3,C4,ANA and anti DNA antibodies to differentiate exacerbations from PET.fetal monitoring for increased risk of IUGR by referring the woman for uterine artery doppler at 20 weeks and serial growth scane,liquor volume and umbilical artery dopplers from 26-28 weeks.the prescence of anti RO/LA antibodies indicate refrral for fetal echo at 20 weeks and again at 28 weeks if normal to detect heart block.the risk of spontaneous and iatrogenic preterm labour is increased regardless of disease control indicating administration of antenatal steroids considered from 32 weeks or earlier if indicated.delivery should be in a consultant led unit with facilities for emergency delivery and blood transfusion and neonatal care.timing of delivery should be individualised however a planned delivery at 39 weeks is approperiate.aiming at vaginal delivery unless ceasaren section for obstetric reasons.continous fetal monitoring in labour.blood should be cross matched if anti RBC antibodies detected antenataly.neonatologist should examine the baby once delivered for evidence of heart block.postpartum thromboprophylaxis for at least 6 weeks by LMWH or warfarin.monitoring blood pressure and switching back to prepregnancy medications as well as monitoring renal functions and proteinurea for the increased risk of exacerbations in the puerperium.

SLE Posted by Julie A.

a)      Detailed history regarding the severity of the disease should be asked.Symptoms of SLE such as rash, arthritis ,oral ulcers,haematuria ,headaches ,seizures ,stroke, fatigue,myalgia,loss of weight should be elicited.Time of last flare up ,history of VTE, renal disease and family history of  the disease also should be asked.Details of medication history  includes intake of any warfarin, immunosuppressives such as cyclophosphamide, methotrexate,azathioprine and mycophenolate .Pregnancy symptoms such as nausea and vomiting  should be elicited because of the risk of reduced absorption of drugs and flare up in the pregnancy.

Clinical examination includes general examination to look for pallor,rash,joint swelling and tenderness .Measure BMI  and examination of   chest and cardiovascular system for signs of pleuritis and pericarditis. Blood Pressure  and urine protein to look for preeclampsia and lupus nephritis.

b)      Check full blood count as SLE can cause  haemolytic  anaemia,leucopenia,lymphopenia and thrombocytopenia.Check  serum urea and creatinine by doing renal function tests as SLE can cause lupus nephritis. Also check GFR ,Urine PCR,urine dipstick,MSU  for  RBC casts to look for any evidence of proteinuria and renal failure.If thrombocytopenia is present,check for LFTs and coagulation profile.

  Confirm the presence of antphospholipid antibodies by checking anticardiolipin and lupus anticoagulant.Check for  other antibodies such as anto-R0 , Anti-La antibodies which is present in 3% of patients with SLE and  associated with risk of congenital heart block due to  neonatal lupus.Also check anti-dsDNA antibodies which will be elevated in patients with SLE  and Complements c3 and c4 which are markedly reduced.

C)She should be booked under multidisciplinary care with input from obstetrician,renal physician,haematologist and rheumatologist.Manage her with lowest dose of immunosuppressive as it can cause teratogenicity.Look for any signs of flare ups as it is more common in first and second trimester.Treat any nausea and vomiting in first trimester because decreased absorption of drug is associated with flareups.As she has antiphospolipid syndrome , start her on prophylactic LMWH and low dose asprin until delivery with omitting dose of LMWH heparin  prior to labour.Monthly check FBC and at the end of each trimester check Anti phospholipid antibodies ,Anti ds DNA ,GFR,Urine PCR ,Complements c3 and c4.. Correct anaemia and start her on folic acid until delivery if not already on.Arrange dating scan and detailed anomaly scan .If Anti R0 and Anti La antibodies positive auscultate for fetal heart from 16 weeks onwards and fetal  cardiac scan at 20-22weeks as risk of congenital heart block due to neonatal lupus. Serial growth scans and echo to detect heart block at an early stage.

Antenatal clinic appointment every 2-4 wks until 28 weeks of gestation ,every 2 weeks from 28 to 36 weeks and then weekly until delivery. Pregnancy with SLE is associated with increased risk of preeclampsia,UTI,gestational diabetes and VTE .Check BPand urine protein to rule out preeclampsia during every visit.MSU should be sent every visit to screen for urinary infections.Arrange oral GTT at 24-28 weeks  to screen for gestational diabetes.Assess VTE risk during each appointment.If thrombocytopenia antenatally, anaesthetic review should be offered to make plans during labour. Aim for vaginal delivery and Caesarean section for fetal indications.Timing of delivery depends on fetal growth and development of maternal and fetal complications.

Posted by SARADA C.

 

 

(a) Discuss your clinical assessment [7 marks].

History is taken if she had previous thromboembolism. Details of previous pregnancies and their outcomes should be asked. Her case notes should be reviewed for the details.

She should be asked about any joint pains and skin rash and their severity.

History of cough, chest pain points to cardio respiratory involvement. 

Enquiry is made about haematuria which indicates renal disease. Enquiry is made about mood disturbances and behavioural problems as SLE is associated with psychosis. 

She should be asked about the medication she has been using and side effects are noted. 

Examination is performed to assess BP and BMI.

cardiovascular and respiratory examination is done to exclude abnormalities like pleural and pericardial rub .

 

b) Justify the additional investigations you would undertake at this visit [6 marks]

 

Urine dipstick and protein: creatinine ratio to screen for protienuria as she is at risk of developing pre eclampsia. Renal function tests are done to exclude renal involvement. 

Chest X ray and lung function tests are performed to rule out lung involvement.

Echocardiography is done to identify complications like pulmonary hypertension, cardiomyopathy and pericarditis. 

Anitibodies should be assessed which include anti ds DNa, anti La/Ro anti bodies and anticardiolipin antibodies. Anti ds DNA is associated with lupus nephritis and flare. Anti La/ Ro antibodies are associated with congenital heart block,. Complement levels are done as flares are associated with raised ant ds DNA antibodies and low c3 and c4  levels.

 

C) Her pregnancy is considered as high risk.  should be managed under multidisciplinary team including obstetricians, physicians and haematologist.

 

  Frequent antenatal visits are required i.e  every 2-4 weeks till 28 weeks and 1-2 weeks till 36 weeks  then weekly until delivery as she is at risk of developing hypertensive disorders and IUGR.

Medication should be reviewed.  Low dose of immunosuppressants should be given. Azathiaprine is safe during pregnancy , Mycophenolate Mofitel and methotrexate are teratogenic so contraindicated. If she has been using hydroxychloroquine, should be continued sincee stopping may precipitate flare. 

Baseline values of FBC, U&E, serum creatinine, anti DNA and complement titres should be established and serial measurements (monthly FBC and three monthly GFR and urinary PCR, anti ds DNA antibodies complement levels )   are recommended according to the disease severity . 

