1. Systemic Lupus Erythematosus and Pregnancy:An Overview
Dr. Anupama Kumar Consultant Rheumatologist
Sagar Hospital, Bangalore

2. Introduction 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

3. Rash and Patchy Hairloss in SLE

5. SLE Overview
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

6. SLE – a multi systemic disease

7. SLE Overview
Characterized by production of antibodies to cell nucleus called ANAs
Who is affected % are young women % of them are in 20 to 40 years age group
More patients plan for pregnancy because of improved prognosis

8. Pregnancy Counseling
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

9. Different Presentations
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

10. Diagnosis-Signs and Symptoms
Fatigue and fevers
Arthritis or arthralgias
Malar rash
Serositis
Raynaud’s phenomenon
Proteinuria
Vasculitis
Leukopenia
Thrombocytopenia
Seizures

11. Malar Rash in SLE

12. Facial Rash in SLE

13. Vasculitic Lesions on Hand

14. Investigations 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

15. Risk Stratification
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

16. What makes a Pregnancy High Risk in Lupus?
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

17. Pregnancy in Lupus-Working both Ways
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

18. Pregnancy Loss
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

19. Causes of Pregnancy Loss
Increased lupus activity at conception or during pregnancy
Hypertension
Hypocomplementaemia
Renal disease
Gestational Lupus

20. Adverse Pregnancy Outcomes
Spontaneous abortions
IUGR
Preterm delivery
postpartum haemorrhage
maternal venous thromboembolism
Neonatal death due to fetal heart block

21. Preeclampsia
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

22. 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 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%

23. Management of Neonatal lupus
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

24. Neonatal Lupus

25. Effects of Pregnancy on 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

26. Treatment of Flares in Pregnancy
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

27. The Risk of Maternal Death
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

28. Differential Diagnosis
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

29. Prevention and Management
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

30. Summing Up 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