Management of the High-Risk Lupus Pregnant Patient

doi:10.1016/j.rdc.2007.02.002

Rheumatic Disease Clinics of North America

Volume 33, Issue 2, May 2007, Pages 253-265

https://doi.org/10.1016/j.rdc.2007.02.002 Get rights and content

Pregnancy in the lupus patient presents a unique clinical challenge. Pregnancy may interact with lupus nephritis and adds preeclampsia to the differential diagnosis of hypertension. Lupus may result in pregnancy loss, fetal growth restriction, and prematurity. The obstetric management of these complex issues is presented for the nonobstetrician.

Section snippets

Initial assessment

The initial assessment must always be a collaborative effort between the obstetrician and the rheumatologist. This must include a comprehensive and up-to-date assessment of the activity of lupus, organ damage, laboratory tests, and medication exposure.

The initial history should include the duration and current activity of the patient's disease. If she is in remission, how long the remission has lasted should be documented. Typical signs or symptoms the patient is known to experience during

Maternal health

Interactions between SLE and pregnancy include the overall activity of lupus and pregnancy outcome, the effect of lupus nephritis on pregnancy, the effect of pregnancy on the progression of lupus nephritis, and the differentiation of hypertension related to lupus nephritis from preeclampsia. The issue of lupus flares and pregnancy will be covered elsewhere in this issue.

Pregnancy loss

Pregnancy loss in patients with SLE is decreased if the patient has been in remission for 6 to 12 months before conception [1]. Patients with SLE experience pregnancy loss at a greater rate than the general population [3], [19], [20]. They experience a 4.7-fold increase in spontaneous abortion after the diagnosis of SLE compared with their reproductive history before the SLE diagnosis [21].

The gestational age at which pregnancy loss occurs in patients with SLE is difficult to determine, because

General

Prenatal care for patients with SLE begins with the standard prenatal care recommended jointly by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists [28]. This standard care should be modified for SLE patients because of their increased risks of pregnancy loss, intrauterine growth restriction, and preeclampsia. Additionally, collaborative monitoring of lupus activity between the rheumatologist and the obstetrician must be included. This part of the

Summary

A pregnancy in a patient with SLE is at high risk for maternal complications of pregnancy and pregnancy wastage. However, most patients can achieve a live birth. This can be achieved by close coordination of care between the patient's rheumatologist, obstetrician, and, in the case of renal involvement, her nephrologist.

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Cited by (27)

