Maternal systemic lupus erythematosus

Although SLE does not affect the fertility of a woman, pregnancies for patients with lupus is associated with increased risks of early miscarriage, intrauterine fetal death, pre-eclampsia, intrauterine growth restriction, and preterm delivery (1).

• several factors such as lupus nephritis, hypertension, antiphospholipid antibodies, and active disease may increase the probability of adverse outcome (2)

Exacerbations of systemic lupus erythematosus (SLE) are commoner during pregnancy and the puerperium

• in general, exacerbations are mild to moderate (often involving dermatological manifestations)
• likelihood of a flare is also increased antenatally or in the puerperium.
  • a prospective case-control study demonstrated that a flare of the disease was present in 65% of the patients who were pregnant compared with 42% of those who were not pregnant during the same time period (1)
  • renal flares are commonly seen in women with active disease at conception than in those in remission (2)

Pregnancy outcome is especially affected in patients with SLE associated renal disease (1).

• increased risk of fetal loss, pre-eclampsia, and intrauterine growth restriction is seen even in inactive renal lupus (2)
  • one study suggested that in pregnant women with SLE and renal disease, changes in renal disease activity and deterioration in renal function were similar to that in non-pregnant patients with lupus nephritis (2)
• only 50% of patients with SLE glomerulonephritis and a raised creatinine (> 130 micromol/L) prior to conception achieve a live birth.
• methyl dopa and hydralazine are used in pre-eclampsia

Pregnant women with SLE are also at an increased risk of maternal thrombosis (venous and arterial)

• this is usually associated with the presence of antiphospholipid antibodies
• low-dose aspirin and low-molecular weight heparin are now the treatment of choice for women with antiphospholipid syndrome and a history of miscarriage
  • the use of combined unfractionated heparin and aspirin may reduce pregnancy loss by 54% in patients with antiphospholipid antibody or lupus anticoagulant (3)

Reference:

• (1) Mackillop LH, Germain SJ, Nelson-Piercy C.Systemic lupus erythematosus. BMJ. 2007;335(7626):933-6.
• (2) D'Cruz DP, Khamashta MA, Hughes GR.Systemic lupus erythematosus. Lancet. 2007;369(9561):587-96.
• (3) Empson M et al. Prevention of recurrent miscarriage for women with antiphospholipid antibody or lupus anticoagulant. Cochrane Database Syst Rev 2005;2:CD002859