Postpartum period in women with systemic lupus erythematosus BY DR KH ELMIZADEH

Some women will experience exacerbations of SLE in the postpartum period. Those who have had active disease at conception Those with significant end-organ damage at greater risk of disease flares in the postpartum period Thus, periodic assessment of disease activity is warranted postpartum. The following laboratory tests are recommended at one month following an uncomplicated delivery.

Postpartum laboratory testing ●Urinalysis, urine protein/urine creatinine ratio ●Renal function if the urinalysis is abnormal ●CBS ●Anti-dsDNA ●Complement (CH50, or C3 and C4)

Treatment of postpartum women with active SLE is the same as that of nonpregnant women. Many medications are not compatible with breastfeeding; thus, breastfeeding women will require thoughtful discussions with their clinicians as to the risks and benefits of various treatment approaches. Medication safety in pregnancy differs in many instances from medication safety in lactation

BREASTFEEDING — Breast feeding is encouraged for most women with systemic lupus erythematosus (SLE). The safety of medications in lactation and their use should be discussed on an individual level and specific risks reviewed. HydroxychloroquineHydroxychloroquine, prednisone, azathioprine, and tacrolimus are considered compatible with breast feeding.prednisoneazathioprinetacrolimus MethotrexateMethotrexate in low or intermittent doses is also considered compatible with breast feeding. Limited information on leflunomide is available. Cyclophosphamide is contraindicated in lactation.leflunomide Cyclophosphamide Premature or ill infants may be at increased risk of some medication exposures.

Rheumatoid arthritis and postpartum care

Postpartum flare — Approximately 90 percent of patients flare during the postpartum period, usually within the first three months. In addition, one study suggested an increased risk of developing RA in the first three months postpartum, particularly after a woman’s first pregnancy. Many clinicians advocate reintroducing medications in the immediate postpartum period because the stress of caring for a newborn can be compounded by the possibility of an RA flare.

Breastfeeding — Some clinicians believe that breastfeeding increases the risk of RA, that this effect is mediated by increased prolactin levels associated with the postpartum state, and that the risk is higher following first pregnancies.The interpretation of these data is difficult because of the known association between disease flare and the immediate postpartum period, the time in which breastfeeding begins. The observation that lactation exerts a protective effect against the development of RA clouds this issue further.

Medication use during breastfeeding — Many of the same restrictions on medication use during pregnancy apply also to breastfeeding mothers. ● NSAIDs can be used, but aspirin should be avoided.aspirin ● Prednisone can be taken in low doses. In patients taking 20 mg/day or more, it is recommended to wait four hours after the dose prior to nursing. Prednisone ● Azathioprine, cyclosporine, cyclophosphamide, methotrexate, and chlorambucil should be avoided in nursing women. Azathioprinecyclosporinecyclophosphamide methotrexatechlorambucil

Post partum care in Antiphospholipid syndrome

Women with laboratory criteria for aPL and a prior history of arterial or venous thrombosis are at high risk of recurrence and are generally on lifelong anticoagulation with warfarin, which should be resumed postpartum.warfarin

● For women with acute venous thromboembolism (VTE) who are still in the active treatment period concurrent unfractionated heparin or low molecular weight (LMW) heparin at therapeutic doses should be administered along with warfarin for a minimum of five days and an additional one to two days after an appropriate International Normalized Ratio (INR) has been obtained.unfractionated heparinwarfarin The unfractionated heparin or LMW heparin can be resumed four to six hours after vaginal delivery or 6 to 12 hours after cesarean delivery, unless there was significant bleeding.unfractionated heparin

There are no high-quality data to guide postpartum management of women with APS and no history of prior thrombosis or women with aPL alone. Whether to begin or continue anticoagulation in all or selected groups of these women is controversial In women receiving antepartum low-dose ASA and heparin regimens, we continue the regimen for six weeks postpartum.

In contrast, the ACCP Evidence-Based Clinical Practice Guidelines concluded that women with aPL and no personal or family history of thrombosis are probably not at increased risk of developing pregnancy-related venous thrombosis, but suggested postpartum anticoagulation for those with a family history of thrombosis

We initiate prophylactic doses of unfractionated heparin or LMW heparin 6 to 12 hours after vaginal delivery and 12 to 24 hours after cesarean delivery.

Duration of postpartum anticoagulation The duration of postpartum anticoagulation depends upon the underlying reason for anticoagulation. ● Women receiving anticoagulation for VTE prophylaxis during pregnancy should continue to receive anticoagulation for at least six weeks postpartum, due to the continued high risk of VTE in the early postpartum period.

In the presence of VTE The total duration of anticoagulant therapy (pregnancy plus the postpartum period) should be at least three to six months for women whose only risk factors for VTE were transient (eg, pregnancy, cesarean section). Anticoagulant therapy generally continues for at least six weeks postpartum. Patients with persistent risk factors for VTE may require a longer duration of therapy.