The best time for a patient to get married is when the disease is stable and there is no serious damage to internal organs. Patients with lupus who have children or whose disease is active should use strict contraception, and should not use contraceptives containing estrogen or a mixture of estrogen and progestin. Condoms.
Conditions in which lupus patients cannot get pregnant.
(1) In the first 2 years of lupus;
(2) Those whose disease is not yet under control (on high doses of hormones) or has not been stabilized for a long period of time, because more than 60% of pregnancies during the active phase worsen, but only 7% worsen when the disease is under control and only low doses of hormones are used. In addition, the risk to the fetus is high in active pregnancies;
(3) Those with important organ involvement such as kidney, brain, heart and lung;
(4) Active kidney disease or blood creatinine >2mg/ml (176.8umol/L).
Timing of pregnancy in patients with lupus.
(1) No involvement of vital organs;
(2) Stable disease in remission > 1 year;
(3) Prednisone maintenance <10mg/day;
(4) No immunosuppressive drugs for at least 6 months.
Pre-pregnancy precautions.
(1) Visit the obstetrics and gynecology department: check for relevant items such as anti-Toxoplasma antibodies;
(2) Visit rheumatology department and be well prepared: because 10-50% of patients have recurrence of the disease during pregnancy or several months after delivery, lupus can cause miscarriage, preterm delivery, stillbirth and intrauterine growth retardation, etc. Those with positive serum antiphospholipid antibodies are prone to miscarriage and intrauterine fetal death.
Attention after pregnancy.
(1)Regularly visit the obstetrics and rheumatology departments and closely monitor the activity of lupus;
(2) The first and second trimesters of pregnancy are the key observation periods, and hormones should be increased or decreased as appropriate: the first trimester is prone to miscarriage, and the second trimester and after delivery are prone to relapse, so do not use medication at will, and do not adjust the hormone dose in stable patients.
Principles of drug use in lupus patients after pregnancy.
(1) Only use the drug when the adaptation is proven and the benefits (often for the mother) exceed the potential risks of the drug (often for the fetus);
(2) Avoid the use of any medication (including over-the-counter medications) during the first trimester of pregnancy;
(3) Use the smallest effective dose and the shortest duration;
(4) Try to use drugs that have been widely used during pregnancy and have a good safety profile, and avoid new drugs that are theoretically feasible but not yet proven;
(5) Most drugs with molecular weights <1500 can cross the placenta and may affect the fetus;< span="">
(6) Try to avoid using multiple drugs at the same time.
Commonly used drugs recommended.
(1) Non-steroidal anti-inflammatory drugs: These include drugs such as fentanyl, fotarol, lexapro, and mobicol. These drugs are usually safe, but such drugs may cause fluid retention, aggravate hypertension and renal insufficiency, and should be avoided in the second trimester because they can also cause ductus arteriosus in the immature fetus.
(2) Hormones: Except for fluorine-containing hormones such as dexamethasone and betamethasone, other hormones including prednisone, medrol and prednisolone can be used as they can be inactivated by the hydroxylase enzyme of the placenta and not absorbed by the fetus. However, hormones can also cause some more serious problems, including diabetes, hypertension, pre-eclampsia and premature rupture of membranes in immature fetuses. Therefore, if hormones are applied for a long time, prednisone or prednisolone doses should be less than 5 mg. For patients with extremely active lupus, it may be safe to use methylprednisolone in shock doses of 250 mg and 500 mg.
(3) Immunosuppressants: In addition to azathioprine, cyclosporine and tacrolimus, other immunosuppressants including cyclophosphamide, methotrexate, mycophenolate, and leflunomide are contraindicated.
(4) Hydroxychloroquine: This is the cornerstone drug for lupus treatment, which is important in controlling disease activity, preventing thrombosis, preventing relapse, reducing metabolic syndrome and enabling long-term survival of patients. Its safety in pregnant women with lupus or other connective tissue diseases has been demonstrated, and no fetal malformations, hearing and vision, or neurotoxicity have been reported. Moreover, the risk of lupus outbreaks is significantly higher after discontinuation of hydroxychloroquine during pregnancy. Therefore, hydroxychloroquine should not be discontinued after pregnancy. Because chloroquine phosphate is somewhat more toxic than hydroxychloroquine, patients using chloroquine phosphate are advised to switch to hydroxychloroquine.