She is at risk of developing flare in pregnancy. It is difficult to differentiate normal pregnancy symptoms and relapse.Flares should be actively managed .  Corticosteroids are the drug of choice. 

She is at increased risk of thromboembolism and LMWH heparin prophylaxis should be given according to the risk assessment. 

She is at increased risk of preeclamplsia , blood pressure recording should be done along with screening for proteinuria at each visit. Uterine artery doppler should be started at 20 weeks which should be repeated every 4 weeks if normal. Raised pulsatility index and diastolic notching are associated with increased risk of developing preeclampsia. 

 

Prophylactic dosages of low molecular weight heparin anda low dose aspirin are  associated with increased live birth rate. 

The fetus is at the risk of developing congenital heart block at 18 - 28 weeks, fetal heart reate should be monitored and recorded at each visit.  Fetal echocardiography made at 18-20 weeks and at 28 weeks gestation. . As there is increased risk of fetal growth restriction, and fetal hydrops, serial growth scans are required

 

Posted by deva priya dhar M.

a,This is a high risk pregnancy and assessment should be done by multidisciplinary team involving obstetrician, physician,haematologist.A detail history should be taken regarding symptoms to assess the disease severity. history of thromboembolism in the past and whether she is on warfarin therapy should be asked.any history of lupus nephritis and whether she is in remision should be assessed.Drugs for immunosuppression and antihypertensives like angiotension converting enzyme inhibitors, angiotension receptor blocking agents should be reviewed. bp/ bmi/should be checked.cardiac,  respiratory and renal functions assessed.

b/ investigations should be fbc to detect anaemia,thrombocytopenia,leucopenia..urinalysis for proteinuria and casts , bloodcells .renal function tests and liver function tests should be done to know the disease severity and as a baseline for further monitoring / anti ro / anti La antibodies should be checked. anti ds dna levels and c3 c4 levels measured.

A scan should be done to determine viability and gestational age

c, Management in this pregnancy by multidisciplinary team approach and sensitively.there is increased risk of miscarriage, stillbirth, preterm delivery,fgr.Increased risk of pre eclampsia. gestational diabetes,venous thrombolism.drugs which are teratogenic like cyclophophomide, ace inhibitors and arbs should be stopped. if on warfarin should be changed to low molecular weight heparin. bec of pre rec miscarriages , advisable to start aspirin 75 mg and LMWh and continued throughout preganacy.folic acid 5mg should be given. uterine artery doppler at 18-20wks, fetal echocardiography at 24 and at 28 weeks if anti ro anti la antibodies present.fetal growth scan every 2-3  weeks from 24 wks since there is a high risk of IUGR.Blood pressure monitoring and urinalysis should be done at each antenatal visit to identify early development of PE.  Fetal surveilane should  be initiated from 30-32 weeks.Delivery should be planned if any disease severity  or fetal compromise

 

 

Posted by LY Y.

A 33 year old nulliparous woman attends the antenatal clinic at 8 weeks gestation. She is known to have SLE with positive anti-phospholipid antibodies and three previous first trimester miscarriages. (a) Discuss your clinical assessment [7 marks]. (b) Justify the additional investigations you would undertake at this visit [6 marks]. (c) Assuming there are no additional complications, discuss the antenatal interventions to monitor maternal disease and optimise perinatal outcome [7 marks]

 

a)

I would take a history regarding her lupus disease status, including when it was diagnosed, her current symptoms, when last flare was, and also assess for  complications such as hypertension, renal impairment and other organ involvement. Active SLE and SLE with organ involvement are associated with greater maternal and fetal risks. I would also review the medication she has been taking for her lupus to ensure that teratogenic medications such as methotrexate have been stopped. 

Her history suggests obstetric anti-phospholipid syndrome. I would ask her when the miscarriages occured as well as the results of other investigations such as thrombophilia screen, karyotyping and ultrasound scan done as part of the work up for recurrent miscarriage. I would ask to review her laboratory results for the titre of antiphospholipid antibodies to confirm the diagnosis of APS. 

I would ask if she has any personal or family history of thromboembolic events such as deep vein thrombosis.  

I would ask about her current pregnancy, including whether she is on folic acid and whether she has had a dating scan. I would also enquire about her past medical history and social history, paying particular attention to other risk factors for pre-eclampsia and growth restriction, such as family history of pre-eclampsia. 

I would do a physical examination, focusing particularly on her blood pressure, BMI and urine dipstick. I would also look out for signs of pericarditis and pleuritis, as well as malar rash and joint involvement which might suggest active disease. 

b) I would do a full blood count to look for anaemia and thrombocytopenia. SLE is associated with  thrombocytopenia due to APS and immune thrombocytopenia, so a baseline level would be helpful. Haemoglobin level would help to guide need for iron supplementation or screening for other haemoglobinopathies.

I would assess her renal function, particularly her creatinine levels, and do a 24 hour urine total protein to evaluate the degree of proteinuriaas.  Renal function may deteriorate in pregnancy and poor renal function and proteinuria are associated with higher risk of developing pre-eclampsia. I would also screen for the presence of haematuria. 

i would check her antibody profile. Presence of anti-Ro/La antibodies are associated with a 2% risk of neonatal heart block and 5% risk of neonatal cutaneous lupus. She would need to be counselled regarding these risks, and undergo fetal surveillance from 18 weeks for fetal heart block. I would also check her lupus anticoagulant and anti-cardiolipin antibody levels. Double stranded DNA (dsDNA) and C3/C4 levels to establish a baseline, which will be useful for assessing disease activity when a flare is suspected. 

If she is known to have lupus complicated by organ involvement, or if there is a cardiac murmur or lung crepitations on examination, I would advise an echocardiogram to evaluae cardiac function and pulmonary hypertension, and also consider a chest XR with fetal shielding. I would also do a dating ultrasound scan if this has not been done, as early dating is important for subsequent assessment of fetal growth. 

c) Assuming there are no additional complications, discuss the antenatal interventions to monitor maternal disease and optimise perinatal outcome [7 marks]

Due to her APS, she is at risk of a recurrent miscarriage, pre-eclampsia, fetal growth restriction and thrombosis. I would start daily subcutaneous low molecular weight heparin as well as aspirin as soon as possible and before 12 weeks, as these have been shown to reduce the risk of miscarriage and development of pre-eclampsia. Aspirin & LMWH medications may be continued until delivery, although LMWH would have to be stopped once she has symptoms of labour or before a planned Caesarean section for obstetric indications. 
 
Teratogenic medications like methotrexate & cyclophosphamide should be stopped. Azathioprine, steroids, sulfasalazine and hydroxychloroquine may be continued.
 
