Lupus in pregnancy TOG 2011 Flashcards
Incidence of lupus in UK
1/1000
Average age of onset, what % have other autoimmune conditions
Average 30 years
6% other autoimmune condition
Commensts clinical features
Joint involvement - 90%, non errosive - swelling and tenderness
Skin involvement 80% malar rash, photosensitivity, raynauds, fever
Serositis - pleuritis, pericarditis.
Renal involvement
Neurological 0 psychosis, seizures
Haematological - haemolytic anaemia, thrombocytopenia
What % of women with lupus will have anti-phospholipid antibodies?
30-40%
Most common autoantibody in SLE
ANA 96%
Which antibodies most specific to Lupus? Associated with which clinical finding?
Anti double stranded DNA and smith
Associated glomerulonephritis
How common are anti-Ro and Anto La and aPLs in Lupus
40%
Effect of pregnancy on SLE
Risk of flare increases 40 to 60%
Risk of renal flare 30% - advice avoid pregnancy until 6 months after lupus nephritis flare
Effect of SLE on pregnancy
Increased risk micarriage, fetal death, PET, PTL, FGR (if anticaediolipin, lupus anticoagulant, lupus nephritis or HTN)
If lupus nephritis risk <2.5kg 30%
Risk of fetal loss if SLE with active lupus nephritis?
Up to 75%
Ro +ve mothers risk of
- transient neonatal cutaneous lupus
- congenital heart block
- 5%
- 2%
AN management SLE
- Baseline autoantibodies
- Consider aspirin + LMWH
- UAD 20-24 weeks, regular growth USS
- Control HTN
- Continue hydroxychloroquine if taking
What features suggest lupus flare
Symptoms (arthralgia, pleuritic pain, skin rash)
Rising anti-dsDNA antibody titres
Red blood cells or cellular class in urinary sediment
Fall in complement levels, fall C3/C4 >25%
How to differentiate between PET and lupus flare
Abrnoemal LFT and low PIGF - more likely PET
Liver Bx - not done in pregnancy
Proteinuria in lupus is associated with cellular casts whilst PET is not
When does transient neonatal cutaneous lupus present?
1st 2 weeks of life, may develop after sunlight exposure
Disappears 4-6 months
Residual hypopigmentation/telangiestasia may persist for up 2 years
When does congenital heart block appear
In utero, is permanent and is fatal 15-20%
Normally detect from 18-28 weeks
Dexamethsone may prevent lesser degrees of heart block developing into complete heart block. Risk Hydrops.
Recurrence rate of congenital heart block?
16%
Lupus + Anti Ro, how often to check FHR to detect heart block?
FHR every 2-4 weeks until 28/40
Every 1-2 28-36 weeks
Weekly from 36 weeks
ECHO 24 weeks
Can you give NSAIDs in pregnancy
Premature closure ductus arterioles
Do not use 3rd trimester
Can you give prednisolone in pregnancy
Yes - crosses placenta but 10% maternal conc
Can you give hydroxychloroquine in pregnancy
Long half life, detected 6 months later
Stopping associated with flares
Continues
Can you give azathiproine in pregnancy
Prodrug, metabolised in adults to 6-mecarptopurine Crosses placenta but not converted into active metabolites, low risk congenial abnormality
Used in pregnancy, can breastfeed
Associated with low birth weight, prematurity and neonatal jaundice
How does the metabolism of cyclosporine change in pregnancy?
Metabolism increases, higher doses to maintain plasma levels
Associated low birth weight, DM and hyptertneion
How is tacrollimus excreted? How must the dose be changed in prengnay?
hepatic cytochrome P450
Reduce dose by 60% to avoid toxicity
Can you give cyclophosphamide in pregnancy?
Teratogenic (same as methotrexate and chlorambucil) - stop 3 months pre-conception
COCP with low dose oestrogen <35 can be used with most people with SLE.
COCP is contraindicated in women with SLE and
Migranes
Raynauds
Previous VTE
Antiphopholipid antibodies
Kidney disease
+ve or unknown anti-phospholipid antibodies
If on immunosuppressive agents - avoid IUCD
