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Parturient with systemic lupus erythematosus & acute onset diffuse alveolar hemorrhage
Abstract Number: SUN-41
Abstract Type: Case Report/Case Series
Systemic lupus erythematosus (SLE) is an autoimmune, chronic inflammatory disease with multisystem abnormalities creating unique anesthetic challenges. Pregnancy in patients with SLE is high risk with known increase in fetal loss, preterm delivery, growth restriction & preeclampsia(1). We present a case of SLE in pregnancy complicated by vasculitis, lupus nephritis and diffuse alveolar hemorrhage (DAH).
An 18 yo nulliparous pt presented to our institution at 29-wks gestation with 4 days of dyspnea, epistaxis, cough, hemoptysis and progressive facial swelling. Pregnancy was complicated by noncompliance and SLE lupus nephritis. Nephritis was diagnosed 1 month prior to her admission with petechial rash & hematuria. Noncompliance with treatment led to further blood transfusions & continued flairs. On exam, she was normotensive, tachycardic, tachypneic with no apparent distress. Her admission ABG: 7.47/34/57 on 2L nasal cannula. Chest x-ray showed bilateral diffuse infiltrates. Bronchoscopy confirmed DAH. ICU care included broad-spectrum antibiotics, azathioprine, hydroxychloroquine, high dose pulse steroids & IVIG.
While in the ICU, non-reassuring fetal assessment was noted on external fetal monitoring. Anesthesia was consulted for possible emergent cesarean delivery. A multidisciplinary team discussed delivery planning. Controlled cesarean delivery under neuraxial anesthesia was preferred to avoid pulmonary hemorrhage from emergent intubation and positive pressure ventilation. Prophylactic administration of lovenox prevented neuraxial anesthesia. Expectant management & conservative measures were employed to improve fetal status, Over the next several hrs, fetal monitoring improved; however, she developed preeclampsia with severe features and required delivery for refractory hypertension. Epidural was placed without incident; a 1590g infant was vaginally delivered.
Clinical manifestations of SLE is heterogeneous; management plan should be tailored. SLE vasculitis with visceral involvement is rare and carries significant mortality. In non-obstetric population, DAH occurs in less than 2% of SLE patients with mortality as high as 70-90%(2). DAH is associated with lupus nephritis occurring in 64-100% of pts with active renal disease(3). New treatment options for lupus nephritis (e.g. IVIG) may affect overall outcome. Risk of hematoma from neuraxial block in presence of systemic small vessel vasculitis is unknown. This case highlights the importance of multidisciplinary, collaborative approach in managing pts with complicated & evolving clinical course.
1 Radeka G, et al. Systemic lupus erythematosus in pregnancy-case report. Med Pregl. 2005;58:301–7
2 Santos-Ocampo AS, et al. Alveolar hemorrhage in systemic lupus erythematosus: presentation and management. Chest 2000;118:1083–90
3. Pego-Reigosa JM, et al. Respiratory manifestations of systemic lupus erythematosus: old and new concepts. Best Pract Res Clin Rheumatol 2009;23:469–80.