62 Journal of The Association of Physicians of India ■ Vol.
64 ■ August 2016
Update Article
Management of Pregnancy in Lupus Patients
Renu Saigal1, Laxmikant Goyal2, ML Tank3, Suresh Saigal4 5. Historyofseverepre- Abstract eclampsia or HELLP syndrome (haemolysis, elevated liver Systemic lupus erythematosus (SLE) mostly affects young women of enzymes and low platelets reproductive age group. SLE patients may conceive as any normal syndrome) despite therapy. woman but complication may occur in these patients if the disease is active. Pregnancy in SLE may lead to 1. Aggravation of SLE (Lupus Pregnancy should be deferred if flare) 2. Pre-term delivery, intrauterine growth retardation and foetal there is 1) severe disease flare within past 6 months, 2) recent stroke loss (in presence of antiphospholipid antibodies) 3. Neonatal lupus within past six weeks and 3) active especially in presence of Anti-Ro / La antibody. For a successful lupus nephritis.1 pregnancy, both from maternal and foetal aspects, disease should be quiescent for at least six months before the conception. Before planning for pregnancy, estimations of certain antibodies are Lupus patients with pregnancy require specific management to improve helpful1 (Table 1). the maternal and fetal outcomes. Many safe drugs are available for the When the patient conceives, management of pregnancy in SLE. antenatal monitoring for disease activity and pregnancy related complications are essential part of Introduction nephritis (LN), active disease during management (Table 2).1 the past six months before S LE mostly affects young women of conception and discontinuation of hydroxychloroquine (HCQ). For a Complications of Pregnancy in SLE reproductive age group and fertility is not affected by SLE. Pregnancy in SLE better outcome, drugs safe in may lead to 1. Aggravation of SLE pregnancy must be started Maternal and fetal risks are h i g h (Lupus flare) preconception so that the disease e r i n l u p u s p a t i e n t s a s 2. Pre-term delivery, intrauterine remains under control. compared to the healthy women. growth retardation and foetal loss Pr egnancysh oul db e LN was associated with preterm especially in presence of contraindicated in following as birth and maternal hypertensive antiphospholipid antibodies (APL) maternal risk is considerably disorders in women with active, 3. Neonatal lupus especially in increased in these conditions:1 compared with quiescent disease.2 presence of Anti-Ro/ La antibody. Disease Flares 1. Renal insufficiency (serum For a successful pregnancy, both creatinine level >2.8 mg%) If SLE is active at the time of from maternal and foetal aspects, 2. Severe pulmonary hypertension conception then frequency of flare disease should be quiescent for at (systemic pulmonary artery was found to be higher (61-67 %) least six months before the pressure>50mmHgor during pregnancy as compared to conception. symptomatic) those who were in remission for six Planning for Pregnancy months (7- 33%).3 Patients with LN 3. Severe restrictive lung disease may have renal flare during (forced vital capacity <1 L) Lupus flare during pregnancy pregnancy.4 occurs more in patients with lupus 4. Severe cardiac disease leading to Flares may occur with equal heart failure Table 1: Preconception antibody frequency in any of the trimester profile estimation Journal of The Association of An 1Consultant Physicians of India ■ Vol. 64 ■ August tic Rheumatologist and 2016 ar di Senior Physician, Apex Hospital Pvt. 63 oli Table 2: Ante- Ltd., Ex-Professor pi and Head, natal n Upgraded monitori Table 3: Lupus nephritis (LN) versus pre- ant Department of ng by a eclampsia in pregnant lupus patient ibo Medicine, Former rheumat die In-Charge ologist Lupus nephritis (LN) Pre-eclamp s Rheumatology and Urine Proteinuria with active Only protein an Services, SMS obstetrician sediment d Medical College and (every 4-6 Complement Low Normal or l lu Hospital, Jaipur, Anti ds DNA† Increased levels Absent weeks and pu Rajasthan; Other organ involvement Present Biomarkers‡ s 2Assistant more frequently if Hypertension At any time during pregnancy After 20 wee ant Professor, ico Department of the disease Other features May persist even in post- More comm is active)2 (Thrombocytopenia, elevated partum period after deliver ag Medicine, liver enzymes, hyperuricemia ula Consultant Blood pressure (>5.5 mg%), decreased 24hrs nt Rheumatology monitoring (more urinary excretion of calcium Ant Services, SMS frequent if there is (<195 mg%) i-Ro Medical College, history of hypertension, Renal biopsy (Avoided Confirm LN Jaipur, Rajasthan; and nephritis or pre- usually) 3Associate anti eclampsia) Professor, †Anti dsDNA antibodies may potentiate pregnancy loss -La Complete blood by cross reacting with laminin, molecule important for Department of anti counts, Serum uric placental implantation.6 ‡In pre-eclampsia biomarkers Medicine, 4Assistant bod acid, serum urea, with low sensitivity viz placenta growth factor (PlGF), Professor, ies serum creatinine, vascular endothelial growth factor (VEGF), soluble fms- Department of liver function test like tyrosine kinase-1 (sFLT1) and soluble endoglin Ant Surgery, MG Complement C3, anti- (sENG), may be present.7-8 i Medical College, dsDNA and urine dsD Jaipur, Rajasthan examination, spot NA Received: urine and 11.02.2015; Revised: protein/creatinine ratio, C3 22.06.2015; Lupus anticoagulant (to Accepted: asse (LA), anticardiolipin 03.07.2015 ss antibody (aCL) dise USG monitoring for foetal ase growth and well being acti (between 16-20 weeks of vity gestation) ) Fetal monitoring from S. week 26 Free AntiRo Antibody if positive – Fetal echocardiography T3, weekly from week 16-26, T4 then biweekly till day, falling thrombosis may be and delivery complement levels seen with former.1 TS and rising anti ds- Maternal Morbidity Preeclampsia–Uterine H artery Doppler (at week DNA levels, may be 20 and then 4 weekly), Pre-eclampsia, present. For these fetal umbilical artery hypertension, flares, patient may Doppler velocimetry be given bleeding, serious and in postpartum corticosteroid (CS) infections, preterm period. In SLE flare, in lowest dose or delivery, unplanned photosensitive rash, short courses of cesarean delivery, oral or nasal ulcers, high dose of CS and maternal venous inflammatory azathioprine or thromboembolism arthritis, fever, calcineurin occur with higher lymphadenopathy, inhibitors . Intra frequency in pleuritis, leucopenia, venous pregnant SLE lymphopenia, Immunoglobulins patients.5 immune haemolytic (IVIg) and anaemia, plasmapheresis LN and pre - thrombocytopaenia, may be other eclampsia may active urinary options but fluid closely resemble as sediment, overload and risk of both may p r e s e n t proteinuria >300 mg/ withproteinur i a , diffe growth done if IUGR is lupus rash CHB. Since CHB is hypert renti restricti suspected. manifests between irreversible and ension ate on Neonatal Lupus 4– 6 weeks after mortality is high thromb betw (IUGR) Syndrome (NLS) birth and may be therefore all patients ocytop een and Those lupus seen up to 25% of with increased PR enia a these neonat patients who have newborns.13 These interval should be ndde two al anti - Ro and anti - manifestations promptly diagnosed terio cond lupus La subtypes of ANA disappear 6-8 and treated.19 ratio ition syndro targeting 52 kD or 60 months after birth Fluorinated ninre s as mes kD SSA /Ro and 48 and coincide with corticosteroids ( d e x n a l enu are few kD SSB/La proteins, the disappearance amethasonean functio mera of the respectively, cross of the maternal d n . 