Systemic lupus erythematosus and pregnancy
Encyclopedia
For women with systemic lupus erythematosus
(SLE), pregnancy
can present some particular challenges for both mother and child.
While most infants born to mothers who have SLE are healthy, pregnant mothers with SLE should remain under medical care until delivery. In general, women with SLE and, in addition, hypertension
, proteinuria
, and azotemia
have an extra increased risk for pregnancy complications. Pregnancy outcomes in women with SLE who receive renal transplants are similar to those of transplant recipients without SLE.
Women pregnant and known to have anti-Ro (SSA) or anti-La antibodies (SSB) often have echocardiograms during the 16th and 30th weeks of pregnancy to monitor the health of the heart and surrounding vasculature.
Contraception
and other reliable forms of pregnancy prevention is routinely advised for women with SLE, since getting pregnant during active disease was found to be harmful. Lupus nephritis
was the most common manifestation.
Of life births, approximately one third are delivered prematurely
.
Miscarriage in the first trimester appear either to have no known cause or to be associated with signs of active SLE. Later losses appear to occur primarily due to the antiphospholipid syndrome
, in spite of treatment with heparin
and aspirin
. All women with lupus, even those without previous history of miscarriage, are recommended to be screened for antiphospholipid antibodies, both the lupus anticoagulant
(the RVVT and sensitive PTT are the best screening battery) and anticardiolipin antibodies.
born from a mother with SLE, most commonly presenting with a rash resembling discoid lupus erythematosus
, and sometimes with systemic abnormalities such as heart block
or hepatosplenomegaly
. Neonatal lupus is usually benign and self-limited. Still, identification of mothers at highest risk for complications allows for prompt treatment before or after birth. In addition, SLE can flare up during pregnancy, and proper treatment can maintain the health of the mother longer.
, prolactin
, and certain cytokines. However, a long time of remission before pregnancy decreases the risk of aggravation, with an incidence of 7-33% in women who have been in remission for at least 6 months, and an incidence of 61-67% in women who have active SLE at the time of conception.
Renal disease flare-up is the most common presentation of SLE aggravation in pregnancy, and is seen equally in United States and European populations. Serositis with pleural and pericardial effusions are seen in up to 10% of these patients.
On the other hand, flares of SLE are uncommon during pregnancy and are often easily treated. The most common symptoms of these flares include arthritis
, rash
es, and fatigue
.
Also, in the postpartum period, there may be exacerbations of SLE sue to decreased levels of anti-inflammatory steroids, elevated levels of prolactin
and estrogen
and progesterone
changes.
In diagnosing an aggravation of SLE in pregnancy, there need to be a differential diagnosis
from SLE-unrelated complications of pregnancy
that may appear in a similar fashion. For example, chloasma may appear like the malar rash
of SLE, proteinuria
from preeclampsia may appear like that of lupus nephritis
, thrombocytopenia of the HELLP syndrome
may appear like that of SLE, and pregnancy-related edema of joints can appear like arthritis of SLE.
s at the lowest effective dose and/or cautious use of azathioprine
may be preferred in some patients, but needs to be weighed against potential adverse effects of such medications.
Systemic lupus erythematosus
Systemic lupus erythematosus , often abbreviated to SLE or lupus, is a systemic autoimmune disease that can affect any part of the body. As occurs in other autoimmune diseases, the immune system attacks the body's cells and tissue, resulting in inflammation and tissue damage...
(SLE), pregnancy
Pregnancy
Pregnancy refers to the fertilization and development of one or more offspring, known as a fetus or embryo, in a woman's uterus. In a pregnancy, there can be multiple gestations, as in the case of twins or triplets...
can present some particular challenges for both mother and child.
While most infants born to mothers who have SLE are healthy, pregnant mothers with SLE should remain under medical care until delivery. In general, women with SLE and, in addition, hypertension
Hypertension
Hypertension or high blood pressure is a cardiac chronic medical condition in which the systemic arterial blood pressure is elevated. What that means is that the heart is having to work harder than it should to pump the blood around the body. Blood pressure involves two measurements, systolic and...
, proteinuria
Proteinuria
Proteinuria means the presence of anexcess of serum proteins in the urine. The protein in the urine often causes the urine to become foamy, although foamy urine may also be caused by bilirubin in the urine , retrograde ejaculation, pneumaturia due to a fistula, or drugs such as pyridium.- Causes...
, and azotemia
Azotemia
Azotemia is a medical condition characterized by abnormally high levels of nitrogen-containing compounds, such as urea, creatinine, various body waste compounds, and other nitrogen-rich compounds in the blood...
have an extra increased risk for pregnancy complications. Pregnancy outcomes in women with SLE who receive renal transplants are similar to those of transplant recipients without SLE.
