Understanding and Managing Pregnancy in Patients with Lupus

Abstract

Systemic lupus erythematosus (SLE) is a chronic, multisystemic autoimmune disease that occurs predominantly in women of fertile age. The association of SLE and pregnancy, mainly with active disease and especially with nephritis, has poorer pregnancy outcomes, with increased frequency of preeclampsia, fetal loss, prematurity, growth restriction, and newborns small for gestational age. Therefore, SLE pregnancies are considered high risk condition, should be monitored frequently during pregnancy and delivery should occur in a controlled setting. Pregnancy induces dramatic immune and neuroendocrine changes in the maternal body in order to protect the fetus from immunologic attack and these modifications can be affected by SLE. The risk of flares depends on the level of maternal disease activity in the 6–12 months before conception and is higher in women with repeated flares before conception, in those who discontinue useful medications and in women with active glomerulonephritis at conception. It is a challenge to differentiate lupus nephritis from preeclampsia and, in this context, the angiogenic and antiangiogenic cytokines are promising. Prenatal care of pregnant patients with SLE requires close collaboration between rheumatologist and obstetrician. Planning pregnancy is essential to increase the probability of successful pregnancies.

Pregnancy and autoimmune connective tissue diseases

“…Contraindications to pregnancy for women with lupus in particular, and rheumatic connective tissue diseases in general, include pulmonary hypertension defined by a mean pulmonary artery pressure of ≥25 mm Hg at rest, measured during right heart catheterization [84,85], advanced heart failure, severe restrictive lung disease (FVC <1L), chronic renal failure (Cr > 2.8 mg/dL), previous severe preeclampsia or HELLP syndrome despite therapy with aspirin and heparin, stroke or severe lupus flare within the previous 6 months [86]. …”

An ever-challenging relationship: lupus and pregnancy

“…However, the pathogenic mechanisms which form the basis of the clinical manifestations during pregnancy or which have an influence on the pregnancy evolution in SLE are not completely understood. The most often incriminated causes are pregnancy-specific hormonal changes (mainly increased levels of estrogens and prolactin) [13]. …”

“…High concentrations of IL-17 have been found in females with SLE with pre-eclampsia and recurrent abortions [15]. Another important cytokine produced in excess in SLE is IL-10, which leads to continuous, excessive stimulation of B lymphocytes [13]. …”

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“…Although lupus and/or aPL-positive patients are not included in these studies, these patients are at increased the risk of preeclampsia (125). Thus, independent of aPL, several groups recommend LDA for all lupus patients, even without a history of pregnancy morbidity (117,118,(126)(127)(128); however, there are no clinical trials supporting this recommendation.…”