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Pregnancy in SLE

Fast Facts

• Fertility is usually normal in SLE, although disease activity and certain drugs can contribute to menstrual disorders.
• Planning before pregnancy is important.
• The patient should have no signs or symptoms of SLE and be taking no medications for at least six months before she becomes pregnant.
• As SLE can flare during pregnancy, it is important for the patient to be under a doctor’s care during pregnancy.

Although pregnancy in Systemic Lupus Erythematosus (SLE) is considered high risk, most women with SLE carry their babies safely to the end of their pregnancy. However, it must be stressed that planning before pregnancy is important. Ideally, a woman should have no signs or symptoms of SLE and be taking no medications for at least six months before she becomes pregnant.

Problems during Pregnancy

It is important for the mother with SLE to be under a doctor’s care during pregnancy as frequency of flares is slightly higher in pregnant than in non-pregnant SLE patients, especially during the second and third trimester, and most commonly after the delivery of the baby. This is due to changes in hormonal levels during pregnancy, i.e., increased estrogen level. Kidney flares tend to pre-dominate while musculoskeletal flares seem to decrease. Prompt treatment will help to keep the mother healthy.

Some points to note:

• Women with SLE have a higher rate of miscarriage and premature births compared with the general population.
• Women who have antiphospholipid antibodies are at a greater risk of miscarriage in the second trimester because of their increased risk of blood clotting in the placenta.
• SLE patients with a history of kidney disease have a higher risk of pre-eclampsia (hypertension with a build-up of excess watery fluid in cells or tissues of the body).
• Pregnant women with SLE, especially those taking corticosteroids, are also more likely to develop high blood pressure, diabetes, hyperglycemia (high blood sugar), and kidney complications, so regular care and good nutrition during pregnancy are essential.
• It is advisable to have access to a neonatal (newborn) intensive care unit at the time of delivery in case the baby requires special medical attention.

Monitoring during Pregnancy
In women with stable kidney disease before the pregnancy, the pregnancy does not jeopardise kidney function in the long term. However, SLE kidney disorder may manifest for the first time in pregnancy. Doctors must take note that lupus flares may be difficult to diagnose during pregnancy since many of the features may also occur in normal pregnancy.

Monthly follow-ups are best done in combined (obstetric and medical) clinics. History and physical examination remains the mainstay of monitoring disease activity in pregnancy. Early control of disease activity is essential. Initial assessment involves:

• Testing for anti-Ro and anti-La antibodies
• Testing for antiphospholipid antibodies for those with past pregnancy losses.

Management of Lupus Pregnancy

Medications which can be used during pregnancy are:

• Aspirin or non-steroidal anti-inflammatory drugs (NSAIDs) which are used in the relief of joint or muscle pain. NSAIDs other than aspirin should be avoided in the second and third trimester.
• Anti-malarials such as Plaquenil which is useful for those with skin and joint disease.
• Low-dose prednisolone. As pregnancies should be planned only when the disease is under control, most patients are already be on low-dose prednisolone by the time they become pregnant. As there are certain risks of gestational diabetes and hypertension, doctors should try to keep the prednisolone below the 10mg daily level.

In the event of a lupus flare, intravenous methylprednisolone can be used. However, cyclophosphamide should be avoided because of its association with birth defects.

Decision to Terminate the Pregnancy
Doctors take into consideration the following factors:

• Is the mother’s health likely to deteriorate irreversibly if pregnancy continues?
• Is the baby likely to grow better delivered than in the womb?

Maternal complications are more often pregnancy related than lupus related. Vaginal or Caesarian section is an obstetric decision. Specific lupus issues rarely determine the delivery route, though they may upgrade urgency for operation.

Post-Partum Period
It is advisable to continue steroid medication for two to three months after the post-partum period (six weeks after delivery) if there was active SLE throughout the pregnancy. Care should be taken as flares are most frequent in the second and third trimester and the post-partum period. It would be useful to alert the neonatology staff about the new mother’s anti-Ro and anti-La status.

Breast Feeding
SLE patients can breastfeed. Generally very little steroid is transmitted to breast milk, especially when the patient is on low-dose prednisolone. The neonatal effect of using 20mg prednisolone daily or less is insignificant. The exposure of the baby to steroids can be further minimised by breastfeeding just prior to taking the prednisolone. Anti-coagulants such as heparin are safe, while cytotoxics such as cyclophosphamide are not safe.

Neonatal Lupus
This is a rare disorder that can occur in newborn babies in which auto-antibodies in the mother’s blood called anti-Ro and anti-La are thought to have the potential effect of skin rashes and to injure fetal heart conduction tissue. There are usually skin rashes during the first to third months after birth, which disappear without treatment after about six months. In those rare cases (less than 2%) where there is congenital heart block, the condition is usually irreversible and the baby may require a pacemaker.

Antiphospholipid Syndrome
A syndrome characterised by “sticky blood” was described by Dr Graham Hughes in 1983, and is associated with the presence of circulating antibodies against phospholipids. Two tests are usually requested – anti-cardiolipin antibody and lupus anti-coagulant. The major features of Antiphospholipid Syndrome are:

• Vein thrombosis, i.e. arm vein thrombosis, thrombosis in the eye, leg vein thrombosis, and thrombosis of the veins of the brain.
• Arterial thrombosis, i.e. leg artery clots or heart attack.
• Recurrent miscarriage.

Other features are low platelet count, blotchy skin rash, migraine, and positive blood tests for antiphospholipid antibodies.

For patients with Antiphospholipid Syndrome, pregnancy loss is most typically in the second trimester. Treatment is with aspirin plus heparin. Heparin is stopped at the time the patient goes into labour but is resumed after delivery. The greatest thrombotic risk to mother is during the post-partum period.

Childhood
Although there are few long-term follow-up studies of children born to SLE mothers, there seem to be very little risk of SLE in the children born to patients. Male children seemingly had more learning disabilities compared with female children.

Conclusion

Successful pregnancy is now achievable by women with SLE. You do not have to deny yourself the happiness of being a mother, but be aware of the situation and take special care during and after your pregnancy. Be sensible and follow your doctor’s advice as to when it is safe to get pregnant.