Challenges of sle and pregnancy

Challenges of SLE and pregnancy

Mahantesh Karoshi,

Consultant Obstetrician & Gynaecologist

Barnet General Hospital, London, UKBlog : http://labourwardexperiences.blogspot.co.uk/2013/06/sleinpregnancy.html

Systemic lupus erythematosus in Pregnancy

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• SLE is known to increase the risk of spontaneous miscarriage; it can also cause fetal growth restriction and increased rates of sudden intrauterine death, pre-eclampsia and preterm delivery

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Pre-pregnancy consultation

• The presence of anti-Ro/La and antiphospholipid antibodies should be determined.

• These antibodies are associated with congenital heart block and neonatal cutaneous lupus syndrome.

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• Antiphospholipid antibodies are present in about 30% of women with SLE and

• are associated with arterial and venous thrombosis, recurrent miscarriage, fetal growth restriction, fetal loss and preterm

• delivery due to uteroplacental insufficiency

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Pre-pregnancy consultation 2

• Quiescent disease, without associated antiphospholipid syndrome (APS), hypertension or renal involvement the risks of miscarriage/stillbirth and fetal growth restriction are not significantly increased

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• The risk of miscarriage and stillbirth in pregnancies complicated by lupus varies from 6–35% and from 0–22%

• The great concern are women with SLE and associated pulmonary arterial hypertension who wish to conceive: maternal mortality rates have been quoted as being as high as 33%

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• Patients should be advised not to conceive during a period of active disease, particularly with lupus nephritis, because of worse maternal and fetal outcomes

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• Counsel women with SLE for increased risk of pre-eclampsia, preterm delivery and fetal growth restriction

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• In active lupus nephritis with worsening renal function, increasing proteinuria and hypertension,it may be necessary to use treatments such as cyclophosphamide and mycophenolate mofetil, which are associated with congenital malformations if used in the first trimester,

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• Pregnant women with active SLE/lupus nephritis or anti- Ro/La/antiphospholipid antibodies should be considered as a higher risk group and managed in tertiary centre

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• For patients with stable disease, 4-weekly reviews of disease activity and regular assessment of fetal growth, blood pressure and proteinuria should be undertaken

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Pregnancy consultation 1

• For those women who are anti-Ro/La positive the fetal heart rate should be monitored and recorded at each visit and fetal echocardiography assessments made at 18–20 and ~28 weeks of gestation

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• Women who have had a previous venous thromboembolism should receive thromboprophylaxis with low molecular weight heparin throughout pregnancy and for 6 weeks postpartum

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• The risk of an SLE flare in pregnancy is increased with active disease in the 3–6 months prior to conception, with the majority of flares occurring after the 20th weeks of pregnancy

• Most flares are managed expectantly with medical management and adjustments to drug therapy

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• At every antenatal visit, measure the BP, test the urine for proteinuria, and quantify the proteinuria by PCR or 24 hour urine proetein estimation.

• The features of lupus nephritis include hypertension and proteinuria with or without haematuria and renal impairment

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• The presence of hematuria or red cell casts as well as a rise in anti-dsDNA titres or a fall in complement levels help to distinguish this from pre-eclampsia

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• In cases of lupus nephritis that fail to respond to increasing dosages of steroids and azathioprine, and where there is a deterioration of renal function and/or hypertension, other immunosuppressive drugs may be considered, such as mycophenolate mofetil or tacrolimus. Such management decisions should be undertaken in consultation with nephrologists and rheumatologists,

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• Premature rupture of membranes is also being more frequent in pregnancies complicated by SLE; rates vary and are generally quoted at ~20% and is common in women who are on steroids

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SLE and fetal risks

• Increased risks of congenital heart block, fetal growth restriction and increased rates of preterm delivery

• Scanning at least every 4 weeks to screen for fetal growth restriction in those women at risk is generally accepted and fetal echocardiography referral should be arranged for those with anti-Ro/La antibodie

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• Doppler studies can be used to estimate placental function A uterine artery Doppler should be first carried out at 20 weeks and repeated 4 weeks later if any abnormality is found A raised pulsatility index or diastolic notching are associated with increased risk for developing pre-eclampsia, as they can indicate underlying placental dysfunction

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SLE and fetal risks

• Congenital heart block is associated with maternal anti-Ro/La autoantibodies. usual presentation is a fixed fetal bradycardia of 60–80 beats per minute on ultrasound scan. It occurs in 2–3% of fetuses of women with the anti-Ro/La antibody CHB is associated with significant perinatal morbidity and mortality, with about half of infants requiring pacing by the first year of life.

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SLE and fetal risks

• Congenital heart block develops between 18– 28 weeks of gestation and fetal echocardiography should be performed around this period to detect it. Hydrops fetalis can occur in utero and is thought to be due to the degree of endomyocardial fibrosis and associated myocarditis.

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SLE and fetal risks

Drug treatment in pregnant SLE patient

• Glucocorticoids, mainly in the form of prednisolone, are frequently but not exclusively used as one of the first-line treatments in pregnancy Women on moderate to high dosages of steroids should should be screened regularly for gestational diabetes.

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• Immunosuppressants that are used and are generally considered safe during pregnancy include azathioprine and hydroxychloroquine. There is no need to discontinue them during pregnancy

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Drug treatment in pregnant SLE patient

•To consider thromboprophylaxis

•Manage hypertension

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Postpartum management

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Challenges of sle and pregnancy