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MRCOG PART 2 SBAs and EMQs

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Essay 303 - SLE

Posted by SANCHU R.
a)
Active disease at the time of conception is associated with a worse prognosis. The duration of remission should be at least 6 months to plan her pregnancy.
The presence of lupus nephritis has an adverse effect on pregnancy. 6 months of remission after a lupus nephritis flare is important although even silent lupus nephritis can affect pregnancy. If the S.creatinine is >125micmol/l ,her pregnancy is at very high risk. Normal Renal functions indicate a favourable prognosis.
Presence of Hypertension and proteinuria indicate adverse outcome.
The presence of Anti-phospholipid Antibodies namely Lupus Anticoagulant and Anti-Cardiolipin Antibodies are associated with an adverse outcome of miscarriage, IUGR, pre-eclampsia and IUD.
The presence of Anti-Ro and Anti-la antibodies are associated with a 5% risk of neonatal Lupus and a 2% risk of Congenital Heart Block. Neonatal lupus is self-limiting in 6 months whereas CHB has a high perinatal mortality.
The drugs she is taking for her SLE like Mycophenolate, cyclophosphamide may be teratogenic and should be reviewed before trying for pregnancy.
(b) Discuss and justify any additional monitoring you would undertake in the antenatal period.
She should be under multi-disciplinary care which include the obstetrician, rheumatologist, nephrologist, anaesthetist and paediatrician.
A complete baseline assessment of her SLE should be done for early intervention and in order to identify flares at later stages. That includes FBC-normocytic anaemia, neutropenia and thrombocytopenia may be present in SLE.
Renal function tests-U& E, S.Creatinine, 24hr Urine protein estimation. Abnormal renal functions indicate adverse pregnancy outcome which necessitate nephrologist\'s input. Baseline values help to identify pre-eclampsia or nephritis flare later.
Lupus Anticoagulant and Anti-cardiolipin Antibodies- secondary Antiphospholipid Antibody syndrome indicates worse prognosis which may be prevented by treatment with Aspirin and LMW Heparin.
Anti-ds DNA,C4 and C5 baseline levels-since drop in levels indicates flare.
Anti-Ro, Anti La antibodies if present indicate counselling and vigilance for Congenital heart block and neonatal lupus.
She must have monthly review in the ante-natal clinic and the rheumatologist. BP and Urine dipstick for blood or protein is done to diagnose pre-eclampsia or nephritis flare.Since she may be on immunosuppressants, we should be watchful for any infections.
If there is history of lupus nephritis, monthly assessment of renal functions and MSU -culture should be done. Otherwise, they are checked at the end of each trimester along with Anti-phospholipid antibodies, C3, C4, Anti-ds DNA.
Detailed anamoly scan at 20 weeks should be done with uterine A. Doppler for Diastolic notching- early sign of placental insufficiency should be done.
Regular growth scans at 28, 32 and 36 weeks should be done. Those with anti-Ro, anti-la should have serial fetal echocardiogram to pick up and treat congenital heart Block with maternal Dexamethasone.
Induction of labour or Caesarean section is planned according to the course of pregnancy and the disease.





Posted by Johnson  O.
A/
Systemic Lupus erythematosus is an autoimmune disorder which may improve, worse or remain the same during pregnancy.
The condition of her health before she becomes pregnant would have effect on it. The disease has period of flares and remission. If she become pregnant in the remission period, she would likely have successful outcome. If the woman becomes pregnant in the flare period, there is increse risk of poor outcome.
Therefore it is important to avoid unwanted or unprepared pregnancy by using effective contraception until the remission state.
Optimal renal function is important for succesful pregnancy ouitcome. High creatinine level increases risk of poor prognosis.
Presence of Anti-Ro and Anti La antibodies in her blood can pass through the placenta and cause congenital heart block, intrauterine death. There is also increase risk of neonatal lupus.
Presence of Thrombopilia, both acquired and inherited increase her risk of spontaneous miscarriage, intrauterine growth retardation.
High blood pressure can worsen during pregnancy with increase risk of pre-eclampsia. Antihypertensive drugs like ACE inihibitor is teratogenic. Most of the immunosuppressive drugs are safe in pregnancy. Non-steroidal anti inflammatory drugs can cause fetal renal impairement and oligohydraminos.
Management under multidisciplinary team including senior obstetrician with special interest in SLE, Physician, heamatologist and anaesthetist would increase her chance of successful pregnancy outcome.
Previous succsful pregnacy outcome will likely be an indication for a good outcome in future.
B/
Regular Joint obstetric/medical clinic. At every visit Blood pressure and urinalysis for protein should be checked because of risk of pre-eclampsia.
She is at increase risk of anaemia, haemoglobin would be monitored. Regular platelet count monitoring becuase of the risk of thrombocytopenia or thrombocytosis. She is at increase risk of worsening renal function, therefore, Urea and electrolyte measurement, Creatinine level will be monitored regularly depending on her condition and advise from physician.
I will organise Detailed anomaly scan around 18-20weeks gestation because of risk of congenital anomaly. Fetal echocardiogram will arranged around 20-22weeks gestation due to the increase risk of congenital heart defect. I will arrange regular fetal growth scan and liqour volume at 28, 32 and 36weeks gestation because of the risk of intrauterine growth restriction. Ultrasound umbilical artery doppler for fetal survellance. Regular Electronic fetal monitoring as fetus is at risk congenital heart block.
Posted by Leen K.
LEEN
A 25 year old woman with a history of systemic lupus erythematosus (SLE) is planning a pregnancy.
(a) Discuss the factors related to her SLE which will influence outcome in a future pregnancy [10 marks].

SLE is associated with an increased risk of miscarriage, intrauterine death, intrauterine growth restriction (IUGR), low birth weight and preterm delivery (may be due to iatrogenic reasons). SLE patients are also more at risk of venous thromboembolism (VTE) (especially if she has a history of a previous VTE), and pre-ecllampsia toxaemia (PET). SLE flares are less common if her SLE has been quiescent for at least 6 months prior to pregnancy. Therefore good disease control is vital to ensure the best possible outcome for the pregnancy.
The presence of nephropathy and/or high blood pressure tends to be associated with poorer outcome of the pregnancy. These patients are more at risk of developing PET and iatrogenic preterm delivery is more likely (leading to increased risk of neonatal complications associated with prematurity). The presence of anti-Ro or anti-La antobodies (may be associated with fetal heart block), as welll as anticardiolipin (ACA) and lupus anticoagulant (LAC) antibodies are also worse prognostic factors.
Certain medications for SLE are contraindicated in pregnancy - methotrexate and cyclophosphamide are teratogenic; nonsteroidal anti-inflammatory drugs (NSAIDs) can cause premature closure of ductus arteriosus in the fetus. Steroids and azathioprine are not associated with significant adverse effects on the oregnancy and women should be informed of this to ensure drug compliance. Non-compliance to drug therapy may result in SLE flares, and are associated with poorer pregnancy outcome.
She shoould be advised to use reliable contraceptive methods until her diease is well controlled and quiescent for at least 6 months and her drug therapy modified to take into account risk of pregnancy (eg. methotrexate and cyclophosphamide). All these should be managed in a multidisciplinary setting, involving her rheumatologist and nephrologist (if nephropathy present).



(b) Discuss and justify any additional monitoring you would undertake in the antenatal period [10 marks].

