A 31-year-old primigravida comes to the office seeking advice regarding her pregnancy. She discovered that she was pregnant approximately a week ago. The patient was diagnosed with systemic lupus erythematosus 8 months ago and was started on hydroxychloroquine. Her initial clinical features included fatigue, pain and swelling of the finger joints, and facial rash. Her symptoms have subsided with therapy.
The patient has a positive antinuclear antibody test with a 1:640 titer in a homogeneous pattern. Liver function tests, serum creatinine, complete blood count, and differential are normal. Urinalysis shows trace protein and 1-2 red blood cells/hpf. Anti-double-stranded DNA antibodies are positive at 1:120 titer, and anti-Ro/SSA and anti-La/SSB antibodies are negative. Complement levels are normal.
Which of the following is the best next step in management of this patient?

Question

A 31-year-old primigravida comes to the office seeking advice regarding her pregnancy.  She discovered that she was pregnant approximately a week ago.  The patient was diagnosed with systemic lupus erythematosus 8 months ago and was started on hydroxychloroquine.  Her initial clinical features included fatigue, pain and swelling of the finger joints, and facial rash.  Her symptoms have subsided with therapy.
The patient has a positive antinuclear antibody test with a 1:640 titer in a homogeneous pattern.  Liver function tests, serum creatinine, complete blood count, and differential are normal.  Urinalysis shows trace protein and 1-2 red blood cells/hpf.  Anti-double-stranded DNA antibodies are positive at 1:120 titer, and anti-Ro/SSA and anti-La/SSB antibodies are negative.  Complement levels are normal.
Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Current guidelines recommend checking antiphospholipid (APL) antibodies at the time of diagnosis of systemic lupus erythematosus (SLE) in all patients, regardless of pregnancy/miscarriage history. Antiphospholipid antibody syndrome is associated with recurrent arterial or venous thrombosis and pregnancy loss. Pregnant patients with active SLE and APL disease have an increased risk of maternal and fetal complications. Anti-SSA/Ro and anti-SSB/La antibodies should also be checked in this patient as these antibodies are associated with neonatal lupus and congenital heart block. Antiphospholipid syndrome is usually confirmed with positive anti-cardiolipin antibodies, lupus anticoagulant, or anti-beta 2-glycoprotein 1 antibodies (often confused with beta-2 microglobulin test). All 3 tests should be performed, as only one must be positive to diagnose APL syndrome in patients with the appropriate clinical history (eg, thrombotic events, pregnancy loss). Pregnant women with APL syndrome are usually treated with aspirin and/or low-molecular-weight heparin, depending on prior pregnancy complications (eg, fetal loss, preeclampsia). (Choice B) The erythrocyte sedimentation rate (ESR) can be a marker for disease activity in SLE, but this patient appears stable and would likely have a normal to mildly elevated ESR. Rheumatoid factor is falsely positive in many SLE patients and would add little therapeutic value. (Choice C) Hydroxychloroquine is safe for use during pregnancy and is associated with improved pregnancy outcomes in patients with SLE. Discontinuation may lead to disease flares. (Choice D) Re-checking the antinuclear antibody titer is rarely useful in patients with an established diagnosis of lupus as there is a poor correlation between titer level and disease activity. Anti-double-stranded DNA antibody titers have been associated with lupus nephritis flares in some patients, but even this association is inconsistent and unreliable. (Choice E) Patients with active SLE have poor maternal and fetal outcomes, but this patient is stable and has no indications for additional immunosuppressive medications. In addition, methotrexate is a teratogen and is contraindicated in pregnancy. Educational objective: All patients with systemic lupus erythematosus (SLE) should be screened for antiphospholipid syndrome as antiphospholipid antibodies are associated with an increased risk for poor maternal and fetal outcomes. Hydroxychloroquine is safe for use during pregnancy and improves pregnancy outcomes in patients with SLE. Anti-SSA/Ro and Anti-SSB/La antibodies are associated with neonatal lupus and congenital heart block. __________ References: Hydroxychloroquine in lupus pregnancy. (http://www.ncbi.nlm.nih.gov/pubmed/17075810) Risk of thromboembolic events after recurrent spontaneous abortion in antiphospholipid syndrome: a case-control study. (http://www.ncbi.nlm.nih.gov/pubmed/21900285) Lupus and pregnancy. (http://www.ncbi.nlm.nih.gov/pubmed/22112525)

A 31-Year-Old Primigravida Comes to the Office Seeking Advice Regarding