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1. Rheum RC > Pregnancy > Flashcards

Pregnancy Flashcards

1
Q

Cardiovascular changes during pregnancy

A

Increased HR, SV, plasma vol (can strain heart)
-Vasodilation (improves Raynaud)

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2
Q

Pulmonary changes during pregnancy

A

Increased minute ventilation → resp alkalosis
-Can stress underlying ILD
-AVOID PREG in pHTN

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3
Q

Renal changes during pregnancy

A

Increased GFR and urinary protein

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4
Q

Hepatic changes during pregnancy

A

Increased hepatic prot synthesis, complement, fibrinogen (eg ESR and complements; can increase clot risk)

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5
Q

Heme changes during pregnancy

A

Increased WBC
-Hemodilution (decreased Hgb, Plt)

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6
Q

Lab changes during pregnancy
and cytokine type
and when IgG crosses

A

Increased acute phase reactant (ESR, ALP - secreted by placenta)
-TH2 cytokine dominant → SLE flare
-IgG cross placenta at 13-16wks

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7
Q

MSK changes during pregnancy

A

Muscles relax → GERD
-OP risk increases as preg/lactation pulls Ca from bones (reversible)
-Edema → CTS

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8
Q

Skin changes during pregnancy

A

Hypervascular changes
-Melasma
-Mimic lupus rash

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9
Q

Estrogen containing contraceptive - who can use, and who cannot

A

Can use: stable SLE without APLAs or clotting hx/RF
-Cannot use: APLA+ (even w/o clot hx/RF)

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10
Q

** Fetal complications in SLE **

A

Neonatal lupus
-Fetal heart block
-Preterm birth
-SGA
-Low birth weight
-APGAR <7 at 1 and 5 min
-IUGR
-Miscarriage

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11
Q

** Maternal complications in SLE **

A

-Preeclampsia
-HELLP
-Gestational DM, HTN during preg
-PROM
-C/S, Preterm birth
-Still birth, Fetal loss, Spontaneous abortion

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12
Q

** Pregnancy risks in SLE with active LN **

A

Renal flare during/after preg
-Fetal loss
-Preterm delivery

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13
Q

RF for SLE flare in preg

A

-Active dz 6mo before conception
-Stopped meds eg HCQ

-Primigravida

-Low C4 b4 conception and at each trimester
-LN hx or active during preg

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14
Q

Recommendations for pre-preg SLE nephritis

A

STOP RAAS blocker before conception
-Disease remission x 6 mo
-Follow proteinuria off ACE/ARB prior to preg
-HCQ to prevent IUGR

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15
Q

** Preeclampsia vs LN**

A

Timing: >20wks GA vs anytime
-BP: high vs N/high
-Liver enzymes: high vs N/high
-Uric acid: high vs N/high
-
-dsDNA: normal/stable vs high
-Complements: Low/N in BOTH
-Plt: low/N in BOTH
-Proteinuria: in BOTH
-Hemolysis: in BOTH
-
-Hematuria: NO CASTS vs CASTS
-24h UCa: LOW vs HIGH
-
-SLE sx: absent vs present

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16
Q

** Pregnancy induced HTN vs Preeclampsia **

A

Preeclampsia = PIH + proteinuria

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17
Q

** PROMISSE study predictors of poor outcomes (Excluded pt w/ LN)**

A

Thrombocytopenia <100
-Noncaucasian
-HTN meds
-LAC +
-Physician global >1

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18
Q

Steroids in Preg / Breastfeeding / Men

A

Preg: ideally <20mg; risks: oral cleft, preterm birth, low birth weight, GDM, HTN, PROM, IUGR
-BF: ideally hold for 4 hrs after dose
-Men: long term → decreased T

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19
Q

MTX in Preg / Breastfeeding / Men

A

Preg: NO, teratogenic ; DC 1-3 mo before preg

-BF: NO, insuff data

-Men: continue

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20
Q

LFN in Preg / Breastfeeding / Men

A

Preg:NO, teratogenic ; cholestyramine if unplanned or detectable while planning; DC 3.5mo to 2 yrs before

-BF:NO, insuff data

-Men: continue, Insuff data

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21
Q

SFZ in Preg / Breastfeeding / Men

A

Preg: OK, folic supplement needed

-BF:OK

-Men: Reversible azoospermia (w/i 2-3mo of DC)

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22
Q

HCQ in Preg / Breastfeeding / Men

A

Preg: OK
-BF: OK
-Men: no known risk

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23
Q

AZA in Preg / Breastfeeding / Men

A

Preg: OK (crosses but fetus lacks liver enzyme to convert to active)
-BF: OK
-Men: no known risk

