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lupus erythematosus in pregnancy

Clinical manifestations: 1) normal fertility rates 2) babies are generally small for gestational age, but healthy 3) neonatal lupus is rare 4) poor fetal outcomes occur in women who develop clinically apparent SLE years after pregnancy [2] Laboratory: 1) anti-phospholipid antibodies place fetus at increased risk 2) anti-SSA Ab (anti-Ro Ab) in high titer associated with neonatal heart block [1] Special laboratory: - if anti-Ro Ab, obtain fetal cardiac ultrasound to assess neonatal heart block [1] Complications: 1) miscarriage 1.5-3 fold increase 2) effects of pregnancy on incidence of lupus flares is controversial 3) active maternal lupus places fetus at increased risk 4) SLE disease activity increases risk of preeclampsia [1] - pre-eclampsia in pregnant women with SLE may be difficult to distinguish from lupus nephritis [1] 5) antiphospholipid antibodies in pregnant women with SLE a) predispose to venous thromboembolism both 1] intra-partum 2] post-partum b) associated with 2nd & 3rd trimester fetal loss [1] 6) neonatal lupus effects 1-2% of children with mothers having anti-SSA or anti-SSB, regardless if mother has SLE or Sjogren's syndrome [1] 7) lupus nephritis is common in women with active SLE during pregnancy [9] Management: 1) a rheumatologist & an obsetrician with experience in high-risk pregnancy should monitor women within 6 months of conception through the puerperium [1] 2) pregnancy recommended only for women taking < 10 mg/day of prednisone 3) patients whose disease has been quiescent for 6 months prior to pregnancy & who are not taking medications or who are taking medications that may be continued during pregnancy, generally have favorable outcomes 4) permitted medications during pregnancy include prednisone. hydroxychloroquine & azathioprine 5) hydroxychloroquine is safe during pregnancy despite pregnancy category 3 rating [1] - indicated during pregnancy even in stable patients with minimal disease activity [1] 6) women with antiphospholipid antibodies & a history of miscarriage may be treated with low-dose aspirin & LMW heparin 7) fetal heart block may be treated with fetal cardiac pacing [7] - fetal heart block detected by fetal cardiac ultrasound

Related

neonatal lupus erythematosus

General

systemic lupus erythematosus pregnancy disorder; obstetric disorder; pregnancy complication

References

  1. Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 15, 16, 17. American College of Physicians, Philadelphia 1998, 2006, 2009, 2012, 2015.
  2. Dhar JP, Essenmacher LM, Ager JW, Sokol RJ. Pregnancy outcomes before and after a diagnosis of systemic lupus erythematosus. Am J Obstet Gynecol. 2005 Oct;193(4):1444-55. PMID: 16202739
  3. Ruiz-Irastorza G, Ramos-Casals M, Brito-Zeron P, Khamashta MA. Clinical efficacy and side effects of antimalarials in systemic lupus erythematosus: a systematic review. Ann Rheum Dis. 2010 Jan;69(1):20-8 PMID: 19103632
  4. Clowse ME, Jamison M, Myers E, James AH. A national study of the complications of lupus in pregnancy. Am J Obstet Gynecol. 2008 Aug;199(2):127.e1-6 PMID: 18456233
  5. Lateef A, Petri M. Management of pregnancy in systemic lupus erythematosus. Nat Rev Rheumatol. 2012 Dec;8(12):710-8. PMID: 22907290
  6. Izmirly PM, Costedoat-Chalumeau N, Pisoni CN et al Maternal use of hydroxychloroquine is associated with a reduced risk of recurrent anti-SSA/Ro-antibody-associated cardiac manifestations of neonatal lupus. Circulation. 2012 Jul 3;126(1):76-82 PMID: 22626746
  7. NEJM Knowledge+ Rheumatology
  8. Clowse MEB, Eudy AM, Kiernan E et al The prevention, screening and treatment of congenital heart block from neonatal lupus: a survey of provider practices. Rheumatology (Oxford). 2018 Jul 1;57(suppl_5):v9-v17 PMID: 30137589 PMCID: PMC6099126 Free PMC article PMID: 19493059
  9. NEJM Knowledge+ Nephrology/Urology