Lupus questions

Lupus Exam Questions
1.) Which of the following statements is most accurate regarding lupus and female fertility?
a.) Women with lupus have a poor fertility prognosis
b.) Women with positive anti-phospholipid antibodies experience a higher fertility rate
c.) Fertility is highly dependent on disease activity and medications that are prescribed
d.) The use of chemotherapy medications during flare-ups can improve fertility by
protecting the ovaries from autoimmune attack

Correct Answer: C: Rationale: Women with lupus can be as fertile as the general population, but the rate is very dependent on the presence and duration of disease exacerbation; for example, women who experience a “flare-up” may also have concurrent renal impairment and active antiphospholipid antibodies- consequently, the presence of both of these conditions severely reduces a women’s fertility. Also, if the woman is taking high dose steroids or chemotherapeutic agents, these too can alter menstruation and ultimately impact fertility.

Wrong Choices:
a.) If the disease is controlled, women with lupus have a very good fertility prognosis; in fact, a pregnancy rate of 2.0-2.5 pregnancies/patient has been cited in the literature
b.) The presence of antiphospholipid antibodies has been shown to cause reproductive failure
c.) Actively taking chemotherapeutic drugs can increase the risk for premature ovarian failure, especially in women older than 35 years. Studies have shown that pre-menarch girls have the lowest risk of experiencing POF during and after chemotherapy treatment (protected from gonadotoxic effects)

2.) Mrs. Bertha, 30 years old, comes to your office to discuss her desire to have children. You are aware that Mrs. Bertha has a 10 year history of lupus, is recently married, and has never been pregnant. Which of the following statements best indicates that the chances of Mrs. Bertha conceiving and having a safe and successful pregnancy are good?

a.) Urinalysis done last week showed proteinuria

b.) She completed a regimen of high dose corticosteroids 2 months ago, and is now feeling great

c.) Her vital signs this morning were BP: 150/90, HR 85, Resp 18: Temp; 98.9

d.) She last remembers experiencing extreme fatigue, facial butterfly rash, lymphadenopathy, and painful, swollen joints about 9 months ago.

Correct Answer: D: Rationale: This statement provides evidence that her last “flare-up” was 9 months ago. The signs and symptoms described above are all common manifestations of an exacerbation. However, the best prognosis for a successful pregnancy is disease inactivity for at least 6 months. If she has been symptom free for 9 months, it is a good sign and she might be ready to try to conceive. Of course, additional lab tests would be needed to verify disease inactivity.

Incorrect Choices:
a.) The presence of proteinuria might be a sign that she is experiencing a flare-up, even if a minor one. A repeat urine and additional labs would need to be considered. However, lupus nephritis at the time of conception places one at risk for experiencing significant complications during pregnancy
b.) It is good news that she is feeling well now. However, the need for high dose steroids only two months ago indicates that she experienced a significant flare up at that time. Six months of disease quiescence is recommended before even considering a pregnancy.
c.) Her elevated blood pressure indicates possible lupus nephritis. Of course, multiple measurements would be needed along with additional labs, but she would need to follow up on this finding. Women who have lupus and become pregnant are at higher risk for developing pre-eclampsia; so, to reduce this risk as much as possible, a woman who desires to become pregnant should have a near normal/controlled blood pressure.

3.) Ms. Newton-John, 21 years old and with history of SLE for 3 years, presents to your clinic for a work-related physical. Upon reviewing labs before the encounter, you note that she has a positive HCG. As soon as you reveal this to her, she rejoices that she is finally pregnant and cant wait to start a family with her boyfriend. You know that she has been symptom free for almost two years and she appears in good health; regardless, you are also aware that the most common complication experienced by pregnant women with SLE is which of the following?

a.) Preterm delivery

b.) Spontaneous abortion

c.) thromboembolism

d.) Transient congestive heart failure

Correct Choice: A: Rationale: The literature identifies pre-term delivery as the most common complication experienced by pregnant women with a history of SLE. Preterm births occur in approximately 20% of women with SLE. Although she is symptom free at the moment, she is still at risk for developing a flare-up during the gestational period, which can inevitably cause nephritis, pre-eclampsia and ultimately pre-term delivery. So, after you reprimand her for “risky” behavior considering her disease history, you would then refer her to a high risk OB-GYN specialist.