A good prognostic factor for outcome in pregnancy is the patient\'s creatinine clearance. I would organise serum urea and electrolytes (UE), livery function tests, full blood count and blood group and antibody screen, as baseline tests. I would make sure her creatinine clearance is checked, and take bloods to look for presence of antibodies such as anti-Ro or anti-La; and ACA, LAC, antiphospholipid antibodies - presence of these are worse prognostic factors.
I would make sure her blood pressure and urine (to check for protenuria) are checked on a regular basis - the frequency depends on disease severity and progression.; to look for signs of PET. It can sometimes be difficult to distinguich between PET and renal problems caused be SLE, therefore microscopy of urine (to look for presence of red blood casts) and serum albumin (low in nephropathy) may help. Infection and hypertension should be treated appropriately.
Regular growth scans and/or umbilical artery Doppler should be organised as these babies are more prone to IUGR; and if anti-Ro antibodies are present, there is a risk of fetal heart block and subsequent hydrops - therefore fetal heart rate should be checked and hydrops looked out for at each ultrasound scan. Detailed scan to look for fetal anomalies, especially if she had taken teratogenic medications (eg methotrexate or cyclophosphamide) in the pregnancy.
Risk of VTE is higher, especialy if she has had previous VTE, and VTE thromboprophylaxis may be appropriate to reduce this risk. Patients should be advised on signs and symptoms of VTE to look out for in pregnancy and attend hospital if present for investigations.
All monitoring and care should ideally be in a joint antenatal clinice with a rheumatologist ( or liased with a rheumatologist) and liason with a nephrologist may be appropriate. Disease activity dshould be monitored (guided by rheumatologist\'s advice) - glomerular filtration rate, complements, ACA/LAC antibodies at least once every trimester, and if disease progresses, more intense monitoring (as discussed above) and/or early delivery (involve the paediatricians) may be required.
Posted by shipra K.
Shipra
A)The factors influencing the outcome of the disease first and the foremost is active disease at the the time of pregnancy is associated with a poor pregnancy outcome. the patient should be told that 6 months or more period of disease remission is associated with a better pregnancy outcome and lesser chance of disease flare..
Disease with renal involvement has poor outcome and it has been seen that serum creatinine of more than 140µmol/dl is associated a 50% chance of pregnancy loss.Also these patients are more likely to have superimposed preeclampsia.
Previous history of pregnancy loss is again associated with a higher chance of pregnancy loss.
Medication to control disease could be teratogenic and be associated with side effects. methotrexate needs to be stopped 3 months prior to conception as it is associated with congenital malformations.Cyclosporine is associated with 40%chance of preterm birth,and 3% chance of congenital malformations,Methylprednisolone,azathioprine ,is safe and can be continued .Hydroxychloroquine is associated with increased chances of congenital malformation.
Patients recent investigations need to be reviewed –presence of Ds DNA shows active disease ,presence of antiphospholipid antibodies is associated with poor pregnancy outcome.Anti –Rho and anti-la antibodies is associated with 2% chance of congenital heart block.
Patient needs to be told inceaed chances preeclampsia,IUGR,intrauterine fetal death, pretrm birth chances of flaring up of disease.
B)Patient during pregnancy should be looked after multidisciplinary team which includes a physician,hematologist,ultrasonologistand obstetrician.
Patient should be advised regular antenatal visits with monthly visits till 28 weeks,then fortnightly till 36 weeks then biweekly.thereafter. or more frequently if required. Regular BP , fetal growth monitoring should be done.
Full blood counts will show hemolytic anaemia,leucopenia,thrombocytopenia if there is an active diease.Urine routine microscopy would show hematuria,casts in presence of active disease and if preeclampsia is developing and these tests need to be repeated monthly.
A renal function test should be monthly to note any detoriation of disease.
Complement C3 C4 need to be done would show active disease.
A detailed scan to note any congenital malformation ,echocardiography at 22 weeks for any congenital heart block,
Color Doppler scan at 24 weeks to see for diastolic notching would predict preclampsia.,also fetal Doppler would detect any fetal compromise. Regular growth scans to detect any IUGR.This patient requires good fetal monitoring regular biophysical profiles would be needed .
Antiphospholipid antibodies need to be done an if positive and without a history of previous pregnancy loss aspirin to be started.If previous pregnancy loss present then LMWH plus heparin given(enoxaparine 40mg OD subcutaneously.)If patient with previous history of thrombosis and on warfarin it should be stopped as it is teratogenic.LMWH started
Posted by Shaimaa M.
SLE is an autoimmune connective tissue disorder. Pregnancy outcome is improved if conception occurs during disease remission. Adverse pregnancy outcome is related to the presence of renal involvement even quiescent renal lupus is associated with increased risk of fetal loss. Prepregnancy hypertension carries the risk of superimposed preeclampsia and IUGR. The presence of anti phospholipid antibodies carries the risk spontansous miscarriage and fetal death. Presence of Anti RO or Anti LA carries a risk of transient neonatal cutaneous lupus and risk of congenital heart block. Presence of proteinuria might make it difficult to differentiate pre-eclampsia from SLE. Elevated creatinine levels carries complicated pregnancy outcome. Neonatal risks are increased if there is a history of previous child affected (16-18% with one child up to 50% if two children affected). Type of treatment to control flare might affect pregnancy, NSAID might lead to oligohydramnios, corticosteroids carries increased risk of gestational diabetes and PROM, azathioprine is safe and carries no fetal adverse effects.

Antenatally, pregnancy care should be understaken by multidiscplinary team in comined physician and consultant obstetrican and neonatologist. I will aim is monitor disease activity and fetal growth. If hypertension is diagnosed pre-conception I will shift to other pregnancy suitable medication like methyledopa or nifidipine. Regular Blood measurement to detect early rising values and start treatment accordingly. I will establish baseline values for Full blood count, Urea and electrolytes, serum creatinine, uric acid and liver functions. Rising Anti DNA antibody titre and falling Complement levels may point to disease flare. I will have quantitive measurement of proteinuria to help differentiate pre-eclampsia if it develops later on. I will managing active flare with corticosteroids mainly predinsolone. If the patient got pregnant while using hydroxychloroquine I shall continue using it since stopping may precipitate flare. I will arrange uterine artery doppler at 20-24 weeks as it might help to predict pre-eclampsia. I will arrange serial growth scans every 4 weeks and umbilical artery doppler from 24 weeks to predict and anticipate IUGR and fetal welbeing. Detailed scanning of fetal heart as bradycardia or atrioventricualr dissociation may point to Congenital heart block. Neonatologist shall explain the risk of neonatal lupus syndrome including congenital heart block and cutaneous lupus.
Posted by Asa A.
asa
a)The factors which affect pregnancy include if she is currently in remission or flare , pregnancy should be planned in a remission of at least 6 months .The degree of her renal affection ,creatinine clearance of less than 125 umol/L gives the best outcome . Her blood pressure should be well controlled as she is in a higher risk of developing PET . The medication used to control her BP should be safe with pregnancy . The patient may be using steroids in high doses and this predispose to many problems during pregnancy as hyperglyceamia , osteoporosis and adrenal suppression . The use of pain killers as NSAIs should be changed to more safe options as codeine . Whether she is using methotrexate for disease control is important as this drug is teratogenic and should be stopped before embarking into pregnancy . previous history of thromboembolism or recurrent miscarriages may indicate the presence of secondary antiphosphlipid syndrome and this will worsen the pregnancy outcome and successful live birth is achieved only in 10% of cases without treatment . If her CNS is affected she may be on medications like tegretol which increase the risk of neural tube defects . The patient may have severe joint affection and this may interfere with handling and caring for the baby . Low immunity predisposes her to rubella , CMV and hepatitis infections so testing for these infections and immunization is advised before pregnancy .
b)Her ANC must be done in a high risk pregnancy unit in conjunction with rheumatologist and nephrologist . Monitoring will cover complications and deterioration of the disease itself and resulting obstetric complications . Monitoring her BP is important as she is in higher risk of developing PET . She can use methyldopa or labetolol but not as they affect thekidny fuctions of the fetus . Renal function tests , 24 hrs protinurai and creatinine clearance need to be done every month till 28 ws and more frequent after that to detect deterioration . Urine analysis and MSU need to be done monthly to detect asymptomatic bacteurea which predisposes to pyelonephritis and preterm labour . If her blood sugar is normal before pregnancy she will need OGTT at 16 and 28 ws as she is in risk of developing GDM . She will receive low dose aspirin and low molecular weight heparin to improve pregnancy outcome and monitoring her platelets and FBC regularly is important . Lupus flare may be mistaken for PET and the level of anti Lo and anti LE will be checked regularly .
Regarding fetal growth the patient is liable to miscarriage growth restriction , IUFD and hydrops fetalis . Dating scan early in pregnancy is important . Anomaly scan 18-22 ws is important as some medications may be teratogenic . Fetal heart block may develop in 2% of patients due to passage of antibodies to the fetus and this could be detected early . Fetal growth scans must be done regulary starting at 28 ws . Umbilical a Doppler will detect fetuses at risk of placental insufficiency together with the amount of liquor . Uterine a wave form notching may indicate developing PET .
Posted by Bee N.
A)Pregnancy generally worsens disease activity. Active disease just prior to pregnancy is associated with worse prognosis. Pregnancy better delayed until disease in remission. Active disease can be determined by level of anti nuclear, anti DNA, anti smith antibodies and falling level of complement C3 and C4.
Presence of hypentension and/or proteinuria or red cell casts in urine indicate nephritis which can cause miscarriage, still birth, intrauterine growth restriction(IUGR), preterm labour.
Use of multidrugs immunosuppresants like azathioprine, tacrolismus increases possibility of teratogenicity. Low dose monotherapy better if controlling disease.Poor disease control pre pregnancy also associated with poorer prognosis in pregnancy
Presence of antiphospholipid antibodies predisposis to recurrent miscarriages, IUGR , preeclampsia and thrombosis.
Presence of anti Ro antibodies predisposis fetus to congenital heart block which is irreversible.
History of previous flares in previous pregnancy also associated with increased chances of flare in present pregnancy.