1 ted compli the placenta and antibodies. Some in cations produce neonatal l u Congenital Heart feature Table which pussyndrome Block (CHB) s can 3.1,6-8 may be ( N L S ) , a passively CHBaffects Preec seen in acquired a b o u t 2 % o f lamp foetuse autoimmune children born to sia is s born syndrome. NLS is primigravid women a to SLE characterized b y r a with anti-Ro frequ mother sh(photosensi antibodies.14 Risk of ent s. t i v e ) , recurrence is high com Active haematologic in anti Ro positive plica lupus, (thrombocytopenia mothers with tion presen and neutropenia) myxedema and risk of ce of and hepatic a b n o r also increases in lupu nephrit malitiesorcar subsequent s is, d i a c complications pregnancies.15 Fetal preg presen (Congenital heart genetic nanc ce o f A block, endocardio- polymorphisms, y PL,gl fibroelastosis, involving the Fc - and u c o c structural gamma receptors occu ortic abnormalities and and transforming rs o i d u cardiomyopathy) . 12 growth factor-β, more s e , Neonatal and hypoxia have frequ hypert been suggested to ently ension, have a role in CHB in preecla in NLS.16 LN. mpsia and CHB mostly Fetal develops between Morb thromb 18-24 weeks of idity ocytop gestation. Foetal and enia echocardiography Mort increas ality should be e the performed from 16- Hi foetal 26 weeks of gher compli gestation and then rates cations. 9-11 biweekly . F o e t a l of Umbili kinetocardio fetal cal gramandtrans loss, artery abdominalfoe prete Dopple t a l rm r electrocardiogram birth ultraso can diagnose these (befo nograp abnormalities.17-18 re 37 hy Increased PR week should interval (first degree s), be heart block) intra forewarns the - subsequent uteri development of ne 64 Journal of The Association of Physicians of India ■ Vol. 64 ■ August 2016 Preg activity, Aceta Glu foetal be dbe nanc risk of minophe cocorti heart for f o r betamet CHB and n: It is coids: (Prednis blocks. e e y hasone) neonatal safe These olone < Calciu co preg cross in lupus during must b 10 m nc nanc placenta SLE activity. pregnan e us e mg/day) supplem ep y as and Flare cy. d a t t that ents, in Ma tio reach may h e l o controls Vitamin Ritu Hepa n foetal nagem occur on we s t disease D should xima rin: It as circulati ent of discontin dose activity. be given b does not all on and pregna uation of High to plac cross p l ar may ncy in HCQ.24 dose patients ental a c e n t normaliz SLE may be e trans Azath a andi who are e the patient ioprine: associate on ter fer ssafed increase requir d with corticost at may This is u r i n g d PR es co- diabetes eroids og occu safe pregnan interval efforts mellitus, and en ran during cy. Ease but not of hyperten heparin ic. dfo pregnan of in all as rheum sion, as both rBe cy in administ the effect atologi preeclam these 2. Rit lim dose of ration, is not st and psia and drugs ux u m 2mg/kg/ higher consiste obstetr prematu can im abd day. anti- ntly ician. re ab a t a thrombo cause observed Tacrol rupture (B rega Dru tic to osteopor , so role imus of cel rdin gs for anti- osis. of CS is and membra l g SLE Cyclosp coagulan Drugs controve nes.29 For de safet Manag orine: S i t ratio which rsial.20-21 disease pl y are ement nce,bo and are Pacemak flares eti lacki Durin thares predicta contra ers may short ng ng.30 g afe du ble b i o indica be courses an Pregna r i n g availa 3. Ticlo required of high ted: tib ncy: bility pidi in the pregnan dose of od makes 1. Cyc ne, majority D r cy and CS or y) l o w - lop Clop for better ugsw during intraven an molecula hos idog survival h i c h breast ous d r weight pha rel: rates. To a r e S feeding, pulse Be heparin m i All reduce afein these therapy li (LMWH) d e , anti risk of Pregna may be may be m the anti- Myc plate CHB in ncy used for used. If u coagulan ophe lets subsequ are: suppress patient m t of nola exce ent HC ing has been ab choice.27- pt pregnan Q: It is disease on te (B 28 Aspi cies, safe activity.2 prolonge mof A Anti- rin HCQ is for 5-26 d CS etil FF Anti- platelets: shou effective. fetus therapy and in hyperten Aspirin ld be 22 Role of stress hi and s Met stop IVIg in sive is the dose of houl hotr bit preventi drugs: only CS at the ped dbec exat or ng this Drugs anti- time of befo o n t i e: ): recurren safe in platelet delivery re nued Bo ce has pregnan may be Thes preg d u r i drug th not been cy are required. e nanc n g safe in sh found to Methyld Betamet shou y. pregna pregnan ou be opa, hasone ld be ld 4. Warf ncy as cy and