MKSAP: 29-year-old woman with systemic lupus erythematosus (SLE)

Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 29-year-old woman with systemic lupus erythematosus (SLE) is evaluated in the office after obtaining positive results on a home pregnancy test. She has a 1-month history of nausea but is otherwise asymptomatic. Her last menstrual period was 2 months ago. This is her first pregnancy. Her SLE is well controlled with hydroxychloroquine, and her last flare was 10 months ago.

On physical examination, temperature is 36.2 °C (97.2 °F), blood pressure is 110/72 mm Hg, pulse rate is 76/min, and respiration rate is 16/min. Physical examination is normal. A repeat pregnancy test is positive.

Laboratory studies:

Hemoglobin 12.1 g/dL (121 g/L)
Leukocyte count 5400/µL (5.4 × 109/L)
Platelet count 342,000/µL (342 × 109/L)
Serum creatinine 0.7 mg/dL (53.4 µmol/L)
Serum complement (C3 and C4) Normal
Antinuclear antibodies Titer of 1:2560
Anti-Ro/SSA antibodies Positive
Anti–double-stranded DNA antibodies Negative
Anti-Smith antibodies Positive
Urinalysis Normal

She seeks advice on how to manage her SLE during her pregnancy.

Which of the following is the most appropriate management of this patient?

A) Discontinue hydroxychloroquine
B) Recommend termination of pregnancy
C) Start prednisone
D) No change in management

MKSAP Answer and Critique

The correct answer is D) No change in management. This item is available to MKSAP 15 subscribers as item 66 in the Rheumatology section.

MKSAP 16 released Part A on July 31. More information is available online.

This patient has systemic lupus erythematosus (SLE) and is in her first trimester of pregnancy, but her disease is well controlled with hydroxychloroquine. No change in treatment is warranted. She has had no symptoms of SLE for 10 months and currently has no signs of active disease, such as anemia, leukopenia, thrombocytopenia, hypocomplementemia, or anti–doubled-stranded DNA antibodies. She does have antinuclear, anti-Smith, and anti-Ro/SSA antibodies, but the presence of these autoantibodies does not vary with disease activity. Anti-Ro/SSA antibodies may be associated with congenital heart block in the fetus, and pregnant patients with these antibodies should undergo fetal echocardiography starting at 16 weeks of pregnancy.

Hydroxychloroquine is a U.S. Food and Drug Administration category C agent in pregnancy. However, this agent is useful for preventing SLE flares, and expert opinion considers use of this agent to be appropriate during pregnancy because the benefits outweigh the risks. Discontinuation of this agent is therefore not needed in this patient.

Patients with SLE whose disease has been quiescent for at least 6 months, during which time they either did not use medications for SLE or used medications that can safely be continued during pregnancy, generally have positive pregnancy outcomes. Therefore, there is no need to recommend termination of this patient’s pregnancy.

Pregnancy may trigger SLE flares, and, if needed, prednisone can be used during pregnancy. However, the addition of prednisone would not be warranted in a patient with no signs of active SLE, and corticosteroids generally are not used prophylactically.

Key Point

  • Hydroxychloroquine is safe to use in pregnancy and is useful for preventing systemic lupus erythematosus flares.

Learn more about ACP’s MKSAP 16.

This content is excerpted from MKSAP 15 with permission from the American College of Physicians (ACP). Use is restricted in the same manner as that defined in the MKSAP 15 Digital license agreement. This material should never be used as a substitute for clinical judgment and does not represent an official position of ACP. All content is licensed to on an “AS IS” basis without any warranty of any nature. The publisher, ACP, shall not be liable for any damage or loss of any kind arising out of or resulting from use of content, regardless of whether such liability is based in tort, contract or otherwise.

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