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SLE AND PREGNANCYCase-1
Dr. Ashwini Ingale(Obstetric Medicine Fellow)
Dr. Malini Sukayogula
Hyderabad, Indiawww.fernandez.foundation
o Mrs S, 28 years, Occupation- Home maker, Resident-
Nizamabad
o G6 P0 L0 A5, 32+1 weeks of gestation with previous adverse
pregnancy outcomes, GDM , FGR
o Known case of – SLE, APS-? Primary APLA
HISTORY
Married since : 2011
Nonconsanguineous marriage
LMP : 27-JULY-2019
EDD : 02-MAY-2020
2012 – Missed Miscarriage- 8 weeks - OPMERPC
2013 – Missed miscarriage- 13 weeks, CRL documented- Surgical ERPC.
2015 – TOP- 6 weeks -was on Cyclophosphamide
2016 –Missed miscarriage- 6 weeks – OPMERPC
2018 April – Missed miscarriage - 10 weeks Surgical ERPC
2019 - Present pregnancy, Spontaneous conception
Obs History
2009 – Left 2nd toe gangrene- managed with antibiotics-
resolved in 2 months
2013- Symptomatic started 5 days after 2nd miscarriage.
Fever - low grade, continuous, not associated with chills and
rigors
Joint pains involving bil PlP, MCP Jts, wrists ,no h/o swelling.
Past History
Blackish discoloration over dorsum of feet and toes (Rt > Lt )
associated with severe pain, burning in nature.
No h/o Raynaud's phenomenon. No h/o trauma.
No h/o oral ulcers /malar rash / photosensitivity/alopecia.
No sicca symptoms. No h/o headache / seizures / LOC.
No h/o SOB/Chest pain/Palpitation.
No h/o haematuria / pyuria.
Absent right DPA and post tibial artery pulsations
Significance of the negative history
Differential diagnosis
Evaluation: -ANA 3 + speckled
-ds DNA and ACL & LAC –Neg
- C3 C4 –Normal
- CBC, Coagulation profile- Normal
Colour Doppler- Absent colour uptake at bilat distal Anterior tibial artery
2 D ECHO- Normal
Skin biopsy- Thrombotic microangiopathy
Hypertension-
Renal biopsy-normal
History
Diagnostic criteria for TMA
Rheumatologist
Received Heparin infusion and overlapped with oral
anticoagulation.
H/o recurrent non healing ulcer on toes- on and off-
managed conservatively, was on Warfarin and Enalapril
Case…
2015 Jan- Off anticoagulant- on her own
Right foot drop and left median nerve neuropathy
? Lupus vasculitis
Nerve biopsy- Chronic axonopathy - Mononeuritis multiplex
ANA 3 + , dsDNA- Neg, C3 C4- Normal
History
Is MNM part of APS/ SLE spectrum ?
Rheumatologist
Received 6 cycles of cyclophosphamide pulse therapy
with Prednisolone (1mg/kg), Acitrom, HCQ, Enalapril
Started on Azathioprine after the pulse therapy.
No residual deficits
History
What do you advise a patient who is on cyclophosphamide?
Dr. Ashwini/ Rheumatologist
How would you monitor a patient on Azathioprine ?
Rheumatologist
H/o Herpes zoster at neck –treated with Acyclovir
Regular follow up at NIMS till 2017
Planning for pregnancy
2017 October: Prepregnancy counseling
Past History
2017 October: Prepregnancy counseling
Evaluation?
Pre pregnancy counselling advise?
Prepregnancy counseling
APLA
Anti-Ro/SSA and anti-La/SSB antibodies
Renal function (creatinine, urinalysis with urine sediment, spot
urine protein/creatinine ratio)
Complete blood count (CBC)
Liver function tests
Anti-double-stranded deoxyribonucleic acid (dsDNA) antibodies
Complement (C3 and C4)
Booked at 7+4 weeks. Booking BMI 22.07.
No new gangrene, ulcer, paresthesias
No symptoms of flare or other organ involvement
Present pregnancy
On Examination-
Autoamputation of digits of left foot- lateral 4 toes and 1
toe of right foot
-Left dorsalis pedis artery-feeble
-Right dorsalis pedis –palpable
BP-120/80 mmHg
Present pregnancy
Motor examination of both upper and lower limb- Normal
RS/CVS-NAD; P/A-Soft
After confirmation of viability: Acitrom was stopped and Inj
Enoxaparin 40 mg s.c once daily started.