Maternal and perinatal outcomes of pregnancies in systemic lupus erythematosus: A nationwide population-based study
2020, Seminars in Arthritis and Rheumatism
Citation Excerpt :
The 2016 WHO Antenatal Care guideline recommends that the general pregnant population have the first antenatal care contacts at 12 gestational weeks, followed by every 4 weeks from 20 to 34 weeks and then biweekly till 40 weeks [36]. For pregnant SLE patients, previous reports suggest obstetric visits every 4 weeks until 20 gestational weeks, followed by visits every 2 weeks afterwards until 28 weeks, and then, weekly until delivery, because preeclampsia occurs after 20 weeks [12]. We observed a trend toward greater prevalence of stillbirths due to placenta-mediated pregnancy complications in mothers with SLE compared with controls (44% [95% CI 14, 79] versus 15% [95% CI 6, 28]); this constituted the most frequent cause of stillbirth in the SLE group.
Objectives: Systemic lupus erythematosus (SLE) is an autoimmune disease that develops mainly in women of reproductive age. We aimed to explore the risk of pregnancy complications in Asian patients with SLE.
Methods: From January 2005 to December 2014, we conducted a nationwide case-control study, using Taiwan's National Health Insurance Research Database. Obstetric complications and perinatal outcomes in SLE patients were compared with those without SLE.
Results: 2059 SLE offspring and 8236 age-matched, maternal healthy controls were enrolled. We found increased obstetric and perinatal complications in SLE population compared with healthy controls. SLE patients exhibited increased risk of preeclampsia/eclampsia (8.98% vs.1.98%, odds ratio [OR]: 3.87, 95% confidence interval [95% CI]: 3.08–4.87, p<0.0001). Their offspring tended to have lower Apgar scores (<7) at both 1 min (10.7% vs. 2.58%, p<0.0001) and 5 min (4.25% vs. 1.17%, p<0.0001), as well as higher rates of intrauterine growth restriction (IUGR, 9.91% vs. 4.12%, OR: 2.24, 95% CI: 1.85–2.71, p<0.0001), preterm birth (23.70% vs 7.56%, OR: 3.00, 95% CI: 2.61–3.45, p<0.0001), and stillbirth (4.23% vs. 0.87%, OR: 3.59, 95% CI: 2.54–5.06, p<0.0001). The risks of preterm birth and stillbirth were markedly increased in SLE patients with concomitant preeclampsia/eclampsia or IUGR. Preterm birth of SLE patients was 1~4 gestational weeks earlier than that of healthy controls and the peak occurrence of stillbirth in SLE population was at 20~30 gestational weeks.
Conclusions: Asian SLE patients exhibited increased risks of maternal complications and adverse birth outcomes. Frequent antenatal visits before 20 gestational weeks are recommended in high-risk SLE patients.
Treatment of Pregnancy Complications in Antiphospholipid Syndrome
2017, Handbook of Systemic Autoimmune Diseases
Citation Excerpt :
APS is a predictor of adverse pregnancy complications in pregnant women with SLE, most notably predicting a high risk of second- and third-trimester losses and stillbirths [159,160]. In women with active SLE who are maintained on hydroxychloroquine, there is a consensus to continue treatment during pregnancy [161]. Although hydroxychloroquine crosses the placenta, it has been used safely in pregnancy with no reported foetal toxicity [162,163].
Antiphospholipid syndrome (APS) is characterized by arterial and venous thrombosis and pregnancy complications that include recurrent early pregnancy loss and late adverse pregnancy outcomes such as foetal death, severe preeclampsia, placental insufficiency, and foetal growth restriction. The pathogenic mechanisms that lead to injury in vivo are not clearly understood, and evidence-based management of ongoing pregnancies in women with APS and late pregnancy complications is difficult to provide due to the lack of randomized clinical trials for this particular group of women. In this chapter, we outline some of the proposed mechanisms by which antiphospholipid antibodies can cause and may perpetuate late complications of pregnancy. The identification of new mechanisms holds promise for new, more effective, and safer treatments. In addition, we focus on available therapeutic options for pregnant women with APS and late adverse pregnancy outcomes.
Clinical practice guidelines for the management of pregnancy in women with autoimmune rheumatic diseases of the Mexican College of Rheumatology. Part I
2015, Reumatologia Clinica
El embarazo en mujeres con enfermedades reumáticas autoinmunes se asocia a diversas complicaciones maternofetales. El desarrollo de guías de práctica clínica con la mejor evidencia científica disponible puede ayudar a homogeneizar la atención en estas pacientes.
Proporcionar recomendaciones respecto al control prenatal, el tratamiento y el seguimiento más efectivo de la mujer embarazada con lupus eritematoso (LES), artritis reumatoide (AR) y síndrome por anticuerpos antifosfolípidos (SAF).
Para la elaboración de las recomendaciones se conformaron grupos nominales de expertos y se realizaron consensos formales, búsqueda sistematizada de la información, elaboración de preguntas clínicas, elaboración y calificación de las recomendaciones, fase de validación interna por pares y validación externa del documento final teniendo en cuenta los criterios de calidad del instrumento AGREE II.
Los grupos de trabajo contestaron las 37 preguntas relacionadas con la atención maternofetal en LES, AR y SAF, así como de fármacos antirreumáticos durante el embarazo y la lactancia. Las recomendaciones fueron discutidas e integradas en un manuscrito final y se elaboraron los algoritmos correspondientes. En esta primera parte se presentan las recomendaciones para mujeres embarazadas con LES.
La guía mexicana de práctica clínica para la atención del embarazo en mujeres con LES proporciona recomendaciones e integra la mejor evidencia disponible para el tratamiento y el seguimiento de estas pacientes.
Pregnancy in women with autoimmune rheumatic diseases is associated with several maternal and fetal complications. The development of clinical practice guidelines with the best available scientific evidence may help standardize the care of these patients.
To provide recommendations regarding prenatal care, treatment, and a more effective monitoring of pregnancy in women with lupus erythematosus (SLE), rheumatoid arthritis (RA) and antiphospholipid antibody syndrome (APS).
Nominal panels were formed for consensus, systematic search of information, development of clinical questions, processing and grading of recommendations, internal validation by peers, and external validation of the final document. The quality criteria of the AGREE II instrument were followed.
The various panels answered the 37 questions related to maternal and fetal care in SLE, RA, and APS, as well as to the use of antirheumatic drugs during pregnancy and lactation. The recommendations were discussed and integrated into a final manuscript. Finally, the corresponding algorithms were developed. We present the recommendations for pregnant women with SLE in this first part.
We believe that the Mexican clinical practice guidelines for the management of pregnancy in women with SLE integrate the best available evidence for the treatment and follow-up of patients with these conditions.
Consensus of the Brazilian Society of Rheumatology for the diagnosis, management and treatment of lupus nephritis
2015, Revista Brasileira de Reumatologia
Elaborar recomendações para o diagnóstico, manejo e tratamento da nefrite lúpica no Brasil.
Revisão extensa da literatura com seleção dos artigos com base na força de evidência científica e opinião dos membros da Comissão de Lúpus Eritematoso Sistêmico da Sociedade Brasileira de Reumatologia.
1) A biópsia renal deve ser feita sempre que possível e houver indicação e quando não for possível, o tratamento deve ser orientado com base na inferência da clase histológica. 2) Devem ser implementados medidas e cuidados idealmente antes do início do tratamento, com ênfase na atenção ao risco de infecção. 3) Devem‐se compartilhar riscos e benefícios do tratamento com pacientes e familiares. 4) O uso da hidroxicloroquina (preferencialmente) ou difosfato de cloroquina é recomendado para todos os pacientes (exceto contraindicação) durante as fases de indução e manutenção. 5) A avaliação da eficácia do tratamento deve ser feita com critérios objetivos de resposta (remissão completa/remissão parcial/refratariedade). 6) Os IECA e/ou BRA são recomendados como antiproteinúricos para todos os pacientes (exceto contraindicação). 7) A identificação de sinais clínicos e/ou laboratoriais sugestivos de GN laboratoriais sugestivos de glomerulonefrite proliferativa ou membranosa deve indicar início imediato de terapia específica incluindo corticosteroides e agente imunossupressor, mesmo que não seja possível comprovação histológica. 8) O tempo de uso dos imunossupressores deve ser no mínimo de 36 meses, mas eles podem ser mantidos por períodos mais longos. A sua suspensão só deve ser feita quando o paciente atingir e mantiver remissão completa sustentada. 9) Deve‐se considerar nefrite lúpica refratária quando a remissão completa ou parcial não for alcançada após 12 meses de tratamento adequado, quando uma nova biópsia renal deve ser considerada para auxiliar na identificação da causa da refratariedade e decisão terapêutica.
To develop recommendations for the diagnosis, management and treatment of lupus nephritis in Brazil.
Extensive literature review with a selection of papers based on the strength of scientific evidence and opinion of the Commission on Systemic Lupus Erythematosus members, Brazilian Society of Rheumatology.
1) Renal biopsy should be performed whenever possible and if this procedure is indicated; and, when the procedure is not possible, the treatment should be guided with the inference of histologic class. 2) Ideally, measures and precautions should be implemented before starting treatment, with emphasis on attention to the risk of infection. 3) Risks and benefits of treatment should be shared with the patient and his/her family. 4) The use of hydroxychloroquine (preferably) or chloroquine diphosphate is recommended for all patients (unless contraindicated) during induction and maintenance phases. 5) The evaluation of the effectiveness of treatment should be made with objective criteria of response (complete remission/partial remission/refractoriness). 6) ACE inhibitors and/or ARBs are recommended as antiproteinuric agents for all patients (unless contraindicated). 7) The identification of clinical and/or laboratory signs suggestive of proliferative or membranous glomerulonephritis should indicate an immediate implementation of specific therapy, including steroids and an immunosuppressive agent, even though histological confirmation is not possible. 8) Immunosuppressives must be used during at least 36 months, but these medications can be kept for longer periods. Its discontinuation should only be done when the patient achieve and maintain a sustained and complete remission. 9) Lupus nephritis should be considered as refractory when a full or partial remission is not achieved after 12 months of an appropriate treatment, when a new renal biopsy should be considered to assist in identifying the cause of refractoriness and in the therapeutic decision.
Management of the Patient with Rheumatic Disease During and After Pregnancy
2010, Targeted Treatment of the Rheumatic Diseases
Management of the patient with rheumatic disease during and after pregnancy
2009, Targeted Treatment of the Rheumatic Diseases: Expert Consult

