Lupus and pregnancy

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Lupus and pregnancy can present some particular challenges for both mother and child.

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While most infants born to mothers who have lupus are healthy, mothers with lupus as a pre-existing disease in pregnancy should remain under medical care until delivery. [1] In general, women with lupus and, in addition, hypertension, proteinuria, and azotemia have an extra increased risk for pregnancy complications, [2] [3] including miscarriage, stillbirth, pre-eclampsia, preterm birth, and intrauterine growth restriction. [4] Pregnancy outcomes in women with lupus who receive kidney transplants are similar to those of transplant recipients without lupus. [2]

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. [5]

Contraception and other reliable forms of pregnancy prevention is routinely advised for women with lupus, since getting pregnant during active disease was found to be harmful. Lupus nephritis was the most common manifestation.

Of live births, approximately one third are delivered prematurely. [2]

Miscarriage

Lupus causes an increased rate of fetal death in utero and spontaneous abortion (miscarriage). The overall live-birth rate in somebody with lupus has been estimated to be 72%. [6] Pregnancy outcome appears to be worse in those with lupus whose disease flares up during pregnancy. [7]

Miscarriages in the first trimester appear either to have no known cause or to be associated with signs of active lupus. [8] Later losses appear to occur primarily due to the antiphospholipid syndrome, in spite of treatment with heparin and aspirin. [8] 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. [8]

Neonatal lupus

Neonatal lupus is the occurrence of lupus symptoms in an infant born from a mother with lupus, most commonly presenting with a rash resembling discoid lupus erythematosus, and sometimes with systemic abnormalities such as heart block or hepatosplenomegaly. [9] Neonatal lupus is usually benign and self-limited. [9] Still, identification of mothers at highest risk for complications allows for prompt treatment before or after birth. In addition, lupus can flare up during pregnancy, and proper treatment can maintain the health of the mother for longer. [10]

Aggravation of lupus

Aggravation (or exacerbation) of lupus has been estimated to occur in about 20-30% pregnancies where the mother has lupus. [2] Increased disease activity of lupus is expected during pregnancy because of increased levels of estrogen, prolactin, and certain cytokines. [2] However, a long time of remission before pregnancy decreases the risk of aggravation, [11] 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 lupus at the time of conception. [2]

Renal disease flare-up is the most common presentation of lupus aggravation in pregnancy, and is seen equally in United States and European populations. [2] Serositis with pleural and pericardial effusions are seen in up to 10% of these patients. [2]

On the other hand, flares of lupus are uncommon during pregnancy and are often easily treated. [2] The most common symptoms of these flares include arthritis, rashes, and fatigue. [2]

Also, in the postpartum period, there may be exacerbations of lupus due to decreased levels of anti-inflammatory steroids, elevated levels of prolactin and estrogen and progesterone changes. [2]

In diagnosing an aggravation of lupus in pregnancy, there need to be a differential diagnosis from lupus-unrelated complications of pregnancy that may appear in a similar fashion. For example, chloasma may appear like the malar rash of lupus, proteinuria from preeclampsia may appear like that of lupus nephritis, thrombocytopenia of the HELLP syndrome may appear like that of lupus, and pregnancy-related edema of joints can appear like arthritis of lupus. [2]

General preventive measures

Continuing glucocorticoids 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. [2]

Related Research Articles

<span class="mw-page-title-main">Antiphospholipid syndrome</span> Medical condition

Antiphospholipid syndrome, or antiphospholipid antibody syndrome, is an autoimmune, hypercoagulable state caused by antiphospholipid antibodies. APS can lead to blood clots (thrombosis) in both arteries and veins, pregnancy-related complications, and other symptoms like low platelets, kidney disease, heart disease, and rash. Although the exact etiology of APS is still not clear, genetics is believed to play a key role in the development of the disease. Diagnosis is made based on symptoms and testing, but sometimes research criteria is used to aid in diagnosis. The research criteria for definite APS requires one clinical event and two positive blood test results spaced at least three months apart that detect lupus anticoagulant, anti-apolipoprotein antibodies, and/or anti-cardiolipin antibodies.

<span class="mw-page-title-main">Nephritis</span> Inflammation of the kidneys

Nephritis is inflammation of the kidneys and may involve the glomeruli, tubules, or interstitial tissue surrounding the glomeruli and tubules. It is one of several different types of nephropathy.

<span class="mw-page-title-main">Antinuclear antibody</span> Autoantibody that binds to contents of the cell nucleus

Antinuclear antibodies are autoantibodies that bind to contents of the cell nucleus. In normal individuals, the immune system produces antibodies to foreign proteins (antigens) but not to human proteins (autoantigens). In some cases, antibodies to human antigens are produced.

