The course of pregnancy in female patients with systemic lupus erythematosus
Authors:
D. Tegzová; K. Andělová
Authors place of work:
ÚPMD, Praha
; Revmatologický ústav, Praha
Published in the journal:
Čes. Revmatol., 21, 2013, No. 2, p. 72-80.
Category:
Original Papers
Summary
The course of pregnancy and lactation in female patients with systemic lupus erythematosus (SLE) is a risk. The risk arises from the disease itself, disease activity, organ involvement, and treatment of the mother prior to conception, during pregnancy and lactation. A flare in the form of skin and joint involvement, leukopenia or renal relapse occurs most commonly. There is also a risk of lupus neonatorum with irreversible AV block type III in the newborns of mothers with positive anti-Ro and anti-La antibodies. There is a higher risk of repeated abortions due to antiphospholipid syndrome (APS). A systemic disease with autoantibodies with prothrombotic and proinflammatory properties can cause a number of complications during pregnancy including a higher number of abortions, increased incidence of preeclampsia, hypertension, growth retardation and premature labour. The immunosuppressive therapy of SLE bears serious risks with respect to pregnancy, as well. Coordinated treatment that should be initiated prior to pregnancy by choosing the right birth control and planning the conception during a period, when the disease is under control or completely in remission, is essential for monitoring of pregnant patients with SLE at risk. A long-time research of pregnancies in SLE at risk is ongoing in the Institute of Rheumatology in cooperation with ÚPMD in Prague-Podolí.
Objectives:
The aim of monitoring within the last two years was to evaluate the course of pregnancy in 44 women with SLE and to monitor the development of selected clinical and laboratory parameters.
Methods:
We evaluated the clinical condition, the overall activity of SLE according to SLEDAI score, therapy during pregnancy and selected hematological, biochemical and immunological parameters. Patients underwent an examination before conception, as well as during early pregnancy, then after each trimester of pregnancy and immediately after labour. The occurrence of the following complications of pregnancy was monitored: SLE flare, the emergence of gestational diabetes, hypertension, preeclampsia, fetal growth disorders, the incidence of neonatal lupus and congenital defects.
Results:
Most patients with SLE were treated with low-dose glucocorticoids, and patients with APS were treated with antiplatelet therapy with a low dose acetylsalicylic acid, and low molecular weight heparin during pregnancy. The total activity of SLE was low in the majority of patients, as expressed by a low value of SLEDAI score. Organ manifestations of SLE were infrequent. 17 women gave birth by Caesarean section. The number of births of full-term newborns after 37th week was 25. The average birth weight was 2860 g, ie lower than the weight of normal population. In 6 female patients, there were signs of late growth retardation. Mothers of these children were more frequently treated for hypertension and also had persistent proteinuria during pregnancy. Hypertension was the most common complication during pregnancy. Only one female patient developed pre-eclampsia, which was an indication for termination of pregnancy. Gestational diabetes was diagnosed in 6 patients, all of which were treated with long-term glucocorticoids. The incidence of gestational diabetes was independent of the dose of glucocorticoids and its occurrence was higher than in the healthy population. Interestingly, we observed a high number of female patients with a concomitant thyroid gland disorder, which, in all cases, turned out to be hypothyroidism treated with thyroid hormone substitution. The most likely explanation is an autoimmune origin in the milieu of increased alert of formation of autoantibodies. We found no congenital defect or neonatal lupus.
Conclusion:
The course of pregnancy was without any complications and without exacerbation of the disease in most female patients with SLE (with/without the presence of secondary APS), which had a low disease activity at conception. The increase in the disease activity of SLE and the presence of organ manifestations during pregnancy were an important predictor of the development of SLE and the whole course of pregnancy in the monitored group.
Key words:
Systemic lupus erythematosus, antiphospholipid syndrome, pregnancy, complication, relapse
Zdroje
1. Lateef A, Petri M. Management of pregnancy in systemic lupus erythematosus. Nat Rev Rheumatol 2012;8(12):710-8.
2. Stojan G, Baer AN. Flares of systemic lupus erythematosus during pregnancy and the puerperium: prevention, diagnosis and management. Expert Rev Clin Immunol 2012;8(5):439-53.
3. Alvarez-Nemegyei J, Domínguez-Vallejo S, Saavedra-Déciga ME. Relapsing risk and obstetric-neonatal outcome in pregnancy and systemic lupus erythematosus. Rev Med Inst Mex Seguro Soc 2012;50(4):355-61.
4. Dostál C, Vencovský J. Těhotenství a SLE. In: Systémový lupus erytematodes. Praha, Medprint, 1997: 147-153.
5. Petri M, Albritton J. Fetal outcome of lupus pregnancy: A retrospective case-control study of the Hopkins lupus cohort. J Rheumatol 1993;20:650-4.