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24
Q

** MMF in Preg / Breastfeeding / Men**

A

Preg: NO, teratogenic → T1 preg loss;
-DC: 1-3mo before

-BF: NO

-Men: OK

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25
Anti TNF in Preg / Breastfeeding / Men
Preg: OK, consider hold during T3 if good disease control (except cimzia) -BF: OK -Men: no known risk
26
CYC in Preg / Breastfeeding / Men
Preg: NO, teratogenic ; dose/age dep infertility incl premature ovarian failure, - DC 3mo before conception and during oocyte harvesting for preservation - OK in T2/3 if life threatening BF: NO Men: - DC 3mo before conception - Collect sperm prior to CYC or 3 mo after CYC if preserving (dose dep infertility including IRREVERSIBLE azoospermia)
27
Cyclosporine/Tacro in Preg / Breastfeeding / Men
Preg: OK - but monitor BP (risk preterm/low birth weight. May need to increase tacro dose) -BF: conditional recommend continue, insuff data -Men: no known risk
28
Abatacept, Ritux, Belimumab, Anti-IL6, Anti IL17, JAKi in Preg / Breastfeeding / Men
Preg: NO (insuff data) - IgG cross placenta in T2 -Can continue during preconception -Can give Ritux if life threatening - No recommendations on JAKi -BF: OK (conditional) -Men: no recommendation bc insuff data
29
Colchicine in Preg / Breastfeeding / Men
Preg: OK -BF: OK -Men: OK
30
** NSAID in Preg / Breastfeeding / Men**
Preg: use nonselective > COX2 selective - DC if trouble conceiving (can inhib ovulation - hold 8-20d before preg) -T1 miscarriage risk (but can continue T1/2) -**Stop in T3** to prevent premature closure of fetal ductus arteriosus. -**misoprostol as part of arthrotec is contraindicated as it can cause miscarraige, premature birth or birth defect -BF: OK -Men: OK
31
** ARB/ACEi in Preg / Breastfeeding / Men**
Preg: NO (T1 teratogen; T2/3 fetal renal fx) -DC before preg and follow proteinuria off ACE/ARB prior to pregnancy - stop before pregnancy bc teratogenic in T1 - Can use if lifethreatening eg SSc Renal crisis -BF: no known risk enalapril/captopril, others insuff data -Men: OK
32
APLA pregnancy risks
Fetal loss (early: T1 spontaneous abortion; or late: stillbirth) -Preeclampsia -Preterm birth -IUGR -Thrombosis -Neurocognitive delay (microvascular insult on developing neural tissue)
33
Troublesome antibodies in Preg
Ro/La (neonatal lupus) -APLA -Antiplatelet AB (cause autoimmune thrombocytopenia, hemorrhage at delivery)
34
** Neonatal lupus DERM manifestationsand when do they clear **
Subacute SLE rash (annular, erythematous, papulosquamous) -*noncardiac manifestations clear when AB degrade in 6 mo
35
** Neonatal lupus Liver manifestations**
Elev transaminitis, -Cholestatic elevation w/ conjugated hyperbili, HSM
36
** Neonatal lupus Heme manifestations**
Thrombocytopenia -Neutropenia -AIHA -MAHA
37
** Neonatal lupus Cardiac manifestations**
Heart block, -Endocardial fibroelastosis, -Myocarditis, -Dilated cardiomyopathy w/ hydrops fetalis
38
Fetal heart block MoA
IgG antiRo/La bind fetal cardiocytes → inflamm injury
39
Fetal heart block screening
Ro/La testing 3 mo before preg -If positive: refer to high risk OB and consider HCQ -- Serial fetal TTE 16-26 if 1st baby (weekly if prior baby w/ heart block)
40
** 3 pieces of evidence that autoantigen plays a role in CHB?**
-- Risk of CHB higher in offspring of seropositive mothers -- HCQ associated with decreased rate of CHB
41
** What isotype crosses the placenta? When does it cross the placenta? When can it no longer be detected in the infant post-partum?**
IgG to SSA crosses membrane -Crosses at 13 weeks of gestation -No longer detected 6-8months postpartum
42
Congenital heart block Features and Tx - 1st Deg
Prolonged PR, can be transient -Monitor and consider steroids
43
Congenital heart block Features and Tx - 2nd Deg
Can revert to sinus or progress to 3rd degree -Consider Dex 4mg daily (taper to 2mg until delivery after weeks) , IVIG, Plex
44
Congenital heart block Features and Tx - 3rd Deg
