A 26 years old nulliparous women with SLE lupus nephritis is planning a pregnancy In one years time.She is referred to you for pre pregnancy counselling. Justify why this consultation is essential to optimize the outcome of her pregnancy?
SLE is a autoimmune condition which has multi systemic involvement(prevalence 1/1000).
Planning of pregnancy is of paramount importance as SLE lupus nephritis has detrimental effects on both mother and fetus.
Prepregnancy counselling is important because she need to be managed by a multi disciplinary team(Rheumatoligist,Obstetrician,Nephrologist,Anaesthetist and Neonatologist)
,Should be flare free for more than 6 months,
End organ assessment need to be done,
Assessment of contraindications of pregnancy,
Optimization with non teratogenic drugs,
Screening for steroid induced diabetes,
May need LMWH ,
Proper contraception until optimized for pregnancy,
Advice on early booking visit.
If the mother get pregnant within 4-6 months of flare she will develop 2 to 4 fold risk of SLE related complications.
Patient might be on teratogenic drugs(ACE inhibitors, beta blockers, immunosuppressive drugs)at the time of conception which need to be stopped
and converted to other less teratogenic/non teratogenic drugs.
patient need to be put on higher dose of folic acid prior to conception.
Behavioral modifications need to be done.
High blood pressure during pregnancy is difficult to diagnose in pregnancy whether it is due to preeclampsia or lupus nephritis.
She might need contraception prior to disease optimization.
Fetus also can suffer from issues like first trimester miscarriages, fetal growth restriction, preterm delivery, sudden IUD.
After delivery baby can suffer from neonatal lupus syndrome and congenital heat blocks.
Prior to pregnancy thorough multisystem assessment is important to detect systemic complications like serosal involvement(chest xray for pleural involvemnt,2d echo for cardiac function+ pulmonary hypertension ,
creatinine,UFR eGFR for renal involvement,
FBC,CRP for haematological parameters as she might be having anaemia, thrombocytopaenia, leukopaenia).
Pregancy increases flares by 40 -50%.Flares more likely in 2nd half of pregnancy.
If they are associated with anti phospholipid syndrome they are at increased risk of arterial and venous thrombosis.
Because of lupus nephritis they can have pre eclampsia/eclampsia/HELLP Xn.
So pressure need to be optimized prior to pregnancy with non teratogenic anti hypertensive drugs.
They might be on teratogenic immunosuppressive drugs like MTX, mycophenolate mofetil, Cyclophosphamide and NSAIDS which need to be stopped.
She should be changed to azathioprine, ciclosporin, hydroxychloroquine and steroids
They might be having other auto immune conditions which need to be evaluated.
They are more to develop infections.
They also can have neurological disorders like psychosis, chorea, seizures which need evaluation if symptomatic.
Fetus can have high incidence of first trimester loss if associated with APLS.
2nd TM miscarriage ,intra uterine death risks are also high.
Spontaneous preterm delivery, iatrogenic preterm delivery risk is high.
Fetal growth restriction risk is high.
So serial growth scan assessment is a must.
If mother’s anti ro ,anti La antibodies present baby can have congenital heart blocks which ca be detected at 22 week fetal 2d echo.
It occurs in 2-3% of fetuses of women with the anti Ro/ anti La antibody and recurrence is 16%.
congenital heart block develop between 18 & 28 weeks.
They might need pace makers after delivery.
baby can develop neonatal lupus syndrome.(Cutaneous lupus, congenital heart blocks, Haematological parameters alteration)
So pre pregnancy counselling in a SLE lupus nephritis patient is of utmost important in reducing maternal and fetal complications,
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