CASE 2

Presentor- Dr. Prathima PrabhuFNB Fellow in High Risk Pregnancy

and PerinatologyModerator- Dr.Rama V

Hyderabad, Indiawww.fernandez.foundation

HISTORY

Mrs S, 27yr, B Ed, post office employee,

W/o Mr Y, 31yrs, Graduate, Bank employee

Resident of Medak

Primigravida, 34+3 weeks of gestation

Known case of - SLE, secondary APLA

- Mononeuritis multiplex

- h/o mesenteric ischemia

- Hypothyroid

Married since 2019

Non consanguinous

LMP-4/10/19

EDD-10/7/20

GA- 34weeks 4 days

HISTORY

• 2016- Admitted at NIMS

• H/o low grade fever, no chills and rigors

• Pedal edema and facial puffiness

• Grade II SOB, left sided pleuritic chest pain, no orthopnoea

• Pain and numbness of both LL, difficulty in walking , slippage of foot wear, paresthesias,

• Right sided facial rash, alopecia,

• Loss of appetite, loose stools, occasional abdominal discomfort

HISTORY

HISTORY

• Evaluation-

• Anemia (Hb 9.4 gm/dl)

• Thrombocytopenia (20000)

• ANA 4+

• ds DNA +ve

• low C3/C4( 35/14)

• ACL IgG/IgM positive(35/40)

• S. albumin-2.2

• SGOT/SGPT-10/31

• 24hrs urine protein-580mg

• Creatinine 0.5 mg/dl

• 2D ECHO- Normal

• Diagnosed - SLE-APS with mononeuritis multiplex, ? Cytopenias, serositis and ? Enteritis

• Started on Methylprednisolone pulses• Initial improvement in symptoms• Developed colicky abdominal pain and dystentry

– USG abdomen – B/l moderate pleural effusion and ascites, GB sludge, diffuse wall thickening of multiple bowel loops, increased PSV in SMA and coeliac +

– CECT abdomen – Thickened and edematous small bowel loops,? Mesentricischemia, ascites, b/l pleural effusion. Consolidation in right lower lobe ? infarct

HISTORY

• Received cyclophosphamide,IV Methyl prednisolone,

anticoagulation- IV Heparin followed by acitrom, Wysolone

• Received 6 doses of cyclophosphamide followed by

Azathioprine 75 mg till 2018

• ACL IgG/IGM after 6 months - (10/32), previously (35/40)

• 2018 – ACL IGG/IGM -negative (18/4)

