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Scheduled C-section with AUTOIMMUNE DISEASE. Risk of NEONATAL LUPUS?

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Hi there,

I have autoimmune issues and I am also currently 38 weeks pregnant. I am scheduled to have a c-section on December 1st, mostly at my own insistence, because there are some small risks associated with vaginal delivery for my baby. Not to do with my autoimmune, but because the umbilical cord is inserted in a fragile way (velamentous cord insertion), and I want to avoid any possible risk to my baby. The doctors have said that it would likely be safe to do a vaginal delivery, however, they are allowing me the option to have a c-section and I have accepted it to eliminate any risks to the baby. I am scheduled to have this done on December 1st. Now, however, I am beginning to worry about whether or not having a c-section is more likely to cause a flare in my autoimmune disease - or activate it. Can you advise me as to whether or not there is a difference in the likelihood of an autoimmune flare between a c-section and a normal vaginal delivery? I currently have SSA- autoantibodies and I am ANA positive. Prior to pregnancy, I also showed RNP antibodies in my blood work, which I know is associated with Mixed Connective Tissue disease. However, in my first trimester, the RNP disappeared from my blood work. I'm not sure if it will return after the baby is born (IE is the pregnancy suppressing my immune system to the point that it suppressed the RNP activity only for it to return upon delivery?). Anyway, the only clinical symptoms I have ever exhibited are: dry eyes, dry mouth, dry skin, sun sensitivity and an episode of pigmented purpuria on my legs that cleared up on its own. In the past few weeks, I have noticed that my fingers are slightly swollen and that it feels mildly painful to make a fist - especially first thing in the morning. I'm not sure if this is autoimmune related or pregnancy related. It's hard to tell. Throughout the pregnancy I have felt fine other than those symptoms, which are not bothersome and very manageable without medication. I am really hoping to remain that way so I can be a good mother to my new baby. Due to the SSA auto-antibodies, and their association with Neonatal Lupus and Congenital Heart Block, I have been closely monitored throughout the pregnancy, and have had serial echocardiograms done on the baby. The baby's heart is fine, thank goodness. Do you think that means that the baby will likely be born without Neonatal Lupus (IE skin rash, liver problems, etc)? I worry about this too, and whether or not a c-section will be better or worse for the baby in terms of autoimmune possibly affecting it.

I guess, all around, what I most want to know is: do you think I have a higher chance of having an autoimmune flare up following a c-section than a vaginal delivery. And, do you think that my baby is more likely to develop an autoimmune issue in one form of delivery versus the other. I have read articles online linking c-sections to greater chance of autoimmune development and I am already worried about the Neonatal Lupus.

Really looking forward to your answer as I am quite anxious and find that I cannot stop worrying about this….Thank you in advance!

Krista


Category: Rheumatologist

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Category: Internal Medicine Specialist
Dr. Bimlesh Dhar Pandey is online now

Expert:  Dr. Bimlesh Dhar Pandey replied 4 Days.

Hello,
Thank you for your query at DoctorSpring.com
Good to hear from you again.
We have communicated before , regarding the fluid filled bowel loop if I remember correctly, and , of course, the velamentous cord .
Autoimmune diseases behave very unpredictably, and when you throw in a complex condition such as pregnancy, they become even more unpredictable.
They often regress during pregnancy ( would definitely explain the disappearing RNP ), and often flare up ( explaining the slight discomfort in your fingers ).
You do not have a definite diagnosis anyway, apart from the markers, so it further compounds the uncertainty.
THe baby has no evidence of heart block, neonatal lupus is a rare possibility, but it does exist.
Regarding the mode of delivery, there is no evidence to suggest that a C section would increase the risk of auto immune flare ups in your own case, or increase the risk of neonatal lupus either.
All the best
Please feel free to discuss further


Patient replied :

