1. Samar Al-Emadi MD.FACR.FRCPC.ABIM Hamad Medical Corporation Doha-Qatar
SLE and Pregnancy
Samar Al-Emadi
MD.FACR.FRCPC.ABIM
Hamad Medical Corporation
Doha-Qatar

2. Road Map Introduction Effect of pregnancy on Lupus and vise versa
Local Data

4. Concerns of women with rheumatic disease
Will I be able to get pregnant? Stay pregnant? How will my disease affect the pregnancy? How will the pregnancy affect my disease during pregnancy and post partum? In the long run? Which drugs are safe during pregnancy

5. Concerns of women with rheumatic disease
Can a disease flare be treated safely during pregnancy?
Can I breastfeed?
What is the risk of passing my disease to my child?

6. Lessons learned from the patients
Many doctors know little about the interaction of pregnancy and rheumatic disease
Doctors often forget to address family planning
No structured plan for interdisciplinary monitoring of disease during pregnancy
Many unanswered questions about drugs during pregnancy and lactation

7. Myth and truth about reproduction issues

8. Myth and truth about reproduction issues

10. SLE in pregnancy

11. Risk for the SLE mother during pregnancy
Flare
Pregnancy complications (2-4 fold higher in SLE pregnancies)
Hypertension
Preeclampsia/HELLP
Other complications
Premature delivery and Cesarean section

12. Lupus activity in pregnancy Clowse M, 2007; Doria A 2002
Tow to three -fold increase in SLE activity during pregnancy.
Some activity in 35–70% of SLE pregnancies
The risk for a moderate to severe flare is 15–30%
Risk for flare x 7.25 if SLE active before conception
Most common activity:
Skin
Joints
Hematological

13. SLE pregnancies carry significantly higher risks for adverse outcomes

14. Lupus nephritis and pregnancy
Associated with increase in adverse maternal and fetal outcomes independent of histology of lupus nephritis
Pregnancy-associated decline in renal function associated with severe renal impairment (Cr>250μmol/l) at conception.
Conception with preserved renal function (Cr<125μmol/l) is not associated with irreversible deterioration.

15. Maternal complications in SLE pregnancy
Bramham et al. J Rheumatol 2011, 107pregnancies

16. Differentiation of worsening SLE renal disease from preeclampsia: often mixed picture
Clinical measure
Preeclampsia
SLE nephritis
hypertension +
+/-
24 hr. urine protein
Dose not differentiate
Onset of proteinuria
Abrupt
Gradual /abrupt
Urine red cell cast/active sediment
Rare
Common
Liver function test
May be elevated in HELP
normal
Abdominal pain
thrombocytopenia
May be present
Complement
Normal or high
low
Anti-Ds DNA
Negative or stable
Positive /increasing
Uric acid
High
Normal
Urine calcium
Other SLE symptoms
Not present

18. Presence of auto-antibodies and associated risk for mother and child

19. Neonatal lupus syndromes
Caused by transplacental passage of SS-A (anti-Ro) and SS-B (anti-La antibodies)
Sjögren syndrome, SLE, MCTD, RA
Transient NLS (skin, cytopenia, liver enzymes
Congenital heart block

20. Risk of congenital heart block in SSA/SSB positive mothers
In primigravidae 1-2%
Higher when 1st degree AV-block is considered Sonnesson et al. Arthr Rheum 2004
Higher in Sjögren‘s syndrome than SLE
3-5 times higher risk if already one child with CHB (15-19% CHB children)
Recommendation: weekly Doppler fetal echocardiography from gestational week 16 to 26, then bi-weekly control to week 32 (Jill Buyon)

21. Risk assessment necessary for pre-pregnancy counseling
Age
Previous pregnancy complications?
Irreversible organ damage present?
Recent or current disease activity?
Antiphospholipid antibodies / APS?
Positivity of anti-Ro / anti-La?
Current treatment with feto toxic drugs?
Treatment with high doses of glucocorticoids
Other chronic medical conditions?
Smoking?

22. The right time and right condition for pregnancy
In remission or stable low disease activity for at least 6 months
Patient on stable medication with drugs compatible with pregnancy
Frequency of medical controls planned
Contact established between doctors involved in follow-up during pregnancy

23. Reasons to postpone or contradict pregnancy
Patients with active disease during the last 6 months
Active in any organ system
Therapy with teratogenic drugs
Patients with severe organ manifestations
Severe renal, pulmonary, cardiac, CNS impairment or severe organ damage

24. Recent local data

25. Pregnancy outcome in 69 SLE subjects
69 pregnancies from 36 SLE Patients were analyzed
From January 2006 till July 2012
Lupus activity index was used (SLEDI)
The aim was to determine the frequency of abnormal pregnancy out comes in a cohort of SLE patient to identify the clinical ,laboratory factors predicting fetal outcomes

29. Conclusion
SLE in pregnancies in Qatar population were associated with higher risk adverse pregnancy outcomes.
Disease activity during pregnancy, proteinuria, lupus nephritis and eclampsia/preeclampsia were all negatively associated with pregnancy outcome such as IUGR, still births and preterm delivery.
Anti-Ro/La antibodies and low level of C3 were also associated with adverse pregnancy outcomes.

30. Summary and take home message
Educate patients early and often
Know and recommend appropriate contraception
R0le out serious underlying disease related damage
Timing is critical : best maternal and fetal out comes is with quiescent disease at conception
Review medication before pregnancy and change to pregnancy-compatible meds.
Counsel patient/partner ahead of time
Close monitoring with rheumatologist ,OB,and other specialty if needed .