(5) Biologics: There is little experience with treatment in pregnant women, and further observation is needed.
(6) Anticoagulants: Low doses of aspirin and pentoxifylline are safe, various doses of heparin are safe, and ticlopidine (Ticlopidine) and clopidogrel (Bolivar) are contraindicated. Warfarin and coumadin are contraindicated during the fetal organogenesis period (6-10 weeks of gestation). Note: Patients receiving heparin anticoagulation should take calcium and vitamin D until the end of lactation.
(7) Antihypertensive drugs: The antihypertensive drugs that can be used are mainly those older antihypertensive drugs such as methyldopa and nifedipine, while other antihypertensive drugs such as angiotensin-converting enzyme inhibitors, angiotensin receptor antagonists and diuretics are prohibited because of their toxicity in causing fetal renal failure and amniotic fluid reduction. The use of angiotensin-converting enzyme inhibitors in early pregnancy has been reported to cause congenital malformations in the fetus.
Treatment of lupus in pregnant women with active disease.
(1) The safety of the mother and fetus should be fully considered in the use of drugs;
(2) Increase the dose of hormones or methylprednisolone shock therapy;
(3) Immunoglobulin shock therapy may be used;
(4) CTX shock can be applied if fetal safety is not considered.
Fetal monitoring in pregnant women with lupus.
(1)Early pregnancy:monitor fetal heart sounds at each visit starting from the 10th week;
(2)Middle pregnancy: monitor fetal heart sounds every 2 weeks, apply ultrasound to check for congenital defects in the 18th and 20th week, and assess the developmental status of the fetus by measuring the height of the uterine fundus, and apply ultrasound if necessary;
(3) Late pregnancy: ultrasound examination every 3–4 weeks, weekly fundal height to assess the developmental status of the fetus, and application of multispectral ultrasound for biophysical testing (such as amniotic fluid volume, fetal movement, respiration and fetal heart sounds) in the 28th–30th week.
Indications for termination of pregnancy in patients with lupus.
(1) Cardiac involvement: e.g. endocarditis, myocarditis and cardiac insufficiency;
(2) Progressive glomerulonephritis or renal failure;
(3) Nephrotic syndrome;
(4) Those who have no obvious symptoms but have significantly elevated immune monitoring indicators.
Precautions for delivery in patients with lupus.
(1) Generally, pregnancy with stable disease and no obvious visceral damage can lead to safe delivery;
(2) Hospitalization in advance before delivery;
(3) During labor, gastrointestinal delivery time is prolonged due to slowed gastric emptying and weakened intestinal dynamics, so parenteral administration of drugs is often used;
(4) Hydrocortisone succinate at the time of delivery (200 mg/day), equivalent to one times the prenatal hormone dose; Day 1 postpartum: Hydrocortisone succinate 200 – 300 mg IV; Day 2 postpartum: Hydrocortisone succinate 160 – 200 mg IV; Hydrocortisone succinate 160 – 200 mg IV. -200mg IV; on postpartum day 3, resume prenatal dose and maintain prednisone at least 10mg/d for 6 weeks.
Precautions for lupus patients during breastfeeding.
(1) It is best not to feed the baby personally to avoid increasing the physical and mental burden and the entry of antinuclear antibodies into the fetus through breast milk;
(2) If you need to feed the baby yourself, you should take more rest;
(3) Prednisone and methylprednisolone can be used, as they are only present in low concentrations in breast milk;
(4) If prednisone >20mg/day, breastfeeding should be done 4h after administration;
(5) All immunosuppressive agents, including Imuran, are prohibited;
(6) available non-steroidal anti-inflammatory drugs with a short half-life, such as ibuprofen, etc.