1. Systemic Lupus Erythematosus and Pregnancy Andres Quiceno, MD Rheumatology

2. Case Presentation 28 y/o WF with PMHx of SLE diagnosed in 1993 when presented with thrombocytopenia, arthritis, malar rash and +ANA. Patient was clinically in remission for the last 2 years on Plaquenil. On 9/30/2004 she was evaluated in a routine visit and petechiae were noted in her lower extremities. Patient stated at that time that she was trying to become pregnant.

3. CBC done that day revealed a platelet count of 62K. PMHx: G1 P1C1. Pregnancy was ended at week 36 because pre-eclampsia. During the pregnancy patient received treatment with prednisone 10 mg PO QD. Family Hx: maternal aunt with SLE.

4. Clinical Course 10/4/04 Platelet count 317K, prednisone decreased to 20 mg PO QD. 10/13/04 Platelet count 10K, patient admitted to the hospital, treated with methyl-prednisolone 1 gr IV x 3 and IVIG 1gr/kg/day x 2. Patient was started on azathioprine 50 mg a day. Urine pregnancy test was negative. Instructed to avoid pregnancy because SLE flare.

5. 11/2/04 Patient evaluated because 24 hrs nausea, vomiting and abdominal pain. Patient no missing her period and she denied any sexual encounter since her last admission. Patient sent to the ER for hydration. Pregnancy test ordered there was positive. Beta HCG 11824 U (7-12 weeks pregnancy). Platelet count 32K. Prednisone increased to 100 mg a day.

6. 12/16/04 Admitted to high risk pregnancy service because BP 160/100 and +2 protein in U/A. 14 weeks pregnancy. 24 hrs urine collection 1700 mg. Creat 0.5. Platelet 342K. SSA/SSB negative. dsDNA 130, C3 and C4 within normal limits. Patient received treatment with azathioprine 200 mg a day, labetalol 100 mg BID and prednisone 80 mg a day.

7. Pregnancy and flares of SLE It is not clear if flares of SLE are more frequent during pregnancy. Lupus flares during pregnancy do not seem to be more serious than those occurring in non-pregnant patients. Lupus may flare at any trimester and the postpartum period. Postgrad Med J.2001:157-165.

8. Obstetric and fetal outcome in lupus prengancy The incidence of pre-eclampsia is increased. Pre-existing hypertension, nephritis and presence of aPL are risk factors for pre- eclampsia. Fetal wastage, prematurity and intrauterine growth retardation are more common. Active nephritis at conception and the presence of aPL are predictors of fetal loss. Postgrad Med J.2001:157-165.

9. Congenital heart block Having SLE per se is not an independent risk factor. The risk depends solely in the presence of anti-SSA/Ro or SSB/La. The risk is approximately 7% in SLE mothers with positive anti-SSA/Ro. Postgrad Med J.2001:157-165.

10. Use of medications in lupus pregnancies NSAIDs should be avoided in the last few weeks of pregnancy. Corticosteroids and hydroxychloroquine have not been shown to be teratogenic. Azathioprine and cyclosporine can be used in pregnancy when intense immunosupression is necessary. Cyclophosphamide is teratogenic and should be avoided. Postgrad Med J.2001:157-165.

11. Lupus and Lactation Big doses of aspirin should be avoided in nursing mothers. NSAIDs are contraindicated in nursing mothers with jaundiced neonates. Prednisone, prednisolone and hydroxychloroquine are compatible with breast feeding. Breast feeding should be avoided by mothers on cytotoxic medications. Postgrad Med J.2001:157-165.

12. Contraception in SLE patients. Low dose estrogen contraceptives can be used in patients with stable disease and no history of thromboembolism. Barrier methods or progestogens are alternatives in patients with contraindications to steroids. Intrauterine contraceptive device is associated with an increase risk of infections. Postgrad Med J.2001:157-165.