B)Baseline renal function, antibody titres and level of complement C3 and C4 early in pregnancy to help monitor disease progression when compared with later values. Serum screening for chromosomal anomaly and spina bifida as well as 18 to 20 weeks anomaly scan to detect effects of teratogenicity. Cardiac scan at 24 weeks may detect congenital heart block(CHB).
Weekly cardiotocograph as from 28 weeks will also detect bradycardia which may then necessitate further cardiac scans to detect CHB. Patient would be managed in a consultant led unit and multidisciplinary involvement consisting of obstetrician, physician, neonatologist to monitor disease progression and determine optimal delivery time. Patient seen 2 weekly from 24 weeks gestation and weekly from 32 weeks gestation to monitor progression. Bloods taken for full blood count every visit to monitor anaemia, electrolyte and urea/ creatinine to monitor renal function, liver function testand urate to detect developing pre eclampsia, coagulation screen to detect coagulation disorder.
Antibody and complement 3 and 4 levels monitored as determined by the physician to detect active disease. Regular growth scan and liquor volume from 24 weeks as well as umbilical artery doppler and uterine artery doppler to detect IUGR.
Patient must be assessed regularly for need for thromboprophylaxis. Urine should be cultured in every visit to detect infection which may worsen renal disease. Ceasarean section is considered for obstetric reason. Early Induction of labour considered especially if fetal/ maternal wellbeing. compromised
Posted by H H.
The factors that can influence outcome in a future pregnancy can be gathered from detailed history.Will get information if she is being followed with a immunologist or physician and if she is in remission or relapse.Pregnancy is only allowed if she is in remission . Advise contraception if in relapse to prevent worse outcome. History of arterial or venous thrombosis would influence management and outcome.Obstetric history including history of repeated 1st trimester miscarriage, intrauterine fetal death after 10 weeks, pre eclampsia at an early gestation or stillbirth at an early gestation may point to the severity of the condition. Personal history history of hypertension would influence outcome with increased risk of pre eclampsia, intrauterine death and stillbirth.
Renal function if affected by SLE would affect outcome. Drugs taken to treat hypertension or to treat SLE should be reviewed. Dexamethasone can cause suppression of fetal adrenal.Patient on corticosteroid treatment should receive steroid cover in labour.
Other important factors include, presence of antiphospholipid like lupus anticoagulant (LA)and anticardiolipin antibodies(ACL), the later being involved in development of congenital heart block in fetus, which need follow up and pediatric and cardiologist care after delivery.


B)This patient will require additional monitoring in a multidisciplinary team manner including the obstetrician , nephrologist, physician interested in autoimmune disorders, pediatrician, hematologist and midwife.
Monitoring of renal function during pregnancy including serum creatinine and watch for proteinuria to detect any deterioration in renal function.
Detection of LA and ACL antibodies to detect risk heart block in fetus which will be confirmed during detailed ultrasound at 20-22 wk and echocardiography.
Clotting screen for risk of thrombosis and if patient is taking unfractionated heparin will need do partial thromboplastin time if on therapeutic dose.No need for doing anti factor X a if on low molecular weight heparin.
Uterine artery Doppler at 20 week will detect her risk of development of pre eclampsia.
Growth scan from 28wk to detect development of fetal growth restriction.
More frequent antenatal visits to monitor development of hypertension , its worsening , no response to treatment or development of pre eclampsia.
Early diagnosis and treatment of urinary tract infections.
Proper monitoring of fetal wellbeing starting early in third trimester with CTG, Doppler flow in umbilical arteries and liquor volume.

Posted by Sophia Y.
A 25 year old woman with a history of systemic lupus erythematosus (SLE) is planning a pregnancy. (a) Discuss the factors related to her SLE which will influence outcome in a future pregnancy [10 marks].

Systemic lupus erythematosus (SLE) is an autoimmune disease that can affect multi-organs giving a wide range of clinical manifestations. We need to ask her duration of disease, the severity & which organs are involved and treatment she has had. This can be available in her medical notes. She can be subfertile if the disease is severe. Women with lupus nephritis have high fetal loss. I will ask her obstetric history as many women have anti-phospholipid syndrome (APS) with recurrent miscarriages before 10 weeks gestation, fetal loss after 10/40 or premature delivery. I will tell her to avoid being pregnant by using effective contraception when the disease is flaring up. She should wait till the disease is resolved for at least for 6 months. Pregnancy when the disease is active worsens pregnancy outcome. In addition some immunosuppressants can be teratogenic and fetotoxic. When the disease has been on remission for at least 6 months, she should see her consultant haematologist/ rheumatologist or nephrologist to modify her medications. She should also start folic acid 5mg during this period and continue throughout whole pregnancy as at risk of haemolytic anaemia and neural tube defect. She needs to take aspirin 75mg up to 34 weeks as many women with SLE have antiphospholipid syndrome. Aspirin can improve fetal outcome.

She should stop warfarin for venous thromboembolism as it is teratogenic. She should change it to low molecular weight subcutaneous heparin (eg clexane 40mg) preconception period continue throughout pregnancy.

She should be advised that once she finds out that she is pregnant, she needs to book her antenatal care and have early dating scan.

(b) Discuss and justify any additional monitoring you would undertake in the antenatal period [10 marks].

