Obstetric Anaesthesia Annual Scientific Meeting 2023

A Case Report of a New Diagnosis of Neuropsychiatric Lupus in an Acute Presentation of Coma and Seizure in Pregnancy

INTRODUCTION

• Systemic Lupus Erythematosus (SLE) is a multi-system, autoimmune disease predominantly affecting women of childbearing age.1

•Neuropsychiatric lupus (NL) is a severe form of SLE with psychiatric &/or neurological manifestations. It is a rare cause of coma & seizure in pregnancy, with significant associated maternal & foetal, morbidity & mortality.1

•We report a rare case of first presentation of NL during pregnancy.

CASE REPORT

Background:

•Patient X, 34-year-old fit & well Primigravida, 18 weeks gestation

Presentation:

•Covid positive with a 2-day history of headache, cough & pyrexia

•Acutely reduced Glasgow Coma Score followed by generalised tonic-clonic seizure

Initial Management

•Intubation, ventilation, sedation, antiepileptic agent loading & maintenance of normal blood serum biochemistry

•Uncommon presentation in previously healthy patient led to diagnostic uncertainty

Investigations:

•CT head: normal. MRI head & spine: cerebral oedema (see Figure 3)

•Electroencephalogram: cerebral dysfunction consistent with encephalitis. (see Figure 1)

•Antibodies: Positive for Anti-La SS antibodies

Specific treatment:

•Plasma exchange + Methylprednisolone

•Extubated on day 10 & discharged from hospital on day 22

•Regular review by Maternal Medicine Team & MDT discussion

Delivery Plan

•Elective lower segment caesarean section (LSCS) performed at 37/40 under uncomplicated spinal anaesthesia. Baby was delivered in good condition. 

Follow Up

•Both mother & baby were discharged post-delivery on day 4.  

•At 8-week follow-up the mother remained asymptomatic whilst continuing a tapering dose of oral steroid

DISCUSSION

SLE can affect any organ system (see Figure 4) & is therefore of huge relevance to anaesthetists. In pregnancy, it increases the risk of maternal & foetal death, pre-eclampsia, thrombosis & preterm labour1. In those with established SLE, thorough monitoring for flare-ups is key. Although rare, NL should be considered amongst a broad range of differentials for parturients presenting with seizure activity &/or reduced GCS.

The key to the successful management in this case & delivery of a healthy baby was a huge degree of multiple multidisciplinary team (MDT) working; Intensive Care (initially), Radiology, Rheumatology, Neurology, Midwives, Maternal Medicine Team (Obstetricians & Obstetric Physicians), Anaesthesia, Neonatology.

General anaesthesia & central neuraxial techniques are recognised options in parturients with SLE. Full assessment & MDT discussion of the severity of disease & systems involved will inform choice. In this case, the absence of spinal cord inflammatory processes & thrombocytopenia, along with the history of seizures, guided the decision towards central neuraxial anaesthesia.

This case report emphasises the importance of collaborative multidisciplinary teamwork in assessing a patient with rare but severe disease & developing an individualised patient pathway. 

Obstetric Anaesthesia Annual Scientific Meeting 2023

A case report of a new diagnosis of neuropsychiatric lupus in an acute presentation of coma and seizure in pregnancy

Poster Presenter

Authors

Affiliations

Part of Topic