The patient should be closely followed up in a high risk clinic with a multi-disclipinary team consisting of rheumatologists, obstetricians experienced in management of lupus and specialist midwives. She should be given written information on the role of aspirin and LMWH, educated on how to dispose of needles, and provided with adequate support. At each visit, her blood pressure and urine dipstick should be checked to screen for pre-eclampsia and she should be asked about joint pain and other symptoms of disease flare. Flares may be treated with steroids and titration of medications. She should have an OGTT done at 28 weeks to screen for GDM. Flares may be hard to differentiate from pregnancy complications e.g. proteinuria may be due to pre-eclampsia or lupus nephritis. Lowered complement levels and rise in dsDNA, haemturia and casts suggest a flare, but the advice of a rheumatologist should be sought. 
 
Ultrasound to screen for fetal heart block should be done at 18 and 28 weeks, and the fetal heart rate should be monitored each visit. If fetal heart block is detected, she should be referred to a fetal medicine specialist. She should also have serial ultrasound scans for growth and umbilical artery doppler from 28 weeks to monitor for IUGR. 
 
  

 

 

SLE Posted by J K.

a) Duration and control of SLE is important as a flare within 6 months of conception is associated with increased maternal morbidity and perinatal morbidity. It is important she has been in remission in the past 6 months. Her current condition is assessed to ensure she is in remission. I will ascertain her current medications use as medications such as mycophenolate mofetil is associated with abnormal fetus. Hydroxychoroquine and Azathioprine can safely be used in pregnancy. I will ascertian if she has other complications such as hypertension, diabetes, lupus nephritis and cerebral lupus as all these conditions can worsen during pregnancy. Previous history of venousthromboembolism will be enquired as she has increased risk of VTE in current pregnancy. On exaination, blood pressure will be taken as baseline and pre-eclempsia in her. A full neurological assessment including funduscopy will be carried out if she has lupus nephritis.

 

b) A baseline full blood count is important as SLE is associated with thrombocytopenia. A coagulation profile will be required if thrombocytopenia is present. As she is at risk of worsening renal function, a baseline urea, electrolytes and creatinine will be taken. A baseline liver function test should be taken before medications such as heparin is started. If not known, antiRo and antial should be taken as presence of antiRo is associated with neonatal heart block. Urine analysis is staken to look for prsence of proteinuria, this can be achieved yb urine protein creatiinne ratio or 24 hour urinary protein as she is at risk of developing pre-eclempsia.

 

c) It is important that she is taken care by a multidisciplinary team involving physician specializing in SLE, obstetrician with interest in SLE, specialist midwife and hematologist. She will require more frequent follow up to assess complications of SLE such as pre-eclempsia, pregnancy induced hypertension. Blood pressure and proteinuria will be checked at each antenatal visit to detect progression of disease. SHe will require dating scan as usual as well as anomaly scan at 18-20 weeks with fetal echocardiography to look for neonatal heart block whcih can be treated with maternal steroids. She will also need regular growth scans as her fetus is at risk of intrauterine growth restriction due to SLE. Aspirin and low molecular weight heparin should be started to improve live birth rates compared to aspirin alone. as well as for thromboprophylaxis. Her SLE medications such as Hydroxychloroquine and Azathioprine should be continued and she will be reassured that safety in pregnancy is not an issue. If total heart block is detected, the paediatrician involved should be alerted as the baby may need pacing upon delivery.

Posted by Meeta C.

a) A detailed history should be taken of the disease, including the duration, severity and type of disease (renal or skin). History of malar, discoid rash or photosensitivity to be taken. Renal involvement in the form of hypertension or proteinuria should also be taken. The timing of the last flare to also be noted. Pregnancies associated with an increased risk of SLE flare and are difficult to diagnose. General symptoms of fatigue, hair fall are enquired about. Drug history is also taken, steroids can be continued throughout pregnancy and are important to treat flare. Hydroxychloroquine is also continued, so is azathoprine, as these are safe and withdrawal may precipitate a flare. If on ACE inhibitors for hypertension, it should be changed to labetalol. NSAIDs to be continued too. History is also taken of VTE and whether she is on anticoagulant therapy and if on warfarin, it should be changed to LMWH. Examination would include BP check, respiratory and CVS examination, oedema, pallor & bleeding tendencies to be looked for. Investigations would include routine FBC, urine for proteinurea, serum urea and creatinime. A viability scan is also done.

b) Additional investigations would include, urine examinations for RBC and red cell casts to rule out renal lupus flare. A 24 hour urine protein, more than 500mg per day would denote renal involvement. A falling level of complement (C3 & C4) denotes active disease as does rise in anti-DNA titre. Anti-RO and anti- La antibodies are checked as they may cause heart block in the fetus and if found would warrant fetal cardiology screening. Base line LFT (specially transminases) are done so as to differentiate a lupus flare from preeclampsia later on in pregnancy.

c) Antenatal interventions to monitor maternal disease would be a consultant lead unit with input from a rheumatologist & specialist nurse. These women are prone to miscarriages, fetal growth restriction, still birth, pre-term labour, preclampsia and placental abruption. Low dose aspirin is started and continued till delivery. LMWH prophylactic dose is started as early as possible, if there is no past history of thrombosis. With a past history of Thrombosis, if she is on warfarin, it should be discontinued and LMWH should be started. Anomaly scan may reveal abnormal uterine artery doppler studies and the need to have fetal size assessment and umblical artery doppler studies from 26-28 weeks, every two weeks. Serial growth scans and tests for fetal well-being are also done. In case of a severely growth restricted fetus with absent or reversed diastolic flow, a caesarean section is recommended. If doppler studies are normal, caesarean section is for obstetric reasons. The neonate is assessed by a neonatologist, if there are signs of cutaneous neonatal lupus, which may happen in 5% of babies born to women with anti-RO antibodies, 1 to 2 % babies may have congenital heart block. Post partum thromboprophylaxis is for 6 weeks. She can be reverted back to warfarin as it is safe during breast feeding.   

SLE Posted by farzana S.

Detailed history is taken about the frequency of flares.Good pregnanacy outcome is expected if she has been in remission for 3-6months  before conception.

She should be enquired about  renal disease as it  will increase her risk of pregnancy loss, hypertension and preeclampsia .

Obstetric history is taken regarding her parity,whether the miscarriages are consecutive or there  are any live births in between the miscarriages.Presense of Antiphospho lipid antibodies  with three consecutive miscarriages is charecterisic of antiphospholipid syndrome,and she  is at high risk of miscarriage  ,pre eclamsia ,low birth weight and preterm birth.

Drug history is taken .corticosteroids,azathioprine and hydroxychloroquine may be continued in pregnancy.NSAIDS  can also be used in first and second trimester.Methotrexate,mycophenolate mofetil are teratogenic ,hence contraindicated.If she is using warfarin anticoagulant ,it should be changed to LMWH.Anihypertensives may need to be changed to safer drugs such as methyldopa or labetalol.

