Lupus in pregnancy TOG 2011

Question 1

Incidence of lupus in UK

Answer 1

1/1000

Question 2

Average age of onset, what % have other autoimmune conditions

Answer 2

Average 30 years
6% other autoimmune condition

Question 3

Commensts clinical features

Answer 3

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

Question 4

What % of women with lupus will have anti-phospholipid antibodies?

Answer 4

30-40%

Question 5

Most common autoantibody in SLE

Answer 5

ANA 96%

Question 6

Which antibodies most specific to Lupus? Associated with which clinical finding?

Answer 6

Anti double stranded DNA and smith

Associated glomerulonephritis

Question 7

How common are anti-Ro and Anto La and aPLs in Lupus

Answer 7

40%

Question 8

Effect of pregnancy on SLE

Answer 8

Risk of flare increases 40 to 60%
Risk of renal flare 30% - advice avoid pregnancy until 6 months after lupus nephritis flare

Question 9

Effect of SLE on pregnancy

Answer 9

Increased risk micarriage, fetal death, PET, PTL, FGR (if anticaediolipin, lupus anticoagulant, lupus nephritis or HTN)

If lupus nephritis risk <2.5kg 30%

Question 10

Risk of fetal loss if SLE with active lupus nephritis?

Answer 10

Up to 75%

Question 11

Ro +ve mothers risk of
- transient neonatal cutaneous lupus
- congenital heart block

Answer 11

• 5%
• 2%

Question 12

AN management SLE

Answer 12

• Baseline autoantibodies
• Consider aspirin + LMWH
• UAD 20-24 weeks, regular growth USS
• Control HTN
• Continue hydroxychloroquine if taking

Question 13

What features suggest lupus flare

Answer 13

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%

Question 14

How to differentiate between PET and lupus flare

Answer 14

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

Question 15

When does transient neonatal cutaneous lupus present?

Answer 15

1st 2 weeks of life, may develop after sunlight exposure
Disappears 4-6 months
Residual hypopigmentation/telangiestasia may persist for up 2 years

Question 16

When does congenital heart block appear

Answer 16

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.

Question 17

Recurrence rate of congenital heart block?

Answer 17

16%

Question 18

Lupus + Anti Ro, how often to check FHR to detect heart block?

Answer 18

FHR every 2-4 weeks until 28/40
Every 1-2 28-36 weeks
Weekly from 36 weeks
ECHO 24 weeks

Question 19

Can you give NSAIDs in pregnancy

Answer 19

Premature closure ductus arterioles
Do not use 3rd trimester

Question 20

Can you give prednisolone in pregnancy

Answer 20

Yes - crosses placenta but 10% maternal conc

Question 21

Can you give hydroxychloroquine in pregnancy

Answer 21

Long half life, detected 6 months later
Stopping associated with flares
Continues

Question 22

Can you give azathiproine in pregnancy

Answer 22

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

Question 23

How does the metabolism of cyclosporine change in pregnancy?

Answer 23

Metabolism increases, higher doses to maintain plasma levels

Associated low birth weight, DM and hyptertneion

Question 24

How is tacrollimus excreted? How must the dose be changed in prengnay?

Answer 24

hepatic cytochrome P450
Reduce dose by 60% to avoid toxicity

Question 25

Can you give cyclophosphamide in pregnancy?

Answer 25

Teratogenic (same as methotrexate and chlorambucil) - stop 3 months pre-conception

Question 26

COCP with low dose oestrogen <35 can be used with most people with SLE.

COCP is contraindicated in women with SLE and

Answer 26

Migranes
Raynauds
Previous VTE
Antiphopholipid antibodies
Kidney disease
+ve or unknown anti-phospholipid antibodies

If on immunosuppressive agents - avoid IUCD