• Stopped anticoagulation due to no documented

thrombosis and non reproducibility of antibodies

HISTORY

• In remission since 2018

• Continued on

• Azathioprine 50 mg,

• HCQs 200 mg,

• Wysolone 5 mg

• Ecosprin 75 mg

• Sep 2019 – Wysolone reduced to 2.5 mg

Hypothyroid- 2019 on Levothyroxine as per TSH levels

HISTORY

Spontaneous conception

Booking visit- 6 weeks

Weight- 54.5kg, BMI- 20.2

No Signs and symptoms of flare

Started on folic acid

Advised to continue same medications by Rheumatologist

PRESENT PREGNANCY

O POSITIVE

HIV/HBSAG/RPR- NR

S TSH- 1.32

HBA1C- 5.2

HPLC- HB-8.5,

Iron deficiency anaemia

Early pregnancy scan- SLIUF 6weeks

EFTS- low risk for trisomy, screen negative for Pre eclampsia

FIRST TRIMESTER

Urine C/S- sterile

S creatinine- 0.8

SS-A Ro/La IgG- Negative

APLA IgG/IgM- negative

LAC- negative

Anti ds DNA- negative

QUESTION

Role of anticoagulation in this pregnancy

Continued medications

Iron/ca/vit D

TT inj

TIFFA scan, Fetal ECHO- normal

CBC- 10.9/58000/155000

OGTT- Normal

Urine C/S- no growth

S creatinine-0.8

SECOND TRIMESTER

Fetal well being scan at 30 wks 6days-

SLIUF 30w6d, cephalic, normal AFI, 1.2kg, EFW 2 centile, FGR with

normal doppler- fetal and maternal

THIRD TRIMESTER

QUESTION

Incidence of FGR in SLE mothers

Is this FGR as per DELPHI consensus

DELPHI CONSENSUS CRITERIA FOR FGR

EARLY FGR < 32weeks

AC/EFW <3rd centile OR UA-AEDF

OR

1. AC/EFW <10th centile combined with

2. UtA-PI>95th centile and/or

3. UA-PI> 95th centile

LATE FGR >32weeks

AC/EFW< 3rd Centile

Or atleast two out of three of the following

1. AC/EFW <10th centile

2. AC/EFW crossing centiles >2quartiles on growth centiles

3. CPR <5th centile or UA-PI >95th centile

31.6 weeks - Normal liquor, normal blood flow in umbilical artery and DV, MCA redistribution (CP ratio 1.88)

32.6 weeks - 1.5kg/ FGR /EFW 1 centile/ normal liquor and doppler

33.6weeks- Normal liquor and doppler

Steroid covered at 33w6d

Came with decreased fetal movements-34w3d

THIRD TRIMESTER

QUESTION

How will you monitor FGR fetus?

FGR Protocol

Stage based classification and management of FGR

Stage Pathophysiological criteria

Criteria (any of) monitoring GA & Mode of delivery

I Severe smallness or mild placental insufficiency

EFW <3rd cUt A PI > p95UA PI> p95MCA PI<p5CPR<p5

weekly 37 weeksInduce labour

II Severe placental insufficiency

UA AEDVReverse AoI

Biweekly 34 weeksCesarean section

III Low suspicion fetalacidosis

UA REDVDV PI>p95

1-2 days 30 weeksCesarean section

IV High suspicion fetalacidosis

DV reverse a flowFHR decelerations

12hours 26weeksCesarean section

GPE- conscious, oriented, no pallor, icterus, pedal edema

Weight-64kg, weight gain-9.5kg BMI- 27.70

Vitals- PR- 84/min BP- 110/70mmHg RR 18/min, afebrile

CVS RS- NAD

P/A- uterus 32w, cephalic, relaxed, FHS- absent

USG- absent cardiac activity

ADMISSION

27 yr old primigravida at 34 weeks 3 days, known case of SLE in

remission, hypothyroid, FGR with intrauterine fetal demise for

management and delivery.

DIAGNOSIS

Investigations- CBC- 11.4/4700/148000

PT/APTT/INR- 15/29.1/1.02

Plasma fibrinogen- 438

FDP-negative

Labour induced with PGE1.

Received stress dose of steroids during labour

COURSE IN HOSPITAL

Delivered a still born male fetus/VD/ 1.76kg(8c)

No gross fetal/cord/placental anomalies

Placenta- 300gm, cord 50cm

Placenta sent for HPE

Fetal autopsy- declined

KB test- no fetal RBCs

COURSE IN HOSPITAL

Placental stroma - diffuse villous sclerosis and reduced vascularity

Areas of villous agglutination and Tenny Parker changes seen

Basal plate - retroplacental hematoma

No evidence of villitis or intervillositis

Impression- Features consistent with IUFD

Features suggestive of antepartum haemorrhage

PLACENTAL HISTOPATHOLOGY

Antibiotics, analgesics

Continue Wysolone 5mg, Azathioprine 50mg, HCQ 200mg OD

Tab Cabergoline

Inj Enoxaparin for 6weeks

Uneventful

Advice- to follow up at NIMS 6weeks post delivery

POST NATAL

6weeks NIMS- Advised to continue Wysolone 5mg

HCQ 200mg

Azathioprine 50mg

Ecospirin 75mg

Doing well

FOLLOW UP

How will you manage subsequent pregnancy?

QUESTION

THANK YOU