Irreversible and cause fetal demise in up to 25% -Steroids DO NOT WORK (don't give unless also cardiac inflammation) -Possible pacemaker
45
Mx of Cardiomyopathy, Endocardial fibroelastosis, Hydrops in Neonatal SLE
Global disease accompanying heart block -Steroids and/or IVIG or PLEX for inflamm cardiac disease +/- heart block
46
Criteria for pregnancy assoc’d APS
Positive APLAs (2x separated by 12 wks) AND 1 of: - 3 or more loss <10wks GA w/ normal genetics - Fetal loss >10wks GA w/ normal fetal morphology - Preterm (<34GA) delivery due to PEC, IUGR, fetal distress
47
APS Tx - repeatedly positive APLA w/o preg morbidity
ASA 81 daily starting in T1 (before 16 weeks) until delivery -Consider adding prophylactic heparin if LAC, triple + aPL, and/or high titer APLA - NO HCQ unless SLE or meet criteria for APS
48
APS Tx - SLE +/- APLAs
HCQ ASA (all SLE get ASA regardless of APS) before 16 weeks
49
APS Tx - +APLA and preterm birth due to preeclampsia (ie obstetric APS)
HCQ Low dose ASA + prophylactic LMWH until 6-12 wks post-partum
50
APS Tx - SLE and/or APS w/ preg failure despite low dose ASA
HCQ -Ppx heparin or LMWH
51
APS Tx - severe preeclampsia and +APLA
ASA consider: Ppx heparin or LMWH
52
APS Tx - +APLA and prior thrombotic event (meets APS criteria before preg)
Full dose LMWH and ASA during pregnancy and postpartum
53
APS Tx - Preg loss w/ APLA+ despite ppx heparin and aspirin
ASA + PPX LMWH Consider adding (but (conditional AGAINST) - IVIG - Low dose pred - Change to full dose LMWH
54
Preg fx on spondyloarthropathy / vice versa
Fertility unaffected -Increased risk C/S, preterm birth, SGA -Ank Spond: ⅓ worsens, ⅓ improves, ⅔ worsen postpartum (LBP) -PsA: 50% improve
55
SSc fertility/preg complications
Fertility unaffected -pHTN = CONTRAINDICTAION to preg -Preterm delivery -IUGR -Low birth weight
56
SSc RF for worse outcomes
Early disease -Diffuse cutaneous SSc -Anti-SCl70 AB -Anti RNA Pol III AB
57
Preg fx on SSc
No effect on visceral involvement or SRC -Raynauds improves -GERD/arthralgias worsen
58
Preg in SLE
Higher rates of flare (heme, renal) bc dominant Th2 cytokine profile -Risk of maternal death, pre-eclampsia, preterm labor, thrombosis, infxn, heme complications -Fetal loss, preterm birth, IUGR
59
Risk factors for SLE flare in Preg
-Discontinuing HCQ -1 major flare w/i 6mo of conception -High disease activity (high SLEDAI) -Renal disease -Hx of preeclampsia or HELLP -APLA: triple positive or LAC
60
IIM fx on preg
-Fetal loss -Preterm delivery -Small for GA
61
Preg fx on -AAV --PAN --TA -- Behcet
AAV: 40% flare; assoc’d w/ preterm delivery and miscarriage -PAN: maternal mortality if dz onset during preg -TA: HTN, preeclampsia -Behcet: 30% relapse during preg
62
How is male fertility affected by: -- Vasculitis -- Ank Spond -- RA -- SLE
-- PAN affects fertility if testes involved -- Behcet = normal fertility -- Ank spond = higher varicocele rates, no change to sperm -- RA: causes hypogoandism and decreased sperm production/fcn -- SLE: decreased libido, ED
63
** RA pregnancies risk **
HTN -Preterm delivery -IUGR, SGA -C/S -PROM -Antepartum hemorrhage
64
Guidelines Contraceptive for -MMF -Non SLE -SLE -APS -OP
- IUD or combo of 2 contraceptions (eg pill + condom) - IUDs*, progestin implant, combined E2/Prog pill, progestin- only pill (less effective), transdermal patch, vaginal ring, or DMPA - Above WITHOUT E2 patch and (also avoid combined combined E2/prog or ring if active dz) - IUD preferred; avoid E2 - No DMPA (depot progesterone)
65
Guidelines ART - Immunosuppressive management - Positive aPL w/o clinical APS - Positive OB APS - Positive Thrombotic APS
- Continue immunosuppressives except CYC and do ART only if low dz activity - Treat w/ PPX LMWH during ART - Treat w/ PPX LMWH during ART - Treat w/ THERAPEUTIC LMWH during ART
66
Who can have HRT
- Negative aPL - Positive aPL but NO obs/thrombotic APS AND current negative titres - Quiescent SLE

1. Rheum RC (23 decks)

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