View all citing articles on Scopus

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Management of the High-Risk Lupus Pregnant Patient

Section snippets

Initial assessment

Maternal health

Pregnancy loss

General

Summary

Kidney International

Rheum Dis Clin North Am

Semin Perinatol

Am J Med

Eur J Obstet Gynecol Reprod Biol

Obstet Gynecol

Obstet Gynecol

Fertil Steril

Am J Obstet Gynecol

Obstet Gynecol

Obstet Gynecol

Am J Obstet Gynecol

Am J Obstet Gynecol

The effects of pregnancy on autoimmune disease

J Leukoc Biol

Trends in deaths from systemic lupus erythematosus–United States, 1979–1998

MMWR Morb Mortal Wkly Rep

Pregnancy outcomes in women with systemic lupus erythematosus

J Matern Fetal Med

Preconception, prenatal care and breastfeeding in Lambrou NC

Pregnancy and lupus nephritis

Scand J Urol Nephrol

Pregnancy in lupus nephritis and related disorders

Am J Kidney Dis

Systemic lupus erythematosus in pregnancy

Ann Intern Med

Pregnancy in women with renal disease and moderate renal insufficiency

Am J Med

Pregnancy among patients with systemic lupus erythematosus receiving immunosuppressive therapy

J Rheumatol

Diagnosis and management of preeclampsia and eclampsia

Fetal outcome of lupus pregnancy: a retrospective case-control study of the Hopkins lupus cohort

J Rheumatol

Pregnancy outcome in women with system lupus erythematosus

Obstet Gynecol

The physiology of human pregnancy

Urinary calcium as an early marker for preeclampsia

Obstet Gynecol