She needs to be booked under the multi-disciplinary consultant led antenatal clinic involving the obstetrician, haematologists, nephrologists and rhematologists because of the multi-organ involvement of disease. She needs to be reviewed at the clinic frequently - monthly in 1st & 2nd trimester & at least every 2 weeks in third trimester or more frequently pending the severity of disease. Blood pressure for hypertension and dipstix urine to exclude proteinuria as she is at risk of developing pre-eclampsia. She needs to have baseline renal function at least monthly. Full blood count should be taken at least monthly to exclude thrombocytopenia. If lupus nephritis is involved, she needs monthly 24 hour urinary protein & creatinine to monitor severity. Raised anti-double stranded DNA (anti-ds DNA) with casts cells in urine suggest active SLE disease. Normal anti-ds DNA, absent cast cells in urine, raised urate is likely to be pre-eclampsia. Thrombocytopenia & proteinuria can be seen in both pre-eclampsia and active SLE.

She needs anaesthetic review at 34 weeks gestation to discuss about pain relief at delivery and when she should stop clexane.

Neonatalogists need to be alerted during antenatal period. She is at risk of preterm birth, fetal loss and intrauterine growth restriction (IUGR). Serial growth scan at 28, 32 & 36 weeks will be needed to monitor growth. Uterine artery doppler should be done at 24 weeks as it can identify uteroplacental insufficiency and predict IUGR. If she has positive anti-la & anti-ro antibobodies, baby is at risk of developing neonatal lupus. She needs to be referred to feto-specialist for echo-cardiogram at around 22-24 weeks to exclude congenital heart block with complications including hydrops & fetal death.
Posted by C P.
A 25 year old woman with a history of systemic lupus erythematosus (SLE) is planning a pregnancy. (a) Discuss the factors related to her SLE which will influence outcome in a future pregnancy [10 marks]. (b) Discuss and justify any additional monitoring you would undertake in the antenatal period [10 marks].
C.
(a)
SLE is a autoimmune disorder which can affect the kidney, joints, heart and vascular system and skin. If the patient become pregnant during active phase of the disease it brings increased risk of maternal morbidity and perinatal morbidity and mortality.
During the active phase, conception will be delayed because of the disease and well the medication what is on. Pregnancy may end up in miscarriage.
If the patient’s renal function is abnormal this can give rise high blood pressure and which can super impose to pre eclampsia. This may result in convulsion, cerebrovascular accident, abruption and pulmonary oedema. All these increases the risk of maternal and foetal morbidity.
She is more prone to have thrombo embolism. Which will increases maternal morbidity and mortality.
Renal function can deteriorate during pregnancy which in tern bring poor outcome of the pregnancy.
If the patient is on ACE inhibitors and NSAD this will affect the foetal kidney. This should be changed prior to contemplating pregnancy. Steroids and immunosuppressive does not do any harm to the pregnancy.
If the patient has Anti Ro antibody this can gives rise to foetal cardiac arrythmia and cardiac failure.
The foetus has the risk of IUGR and pre term delivery. This intern increases the risk of perinatal morbidity and mortality.

(b)
Patient’s must be managed by obstetrician and a physician. Her renal function should be monitored regularly. If protein is found in the urine 24 hours urine much be assessed. Serum creatinine level should be monitored regularly. Her blood pressure should be closely monitored. If blood pressure is high appropriated measure should be taken along with her physician. Pre eclampsia can super impose with high blood pressure.
This patient ‘s risk assessed for thrombo embolism, should be done, whenever her risk is increases they should be low threshold to start prophylactic LMWH.
The foetus has the risk of IUGR, from 24 weeks onwards serial growth scan need to be arranged. If IUGR is detected at any time further amniotic fluid volume and Doppler will be helpful to monitor the foetus further.
If the mother has anti Ro antibodies the baby could have cardiac arrythmia. Whenever this is suspected cardiac echo should be arrange in the foetal medicine unit. If present further management plans will be drawn from foeto medicine specialist.
During pregnancy skin manifestation or arthritis can devolope. This should be treated with the help of the physician.
To have the good outcome of the pregnancy patient must be advised to contemplate her pregnancy during the disease remission period and she should be told the important of the regular antenatal follow up.
Posted by Nur Sakina K.
NSK
From A:
The prognosis for mother and child is best when SLE has been quiescent for at least six months prior to the pregnancy and the patient\'s underlying renal function is stable and normal. Preeclampsia (PET) is a frequent complication of pregnancy in SLE, occurring in approximately 13 percent of patients. The risk is higher if she has active renal disease. She is also at higher risk of developing venous thromboembolic diseases (VTED). The rate of unplanned caesarean sections and postpartum heamorrhage is also higher in pregnancies complicated by SLE. However, the mechanism behind this is unknown.
The fetus is at higher risk of developing complications during the pregnancy. There is a higher risk of miscarriages, intrauterine deaths and still births. This risk is higher in woman with active lupus, hypertension and high titres of antiphospholipid (aPL) antibodies. Preterm deliveries are 3 times higher in these women. Her baby is also at higher risk of intrauterine growth retardation (IUGR). This risk is associated with corticosteroid dose, renal complications, hypertension, aPL, preeclampsia, or premature rupture of membranes. Neonatal lupus can occur due to passive transfer of anti-Ro and anti-La antibodies from the mother. The most important complication as a result of this is congenital heart block (2%) which can recur in subsequent pregnancies (15%). Isolated skin rashes can also occur. However, SLE is not associated with any congenital anomalies.
If pregnancy was contemplated in suboptimal conditions (poorly controlled SLE) or poor renal function, these can worsen as the pregnancy progresses with increasing pregnancy risks to both mum and baby.

