Pregnancy at Lupus (SLE) 4.67/5 (3)

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Pregnancy in SLE

Pregnancy at Lupus / SLE carries some increased risk. Pre-pregnancy examinations are recommended. Pxhere CC0

Pregnancy & SLE

Definition

There is an increased risk of complications for both pregnant women and the fetus during pregnancy at SLE. However, this applies most to those who have some disease activity before and during pregnancy. If the disease is under good control, with no measurable disease activity, the risk of complications such as pre-eclampsia and early births is almost not increased (reference Crust CG, 2017).

  • Foreign data generally show that complications that can be severe occur collectively in approximately 15-20% of pregnancies (reference: Buyon J, 2015). Pregnancy at SLE is therefore classified as "risk aversion".

About one in three of women with SLE have antiphospholipid antibodies in their blood. It increases the risk of thrombosis og miscarriage considerable (antiphospholipid syndrome, APLS). Blood tests reveal risk. More about APLS and pregnancy here.

Although most people with SLE can perform normal pregnancies and births, precautions are essential. In general, the risk of complications is greatest in the first pregnancy and when the disease starts during pregnancy

Schedule of pregnancy at SLE

Pregnancy should be planned in a Calm and stable disease phase without disease activity in the last 6-12 months.

  • This is especially true if the blood, kidneys or other internal organs are attacked. The risk of recurrence of the disease, increased drug needs and complications during pregnancy is thus less
  • At least 3-6 months before pregnancy, the specialist should evaluate the disease activity, organ functions and whether any medications are appropriate for pregnancy.

Risk factors for pregnancy complications

  • Blood samples that show low Complement C3 or C4 or anti-DNA
  • Previous pregnancy complications
  • At ongoing SLE caused Kidney inflammation (lupus nephritis)
  • Women with Antiphospholipid syndrome (APLS) and SLE has increased blood clot and abortion risk (OR 12,1).
    • It is important to assess thrombocytopenic treatment either before pregnancy or as early as possible in pregnancy.
    • Albyl-E (75mg) and Fragmin, Klexane or Heparin can be used.
    • Warfarin must be replaced with another anticoagulant.
    • Previous blood clot (venous thrombosis) increases the risk (OR 3,6-12,7)
    • Own page about APLS and pregnancy here
  • If SSA (Ro) or SSB (La) Antibodies present, additional controls are recommended (see below)

Medication that Prednisone, Plaquenil og Azathioprine most often should not be terminated since drug arrest may trigger recurrence of the disease which is particularly unfavorable during pregnancy

  • Methotrexate (Ebetrex, Metex, Methotrexate) must be stopped at least 3 months before pregnancy as the drug may harm the fetus. Folic acid supplements (often given with Metotrexate treatment) should continue throughout pregnancy
  • Mycophenolate (CellCept, Myfortic) can harm the fetus. Treatment should be stopped at least 6 weeks prior to pregnancy
  • Blood pressure medications like ACE inhibitors (Enalapril, Renitec, Zestoretic Zanipress and others) and others it is often relevant to replace with other types suitable during pregnancy

Other risk factors that should be considered

More about medication during pregnancy here

Pregnancy is not recommended for the following complications

Follow-up during SLE pregnancy

SLE pregnancy is perceived as "Risk pregnancy". In addition For routine pregnancy checks at the GP, the follow-up may involve good cooperation between rheumatologist, maternity / outpatient clinic / pregnancy clinic and regular doctor.

  • Close follow-up of rheumatologist
    • Follow-up by rheumatologists can be routinely performed every 4 week, more often in case of unstable disease or high disease activity
  • In addition, referral to obstetrician (gynecologist), preferably within pregnancy week 12.
  • Maternity ward/ Pregnancy outpatient clinic evaluates and follows up
    • Control intervals at maternity clinics vary, more often in the last part of pregnancy, for example, when every 1-2 week
    • Monitoring with Ultrasound examinations of the fetus
      • First 1 / 3 of pregnancy at approx. 11-14 weeks of pregnancy after individual assessment
      • In the second third of pregnancy, an ultrasound study is recommended for 18-24 weeks pregnancy (routine at 18 weeks)
      • For those who have antibodies SSA / Ro or SSB / La is assessed fetus heart rate carefully (especially in pregnancy week 16-26) because "heart block" occurs in approx. 2%
      • In the last trimester, minimum monthly ultrasound examinations are recommended until birth
      • In the case of high disease activity, more frequent ultrasound examinations and growth controls are relevant
      • (reference: Andreoli L, 2017)
    • Birthplace is agreed with the maternity department
  • At the rheumatologist controls, blood and urine tests are examined which contribute to the assessment of SLE disease activity and possible organ damage
    • The samples should assess the number of blood cells (leukocytes, platelets, hemoglobin), renal function and any signs of renal insufficiency (urine)
  • Blood glucose measurements and glucose loading test (at GP) in week 28 is applicable if Prednisone or other cortisone is used, more often if suspected gestational or known diabetes / diabetes

