Sle in Pregnancy

SLE in Pregnancy
SLE provides challenges in pre pregnancy, antenatal, intrapartum and postpartum

periods for t women. The best fetomaternal outcomes are obtained with planned
pregnancy and a cohesive multidisciplinary approach.
Women are at risk of lupus flares, worsening renal impairment, onset of or

worsening hypertension, preeclampsia, and/or venous thromboembolism, and
miscarriage, intrauterine growth restriction, preterm delivery, and/or neonatal lupus
syndrome (congenital heart block or neonatal lupus erythematosus)
Systemic lupus erythematosus (SLE) is a rare, multisystem, chronic autoimmune
disease which can vary from mild to life-threatening
It can present with a variety of symptoms including rash, arthritis, anemia,

thrombocytopenia, serositis, nephritis, seizures, and/or psychosis
It typically shows a waxing and waning clinical course, but some patients have
continuous disease activity
Patients with SLE have increased mortality due to lupus complications or infection
in earlier adult life, and myocardial infarction or stroke in later adult life
The overall survival in patients diagnosed with SLE is 92% after 10 years
SLE is the commonest autoimmune rheumatic disease encountered in pregnancy
Complications during pregnancy may be maternal (lupus flares, worsening renal

impairment, onset of or worsening hypertension, development of preeclampsia, or
venous thromboembolism [VTE]) and/or fetal–neonatal (miscarriage, intrauterine
growth restriction [IUGR], preterm delivery, neonatal lupus syndrome [NLS]
As with many medical conditions in pregnancy, the best maternal and
fetal–neonatal outcomes are obtained with a cohesive multidisciplinary approach.
For patients with SLE, the multidisciplinary team may include a rheumatologist
(ideally familiar with pregnancy in patients with SLE), obstetrician, nephrologist,
fetal cardiologist, fetal medicine specialist, neonatologist
Early recognition and management of flares and complications (medical and/or

obstetric) are important, with involvement of practitioners experienced in managing
pregnancy in patients with SLE
women with SLE can be stratified into the following groups: 1) current remission,
or stable low disease activity, with stable treatment; 2) early-stage or currently
active disease; or 3) severe impairment of organ function ± preexisting severe
organ damage
Women in group 3 are at particularly high risk of complications including

