SLE

Question 1

Hx/Exam/Ix

Answer 1

Hx
- dx-when/how - skin/joint…
- rx-pred/hydroxy vs myco/cyclo/MTX)
- cx- flares/VTEs…

• HTN/CKD/proteinuria
• Phx/med/surg/psych
• OGHx - G/P, miscarriage/IUGR/FDIU, menstrual cycle, CST, contraception, STIs
• Shx - smoke/etoh

Question 2

Pre-pregnancy counselling

Answer 2

• MDI - MFM/Obs med/Rheum
• ideally not active for >=6/12
  (more renal cx & high dose meds)
• if active, optimize first
• contraception till disease in remission
• Med - pred, plaq (hydroxy), aza = safe
• Stop - MTx/cyclophos/NSAID/ACEI/ARB
• Risk discussion
  M - risk - LN flare/PET/VTE/PPH
  F - risk - NLS (CHB)/FGR/PTB/SB

Precon Ix + Sup
- FBE/UEC/LFT/G&S/24 urine protein
- aPLs (VTE), anti-Ro/La, c3/4/DS-DNA
- HIV/HCV/HBV/Syphilis/Rubella/VZV
- +/- LMWH +/- LDA
- 5mg FA

Question 3

AN/IP/PN mx

Scenario 1 - Lupus dx on bkg RMC including 23/40 loss, now conceived twin preg

Answer 3

• MDI - MFM/Obs Med/Rheum/Haem
• cFTS for PET predict (e.g. PAPP-A..UtA)
• LDA +/- Ca +/- LMWH (PET/VTE)
• early OGTT (if on pred)
• Tertiary morph + serial G/S 28/40
• Fetal echo from 16-26/40 (if Ro/La)
• Tri-mesterly - C3/4/DS-DNA/UEC
• Timing - 39-40/40
• MOD (obstetric indications)
• IP - +/- stress dosing of steroid
• PN:
  BF/VTE/Contraception
  Restart pre-preg meds
  F/U for SLE

Question 4

Lupus nephritis recognition & mx (antenatal)

Answer 4

Key issues
- HTN + proteinuria -> hard to distinguish lupus nephritis vs PET
- LN - hematuria/cast, anti-DS-DNA (up), C3/4 (drop), lupus in non-renal organ
- PET - sflt/PLGF, hyperuricemia, LFT derangement
- Gold std to diff btw PET vs lupus nephritis = renal bx (high risk for bleeding)

• associated features
  1. maternal - joint ache, malaise, discoid rash (torso/abdo/upper limb)
  2. fetal - DFM, FGR
  3. consider ddx of rash +/- further ix & mx - PEP, PG
• flare mx - MDI, high dose pred, azathioprine
• blood pressure control
• fetal wellbeing +/- consider early delivery +/- steroid loading
• intrapartum - stress steroids, bleeding risk (LDA/LMWH)

Question 5

Mx of Neonatal lupus

Scenario 1 - 30/40, SLE, anti-Ro +’ve severe hydrops, FHR55

Answer 5

Dx
- complete HB 2nd to anti-Ro
- NLS

• inform paeds/anaesthetic
• cat 1 CS to facilitate delivery
• risk of PPH (if on LDA/LWMH)
• IV stress steroid during delivery
• NICU stabilization/Neonatal card rv