University Journal of Surgery and Surgical Specialities

ISSN 2455-2860 2019, Vol. 5(5)

LUPUS FLARE DURING PREGNANCY LUIJIM MALA S SELVAMOHAN Department of Obstetrics and Gynaecology, KILPAUK MEDICAL COLLEGE AND HOSPITAL

Abstract : to end-stage renal disease. Second, these pregnancies are at Systemic lupus erythematosus (SLE) is a complex high risk for maternal and fetal complications, including autoimmune disease that predominantly affects women of spontaneous abortion and premature delivery, intrauterine fertile age. Women with systemic lupus erythematosus (SLE) growth retardation (IUGR), and superimposed pre-eclampsia. face significant risks when embarking on a pregnancy, but Due to the unpredictable nature of the disease and the increased attending a multidisciplinary clinic staffed by an experienced risk of the disease flaring up during pregnancy, women with SLE team can improve pregnancy outcome for women and their have previously often been advised to avoid pregnancy. babies. Queries regarding the risk of disease flares during CASE SCENARIO: pregnancy, chance of fetal loss, and the safety of various A 26 year primi was admitted in the Labor ward on 18-04-2013 drugs are often raised. With the improvement in the with LMP 21-10-2012, EDD on 28-7- 2013 and 26 weeks understanding of the pathogenesis of SLE and the judicious gestational age. She was referred from a Thiruvilangadu PHC for use of immunosuppressive drugs, better disease control can anaemia evaluation. Her Hb was 5.6 g % and a fetal movement now be achieved and SLE patients should not be deprived of is well perceived. She attained menarche at the age of 13. the opportunity for bearing children. The aim of this study was History taking was targeted at identifying systemic lupus to examine the pregnancy outcomes in patients with systemic erythematosus (SLE) disease activity, complications related to lupus erythematosus (SLE) and the effect of SLE flare and pregnancy, and adverse effects of various medications. treatment on pregnancy outcomes. In this review, important OBSTETRIC HISTORY: issues regarding the fertility rate, risk of disease flares during She confirmed pregnancy at 2 months of amenorrhea. lupus pregnancy, pregnancy course, fetal outcome, safety of First Trimester: various drugs used for disease control during pregnancy and Ø No history of Hyperemesis lactation, and contraceptive advice are discussed. Ø No history of pica and Hydroxychloroquine, pulse intravenous methylprednisolone Ø No history of bleeding PV and azathioprine are safe to treat lupus flares during Second Trimester: pregnancy. Appropriate individual based advice was given to l Quickening felt at 5 months of amenorrhea couples during pre-pregnancy counseling. l Anomaly scan done – No anomaly Keyword : l History of being treated for Anaemia with 5 doses of systemic lupus erythematosus, pregnancy, flare, hormone parenteral iron INTRODUCTION: Past History: Systemic lupus erythematosus (SLE) is a multisystem No history of DM/HT/BA/Epileptic/ TB/Jaundice/RF/blood autoimmune connective tissue disorder that primarily affects transfusion/renal disease /Heart disease/thyroid disease women of childbearing age. Normal fertility and sterility rates GENERAL EXAMINATION: have been reported, and as such, pregnancy is a frequent She was afebrile, O/E Pt is Conscious, Pallor+, Not occurrence in these patients. Two major issues exist dyspnoeic, No PE, CVS-S1&S2 +, RS-NVBS +, P/A- UT-22-24 regarding the risks and management of pregnancy in women wks and FP+. In addition, the following investigations have been with SLE and renal disease. First, pregnancy may increase done on the following days. SLE activity and the short- and long-term adverse effects on renal function, potentially leading to accelerated progression

An Initiative of The Tamil Nadu Dr. M.G.R. Medical University University Journal of Surgery and Surgical Specialities

On 04-04-2013: l SLIUG GA-23-24wks On 18-04-2013: l SLIUG cephalic l BPD-6.2 25wk 2d l FL- 4.5 25wk 2d l FH-good l placenta- posterior l FEVER INVESTIGATION l WIDAL-NEG l MSAT-NEG l URINE C/S- NO GROWTH l PS-MP –NEG l MF-NEG OPINION SOUGHT FROM: 1. DAP 2. Cardiologist 3. Rheumatologist 4. Radiologist 5. Nephrologists

An Initiative of The Tamil Nadu Dr. M.G.R. Medical University University Journal of Surgery and Surgical Specialities

Based on the clinical history, general examination, opinion sought from DAP, Cardiologist, Rheumatologist, Radiologist, Nephrologists and her clinical presentation, the patient was diagnosed as a case of SLE at 26 weeks of gestation and advised accordingly. Patients with SLE have an increased risk of pre-eclampsia during pregnancies. The incidence of pre-eclampsia in lupus pregnancies ranges from 5% to 38% in various reported series, which is higher than that of pregnancies in women without SLE. Women with previous pregnancy losses, an ongoing active disease with nephritis or hypertension and positive antiphospholipid antibodies, have an increased risk of pregnancy loss. The most favourable pregnancy outcomes are achieved when conception takes place during a remission of the disease and the treatment of neonates with low birth weight are ensured. In this review, important issues regarding the fertility rate, optimal timing of conception, risk of disease flares during lupus pregnancy, pregnancy course, fetal outcome, safety of various drugs used for disease control during pregnancy and lactation, and contraceptive advice are discussed. Severe SLE with CNS and renal involvement, the Intravenous pulse glucocorticoid treatment was given as detailed below: 1. Dose methylprednisolone 10 – 30 mg per Kg / 500 -1000 mg for 3 to 6 day 2. Thereafter, treatment with 1 – 1.5 mg per Kg /day in divided doses and rapidly tapered over the course of 1 month 3. 75% of patients will responsible this regimen 4. In severe cases, the dose can be repeated every 1-2 months as an alternative to cytotoxic drugs. CONCLUSION: There are few absolute contraindications for pregnancies in women with SLE. Women with SLE may experience uncomplicated pregnancies, but they need to plan their pregnancies as the risk for complications is increased. Best results are achieved through the cooperation of rheumatologists, gynaecologists and nephrologists. Glucocorticosteroids, hydroxychlorocine, azathioprine and anticoagulation may be used during pregnancy. Pre-pregnancy counseling and close collaboration with other specialists is essential in optimizing the maternal and fetal outcome in lupus pregnancies.

An Initiative of The Tamil Nadu Dr. M.G.R. Medical University University Journal of Surgery and Surgical Specialities