Answer to Monday's Question of the Day: Contraception for a patient w/ SLE

The question of contraception for a patient with SLE raises the issue of weighing benefits versus risks in a patient-centered context. First and foremost, pregnancy may be much riskier for this patient than any contraceptive, so it calls for a careful and thorough exploration of the patient's needs and the risks/benfits of various methods. As 2 students posted on the @OBGYNclerk twitter account, becasue a Mirena IUD is a progestin-only contraceptive, it may be the best alternative. In a recent article published in the August 2009 issue of Obstetrics & Gynecology, Dr. Culwell concludes: "Available evidence indicates that many women with SLE can be considered good candidates for most contraceptive methods, including hormonal contraceptives. The benefits of contraception for many women with SLE likely outweigh the risks of unintended pregnancy in this population. Women with positive antiphospholipid antibodies are not good candidates for combined hormonal contraception given their elevated baseline risk of thrombosis." You can read this article at: http://bit.ly/yr90D

TBL Session F/U: Order Set for patient with IUFD at 36 weeks

Order set for 32yo G1P0 who presents at 36 wks to L&D for c/o decreased fetal movement and is found to have an IUFD.

I would have explained the finding of IUFD, offered her support and counseled her about options (immediate vs delayed induction of labor; consent for autopsy/burial; course of labor/preferences for pain management) and then written the following orders. By history and physical exam and prenatal labs, we could have likely ruled out many of the maternal causes of stillbirth, so glucose/thyroid testing would be non-productive. You could make an argument that if the fetus is not IUGR, then sending a thrombophilia work-up is not going to be helpful either. But most often, so as to “cover all bases”, these labs are sent.

1) Admit to L&D for induction of labor

2) Dx: intrauterine fetal demise at 36 weeks, not in labor

3) Condition: stable but in need of emotional support

4) Vitals: per L&D protocol

5) Activity: up ad lib until epidural, then only with assistance

6) Diet: clears

7) IV: start peripheral IV with IVF: D₅.45NS @ 125cc/hr (total fluids)

8) Medications: misoprostol 50 micrograms per vagina to be placed by ROD; repeat dose in 4hrs at discretion of attending physician;pitocin per L&D protocol for labor (start at discretion of attending)

9) Labs: T&S, CBC, flow cytometry for fetal cells*, RPR, CMV/toxo/parvovirus IgG & IgM; Anticardiolipin abs, thrombophilia panel (FVL, PT mutation, ATIII, Prot C&S); placenta and newborn to pathology with placental path and fetal autopsy requisition; ROD to obtain fetal tissue, place in culture media and send to genetics; PT/PTT/Fibrinogen**

10) Anesthesia consult

11) Perinatal Loss coordinator consult

12) Chaplain consult if desired by patient

* flow cytometry has replaced Kleihauer-Betke as the method for detecting fetal cells in the maternal circulation

**because DIC can occur with late-presenting IUFDs (usually at least 28 days after the demise), anesthesia is likely to want to know her coagulation status before putting in an epidural catheter (if it is desired for pain control).

Concept Map for Fetal Death