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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 Systemic lupus erythematosus In Pregnancy
    • 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 SLE In Pregnancy
    • 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)

SLE In Pregnancy
  • 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

Last Update: 2023-09-29 06:19:29
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