Hello again! I must be functioning at half capacity these days, as I meant to post this question to a rheumatologist and thought that's what I selected! (Since I can't get in to see my rheumatologist until December 22, long after the delivery will be over). But, I'm glad that if I had to post it in the wrong category, I got you at least. I really appreciated your last, candid answer about the c-section (in response to the velamentous cord) and it helped me to make my decision more comfortably (until the autoimmune problem occured to me). Thanks again for that. I am hoping that the recovery is not too bad and that my autoimmune doesn't activate or something! Thank you for this answer as well. I'm sure that you are right and that the delivery method doesn't matter much in terms of predicting an autoimmune flare. I'm sure a vaginal birth could cause a flare as well.
Kind regards,
Krista


Expert:  Dr. Bimlesh Dhar Pandey replied 3 Days.

Your concerns are valid, and your insight and research also is admirable.
I have a gut feeling you will come out without any issues in terms of the cord, or the autoimmune condition.
I wish you luck and lots of prayers for you.
Note from the InHouse Physician :
Our Rheumatologist has replied. I sincerely apologise for the delay.
Please find his reply below.
Hello,
Few things about your autoimmune disease and LSCS and vaginal delivery. There are very authentic long term data about aggravated autoimmune disease activity and LSCS.
So I would not warn a patient about the mode of delivery and disease activity. However there is change in immune cells and disease activity per se post partum and disease activity Please take medicines as asked by your doctor. I don't get worried about neonatal lupus as it is transient since intrauterine heart evaluation is normal there is no point of neonatal heart block either. Per se your disease is probably sjogren/lupus not MCTD, so go ahead with LSCS.
Feel free to discuss further queries,
Regards.


Patient replied :

I just wanted to say thank you to Dr. Vazirani for her kind words and prayers :) I apreciate it!
Now, in response to the Rheumatologist, I just have one follow up question: What in particular leads you to the diagnosis of Sjogren's/Lupus versus Sjogren's/MCTD? I understand that all my symptoms seem to point toward Sjogren's for sure, and I likely have that actively. However, I know that due to the ANA and the RNP, something else is likely lurking. But, my understanding was that U1 RNP without the presence of a double stranded DNA indicated MCTD. And, that the presence of the U1 RNP often precedes the onset of the clinical disease. So, I am always worried about developing the clinical disease.
RNP is presently not showing in my bloodwork and hasn't since the beginning of my pregnancy. (The numbers were low to begin with anyway). Do you think it is likely to return following delivery and if so, does this indicated the level of disease activity or the prognosis? I would rather have SLE than MCTD I think, because reading about MCTD scares me more and sounds like it can be much more crippling. That's why I am just curious as to why you think that. One Rheumatologist here has told me Sjogren's with the possibility of MCTD. And another Rheumatologist here has told me Sjogren's with the possibility of SLE. I know you agree with the second one, I would just like to know why, specifically. (Knowing which disease I may be facing after delivery makes me feel better equipped to deal with it, as I would like to research it and try as many different things to prevent it as possible).
Thanks a lot!
Krista


Expert:  Dr. Bimlesh Dhar Pandey replied 2 Days.

Dear Krista.
The simple understanding of multiple markers in connective tissue disorder is to go by clinical presentation and not by markers
I have seen this every time when I see the reports the dictum is to go by clinical presentation and treat accordingly
I have a simple way to put it across : say you have ana 1:320 but no signs or symptoms do you treat these patient not at all we observe closely . If your titres are 1:40,but you have florid disease we treat the patient aggressively so your case is mild sjogren like disease as per available history and lab results. Thanks for very good query.
I feel this as the best question in natural history of disease
Regards.


Dr. Bimlesh Dhar Pandey
Category: Internal Medicine Specialist
Experience: 
Senior Residency: Rhematology, All India Institute of Medical Schiences, New Delhi, 2009
Post Graduate, Junior Residency: MD (Internal Medicine), Rajendra Institute of Medical Sciences, Jharkhand, 2006
Residency: Physiology, Institute of Medical Science, Banaras Hindu University, Varanasi, 2003
Internship: Government Medical College, Trichur, 2001
Medical School: MBBS, Calicut University, 2001
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