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