consiste Labetalol and disc be arin: it leads may be nt. 23 , dexamet onti d i It is to continue Nifedipi hasone nue s c terat Manag reduce d if ne, cross the d 3 o ogen d indicate ement Hydrala placenta mon n t ic diseas d. of zine. and is ths i n whe e given in ue n used ne plac us and is 10. Be in in on ental e seco give ta SLE. earl at perf disc aft nd n for bl Pre y al usio onti er trim elev oc gna preg art n. nue 32 ester en ke ncy nanc eri Bisp d 6- w of days with 7. rs: y. al hosp 12 ee preg and Anti Al Warf hy mon ks nanc level hona l β pho arin po ths of y.33 of sph tes bl may te prio ge Lefl leflu olipi shou sta 9. nom oc cros ns r to uno d ld be tio ide ke s the io preg mid Anti plac n, n e: in rs nanc bodi enta re y. ca This seru ca es and na n drug m n 8. N S (AP caus l lea shou shou ca A I L) e fai d ld be ld be us Ds: APLs fetal lur to disc < e F i r are hae e, pr onti 0.02 IU s t t present mor an e nue mg/ G rim in 25- rhag d m d 2 L on R e s t 50% e so ev at year two an e r patients it is en ur s occa d use of SLE bette de e befo sion br may but less r to at clo re s 14 ad be than h a l avoi h.3 su conc days yc asso fofthe d 1 re epti apar ar ciate sepati oral 6. Di of on t di d e n t s h anti- ur du as it befo a with a ve coag eti ct has re in high antiphos ulan cs: us a conc ne er pholipid ts. Th art long epti on risk syndrom es eri half- on is ate 5. ACE of e (APS). e os life cont an inhi cong APS may m us. or a emp d bitor enit manifest ay 32 was lated ca s al H clinically ca h ). n and malf o as us out How lea ARB orm w thrombo e proc ever, d s: atio ev tic or m edur ther to Thes ns. er obstetric at e e are ag e If th complica er mus stud gr shou used er tion na t be ies a ld after e along l und that va be 20 ar with one vo erta inad t i avoi wee e serologic lu ken vert o ded ks of re al test L m with ent n in gest po upusa e chol expo o f preg atio rts nticoa de estyr sure R nanc n th gulant pl ami to ay y as foet at ( L A eti ne leflu n ther al N C ) , on (or nom a e is rena S anticardi an activ ide u risk l AI olipin d ated did d of imp Ds antibodi re char not ph ACE airm ar es (ACL) du coal, lead - ent e en or Anti ce 8 g to inhi may saf o beta 2 d thre terat bitor occu e m glycopro ut e ogen feto r in en tein 1, er time icity. path whil fir 34 on positive o- e st s a y, in day medium to high titer on two occasion s 12 weeks apart. APL positive patients present with 3 or more early pregnan cy losses (<10 weeks) or one pregnan cy loss >10 weeks or one prematu re birth due to severe pre- eclampsi a or placental insufficie ncy.35 APLs increase the risk of pre- eclampsi a, HELLP Journal of The Association of Physicians of India ■ Vol. 64 ■ August 2016 65 d to Heparin that anti- mg/ kg impairm APS, I n A 58% dose coagulati every ent is HELL PSpati syndrom with should on may 12 100 present.4 P entsse e, aspirin be be hours units/kg 0 syndro vereth placental monot monitore reversed or 1.5 SC every Patien me rombo insufficie herapy d by at the mg/kg 12 hours t and c y t o p ncy, .37 measuri time of /day of or refractor pre- enia(< IUGR Hepari ng delivery. enoxa 200 y to low eclamp 50,000 and pre- n in activity parin units/kg/ dose sia. / mm3) APS term additio of anti- without or day may Aspirin Late requires delivery. n to its factor Xa prior 10,000 be used. (LDA) onset IVIg, LAC is a anticoa as thrombo to 39 Target and throm control better gulant prolonge sis: 12,000 anti– heparin bocyto of predicto effect d Prophyla units factor Xa may be penia hyperten r of and activated ctic UFH 4 hours given occurs sion and adverse preven partial doses, SC after the corticost in early pregnan tion of thrombo such as every last dose eroids, pregna delivery. cy placen plastin 0.5 12 for a IVIg, nt 27
outcome tal t h r time mg/kg/d hours level of and patient