Women pregnant and known to have anti-Ro (SSA) or anti-La antibodies (SSB) often have echocardiograms during the 16th and 30th weeks of pregnancy to monitor the health of the heart and surrounding vasculature.
Contraception
Contraception
Contraception is the prevention of the fusion of gametes during or after sexual activity. The term contraception is a contraction of contra, which means against, and the word conception, meaning fertilization...
and other reliable forms of pregnancy prevention is routinely advised for women with SLE, since getting pregnant during active disease was found to be harmful. Lupus nephritis
Lupus nephritis
Lupus nephritis is an inflammation of the kidney caused by systemic lupus erythematosus , a disease of the immune system. Apart from the kidneys, SLE can also damage the skin, joints, nervous system and virtually any organ or system in the body....
was the most common manifestation.
Of life births, approximately one third are delivered prematurely
Premature birth
In humans preterm birth refers to the birth of a baby of less than 37 weeks gestational age. The cause for preterm birth is in many situations elusive and unknown; many factors appear to be associated with the development of preterm birth, making the reduction of preterm birth a challenging...
.
Miscarriage
SLE causes an increased rate of fetal death in utero and spontaneous abortion (miscarriage). The overall live-birth rate in SLE patient has been estimated to be 72%. Pregnancy outcome appears to be worse in SLE patients whose disease flares up during pregnancy.Miscarriage in the first trimester appear either to have no known cause or to be associated with signs of active SLE. Later losses appear to occur primarily due to the antiphospholipid syndrome
Antiphospholipid syndrome
Antiphospholipid syndrome or antiphospholipid antibody syndrome , often also Hughes syndrome, is an autoimmune, hypercoagulable state caused by antibodies against cell-membrane phospholipids that provokes blood clots in both arteries and veins as well as pregnancy-related complications such as...
, in spite of treatment with heparin
Heparin
Heparin , also known as unfractionated heparin, a highly sulfated glycosaminoglycan, is widely used as an injectable anticoagulant, and has the highest negative charge density of any known biological molecule...
and aspirin
Aspirin
Aspirin , also known as acetylsalicylic acid , is a salicylate drug, often used as an analgesic to relieve minor aches and pains, as an antipyretic to reduce fever, and as an anti-inflammatory medication. It was discovered by Arthur Eichengrun, a chemist with the German company Bayer...
. All women with lupus, even those without previous history of miscarriage, are recommended to be screened for antiphospholipid antibodies, both the lupus anticoagulant
Lupus anticoagulant
Lupus anticoagulant is an immunoglobulin that binds to phospholipids and proteins associated with the cell membrane. It is important to note that this disease name is actually a misnomer...
(the RVVT and sensitive PTT are the best screening battery) and anticardiolipin antibodies.
Neonatal lupus
Neonatal lupus is the occurrence of SLE symptoms in an infantInfant
A newborn or baby is the very young offspring of a human or other mammal. A newborn is an infant who is within hours, days, or up to a few weeks from birth. In medical contexts, newborn or neonate refers to an infant in the first 28 days after birth...
born from a mother with SLE, most commonly presenting with a rash resembling discoid lupus erythematosus
Discoid lupus erythematosus
Discoid lupus erythematosus is an uncommon autoimmune disease of the basal cell layer of the skin. It occurs in humans and cats, more frequently occurring in dogs. It does not progress to systemic lupus erythematosus in dogs. SLE can also have skin symptoms, but it appears that the two are...
, and sometimes with systemic abnormalities such as heart block
Heart block
A heart block can be a blockage at any level of the electrical conduction system of the heart .* Blocks that occur within the sinoatrial node are described as SA nodal blocks....
or hepatosplenomegaly
Hepatosplenomegaly
Hepatosplenomegaly is the simultaneous enlargement of both the liver and the spleen . Hepatosplenomegaly can occur as the result of acute viral hepatitis or infectious mononucleosis, or it can be the sign of a serious and life threatening lysosomal storage disease...
. Neonatal lupus is usually benign and self-limited. Still, identification of mothers at highest risk for complications allows for prompt treatment before or after birth. In addition, SLE can flare up during pregnancy, and proper treatment can maintain the health of the mother longer.
Aggravation of SLE
Aggravation (or exacerbation) of SLE has been estimated to occur in about 20-30% pregnancies where the mother has SLE. Increased disease activity of SLE is expected during pregnancy because of increased levels of estrogenEstrogen
Estrogens , oestrogens , or œstrogens, are a group of compounds named for their importance in the estrous cycle of humans and other animals. They are the primary female sex hormones. Natural estrogens are steroid hormones, while some synthetic ones are non-steroidal...
, prolactin
Prolactin
Prolactin also known as luteotropic hormone is a protein that in humans is encoded by the PRL gene.Prolactin is a peptide hormone discovered by Henry Friesen...
