Systemic lupus erythematosus

Regarding systemic lupus erythematosus (SLE), the following statements are correct EXCEPT which one?

a) There is a 10:1 female preponderance, particularly affecting women of childbearing age

b) Patients with SLE and isolated lupus anticoagulant antibody are clinically coagulopathic contraindicating central neuraxial blockade

c) Peri-partum high dose steroid therapy may be necessary

d) Pregnant patients are at increased risk of pregnancy-induced hypertension, regardless of their pre-pregnancy renal status

e) More than 50% of patients with SLE have demonstrable psychiatric or neurological abnormalities including seizures and cerebrovascular events

Answer: b

Explanation

Systemic lupus erythematosus is an immune-mediated multisystem inflammatory disorderwhere autoantibodies are responsible for a diverse range of tissue damage and thus clinical manifestations. The condition’s impact on coagulation is complex and not entirely intuitive. Patients may be coagulopathic or thrombophilic. Those patients with only the lupus anticoagulant IgG (or sometimes IgM) have prolonged activated partial thromboplastin time (APTT) in vitro, but do not have a bleeding tendency and the use of central neuraxial blockade is acceptable.However, cautionmust be exercised because prolonged APTT may also be caused by clinically relevant coagulopathies secondary to autoantibodies to clotting factors II,VII,VIII, IX and X. Pancytopenia is not uncommonwith active disease.  Hypercoagulable patientsmay present on anticoagulant therapy and liaison with a haematologist, well in advance of anaesthetic involvement, is prudent. Aside from the  haematological manifestations, SLE is considered a connective tissue disorder although these abnormalities rarely impact on the anaesthetist here. Neurological, renal and  cardiopulmonary complications do have implications for anaesthesia. Glomerulonephritis, hypertension and proteinuria are all common, but even without these pregnant patients with SLE are at elevated risk of pregnancy-induced hypertension. Patients may have accelerated coronary artery disease and pulmonary infiltrates or fibrosis. Therapy for SLE aims to ameliorate manifestations and dampen immune activity. It is common that SLE patients will be on glucocorticoid treatment, especially during pregnancy. Suppression of the hypothalamo–pituitary–adrenal axis should be considered and steroid supplementation at the time of  delivery administered if necessary.

Reference

Davies SR. Systemic lupus erythematosus and the obstetrical patient – implications for

the anaesthetist. Can J Anaesth 1991; 38(6): 790–5.