From B:
Monitoring of both mum and baby is vital to ensure early detection of complications. At booking, maternal blood pressure for baseline levels and comparison for the development of PET at later gestations is helpful. Urinalysis for protein screens for renal dysfunction. Serum renal function test (U&E) and urine protein/creatinine ratio (PCR) should be performed if urinalysis is abnormal to quantify urinary protein. Immunology studies include anti ds DNA, complement levels and anti Ro/anti La levels. If anti Ro/La levels are high, there’s an increased risk of neonatal lupus. Anti-Cardiolipin and lupus anticoagulant levels determine the need for aspirin prophylaxis in pregnancy. If these are high in presence of a poor obstetrics history (recurrent miscarriage, severe PET, IUGR) she has anti-phopholipid syndrome which requires aspirin and low molecular weight heparin to help improve pregnancy outcome.
Fetal monitoring involves early dating scan to confirm viability as she is at higher risk of spontaneous miscarriage. If neonatal lupus is suspected, serial fetal echocardiogram from 18/40 is performed to identify congenital heart block. Serial growth scans is performed to exclude IUGR. If IUGR is present, umbilical artery Doppler is done to monitor fetal well being and guide timing of delivery.
Posted by Akanksha G.
A 25 year old woman with a history of systemic lupus erythematosus (SLE) is planning a pregnancy. (a) Discuss the factors related to her SLE which will influence outcome in a future pregnancy [10 marks].
Disease activity is known to affect pregnancy outcome. conception during active SLE carries poor prognosis, it is advisable for a women to conceive during remmision for best outcome.disease which is well controlled and stable with or without medication gives best outcome.disease activity can be assessed by presence of high titres of anti dsDNA antibodies. presence of lupus nephritis carries a poor outcome especially diffuse progresive glomerulonephritis. there is a possibility of worsening nephritis in upto 25% of women and upto 7% may land up in irriversible kidney damage later on. presence fof lupus nephritis puts the women to a higher risk of pregnancy induced hypertension, preeclampsia/eclapsia, IUGR. women should be advised to avoid pregnancy untill the disease is stabilised, hypertension well controlled with medication.advanced renal failure with s.creatinine >2mg/dl is a contraindication for pregnancy. SLE with secondary antiphospholipid syndrome crries a higher risk of miscarriage, IUGR, and fetal death. presence of antiRO and anti LA antibodies is associated with congenital heart block in the fetus. presence of SLE lung disease can increase maternal morbidity and mortality. drugs used for SLE like thalidomide, cyclophosphamide, methotrexate are contraindicated in pregnancy. NSAIDS are rellatively contraindicated especially after 32 wks since they can cause premature closure or constriction of ductus arteriosus. however glucocorticoids, hydroxycloroquine, azathioprine can be continued in pregnancy.prednisolone and azathiprine are associated with IUGR and growth monitoring is warrented.
(b) Discuss and justify any additional monitoring you would undertake in the antenatal period [10 marks].
women with SLE and pregnant should ideally be seen every 2 weeks in the first and second trimester and every week thereafter. the increased frequency of visits is to screen for hypertension, preeclampsia and SLE flare. at booking visit checking the antidsDNAtitres, anti Ro anti LA gives an idea of the activity of the disease, and antiRO antiLA are known to be associated with congenital heart block in the fetus. screening for hematological and renal manifestations of SLE would include checking FBC, liver function tests, urea, electrolytes, creatinine, urine protein, casts, 24 hr urine protein creatinine ratio, at booking and every trimester or earlier as the maternal condition dictates. if patient develops preeclampsia, serum uric acid and compliment levels may help in diffrentiating SLE flare froom preeclampsia. women who are on glucocorticoids or hydroxycloroquine or azathioprine for SLE would require a detailed tertiary level anomaly scan. presence of anti Ro antiLa requires a additional fetal ECHO. 4 -6 weekly fetal growth scans starting from 24 weeks is indicated since these women are at high risk of IUGR. weekly nonstress test and amniotic fluid index is justified from 32 wks onwards dictated by the presence and severity growth restriction. timing and mode of delivery would depend on obstetric indications.
Posted by robina K.
The women should be assessed in a joint clinic with her physician to discuss the extent of condition, complications and medications she is on .
The factors which will influence outcome are ,Wheather SLE is in remission or relapse state .If she concieves while in relapse state there is increased risk of misscariage by 40% and maternal flare .
Associated hypertension (HTN) and lupus nephritis increases risk of early onset pre eclampsia by 25% and IUGR by 30% .Pregnancy should be contra indicated if there is severe HTN or severe renal dysfunction like nephrotic syndrome and effective contraception is advised . History of arterial or venous thrombosis increases risk of recurrence in pregnancy with increased morbidity and mortality and pregnancy should be avoided . Presence of antiphospholipid antibodies increases risk of misscarriage , IUGR , pre eclampsia .preterm delivery spontaneous or iatrogenic , intrauterine fetal death and thrombo embolism . Presence of anti RO antibodies increases risk of congenital heart blocks by 1-2 % , women should be informed about it . Presence of anti LO antibodies, anti double strenth DNA antibodies is associated with neonatal lupus by 5-6% .
Informations should be obtained about drugs and there dosage . Corticosteroid like prednisolone is not teratogenic in smaller dosage but may cause cleft lip and palate in higher dosage animal studies . NSAIDS should be stopped due to its effect on fetal kidneys , acetamonophen my be taken as an analgesic . Antimalarial hydroxychoroquin is not teratogenic and may be continued . Rarely women may be taking methotrexate or cyclophosphamide which should be stopped if she is planning for a pregnancy . General illhealth , anemia , thrombocytopenia and arthritis may have adverse effect on pregnancy outcome and should be treated before .
Rubella, hep B, HIV, and syphilis screening is offered. Folic acid 5mg is advised .
(B) A combine care should be provided including consultant obstetrician, physician with special interest in SLE , neonatologist and midwife .
Early booking and dating scan is advised . Base line tests like FBC, U&E, serum creatinin ,creatinin clearance , urine diopstick, 24 hrs urinary priteins, anti RO, anti LO, anti phospholipid anti bodies , anti nuclear and anti double strengh DNA antibodies screening is offered . these tests should be repeated on each visit . Frequent and regular visits at joint clinic are advised ,every 2 weeks in first trimester and every week subsequetly . Screening for aneuploidy is offered. At 18 weeks anomaly scan and at 20 weeks echo cardiography is advised in tertiary centre .
Regular screening for pre eclampsia is advised BP measurement at each visit ,RFT and urine protein estimation is carried out .
Serial growth scan every 2-4 weeks is advised from 24 weeks onward . Tests of fetal survillance should be started earlier from 32 weeks onward .These include fetal movement record, ultra sound assessment of IUGR, ligour volume and fetal wellbeing , doppler studies, biophysical profile score and CTG .
Women should be informed about the symptoms of SLE flare like extreme fatigue, rash on face or arthritis. Access to the hospital is facilitated by giving her contact numbers .In case of flare admission and I.V prednisolone therapy may be needed . The signs and symptoms of SLE flare mimmicks pre eclampsia like HTN, protein uria and thrombocytopenia It can only be differenciated by abnormal LFTs which indicates preeclampsia ,blood and casts in urine indicates SLE flare . Plan of management should be agreed with the women and documented . Hospital delivery should be advised, she is reassured that a vaginal delivery and a normal fetal outcome is anticipated . Option for analgesia and anesthesia should be discussed . Epidural is not cotraindicated .
Written informatin is provided and further followup appointment date is given
Posted by Manoj M.

M
(a) Active disease at conception (or) renal involvement with SLE (or) associated with anti phospholipid syndrome increases the risk for miscarriage, IUGR, premature labour, still birth. Activity of disease in the last 6 months prior to conception also increases this risk.
Renal involvement with SLE like lupus nephritis is associated with poor fetal outcomes in subsequent pregnancy like miscarriage, IUGR and stillbirth.
Nephrotic proteinuria increases risk of premature labour and associated with increased risk of thrombosis.
Presence of anti Ro and Anti La antibodies increases risk of congenital fetal heart block.
SLE flareups can happen at any stage of pregnancy and in puerperium and may be difficult to differentiate with symptoms of pregnancy itself e.g. skin lesions of SLE.
SLE may complicate with preeclampsia in pregnancy and may be difficult to differentiate between lupus nephritis.
Medications used to control SLE like NSAIDs may cause adverse effects like premature closure of ductus arteriosus and oligohydramnious.
Steroid use to control SLE may increase the risk of gestational diabetes in pregnancy and drug use like cyclophosphamide for SLE may cause congenital abnormalities like cleft palate and skeletal abnormalities.
A quiescent disease longer than 6 months, no renal involvement and anti Ro and anti LA negative more likely have good outcome with pregnancies.

(b) Her antenatal care should be monitored under MDT care involving obstetritian, physician, neonatologist, anaesthetist.
She should be booked earlier under obstetric consultant at around 10weeks to confirm continuing pregnancy with earlier dating scans as increased risk of miscarriage.
If on NSAID\'s or any teratogenic agents like cyclophosphamide these should be stopped however hydrochloroquine, prednisolone and azathioprine is safe to continue in pregnancy.
If associated with APS may need to consider aspirin and heparin prophylaxis to increase pregnancy outcome with live birth.
Nephrotic proteinuria need thromboprophylaxis antenatally and postnatally for atleast 6 weeks.
If on steroid treatment for SLE consider oral glucose tolerance test to exclude gestational diabetes at around 24-28weeks.
Anomaly scan to detect any fetal abnormality especialy if on teatogenic medication at conception at around 18-20weeks gestation.
Uterine artery doppler at 20-24 weeks may suggest increased risk with uteroplacental insuffieceny and possible risk of preeclampsia and IUGR.
With renal disease, 24 hour proteinuria to quantify proteinuria at booking for baseline studies along with blood urea and creatinine.
Monthly assement of C3, C4, dsDNA levels to detect flare ups with specialist physician input.
Increased antenetal surveillance to detect any flareups especially if associated with renal involvement.
If anti Ro and antLa positive offer cardiac scan to detect congenital heart block and may need scans between 18-30weeks.
Serial third trimester growth scans as increased risk of IUGR.
BP and proteinuria assessment at every visit as increased risk of preeclapmsia and may need frequent 24hrs proteinuria with renal involvement.
Renal lupus may be difficult to differentiate from preeclampsia. Redcell cast in urine and rising dsDNA titres may suggest lupus while rising transminase and uric acid may suggest preeclampsia.
She should be provided with written information , support groups information and contact details.
Posted by Mohamed A.
M.A.
a)

For achieving a good pregnancy outcome, proper pre-pregnancy counseling is mandatory. Multidisciplinary approach including consultant obstetrician, physician and immunologist or management in joint clinics preferred preconceptionally and during pregnancy.