Possible complications of SLE and pregnancy

  • Miscarriages
    • The incidence is increased if the disease is not under good control
  • Stillbirths
    • The incidence is increased if the disease is not under good control
  • Premature born
    • The incidence is increased if the disease is not under good control
    • Birth prior to pregnancy week 37 at 22,1% with SLE at first pregnancy and 7,2% at later pregnancy (reference: Wallenius M, 2014)
  • "Small for date-child"
    • Low birth weight in relation to the duration of pregnancy. The incidence is increased if the disease is not under good control
  • Birth weight below 2500g in 20% in first pregnancy, later 12,4% (reference: Wallenius M, 2014)
  • Heart Block. SSA / B antibody predisposes to fetal heart block (about 2%)
  • Death in the newborn is rare
  • Blood clots. Antiphospholipid antibodies, Lupus anticoagulant, beta2 glycoprotein and cardiolipin antibody contribute to increased thromboembolic risk
  • There is an increased risk of "pregnancy poisoning" (pre-eclampsia) at SLE during the last part of the pregnancy
    • The incidence is in 14,7% in the first pregnancy, 10,3% in later pregnancy (reference: Wallenius M, 2014)
    • Symptoms are increasing swelling (edema) in the feet, increasing blood pressure and protein (egg white) in urine test
    • Albyl-E seems somewhat preventative (Albyl-E 75 mg / day is often given from gestational week 12 and ends within week 37)
    • The treatment is to speed up the birth

For patients in the Oslo area, OUS offers the Rikshospitalet via rheumatological section a close follow-up in collaboration with the Women's Clinic. It is also offered to participate in a research project (RevNatus project) that will reveal more about the risk of SLE pregnancies and is a collaboration with NKSR at St.Olavs Hospital in Trondheim.

Treatment in pregnancy

  1. Continue with Plaquenil, Imurel and / or Prednisolone
  2. Folic acid 0,4mg in the first trimester as in all pregnancies
  3. Calcigran Forte (calcium and vitamin D), especially if prednisolone is used or osteoporosis is present
    1. Pregnancy osteoporosis is described here
  4. Prevention against preeclampsia is given Albyl-E 75mg / day from pregnancy week 12 to week 37 (ending 3 weeks pre-planned birth)
  5. If increased risk of blood clots
    1. Consider Albyl-E 75mg / day from early pregnancy or beforehand
    2. Consider Fragmin (heparin) from early pregnancy or beforehand
  6. If repeated spontaneous abortion despite common measures against Antifosfolipid syndrome
    1. Contact the specialist department
    2. Take Plaquenil from early pregnancy or beforehand
    3. Consider Prednisolone 10mg / day from early pregnancy or in advance in the first three months of pregnancy
    4. Consider intravenous immunoglobulin from early pregnancy or in advance
    5. Consider a combination of the above mentioned measures

Birth at SLE

Most women give birth in a normal, vaginal way

  • In case of SSA or SSB antibody in mother, the newborn child may temporarily get rash during the first weeks months ("neonatal lupus"). This pass spontaneously and is not the start of chronic disease
    • The risk of Neonatal lupus may be reduced to some extent by the use of hydroxyclorokine (Plaquenil) during pregnancy (reference: Barsalou J, 2018)

For women with Antiphospholipid syndrome (APLS) and Fragmin or Klexane treatment it is appropriate to continue with this antiplatelet treatment for a few weeks (often 6 weeks) after birth

After the birth

Neonatal lupus is the lupus rash in the newborn

  • Occurs in 5% of newborns if mother had SSA (Ro) antibody
  • May be triggered or aggravated if light therapy (against jaundice) is required
  • Neonatal lupus is harmless and passes within a few weeks, without treatment
  • It is possible Plaquenil (hydroxychlorokine) during pregnancy reduces the risk of neonatal lupus (reference: Izmirly, Circulation 2012)

Literature



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