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MRCOG PART 2 SBAs and EMQs

MRCOG Part 2, MRCOG 2

Course PAID
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ESSAY 210 - SLE & Pregnancy

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		Posted by neera B. Tue Aug 22, 2006 02:20 pm
Ask her whether she is having acute exacerbation, such as fever , joint pains, rash, renal disease. I would advise her that she conceives during remission because this is associated with fewer complications. Her present medications would be asked. I would tell her that steroids, cyclosporin and azathioprine are safe but cytotoxic drugs should be stopped before pregnancy due to teratogenic effects. She would be sdvised booking under a consultant , a multidisciplinary team including a clinical immunologist, senior obstetrician, senior neonatologist, GP, and a experienced midwife should look after her. Blood tests for assessing renal function, antiphospholipid antibody, lupus anticoagulant, platelet count, FBC, would be done now and serially during pregnancy. she should book early and emphasis on regular antenatal visits would be laid.I would explain that SLE exacerbation is more likely in pregnancy. Increased miscarriage, recurrent miscarriage, IUGR, late fetal death, intrauterine fetal death, preeclampsia, renal compromise, prematurity, are seen with SLE, but fetal cardiac block , endocardial fibroelastosis and neonatal lupus may occur if anti Ro and anti la antibodies are present. If antiphospholipid antibody and lupus anticoagulant are present , past history of arterial and venous thrombosis is present, LMWH antenatally and 6 wks postpartum is recommended . Careful watch on blood pressure and urinary protein is essential due to risk of pre eclampsia. Perinatal mortality and morbidity are increased. Dating scan at 10 - 12 weeks, fetal ECHO at 22 wks, anomaly scan at 18-20 wks, 2 wkly growth scans and color doppler from 24 wks onwards are recommended. If fetal / maternal compromise is found antenatal steroids are given and early induction / CS may be needed. If there is no compromise she is allowed vaginal delivery at term. Caesarian is for obstetric indication only. Breast feeding on steroids, azathioprine, and cyclosporin is safe. Neonatal ECHO for cong. heart block and follow up with neonatologist is required as 5 % have neonatal lupus. Contraceptive advise is given . Follow up visit is arranged. Information leaflet is given.
		Posted by Vinayak B. Tue Aug 22, 2006 03:42 pm
Systemic lupus erythematosus is autoimmune coneective disorder with multiorgan involvement. It has active phase (flare ups) and remissions. Patient should conceive during disease remissions to avoid pregnancy complications such as missed abortion , Iugr. Pregnancy outcome improves if she is on minimum maintainance drug doses or off dru gs . If active disease should use contraception. Till remission occurs Assessment of renal function required If she has recent Lupus nephritis flare up , should avoid pregnancy atleast for 6 months . Hypertension should be controlled and serum creatinine less than 125umol/l is associated with better pregnancy outcome, as suggestive of mild moderate renal involvement.. . During pregnancy requires multidisciplinary care with physician to adjust doses, treat flare ups . Renal physician contribution if kidneys are involved. SLE nephropathy may manifest first time during pregnancy . Frequent antenatal visits. SLE may falre up during pregnancy and drugs has to be restarted. She is at risk of Pregnancy induced hypertension. Renal flare ups or hypertension. NSAIDs non teratogenic should be stopped at 32 34 weeks due to prmature closure of ductus arteriosus. Predinisolone does not cross placenta and not teratogenc if she is on azathioprine can continue during pregnancy. Thereis no role for prophylactic drugs to prevent flare ups.she is high risk for thrombosis if associated with secondary phosphor lipid syndrome.Need of thromboprophylaxis during preg nancy and in puerperium. Discussed with her. She has increased . risk of miscarriage, Intrautrine growth restriction,Intrutrine death.preterm labour ., needs fetal monitoring with usg, Doppler assessment and early induction. Fetus is at risk of intrauterine complete heart block due to passage of Anti Ro AntiLa antibodies affecting nerve conduction. Need of pace maker throughout life. With increased perinatal mortality during intrapartum and post partum period . In first two weeks neonatal lupus syndrome is known due to transplacental passage of maternal antibodies affecting fetal skin . Usualy they disappear within 6 weeks without treatment. They are photosensitive hence exposure to sun avoided. Leaf lets are given and information about SLE support group given .
