148 Obstetrics and Gynecology Board Review •••
❍ What is the incidence of postpartum thyroiditis, and what is the treatment?
Postpartum thyroiditis occurs in 5% of pregnancies. The first phase occurs 2 to 6 months postpartum and is characterized
by a hyperthyroid phase due to rebounding immune function and increased levels of thyroid-stimulating antibodies.
Intervention is not usually required other than possibly a short course of beta blockers for symptomatic management.
The second phase involved hypothyroidism and occurs between 3 and 12 months postpartum, and resolves by
12 months postpartum. Levothyroxine treatment may be necessary but can be discontinued 1 year after delivery.
RHEUMATOLOGY
Systemic Lupus Erythematosus
❍ How is systemic lupus erythematosus (SLE) diagnosed?
Four of the following eleven criteria must be fulfilled, in which case a diagnosis of SLE can be made with a
sensitivity of 95% and specificity of 75%.
- Malar rash
- Discoid rash
- Photosensitivity
- Oral ulcers
- Arthritis (joint pain and swelling of two or more joints)
- Serositis (pleuritis or pericarditis)
- Kidney disorder (persistent proteinuria or cellular casts in the urine)
- Neurologic disorder (seizures or psychosis)
- Hematologic disorder (anemia, leukopenia, lymphopenia, or thrombocytopenia)
- Immunologic disorder (positive anti-dsDNA, anti-Sm, or antiphospholipid antibodies)
- Abnormal antinuclear antibodies
❍ How does pregnancy affect lupus?
A third of women experience improvement in their disease, however a third have worsening disease and a third stay
the same.
❍ When is the prognosis for mother and child best?
When the disease has been quiescent for 6 months prior to conception, there is no active renal involvement,
superimposed preeclampsia does not develop, and there is no evidence of antiphospholipid antibody activity.
❍ How is worsening lupus differentiated from preeclampsia?
Decreased complement levels or increased anti-DNA antibody titers are useful in identifying a lupus flare. Elevated
serum levels of liver enzymes and uric acid, as well as decreased urinary excretion of calcium, are more suggestive of
preeclampsia.
❍ What is the incidence of preeclampsia in women with SLE?
Chronic hypertension complicates 30% of pregnancies of women with SLE. Superimposed preeclampsia develops
in 13% to 35%, and is higher in women with lupus nephritis or antiphospholipid antibodies.
❍ What is the recommended laboratory workup in the first prenatal visit for a woman with SLE?
In addition to routine blood work there should also be a measurement of disease activity (C3, C4, CH50, anti-ds
DNA antibodies), risk of neonatal lupus (anti-SSA and anti-La antibody (SSB)), risk of fetal loss (lupus
anticoagulant, anticardiolipin antibodies), and risk of renal function (24-hour urine protein).