6. Neds CJ, Brooks PM. Antirheumatic medicaton during lactation. Br J Rheumatol 1985;24:291-6.
7. Parke A, West B. Hydroxychloroquine in pregnant patients with systemic lupus erythematosus. J Rheumatol 1996;23:1715-1718
8. American College of Rheumatology Subcommittee on Rheumatoid Arthritis guidelines. Guidelines for the management of rheumatoid arthritis. 2002 update. Arthritis Rheum 2002;46:328-46.
9. Dostál C, Kolblová V, Nouza K. Systémový lupus erythematodes a těhotenství. Současný stav problému. Čas Lék čes 1992;19:582-587.
10. Dostál C, Madar J, Vítová J, et al. Praktické výsledky sledování těhotenství u žen se systémovým lupus erytematodes. Čas Lék čes 1996;24:789-95.
11. Palmsten K, Hernández-Díaz S, Kuriya B, Solomon DH. Use of disease-modifying antirheumatic drugs during pregnancy and risk of preeclampsia. Arthritis Care Res (Hoboken) 2012;64(11):1730-8.
12. Izmirly PM, Costedoat-Chalumeau N, et al. Maternal use of hydroxychloroquine is associated with a reduced risk of recurrent anti-SSA/Ro-antibody-associated cardiac manifestations of neonatal lupus. Circulation 2012;126(1):76-82.
13. Bramham K, Soh MC, Nelson-Piercy C. Pregnancy and renal outcomes in lupus nephritis: an update and guide to management. Lupus 2012 Oct;21(12):1271-83.
14. Wright D, Akolekar R, Syngelaki A, Poon LC, Nicolaides KH. A competing risks model in early screening for preeclampsia. Fetal Diagn Ther 2012;32(3):171-8.
15. Suzumori N, Obayashi S, Kumagai K, Goto S, Yoshida A, Sugiura-Ogasawara M. A Case of Microangiopathic Antiphospholipid-Associated Syndromes during Pregnancy. Case Report Med 2012: 827543
16. Ragab A, Barakat R, Ragheb M, State O, Badawy A. Subfertility treatment in women with systemic lupus erythematosus. J Obstet Gynaecol 2012;32(6):569-71.
17. Yee CS, Akil M, Khamashta M, et al. The BILAG 2004 - Pregnancy index is reliable for assessment of disease activity in pregnant SLE patients. Rheumatology (Oxford) 2012;51(10):1877-80.
18. Shand AW, Algert CS, March L, Roberts CL. Second pregnancy outcomes for women with systemic lupus erythematosus. Ann Rheum Dis 2012 Jun 29. [Epub ahead of print.
19. Sciascia S, Murru V, Sanna G, Roccatello D, Khamashta MA, Bertolaccini ML. Clinical accuracy for diagnosis of antiphospholipid syndrome in systemic lupus erythematosus: evaluation of 23 possible combinations of antiphospholipid antibody specificities. J Thromb Haemost 2012;10(12):2512-8.
20. Andrade SE, Scott PE, Davis RL, et al. Validity of health plan and birth certificate data for pregnancy research. Pharmacoepidemiol Drug Saf. 2012 Jul 3. doi: 10.1002/pds.3319.
21. Fischer-Betz R. Rheumatic diseases during pregnancy. Internist (Berl) 2012;53(9):1047-53.
22. Alijotas-Reig J, Ferrer-Oliveras R. EUROAPS Study Group.The European Registry on Obstetric Antiphospholipid Syndrome (EUROAPS): a preliminary first year report. Lupus 2012;21(7):766-8.
23. Bertero MT. Primary prevention in antiphospholipid antibody carriers. Lupus 2012;21(7):751-4.
24. Ruffatti A, Calligaro A, Del Ross T, et al. Risk-based secondary prevention of obstetric antiphospholipid syndrome. Lupus 2012;21(7):741-3.
25. Erkan D, Lockshin MD. APS ACTION members. APS ACTION-AntiPhospholipid Syndrome Alliance For Clinical Trials and International Networking. Lupus 2012;21(7):695-8.
26. Blanford AT, Murphy BP. In vitro metabolism of prednisolone, dexamethasone, betamethasone and cortisol by the human placenta. Am J Obstet Gynecol 1977;27: 264-268.
27. Björkander S, Bremme K, Persson JO, van Vollenhoven RF, Sverremark-Ekström E, Holmlund U. Pregnancy-associated inflammatory markers are elevated in pregnant women with systemic lupus erythematosus. Cytokine 2012;59(2):392-9.
28. Wechsler B, Le Thi Huong D, Piette JC. Pregnancy and systemic lupus erythematosus. Ann Med Interne 1999;150: 408-18.
29. Janssen NM, Genta MS. The effects of immunosuppressive and anti-inflammatory medications on fertility, pregnancy and lactation. Arch Intern Med 2000;160:610-619.
30. Neson JL, Ostensen M. Pregnancy and rheumatoid arthritis. Rheum Dis Clin North Am 1997;23:195-212
31. Mintz G, Niz J, Gutierrez G, et al. Prospective study of pregnancy in systemic lupus erythematosus. Results of multidisvciplinary approach. J Rheumatol 1986;13:4-6.
