{
  "abstract": "Case 1: A 35-year-old female with SLE and planning IVF pregnancy In October 2024 a 35-year-old female with systemic lupus erythematosus (SLE) was reviewed for planning of in vitro fertilization (IVF) pregnancy. SLE was diagnosed in 2016 (serositis, positive anti-Ro) and treated with steroids, hydroxychloroquine and azathioprine. The azathioprine was stopped after a side-effect. Use of mycophenolate mofetil or methotrexate was declined due to pregnancy wishes. In 2023 she experienced flare of serositis treated with steroids and rituximab. Obstetric history included a live birth 3 years ago, followed by spontaneous first trimester miscarriage and subsequent inability to conceive. Medication was hydroxychloroquine and prednisolone 5 mg/day. In October 2024 she had episodic chest pain. She was counselled regarding the importance of disease control pre-conception and during pregnancy and risk of anti-Ro related complications. Further tests were arranged to evaluate disease activity and timing of IVF, with low threshold to treat with rituximab (in preconception or first trimester) if active SLE.In January 2025 she still had intermittent chest pain and blood tests showed rising dsDNA/ESR with falling C3 so steroids were increased. They were advised to pause IVF until was SLE suppressed with increased prednisolone and possible rituximab.She went ahead with IVF and in March 2025 were 9 weeks and 5 days pregnant, on 7.5 mg/day prednisolone, hydroxychloroquine 400mg/day, aspirin 150 mg/nocte plus vitamins. They reported malar rash and chest pain, therefore prednisolone was increased, enoxaparin started, and rituximab arranged in April 2025.In May 2025 at 18 weeks 3 days pregnant her symptoms were improving on reduced prednisolone 5 mg/day. The plan is to continue enoxaparin and aspirin and wean off prednisolone with evaluation and monitoring in relation to anti-Ro positivity.Learning Objectives At the end of this workshop participants will be able to:Explain the importance of pre-conception counselling in SLEProvide recommendations relating to IVF in SLELearn additional counselling and management of ant-Ro positive SLEDiscuss therapeutic options for active SLE in pregnancyCase 2: Same patient, two different pregnancies A 24-year-old woman was referred to us for diagnostic work-up in December 2014, following a right-sided arteria cerebri posterior stroke one month earlier. She had no residual symptoms. She was put on low dose aspirin (LDA) and low molecular weight heparin (LMWH) due to suspicion of antiphospholipid syndrome (APS). Medical history: positive for unclear dissection of the right ACI in 2008, resulting in arterial occlusion. Otherwise, further history and physical examination were unremarkable. Laboratory findings: highly positive APS antibodies (triple-positive constellation), ANA 1:80, low titer anti-dsDNA in one test, normal complement levels (C3 and C4), mild thrombocytopenia. A switch to VKA was discussed (planned with her healthcare practitioner), no pregnancy planned now but for the future – around 1–2 years. The patient received initial counselling regarding the use of a vitamin K antagonist (VKA), contraception, and pregnancy planning during stable disease.Three weeks later the patient called to report a positive pregnancy test - an unplanned pregnancy. She had not yet started VKA therapy and was still on LDA and LMWH. Medical care was provided by an interdisciplinary team consisting of rheumatology, neurology, and obstetrics specialists. At the 20th week of gestation, she experienced two episodes of blurred vision accompanied by headache. Blood pressure was within the normal range, there was no proteinuria, and neurological examination was normal. The episodes were interpreted as migraine; no other episodes occurred. An uneventful caesarean section was performed at 38 weeks of gestation due to maternal disease, and a healthy baby girl was delivered (2835g/51cm - 15th percentile, APGAR 9/10/10).2017: Patient lost to follow-up.2019: Patient presented with acute venous thrombosis of right popliteal vein. She had discontinued VKA therapy one year earlier and had been continuing aspirin only. VKA therapy was re-initiated, and she received counselling regarding contraception and future pregnancy planning.2022: She returned to the clinic with a new desire to conceive. Counselling was provided regarding pregnancy and the appropriate timing for switching from VKA to LMWH.2023: The patient had a positive pregnancy test, she was already on aspirin and LMWH as recommended. At the 21st week of gestation, severe intrauterine growth restriction (IUGR) was detected (<1st percentile), along with high resistance in the uterine and umbilical arteries and oligohydramnios. An interdisciplinary decision was made to terminate the pregnancy.Five days later, the patient developed fever, abdominal pain, shortness of breath, and right-sided hearing loss. Blood test: pancytopenia, schistocytes 5% blood smear, Coombs test positive, microhematuria, proteinuria 1230mg/g creatinine, blood cultures negative. Imaging (CT/MRI) revealed acute pulmonary embolism, additional thrombosis of the inferior vena cava as well as ischemic changes of inner ear/MAI. A diagnosis of catastrophic APS (CAPS) was made. Treatment was initiated with high-dose corticosteroids, six sessions of plasmapheresis, and rituximab. Due to persistent pancytopenia with febrile neutropenia, empiric antibiotic therapy was started. Bone marrow biopsy revealed severe necrosis and depletion of hematopoietic cells. The patient experienced a slow recovery of blood cell counts, supported by intermittent therapy with granulocyte colony stimulating factor, in addition to ongoing immunosuppressive treatment.Learning Objectives At the end of this workshop participants will be able to:Describe pre-conception counselling in APS (disease specific and medication specific aspects)Explain therapeutic concepts during pregnancy in APS patients, with and without previous thromboembolic eventsRecognise differences between pre-eclampsia/HELLP syndrome, haemolytic uremic syndrome/thrombotic thrombocytopenic purpura and catastrophic APSDiscuss therapeutic options in catastrophic APS",
  "authors": [
    {
      "affiliations": [
        "University College London, UK"
      ],
      "name": "Ian Giles"
    },
    {
      "affiliations": [
        "Charité University Hospitals Berlin, Germany"
      ],
      "name": "Ana-Luisa Stefanski"
    }
  ],
  "title": "12 Family planning and pregnancy in SLE",
  "uid": "1457e114-cd9b-5c1b-94d6-3bc1d6fd1a5f"
}