, and certain cytokines. However, a long time of remission before pregnancy decreases the risk of aggravation, with an incidence of 7-33% in women who have been in remission for at least 6 months, and an incidence of 61-67% in women who have active SLE at the time of conception.
Renal disease flare-up is the most common presentation of SLE aggravation in pregnancy, and is seen equally in United States and European populations. Serositis with pleural and pericardial effusions are seen in up to 10% of these patients.
On the other hand, flares of SLE are uncommon during pregnancy and are often easily treated. The most common symptoms of these flares include arthritis
Arthritis
Arthritis is a form of joint disorder that involves inflammation of one or more joints....
, rash
Rash
A rash is a change of the skin which affects its color, appearance or texture. A rash may be localized in one part of the body, or affect all the skin. Rashes may cause the skin to change color, itch, become warm, bumpy, chapped, dry, cracked or blistered, swell and may be painful. The causes, and...
es, and fatigue
Fatigue
Fatigue may refer to:*Fatigue , structural damage from repeated loading*Fatigue , a state of physical and/or mental weakness*Fatigue , safety implications of tiredness...
.
Also, in the postpartum period, there may be exacerbations of SLE sue to decreased levels of anti-inflammatory steroids, elevated levels of prolactin
Prolactin
Prolactin also known as luteotropic hormone is a protein that in humans is encoded by the PRL gene.Prolactin is a peptide hormone discovered by Henry Friesen...
and estrogen
Estrogen
Estrogens , oestrogens , or œstrogens, are a group of compounds named for their importance in the estrous cycle of humans and other animals. They are the primary female sex hormones. Natural estrogens are steroid hormones, while some synthetic ones are non-steroidal...
and progesterone
Progesterone
Progesterone also known as P4 is a C-21 steroid hormone involved in the female menstrual cycle, pregnancy and embryogenesis of humans and other species...
changes.
In diagnosing an aggravation of SLE in pregnancy, there need to be a differential diagnosis
Differential diagnosis
A differential diagnosis is a systematic diagnostic method used to identify the presence of an entity where multiple alternatives are possible , and may also refer to any of the included candidate alternatives A differential diagnosis (sometimes abbreviated DDx, ddx, DD, D/Dx, or ΔΔ) is a...
from SLE-unrelated complications of pregnancy
Complications of pregnancy
Complications of pregnancy are the symptoms and problems that are associated with pregnancy. There are both routine problems and serious, even potentially fatal problems. The routine problems are normal complications, and pose no significant danger to either the woman or the fetus...
that may appear in a similar fashion. For example, chloasma may appear like the malar rash
Malar rash
In medicine, malar rash , also called butterfly rash, is a medical sign consisting of a characteristic form of facial rash. It is often seen in Lupus erythematosus but is not pathognomonic - it is also seen in other diseases such as Pellagra, dermatomyositis and Bloom Syndrome.The malar rash of...
of SLE, proteinuria
Proteinuria
Proteinuria means the presence of anexcess of serum proteins in the urine. The protein in the urine often causes the urine to become foamy, although foamy urine may also be caused by bilirubin in the urine , retrograde ejaculation, pneumaturia due to a fistula, or drugs such as pyridium.- Causes...
from preeclampsia may appear like that of lupus nephritis
Lupus nephritis
Lupus nephritis is an inflammation of the kidney caused by systemic lupus erythematosus , a disease of the immune system. Apart from the kidneys, SLE can also damage the skin, joints, nervous system and virtually any organ or system in the body....
, thrombocytopenia of the HELLP syndrome
HELLP syndrome
HELLP syndrome is a life-threatening obstetric complication usually considered to be a variant of pre-eclampsia. Both conditions usually occur during the later stages of pregnancy, or sometimes after childbirth.HELLP is an abbreviation of the main findings:...
may appear like that of SLE, and pregnancy-related edema of joints can appear like arthritis of SLE.
General preventive measures
Continuing glucocorticoidGlucocorticoid
Glucocorticoids are a class of steroid hormones that bind to the glucocorticoid receptor , which is present in almost every vertebrate animal cell...
s at the lowest effective dose and/or cautious use of azathioprine
Azathioprine
Azathioprine is a purine analogue immunosuppressive drug. It is used to prevent organ rejection following organ transplantation and to treat a vast array of autoimmune diseases, including rheumatoid arthritis, pemphigus, inflammatory bowel disease , multiple sclerosis, autoimmune hepatitis, atopic...
may be preferred in some patients, but needs to be weighed against potential adverse effects of such medications.
External links
- Systemic Lupus Erythematosus and Pregnancy at Medscape. Author: Ritu Khurana. Chief Editor: David Chelmow.