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76]

Case Report

Anesthetic implications in systemic lupus

erythematosus patients posted for cesarean
section: A series of five cases
Parul Jindal, Ruchi Kapoor,
ABSTRACT
Gurjeet Khurana,
Jaya Chaturvedi1 Management of a parturient with systemic lupus erythematosus (SLE) requires a multidisciplinary
Departments of Anesthesiology, approach. Although the ideal treatment strategy has not been formulated, certain management
1
Gynaecology and Obstetric, principles are recommended. We discuss the perioperative course and anesthetic management
Himalayan Institute of Medical of five parturient with history of SLE who underwent cesarean section.
Sciences, Himalayan Institute
Hospital Trust University, Dehradun,
Uttarakhand, India
Address for correspondence:
Dr. Parul Jindal,
Department of Anesthesiology,
Pain Management and ICU,
Himalayan Institute of Medical Sciences,
Jolly Grant, Dehradun, Uttarakhand, India.
E-mail: parulpjindal@yahoo.co.in Key words: Anesthetic implications, pregnant, systemic lupus erythematosus

INTRODUCTION parturient with history of SLE posted for emergency or

elective cesarean section.

S ystemic lupus erythematosus (SLE) is an autoimmune

disease with heterogeneous presentation. It is is
characterized by the presence of autoantibodies directed
CASE REPORT

against nuclear antigens. The prevalence of SLE varies with
ethnicity, but is estimated to be about 1 per 1,000 overall; with
female to male ratio of 10:1, peak age of onset being between
15 and 40 years.[1-3] Therefore, it may coexist in pregnancy
leading to complications in the parturient and adverse fetal
outcome. Since it is a multisystem disorder, a thorough
preanesthetic evaluation is mandatory for safe anesthesia.
Anesthetic plan must be individualized based on the degree of
the involvement of the various systems, current medications
the patient is taking, and on the laboratory investigations.[2]
We present the perioperative management of a series of five
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DOI:
10.4103/2249-4472.123306
We present a series of five parturient who were booked cases
with confirmed diagnosis of SLE undergoing regular antenatal
check-up [Table 1].
In the present series, the parturient had been managed
successfully in the antenatal period and had been able to continue
their pregnancy up to third trimester. All patients underwent
clinical evaluation, including history and review of historical
data from case records, examination, and investigations.
The risks and benefits of general and regional anesthesia
were discussed with the subjects and informed consent was
taken from them. Appropriate antibiotic prophylaxis was
administered in all the parturient. Intraoperative monitoring
included electrocardiogram, pulse oximeter, noninvasive
blood pressure in all the cases, and end tidal carbon dioxide
monitoring in general anesthesia (GA) case. Normothermia
was maintained in all the patients. There was no significant
blood loss in any case. All the patients had uneventful recovery
and were discharged in satisfactory condition.

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Jindal, et al.: Pregnancy with SLE: Anesthetic management

Table 1: Depicts the profile of the patients with SLE who underwent emergency/elective cesarean section
Patient 1 Patient 2 Patient 3 Patient 4 Patient 5
Age (years) 22 28 25 31 33
Gestation period (weeks) 38 37 36 38 37
G0P0A0L0 G1P1 G4P2L1A2 G3P2L0A2 G5P5L0A4 G2P2L1
Associated conditions Raynaud’s disease Herpes zoster, obesity Pregnancy induced Obesity Anemia,
hypertension (PIH) thrombocytopenia,
arthralgia
Medications Methyl prednisolone Tab acyclovir 200 mg 250 mg Methyl prednisolone Packed red blood
4 mg thrice daily, tab. orally five times a Methyldopa orally 4 mg thrice daily cells transfusion
ecospirin 75 mg once day for 10 days. three times daily, preoperatively to
daily Methyl prednisolone methylprednisolone correct anemia
4 mg thrice daily, tab. 8 mg thrice daily
ecospirin 75 mg once
daily
Emergency/elective Elective Emergency Emergency Elective Emergency
Indication for LSCS Precious pregnancy Failed induction Leaking per Precious pregnancy Scar tenderness
with contracted pelvis vaginum with bad obstetric
history
Type of anesthesia Subarachnoid block Subarachnoid block Subarachnoid block Subarachnoid block General anesthesia
Technique administered In sitting position In sitting position In sitting position In sitting position Induced with
23G gauge at L3-4 23G gauge at L3-4 23G gauge at L3-4 23G gauge at L3-4 thiopentone,
space, clear CSF, space, clear CSF, space, clear CSF, space, clear CSF, succinylcholine;
0.5% bupivacaine 2 ml 0.5% bupivacaine 0.5% bupivacaine 0.5% bupivacaine maintained on O2,
+25 g fentanyl 2.2 ml+25 g fentanyl 2.2 ml 2.5 ml N2O, isoflurane,
and vecuronium and
fentanyl
Complications Uneventful Hypotension Shivering, Nausea Uneventful
hypotension
Apgar score 7 at 1 min 8 at 1 min 9 at 1 min 8 at 1 min 7 at 1 min
8 at 3 min 8 at 3 min 9 at 3 min 8 at 3 min 8 at 3 min
LSCS: Lower segment cesarean section, CSF: Cerebrospinal fluid

