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Treatment for pregnancy complicated with systemic lupus erythematosus
Treatment for pregnancy complicated with systemic lupus erythematosus. For pregnant women with systemic lupus erythematosus, the medication needs to be guided by multidisciplinary experts under the joint consultation of obstetricians and rheumatologists.
The diagnosis and treatment of patients with systemic lupuserythematosus (SLE) during pregnancy has always been a challenge for clinicians, and the diagnosis and treatment are complicated. Pregnancy can increase the disease activity of systemic lupus erythematosus (SLE) and the recurrence of mild to moderate disease, mainly manifested by the involvement of the skin, joints and blood system.
Lupus nephritis (LN) and antiphospholipid antibodies (APL) are risk factors for pregnancy-induced hypertension and preeclampsia, which may lead to adverse pregnancy outcomes such as miscarriage, stillbirth, and preterm delivery. APL and LN are also associated with low birth weight and fetal intrauterine dysplasia. Fetal congenital heart block (CHB) is another complication of SLE pregnancy, the incidence is about 2%-4.5%, and it is related to anti-SSA/SSB antibodies.
First. Treatment of SLE with recurrent miscarriage (RSA):
In 2020, the application of immunosuppressive agents in recurrent miscarriage with rheumatism immunological diseases is recommended by the consensus of Chinese experts.  In addition to antiplatelet and anticoagulant therapy for the management of RSA patients with SLE during pregnancy, immunosuppressive therapy is also necessary. The purpose of application is to control the condition of SLE and improve pregnancy outcome. Specific dosing schedule reference:
- 1. The maintenance dose of prednisone ≤ 10mg/d (or equivalent other non-fluorine-free glucocorticoids such as prednisolone, methylprednisolone and other maintenance treatments).
- 2. Plan to start taking HCQ (0.2~0.4g/d in 2 doses) 3-6 months before pregnancy, and continue taking HCQ during pregnancy until at least 3 months postpartum.
- 3. Add low-dose glucocorticoids (prednisone 10mg/d, or equivalent other non-fluoride glucocorticoids such as prednisolone, methylprednisolone, etc.).
Second, the treatment of SLE secondary APS complicated with pregnancy
When SLE patients with APS during pregnancy, in addition to actively controlling the SLE condition, the treatment of APS is also very important. If treated according to the law, the pregnancy success rate can be greatly improved. Pre-eclampsia risk factors, especially SLE pregnant women with LN or high-risk aPL spectrum, if there is no thrombosis or pregnancy complications, they can start treatment with aspirin 75-100mg/d before 16 weeks of pregnancy.
For patients with APS without a history of thrombosis, it is recommended that low-dose aspirin combined with preventive dose heparin (unfractionated heparin or low-molecular-weight heparin) treatment is recommended. It is best to start taking aspirin before pregnancy, and heparin should be added once pregnancy is established. If there is a history of thrombosis, adjust to the therapeutic dose of heparin. If warfarin anticoagulation is taken before pregnancy, heparin anticoagulation should be changed after pregnancy is established. When pregnancy complications still occur, hydroxychloroquine and low-dose hormones can be combined.
Third. Treatment of fetal/neonatal SLE disease
If the echocardiogram shows that the fetus has CHB or second-degree CHB, oral fluorine-containing glucocorticoids such as dexamethasone or betamethasone (both 4 mg/d), intravenous immunoglobulin or even plasma exchange can be used to restore normal heart rate or change For low-grade CHB, it is recommended that fluorine-containing glucocorticoids be used until delivery; if the progression to complete CHB (because complete CHB is almost irreversible), fluorine-containing glucocorticoids should be stopped.
Hydroxychloride can reduce the incidence of CHB. It is recommended for pregnant women with positive anti-SSA and/or anti-SSB antibodies. The recommended dose is 200 mg/time × 2 times/d. For children with complete CHB, most of them need to implant a permanent pacemaker during the neonatal period.