Continued Tab Amlodepin
Baseline investigations-Normal
Visited Rheumatologist- Advised to continue HCQ, AZA,
Amlodepin, Ecosprin
In view of Thrombotic microangiopathy Inj Enoxaparin dose
changed to 60 mg S.C. twice daily (1mg/Kg bd wt)
ds DNA -1, borderline +ve; anti Ro, anti La-Negative
ACL/LAC /beta 2 Glycoprotein1: neg
SGOT,SGPT, CUE, ESR ,Creatinine, C3,C4-Normal
Why was therapeutic dosage of LMWH advised for this mother?
FTS - Normal.
Screen positive for Pre-eclampsia –Tab Ecospirin
increased to 150mg.(ASPRE TRIAL)
Present pregnancy
Second trimester: Iron, calcium, Vitamin D supplementation
taken, AZA, HCQS, LMWH
TIFFA –Normal.
OGTT- deranged-Gestational Diabetes-On medical nutrition
therapy
Follow-up scan at- 23 + 5 week- BPD and HC on 5th centile
Present pregnancy continued
Plan of Antenatal care for this mother?
Plan of fetal monitoring?
Third trimester:
29+5 weeks- admitted for accelerated Hypertension, added on
Tab Labetalol 100 mg thrice daily
-Recd steroid cover.
-SGPT,Creatinine-Normal. Urine albumin-Negative, Platelet-
111000
- Platelet monitored weekly
Present pregnancy cont….
7 week 27 week 29+5 week 31+5 week
Hb 9.1 13.3
Platelet 199000 134000 110000 110000
SGPT 31 26 24 23
LDH 216 154 152 187
Creatinine 0.6 0.6 0.6 0.47
ANA 3+
APLA Negative
Anti ds DNA Borderline +ve
C3 115
C4 17
Anti Ro/La Negative
Gestation age
EFW Umbilical artery AFI NST
27+5 9c Increased resi. Normal Reactive
29+2 2c Increased resi. Normal Reactive
31+2 2.9c (1.2Kg)
Increased resi. Normal Reactive
Fetal Monitoring
32+1 weeks- readmitted for accelerated hypertension
Maternal monitoring-
Antihypertensives dose adjustment
SGPT, Platelet, creatinine, urine albumin- Biweekly
Fetal plan-
Inj Betamethasone 12 mg i.m. rescue dose.
Counselling by neonatal team
Alternate day NST, Biweekly Doppler
Delivery by 34 week or earlier sos if persistent increase BP, NRNST,AEDF, Lab
derangement
32+1 32+2 32+3 32+4 32+5
Platelet 94000 115000 100000 104000 95000
Creatinine 0.6 0.6 0.6 0.7 0.6
SGPT 33 34 27 27 30
LDH 175 174 179 177 171
PT 14.6/14.5 14/14.5
INR 1.01 <1
aPTT 44/31.1 42/31.1
Urine Alb 3+ 3+ 2+
Investigations
Urine albumin : 3+
Platelet 94,000
What are the differential diagnosis at this point?
Further increase in BP
Antihypertensives and dosage adjusted
Repeat platelet- Stable
Coagulation profile- Normal
LMWH changed to UFH 7500U s.c thrice daily
Inj MgSO4 started for seizure prophylaxis
Further course
32+1 32+2 32+3 32+4 32+5 Post Op
Platelet 94000 115000 100000 104000 95000 99000
Creatinine 0.6 0.6 0.6 0.7 0.6 0.6
SGPT 33 34 27 27 30 30
LDH 175 174 179 177 171 159
PT 14.6/14.5 14/14.5
INR 1.01 <1
aPTT 44/31.1 42/31.1
Urine Alb 3+ 3+ 2+
Investigations
Decision of delivery made –LSCS for maternal
indication
Superimposed severe pre-eclampsia
Baby-Female 1.3 Kg-NICU for 21 days
Post op period –uneventful
Discharged on POD 3
–On Tab Labetalol 300mg thrice daily , Tab Enalapril 5mg
twice daily, Tab Amlodepin 5 mg twice daily
LMWH for 6 weeks
Continued Tab HCQ 200mg and Tab Azathioprine 50 mg once
daily
After 6 weeks post partum – Changed to oral anticoagulant
Post op
Contraception
Contraception
Dr.Ashwini
THANK YOU