SLE

Question 1

Outline preconceptual counselling for a woman with SLE

Answer 1

• Risks to mum: flares/nephritis, PET, VTE, miscarriage
• Risks to fetus/neonate: IUGR, PTB, stillbirth, congenital HB, cutaneous lupus, thrombocytopenia, myocarditis, hepatitis.
• Timing of conception: >6 months of remission.
• Contraindications to pregnancy: pulm HTN, prev severe PET, Cr >150, active lupus nephritis, poor lung or heart function, hx stroke.
• Reliable contraception; avoid oestrogen.
• Baseline severity assessment:
  
  • FBC, U&E, LFTs, CRP, ESR
  • 24 hr urine protein, urine micro
  • Antiphospholipid AB
  • Anti-Ro and Anti-La
  • Anti-dsDNA
  • Complement levels
  • +/- CXR, ECHO, lung function
• Meds:
  
  • Yes: HCQ, prednisolone, azathioprine, cyclosporine.
  • No: cyclosphosphamide, MTX
• Referral to specialists
• Booking bloods, supplements, prenatal advice.

Question 2

Outline management of woman with SLE at booking

Answer 2

• Discuss risks to mum and fetus/neonate.
• Assessment of severity:
  
  • Clinical
  • Baseline investigations
  • Option of TOP if severe
• Specific to SLE:
  
  • MDT high risk team
  • Monthly investigations for markers of disease activity
  • Low dose aspirin: APLS, lupus nephritis, vasculitis.
  • Anti-Ro/-LA positive: weekly FHB between 16-24 weeks; fetal ECHO.
    
    • Advise immunosuppression will not completely prevent HB.
  • BP and proteinuria monitoring.
  • OGTT: early if on steroids.
  • Uterine artery doppler 20-24 weeks.
  • Anatomy scan.
  • Serial growth scans
  • Routine pregnancy booking stuff.