Systemic lupus erythematosus (SLE) In Pregnancy | Dr N Layyous

Systemic lupus erythematosus (SLE) In Pregnancy

Systemic lupus erythematosus (SLE) is a chronic inflammatory, autoimmune disease that can affect various organs of the body. Characterized by production of antibodies to components of cell nucleus.

• Who’s affected:
  • Young women, peak incidence age 15-40 years with female: male ratio 5:1
  • African Americans have higher lupus mortality risk compared to Hispanics and Caucasians
• Causes Of Systemic lupus erythematosus (SLE)
  • Unknown
  • Genetic factors
  • Environmental factors, which may include:
    • Sunlight (UV rays)
    • Stress
  • Viral or other type of infection
  • Drugs
    • There are drugs that cause Drug Induced Lupus
    • Most common : Hydralazine, Procainamide, and Isoniazid
• Pathogenesis Of Systemic lupus erythematosus (SLE)
  • central immunologic disturbance is autoantibody production
  • Antinuclear antibodies (ANA) found in >95% :
    • anti-SSA (anti-Ro)
    • anti-dsDNA and anti-Sm specific to SLE
    • anti-ssDNA
    • Others: anti-histones (H1, H2A, H2B, H3),anti-U1RNP,anti-SS-B
• Organs involved
  • 90% joints
  • 80% skin, serous membranes, lungs
  • 67% kidneys, heart
  • 25% CNS, small vessels
• Risk factors of Systemic lupus erythematosus (SLE)
  • Genetic predisposition (i.e. black race, 25-50% monozygotic twin concordance, 5% dizygotic twin concordance)
  • Postmenopausal hormone replacement therapy increases the risk for developing SLE
  • Smoking increases the risk for SLE and ex-smokers have an increased risk for SLE
• Diagnosis of Systemic lupus erythematosus (SLE)
  • Diagnosis is clinical
  • Any 4 or more of 11 criteria
    1. Malar rash, fixed erythema, flat or raised.
    2. Discoid lupus , erythematous raised patches with adherent keratotic scaling .
    3. Photosensitivity , skin rash resulting from unusual reaction to sunlight
    4. Painless oral or nasopharyngeal ulcers.
    5. Non-erosive arthritis , involving 2 or more peripheral joints
    6. Serositis , pleuritis or pericarditis
    7. Renal involvement include persistent proteinuria or cellular casts
    8. Seizures or psychosis without other organic cause
    9. Hematologic disorder
       • Hemolytic anemia with reticulocytosis
       • WBC < 4,000 at least 2 times
       • Absolute lymphocyte count < 1,500/mm3 at least 2 times
       • Platelet count < 100,000/mm3 without thrombocytopenic drugs
    10. Immunologic disorder
        • Anti-DNA, in abnormal titer
        • Anti-Smith antibody
        • Positive finding of antiphospholipid antibodies based on
          • Abnormal serum level of IgG or IgM anticardiolipin antibodies
          • Positive lupus anticoagulant
          • False positive serologic test for syphilis for at least 6 months
    11. Positive ANA of abnormal titer in absence of drugs associated with "drug-induced lupus"
• Treatment of Systemic lupus erythematosus (SLE)
  • Prompt evaluation of unexplained fever
  • Lifestyle measures
  • Medications guided by specific symptoms
    • Nonsteroidal anti-inflammatory drugs
      • For constitutional symptoms, musculoskeletal symptoms and mild serositis
      • Caution regarding renal toxicity
    • Antimalarials
      • For skin manifestations and for musculoskeletal symptoms unresponsive to NSAIDs
      • Ophthalmologic monitoring recommended every 6-12 months
    • Corticosteroids
      • Topical steroids useful for skin manifestations
      • Systemic steroids may be needed for severe symptoms in any organ system
• Immunosuppressive agents
  • Used alone or with steroids
  • Particularly effective for renal and CNS symptoms
  • Low-dose methotrexate is effective for arthritis
    • Omega-3 fatty acids may be effective for SLE
      • Based on small randomized trial
      • Omega-3 fatty acid group had significant reductions from baseline in disease activity measures

Systemic lupus erythematosus (SLE) in Pregnancy

• There is no increase in infertility
• Outcome is best for mother and child when SLE has been controlled for at least 6 months prior to pregnancy
• Flares during pregnancy occur in 7-33%

Pregnancy Complications with Systemic lupus erythematosus (SLE)

• Preeclampsia
• Fetal Loss: Women with persistent high titers of antiphospholipid antibodies are at increased risk
  Women with lupus nephritis have increased risk of fetal loss by 75%
• Preterm Delivery
• Low Birth Weight Infant :Infant less than 2500g
• Deep Vein Thrombosis/Pulmonary Embolism :Risk of DVT and PE increases dramatically with SLEInfant less than 2500g

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 across the placenta to the developing baby after about 20 weeks
• Signs of neonatal lupus includes skin manifestations red, raised rash on the scalp and around the eyes that resolves by 6-8 months
• Complete heart block and learning disabilities
• Risk of neonatal lupus in subsequent pregnancy is 17%

Preparing for Pregnancy with Systemic lupus erythematosus (SLE)

• Discuss desire to have child with rheumatologist and Obstetrical doctor
• Follow-up with prenatal visits
  • After 28 weeks, visits will be weekly to asses fetal condition (. Biophysical profile and NST)
• Women with lupus nephritis should delay pregnancy until their disease is inactive for at least 6 months
• Discuss medication effects
• Women with SLE may need anticoagulation
  • Used in women with antiphospholipid syndrome
  • Low dose aspirin is safe
  • Increased rates of stillbirth has been shown with aspirin doses greater than 325 mg/day

Medications during Pregnancy for Systemic lupus erythematosus (SLE)

• Drugs to avoid immunosuppressant therapy
  • Mycophenolate mofetil
  • Cyclophosphamide
  • Methotrexate
  • Biologic medications
    • Etanerecpt, infliximab, anakinra
    • Until more data is available, these meds should be avoided
• Drugs with small risk of harm
  • Aspirin
  • Prednisone/Glucocorticoids
  • Azathioprine
  • NSAIDs
• Drugs that are probably safe
  • Antimalarials (Hydroxychloroquine)
  • No evidence that antimalarials increases risk of miscarriages or birth defects at normal doses
• Delivery in cases of Systemic lupus erythematosus (SLE):
  • Will need stress dose during active labor
• Breastfeeding in cases of Systemic lupus erythematosus (SLE):
  • Is recommended even for women with SLE
• Birth control in cases of Systemic lupus erythematosus (SLE):
  • IUD is effective
  • OCP can be used but should be avoided in women with the following:
• Migraine headaches
• Raynaud Phenomenon
• Past history DVT
• Presence of antiphospholipid antibodies
• Kidney disease and active SLE

Dr Najeeb Layyous F.R.C.O.G

Consultant Obstetrician, Gynecologist and Infertility Specialist