Systemic Lupus Erythematosus and Pregnancy:An Overview

1. Systemic Lupus Erythematosus and Pregnancy:An Overview Dr. Anupama Kumar Consultant Rheumatologist Sagar Hospital, Bangalore

2. Introduction • Biological prerogative of every woman • Pregnancy in lupus is not contraindicated • Many lupus patients deliver healthy babies • Many families at least want one child • Fertility is not affected in patients with lupus

3. Rash and Patchy Hairloss in SLE

5. SLE Overview • SLE is the most common autoimmune multisystemic disease to affect women in child-bearing years • Prognosis for both mother and baby have important implications during pregnancy • Marriage, pregnancy and childbirth are burning issues for most patients

6. SLE – a multi systemic disease

7. SLE Overview • Characterized by production of antibodies to cell nucleus called ANAs • Who is affected - 90% are young women 90% of them are in 20 to 40 years age group • More patients plan for pregnancy because of improved prognosis

8. Pregnancy Counseling • Pregnancy outcomes are good when lupus is in remission • Ideally lupus should be inactive for six months • Serious disease such as active lupus nephritis, myocarditis, seizures is a contra-indication • Teratogenic drugs like cyclophosphamide, methotrexate should be stopped six months before conception

9. Different Presentations • Lupus patients for pregnancy counseling • Known lupus cases coming for antenatal care • Undiagnosed or misdiagnosed lupus in pregnancy • Asymptomatic pregnant patients who have history of neonatal lupus or concerned antibodies

10. Diagnosis-Signs and Symptoms • Fatigue and fevers • Arthritis or arthralgias • Malar rash • Serositis • Raynaud’s phenomenon • Proteinuria • Vasculitis • Leukopenia • Thrombocytopenia • Seizures

11. Malar Rash in SLE

12. Facial Rash in SLE

13. Vasculitic Lesions on Hand

14. Investigations • Complete blood count • Anti Nuclear Antibodies by IF or HEP2 • Anti double stranded DNA antibodies • Anti Ro and Anti La antibodies • Complement studies-C3 AND C4 • Urine analysis • Renal function tests • Lupus anticoagulant and Anti cardiolipin antibodies

15. Risk Stratification • Mild risk cases-Mild disease, those who are in remission, on no medication except mild ones • High risk cases-Severe active disease. Major organ involvement,those with Anti Ro or APL antibodies • Moderate risk cases-Majority are in this group

16. What makes a Pregnancy High Risk in Lupus? • H/O Previous pregnancy with complication • Underlying kidney, heart or lung disease • Active phase of the disease • Presence of Anti Ro and Anti La antibodies • A history of previous thrombotic event • APLA • Additional factors like maternal age>40 years and pregnancy with twins or triplets

17. Pregnancy in Lupus-Working both Ways Risks of Lupus to pregnancy • Pregnancy loss • Preterm delivery • Eclampsia • Neonatal lupus due to Ro and La antibodies Risks of pregnancy to lupus • Lupus flares • Progressive renal disease • Maternal thromboembolism

18. Pregnancy Loss • Miscarriages(before 20 weeks) is the most common form, averaging about 20% • Stillbirths are especially increased in Lupus -11% • Neonatal lupus and death due to CHB because of Anti Ro and Anti La antibodies • APS related repeated pregnancy failures

19. Causes of Pregnancy Loss • Increased lupus activity at conception or during pregnancy • Hypertension • Hypocomplementaemia • Renal disease • Gestational Lupus

20. Adverse Pregnancy Outcomes • Spontaneous abortions • IUGR • Preterm delivery • postpartum haemorrhage • maternal venous thromboembolism • Neonatal death due to fetal heart block

21. Preeclampsia • High blood pressure in the mother after 20 weeks of pregnancy • Occurs in ~13% of women w/ SLE • Tx: DELIVERY • Delivery may be delayed in some women who are less than 34 weeks to give steroids for lung maturity

22. Neonatal Lupus • Occurs in about 2% of babies born to mothers with anti-Ro/SSA and or anti-La/SSB antibodies • Caused by passage of the antibodies from the mother’s bloodstream across the placenta to the developing baby after about 20 weeks • Signs of neonatal lupus includes red, raised rash on the scalp and around the eyes that resolves by 6-8 months (because the antibodies clear the blood stream) • SLE complications in babies: complete heart block and learning disabilities • Risk of neonatal lupus in subsequent pregnancy is 17%

23. Management of Neonatal lupus • Fetal bradycardia should be investigated looking for maternal Anti Ro antibodies as mothers may be asymptomatic or may develop lupus later • All suspected neonates should have an ECG as CHB recquires permanent pacing • Subsequent pregnancies have more risk of neonatal lupus

24. Neonatal Lupus

25. Effects of Pregnancy on Lupus • Lupus flares are seen in all trimesters • In mild to moderate lupus, 40% show no change, 40% flare and 20% improve • Flares are more common when disease is active at conception • Renal flares are most feared • Postpartum flares are common as beneficial effect of steroid produced by placenta wears off • The pattern of the diseases activity is usually repeated in subsequent pregnancies

26. Treatment of Flares in Pregnancy • Musculoskeletal and cutaneous flares are common and easier to manage by increasing the dose of prednisolone • IV Methylprednisolone may be required for severe flares • Use or continuation of Azathioprine is allowed • HCQ not to be discontinued as it is seen to cause flares

27. The Risk of Maternal Death • Low, but higher than general population • Lupus related deaths are due to • HELLP Syndrome • Thromboembolism associated with APS • Pulmonary hypertension • Infection following severe lupus flare

28. Differential Diagnosis • Chloasma or malar rash • Proteinuria of pre-eclampsia or worsening lupus nephritis • Thrombocytopenia in pregnancy (HELLP) or that of lupus exacerbation • oedema and fluid accumulation in joints in late pregnancy or arthritis of SLE

29. Prevention and Management • Prenatal counseling • Frequent antenatal check up • Monitoring of disease activity-CBC, monthly urine analysis, monthly complements • Fetal surveillance by frequent ultrasound • Patients may need anticoagulation • Combined care: Rheumatologist, Obstretitian and Nephrologist if required

30. Summing Up • Lupus patients are normally fertile • Lupus pregnancies are successful two thirds of the time • Mild to moderate lupus does quite well in pregnancy • Steroids are safe for exacerbation of lupus in pregnancy • Hydroxychloroquine should not be stopped in pregnancy