32. Lockshin MD. Pregnancy does not cause SLE to worsen. Arthritis Rheum 1989;32:665-70.
33. Petri M, Howard D, Repke J. Frequency of lupus flare in pregnancy: The Hopkins lupus pregnancy centre experience. Arthritis Rheum 1991;34:1358-64.
34. Urowitz MB, Gladman DD, Farewell VT, et al. Lupus and pregnancy studies. Arthritis Rheum 1993;36:1392-6.
35. Domic, R, Ramsey-Goldman R, Manzi S. Epidemiology and classification of systemic lupus erythematosus. In: Hochberg MC, et al. Rheumatology. Vth ed. Philadelphia, Elsevier, 2008:1211-13.
36. Salmon JE, Pricip LD, Agati V. Immunopathology of systemic lupus erythematosus. In: Hochberg, MC., et al. Rheumatology. Vth ed. Philadelphia, Elsevier, 2008:1217–1237.
37. Gladman DD, Urowitz MB. Clinical features of systemic lupus erythematosus. In Hochberg, MC., et al. Rheumatology. Vth ed. Philadelphia, Elsevier, 2008:1277.
38. Mulherin D, Bresnihan B. Systemic lupus erythematodes Bailliere´s. Clin Rheumatol 1991;7:31–57.
39. Gordon C. Long-term complications of systemic lupus erythematosus. Rheumatology 2002;41:1095–1100.
40. Ruiz-Irastorza G, Lima F, Alves J, et al. Increased rate of lupus flare during pregnancy and : the puerperium. A prospective study of 78 pregnancies. Br J Rheumatol 1996;35:133-9.
41. Hayslett JP. Maternal and fetal complications in pregnant women with systemic lupus erythematosus. Am J Kidney Dis 1991;17:123-8.
42. Bobrie J, Liote F, Houillier P, et al. Pregnancy in lupus nephritis and related disorders. Am Kidney Dis 1987; 9:339-43.
43. Julkunen H, Kaaja R, Palosuo T, et al. Pregnancy in lupus nephropahy. Acta Obstet Gynecol Scand 1993;72:258-63.
44. Repke JT. Hypertensive disorders of pregnancy. Differentiating preeclampsia from active systemic lupus erythematosus. J Repord Med 1998, 43:350-5
45. Julkunen H, Jouhaikainen T, Kaaja R, et al. Fetal outcome in lupus pregnancy: A retrospective case-control study o 242 pregnanties in 112 patients. Lupus 1993;2:125-9.
46. Caritis S, Sibai B, Hauth J, et al. Low aspirin to prevent preeclampsia in women at high risk. N Engl J Med 1998;338: 701-705.
47. Hunt BJ, Doughty H, Majumdar G, et al. Thromboprophylaxis with low molecular weight heparin in high-risk pregnancy. Thrombo Haemost 1997;77:39-43
48. Fritzler, MJ, Elkon KB. Autoantibodies in SLE. In Hochberg, MC., et al. Rheumatology. Vth ed. Philadelphia, Elsevier, 2008:1253–1264.
49. Brewster JA, Shaw NJ, Farquharson RG, et al. Neonatal and pediatric outcome of infants born to mothers with antiphospholipid syndrome. J Perinat Med 1999; 27:183-7.
50. Brester JA, Quenby SM. Alfirevic Z, et al. Intra-uterine death due to umbilical cord trombosis secondary to antiphospholipid syndrome. Lupus 1999;8:558-9.
51. Backos M, Rai R, Regan L, et al. Pregnancy complications in women with recurrent miscariiage associated with antiphospholipid antibodies treated with low dose aspirin and heparin. Br J Obstet Gynaecol 1999;106:102-7.
52. Juste JR, Beloqui O, Prieto J, et al. Antiphospholipid syndrome. Rev Med Univ Navarra 1998;42:194-207.
53. Lockshin MD, Reinitz E, Druzin ML, et al. Lupus pregnancy. Case-control prospective study demonstrating absence of lupus exacerbation during or after pregnancy. Am J Med 1984;77:893-7.
54. Meehan RT, Dorsey JK. Pregnancy among patients with systemic lupus erythematosus receiving immunosupressive therapy. J Rheumatol 1987;14:252-5.
55. Briggs GG, Freeman RK, Yaffe SJ. Drugs in pregnancy and lactation. 5thd. Baltimore, Williams and Wilkins, 1998: 321-6.
Štítky
Dermatology & STDs Paediatric rheumatology RheumatologyČlánok vyšiel v časopise
Czech Rheumatology
2013 Číslo 2
Najčítanejšie v tomto čísle
- The course of pregnancy in female patients with systemic lupus erythematosus
- Eosinophilic fasciitis
- Recommendations of the Czech Society for Rheumatology for the diagnosis and monitoring of patients with systemic lupus erythematosus
- What we should know about diagnostic tests