1. Pay attention to normal pregnancy manifestations that are easily confused with lupus activity:
(1) Fatigue: throughout pregnancy.
(2) palmar erythema, facial flushing and “chloasma” (photosensitive pigmented spots on the cheeks and forehead): associated with increased estrogen.
(3) Postpartum hair loss: associated with reduced estrogen levels.
(4) Joint pain and back pain: associated with physiological ligamentous laxity and lumbar lordosis.
(5) Rapid respiratory rate and dyspnea: accelerated respiration due to progesterone action in the early stage and dyspnea due to increased uterine size in the late stage.
(6) headache: can be a normal pregnancy performance.
2, pay attention to the changes in the normal values of pregnancy.
(1) The upper limit of normal blood pressure is reduced: the blood pressure decreases by about 10 mm Hg due to the decrease in systemic vascular resistance during normal pregnancy;
(2) The upper limit of normal renal function is reduced: because pregnancy increases the glomerular filtration rate, the creatinine clearance rate is often greater than 100 ml/min;
(3) Increase in the upper limit of normal 24-hour urine protein: it is clinically significant only when it exceeds 200 mg/d, because the urine protein excretion increases to 150-184 mg/d in pregnancy;
(4) Increase in the upper limit of normal blood leukocytes and decrease in the lower limit of normal platelets: because of the increase in leukocytes (sometimes up to 15×109/L, mainly neutrophils) and mild decrease in platelets in late pregnancy.
(5) Elevated upper limit of normal blood sedimentation: physiological increase.
(6) Hypercoagulable state of pregnancy: pregnancy-induced protein S deficiency, increased fibrin, coagulation factor II, coagulation factor V and thrombin, combined with venous stasis, uterine compression of veins and bed rest.
(7) Increased normal upper limit of complement: increased hepatic synthesis of complement due to the action of estrogen.
3. Pregnancy can contribute to lupus recurrence.
(1) Risk factors for relapse: high lupus activity index in the first 6 months of pregnancy, multiple relapses before pregnancy, low serum albumin, high anti-ds-DNA antibody titers, proteinuria and discontinuation of hydroxychloroquine.
(2) Relapses can occur at any time of pregnancy or within a few months after delivery.
4. Lupus adversely affects pregnancy outcome: When lupus patients become pregnant, the incidence of miscarriage, stillbirth, preterm birth, low birth weight and ultra-low birth weight babies is higher than that of normal pregnant women. Risk factors include lupus activity, positive antiphospholipid antibodies, proteinuria, reduced platelets, hypertension, renal insufficiency and taking large amounts of hormones.
5. Identification of pre-eclampsia and lupus activity.
(1) Pre-eclampsia is defined as previous normal blood pressure, blood pressure >140/90 mm Hg after 20 weeks of gestation and proteinuria >0.3 g/24 h. Severe pre-eclampsia is defined as severe hypertension (>160/110 mm Hg), microvascular hemolytic anemia (thrombocytopenia, anemia and increased lactate dehydrogenase), elevated liver enzymes and epigastric pain due to liver damage, central nervous system ischemia caused by headache, vision changes and stroke, and massive proteinuria and increased blood creatinine due to renal impairment. Eclampsia is grand mal seizures.
(2) Both have common symptoms and laboratory manifestations (headache, hypertension, proteinuria and microscopic hematuria, etc.).
(3) Pre-eclampsia is an increased risk in first pregnancies, multiple pregnancies and those with previous pre-eclampsia. Proteinuria is often sudden, without arthritis, plasmacytosis or skin changes, and laboratory tests often show increased transaminases, blood uric acid >5.5 mg/dl and low urinary calcium excretion (<195 mg/d predicts sensitivity of 86% and specificity of 84%), while urine sediment (red and white blood cells, tubular), anti-DNA SLE activity: often with skin lesions, arthritis and pluritis, progressive proteinuria, abnormal urine sediment (positive red and white blood cells, tubular pattern), positive Coomb's test, positive anti-DNA and anti-platelet antibodies, low complement C3 and C4 (complement can also be normal, as estrogen induces the liver to The complement C3 and C4 may be low (complement may also be normal because estrogen induces the liver to synthesize more complement), while transaminases are normal, blood uric acid is unchanged, and urine calcium is normal.
6. Regular monitoring indicators.
(1) Routine tests: blood and urine routine and liver and kidney function.
(2) Other: complement C3, C4, CH50, anti-dsDNA antibody, anti-cardiolipin antibody, lupus anticoagulant, anti-SSA antibody, anti-SSB antibody, 24h urine protein quantification, 24h urine calcium excretion, creatinine clearance rate.
(3) Follow-up density: 1 visit every 2 weeks after 20 weeks of pregnancy and 1 visit every week after 28 weeks.
7. Prevention of lupus recurrence.
(1) Administration of hydroxychloroquine: it should be continued after pregnancy without increasing the incidence of fetal abnormalities and without affecting pregnancy outcome.
(2) Azathioprine: the safest immunosuppressant during pregnancy. There is no enzyme in the fetal liver that metabolizes azathioprine into an activated form, which does not increase the incidence of fetal abnormalities and has the same side effects on the mother as in non-pregnant SLE patients.
8. Treatment of lupus recurrence.
(1) Mild activity: small doses of prednisolone (20 mg/d) are available.
(2) Moderate to severe activity: treat with higher doses of prednisone and methylprednisolone and, if necessary, with shock therapy. Dexamethasone or betamethasone is not needed. Intravenous immunoglobulin can control lupus hematologic and nephropathy and has no effect on pregnancy outcome; cyclophosphamide is tried in acute progressive lupus nephritis where other treatments are ineffective, but it should not be used in early pregnancy because of its teratogenic effect unless the life of the pregnant woman is threatened.
9. Treatment of complications.
(1) hypertension: treatment target 140/90 mmHg, preferred drugs methyldopa and labetalol (labetalol), may be used for a short time with hydrazinepyridazine (prone to lupus-like symptoms beyond 6 months), angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers are prohibited (may cause irreversible fetal kidney damage). If these drugs are not effective or are not tolerated, second-line drugs such as nifedipine (teratogenic in animal models, not found in humans), beta-blockers (atenolol is strongly associated with intrauterine growth restriction; it is not clear whether others are associated with intrauterine fetal growth restriction) and diuretics (to reduce blood volume, use medullary diuretics to maintain renal function) are available.
(2) Antiphospholipid syndrome: prophylactic subcutaneous administration of heparin or low-molecular heparin and low-dose aspirin. Heparin 5000 IU, enoxaparin 30 mg or Dalteparin 2500 IU, all subcutaneously, once/12 h. Replace low molecular heparin with regular heparin 4 weeks before the expected delivery date, stop heparin at the beginning of labor or 8 h before cesarean section (for fear of epidural hematoma during painless delivery), and start low molecular heparin or combined with warfarin 12 h after delivery. Anticoagulation with low molecular heparin or combined with warfarin is started 12 h after delivery, heparin anticoagulation for 6 weeks after delivery, and low dose aspirin (aspirin) can be used for a long time. Pregnant women with SLE who have a history of thrombosis should be fully anticoagulated. Enoxaparin 1 mg/kg or tedelparin 100 IU/kg, both once every 12 h. In the second trimester of pregnancy regular heparin should be administered subcutaneously once every 8 h to achieve an international normalized ratio (INR) of 2.5.