Systemic Lupus Erythematosus (SLE) in Pregnancy

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Dr. Anupama Kumar
Consultant Rheumatologist
Sagar Hospital, Bangalore
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Biological prerogative of every woman
Pregnancy in lupus is not contraindicated
Many lupus patients deliver healthy babies
Many families at least want one child
Fertility is not affected in patients with lupus
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SLE is the most common autoimmune
multisystemic disease to affect women in
child-bearing years
Prognosis for both mother and baby have
important implications during pregnancy
Marriage, pregnancy and childbirth are
burning issues for most patients
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Characterized by production of antibodies to
cell nucleus called ANAs
Who is affected 90% are young women
90% of them are in 20 to 40 years age group
More patients plan for pregnancy because of
improved prognosis
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Pregnancy outcomes are good when lupus is
in remission
Ideally lupus should be inactive for six
months
Serious disease such as active lupus
nephritis, myocarditis, seizures is a contraindication
Teratogenic drugs like cyclophosphamide,
methotrexate should be stopped six months
before conception
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Lupus patients for pregnancy counseling
Known lupus cases coming for antenatal care
Undiagnosed or misdiagnosed lupus in
pregnancy
Asymptomatic pregnant patients who have
history of neonatal lupus or concerned
antibodies
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Fatigue and fevers
Arthritis or arthralgias
Malar rash
Serositis
Raynaud’s phenomenon
Proteinuria
Vasculitis
Leukopenia
Thrombocytopenia
Seizures
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Complete blood count
Anti Nuclear Antibodies by IF or HEP2
Anti double stranded DNA antibodies
Anti Ro and Anti La antibodies
Complement studies-C3 AND C4
Urine analysis
Renal function tests
Lupus anticoagulant and Anti cardiolipin
antibodies
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Mild risk cases-Mild disease, those who are in
remission, on no medication except mild
ones
High risk cases-Severe active disease. Major
organ involvement,those with Anti Ro or APL
antibodies
Moderate risk cases-Majority are in this
group
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H/O Previous pregnancy with complication
Underlying kidney, heart or lung disease
Active phase of the disease
Presence of Anti Ro and Anti La antibodies
A history of previous thrombotic event
APLA
Additional factors like maternal age>40 years
and pregnancy with twins or triplets
Risks of Lupus to
pregnancy
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Pregnancy loss
Preterm delivery
Eclampsia
Neonatal lupus due to
Ro and La antibodies
Risks of pregnancy to
lupus
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Lupus flares
Progressive renal
disease
Maternal
thromboembolism
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Miscarriages(before 20 weeks) is the most
common form, averaging about 20%
Stillbirths are especially increased in Lupus 11%
Neonatal lupus and death due to CHB
because of Anti Ro and Anti La antibodies
APS related repeated pregnancy failures
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Increased lupus activity at conception or
during pregnancy
Hypertension
Hypocomplementaemia
Renal disease
Gestational Lupus
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Spontaneous abortions
IUGR
Preterm delivery
postpartum haemorrhage
maternal venous thromboembolism
Neonatal death due to fetal heart block
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High blood pressure in the mother after 20
weeks of pregnancy
Occurs in ~13% of women w/ SLE
Tx: DELIVERY
Delivery may be delayed in some women who
are less than 34 weeks to give steroids for
lung maturity
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Occurs in about 2% of babies born to mothers with
anti-Ro/SSA and or anti-La/SSB antibodies
Caused by passage of the antibodies from the
mother’s bloodstream across the placenta to the
developing baby after about 20 weeks
Signs of neonatal lupus includes red, raised rash on
the scalp and around the eyes that resolves by 6-8
months (because the antibodies clear the blood
stream)
SLE complications in babies: complete heart block
and learning disabilities
Risk of neonatal lupus in subsequent pregnancy is
17%
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Fetal bradycardia should be investigated
looking for maternal Anti Ro antibodies as
mothers may be asymptomatic or may
develop lupus later
All suspected neonates should have an ECG
as CHB recquires permanent pacing
Subsequent pregnancies have more risk of
neonatal lupus
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Lupus flares are seen in all trimesters
In mild to moderate lupus, 40% show no
change, 40% flare and 20% improve
Flares are more common when disease is
active at conception
Renal flares are most feared
Postpartum flares are common as beneficial
effect of steroid produced by placenta wears
off
The pattern of the diseases activity is usually
repeated in subsequent pregnancies
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Musculoskeletal and cutaneous flares are
common and easier to manage by increasing
the dose of prednisolone
IV Methylprednisolone may be required for
severe flares
Use or continuation of Azathioprine is
allowed
HCQ not to be discontinued as it is seen to
cause flares
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Low, but higher than general population
Lupus related deaths are due to
HELLP Syndrome
Thromboembolism associated with APS
Pulmonary hypertension
Infection following severe lupus flare
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Chloasma or malar rash
Proteinuria of pre-eclampsia or worsening
lupus nephritis
Thrombocytopenia in pregnancy (HELLP) or
that of lupus exacerbation
oedema and fluid accumulation in joints in
late pregnancy or arthritis of SLE
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Prenatal counseling
Frequent antenatal check up
Monitoring of disease activity-CBC, monthly
urine analysis, monthly complements
Fetal surveillance by frequent ultrasound
Patients may need anticoagulation
Combined care: Rheumatologist, Obstretitian
and Nephrologist if required
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Lupus patients are normally fertile
Lupus pregnancies are successful two thirds
of the time
Mild to moderate lupus does quite well in
pregnancy
Steroids are safe for exacerbation of lupus in
pregnancy
Hydroxychloroquine should not be stopped in
pregnancy
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