sle and pregnancy case-1

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