On examination BMI is noted and BP checked.Respiratory and cardiovascular examination  to detect any manifestations of SLE.

b)Baseline investigations  are done ,which will help monitor disease progression.

FBC for anemia and thrombocytopenia.This should be repeated every month.

Renal function tests ,urea&electrolytes. Creatinine  clearance,24 hr urine protein,plasma protein, calcium phosphate are LFTs are done.These are repeated every trimester.

Antibodies screening ,such as anti-La, anti Ro  is done.Presense of anti Ro antibodies is associated with congenital heart block.  Anti ds DNA antibodies  levels  and  complment C3and C4 done to monitor disease activity.

Early scan for dating and viability is done..

c)She should  have multidisciplinary  hospital care with physician/hematologist and obstetrician and specialist mid wife..

She should have antenatal visits every 2-3 weeks ,and close follow up for signs of  SLE flare.SLE flare is treated by steroids. BP is checked  and  urinalysis done in every visit, for early detection of pre eclamsia and any infection.With h/o recurrent miscarriage and positive  anti phospholipid antibodies she should be started on  Aspirin and LMWH,which will increase live birth rate to 70%.

If she has h/o VTE,thromboprophylaxis should be given during both antenatal and 6 weeks post natal.

Uterine artery Doppler is done from 20-24weeks ,abnormal dopplers will require close surveillance for development of preeclampsia.cardiac scan is done at 22-24  to look for congenital heart block ,which occurs  with positive anti Ro antibodies.Growth scans are done every 4weeks for early detection of  IUGR.From 36wks ,she should be followed up every week.

She should be  advised to deliver in consultant led unit. Vaginal delivery should be aim.CS is for obstetric indications .Neonatologist should be informed.

Posted by Shane K.

 

 

a)     The severity and control of her disease should be assessed. Ask about frequency of flares and when last flare occurred. Ask about a history of any renal disease. Ask about what drugs she is on to control her disease. I would explain to her the possible complications of SLE in pregnancy example IUGR , preeclampsia. I would explain that SLE is not usually worsened in pregnancy. Advise that prognosis is usually good. Explain that most immunosuppressant are safe in pregnancy. Explain that other drugs eg methotrexate may be teratogenic. Ask about risk factors for VTE eg. previous VTE etc. Other risk factors for pre-eclampsia should be asked eg. family history. On examination BMI and BP should be done. Cardiovascular and Respiratory exam should be done to check for pleuritic rub or features of pericarditis.

 

b)     FBC to check for anaemia and thrombocytopenia as these are common in  SLE. A RFT should be done to check for renal disease and as a baseline. CRP and ESR ar indicators of severity/control of disease. High levels indicate relapse/ poor control. Urinanalysis should be done and/or spot PCR as baseline. 24hr urine collection for protein should be done as baseline and to check for renal disease. Anti Ro/La antibodies should be checked as these are associated with congenital heart block.

 

c)     She should be managed in a multidisciplinary team with a Rheumatologist, Neonatologist, Haematologist, Consultant Obstetrician. She should have regular / frequent visits to clinic. BP and urinanalysis should be done at each visit to assess for pre-eclampsia. Risk assessment for VTE should be done. I would consider starting LMWH if one other risk factor( eg previous VTE). Assess for other risk factors for pre-eclampsoa. Start ASA 75mg daily if  one more risk factor or if she has renal disease. Serial growth scans should be done from 24wks to detect IUGR. Serial FBC, CRP, ESR should be done (4wkly) to assess control of disease. She should be on lowest dose of drugs/ immunosuppressants  possible to control disease. Drug toxicity levels should be done.

 

 

 

 

 
SLE Posted by vinivee S.

a.) A detailed history to identify the disease activity and duration will be asked.SLE manifestations like malar rash, oral nasopharyngeal ulcers, joint pains, headache, fatigue noted. Any behavioural changes or seizures may suggest psychosis. Presence of haematuria suggests renal involvement. History of venous thromboembolism in the past will be asked. Features like chest pain, shortness of breath, cough points towards respiratory and cardiac involvement. Ask about pregnancy symptoms like nausea, vomiting that may cause decreased absorption of her SLE medication predisposing flare up of the disease.

Details of her previous pregnancy outcomes will be asked and verified from her notes.

Enquiry will be made regarding her medications as drugs like warfarin, cyclophoshamide,mycophenolate ACE inhibitors should be stopped.

Clinical examination will be done to note BP, BMI.Look for pallor, rash and joint swellings. Cardiovascular and respiratory systems examined for signs of pleurisy or pericardites.Urinalysis for proteins and routine antenatal screening advised.

 She will be counselled regarding the increased risk of miscarriage, foetal growth restriction, preterm delivery and flare up of the disease. Rarely TOP maybe considered in the presence of uncontrolled hypertension and worsening renal condition despite optimal therapy.

 

b.)I will do a FBC to note anaemia,leucopenia and thrombocytopenia as there is increased association in SLE.Urine dipstick and protein creatinine ratio for proteinuria since the risk of developing preeclampsia.

Renal function tests, GFR to be assessed for lupus nephritis. Total daily proteins if more than 0.5g/day and haematuria may further suggest the condition. Coagulation screen and LFT to be done in the presence of thrombocytopenia.

Check for antiphospholipid lupus anticoagulant and anticardiolipin antibodies which are associated in 30% of SLE cases. Check Anti ro / Anti La Antibodies as increased levels associated with congenital heart block and cutaneous lupus syndrome.

I will also do Anti dsDNA antibodies as increased levels with low levels of Complement C3, C4 present in flare up of SLE .Chest X-Ray with shielding for pulmonary status and ECHO to evaluate cardiac complications like cardiomyopathy, pulmonary hypertension and pericarditis.

I will do a dating scan to note foetal viability, maturity, chorionicity and to correlate future growth assessment.

 

c.)Being a high risk pregnancy she will be managed by a multidisciplinary team consisting of senior obstetrician, rheumatologist, renal physician and haematologist.

She will be advised more frequent antenatal visits every 2-4 weeks till 28 weeks,1-2 weekly until 36 weeks and weekly thereafter till delivery to screen for Hypertension and IUGR.

The lowest effective dose of immunosuppressive medication will be used. Drugs like Cyclophosphamide, Mycophenolate, Methotrexate are terratogenic and will be discontinued.Azathioprine, Hydroxychloroquine are safe in pregnancy and can be continued. She will be counselled regarding foetal and maternal consequences of drug therapy.

She will be started on low dose Aspirin and Low molecular weight Heparin depending on her risk assessment for antiphospholipid syndrome and increased risk of miscarriage, preterm labour and preeclampsia. This treatment is associated with increased live birth rate and can be continued till delivery.

At every antenatal visit, BP and Urinalysis is done to screen for preeclampsia.

