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Dr. Anupama Kumar Consultant Rheumatologist Sagar Hospital, Bangalore.

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Presentation on theme: "Dr. Anupama Kumar Consultant Rheumatologist Sagar Hospital, Bangalore."— Presentation transcript:

1 Dr. Anupama Kumar Consultant Rheumatologist Sagar Hospital, Bangalore

2  Biological prerogative of every woman  Pregnancy in lupus is not contraindicated  Many lupus patients deliver healthy babies  Many families at least want one child  Fertility is not affected in patients with lupus

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5  SLE is the most common autoimmune multisystemic disease to affect women in child-bearing years  Prognosis for both mother and baby have important implications during pregnancy  Marriage, pregnancy and childbirth are burning issues for most patients

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7  Characterized by production of antibodies to cell nucleus called ANAs  Who is affected - 90% are young women 90% of them are in 20 to 40 years age group  More patients plan for pregnancy because of improved prognosis

8  Pregnancy outcomes are good when lupus is in remission  Ideally lupus should be inactive for six months  Serious disease such as active lupus nephritis, myocarditis, seizures is a contra- indication  Teratogenic drugs like cyclophosphamide, methotrexate should be stopped six months before conception

9  Lupus patients for pregnancy counseling  Known lupus cases coming for antenatal care  Undiagnosed or misdiagnosed lupus in pregnancy  Asymptomatic pregnant patients who have history of neonatal lupus or concerned antibodies

10  Fatigue and fevers  Arthritis or arthralgias  Malar rash  Serositis  Raynaud’s phenomenon  Proteinuria  Vasculitis  Leukopenia  Thrombocytopenia  Seizures

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14  Complete blood count  Anti Nuclear Antibodies by IF or HEP2  Anti double stranded DNA antibodies  Anti Ro and Anti La antibodies  Complement studies-C3 AND C4  Urine analysis  Renal function tests  Lupus anticoagulant and Anti cardiolipin antibodies

15  Mild risk cases-Mild disease, those who are in remission, on no medication except mild ones  High risk cases-Severe active disease. Major organ involvement,those with Anti Ro or APL antibodies  Moderate risk cases-Majority are in this group

16  H/O Previous pregnancy with complication  Underlying kidney, heart or lung disease  Active phase of the disease  Presence of Anti Ro and Anti La antibodies  A history of previous thrombotic event  APLA  Additional factors like maternal age>40 years and pregnancy with twins or triplets

17 Risks of Lupus to pregnancy  Pregnancy loss  Preterm delivery  Eclampsia  Neonatal lupus due to Ro and La antibodies Risks of pregnancy to lupus  Lupus flares  Progressive renal disease  Maternal thromboembolism

18  Miscarriages(before 20 weeks) is the most common form, averaging about 20%  Stillbirths are especially increased in Lupus - 11%  Neonatal lupus and death due to CHB because of Anti Ro and Anti La antibodies  APS related repeated pregnancy failures

19  Increased lupus activity at conception or during pregnancy  Hypertension  Hypocomplementaemia  Renal disease  Gestational Lupus

20  Spontaneous abortions  IUGR  Preterm delivery  postpartum haemorrhage  maternal venous thromboembolism  Neonatal death due to fetal heart block

21  High blood pressure in the mother after 20 weeks of pregnancy  Occurs in ~13% of women w/ SLE  Tx: DELIVERY  Delivery may be delayed in some women who are less than 34 weeks to give steroids for lung maturity

22  Occurs in about 2% of babies born to mothers with anti-Ro/SSA and or anti-La/SSB antibodies  Caused by passage of the antibodies from the mother’s bloodstream across the placenta to the developing baby after about 20 weeks  Signs of neonatal lupus includes red, raised rash on the scalp and around the eyes that resolves by 6-8 months (because the antibodies clear the blood stream)  SLE complications in babies: complete heart block and learning disabilities  Risk of neonatal lupus in subsequent pregnancy is 17%

23  Fetal bradycardia should be investigated looking for maternal Anti Ro antibodies as mothers may be asymptomatic or may develop lupus later  All suspected neonates should have an ECG as CHB recquires permanent pacing  Subsequent pregnancies have more risk of neonatal lupus

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25  Lupus flares are seen in all trimesters  In mild to moderate lupus, 40% show no change, 40% flare and 20% improve  Flares are more common when disease is active at conception  Renal flares are most feared  Postpartum flares are common as beneficial effect of steroid produced by placenta wears off  The pattern of the diseases activity is usually repeated in subsequent pregnancies

26  Musculoskeletal and cutaneous flares are common and easier to manage by increasing the dose of prednisolone  IV Methylprednisolone may be required for severe flares  Use or continuation of Azathioprine is allowed  HCQ not to be discontinued as it is seen to cause flares

27  Low, but higher than general population  Lupus related deaths are due to  HELLP Syndrome  Thromboembolism associated with APS  Pulmonary hypertension  Infection following severe lupus flare

28  Chloasma or malar rash  Proteinuria of pre-eclampsia or worsening lupus nephritis  Thrombocytopenia in pregnancy (HELLP) or that of lupus exacerbation  oedema and fluid accumulation in joints in late pregnancy or arthritis of SLE

29  Prenatal counseling  Frequent antenatal check up  Monitoring of disease activity-CBC, monthly urine analysis, monthly complements  Fetal surveillance by frequent ultrasound  Patients may need anticoagulation  Combined care: Rheumatologist, Obstretitian and Nephrologist if required

30  Lupus patients are normally fertile  Lupus pregnancies are successful two thirds of the time  Mild to moderate lupus does quite well in pregnancy  Steroids are safe for exacerbation of lupus in pregnancy  Hydroxychloroquine should not be stopped in pregnancy


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