Lupus anticoagulant is an immunoglobulin that binds to phospholipids and proteins associated with the cell membrane. Its name is a partial misnomer, as it is actually a prothrombotic antibody in vivo. Lupus anticoagulant in living systems causes a decrease in clotting time. The name derives from their properties in vitro, as these antibodies increase coagulation times in laboratory tests such as the activated partial thromboplastin time (aPTT). Investigators speculate that the antibodies interfere with phospholipids used to induce in vitro coagulation. In vivo, the antibodies are thought to interact with platelet membrane phospholipids, increasing adhesion and aggregation of platelets, which accounts for the in vivo prothrombotic characteristics.

<span class="mw-page-title-main">Lupus nephritis</span> Inflammation of the kidneys

Lupus nephritis is an inflammation of the kidneys caused by systemic lupus erythematosus (SLE), an autoimmune disease. It is a type of glomerulonephritis in which the glomeruli become inflamed. Since it is a result of SLE, this type of glomerulonephritis is said to be secondary, and has a different pattern and outcome from conditions with a primary cause originating in the kidney. The diagnosis of lupus nephritis depends on blood tests, urinalysis, X-rays, ultrasound scans of the kidneys, and a kidney biopsy. On urinalysis, a nephritic picture is found and red blood cell casts, red blood cells and proteinuria is found.

Palindromic rheumatism (PR) is a syndrome characterised by recurrent, self-resolving inflammatory attacks in and around the joints, and consists of arthritis or periarticular soft tissue inflammation. The course is often acute onset, with sudden and rapidly developing attacks or flares. There is pain, redness, swelling, and disability of one or multiple joints. The interval between recurrent palindromic attacks and the length of an attack is extremely variable from few hours to days. Attacks may become more frequent with time but there is no joint damage after attacks. It is thought to be an autoimmune disease, possibly an abortive form of rheumatoid arthritis.

<span class="mw-page-title-main">Belimumab</span>

Belimumab, sold under the brand name Benlysta, is a human monoclonal antibody that inhibits B-cell activating factor (BAFF), also known as B-lymphocyte stimulator (BLyS). It is approved in the United States and Canada, and the European Union to treat systemic lupus erythematosus and lupus nephritis.

Ruplizumab is a humanized monoclonal antibody intended for the treatment of rheumatic diseases like systemic lupus erythematosus and lupus nephritis. A study showed that the drug was associated with life-threatening thromboembolisms, while another study only found thrombocytopenia.

<span class="mw-page-title-main">Anti-cardiolipin antibodies</span> Type of autoantibody

Anti-cardiolipin antibodies (ACA) are antibodies often directed against cardiolipin and found in several diseases, including syphilis, antiphospholipid syndrome, livedoid vasculitis, vertebrobasilar insufficiency, Behçet's syndrome, idiopathic spontaneous abortion, and systemic lupus erythematosus (SLE). They are a form of anti-mitochondrial antibody. In SLE, anti-DNA antibodies and anti-cardiolipin antibodies may be present individually or together; the two types of antibodies act independently. This is in contrast to rheumatoid arthritis with systemic sclerosis (scleroderma) because anti-cardiolipin antibodies are present in both conditions, and therefore may tie the two conditions together.

In autoimmune disease, anti-apolipoprotein H (AAHA) antibodies, also called anti-β2 glycoprotein I antibodies, comprise a subset of anti-cardiolipin antibodies and lupus anticoagulant. These antibodies are involved in sclerosis and are strongly associated with thrombotic forms of lupus. As a result AAHA are strongly implicated in autoimmune deep vein thrombosis.

<span class="mw-page-title-main">Lupus erythematosus</span> Human disease

Lupus erythematosus is a collection of autoimmune diseases in which the human immune system becomes hyperactive and attacks healthy tissues. Symptoms of these diseases can affect many different body systems, including joints, skin, kidneys, blood cells, heart, and lungs. The most common and most severe form is systemic lupus erythematosus.

Michael D. Lockshin is an American professor and medical researcher. He is known for his work as a researcher of autoimmune diseases, with focus on antiphospholipid syndrome and lupus. He is Professor Emeritus of Medicine and the Director Emeritus of the Barbara Volcker Center for Women and Rheumatic Disease at Hospital for Special Surgery. He retired from HSS on January 31st, 2023.

Neonatal lupuserythematosus is an autoimmune disease in an infant born to a mother with anti-Ro/SSA and with or without anti-La/SSB antibodies. The disease most commonly presents with a rash resembling subacute cutaneous lupus erythematosus and can have systemic abnormalities such as complete heart block or hepatosplenomegaly. Neonatal lupus is usually benign and self-limited. Many of the clinical manifestations are transient, but certain heart problems can be permanent. Diagnosis is based on maternal antibodies and clinical manifestations. Treatment and management is mainly supportive and focused on preventing complete heart block if possible.

<span class="mw-page-title-main">Lupus</span> Human autoimmune disease

Lupus, technically known as systemic lupus erythematosus (SLE), is an autoimmune disease in which the body's immune system mistakenly attacks healthy tissue in many parts of the body. Symptoms vary among people and may be mild to severe. Common symptoms include painful and swollen joints, fever, chest pain, hair loss, mouth ulcers, swollen lymph nodes, feeling tired, and a red rash which is most commonly on the face. Often there are periods of illness, called flares, and periods of remission during which there are few symptoms.