Monthly FBC will be done.Antiphospholipid and Anti ds DNA antibodies, GFR, Urine PCR, and Compliment C3 C4 will be checked at the end of every trimester to assess disease activity and flare up. Corticosteroids are indicated for the management of flare-ups along with titration of other medicines.

Uterine Artery Doppler will be offered at 20 weeks to be repeated every 4 weeks if normal. Serial growth scans and Umbilical artery Doppler will be done to monitor foetal growth restriction and hydrops foetalis. Foetal Echo scan will be done at 18-20 weeks to detect heart block at an early stage, to be repeated at 28 weeks with early referral to foetal medicine unit in case of abnormal scans.

Timing of delivery will depend on foetal growth and development of foetal or maternal complications.Vaginal delivery is the aim in a consultant led unit with Caesarean section done for obstetric reasons. Neonatologist should be present at delivery

 

 

 

 

 

 

Posted by drpadmaja V.

A)

I would elicit any history of  joint pain & swelling, fatigue , malar rash which could suggest any flare of SLE . History of flares in the past enquired.

Obstetric history taken in detail regarding any live births, previous miscarriage details & would review details.

History of any drug intake for SLE  like azathiaprine , mycophenolate mofetil, steroids.

I would elicit any past  history of thrombosis , any long term medications she is on like warfarin.

History of difficulty in breathing , chest pain which could suggest other system involvement.

Clinical assessment done for pallor, weight, BMI, malar rash .

General examination for any joint swelling, edema, redness , oral ulcers, and  neurological status assessed.  Cardiovascular assessment  done by checking  blood pressure ,pulse , presence of any murmurs or pleural rub.

B)

I  would do a full blood count to rule out anemia, thrombocytopenia and  neutropenia.

Investigations to assess disease activity like ESR and complement levels,  ds DNA , as raised ESR and falling third & fourth complement levels may indicate active disease.

Anti Ro /La antibodies  to assess fetal risk.

Urine routine  for proteinuria and  protein /creatinine ratio for quantification if proteinuria  present , presence of red cell casts, cellular casts to detect renal involvement. Base line renal function tests like serum creatinine  & urea done.

Ultrasound done for fetal assessment for viability and accurate dating as she is high risk  for preterm , IUGR & previous three miscarriage.

C)

SLE with APLA is considered high risk group, hence management needs expertise with multidisciplinary involvement of haematologist, rheumatologist, consultant obstetrician ,midwife to optimise her care .

Her disease activity is assessed clinically and monitoring done in early pregnancy to establish baseline FBC, renal function tests, uric acid, liver functions, ds DNA ,complement titres and quantify proteinuria. Serial measurements at intervals done depending on disease activity.

 

Review of the drugs she in currently on and change of medications done in liason with rheumatogist. Mycophenolate mofetil  is teratogenic , so prudent to avoid in pregnancy. Hydroy chloroquine and azathiaprine are safe to use in pregnancy hence patients on hydroxy chloroquine are adviced to continue with it as discontinuation may precipitate flare.

Regular antenatal checks of blood pressure, proteinuria, symphysiofundal height measurements, signs and symptoms of DVT and history suggestive of any exacerbation of SLE symptoms enquired. Flares may be difficult to diagnose in pregnancy as many features like hairloss, edema, palmar erythema, fatigue , anemia may also occur in normal pregnancy, therefore requires a high degree of suspicion

 Simple analgesics like paracetamol is used as first as first line to control symptoms of arthritis and step up to Corticosteroids if symptom control insufficient.  Women on steroids should be screened for gestational diabetes and are  at increased risk of preterm delivery. NSAIDs are avoided in third trimester as they are associated with oligoamnios & premature closure of ductus arteriosis. Corticosteroids are  used as the drug of choice for treating disease flares.

Preeclampsia & SLE flare needs to be differentiated as both present similarly with hypertension & proteinuria.  Hypocomplimentemia, redcell casts & raised ds DNA points towards lupus nephritis , whereas raised uric acid & abnormal liver functions points towards preeclampsia.

Folic acid 400mcg every day till 12 weeks, Low dose aspirin 75mg /day & Low molecular weight heparin prophylactic dose started as soon as possible in early pregnancy as it has shown to reduce pregnancy loss and  increase live birth rate to 70% in women with APLA & fetal loss .

Fetal monitoring by dating scan at 10weeks, combined tests at 11-14 weeks. Anomaly scan & Uterine artery dopplers  done at 20-24 weeks to detect diastolic notching .   Fetal echo done at 20 & 28 weeks if Anti Ro/La antibodies are positive.

Serial growth scans and umbilical artery Doppler from 24 weeks every 4 weeks as she is at high risk for IUGR. Intensive monitoring required to allow timely delivery which will improve fetal outcome.

If lupus flare & preeclampsia cannot be differentiated & the fetus is viable beyond 24-28weeks delivery after corticosteroids for lung maturity may be the most  appropriate course if the mother or fetus is at  risk.

.

 

SLE essay Posted by Francina S.

 

A) History needs to include what manifestations of the disease, other that recurrent miscarriage, the patient has, what treatment she is taking and when she had her last flare of active disease. Particular risk factors are pre-existing renal, current or recent flare (within the last 6 months) as these increase her liklihood of worsening of disease or flare in this pregnancy. Identification of the risks associated with her current treatment is important although most medications commonly used in the treatment of SLE can be continued in pregnancy, e.g. steroids or hydroxychloroquine. If she has a past history of deep vein thrombosis or pulmonary embolus she may require a higher dose of low molecular weight heparin. We need to find out whether she is known to have anti-La or anti-Ro antibodies as these are associated with neonatal lupus in the fetus and congenital heart block. Some current treatments may need to be changed e.g. warfarin, monoclonal antibodies or ACE-inhibitors as these are contraindicated in pregnancy. Appropriate alternative treatment will need to be instigated. Rarely termination may need to be considered due to use of teratogenic medication in early pregnancy.

 

B) Routine examination includes blood pressure measurement and urinalysis to identify any baseline hypertension or renal disease. I would request base-line blood tests for renal funcion, liver function and a full blood count as this lady is at increased risk of developing pre-eclampsia but may already have some underlying reduced renal function, which will further increase her risk. I would consider measuring calcium levels, particularly if this patient is high risk for hypocalcaemia (e.g. dark skin colour, wears head covering etc.) as if untreated this increases her risk of pre-eclampsia further. For this reason I would also request a urine protein-creatinine ratio if any proteinuria is found on urinalysis. Urine should also be sent for microscopy to look for casts. Anti-DNA antibody levels and complement titres should also be requested as a baseline to allow comparison if flare occurs during pregnancy. I would also request uterine artery doppler measurement at 20-24 weeks gestation as there is an increased risk of intrauterine growth restriction.