DISCUSSION pleural effusion, alveolar hemorrhage, and interstitial lung

Our own experience, as well as systematic review of the
literature[2,4] suggests that perioperative management must
be tailored to the individual patient. In our series, choice of
anesthetic technique was left to the discretion of the consultant
anesthetist involved. Decision was made after taking into
account severity of the disease, the potential drug interactions
with immunosuppressants, an unexpected difficult airway with
subglottic stenosis or laryngeal edema, and coagulation profile
of the patients.
Patients with SLE have a variety of abnormalities of varying
intensity. Therefore, there are a host of presentations and
the course is highly variable, ranging from relatively mild
and uncomplicated to major life-threatening disease.
Cardiovascular involvement could be in the form of
pericarditis, myocarditis, arthrosclerosis, and myocardial
ischemia.[4] Valvular involvement are seen in form of verrucous
noninfective vegetations known as Libman-Sachs being
the characteristic lesion and endocarditis.[5] Rhythm and
conduction abnormalities are seen; common ones being sinus
tachycardia, conduction abnormalities, and atrioventricular
blocks.[6] Pulmonary involvement could vary from pleuritis,
disease.[7]
Renal involvement is seen in form of lupus nephritis
characterized by proteinuria, hematuria, abnormal urinary
segments.[8] Parturient with SLE are at high risk of developing
pregnancy induced hypertension (PIH) irrespective of their
pre-pregnant renal status. The risk may increase in case the
patient requires more than 30 mg of prednisolone daily.[1] In
our series, one patient who was on high dose of steroids had
developed PIH in third trimester, but was managed successfully
with regional anesthesia.
A 37-95% of SLE patients may manifest central and peripheral
nervous system complications. American College of
Rheumatology (ACR) recommends the term neuropsychiatric
systemic lupus erythromatosus (NPSLE) to encompass all
possible manifestations which may vary from headaches,
seizures, cerebrovascular disease, psychosis, acute confusional
states to even demyelinating disease states.[2]
Hematological manifestations commonly seen in SLE include
anemia, thrombocytopenia, and leucopenia. Anemia is found
in about half of SLE patients with the most common cause