as o m b (aPTT) may plasmap s with Breas of 0.5 to 1.1 compare osis, may be LMWH be U/ml heresis APS t d to a l s o seen in (enoxapa used.39 (with though and Feedi other b l o c these rin) or Altern data are there is k s t h patients twice- limited an ng APL.11 5000 u atively daily The e because twice Daltep dosing), regardin increas Shor manage activat of LAC. daily of arin or 1.0 to g ed risk t-acti ment of ion of Treatme UFH 2.0 U/ml efficacy of fetal n g N S APL in compl nt of subcutan (with of these injury. AIDs, pregnan ement APS with eously once- drugs Hepari antimala targete Pregnan and n cy cy (SC) plus daily rials, d to low-dose modaliti therap low-dose requires dosing).4 decidu Use of (81 mg) es.41-43 y may predniso use of 0 al LMWH aspirin is Treat Warfarin lead to low dose ne (less tissues except recomm ment is hepari aspirin than 15 . for its ended.39 begins at contrain n and to 20 Hepari cost, is Once or concepti dicated induce heparin. mg/day), n a l s preferre twice on and in d warfarin Inob opre d over pregnan throm during continue and stetri s e r ve unfractio cy bocyto treatmen s for 6 to heparin cAPSg s t r o nated because penia ( t, anti– 12 weeks are safe r o u p phob heparin of HIT) factor Xa postpart for the aspirin lasti (UFH) teratoge butu activity um if the infant, as and c because nic nless should patient little or heparin functio of their a n t i be has no effects. no active significa n, efficacy, b od i checked, history T h r drug is ntly reduce less e s 4 hours of omboc secreted reduced s chances specifi after the thrombo ytope in breast the risk genera of bleed cally last dose sis, and n i a milk.44 of tion of and associa for a indefinit Complic pregnan inflam heparin ted level of ely if the ating Sum cy loss mator induced with 0.2 to 0.6 patient Lupus mary by 54%.36 y thrombo HIT U/mL.40 has a Pregnan With mediat cytopeni are APS history cy: Pregn combina ors a and demon with of Thromb ancy in tion and osteopor strable, prior thrombo ocytopen SLE is a treatmen preven osis . 27 hepari thrombo sis. ia may high risk t live ts LMWH n sis: Full Dosing be situation. births of obstetr is should anticoag will need caused Active 74% ic replaced not be ulant to be by active disease were compli by UFH discont doses, reduced SLE, at achieved cations near inued. such as 1 if renal maternal concepti compare .38 term so on is associate e Pract ns al oblast 119
d with quiescen ice in and attach :77
and pre mater ment 8– worse Pregna t. Rese gn nal and 787 maternal ncy Mater arch ant comp migrat . and fetal should nal Clinic wo licatio ion: outcome be complica al me ns. J implic s. planne tions like Rheu n Rheu ations matol wit matol for d disease ogy h 2010; recurr when flares, 2013; sys 37:75 ent the pre - 27:43 te 4– pregn diseas eclampsi 5– mi 758. ancy e is a, and 447. c 5. Clows loss quiesc 2. Smyt lup e ME, in foetal us SLE ent for complica h A, Jamis patien Olivei ery on M, six tions i . e the ts. ra Myers month . GHM, ma E, Am J s. prematu Lahr tos Jame Repr Effecti rity, BD, us. s AH. od A Immu ve IUGR Bailey A m nol contra and KR, J nation 2000; Norby al ceptio NLSs ( i Ki 44:13 SM, study n ncludi Garov dn of the 6. should n g C H ic VD. ey compl 7. Kleinr be A Dis ouwel B) sh o icatio 19 adopte uldbe syste 91; ns of er C, matic lupus et al. d if the diagnose 17: revie in Accur diseas d and w and 12 acy of pregn e is treated meta- 3. ancy. circula active. early. analy 4. Gl Am J ting sis of ad placen P r Many Obste pregn ma t tal econ safe ancy n growt Gyne cepti drug outco DD col h onas options mes , 2008; factor, s e s s are in Ta 199:1 vascul patien nd ment available 27 ar ts on endot should which with A, e1– e6. helial be should syste Iba growt done ne 6. Qures be mic h hi F, regard started lupus z factor, D, Yang ing to eryth Y, solubl emat Ur renal improve owi Jaque e fms- osus like status, maternal and tz s SM, tyrosin organ and lupus MB Johns e on involv foetal nephr . kinase Th MP, ement, outcome itis. Napar 1 and Clin J e APL s. eff stek solubl Am e and Soc ect Y, endog anti Ro Refer Neph of Ulma lin in nsky antibo ences rol lup the us R, dy and 2010; Schu predic 5:206 ne treatm 1. 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