		Posted by Srivas P. Tue Aug 22, 2006 06:12 pm
I would tell her that SLE with pregnancy is high risk pregnancy and she must book into a consultant unit and get multidisciplinary care involving her physician, neonatologist, general practitioner and nurse specialist. Her pregnancy should be a planned event, during remission of disease activity, to avoid flares and exacerbations which affect maternal and perinatal morbidity and mortality. I would go through her records to see her reports for titres of Anti- ds DNA, anti sm which are very specific for SLE and an initial high level may precede a lupus flare and pregnancy should be postponed till the disease activity is controlled. I will see her anti-Ro/SS-a and anti La/SS-B which can be associated with neonatal lupus erythematosis. Her disease is likely to worsen in first 20 weeks of pregnancy and in the immediate post partum period. I will find out the drugs she is taking to control her SLE. Azathioprine is safe in pregnancy and she may continue but drugs like methotrexate, chlorambucil, and cyclophosphamise are teratogenic and fetotoxic and should be stopped atleast 3 months prior to planned pregnancy. Antimalarial like chloroquin are best avoided in pregnancy as they can cause eye damage. NSAIDS are avoided over prolonged period due to unfavorable fetal side effects?ICH, constriction of fetal ductus arteriosus and oligohydramnios and codeine is preferred. The decision on which drug and when to stop should be taken by her physician. She may benefit by LDA throughout pregnancy after 1st trimester, to prevent pre eclampsia especially if she has pre existing renal disease. She will need to be assessed for anaemia, thrombocytopenia, and baseline renal function. Her urine analysis serum creatinine, 24 hr urine creatinine clearance and total protein and Antiphospholipid antibodies should be obtained. I will tell her that there is 50% chances of some renal involvement in pregnancy and she may present with proteins in urine along with cellular casts, blood in urine , hypertension and pus in urine and may need to be put on corticosteroids to control it but permanent deterioration in her renal status is less than 10%. Throughout her antenatal period she should be seen by her physician every 2 weeks in 1st and 2nd trimester and weekly after that and should be assessed for flare by history and urine for blood and protein and regular ANA antibody levels. I will tell her that during her pregnancy she has increased chances of spontaneous abortions. PTD, PROM, IUGR, hypertensionand fetal death and these effects may be directly related to her antiphopholipid antibody levels and occurance of flares. High dose prednisolone given to control may also precipitate hypertension and hyperglycaemia. She would need blood glucose monitoring at regular intervals, at 22, 28 and 34 weeks Very rarely her baby too may get NLE with 5% chance and get skin lesions or sometimes congenital heart block and this may be detected by fetal bradycardia by USG and fetal surveillance is started 4 weekly from 20 weeks onwards if she shows evidence of flare, IUGR, hypertension. This includes CTG, Doppler recordings and amniotic fluid volume During labor she may need high doses of I/V hydrocortisone. She would need continuous fetal monitoring and Neonatologist should be present to deal with potential IUGR or Congenital heart block. Post natal watch for exacerbation of her condition should be kept with appropriate medications given. I will emphasise the importance of compliance with regular AN care and medication and immediate call back anytime she has complaints. She may need prolonged hospitalization for which she should be prepared.
