Systemic Lupus Erythematosus (SLE) is a collagen disease that predominantly affects women of childbearing age. Even if the disease is not clinically recognized, the first diagnosis can be made during pregnancy. In recent years, the 5-year survival rate has increased to over 90%. It is an autoimmune disease with multi-organ involvement, affecting women aged 20-30 years (8:1) and the incidence is higher among blacks.
Lockshin et al. in pregnant SLE; reported that there was no significant difference in terms of remission and exacerbation compared to non-pregnant women. Postpartum period; It is very suitable for exacerbations due to the disappearance of high steroid levels in pregnancy. Recurrent miscarriages in these patients: IUGG intrauterine alum and preeclampsia-eclampsia are common. LAF = Lupus anticoagulant actor and ACA = antibodydiolipin antibody are responsible for these pregnancy complications.
PHENOMENON
KY, 34 years old, Gravida 4. Parity 1; fifteen years ago NSD, Abortus 2, married for 16 years; In 1987, the patient with a butterfly-like rush on his face, E. Ü. He was diagnosed with SLE in TF, then the patient was being treated for SLE. In the kidney biopsy performed in 1992, ACTIVE KIDNEY INVOLVEMENT was detected. The patient was given Utralan 60 mg/day. Endoxan tbl. It was arranged as 5 mg 3xl tbl and Rezokin lxl tbl. He was called to the rheumatology outpatient clinic for control. The patient applied to our outpatient clinic with the complaint of SLE + 18 weeks grosses + Hypertension. He was admitted for further examination and treatment. T.A. 160/100 mm Hg Urea 72.8 mg/dl; Creatinine 0.97 mg/dl; Butterfly style rush on face, Sedim. 100mm/h; CRFT slightly above normal; As a result of internal medicine consultation; Salt-Free Diet, Ultralan 10 mg tbl. lx1.; Baycaron tbl 1xl tbl. edited, alphamethyldopada added. ANA was 1:20 positive, CRP: 0.5. In addition, antiphospholipid antibodies were found to be positive. The patient was started on prednisone as an immunosuppressive and alfamedildopa as an antihypertensive, additionally supportive treatment was given. Insufficient control of blood pressure despite this treatment; It was decided to terminate the pregnancy due to decreased kidney function.
ARGUMENT
SLE is an autoimmune disease with multiorgan involvement. If there is no exacerbation of the disease, the pregnancy can be successfully terminated in those who entered complete remission 6 months before the onset of pregnancy. But often this is not possible. Hypertension and renal functional impairment can be seen in the late stages even in patients whose first diagnosis is made at the beginning of pregnancy, and LE-anticoagulum detected in patients can cross the placental barrier and lead to intrauterine deaths. Clinically, arthritis and arthralgias, skin findings, nephritis, fever, central nervous system findings, Reynaud’s phenomenon, pleurisy, pericarditis, hemolotic anemia, leukopenia, thrombocytopenia are observed. Diagnosis is made by the presence of four or more of the above and positive antinuclear antibodies.
Fertility rates of SLE patients are normal, but it should be kept in mind that amenorrhea may occur with corticosteroid therapy. Pregnancy of patients in remission is normal, but there is an increased risk of premature birth if the disease activity is increased or if the disease is newly established. Increased likelihood of exacerbation of the disease in the postpartum period; THESE PATIENTS REQUIRE VERY CLOSE FOLLOW-UP IN PREGNANCY AND POSTPARTUM PERIOD.
The most common problem in SLE patients is recurrent abortions. Antiphospholipid antibodies are held responsible for these abortions. Among these autoantibodies, anticardiolipin antibodies are detected by ELISA technique, and LAF by prolongation in APTZ. In order to prevent miscarriages in patients with antiphospholipid antibodies, low-dose aspirin or heparin, immunosuppression with prednisolone, and intravenous gammaglobulin treatments are tried. Despite this treatment, preeclampsia is common in pregnant women and both pregnancy and post-partum period should be followed very closely.
Children of pregnant women with SLE have a high rate of congenital heart disease. It was found that isolated congenital complete heart block was found in the children of pregnant women with anti-Rho (SS-A) antibodies, which is seen in 25-30% of SLE.
Management in pregnancy includes a careful history, physical examination, and laboratory evaluation necessary to demonstrate cardiac or renal involvement. The patient is recommended an emotionally stable lifestyle and rest. Previous anti-inflammatory drugs should be continued; These drugs should not be reduced during pregnancy. Renal function should be evaluated repeatedly throughout pregnancy. Fetal growth should also be monitored frequently. Antenatal testing usually begins at week 32.
As a result: SLE; It seriously affects reproductive performance and often leads to recurrent pregnancy loss. In this respect, this possibility should be screened by performing APTZ and ELISA-ACA tests during routine habitual abortion examinations. Care should be taken in terms of postpartum exacerbation.
Clinical Symptoms in SLE (DUBOIS 1976)
Arthralgia 92%
Fever 84%
Skin symptoms 72%
lymphadenopathy 59%
Anorexia, nausea, vomiting, diarrhea 53%
Joint pain 49%
Myalgia 48%
Pleuritis 45%
Henicarditis 32%
Lung changes 30%
Water collection in the pleura 30%
FAQ changes 26%
Hepatomegaly 23%
Sound at Heart 20%
Abdominal pain 19%
Reynaud’s phenomenon 18%
Splenomegaly 9%
Lab Findings in SLE
Strong sedimentation 84%
Anemia 72%
Leukopenia 61%
Thrombocytopenia 15%
Positive antinuclear AK
Especially Anti DNA White 99%
Positive LE cell test 80%
Globulin elevation 77%
Complement C3-C4 75%
Circulating immune complex 70%
Rheumafactor display 20%
False positive Lues 15%
Diagnosis of SLE According to the American Rheumatism Association (ARA)
– Butterfly-shaped erythema on the face
– Discoid Lupus
– Phonosensitivity
– Oral-nasopharyngeal mucosal wounds
– Arthritis in two or more joints
– Kidney changes (persistent proteinuria or roller in urinary sediment)
– Neurological changes (hemalytic anemia, leukopenia, Iymhopenia or thrombocytopenia)
– Immunological changes (LE-Cell or Anti DNA-Ak or false-positive syphilis test)
– Antinuclear factors
SLE+ Pregnancy
Complication Frequency
Sterility 20
Habitual Abort 30
IUGG 65
Premature Birth 50-60
Stillbirth 6-14
Symptoms from Acute SLE
arthritis
nephritis
Skin symptoms
Endo-Myo-Pericarditis
Polyserositis-Pleuritis
Fire
Liver-Spleen involvement
OBSTETRIC BEHAVIOR IN LUPUS ERYTHEMATODES
– Visit to obstetrician and rheumatologist every 2 weeks
– Weekly visit in the last trimester
– USG after 20 weeks of pregnancy
– Weekly CTG-Check in the last trimester
– Hemogram, Urine culture, Creatinine clearance in each trimester; total protein
in 24-hour urine
– In the first trimester
anti – phospholipid-Antibody
anti-Rho (Anti-SSA)
making anti – LA (Anti-SSB)