 

C) I would explain to the patient the effects of pregnancy on SLE: risk of worsening of disease or flare in pregnancy (particularly if recent flare or currently active disease), if renal function poor likely to be exacerbated. Also the effects of SLE on the pregnancy: increased risk of raised blood pressure, pre-eclampsia, intrauterine growth restriction, deep vein thrombosis or pulmonary embolus, stillbirth. In addition to all routine antenatal recommendations I recommend 75mg aspirin daily until 36 weeks gestation plus prophylactic dose low molecular weight heparin (e.g. enoxaparin) if the previous early pregnancy losses occurred when taking low dose aspirin. If the patient has a history of DVT/PE or is currently on anticoagulant treatment a higher dose or treatment dose enoxaparin may be required. I would recommend vitamin D supplementation as this is known to reduce the risk of pre-eclampsia is concurrence with increasing calcium levels. Uterine artery dopplers to predict risk of growth restriction from 20-24 weeks. If these are normal then growth scan in the third trimester only, if these are normal then for growth scans at 28, 32 and 36 weeks gestation. The patient will require antenatal care ideally in a specialist or maternal medicine clinic with at least monthly obstetrician and rheumatology review. If the patient has any other systems affected by SLE e.g. renal these will require assessment at these appointments. If this patient requires low molecular dose herapin for recurrent miscarriages while on aspirin it can be stopped at 20 weeks gestation if the uterine artery dopplers are normal. If this patient requires low molecular weight heparin for previous DVT/PE it should be continued until signs of labour or 24 hours before delivery is planned and should be restarted following delivery. Babies of mothers with anti-Ro or anti-La antibodies need to be reviewed by the neonatology team with consideration of ECG to assess for congenital heart block. 

SLE Posted by A H.

 

This patient has SLE complicated by anti phospholipid syndrome.   I would ask if her SLE has been well controlled over the past six months. Conception should take place during a period of quiescent disease, as this is associated with the best outcome. The risk of complications is increased if she had active disease, hypertension and renal lupus at the time of conception. I will enquire of a history of venous thromboembolism. A positive history increases her risk of venous thromboembolism in this pregnancy and puerperium.

I would take a thorough drug history. Methotrexate, cyclophosphamide and mycophenolate are teratogenic and have long half-lives. They should be stopped 3 months prior to conception. Antihypertensive like ARBs and ACE are teratogenic.  They should be stopped as soon as pregnancy is diagnosed. If she is on warfarin, this should be stopped as soon as pregnancy is diagnosed, ideally before 6 weeks, to reduce the risk of warfarin embryopathy.

Mucous membranes will be assessed for anaemia.  I will measure her weight, height and calculate BMI. The blood pressure will be measured. Full cardiovascular and chest examination will be done to identify complications of SLE like pleuritis, pericarditis and pulmonary fibrosis. An examination of the skin and joints will be done.

b) I will do a full blood count to identify anaemia leucopaenia and thrombocytopaena, which are haematological complications of SLE.  Serum urea, creatinine, electrolytes as well as GFR will be done to assess renal function. Creatinine >250μmol/l is associated with worse outcome. A baseline liver function test will be done. This will be used to monitor for pre-eclampsia.  Antibodies to ds DNA, , as well as anti phospholipid antibodies (aCL and LA) and complement levels will be done to assess disease severity. Hypocomplementemia is associated with active disease. The presence of anti-Ro and anti-La antibodies is associated with development of neonatal lupus. Congenital heart block occurs in 2 %, and cutaneous lupus occurs in up to 5% of babies born to mothers with ant-Ro/La antibodies. Urinalysis will be done for protein, red blood cells, RBC casts and PCR to assess for lupus nephritis. An ultrasound will be requested for viability and dating as there is a risk of fetal loss and FGR. An echocardiogram will be done to assess for pulmonary hypertension and cardiac function.

c) A multidisciplinary team consisting of an obstetrician, a specialist midwife and physician specializing in management of SLE in pregnancy will manage the pregnancy in a joint obstetric/connective tissue disease clinic. Drugs, which are teratogenic, will be discontinued and replaced by alternative drugs known to be safe.     Azathioprine and corticosteroids are safe; the lowest effective dose will be used. She will be counseled about the safety of these drugs.

ASA and LMWH will be commenced because of APS; this is shown to reduce the risk of fetal loss, pre-eclampsia, fetal growth restriction and stillbirth. If she is on warfarin, this will be discontinued. She will be commenced on therapeutic dose of LMWH. Dose of LMWH will be calculated according to her booking weight. Close monitoring of blood pressure will be done to detect pre-eclampsia.

Full blood count will be done monthly to assess for any anaemia, neutropaenia and thrombocytopaenia. At the end of each trimester, GFR,  Antiphospolipid antibodies, complement levels and anti ds-DNA antibodies will be done. Uterine artery Doppler will be done at 20-24 weeks to assess her risk of developing FGR. And echocardiogram will be done at 18-20 weeks to detect fetal CHB; if normal, it will be repeated at about 30 weeks. CHB can develop between 18-30 weeks.

Serial ultrasound will be done for growth velocity, liquor volume and umbilical artery Doppler waveform from 24 weeks. Closer monitoring will be necessary if complications or FGR develops.

SLE Posted by Po Yi S.

(a) Discuss your clinical assessment [7 marks].

 

SLE with a poor obstetric history of three previous miscarriages is associated with significant maternal morbidity and perinatal morbidity and mortality.

 

This woman is at risk of developing hypertensive disorders in pregnancy, e.g. pre-eclampsia and pre-term delivery.  Her fetus is at risk of miscarriage, fetal death, fetal growth restriction and congenital heart block.

 

SLE flares in pregnancy are usually mild, can occur at any stage and it is not certain whether the frequency is increased or not.

 

History involves enquiring about her current symptoms (e.g. fatigue, fever not due to infection, arthralgia) as SLE presentation in early pregnancy is associated with poor outcomes.  I would ask if she had any recent SLE flare (within six months prior to conception) as this is associated with SLE flare in pregnancy.

 

I would ask if she is taking medications for her condition (e.g. MTX or cyclophosphamide) as they are teratogenic.  However, it is too late at 8 weeks gestation to affect teratogenicity.

 

Lastly, I would ask if she has pre-existing lupus nephritis or any child who is affected by neonatal lupus as this is associated with poorer maternal and fetal outcomes. 

 

Examination would focus on signs of SLE such as malar rash, discoid rash or oral ulcers.  I would also check her BP and urinalysis for proteinuria.

 

(b) Justify the additional investigations you would undertake at this visit [6 marks].

I would check her BP and perform baseline 24-hour urinary protein as she is at risk of pre-eclampsia. 

 

Urea, electrolytes and creatinine are taken to assess her renal function.  Renal insufficiency (Creatinine > 150micro-mol/L) is associated with poor fetal outcome.  Suspected lupus nephritis would require a renal biopsy which is not recommended in pregnancy.

