The best time to marry a patient with SLE 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. Contraceptives containing estrogen or a mixture of estrogen and progestin should not be used, but progestin-only contraceptives (which rarely cause relapse of the disease but are more likely to have drug-related complications), birth control rings should not be used (to avoid intrauterine infections), safe periods should not be presumed based on the menstrual cycle, and mechanical barrier methods such as vaginal diaphragms or condoms.
Conditions in which a patient with lupus cannot become pregnant include
1. the first 2 years of lupus onset.
2. those whose disease is not yet under control (being on high doses of hormones) or who have not been stabilized for a long period of time, as pregnancy during the active phase worsens the disease in more than 60% of cases, but only 7% of pregnancies when the disease is under control and only low doses of hormones are used worsen the disease, in addition, pregnancy during the active phase is associated with high fetal risk
3. those with involvement of important organs such as kidney, brain, heart and lungs
4. active kidney disease or blood creatinine >2 mg/ml (176.8 umol/L).
The timing of pregnancy in patients with lupus includes.
1. no involvement of vital organs.
2. stable disease in remission > 1 year.
3. prednisone maintenance <10 mg/day.
4. absence of immunosuppressive drugs for at least 6 months.
Pre-pregnancy notes for patients with lupus.
1. visit the obstetrics and gynecology department: check relevant items such as anti-Toxoplasma antibodies, etc.
2. visit the rheumatology department and be well prepared: as 10-50% of patients have a relapse of the disease during pregnancy or in the months after delivery, lupus can cause miscarriage, premature birth, stillbirth and intrauterine growth retardation, etc. Those with positive serum antiphospholipid antibodies are prone to miscarriage and intrauterine fetal death
Note to lupus patients after pregnancy.
1. regular visits to obstetrics and rheumatology departments to closely monitor the activity of lupus.
2. the first and second trimesters of pregnancy are the key observation periods, and hormones are added or subtracted as appropriate: the first trimester is prone to miscarriage, and the second trimester and after delivery are prone to recurrence, and medication should not be used arbitrarily, and the hormone doses of stable patients are not adjusted.
Principles of drug use in lupus patients after pregnancy.
1. medication should be used only 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, as far as possible, 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 are already widely used during pregnancy and have a good safety profile, and avoid new drugs that are theoretically feasible but have not yet been proven.
5. most drugs with molecular weights <1500 can cross the placenta and may have an effect on the fetus.
6. avoid simultaneous use of multiple drugs as far as possible.
Note on hormone use in lupus patients after pregnancy.
1. dexamethasone and betamethasone should not be used to prevent the effects on fetal growth and development.
2. prednisone or methylprednisolone or hydrocortisone succinate can be chosen (prednisone dose more than <7.5mg/d): as it has no effect on the fetus, prednisone can be oxidized to inactive products by 11-beta-dehydrogenase produced by the placenta, and the concentration of prednisone and prednisolone in the umbilical blood of the fetus is only 1/8-1/10 of the concentration in maternal blood.
Note on the use of NSAIDs in lupus patients after pregnancy.
1. discontinue all NSAIDs, especially in the first and second trimesters of pregnancy.
2. aspirin may be used in small doses (not in large doses, especially in late pregnancy)
3, mid-pregnancy if the fetus has no heart and kidney abnormalities, short-term application of non-steroidal anti-inflammatory drugs such as ibuprofen with short half-life and inactivated metabolites, to reduce the impact on the fetus.
4. painkillers must be used in late pregnancy and can be replaced by acetaminophen: acetaminophen can be safely used during pregnancy and lactation for headache (preferred).
Use of antibiotics in pregnancy in patients with lupus.
1. only very few antibiotics have adverse effects; apply standard adult doses and use them for an adequate period of time if no vital organ damage is present.
2. the use of: aminoglycosides, for causing deafness and vestibular damage and renal damage; tetracyclines, for causing dental and skeletal abnormalities and liver damage; quinolones, for causing irreversible arthropathy; and sulfonamides, for causing hyperbilirubinemia and nuclear jaundice.
Treatment of lupus in pregnant women with active disease.
1. medication should be administered with due consideration for the safety of the mother and fetus.
2. increased doses of hormones or methylprednisolone shock therapy.
3. immunoglobulin shock therapy may be used
4. CTX shocks may 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. mid-pregnancy: monitoring fetal heart sounds every 2 weeks at each visit, applying ultrasound to check for congenital defects in the 18th-20th weeks, assessing the developmental status of the fetus by measuring the height of the uterine fundus, and applying 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 lethality 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, such as 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.
Points to note for lupus patients during delivery.
1. in general, pregnancy with stable disease and no obvious visceral damage can be safely delivered
2. advance hospitalization before delivery.
3. during delivery, the gastrointestinal delivery time is prolonged due to slowed gastric emptying and weakened intestinal dynamics, and extra-gastric administration is commonly used.
4. static dosing (200 mg/day) of hydrocortisone succinate equivalent to one times the prenatal hormone dose at the time of delivery, 200-300 mg of hydrocortisone succinate on postpartum day 1, 160-200 mg of hydrocortisone succinate on postpartum day 2, resumption of prenatal dose on postpartum day 3, and maintenance of prednisone at least 10 mg/d for 6 weeks.
Points to note for lupus patients during breastfeeding.
1. it is better not to feed the baby personally to avoid aggravating the physical and mental burden and the entry of antinuclear antibodies etc. into the fetus through breast milk.
2. If you need to feed the baby yourself, you should take more rest.
3, available prednisone and methylprednisolone, as they are only present in low concentrations in breast milk.
4. when prednisone >20mg/day, breastfeeding should be done 4h after administration of the drug.
5. all immunosuppressive agents including Imuran are prohibited.
6, available non-steroidal anti-inflammatory drugs with a short half-life, such as ibuprofen, etc.