Systemic lupus erythematosus and pregnancy

For women with systemic lupus erythematosus (SLE), pregnancy can present some particular challenges for both mother and child.

While most infants born to mothers who have SLE are healthy, mothers with SLE as an intercurrent disease in pregnancy should remain under medical care until delivery. In general, women with SLE and, in addition, hypertension, proteinuria, and azotemia have an extra increased risk for pregnancy complications.[1] Pregnancy outcomes in women with SLE who receive renal transplants are similar to those of transplant recipients without SLE.[1]

Women pregnant and known to have anti-Ro (SSA) or anti-La antibodies (SSB) often have echocardiograms during the 16th and 30th weeks of pregnancy to monitor the health of the heart and surrounding vasculature.[2]

Contraception and other reliable forms of pregnancy prevention is routinely advised for women with SLE, since getting pregnant during active disease was found to be harmful. Lupus nephritis was the most common manifestation.

Of live births, approximately one third are delivered prematurely.[1]

Miscarriage

SLE causes an increased rate of fetal death in utero and spontaneous abortion (miscarriage). The overall live-birth rate in SLE patient has been estimated to be 72%.[3] Pregnancy outcome appears to be worse in SLE patients whose disease flares up during pregnancy.[4]

Miscarriages in the first trimester appear either to have no known cause or to be associated with signs of active SLE.[5] Later losses appear to occur primarily due to the antiphospholipid syndrome, in spite of treatment with heparin and aspirin.[5] All women with lupus, even those without previous history of miscarriage, are recommended to be screened for antiphospholipid antibodies, both the lupus anticoagulant (the RVVT and sensitive PTT are the best screening battery) and anticardiolipin antibodies.[5]

Neonatal lupus

Neonatal lupus is the occurrence of SLE symptoms in an infant born from a mother with SLE, most commonly presenting with a rash resembling discoid lupus erythematosus, and sometimes with systemic abnormalities such as heart block or hepatosplenomegaly.[6] Neonatal lupus is usually benign and self-limited.[6] Still, identification of mothers at highest risk for complications allows for prompt treatment before or after birth. In addition, SLE can flare up during pregnancy, and proper treatment can maintain the health of the mother for longer.

Aggravation of SLE

Aggravation (or exacerbation) of SLE has been estimated to occur in about 20-30% pregnancies where the mother has SLE.[1] Increased disease activity of SLE is expected during pregnancy because of increased levels of estrogen, prolactin, and certain cytokines.[1] However, a long time of remission before pregnancy decreases the risk of aggravation[7], with an incidence of 7-33% in women who have been in remission for at least 6 months, and an incidence of 61-67% in women who have active SLE at the time of conception.[1]

Renal disease flare-up is the most common presentation of SLE aggravation in pregnancy, and is seen equally in United States and European populations.[1] Serositis with pleural and pericardial effusions are seen in up to 10% of these patients.[1]

On the other hand, flares of SLE are uncommon during pregnancy and are often easily treated.[1] The most common symptoms of these flares include arthritis, rashes, and fatigue.[1]

Also, in the postpartum period, there may be exacerbations of SLE due to decreased levels of anti-inflammatory steroids, elevated levels of prolactin and estrogen and progesterone changes.[1]

In diagnosing an aggravation of SLE in pregnancy, there need to be a differential diagnosis from SLE-unrelated complications of pregnancy that may appear in a similar fashion. For example, chloasma may appear like the malar rash of SLE, proteinuria from preeclampsia may appear like that of lupus nephritis, thrombocytopenia of the HELLP syndrome may appear like that of SLE, and pregnancy-related edema of joints can appear like arthritis of SLE.[1]

General preventive measures

Continuing glucocorticoids at the lowest effective dose and/or cautious use of azathioprine may be preferred in some patients, but needs to be weighed against potential adverse effects of such medications.[1]

References
  1. Systemic Lupus Erythematosus and Pregnancy at Medscape. Author: Ritu Khurana. Chief Editor: David Chelmow. Updated: Sep 20, 2010
  2. "Handout on Health: Systemic Lupus Erythematosus". The National Institute of Arthritis and Musculoskeletal and Skin Diseases. National Institutes of Health. August 2003. Retrieved 2007-11-23.
  3. Smyth, Andrew; Guilherme H.M. Oliveira; Brian D. Lahr; Kent R. Bailey; Suzanne M. Norby; Vesna D. Garovic (November 2010). "A Systematic Review and Meta-Analysis of Pregnancy Outcomes in Patients with Systemic Lupus Erythematosus and Lupus Nephritis". Clinical Journal of the American Society of Nephrology. 5 (11): 2060–2068. doi:10.2215/CJN.00240110. PMC 3001786. PMID 20688887. Retrieved 20 April 2011.
  4. Cortés‐Hernández, J.; J. Ordi‐Ros; F. Paredes; M. Casellas; F. Castillo; M. Vilardell‐Tarres (December 2001). "Clinical predictors of fetal and maternal outcome in systemic lupus erythematosus: a prospective study of 103 pregnancies". Rheumatology. 41 (6): 643–650. doi:10.1093/rheumatology/41.6.643. PMID 12048290. Retrieved 20 April 2011. Check date values in: |year= / |date= mismatch (help)
  5. Lupus and Pregnancy by Michelle Petri. The Johns Hopkins Lupus Center. Retrieved May 2011
  6. thefreedictionary.com > neonatal lupus Citing: Dorland's Medical Dictionary for Health Consumers. Copyright 2007
  7. "Praticar Exercicios Durante Gravidez". Barriga Sonho. Retrieved 6 September 2017.
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