 

FBC is taken to check for anaemia and leucopenia.

 

Raised anti-double stranded DNA and reduced complement levels associated with SLE flare in pregnancy.

 

I would investigate for presence of anti Ro/La antibodies as a positive test increases the risk of neonatal lupus.

 

(c) Assuming there are no additional complications, discuss the antenatal interventions to monitor maternal disease and optimise perinatal outcome [7 marks]

 

This is a high risk pregnancy and requires the involvement of a multidisciplinary team consisting of an obstetrician, rheumatologist, specialist midwives and GP.

 

Drugs such as ACE inhibitors or ARBs should be replaced by methyldopa (not contraindicated in SLE) for control of hypertension.  NSAIDs should be avoided in early pregnancy but can be used from 12-28 weeks gestation.

 

Anti-ds DNA, complement titres, urinalysis (for haematuria and casts) and 24-hour urinary protein should be performed in each trimester to monitor for SLE flare.

 

SLE flare should be actively treated with prednisolone.   Dose and duration is dependent on severity of flare and whether there is renal involvement.

 

Fetal heart auscultation is required weekly from 16 weeks to screen for fetal complete heart block if anti-Ro and/or La antibodies test positive.  Fetal echocardiography is required if suspected complete heart block.

 

Fetal anomaly scan with uterine artery dopplers (look for notching) should be performed at 18-22 weeks.  Woman should be offered cardiac scan at 22 weeks.

 

She should aim for a vaginal delivery.  Consideration should be given to IM hydrocortisone 100mg 6 hourly if she had taken more than 7.5mg prednisolone for > 2 weeks. 

 

Baby should have ECG if mother has anti-Ro/La antibodies.  Breastfeeding contraindicated if taking MTX.  Discuss effective contraception and emphasise importance of pre-conceptual planning in future pregnancies.

SLE Essay Posted by jessy F.
A)Clinical assessment. Iwill take history to evaluate her current symptom that could denote disease activity as joint swelling and dyspnoea if with cardiac involvement, Her previous obstetric outcome could predict current pregnancy outcome, drug history so if any drug contraindicated during pregnancy changed to safer drug, medical history for medical comorbidity as renal and cardiac. Ex. For height ,weight and BMI, blood pressure as base line to check and monitored preeclampsia. B). Investigation . Full blood count to rule out anaemia and thrombocytopenia, that coud modify her management Renal function for associated lupus nephritis , maternal echo to detect pulmonary hypertension that is contraindications for continuation of pregnancy due to high maternal mortality. Scan for viability of fetus due to high risk of miscarriage , Detect other antibody profile as anti ro and Attila ,antibody that coud led to neonatal lupus and congenital heart disease. MSU to rule out urinary tract infection C). Antenatal management to monitored maternal and optimize neonatal outcome Her pregnancy shoud be dealt as high risk pregnancy need multidisciplinary team including consultant obstetric and physician , with documented plan for her antenatal and intrapartum care, She need to be seen every two weeks in second trimester and weekly in third trimester . Due to associated antiphospholipidAB an history of recurrent miscarriage she shoud started on combination of aspirin and LMWH as this combination. Of treatment increase live birth rate to 70% Folic acid prescribed and her medication modified so drug considered unsafe as methotrexate and mycophenolate moppet ail changed to safer one, She need dating scan and regular growth scan to be started from 28 wk due to high risk of IUGR, Anomaly scan at 20wk and fetal cardiac scan at20-22wk especially if associated anti ro and anti la AB,at20wk maternal uterine artery Doppler study coud predict risk of IUGR through notching. At each visit blood pressure monitored and MSU sent for culture due to high risk of preeclampsia and UTI, If assosociated thrombocytopenia she need anaesthesia re view to plan delivery , vaginal delivery is recommended and Caesarean for obstetric indication
Posted by Sarah L.

a. She should be seen by a multidisciplinery team inluding a maternal medicine obstetrician, rheumatologist and a renal physcian.Take a detailed history of disease activity and complications including symtoms of current relapse such as musculoskeletal, cardiac, pulmonary and cutaneous symptoms. Take a history of venous thromboembolism.  A detailed drug history should be taken to establish what drugs she is taking and the risk of taking them in pregnancy.  Body mass index should be calculated.  Blood pressure should be measured.  Cardiovascular and respiratory examinatio should be performed.

b.Full blood count should be taken to check for haemolytic anaemis, thrombocytopenia and leucopenia.  Assessment of renal function should include serum urea and creatinine, GFR, urinary Protein Creatinine Ratio (PCR) to quantify proteinuria and MSU to check for red cell casts.

Screen for anti-Ro and anti-La antibodies as these are associated with risk of congenital heart block in the fetus and neonatal lupus.

An early scan should be offered as there is an incrased risk of miscarriage.

Complement C3/C4 levels should be taken as they can help to differentiated between an SLE flare and PET, taking a baseline at booking can be used to compare to in later pregnacy.

 

c. Prophylactic LMWH and 75mg aspirin should be offered due to the risk of VTE, FGR and pre-eclampsia.  Monthly FBC should be performed to observe for anaemia and thrombocytopenia.  At the end of every trimester complement C3/4 activity, anti-DSDNA antibodies and anti-phospholipid antibodies should be checked to monitor disease activity.  Renal function should be monitored at the end of every trimester by checking GFR and urinary PCR.

Serial growth scans should be offered at 28, 32 and 36 weeks gestation as there is increased risk of fetal growth restriction.

She should be seen in the antenatal clinic every 2-4 weeks until 28 weeks gestation, 2 weekly until 36 weeks and then weekly until term in order to monitor for pre-eclampsia with blood pressure checks and urine dip with a multistick for proteinuria.

Vaginal delivery should be aimed for.

SLE Posted by Priyadarshini G.

A)     Patient should be seen by a multidisciplinary team consisting of physician, consultant obstetrician and specialist midwife.

History should be taken regarding duration of SLE , her symptoms like rash, arthritis, seizures ,whether any associated renal involvement like hematuria.

She should be asked about her medication and last episode of SLE flare. Any previous history of thromboembolism should be taken.

She should be asked whether she has had a preconceptional counseling ,if not then she should be informed that the best outcome of pregnancy is seen if conception occurs at the time of remission of disease. She should be informed that flare can occur anytime in pregnancy or puerperium. She should be informed that there are increased risks of gestational hypertension or preeclampsia, preterm delivery, fetal loss, growth restrictions and neonatal lupus.

She should be told about the importance of early booking and frequent antenatal visits.

Examination will include checking for anemia, blood pressure measurement. A general examination to note skin rashes, arthritis.

Investigation: blood grouping and Rh, rubella status, HIV, Hepatitis B and syphilis screen should be done .

 

B)      Additional investigations to be sent are directed at diagnosing disease flare.