		Posted by Balakrishnan V. Tue Aug 22, 2006 09:00 pm
The aim of prepregnancy councelling of this patient with SLE is to determine her risks and optimise her health before pregnancy to ensure better maternal and fetal outcome. Counselling of this patient will depend upon severity of her disease, whether she is in remission or ongoing active disease, renal function at time of conception and presence of co morbidities like hypertension or proteinuria. Pregnancy outcome is better if conceived in remission period as chances are that disease will remain quiscent during pregnancy avoiding high doses of medications. She should be adviced to continue the contraception till this is achieved. Her medications may need to be changed once her disease is in remission with her renal physician\'s advice. NSAIDs are discontinued in pregnancy. Hydreochloroquinine and Azathioprine are asociated with intrauterine growth restriction. Pridnisolone causes neonatal adrenal insufficiency and thymic hypoplasia. But the patient should be councelled that benefits of continuing these drugs outweigh the risks of discontinuation i.e disease flare. Basic investigations include a full blood count to diagnose anaemia associated with chronic disease. If present will require treatment. Renal functions are assessed by U&E, creatinin clearance and 24 hours urinary protein. Autoantibodies ( antinuclear antibody, anti-Ro and anti-La ) measured as these determine risk of postnatal fetal problems. Close laision with her renal physician, general practisioner, paediatrician and midwife will ensure better antenatal, labour and delivery outcome. She is councelled regarding maternal risks of PIH, preeclampsia, worsening of renal functions and disease flares during pregnancy needind preterm delivery. Close monitoring of BP, U&E, proteinuria is adviced during pregnancy but preeclampsia is difficult to diagnose if there is already high bloodpressure, proteinuria and oedema. Fetal risks are IUGR, stillbirth, congenital heart block (2% risk if anti Ro positive) and cutaneous neonatal lupus. Detailed cardiac scan adviced at 22 weeks. Serial growth scan are required after 24 weeks if their is suspicion of IUGR. If preterm delivery indicated due to uncontrolled bloodpressure or deterioratind renal function antenatal steroids are given for fetal lung maturity. Hospital delivery is adviced. There is no contraindication of vaginal delivery. In labour dehydration as well as fluid overload should be avoided by strictly monitoring of intake and output. Intravenouse steroids and antibiotics are needed. Neonatologist should attend the delivery and observe the baby for congenital heart block and cutaneous neonatal lupus. There is no contraindication to breast feeding. Proper contraception should be given. Renal physician should be consulted for reintroduction of medication.
		Posted by Ismatara B. Wed Aug 23, 2006 07:07 am
SLE is a multisystem autoimmune disease which predominantly affects women in their child bearing age. A young lady with SLE who wants to conceive faces a number of risks to her health and unborn child. A severe disease flare may be life threatening, some drugs are teratogenic and fetotoxic. The risks may be minimized by appropriate timing of pregnancy and adjustment of drugs prior to conception. She should be counseled about maternal and perinatal outcome regarding SLE. Ensure that she can understand the problem that may arise during pregnancy with SLE. A full history should be undertaken weather she is in remission or in active disease requiring treatment. She should be advised to become pregnant during remission phase, as the risk is greater for women with active