If a newborn has a rash, ultraviolet radiation should be avoided, and glucocorticoids can also be applied locally. Most rashes can subside within 6 to 8 months. Newborns should be closely monitored for blood routine and liver function changes. People with mild injuries generally do not need special treatment. If severe blood system and liver function damage occurs, prednisone [1~2mg/(kg.d)] or intravenous injection can be given. Human gamma globulin neonatal antibody titer is high or the mother has a history of SLE neonatal delivery. Even if the newborn is asymptomatic at birth, it should be within 2 weeks of birth, every month within 6 months, and every 3 months after half a year. Follow up once, at least until 1 year old.
Four, hormone therapy for SLE
1. Basic principles of hormone therapy
(1) For induction of remission and long-term maintenance therapy, the initial dose should be sufficient, and then the dose should be reduced slowly for long-term maintenance;
(2) Assess the severity and activity of SLE, and develop individualized treatment plans;
(3) Assess whether there are relative contraindications to the use of hormones. For patients with relative contraindications, strictly evaluate the necessity of using hormones according to the needs of the disease;
(4) It is recommended to use prednisolone or methylprednisolone for patients with liver damage;
(5) Observe the curative effect during treatment and evaluate organ function;
(6) Monitor possible complications during hormone use, and adjust the treatment plan in time.
2. The usage and dosage of hormone therapy
The usage of hormones includes systemic application (intravenous injection and oral administration) and local application (local skin application, joint cavity injection, intraocular injection, etc.). According to the needs of the disease, the hormone can be taken in the morning, every other day or divided daily Administration.
Hormones can be divided into 4 dosage ranges:
(1) Small dose: prednisone ≤ 7.5 mg/d (methylprednisolone ≤ 6 mg/d);
(2) Middle dose: prednisone 7.5~30 mg/d (methylprednisolone 6~24mg/d);
(3) High dose: prednisone 30~100 mg/d (methylprednisolone>24~80 mg/d);
(4) Impact therapy: Methylprednisolone 500~1000mg/d, intravenous drip for 3 days.
The greater the hormone dose, the more significant the effect and the greater the side effects. Hormones are like a double-edged sword. How to minimize the side effects of hormones while pursuing curative effects is one of the most concerned issues for clinicians.
3. The application of hormones before and during pregnancy:
(1) There is no important organ damage before pregnancy, the condition is stable for 1 year or more, the cytotoxic immunosuppressive agent is stopped for half a year, and the hormone only uses prednisone ≤ 10 mg/d, which does not affect pregnancy.
(2) Hormones should be used with caution during pregnancy, and the lowest effective dose should be used, preferably prednisone <20mg/d.
① In the event of illness activity, severe life-threatening needs immediate termination of pregnancy.
② If the pregnancy can continue after the disease evaluation, increase the hormone dose (prednisone ≤30 mg/d) as appropriate. It is recommended to use prednisone, prednisolone, and methylprednisolone. Dexamethasone and dexamethasone are not recommended. Thamesone.
③ The use of hormones within 3 months of pregnancy may increase the risk of fetal cleft lip and palate. Therefore, it is not recommended to use medium and high dose hormones within 3 months of pregnancy.
④ Patients who have been treated with hormones for a long time should use a stress dose during delivery.
⑤ When the disease recurs, consider intravenous infusion of methylprednisolone shock therapy.
(3) In the late pregnancy, dexamethasone can be used to promote fetal lung maturity.
4. Lactation period:
Prednisone is relatively safe at 20-30 mg/d. It is recommended to breastfeed more than 4 hours after taking the hormone. Supplement calcium and vitamin D until the end of lactation.
In short, the medication for pregnant women with systemic lupus erythematosus during pregnancy requires the joint consultation of obstetrics and rheumatologists with the guidance of multidisciplinary experts to safely pass the pregnancy and puerperium to ensure the safety of mother and child!
(source:internet, reference only)