Full blood count for anemia, thrombocytopenia and lymphopenia should be done.

Blood should be sent for compliment levels as C3, Clevels are low in SLE exacerbations. If she is on maintenance dose of prednisolone her blood sugar should be tested.

Blood for anti Ds DNA and anti Ro and anti La antibody detection should be done.

Presence of anti Ro anti La antibodies are associated with neonatal lupus and if positive warrants fetal echocardiography at 23 weeks to detect fetal heart block. Anti Ds DNA levels are highly elevated in SLE flare.

Urine should be sent for routine and microscopy as red cells or red cell casts are highly suggestive of lupus nephritis.

24 hour urine for urinary creatinine clearance can be done to detect renal disease.

Serum urea, creatinine and uric acid to detect renal involvement.

 

C)      She should be offered a dating scan and should be seen by a multidisciplinary team every 2 weeks in first and second trimester and every week thereafter.

She should be started on tablet aspirin 75mg once daily to be continued till delivery and therapeutic dose of low molecular weight heparin dose adjusted according to her body weight. This should be discontinued in labour. If she was on warfarin, it should be stopped.

Her previous medications should be evaluated and if on NSAIDs and methotrexate, these should be discontinued. Hydroxychloroquine and maintenance dose of prednisolone can be continued.

As she is at increased risk of preeclampsia, her blood pressure and urine protein should be monitored at every visit and she should be asked about any symptoms suggesting disease flare like fever, myalgia, fatigue, arthralgia.

Vigilance should be maintained for SLE flare, preeclampsia and IUGR. She should undergo fetal scan for 18-20 weeks every 4weeks for early detection of growth restriction.

If there is evidence of  anti Ro anti La antibody- fetal echocardiography at 23 weeks should be done.

Fetal surveillance in the form of biophysical profile and umbilical artery Doppler should be started as early as 24 weeks in view of her bad obstetric history and APLA positive status. This should be repeated every 4weeks.

If during her antenatal visits she develops gestational hypertension or preeclampsia it is to be managed according to national guidelines.

If there are no complications she can be allowed to deliver at term but postdatism should be avoided. Delivery should be planned in a consultant led unit with consultant obstetrician, anaesthetist, physician, neonatologist being present at delivery.

Posted by iram F.

A.A history should be taken from the woman of previous thrombotic episodes like deep venous thrombosis or pulmonary embolism.Enquire if she is on any anticoagulants like Warfarin . If she is on Warfarin it should be stopped due to risk of congenital malformations in the fetus and low molecular weight heparin started..

History of last flare up of the disease should be asked about.History of any medications for SLE should be taken and if she is on Mycophenalate Mofetil or Methotrexate,these should be stopped due to risk of congenital malformations.Azathiaoprine,Hydroxychloroquine,Prednisolone can be continued in pregnancy.An assessment of her BP and proreinuria should be done.If she is on warfarin it should be stopped due to risk of congenital malformations in the fetus.A full blood count to look for anaemia,neutropenia,thrombocytopenia should be performed.Renal function tests should be done to assess kidney function due to increased risk of Lupus Nephritis in these patients.MSU should be done to look for casts,heamaturia.

B.All the routine booking investigations like MSU;Viral screening for HIV,HBsAG,syphilis;Antibody screen,blood group and typing should be carried out.As women with SLE also have associations with La and Ro antibodies,AntiNuclear antibodies,these should also be tested in the woman.A risk assessment of thrombosis should be made by doing a thrombophilia screen.Proteinuria if present should be quantified with Urine protein/creatinine ratio or 24 hour urinay protein. A viability scan should be performed at this gestation.Echocardiography and Chest Xray should be performed depending on the clinical assessment.Also anti-ds DNA titres and Complement levels should be checked.

C.This woman should be managed in a multidisciplinary team consisting of a Senior Obstetrician,Rheumatologist,Heamatologist,senior Midwife.Low molecular weight heparin and low dose Aspirin 75mg in a once daily dosing should be started as this improves live birth rate to more than 70%.BP,Proteinuria should be tested every 4 weeks to detect preeclampsia.Uterine artery Doppler should be done between 18-20 weeks along with Anomaly scan to detect preeclampsia.Fetal growth scans along with Umbilical artery Doppler should be done every 4 weeks to detect any fetal growth restriction.Cesarean section should be performed for obstetric reasons.Azathioprone,Predinsolone and Hydroxychloroquine should be continued.

 

Imad Posted by Imad Aldeen E.

This patient has a high risk pregnancy because of S L E and antiphospholipid syndrome ( APS). Detailed history should be elicited including symptoms of S LE such asmalar rah, dicoid rash, oral ulcer, arthritis and when were these symptoms before pregnancy. Medical history should be explored such as hypertension, renal impartment, previous  thromboembolism. Drug history should be obtained as any anti hypertension, Anti coagulation, immunosuppressions because they have adverse effects to the fetus. Clinical examination should include measuring BP and BMI . General examination for skin rash, oral ulcers, cardiovascular  signs, CNS signs.

Full blood count (FBC) should be ordered to check for anaemia, leukopenia and thrombocytopenia which can be hapened in S L E. Anti d s-DNA and Anti R0 and La antibodies and complement C3 and C4 should be ordered in SLE flares. Renal function tests should be ordered such as urea, creatinine because  they are increase in lupus nephritis and renal impairment. Urineanalysis should be ordered for proteinuria, haematouria and RBC casts and protine to creatinine ratio in urine should be obtained .Ultrasound for the uterus to identify the viability and age ofpregnancy should be done.

Multidiscplinary team should be invoved including obstetrician, heamatologist, nephrologist and anaesthetist. Special protocol in the unit should be followed up in management . Observe BP because the risk of hypertention and give anthypertesion drugs when there is hypertension. Low dose aspirin and LMWH should be given to reduce the risk of thrombosis because of APS and SLE. Renal fuction tests such as urea and creatinine  and electrolytes with uninanlysis for heamaturia proteinuria  and protin to creatinine ratio in urine should be ordered to asses the renal fuction. Titer of Anti L0 and La antibodies and ds DNA level to assess the risk of affected fetus  . Details Ultrasound for abnormalities should be done between 18 -22 weeks and check the echocardiography of the  fetus heart to identify the congenital heart block .Serial fetal growth should be done for Fetal Growth Restriction (FGR) . Quick diagnosis and treatment of any symptoms of SLE flares by Prednisolone or immunosuppression . Increasing the frequency of visiting in antenatal period and when there is a fetal bradycardia ( congenital Fetal block ), delivery of the fetus should be done  if it is mature with immediate intervention after delivery to insert pacemaker . Plane for delivery should be discussed and documented .   

correction of saq Posted by Priyadarshini G.

dear paul,please correct my answer to sle in pregnancy.maybe you have missed it.It is just before dr padmaja's whose answer you have already corrected.