disease within 6 months of conception and the disease does not influence in pregnancy in period of remission for at least 6 months. A treatment history should be taken. If she is with APL aspirin (75mg daily) should be started preconceptually and continued. It is safe during pregnancy. Prednisolone and Azathioprine are safe in pregnancy, so she can continue if she is on. Non Steroidal antinflammatory agents are not teratogenic. But it may cause premature closure of ductus arteriosus, if used in third trimester. Hydroxychloroquine can be continued, safe in pregnancy and withdrawal may precipitate flare.Cyclophosphomide is contraindicated in pregnancy. So should be switched over to other drug. Basic investigation should include a FBC to ascertain weather anemia associated with chronic disease, may need haematinics, or any haemolytic anaemia. Urea and electrolyte should be measured to determine renal function and if an abnormal urinanlysis, 24 hr urinary protein and creatinine clearance should be done. Antiphospholipid antibody, Ro, La, smith and cardiolipin antibodies should also be measured, as this will determine the fetal risk of postnatal problem. The prognosis is associated with serum creatinine levels> 132mmol/L being associated with a 50% fetal loss if lupus nephritis. If the disease is in remission,with no renal involvment and no Anti-Ro antibody and anti-La antibody, She should be reassured that there is no adverse effect on pregnancy. Pregnancy should be deffered, if she is in active phase with renal involvements, antiphospholipid, anti-Ro and La antibodies and immunosuppressed therapy increased the risks with miscarriage, IUGR, fetal loss, maternal venous and arterial thromboembolism, preeclampsia, prematurity, thrombocytopaenia, placental abruption and anxiety. At the same time folic acid and rubella vaccination should be given preconceptually to prevent NTD and rubella. She should be managed involving a multidisciplinary team with senior obstetrician, ultrasonogrpher, haematologist, physician, community MW, GP. She should be booked earlier under consultant care. More intensive maternal monitoring at every 2-4 wks in early pregnancy and weekly from 24-28 wks if everything is going well. Her pulse, BP, pallor, weight gain, and urine analysis should be checked in each antenatal visit. Monthly measurement of dsDNA, complement, urea and electrolyte and FBC should be done. Fetal monitoring with dating scan, detailed anomaly scan at 20 wks, growth scan from 24wks-2-4wkly, CTG, BPP and umbilical artery Doppler should be done at regular interval. In disease flare or if hypertension more regular in patient fetal monitoring will require by serial growth scan and fetal cerebral blood flow redistribution if suspected IUGR. Hypertension should be treated with methyldopa, labetolol and nifedipine is other alternative. Deterioration in renal function may necessiate early IOL. If the disease flares during pregnancy, corticosteroid should be started or increased the dose if she already took. Azathioprine may be started in resistant case. If anti-Ro antibody is positive, risk of congenital heart block in 2% fetus or neonatal cutaneous discoid lupus. Most commonly in 18-30 wks, and permanent and require postnatal cardiac pacing. Fetal echocardiography is indicated at that time. Discoid lupus develops within first 2 wks of life and usually resolves within 6 months. Aim for vaginal delivery at term unless fetal compromise or preterm delivery is indicated. Anaesthetic review should be done with senior anaesthesist, epidural is not contraindicated. Continuous intrapartum fetal monitoring should be done. Neonatologist should present during delivery to look for congenital heart block and other abnormality. She is at high risk for thromboembolism, so thromboprophylaxis (early ambulation, good hydration, TED stocking, LMWH/warfarin) according to hospital protocol should be given. Breastfeeding is not contraindicated. Contraceptive advice should be given. Information leaflet should be provided and to achieve the best outcome, pregnancy should be planned with an agreed management plan in full consultation with the woman prior to conception.
