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Sle. medi

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SLE in pregnancy, Lupus, autoimmune disease in pregnancy
systemic lupus erythematosus

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Sle. medi

  1. 1. SYSTEMIC LUPUS ERYTHEMATOSUS Mediana Sutopo Liedapraja PPDS Tahap 1B Obstetri dan Ginekologi Fakultas Kedokteran Universitas Indonesia
  2. 2. SLE • Lupus is a heterogeneous autoimmune disease with a complex pathogenesis • Immune system abnormalities • Overactive B lymphocytes • Autoantibody production. • Result in tissue and cellular damage • Immunosupression is impaired  Regulatory T-Cell Function
  3. 3. • The 10-year survival rate is 70 to 90 percent • End-organ failure • Hypertension • Stroke • Infection • Lupus flares • Cardiovascular disease account for most deaths
  4. 4. MANIFESTASI KLINIS
  5. 5. http://en.wikipedia.org/wiki/File:Symptoms_of_SLE.png
  6. 6. Malar Rash Livido Reticularis Discoid Rash Polyarthritis
  7. 7. Autoantibodies produced in patients with lupus Spesifik terhadap lupus - Anti-ds-DNA - Anti-Sm Antinuclear antibodies (ANA) is the best screening test. A positive result is not specific for lupus. Low titers are found in normal individuals, other autoimmune diseases, acute viral infections, and chronic inflammatory processes
  8. 8. Autoantibodies produced in patients with lupus Spesifik terhadap lupus - Anti-ds-DNA - Anti-Sm Antinuclear antibodies (ANA) is the best screening test. A positive result is not specific for lupus. Low titers are found in normal individuals, other autoimmune diseases, acute viral infections, and chronic inflammatory processes Other laboratory findings • False-positive syphilis serology • Prolonged partial thromboplastin time • Higher rheumatoid factor levels Elevated serum d-dimer levels often follow a flare or infection, Unexplained persistent elevations  high risk for thrombosis
  9. 9. DIAGNOSIS American Rheumatism Association (ARA) Drugs can induce a lupus-like syndrome. • Procainamide, • Quinidine • Hydralazine, • α-methyldopa • Phenytoin • Phenobarbital. • 4 or more of these 11 criteria are present
  10. 10. Revised criteria of ARA for SLE If 4/11 criteria are present, diagnosis may be made with 75% specificity and 95% sensitivity D O P A M I N - R A S H !!!! 1. Discoid rash 2. Oral ulcers 3. Photosensitivity 4. Arthritis 5. Malar rash 6. Immunological 7. Neurological 8. Renal disorder 9. ANA 10. Serositis 11. Hematological
  11. 11. SLE-Pregnancy Disease Activity Index (SLEPDAI)
  12. 12. Yang harus diketahui pada prakonsepsi adalah: • Usia • Kehamilan sebelumnya • Keterlibatan organ akibat SLE • Derajat kerusakan yang ireversibel • Aktivitas SLE saat ini • Keberadaan antibodi antifosfolipid • Gambaran positif Anti Ro/ anti La • Penggunaan obat saat ini Best practice and research clinical rheumatology: Managing lupus during pregnancy (2009) KONSELING PRAKONSEPSI Jika berada pada fase lupus yang aktif sebaiknya kehamilan ditunda minimal selama 6 bulan hingga berada dalam fase tenang
  13. 13. Management During Pregnancy • Monitoring maternal clinical • Laboratory conditions • Fetal well-being Pharmacological Treatment ??? • There is no cure, and complete remissions are rare. • Arthralgia and serositis (NSAIDs). • Low-dose aspirin can be used throughout gestation. • Severe disease is managed with corticosteroids such as prednisone, 1 to 2 mg/kg orally per day. • After the disease is controlled  tapered to a daily morning dose of 10 to 15 mg.
  14. 14. Immunosuppressive agents such as azathioprine are beneficial in controlling active disease Azathioprine has a good safety record during pregnancy. Its recommended daily oral dose is 2 to 3 mg/kg. Antimalarials help control skin disease. ( Hydroxychloroquine)  cross the placenta,  but has not been associated with congenital malformations. Antimalarials help control skin disease.  Discontinuing therapy can precipitate a lupus flare  Recommend their continuation during pregnancy
  15. 15. When severe disease ( Lupus flare )  high-dose glucocorticoid therapy is given. Recommends pulse therapy - Methylprednisolone, 1000 mg given intravenously over 90 minutes daily for 3 days, - Then a return to maintenance doses if possible.
  16. 16. • Preterm delivery • Fetal-growth restriction • Stillbirths • Neonatal lupus syndrome • Fetal neutotoxic Perinatal Mortality and Morbidity Decidual vasculopathy with placental infarction and decreased perfusion Congenital Heart Block. - Diffuse myocarditis and fibrosis in the region AV and bundle of his - Developed almost exclusively in fetuses of women with antibodies to the SS-A or SS-B antigens
  17. 17. Long-Term Prognosis and Contraception - Limit family size because of morbidity - Two large multicenter clinical trials  COCs did not increase the incidence of lupus flares American College of Obstetricians and Gynecologists (2013) recommends that COC use be avoided in women who have nephritis, antiphospholipid antibodies, or vascular disease. Progestin-only implants and injections provide effective contraception with no known effects on lupus flares. Concerns that intrauterine device (IUD) use and immunosuppressive therapy lead to increased infection rates in these patients are not evidenced-based.
  18. 18. Lupus and Pregnancy: Complex Yet Manageable (Harper University Hospital, USA) Clinical Medicine & Research. Volume 4, 2006 Number 4: 310-321
  19. 19. Serangan (Lupus Flares) Flares of systemic lupus erythematosus during pregnancy and the puerperium: prevention, diagnosis and management Expert Rev. Clin. Immunol. 8(5), 439–453 (2012)
  20. 20. Harisson Principles of Internal Medicine 16th ed
  21. 21. Thank You

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