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Jindal, et al.: Pregnancy with SLE: Anesthetic management
being anemia of chronic disease; however, other causes include
autoimmune hemolytic anemia, iron deficiency anemia, anemia
of chronic renal failure, and cyclophosphamide myelotoxicity.
This anemia may be worsened by the dilutional anemia of
pregnancy.[2,9] Nonerosive arthritis is seen in patients with SLE.
Prolonged glucocorticoid use for immunosuppression could
cause osteoporosis. Incidence of atlantoaxial subluxation has
been reported.[10]
Antiphospholipid syndrome may occur secondary to SLE
and is characterized clinically by recurrent pregnancy loss
and by presence of lupus anticoagulant antibodies which may
falsely prolong activated partial thromboplastin time in such
individuals.[11] Pregnancy complicated with antiphospholipid
syndrome warrants use of aspirin and heparin to prevent
thrombosis.[12] SLE being an autoimmune disorder, patient is
often on immunosuppressant drugs like corticosteroids which
are continued in the pregnancy.
The prepregnancy visit aims at the activity of the lupus,
organ damage, medication exposure, thorough preanesthetic
assessment, and laboratory test. Care of this high risk group
requires a multidisciplinary approach. In SLE patients with
bad obstetric history, regular assessment of maternal disease
activity and regular intrauterine growth assessment are
recommended.
As SLE symptom are nonspecific and overlap with the
physiological changes during pregnancy the investigations
become mainstay in monitoring pregnancy.[2] Complete blood
count has to be done in all patients alongside coagulation
profile. Platelet count should be repeated every month because
of high risk of thrombocytopenia in lupus pregnancies.[9]
Electrocardiography may be done when suspecting pericarditis,
myocarditis, and chest X-ray may be reserved for extreme
cases where pleural effusion or interstitial pneumonitis is
seen clinically.[1] For patients with renal involvement, every
month creatinine clearance and 24 h urine protein should be
checked. If the patient is on steroids then a close watch on blood
glucose levels is advocated. Anticardiolipin antibody, lupus
anticoagulant, anti 2 glycoprotien should be done to rule out
any secondary involvement in preceding months.
Monitoring during anesthesia includes five lead
electrocardiogram (ECG), noninvasive blood pressure,
pulse oximetery, and invasive monitoring should be used in
patients with myocarditis, valvular involvement, or conduction
abnormalities. Renal protective strategies and maintenance
of urine output, avoidance of nephrotoxic drugs are the
goals during anesthesia. Adequate pain management and
corticosteroid cover should be given intraoperatively to prevent
adrenal suppression. Antibiotics are to be given to prevent
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infection. Patient should be positioned with care to avoid
joint stress.
Regional anesthesia should be preferred over GA in parturients
with history of SLE presenting for cesarean section. Difficult
airway should be anticipated in all the patients, smaller
sized tubes, and laryngeal mask airway must be available
considering potential laryngeal and subglottic involvement.
Laryngeal involvement could vary from mild inflammation
to laryngeal edema, epiglottis, and vocal cord paralysis[13] to
acute airway obstruction. The pathophysiology of laryngeal
inflammation of SLE is not well-understood although the
tissue deposition of immune complexes with activation of
complements is less likely the cause. Compression of recurrent
laryngeal nerve by dilated pulmonary artery has been reported
as cause of left palsy in patients with SLE. Secondary nerve
vasculitis is believed to be a cause especially in vocal cord
palsy involving right side. [14] All these symptoms could
worsen in a pregnant SLE patient presenting for cesarean
section as during pregnancy extracellular fluid and vascular
engorgement may lead to edema and compromise upper
airway.[15] There is a significant risk of failed intubation and
airway trauma during instrumentation.
Dyspepsia is a common symptom in pregnant women and can
be worsened by aspirin, non-steroidal anti-inflammatory drugs,
and corticosteroids therefore, increasing the risk of aspiration
if GA is administered. Fetal outcome is superior in cases where
regional anesthesia is administered.[16] GA should be reserved
for indications such as fetal distress or placenta previa or if
the patient is anticoagulated. In the series, the Apgar score
of the neonates was above 7 both at birth and at 3 min when
spinal anesthesia was administered. While that of parturient
given GA was 6 at 1 min and 7 at 3 min. Isolated case report
in literature have mentioned good fetal outcome irrespective
of the anesthesia technique used. Cuenco et al., administered
GA in a parturient with pulmonary hypertension complicated
by SLE pneumonitis and vasculitis, pulmonary edema, and
severe orthopnea. The patient’s infant daughter showed no
signs of respiratory depression, required no ventilatory support,
and received routine care in the normal newborn nursery.[17]
In yet another case report, Streit et al., reported a successful
maternal-fetal outcome in a pregnant patient with SLE with
associated pulmonary arterial hypertension. A healthy female
infant weighing 2,760 g with Apgar scores of 8, 9, and 10 at
1, 5 and 10 minutes, respectively, were delivered via cesarean
section under epidural anesthesia.[18]
Isolated elevation of partial thromboplastin time secondary
to lupus anticoagulant is not contraindication to regional
anesthesia.[1] Among the five patients we managed, four had
normal platelet counts and coagulation parameters hence
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Jindal, et al.: Pregnancy with SLE: Anesthetic management
subarachnoid block was administered safely. One patient had
thrombocytopenia so GA was administered to the patient.
We did not administer epidural in any patient because three
patients were posted for emergency cesarean section and one
patient was morbidly obese making it technically difficult.
Thus, we conclude that in absence of contraindication regional
anesthesia is the preferred choice for pregnant patient with SLE
who presents for cesarean section.
ACKNOWLEDGEMENT
We would like to express our gratitude and appreciation to our
colleagues in gynecology and obstetrics department who are doing
incredible work.
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Cite this article as: Jindal P, Kapoor R, Khurana G, Chaturvedi J. Anesthetic
implications in systemic lupus erythematosus patients posted for cesarean
section: A series of five cases. J Obstet Anaesth Crit Care 2013;3:97-100.
Source of Support: Nil, Conflict of Interest: None declared.
Journal of Obstetric Anaesthesia and Critical Care / Jul-Dec 2013 / Vol 3 | Issue 2