Dr. Anupama Kumar Consultant

Rheumatologist Sagar Hospital, Bangalore

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

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

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

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

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

Fatigue and fevers Arthritis or arthralgias Malar rash Serositis Raynaud’s phenomenon Proteinuria Vasculitis Leukopenia Thrombocytopenia Seizures

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

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

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

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

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

Increased lupus activity at conception or during pregnancy

Hypertension Hypocomplementaemia

Renal disease Gestational Lupus

Spontaneous abortions IUGR Preterm delivery postpartum haemorrhage maternal venous thromboembolism Neonatal death due to fetal heart block

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

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%

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

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

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

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

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

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

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