		Posted by Aroosha B. Wed Aug 23, 2006 07:52 am
SLE AFFECTS WOMEN MORE THAN MEN (15:1) PARTICULARLY DURING THEIR REPRODUCTIVE YEARS. A WOMAN WITH SLE WHO WANTS TO BECOME PREGNANT FACES A NUMBER OF RISK TO HER HEALTH AND THAT OF HER UNBORN CHILD. THESE RISKS CAN BE MINIMISED BY APPROPRIATE TIMING OF PREGNANCY BY OPTIMISING HER CONDITION PRE CONCEPTIONALLY SO THAT SHE ENTERS HER PREGNANCY DURING REMISSION. SHE SHOULD BE TOLD THAT SLE FLARES IN PREGNANCY CAN BE HARMFUL FOR HER AND HER BABY AND THE RISK OF FLARE IS LEAST IF SHE HAS BEEN IN REMISSION FOR AT LEAST 6 MONTHS BEFORE CONCEPTION. TILL THIS GOAL IS ACHIEVED, SHE SHOULD BE ADVISED APPROPRIATE CONTRACEPTION. THE INCIDENCE OF FLARES IN 54% TO 73%, USUALLY MILD BUT CAN BE LIFE THREATENING. OTHER RISKS TO MOTHER ARE PET. ABRUPTION AND THROMBOEMBOLISM. RISKS TO FETUS BY AN UNCONTROLLED DISEASE INCLUDE MISCARRIAGE, FETAL DEATH, PRETERM DELIVERY AND NEONATAL LUPUS. THE POOR OUTCOME IS RELATED TO THE COMPLICATIONS ASSOCIATED WITH SLE I.E. RENAL DISEASE, HYPERTENTION, ANTIPHOSPHOLIPID ANTIBODIES AND ANTI RO/LA ANTIBODIES. IF HER CONDITION IS OPTIMISED, FETAL RISKS ARE MINIMAL ALTHOUGH NOT COMPLETELY ELIMINATED. SHE SHOULD BE MANAGED CONJOINTLY WITH A PHYSCIAN AND HER DRUG THERAPY OPTIMISED. SHE SHOULD BE OFFERED BASELINE INVESTIGATIONS I.E. FBC, RFT, LFT, APLA,URIANALYSIS, 24 HRS URINE PROTEIN, ANTI RO/LA ANTIBODIES DS DNA AND SMITH A/B AND COMPLEMENT LEVELS. SHE SHOULD BE TOLD THAT RISK OF NEONATAL LUPUS WHICH CAN MANIFEST AS CU LUPUS (5%) WHICH IS TRANSIENT AND NEONATAL DISEASE AND 2% RISK OF CONGENITAL HEART BLOCK WHICH IS FETAL AND PERMANENT. ROUTINE HEALTH ADVISE INCLUDING FOLIC ACID PRECONCEPTIONALLY IS OFFERED. HER RUBELLA STATUS CHECKED AND VACCINATION OFFERED IF NON IMMUNE. A CLEAR MANAGEMENT PLAN FOR HER PREGNANCY IS MADE SHE SHOULD BE TOLD THAT DURING PREGNANCY SHE WILL BE MANAGED BY A MULTIDISCIPLINARY TEAM INVOLVING PHYSCIAN, OBSTETRICIAN, NEONALOGIST, HEMOTOLOGIST, SONOGRAPHER AND MIDWIFE. HER ANTENTAL VISITS WILL INCLUDE AN EARLY BOOKING VISIT FOLLOWED BY FURTHER VISITS DETERMINED BY HER CONDITION. SHE MAY NEED HOSPITALIZATION DURING FETAL ASSESSMENT DURING PREGNANCY WILL INCLUDE ASSESSMENT BY USS FOR FETAL GROWTH, CONGENTIAL HEART BLOCK, DOPPLER STUDIES, FETAL MOVMENTS CHART AND CTGS. IF CONGENITAL HEART BLOCK IS DETECTED, THERE ARE REPORTS OF CONVERSION OF 2ND DEGREE BLOCK TO 1ST DEGREE BY USE OF MATERNAL STERIOD THEREPY. REGARDING DRUG THERAPY DURING PREGNANCY AND LACTATION SHE SHOULD BE TOLD THAT STEROIDS, NSAIDS, AZATHIOPRINE AND HYDROXY CHLOROGUINE CAN BE USED DURING PREGNANCY. NSAIDS CAUSE PREMATURE CLOSURE OF DUCTUS ARTERIOSUS SO HAS TO STOPPED AT 36 WEEKS CYBOFOXICS ARE CONTRAINDICATED IN PREGNANCY AND LACTATION E,G. METHOTREXATE. CYCLOSPORINE ALSO CONTRAINDICATED IN PREGNANCY DUE TO RISK OF TERATOGENESIS. IF SHE HAS APLA, SHE WILL BE GIVEN LOW DOSE ASPRINE THROUGHOUT PREGNANCY BUT IF SHE HAS HISTORY OF THROMBOSIS BEFORE SHE WILL BE OFFERED HEPARIN THERAPY ALSO. SHE WILL BE CONTINOUSLY MONITORED DURING PREGNANCY BY REPEATING BLOOD AND URINE TESTING AND MANAGED ACCORDINGLY. PATIENT IS ALLOWED TO MAKE INFORMED DECISION REGARDING HER CARE AFTER ALL THIS INFORMATION.