Lupus headache is a proposed, specific headache disorder in patients with systemic lupus erythematosus (SLE). Research shows that headache is a symptom commonly described by SLE patients —57% in one meta-analysis, ranging in different studies from 33% to 78%; of which migraine 31.7% and tension-type headache 23.5%. The existence of a special lupus headache is contested, although few high-quality studies are available to form definitive conclusions.

Diffuse proliferative glomerulonephritis (DPGN) is a type of glomerulonephritis that is the most serious form of renal lesions in SLE and is also the most common, occurring in 35% to 60% of patients. In absence of SLE, DPGN pathology looks more like Membranoproliferative glomerulonephritis

The Undifferentiated connective tissue disease (UCTD) is a disease in which the connective tissues are targeted by the immune system. It is a serological and clinical manifestation of an autoimmune disease. When there is proof of an autoimmune disease, it will be diagnosed as UCTD if the disease doesn't answer to any criterion of specific autoimmune disease. Such as systemic lupus erythematosus (SLE), la scleroderma, mixed connective tissue disease, Sjögren syndrome, systemic sclerosis, polymyositis, dermatomyositis, or the rheumatoid arthritis. This is also the case of major rheumatic diseases whose early phase was defined by LeRoy et al. in 1980 as undifferentiated connective tissue disease. The latent Lupus and the incomplete lupus are alternative terms used to describe this condition.

Ianalumab is a monoclonal antibody that is being investigated for autoimmune hepatitis, multiple sclerosis, pemphigus vulgaris, rheumatoid arthritis, Sjögren syndrome, and systemic lupus erythematosus.

James Steel Scott was a Scottish obstetrician and gynaecologist who was a pioneer in the field of reproductive immunology. He was Professor of Obstetrics and Gynaecology at the University of Leeds from 1961 to 1989.

<span class="mw-page-title-main">Congenital heart block</span> Medical condition

The congenital heart block (CHB) is the heart block that is diagnosed in fetus or within the first 28 days after birth, some studies also include the diagnosis during early childhood to the definition of CHB. It refers to the disorder in the electrical conduction system within the heart muscle, which leads to the failure in pumping the blood efficiently into the aorta and the pulmonary trunk. The result of CHB can be first, second, or third-degree (complete) atrioventricular block in which no electric signals move from the atrium to the ventricles

References

  1. ↑ "Planning a pregnancy when you have lupus | Lupus Foundation of America". www.lupus.org. Retrieved 2020-10-25.
  2. 1 2 3 4 5 6 7 8 9 10 11 12 13 Systemic Lupus Erythematosus and Pregnancy at Medscape. Author: Ritu Khurana. Chief Editor: David Chelmow. Updated: Sep 20, 2010
  3. ↑ "Planning a pregnancy when you have lupus | Lupus Foundation of America". www.lupus.org. Retrieved 2020-10-25.
  4. ↑ Baer AN, Witter FR, Petri M (2011). "Lupus and pregnancy". Obstet Gynecol Surv. 66 (10): 639–53. doi:10.1097/OGX.0b013e318239e1ee. PMID   22112525.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  5. ↑ "Handout on Health: Systemic Lupus Erythematosus". The National Institute of Arthritis and Musculoskeletal and Skin Diseases. National Institutes of Health. August 2003. Retrieved 2007-11-23.
  6. ↑ Smyth, Andrew; Guilherme H.M. Oliveira; Brian D. Lahr; Kent R. Bailey; Suzanne M. Norby; Vesna D. Garovic (November 2010). "A Systematic Review and Meta-Analysis of Pregnancy Outcomes in Patients with Systemic Lupus Erythematosus and Lupus Nephritis". Clinical Journal of the American Society of Nephrology. 5 (11): 2060–2068. doi:10.2215/CJN.00240110. PMC   3001786 . PMID   20688887 . Retrieved 20 April 2011.
  7. ↑ Cortés‐Hernández, J.; J. Ordi‐Ros; F. Paredes; M. Casellas; F. Castillo; M. Vilardell‐Tarres (June 2002). "Clinical predictors of fetal and maternal outcome in systemic lupus erythematosus: a prospective study of 103 pregnancies". Rheumatology. 41 (6): 643–650. doi: 10.1093/rheumatology/41.6.643 . PMID   12048290.
  8. 1 2 3 Lupus and Pregnancy by Michelle Petri. The Johns Hopkins Lupus Center. Retrieved May 2011
  9. 1 2 thefreedictionary.com > neonatal lupus Citing: Dorland's Medical Dictionary for Health Consumers. Copyright 2007
  10. ↑ "Pregnancy" . Retrieved 23 July 2017.
  11. ↑ "Praticar Exercicios Durante Gravidez". Barriga Sonho. 24 July 2017. Retrieved 6 September 2017.
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