Incorrect Choices:
b.) Although women with SLE are also at increased risk for a miscarriage, it is not cited in the literature as the most common complication.
c.) Pregnant women may be at higher risk for thromboembolism if they test positive for antiphospholipid antibodies. The presence of these antibodies makes one prone to thrombosus. Not enough information is provided in the question to assume that the patient is at risk for this complication. If she had a past history of miscarriages, then this clue might provide a high reason for suspicion that the patient may in fact possess these antibodies. Anti-phospholipid antibodies are found in 25-35% of women with SLE.
d.) No where in the literature does it state that women with SLE are at an increased risk for developing heart failure compared to women without SLE.

4.) Ms. Bo Jangles, 24 years old, presents to your office to discuss birth control options. Based upon the information her friends have told her, she would like to try combined oral contraceptives (COPs). She has a history of SLE, diagnosed at age 18, and her last flare-up was three years ago (good response to corticosteroids therapy). She takes Motrin PRN for occasional joint pain and she admits to being in a monogamous relationship with her new boyfriend. Which of the following would be a correct response to her request?

a.) Any form of birth control is completely contraindicated considering your history

b.) Based upon the fact that your are relatively healthy, symptom free, and with no evidence of disease exacerbation, lets talk more about COPs and rule out other risk factors from your history

c.) Estrogen containing contraception may make your lupus worse, lets discuss alternative forms of birth control

d.) Unfortunately, your history of SLE might already have caused irreversible infertility, so you will just be wasting your money on birth control

Correct Choice: B: Rationale: Results that appeared in a 2005 issue of The New England Journal of Medicine showed that low-dose estrogen COPs are safe for women with controlled SLE (no evidence of nephritis, no antiphospholipid antibodies) and who lack the normal risk factors for this type of birth control. Women in this study experienced no significant disease exacerbation while taking COPs compared to women who were prescribed other forms of birth controls. COPs may be a very good choice for this patient, although, a more extensive history needs to be taken to rule out other risk factors such as past history of blood clots, breast cancer (family hx), smoking status, etc., It would be incorrect to completely forbid COPs to a patient with mild or controlled SLE and with no other risk factors.

Incorrect Choice
a.) This statement is false. Women of reproductive age who have SLE and who are sexually active are strongly encouraged to take some form of birth control. An unexpected pregnancy can jeopardize both the mother’s and fetus’s health because of the potential complications posed by this disease.
c.) As mentioned above, low dose estrogen-containing contraceptives have been proven to be safe and effective for women with mild or controlled SLE and with no other risk factors.
d.) SLE does not directly cause infertility as discussed in a previous question. Unless this patient was on a chemotherapeutic agent or prolonged high dose steroids, her ovarian function should still be preserved.

5.) Ms. Laura Ingalls, 29, visits you today for her annual pap smear. She was diagnosed with SLE 4 years ago and has experienced a “flare-up” at least every year since then, with her last episode about 7 months ago. She had an I.U.D. (Mirena) placed one year ago since she was not a good candidate for COPs. She states feeling fine today with no disease complications. Which of the following statements might cause you some concern?

a.) “I’ll be sure to get my annual flu shot next week when the clinic gets a new shipment in”

b.) “Since I am getting up in age, I’ve been thinking a lot recently about trying to have a baby”

c.) “Last Saturday night I had a little too much to drink and I forgot how I got home, I really am getting too old to be doing that”

d.) “I’ve noticed a decrease in irregular vaginal bleeding over the last couple of months”

Correct Choice: C: This statement made by the patient should compel you to inquire more about her lifestyle habits or other high risk behaviors and relationship status. Since she has an IUD and has a history of lupus, she is at a high risk for contracting not only a sexually transmitted infection but also fulminant pelvic inflammatory disease. It can only be assumed that these risks were discussed with this patient prior to placement of the IUD. For a long time, IUDs were forbidden in women with SLE; however, recent clinical findings indicate that these women are not at an increased risk for PID as long as they are committed to a monogamous relationship, there disease is stable and they are taking only low dose corticosteroids if any medications at all.

Incorrect Choices:
a.) There are no contraindications that prevent this patient from receiving an influenza vaccine. This is a dead virus and it can enhance her immunity which will prove to be beneficial if she experiences a flare-up during flu season and she becomes immune-compromised
b.) This statement should not concern you as much as it should invite you to discuss with her healthy ways of achieving this goal. This would also be an opportune time to educate her on the potential risks that women with SLE may encounter during the course of their pregnancy. You should emphasize that it is best to delay pregnancy until her last flare-up was at least 6 months ago.
c.) This statement reveals a common, benign response to IUDs. According to GYN lecture notes, Fall 2009, 90% of women with IUDs notice a decrease in irregular bleeding patterns over time.