Active disease at conception, renal involvement and associated APS increase the risk of miscarriage, pre-eclampsia, IUGR, premature delivery and Still birth thus woman should be instructed to conceive only when SLE is in remission for at least 6 months.

Ro-positive women are at risk of her baby having neonatal lupus being cutaneous lupus or congenital heart block (risk almost 1 in 20) with a recurrence risk of 16% if first child is affected and rises to 50 % if 2 children are affected.

Drugs should be modified, once pregnancy is confirmed NSAID’s are discontinued due to risk of premature closure of ductus arteriosus, cytotoxic drugs are discontinued as they are teratogenic. Hydroxychloroquine can be safely continued and withdrawal may precipitate flare, also aspirin, prednisolone and azathioprine should be continued.

SLE flare in future pregnancies may be treated with new or increased doses of steroids.

If the SLE is associated with APS, or history of DVT in between or during previous pregnancies treatment with aspirin and LMWH throughout pregnancy up to 6 weeks postpartum may improve outcome of pregnancy.

Women with history of fetal losses with no APS should be screened for genetic causes of hypercoagulability as factor V Leiden, Prothrombin mutation and hyperhomocystenaemia.

Treatment with cytotoxic drugs eg. Cyclophospahmide may cause premature ovarian failure and impair future fertility.

Prognosis is worse in women who are from afro-carribean origin or Hispanics than in white patients.



b)

Multidisciplinary care is recommended during the antenatal period including a consultant obstetrician , physician and immuonologist. Or management in joint clinics

Once pregnancy is confirmed base line blood pressure assessment and blood tests for FBC, urine analysis and renal functions , also anti dsDNA and complement tests so as to monitor disease progression afterwards.

Tests for antiphpospholipid antibodies as those carries an additional risk of fetal loss, IUGR, VTE and anti-Ro and anti-La antibodies as those carries a risk of neonatal cardiac block if positive,.

A dating ultrasound scan is arranged at 10-12 weeks to confirm ongoing pregnancy and assess dates so as to accurately assess fetal growth afterwards.

During the first 2 trimesters, monthly FBC or platelet count should be performed as there is a risk of haemolytic anemia, leucopenia and thrombocytopenia, also thrombocytopenia may also be associated with APS, thrombotic TTP, and immune thrombocytopenia, each of which may complicate pregnancy in women with SLE.

At the end of each trimester determination of glomerular filtration rate, urine protein to urine creatinine ratio ,complement test (C3 and C4) and antidsDNA antibody to monitor renal functions and assess disease progression.

Because pre-eclampsia is hard to differentiate from lupus flare as she already may be hypertensive and proteinuric, pointers to renal lupus flare include red cells or red cell casts in urine, hypocomplimentaemia (falling C3 and C4) and rising anti-DNA titre. Pointers of diagnosing pre-eclampsia include rising transaminases and hyper-uricaemia.


Woman should be seen every 2-4 weeks till 28 weeks then weekly afterwards, at each visit measuring of blood pressure and urine testing for proteins is done for detection of pre-eclampsia.

She should be instructed to report any symptom suggestive of disease progression as facial rash, oral ulceration or arthritis.

Detailed anomaly scan is recommended at 18-21 weeks. Ro-positive women should be offered fetal cardiology screening (risk of congenital heart block 1 in 20)

Serial growth scans for detection of IUGR every 2-3 weeks should be undertaken from 24-28 weeks and tests of fetal well being including NST, biophysical profile and Doppler velocimetry started 28-30 weeks.

Repeated MSU and culture is recommended for the risk of UTI especially if on immunosuppressant.

Screening for gestational diabetes is recommended especially in patients on steroid therapy.



























Posted by M E.
a) 25 yr old woman with a history of SLE is planning a preganancy. Discuss the factors relating to her SLE which will influence outcome in a future preganacy.

The staus of her SLE prior to conception, since remission for greater than 6 months is associated with an improved outcome. Active SLE is associated with an increased incodence of PIH, pre-eclampsia, IUGR, preterm delivery, thromboembolism and fetal death.
Her renal status is important since lupus nephritis is associated with increased fetal loss and worsening of her renal disease in pregnancy. Serum Creatinine >140umol/L has a 50% pregancy loss. Pregancy outcome is better if her renal disease is in remission for > 6 months.
Diseases associated with SLE such as antiphospholipid syndrome(APS) worsen pregnancy outcome.There is a higer rate of recurrent miscarriages and thromboembolism. Use of aspirin prior to conception improves outcome.
Drugs used to treat SLE , such a cyclophosphamide and methotrexate cause fetal malformations. Teratogenic drugs should be stopped at least 3 months prior to conception and folic acid commenced.
Presence of antiRo and antiLAaantibodies are associated with neonatal lupus and congenital heart block.
b) Discuss and justify any additional monitoring you would undertake in the antenatal period.
Her antenatal care should be provided by a consultant led obstetric team in conjunction with the rheumatologist, nephrologst and anaesthetic teams.
regular reanl function tests should be performed shince she is at increased risk of renal dterioration. Serial creatinine (Cr)levels performed. In patients with preexisting renal disease monthly 24 hr urine collection for Cr clearance and proteinuria. If proteinuria is present microscopy for red call casts and fragmented red cells are predictive for active renal disease. Serial CBC should be performed since she is at increased risk of thrombocytopenia and anaemia.
dS titres, C3 and C4 levels, since a drop in these levels occur with flares.
A detailed anomoly scan at 20 weeks to rule out congentital malformations. Uterine artery doppler should be performed at this time, since notching is associated with IUGR and placental insufficency. Cardiac anomaly scan at 22 weeks in patients with anti RO and anti La antibodies, since there is a higher rate of congenital heart block. If detected Dexamethasone can be commenced and pediatric counselling is required. Serial growth scans to check for IUGR.
Blood pressure should be monitored at every visit, due to the higher risk of PE. Thrombophilia screen should be carried out especially in APS pt and those on LMWH.
Posted by Dr Saritha M.
a)
The women is counselled that pregnancy outcome is good if the disease activity is quiescent for atleast 6 months prior to conception. During pregnancy lupus will improve in about third of women or remains unchanged in third of women and worsens in third of women and can occur at any stage of pregnancy and post partum. If active renal involvement manifested as proteinuria, hypertension, pregnancy is at increased risk of pre eclampsia,preterm delivery otherwise outcome will be good.Women also sreened for anti phospholipid antibody, if associated has increased risk of miscarriage, IUGR, stillbirth, pre-eclampsia. Obstretic history is enquired about the previous pregnancy- mode of conception, pregnancy outcome, any history of previous child with nenatal lupus, congenital heart block because of increased recurrence of 15% if one child affected and about 50%if two children are affected. Drug history in detail as few drugs will cause lupus like syndrome eg, procainamide, methyldopa, phenobarbital,hydralazine, quinidine. Drug induced is transient and reversible with discontinuation of the drugs.
Adequate counselling to control the disease is essential prior to pregnacy.
B)
Ante natal care is carried out in a multidisciplinary unit involving consultant led care, Physician, hematologist. Maternal monitoring for pre eclampsia, pre term labour and lupus flare. Baseline test includes urine dipstick protein analysis, Blood urea and Serum creatinine, complements c3, c4, Anti nuclear antibodies, Anti double stranded DNA,Anti Sm antibodies,(relatively specific for SLE) Ro and La anti bodies (for history of congenital heart block),
Anti phospholipid antibodies including lupus anticoagulant and anti cardiolipin antibody. Hematological screening for anemia, thrombocytopenia and leukopenia and also evidence of hemolysis.
Serum transaminases for hepatic involvement. check for BP.
Her ante natal care includes early identification of lupus flare with ckinical features and with serology, pre eclampsia by regular monitoring of blood pressure, look for proteinuria new- onset, worsening, overt proteinuria, if associated with hypocomplementemia, red cell cast indicates renal flare. if associated with hyperuricemia indicates pre eclampsia. signs of pre term labour should be looked for.
Fetal risk includes prematurity, growth restriction, increased risk of still birth, and neonatal lupus, congenital cardiac anomalies.
Fetal monitoring includes dating scan, and detailed anomaly scan at 20 weeks with fetal medicine specialist, Fetal echo cardiography at 18-24 weeks for cardiac anomalies especially for heart block and cardiac arrythmias in 3% of cases. Serial growth monitoring for IUGR and evidence of compromise with umbilical artery doppler.
Review of treatment: If on Non steroidal anti inflammatory drugs advised to discontinue after 24 weeks because of risk associated with premature ductus closure. If she is on low dose aspirin can continued through out pregnancy.If the severity supervenes it is treated with pulse therapy with corticosteroids intially and continued with maintainence therapy. women is screened for gestational diabetes in pregnacy if on steroids.
Azathioprine and cyclophosphamide is less toxic and is advised in life threatening situation.If she is on hydroxychloroquine she is advised to continue in pregnancy as it is not teratogenic and with drawal causes flare up.
woman is provided with written information leaflets, and plan of care is documented . Women is explained about adverse paerinatal outcomes and morbidity associated with the disease.
Posted by S M.
A 25 year old woman with a history of systemic lupus erythematosus (SLE) is planning a pregnancy. (a) Discuss the factors related to her SLE which will influence outcome in a future pregnancy [10 marks]. (b) Discuss and justify any additional monitoring you would undertake in the antenatal period [10 marks

