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Managing lupus patients during pregnancy

https://doi.org/10.1016/j.berh.2013.07.005Get rights and content

Abstract

Systemic lupus erythematosus (SLE) is an auto-immune disease, primarily affecting young females. Pregnancy in a woman with SLE remains a high-risk situation with higher maternal and foetal mortality and morbidity. Although live births are achieved in majority of the pregnancies, active disease and major organ involvement can negatively affect the outcomes. A higher risk of foetal loss, pre-term birth, intra-uterine growth restriction (IUGR) and neonatal lupus syndromes (NLSs) are major foetal issues. Mothers are faced with disease flares, pre-eclampsia and other complications. Disease flares during SLE pregnancy pose the unique issue of recognition and differentiation between physiologic changes and disease state. Similarly, pre-eclampsia and lupus nephritis may lead to diagnostic confusion. Treatment choices during pregnancy are limited to a few safe drugs, further restricting the options. Refractory pregnancy loss associated with anti-phospholipid antibodies (aPLs) and complete heart block associated with anti-Ro antibodies remain unresolved issues. A multidisciplinary approach, with close monitoring, is essential for optimal outcomes.

Introduction

Systemic lupus erythematosus (SLE) is an auto-immune disease with significant female predominance. The onset during reproductive years, coupled with improved survival, has led to increased numbers of pregnancies in women with SLE. The pregnancy outcomes have also significantly improved. The rate of pregnancy loss has decreased from 43% to 17% in recent years [1]. However, SLE patients have fewer children than their normal counterparts, and SLE pregnancy still carries a high risk of complications [2], [3], [4]. A multidisciplinary approach, with close medical, obstetric and neonatal monitoring, is essential for optimal outcomes. This chapter highlights major issues in SLE pregnancy and discusses the management strategies to minimise maternal and foetal risks.

Section snippets

Pregnancy planning in SLE

Active SLE at the time of conception is known to be the strongest predictor of adverse pregnancy outcomes [5]. Hence, ideally, all pregnancies in women with SLE should be planned during periods of disease control. Unplanned pregnancies during periods of disease activity highlight the often neglected need of effective contraceptive counselling of all young women with SLE [6]. Natural and barrier methods of contraception have a high failure rate and may not be sufficient for a patient with active

Pre-conception evaluation

Pre-conception assessment is an essential component of pregnancy planning in women with SLE. In a limited number of patients, pregnancy may pose an unacceptably high maternal risk, justifying an advice to defer or avoid pregnancy (Table 1). If there are no contraindications, the patient should undergo pre-conception counselling, maternal and foetal risk assessment and medication review, before conception (Fig. 1). A complete set of autoantibodies should be obtained as certain specific maternal

Pre-pregnancy counselling

SLE pregnancies are considered to be of high risk. All patients should be counselled about the possible issues, including the risk of disease flares, higher rates of pregnancy complications, sub-optimal obstetric outcomes and the risk of neonatal lupus syndromes (NLSs). The need for optimal disease control with safe medications during pregnancy should be explained.

Ante-natal management in SLE patients

Ante-natal management of pregnant patients with SLE requires a close collaboration between rheumatologist and obstetrician. The monitoring should be more frequent and detailed than the usual standard of care. Each visit should include a thorough physical examination, routine laboratory tests and specific investigations, tailored to the risk profile of the particular pregnancy (Table 3). Certain situations, such as disease flare or the presence of specific antibodies, require specific

Summary

Pregnancy in women with SLE is a high-risk condition. Despite considerable improvement in success rates, substantially high maternal and foetal morbidity and mortality still remain a cause for concern. Disease activity may worsen during pregnancy and in turn may increase the risk of other maternal and foetal complications. Recognition and treatment of disease flares and pre-eclampsia, during SLE pregnancy, is fraught with difficulties, including overlapping features, lack of specific diagnostic

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