SLE and antiphospholipid syndrome in pregnancy — structured SAQ (15 marks)

(a) Medication problems and immediate changes (4 marks)

One mark per drug decision with named alternative. [3][12]

• Stop mycophenolate mofetil — teratogenic. Switch to azathioprine (target dose up to 2 mg/kg/day) or a calcineurin inhibitor such as tacrolimus (dose-adjusted to trough), which are effective for lupus nephritis and pregnancy-compatible.
• Stop ramipril — ACE inhibitor; fetal renal dysplasia and oligohydramnios. Switch to labetalol 100-200 mg BD (max 800 mg/day) or nifedipine MR 20-60 mg daily to keep BP under 140/90.
• Continue hydroxychloroquine 400 mg daily — strongly recommended by EULAR and ACR; lowers flare, pregnancy loss, preeclampsia and recurrent congenital heart block. Do NOT stop.
• Continue aspirin 75 mg daily and confirm she will continue it for preeclampsia prophylaxis and APS.[3][12]

(b) Confirm APS and stage lupus activity (3 marks)

One mark per element. [1][6]

• Repeat the full aPL panel 12 weeks after the first (lupus anticoagulant, anticardiolipin IgG/IgM, anti-β2-glycoprotein-I IgG/IgM) — the revised Sapporo criteria require the antibody to be positive twice at least 12 weeks apart within 5 years; her two first-trimester losses plus one late loss give the clinical criterion.
• Stage lupus activity: serial complement C3/C4 and dsDNA (falling complement and rising dsDNA = flare; already low here), FBC, U&E, albumin, liver function, spot PCR and 24-hour protein, urine microscopy for red cell casts.
• Placental function: plasma PlGF and sFlt-1:PlGF every 4 weeks from 20 weeks — the PROMISSE study showed angiogenic imbalance predicts severe adverse outcomes in lupus/aPL pregnancy and helps distinguish flare from preeclampsia.[1][6]

(c) Obstetric and medical surveillance plan (4 marks)

One mark per element. [3][12]

• Joint obstetric-rheumatology clinic every 4 weeks — BP, urinalysis, complement, dsDNA, FBC, renal function, tacrolimus trough if used.
• Serial growth scans with umbilical artery Doppler every 4 weeks from 24 weeks — fetal growth restriction risk.
• Antiplatelet and anticoagulation: continue aspirin; if APS is confirmed, add prophylactic-dose LMWH (e.g. enoxaparin 40 mg daily) from now and continue for 6 weeks postpartum; consider hydroxychloroquine already on board.
• Delivery at 37-38 weeks if stable; earlier for flare, deteriorating renal function, superimposed preeclampsia, or fetal compromise.[3][12]

(d) Neonatal lupus, delivery and postpartum (4 marks)

One mark per element. [8][9][12]

• Neonatal lupus surveillance: because she is anti-Ro and anti-La positive, arrange serial fetal echocardiography weekly to fortnightly from 16-18 weeks through the highest-risk window (16-26 weeks). Given a previous child would carry the higher recurrence, hydroxychloroquine 400 mg (already on) reduces recurrence from ~18% to ~7-8%.
• Intrapartum: intravenous hydrocortisone cover if she has received steroids in the last year or is on maintenance prednisolone; continue aspirin until 36 weeks; thromboprophylaxis reassessed.
• Postpartum: continue hydroxychloroquine and immunosuppression; breastfeeding is compatible with hydroxychloroquine, azathioprine, tacrolimus, prednisolone and LMWH/warfarin; re-baseline renal function at 6-12 weeks.
• Contraception: progestogen-only or intrauterine method — combined hormonal contraception is contraindicated in APS. Warn of postpartum flare risk and arrange early rheumatology review.[8][9][12]