SM
a) Active disease 6 months prior to and at conception is an important factor since it increases the risk of miscarriage, intrauterine growth restriction, preterm delivery and stillbirth. The presence of anti Ro and anti La factors increases the risk of congenital heart block in the fetus. Hypertension or lupus nephritis worsen the prognosis. The use of drugs such as cyclophosphamide may have teratogenic effects whereas NSAIDS cause premature closure of the ductus.

b) The woman should be monitored by a mutlidisciplinary team including a consultant obstetrician and physician. Serial ultrasound scans should be done to identify fetal growth restriction. Fetal chocardiogram should be done to identify heart block. C4, dsDNA should be done monthly to identify active disease and flare ups. renal function test should be done for early identification of abnormal renal function.
Posted by SUNDAY A.
Sunday answers.

a) The factors that would influence her pregnancy would include the duration of the diagnosis, present symptoms and current medication and mangement of her pregnacy in a joint Obtestric/ medical clinic the with physician, obstetrician, midwives making their input to achieve the best outcome. Pregnancy is best planned during remission and prenancy outcome is influenced by present renal function with a good outcome if creatinine levels are less than 125mmol/l but a less favourable outcome if levels are higher. Present medication can also influence the pregancy as some of the medication used in SLE may not be ideal in pregnacy particularly in the 1st trimester. Drugs such as azathioprine can still be used. Associated symptoms such as joint pains, skin eruptions etc can also affect the patient\'s ability to cope during pregnancy. Previous pregnancy and outcome can also indirectly influence the prognosis of any planned pregnancy and folic acid 5mg daily should be commenced during this period.

b)Monitoring during the antenatal period would include request for a dating scan to give an accurate EDD and exclude any gross anomaly in the 1st trimester. Serum screening would also be discussed and patient\'s preference taking into consideration. I would explain that these are screening test and a clear plan of action should be borne in mind incase any test came back positive. A routine anomaly scan at 18-20 weeks is justified as its a high risk pregnancy and i would request for a fetal echocardiogram at 24 weeks with uterine artery dopplers to rule out any risk of congenital heart block in the fetus and palcenta insufficiency respectively. A growth scan from 24 weeks every 4 weeks would also be requested with liquor volume and umbilical artery velocimetry to detect any growth restriction which might require early intervention or steroids administartion after 24 weeks. Regular bloods inculding FBC, U/Es, LFT done every 2- 4 weekly interval would be requested to check renal and liver function and rising creatinine levels may indicate a lupus flare in pregancy. BP monitoring would also be indicated in this patient and at times symptoms of pre-eclampsia may be complicate pregnancy and it may be difficult to differentaite this from a lupus flare. Renal biopsy would not normally be recommended in pregnancy.
Posted by laura H.
This woman will be advised that pregnancy in remission at least 6 months will reduce risk of flare in pregnancy. However, pregnancy will lead to flare of SLE in 50–70% of woman. Review her drugs profile to stop teratogenic drugs such as methotroxate and cyclophosphmide 3 months before pregnancy. NSAID associated with fetal renal impairment necrotising enterocoloitis and early closure of ductus arteriosis and ACE is nephrotoxic they will be stopped. She will be also encouraged continuing with drugs that are shown to be safe and their stop may precipitate flare such as hydroxychloroguine, azothioprine and prednisolone. Woman her medical and obstetric history will be reviewed and will be investigated for complication of SLE. Lupus nephritis increase obstetric complication such as preeclampsia, prematurity both iatrogenic and spontaneous and stillbirth. Pre pregnancy creatinine and presence of hypertention and protienuria are good predictors for outcome. Creatinine of more than 125mmol/l associated with poor pregnancy outcome and it cause thrombocytopenia that is risk for PPH. It also associated with nephrotic syndrome which is risk factor for VTE. Untreated Women with APL antibody have only 10% chance of live birth rate, they have risk of recurrent miscarriage, IUGR, prematurity and still birth. Presence of APL is risk factor for sever and early onset preeclampsia and both arterial and venous thrombosis. If this woman has anti Ro & lo she will counsel about the risk of 1-2% of congenital heart block that is increase parental morbidity and mortality and other such as 5 % transient photosensitive neonatal cuteneous lupus and rarely neonatal thrombocytopenia. If she has Long term use of prednisolone makes this her brone to complications such as diabetes and infection. She will advice to book early and take folic acid pre pregnancy
(b)This woman antenatal care will require multidisplinary team involve obstetrician, rheumatologist, neonatologist and midwife. She will require frequent antenatal visit so early detection and treatment of flare, so she will require 4 weekly till 28 weeks and 2 weekly till 36 and then weekly thereafter. I would ask for baseline investigation in booking visit, FBC include plat,ESR, urine analysis and C/S, urea and electrolyte and s.creatinine and if protein urea detect she will require 24 hours protein collection. Full antibody profile (anticardiolipin, lupus anti coagulant, ANA, dsDNA, smith, and Ro & La). Serum C3&C4. Every visit I will check her B/p, to optimise it with anti antihypertension or to detect preeclampsia and superimposed hypertension. I will look every visit for raised anti dsDNA and decreased C3&C4 which indicate flare and in case of lupus nephritis presence of fragmented RBCs and RBCs cast in urine and thrombocytopenia will also indicate disease activity.
If she has APL I would offer her low dose aspirin and prophylaxis LMW heparin from first teamster that will improve live birth by 70%.
I would ask for Dating Ultrasound at booking as she is at risk for both IUGR and preterm labour and anomalies scan at 18-20 weeks and then regular growth scan. Woman with Ro &La will require fetal echocardiography between 24 and 30 weeks to look for heart block. I would also do Doppler u/s for uterine artery it will be useful to predict woman with poor outcome umbilical artery Doppler and biophysical profile for fetal with IUGR.
Posted by Ron C.
RnRn

