Systemic Lupus Erythematosis Flashcards
How is lupus diagnosed?
presence of antinuclear antibodies (ANA) or anti-double-stranded DNA (anti-dsDNA)
and other symptoms including: Arthritis Serositis Renal disorder Neurologic disorder Hematologic disorder Malar rash/ Discoid rash Oral ulcers Photosensitivity
What are maternal and obstetric risks of lupus in pregnancy?
Seizures Pulmonary hypertension Preeclampsia Thrombocytopenia Neonatal lupus Hydrops Heart block Worsening renal disease
What baseline labs do you perform in patients with lupus?
- Obtain antiphospholipid antibodies (lupus anticoagulant, beta 2 glycoprotein IgG/IgM and anticardiolipin antibody IgG/IgM)
- Obtain an early glucose tolerance testing if on chronic steroids
- Obtain a 24 hour urine protein and creatinine clearance every trimester
- Obtain complement and anti-dsDNA antibody every trimester
- Obtain platelet count and serum creatinine monthly
How do you follow a patient during pregnancy with the diagnosis of lupus?
- ASA, hydroxychloroquine sulfate and azathioprine use
- Obtain antiphospholipid antibodies
- Initiate anticoagulation with unfractionated heparin should antiphospholipid antibodies be positive
- Start calcium supplement due to increased risk of bone loss (prednisone and heparin)***
- Obtain an early glucose tolerance testing if on chronic steroids
- Obtain a 24 hour urine protein and creatinine clearance every trimester
- Obtain complement and anti-dsDNA antibody every trimester
- Obtain platelet count and serum creatinine monthly
- Obtain weekly PR interval from 16-26 weeks then bimonthly from 26-34 weeks ***(dexamethasone 4mg/day can be initiated for first and second degree heart block, IVIG could potentially increase survival rates for fetuses with cardiomyopathy and endocardial fibroelastosis)
- Obtain detailed anatomic survey between 18-20 weeks gestation
- Start interval fetal growth every 4 weeks after detailed fetal anatomic survey
- Obtain fetal echocardiogram between 20 and 22 weeks gestation due to positive anti-Ro
- Start antenatal testing at 32 weeks or before if clinically warranted
- ACE inhibitors such as captopril and enalapril is recommended in the postpartum period should hypertension ensue
- Avoid combined oral contraceptives
When do you recommend delivery for patient with lupus?
- Decision regarding timing of delivery is influenced by the status of the fetus and maternal illness progression. If patient remains stable, it is reasonable to deliver at 39 weeks
How do you counsel patient regarding use of hydroxychloroquine during pregnancy complicated with lupus?
Hydroxychloroquine was not associated with adverse pregnancy outcome in more than 300 exposed human pregnancies. Experimental animal studies with the related chloroquine suggested adverse outcome associated only with excessively high maternal exposure levels.
How do you counsel a patient regarding use of steroids in patient with lupus?
- Obtain an early glucose tolerance testing if on chronic steroids
- It is reasonable to initiate stress dose steroid at time of active labor or prior to induction of anesthesia to prevent Addisonian collapse
How do you counsel patient regarding use of azathioprine during pregnancy complicated with lupus?
- Increase in atrial and ventricular septal defect
- Increase in preterm delivery
- Neonatal hematologic and immune impairment
How do you counsel patient regarding use of cyclosporine during pregnancy complicated with lupus?
Experimental animal studies do not predict an increase in congenital anomalies after pregnancy exposure to cyclosporines. A limited number of human case reports are also reassuring.
How do you counsel patient regarding use of tacrolimus during pregnancy complicated with lupus?
Based on experimental animal studies, tacrolimus is not expected to increase the risk of congenital anomalies.
How do you counsel patient regarding use of methotrexate during pregnancy complicated with lupus?
Not recommended.
Causes low-set ears, prominent eyes, and wide nasal bridge. Limb defects and absent ossification centers. anencephaly, hydrocephaly, and meningomyelocele
What is the like the likelihood of a lupus flare occurring during pregnancy?
25-65%
How is lupus nephritis diagnosed?
24 hour urine protein.
Renal biopsy
How does a history of lupus nephritis impact the pregnancy?
Patients with lupus nephritis have a good prognosis if in remission up to 6 months prior to pregnancy (live birth rate is up to 95%).
Pregnancy increases the chance for a lupus nephritis flare; however, the flares are not typically more severe than in nonpregnant patient.
Lupus nephritis increases the risk for premature birth and maternal hypertension.
How does SSA/SSB antibody cause heart block?
Alloantibodies cause damage to the AV node and perkinje fibers