worsening disease progression and end-organ failure, and there will be serious
pregnancy risks for both woman and fetus
Relative contraindications to pregnancy
Severe lupus flare (including renal flare) within the past 6 months
Stroke within the past 6 months
Pulmonary hypertension
Moderate-to-severe heart failure
Severe valvulopathy
Severe restrictive lung disease
Chronic kidney disease stage 4–5
Uncontrolled hypertension
Previous severe early-onset (<28 weeks) preeclampsia or HELLP syndrome despite therapy with aspirin plus heparin
1.SLE in remission, or stable low disease activity: medication should be reviewed and adjusted
as necessary; those women should be advised that it is safe to plan a pregnancy.
2.SLE at an early stage following recent diagnosis, or active disease: those women should be
encouraged to postpone pregnancy and use effective contraception; medication should be
reviewed with prescription of immunosuppressives (ideally hydroxychloroquine [HCQ] and/or
azathioprine which will be safe in pregnancy); further review(s) should be done to monitor
progress; once SLE condition improves (or ideally, enters remission), the women should be
advised that it is safe to plan a pregnancy.
3.Severe impairment of organ function and/or preexisting severe organ damage: those women
should be advised about the serious risks to health and pregnancy-related risks; pregnancy
should be discouraged; alternatives, including adoption and surrogacy (own or donor eggs),
should be discussed.
Women with active disease (current, or during 6 months prior to conception), lupus
nephritis, or cardiac/lung involvement are at higher risk of flares, and medical
and/or obstetric complications during their pregnancy. Women with thrombotic
and/or obstetric antiphospholipid syndrome (APS) are at an increased risk of VTE
and/or pregnancy loss, and may require aspirin and/or low-molecular weight
heparin (LMWH) during pregnancy
It is important to distinguish between aPL and APS
A diagnosis of aPL requires two positive tests, >12 weeks apart, of at least one of
lupus anticoagulant, anticardiolipin antibody (medium/high titer), and
anti-beta2-glycoprotein I antibody.16 aPL may be present in up to 40% of patients
with SLE, and 8%–10% of the normal population
APS is diagnosed if there are aPL with additional clinical features of thrombotic or
obstetric complications
Thrombotic APS involves one or more clinical episodes of arterial, venous, or
small-vessel thrombosis.
Obstetric APS involves the following: one or more adverse pregnancy outcomes
(unexplained fetal death(s) ≥10 weeks of gestation; premature birth(s) of a
morphologically normal fetus <34 weeks due to preeclampsia, eclampsia, or
placental insufficiency (including birthweight less than tenth centile); or three or
more unexplained consecutive spontaneous miscarriages <10 weeks
pregnancy outcomes between women with aPL and obstetric APS
. Both groups received aspirin in pregnancy; women with obstetric APS also
received LMWH if they were at high risk of VTE, had previous late pregnancy
complications, or previous adverse outcome(s) despite aspirin use. Women with
aPL had similar obstetric outcomes to controls, whereas those with obstetric APS
had a fourfold higher rate of pregnancy-induced hypertension or preeclampsia and
a fivefold higher rate of pregnancy loss, with significantly lower birthweight and
increased rate of SGA. They thus recommend that women who only have aPL
should receive aspirin, but not routine LMWH solely for aPL, and can be reassured
and managed as those with normal pregnancy
aPL should also be considered in its context as risk factor for thromboembolism. If
there are three other risk factors, the woman may be considered for antenatal
LMWH; if there are two other risk factors, LMWH may be considered from 28
weeks; if there is one other risk factor, postnatal LMWH may be considered for 10
days. Any woman receiving antenatal LMWH should continue this for 6 weeks
postpartum
Women with thrombotic APS (who will often be on long-term oral anticoagulation)
should be offered thromboprophylaxis with higher dose LMWH antenatally and for
6 weeks postpartum, or until returned to oral anticoagulant therapy after delivery
Women with obstetric APS with recurrent miscarriage <10 weeks should take
aspirin from preconception. If they have previously miscarried while taking aspirin,
LMWH should be added from the confirmation of pregnancy. Consideration may
be given to discontinuing this either at 12 weeks or at 20 weeks if uterine artery
waveform is normal at the anomaly scan
Women with obstetric APS with miscarriage ≥10 weeks of gestation or with
premature birth(s) of a morphologically normal fetus <34 weeks due to
preeclampsia, eclampsia, or placental insufficiency (including birthweight less than
tenth centile) should take aspirin from preconception with LMWH added from
confirmation of pregnancy. This should be continued antenatally and for 6 weeks
postpartum
all women with SLE should be advised to take low-dose aspirin (75 mg) from 12
weeks and throughout pregnancy to reduce their risk of developing preeclampsia
Calcium therapy is also recommended. Previously, this was for women on
long-term corticosteroids or LMWH, or at high risk of osteoporosis. However, a
recent meta-analysis of 13 randomized trials involving >15,000 women showed
that at least 1 g of calcium daily in pregnancy (vs placebo) resulted in >50%
reduction in the risk of pre-eclampsia, and 25% reduction in the risk of preterm
delivery
Fertility is generally not affected in patients with SLE, other than those with
amenorrhea secondary to severe flares
In general, mild flares during pregnancy can be treated with HCQ and/or low-dose
oral steroids (also possibly with nonsteroidal anti-inflammatory drugs if first or
second trimester and previously responsive). Moderate or severe disease may
require the use of pulsed intravenous methylprednisolone or high-dose oral
steroids, followed by rapid reduction to low-dose maintenance oral steroids in
combination with safe immunosuppressants. Intravenous immunoglobulin (IVIg)
may also be necessary
Management of lupus nephritis flares during pregnancy may include pulsed steroid
followed by a combination of prednisolone, HCQ, azathioprine, or tacrolimus.
Two prospective studies corroborated findings, suggesting that women who had
taken HCQ throughout pregnancy had lower disease activity scores and lower
prednisolone doses at the end of pregnancy, whereas those who discontinued
HCQ, or did not take it at all, had higher activity scores, more flares, and required
higher doses of steroids.38,47 HCQ may also offer fetal benefits in women who
have anti-Ro/La antibodies
NLS is a rare complication affecting children born to mothers with anti-Ro/La
antibodies, found in 25%–40% (anti-Ro) and 10%–15% (anti-La) women with
SLE62 as well as other autoimmune diseases (eg, Sjögren’s syndrome). These
IgG antibodies are actively transported across the placenta from 16 to 30 weeks of
gestation
As a guide, women should be reviewed every 4 weeks from 16 to 28 weeks, every
2 weeks from 28 to 34 weeks, and every week from 34 weeks.8 Each visit should
document the presence or absence of flare or preeclampsia symptoms, plus blood
pressure, dipstick urinalysis, symphysial-fundal height, and fetal heart rate.

Sle in Pregnancy

Uploaded by

Copyright:

Available Formats

Sle in Pregnancy

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Sle in Pregnancy

Uploaded by

Copyright:

Available Formats

SLE in Pregnancy

SLE provides challenges in pre pregnancy, antenatal, intrapartum and postpartum

Women are at risk of lupus flares, worsening renal impairment, onset of or

It can present with a variety of symptoms including rash, arthritis, anemia,

SLE is the commonest autoimmune rheumatic disease encountered in pregnancy

Complications during pregnancy may be maternal (lupus flares, worsening renal

Early recognition and management of flares and complications (medical and/or

Women in group 3 are at particularly high risk of complications including

Stroke within the past 6 months

Moderate-to-severe heart failure

Severe restrictive lung disease

Chronic kidney disease stage 4–5

You might also like