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Management of Systemic Lupus Erythematosus in pregnancy

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Parenteral steroids to cover labour if 7.5 mg prednisolone or its equivalent for 2 weeks ... Reduces risk of bone loss which occur with prolonged steroids ... – PowerPoint PPT presentation

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Title: Management of Systemic Lupus Erythematosus in pregnancy


1
Management of Systemic Lupus Erythematosus in
pregnancy
  • Dr. M B C Motha
  • Professorial Medical Unit, Ragama.

2
Maternal mortality
3
Maternal mortality
Annual Report 2004. FHB
4
Maternal mortality
5
Preconceptional care
  • Advise against pregnancy in the presence of
  • Pulmonary hypertension
  • Chronic renal impairment with a baseline
    S.creatinine 250µmol/L
  • Remission for six months prior to conception
  • Maintenance dose of steroid less than the
    equivalent dose of 7 mg/d of prednisolone
  • Prophylaxis steroids have no place

6
Assessment of baseline activity - Lupus
Activity Index in pregnancy (LAI P)
7
Review of drugs
8
Review of drugs
9
Antenatal care
  • SLE complications that influence pregnancy
    outcome
  • Lupus nephritis
  • Antiphospholipid syndrome
  • Risk of lupus flare 30 - 60
  • Predominantly affects the skin and articular
    surfaces
  • Screen for congenital heart block
  • Monitor for diabetes (iatrogenic)

10
Intrapartum care
  • Risk of prematurity
  • Parenteral steroids to cover labour if 7.5 mg
    prednisolone or its equivalent for 2 weeks

11
Postpartum care
  • Drugs to be avoided
  • Methotrexate
  • Azathioprine
  • Cyclophosphamide
  • Cyclosporine A
  • Risk of flare is low.

12
Lupus nephritis in pregnancy
  • Physiological changes in pregnancy
  • Cr cl rises by 50 to 120-160ml/min
  • Fall in serum creatinine (2.0 4.5mmol/l) and
    urea (25 - 75mmol/L)
  • Increase in proteinuria ( upto 300mg/24 hours)

13
Lupus nephritis in pregnancy -
Lupus nephritis vs Pre-eclampsia
14
Does lupus nephritis contraindicate pregnancy ?
15
Lupus nephritis in pregnancy
  • During pregnancy in patients with SLE and renal
    disease, changes in renal disease activity and
    deterioration in renal function are similar to
    those which occur in non pregnant patients with
    lupus nephritis.
  • - The effect of pregnancy on lupus nephritis
  • Arthritis and Rheumatism
    2004503941-3946.

16
Lupus nephritis in pregnancy
  • Lupus nephritis class iii and iv is a risk factor
    for hypertensive disease during pregnancy, but it
    does not contraindicate gestation.
  • Class iii and iv proliferative lupus nephritis
    pregnancy A study of 42 cases
  • American Journal of reproductive Immunology
    200553182-188.

17
Effect of degree of renal impairment on pregnancy
outcome
  • Nelson-Piercy C. Renal disease.
  • Handbook of Obstetric Medicine, 3rd edition.
    Taylor Francis, 2006.

18
Lupus nephritis in pregnancy
  • Low dose aspirin therapy during pregnancy causes
    a favourable fetal outcome
  • Pregnancy in women with preexisting lupus
    nephritis Predictors of fetal and maternal
    outcome
  • Nephrology Dialysis transplantation
    200924519-525.
  • Low dose heparin is useful for pre-eclampsia
    prophylaxis
  • Prevention of pre-eclampsia in high risk women
    with renal disease
  • Nephrology 19951297-300.

19
Contraception
20
Contraception
  • Oestrogen containing pill beneficial
  • Preserve ovarian function and mitigates effects
    of cyclophosphamide
  • Reduces risk of bone loss which occur with
    prolonged steroids

21
Contraception
  • OC-SELENA (Safety of oestrogens in lupus
    erythematosus national assessment trial)
  • Prospective double blinded study in U.S.A. in
    2005
  • Premenopausal women with Inactive disease/stable
    active disease
  • N Engl J Med 2005353 2550-8.

22
Contraception
  • Conclusions
  • The use of oral contraceptives was not
    associated with an increase in total flares over
    the course of 1 year compared to placebo.
  • Oral contraceptives containing oestrogens is
    safe as a birth control choice for SLE patients
    with inactive/stable disease who are at low risk
    of thrombosis.

23
SLE in pregnancy
  • SLE in pregancy poses a grave challenge to the
    clinician
  • Pregnancy outcome is favourable when the
    pregnancy is planned and closely monitored by a
    competent and dedicated team.
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