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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
Q

Anti TNF in Preg / Breastfeeding / Men

A

Preg: OK, consider hold during T3 if good disease control (except cimzia)
-BF: OK
-Men: no known risk

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26
Q

CYC in Preg / Breastfeeding / Men

A

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)

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27
Q

Cyclosporine/Tacro in Preg / Breastfeeding / Men

A

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
Q

Abatacept, Ritux, Belimumab, Anti-IL6, Anti IL17, JAKi in Preg / Breastfeeding / Men

A

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
Q

Colchicine in Preg / Breastfeeding / Men

A

Preg: OK

-BF: OK

-Men: OK

30
Q

** NSAID in Preg / Breastfeeding / Men**

A

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
Q

** ARB/ACEi in Preg / Breastfeeding / Men**

A

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
Q

APLA pregnancy risks

A

Fetal loss (early: T1 spontaneous abortion; or late: stillbirth)
-Preeclampsia
-Preterm birth
-IUGR
-Thrombosis
-Neurocognitive delay (microvascular insult on developing neural tissue)

33
Q

Troublesome antibodies in Preg

A

Ro/La (neonatal lupus)
-APLA
-Antiplatelet AB (cause autoimmune thrombocytopenia, hemorrhage at delivery)

34
Q

** Neonatal lupus DERM manifestationsand when do they clear **

A

Subacute SLE rash (annular, erythematous, papulosquamous)

-*noncardiac manifestations clear when AB degrade in 6 mo

35
Q

** Neonatal lupus Liver manifestations**

A

Elev transaminitis,
-Cholestatic elevation w/ conjugated hyperbili, HSM

36
Q

** Neonatal lupus Heme manifestations**

A

Thrombocytopenia
-Neutropenia
-AIHA
-MAHA

37
Q

** Neonatal lupus Cardiac manifestations**

A

Heart block,
-Endocardial fibroelastosis,
-Myocarditis,
-Dilated cardiomyopathy w/ hydrops fetalis

38
Q

Fetal heart block MoA

A

IgG antiRo/La bind fetal cardiocytes → inflamm injury

39
Q

Fetal heart block screening

A

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
Q

** 3 pieces of evidence that autoantigen plays a role in CHB?**

A

– Risk of CHB higher in offspring of seropositive mothers
– HCQ associated with decreased rate of CHB

41
Q

** What isotype crosses the placenta? When does it cross the placenta? When can it no longer be detected in the infant post-partum?**

A

IgG to SSA crosses membrane
-Crosses at 13 weeks of gestation
-No longer detected 6-8months postpartum

42
Q

Congenital heart block Features and Tx - 1st Deg

A

Prolonged PR, can be transient
-Monitor and consider steroids

43
Q

Congenital heart block Features and Tx - 2nd Deg

A

Can revert to sinus or progress to 3rd degree
-Consider Dex 4mg daily (taper to 2mg until delivery after weeks) , IVIG, Plex

44
Q

Congenital heart block Features and Tx - 3rd Deg

A

Irreversible and cause fetal demise in up to 25%
-Steroids DO NOT WORK (don’t give unless also cardiac inflammation)
-Possible pacemaker

45
Q

Mx of Cardiomyopathy, Endocardial fibroelastosis, Hydrops in Neonatal SLE

A

Global disease accompanying heart block
-Steroids and/or IVIG or PLEX for inflamm cardiac disease +/- heart block

46
Q

Criteria for pregnancy assoc’d APS

A

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
Q

APS Tx - repeatedly positive APLA w/o preg morbidity

A

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
Q

APS Tx - SLE +/- APLAs

A

HCQ
ASA (all SLE get ASA regardless of APS) before 16 weeks

49
Q

APS Tx - +APLA and preterm birth due to preeclampsia (ie obstetric APS)

A

HCQ
Low dose ASA + prophylactic LMWH until 6-12 wks post-partum

50
Q

APS Tx - SLE and/or APS w/ preg failure despite low dose ASA

A

HCQ
-Ppx heparin or LMWH

51
Q

APS Tx - severe preeclampsia and +APLA

A

ASA
consider: Ppx heparin or LMWH

52
Q

APS Tx - +APLA and prior thrombotic event (meets APS criteria before preg)

A

Full dose LMWH and ASA during pregnancy and postpartum

53
Q

APS Tx - Preg loss w/ APLA+ despite ppx heparin and aspirin

A

ASA + PPX LMWH

Consider adding (but (conditional AGAINST)
- IVIG
- Low dose pred
- Change to full dose LMWH

54
Q

Preg fx on spondyloarthropathy / vice versa

A

Fertility unaffected
-Increased risk C/S, preterm birth, SGA
-Ank Spond: ⅓ worsens, ⅓ improves, ⅔ worsen postpartum (LBP)
-PsA: 50% improve

55
Q

SSc fertility/preg complications

A

Fertility unaffected
-pHTN = CONTRAINDICTAION to preg
-Preterm delivery
-IUGR
-Low birth weight

56
Q

SSc RF for worse outcomes

A

Early disease
-Diffuse cutaneous SSc
-Anti-SCl70 AB
-Anti RNA Pol III AB

57
Q

Preg fx on SSc

A

No effect on visceral involvement or SRC
-Raynauds improves
-GERD/arthralgias worsen

58
Q

Preg in SLE

A

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
Q

Risk factors for SLE flare in Preg

A

-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
Q

IIM fx on preg

A

-Fetal loss
-Preterm delivery
-Small for GA

61
Q

Preg fx on
-AAV
–PAN
–TA
– Behcet

A

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
Q

How is male fertility affected by:
– Vasculitis
– Ank Spond
– RA
– SLE

A

– 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
Q

** RA pregnancies risk **

A

HTN
-Preterm delivery
-IUGR, SGA
-C/S
-PROM
-Antepartum hemorrhage

64
Q

Guidelines
Contraceptive for
-MMF
-Non SLE
-SLE
-APS
-OP

A
  • 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
Q

Guidelines
ART
- Immunosuppressive management
- Positive aPL w/o clinical APS
- Positive OB APS
- Positive Thrombotic APS

A
  • 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
Q

Who can have HRT

A
  • Negative aPL
  • Positive aPL but NO obs/thrombotic APS AND current negative titres
  • Quiescent SLE

1. Rheum RC (23 decks)

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