A.
SLE is a multisystem disease characterized by flares of disease activity. Flares are more common in pregnancy. Outcome of pregnancy is difficult to predict, but disease activity in previous pregnancies give some indication. Major problems are increased risk for miscarriage, IUGR, fetal death, pre-eclampsia & premature delivery. These are most likely if conceived during active disease, and in those with anti-phospho-lipid antibodies, or in renal involvement (even if in remission) and especially if hypertension and/or proteinuria are present. Mothers who have anti-Ro and/or anti-La-antibodies may have neonates with congenital cutaneous lupus (5%) or congenital heart block (2%).
When counseling, current disease status has to be taken into account; except in renal involvement and anti-phospholipid antibodies, above risks are probably not different from background population if they had been in remission >6 months prior to conception, and therefore it is advised not to conceive till >6 months in remission. How medication will affect pregnancy & breastfeeding is a different issue. NSAID’s in higher doses may cause hemorrhage in fetus or mother and after 32 weeks may cause premature closure of ductus arteriosis. Corticosteroids are best continued to avoid flares following stopping, and may reduce need for NSAID. Antimalarials like choloroquine are also best continued to avoid flares and are safe in pregnancy. Azathioprine can also be used in pregnancy and may reduce need for corticosteroids. Cytotoxic medication such as methotrexate, penicillamine or chlorambucil are contra-indicated in pregnancy, as they are terattogenic.

B.
Management is multi-disciplinary with joint monitoring of disease by obstetrician & physician (rheumatologist / nephrologist). Ideally baseline bloods are taken to assess disease activity, and subsequent regular blood samples are taken and compared to baseline bloods as they may identify flares, and the intervals depend on clinical disease activity. Full blood count may show decreasing Hb, platelets or white blood cells. Renal function test may show rise in creatinine & uric acid indicating worsening lupus nephritis. Liver enzymes may increase in development of pre-eclampsia. Rising CRP, anti-ds-DNA titres or a drop in C3 &C4 >25% may indicate a flare. Anti-Ro, anti-La and anti-phospholipid antibodies are only done as baseline. As pre-eclampsia is more common, blood pressure is closely monitored and proteinuria is checked on every visit. Increase or new onset proteinuria must be quantified with creatine-protein-ratio or 24-hours sample. In renal involvement sediment must be assessed for erythroctes & cell casts every trimester to identify flares. As IUGR and fetal death risk is -increased, after 20-weeks scan umbilical cord Doppler is done 4-weekly and growth at 28-32 and 36 weeks. During scans any heart block in women with anti-Ro or anti-La antibodies can also be picked up.
Posted by A H.
AH
a) The presence of antiphospholipid antibodies (lupus anticoagulant and anticardiolipin antibodies) are associated with an increased risk of spontaneous miscarriage, intauterine fetal death, preterm delivery and pre-eclampsia.
Renal involvement especially if associated with hypertension and proteinuria is also associated with pre-eclampsia and poor fetal outcome. Quiescent lupus may also be associated with fetal loss and development of pre-eclampsia.
If conception occurs during a flare or within six months of a flare there is an increased risk of disease reactivation during the pregnancy.
The presense of anti-Ro and anti-La antibodies is associated with an increased risk of neonatal lupus syndrome. This can manifest as either neonatal cutaneous cutaneous lupus wih onset within two weeks of birth and may resolve by two years of age, or congenital heart block. The latter is more frequently associated with anti-Ro antibody, devops in-utero and has a high mortality rate.

b) This patient will be monitored jointly by an obstetrician and a physician, preferably one trained or who has an interest in caring for pregnant patients with SLE.
At booking, baseline serum urea, electrolytes and creatinine will be done. Urine will be tested for protein and if present quantification using a 24 hour sample. These will be done for assessing risk as well as a baseline for monitoring, if symptoms of a flare or of pre-eclampsia develops. A high serum creatinine (more than 250 micromols per litre) is associated with a greater risk of a flare.
Hypertension at booking is associated withan increased risk of developing pre- eclampsia. Close surveillance of blood pressure and urine for proteinuria will be done. Also, uterine artery doppler waveform at 20 to 24 weeks will be done as a screening test for pre-eclampsia. In order to faciltate its proper timing, an early dating scan will be done.
Serial fetal growth paramters, liquor volume and umbilical artery doppler waveform will be done from 24 weeks gestation to detect fetal growth restriction and placental insufficiency. The frequency of this monitoring will depend on the severity of any abnormality in these parameters.
If fetal bradycardia is detected a fetal cardiac ultrasound will be done to detect congenital heart block. If present, serial ultrasound to detect features of heart failure will be done so that treatment can be started as soon as possible .
In the presence of reduced end diastolic flow, biophysical profile and twice weekly CTGs will be done while awaiting proper timing of delivery (achieving viability, availability of a cot in NICU or administration of maternal steroids to reduce the risk of respiratory distress syndrome or intraventricular haemorrhage).
Posted by Maayka ..
maayka
(a) A patient with SLE is more prone to flares, which may be difficult to recognize from normal physiological changes in a pregnancy. SLEis more likely to result in increased miscarriages, intrauterine growth restriction (IUGR), pre- eclampsia d pre- term delivery if a pregnancy occurs. The likelihood of these occurring is related to the patient’s state of disease at conception. If in remission for at least 6months, outcomes are better than if conceived while having active disease or within 6 months of active renal lupus. The baseline renal status will determine the chance of renal nephropathy worsening but generally, if normal at start of pregnancy it does not lead to progression to lupus nephritis. The patient’s screening for anti- Ro andante- La antibodies (Abs) will determine the likelihood of flares in the pregnancy, this is increased as well as that of fetal effects like cutaneous lesions which are transient or of congenital heart block (CHB). CHB may be diagnosed antenally or following delivery on examination of the neonate. The nee for corticosteroids and the duration from last use will determine the likelihood and frequency of the patients’ relapse.

(b) The SLE patient should be seen in a joint clinic with a physician and obstetrician. Early booking will allow assessment of the patient’s status of remission or active disease, the latter requiring closely monitoring and treatment with corticosteroids. Baseline blood investigations will include a full blood count - to check for anaemia (normochromic, normocytic), thrombocytopenia; urea and electrolytes, uric acid and serum creatinine – to check renal function; urine culture and microscopy – to rule out red cell casts which will indicate active disease. Also, complement levels of C3, C4, if falling will suggest active disease. The presence of anti- Ro and anti- La Abs should be determined to know the likelihood of fetal/ neonatal involvement and risk of relapse.
The patient should be advised to avoid sunlight to avoid skin manifestations, if present, worsening. A uterine Doppler at 24 weeks will be a screening tool for risk of pre- eclampsia (PE).Likewise her BP, urinalysis and 24 hr urine protein collection if suspected PE. Umbilical artery Doppler should be routinely assessed from 24cweeks gestation because of increased risk of IUGR. A fetal heart rate at each visit from 18 weeks may detect a fetal bradycardia and if possible fetal echocardiography to detect possible CHB.
If flares do occur, the use of corticosteroids is necessary and depending on the symptoms like joint pains and haemotological problems, to treat accordingly.