SLE and antiphospholipid syndrome in pregnancy — structured oral station (12 minutes)

Opening prompt — "Take me through how you would plan this woman's next pregnancy."

Model response — say it in this order: [3][12]

• "This is a high-risk pregnancy that needs planning before conception. The two leading risks are another pregnancy loss and a flare of her lupus nephritis, plus the neonatal lupus risk from her anti-Ro and anti-La antibodies."
• "First I would aim for at least six months of quiescent disease before conception, with stable renal function — her creatinine and proteinuria should be at their baseline."
• "I would switch her teratogenic medications pre-conception: mycophenolate to azathioprine or a calcineurin inhibitor, ramipril to labetalol or nifedipine, and stop the combined oral contraceptive."
• "I would continue hydroxychloroquine 400 mg daily — both EULAR and ACR strongly recommend continuation, because it lowers flare, pregnancy loss, preeclampsia and recurrent congenital heart block."
• "I would start aspirin 75-150 mg from early pregnancy, confirm her aPL status with a repeat panel at least 12 weeks apart, and plan serial fetal echocardiography from 16-18 weeks because she is anti-Ro/La positive."[3][12]

Examiner is listening for: pre-conception planning, teratogenic drug switch, hydroxychloroquine continuation, APS persistence rule, neonatal lupus surveillance. [1][9]

Probe 1 — "She asks why she cannot stay on mycophenolate, which has kept her well. What do you say?"

• "Mycophenolate is teratogenic — major malformations including external ear, cardiac, and limb anomalies. It must be switched before conception, ideally six weeks before, to azathioprine or a calcineurin inhibitor such as tacrolimus, which are effective for lupus nephritis and pregnancy-compatible."
• "I would coordinate the switch with her rheumatologist and nephrologist, and confirm disease quiescence on the new regimen before she conceives."
• "I would also check she is not on warfarin, an ACE inhibitor or ARB, methotrexate, cyclophosphamide, or leflunomide — each is teratogenic."[3][12]

Probe 2 — "Her lupus anticoagulant was positive once, six months ago. Does she have antiphospholipid syndrome?"

• "Not yet on a single positive antibody. The revised Sapporo criteria require one clinical criterion plus one laboratory criterion, with the antibody positive on two occasions at least 12 weeks apart within 5 years."
• "Her second-trimester loss at 18 weeks may satisfy the clinical criterion only if morphologically normal and otherwise unexplained, or if there was severe preeclampsia or placental insufficiency before 34 weeks; I would clarify the detail of that loss."
• "I would repeat the full aPL panel — lupus anticoagulant, anticardiolipin IgG/IgM, anti-β2-glycoprotein-I IgG/IgM — at least 12 weeks after the first positive, and classify APS only if she meets the criteria."
• "If confirmed, the pregnancy regimen is aspirin plus prophylactic LMWH from a positive pregnancy test, with HCQ added; six weeks of postpartum LMWH."[1][2]

Probe 3 — "She becomes pregnant. At 22 weeks she presents with hypertension, proteinuria and a low complement. Is this a flare or preeclampsia, and what do you do?"

• "Falling complement with rising dsDNA, active urinary sediment (red cell casts) and a normal PlGF point to a lupus nephritis flare rather than preeclampsia — preeclampsia typically has normal complement, stable dsDNA, bland sediment and a low PlGF."
• "I admit her, control her blood pressure with labetalol or nifedipine to under 140/90, escalate immunosuppression with pregnancy-safe agents (prednisolone, tacrolimus, azathioprine), continue hydroxychloroquine, and surveil with continuous CTG, daily renal function and serial growth scans."
• "I involve the renal and rheumatology teams immediately; delivery is for maternal or fetal compromise or deteriorating renal function, not for the flare per se."[6][12]

Probe 4 — "At her routine 24-week CTG the fetal heart rate is 75 with a dissociated rhythm. What is the diagnosis and what is your plan?"

• "This is congenital heart block in a known anti-Ro/La-positive mother — second or third degree. I confirm with fetal echocardiography, refer to fetal medicine and paediatric cardiology, and admit for monitoring."
• "Fluorinated steroids (dexamethasone) are considered for second-degree or inflammatory block, though they do not reverse established third-degree block; most surviving children need a pacemaker."
• "For her next pregnancy, hydroxychloroquine 400 mg started before 10 weeks reduces the recurrence rate from about 18% to 7-8%."[8][9]

Probe 5 — "She is frightened about her fertility and the long-term outlook. What do you say?"

This is a scored communication domain. Demonstrate it out loud: [3]

• Sit down, use her name, acknowledge the fear: "I can see this is a lot to take in. Let me explain what we know and what we will do together."
• "Your lupus can be managed through pregnancy when it is planned and your disease is quiet. Your fertility is not affected by lupus itself."
• "We will re-baseline your kidney function after each pregnancy and work with your nephrologist to slow any long-term change. Your contraception needs to be oestrogen-free because of the antiphospholipid antibody — I will arrange that today."
• Avoid jargon, allocate a named support person, and commit to a written plan and a debrief.[3]

Probe 6 — "Tell me about her contraceptive options going forward."

• "Oestrogen-containing combined hormonal contraception is contraindicated in antiphospholipid syndrome — it is prothrombotic. Her options are progestogen-only: the progestogen-only pill, the etonogestrel subdermal implant, or a levonorgestrel intrauterine system."
• "A copper intrauterine device is also acceptable if she prefers non-hormonal methods."[2][3]