1. Challenges of SLE and
pregnancy
Mahantesh Karoshi,
Consultant Obstetrician & Gynaecologist
Barnet General Hospital, London, UK
Blog :
http://labourwardexperiences.blogspot.co.uk/2013/06/sleinpregnancy.html

2. Systemic lupus erythematosus in
Pregnancy
•
• SLE is known to increase the risk of
spontaneous miscarriage; it can also cause
fetal growth restriction and increased rates
of sudden intrauterine death, pre-eclampsia
and preterm delivery
2

3. Pre-pregnancy consultation
• The presence of anti-Ro/La
and antiphospholipid antibodies should be
determined.
• These antibodies are associated with
congenital heart block and neonatal
cutaneous lupus syndrome.
3

4. • Antiphospholipid antibodies are present in
about 30% of women with SLE and
• are associated with arterial and venous
thrombosis, recurrent miscarriage, fetal
growth restriction, fetal loss and preterm
• delivery due to uteroplacental insufficiency
4
Pre-pregnancy consultation 2

5. • Quiescent disease, without associated
antiphospholipid syndrome (APS),
hypertension or renal involvement the risks
of miscarriage/stillbirth and fetal growth
restriction are not significantly increased
5
Pre-pregnancy consultation 3

6. • The risk of miscarriage and stillbirth in
pregnancies complicated by lupus varies
from 6–35% and from 0–22%
• The great concern are women with SLE and
associated pulmonary arterial hypertension
who wish to conceive: maternal mortality
rates have been quoted as being as high as
33%
6
Pre-pregnancy consultation 4

7. • Patients should be advised not to conceive
during a period of active disease,
particularly with lupus nephritis, because of
worse maternal and fetal outcomes
7
Pre-pregnancy consultation 5

8. • Counsel women with SLE for increased risk
of pre-eclampsia, preterm delivery and fetal
growth restriction
8
Pre-pregnancy consultation 6

9. • In active lupus nephritis with worsening
renal function, increasing proteinuria and
hypertension,it may be necessary to use
treatments such as cyclophosphamide and
mycophenolate mofetil, which are
associated with congenital malformations if
used in the first trimester,
9
Pre-pregnancy consultation 7

10. • Pregnant women with active SLE/lupus
nephritis or anti- Ro/La/antiphospholipid
antibodies should be considered as a higher
risk group and managed in tertiary centre
10
Pre-pregnancy consultation 8

11. • For patients with stable disease, 4-weekly
reviews of disease activity and regular
assessment of fetal growth, blood pressure
and proteinuria should be undertaken
11
Pregnancy consultation 1

12. • For those women who are anti-Ro/La
positive the fetal heart rate should be
monitored and recorded at each visit and
fetal echocardiography assessments made at
18–20 and ~28 weeks of gestation
12
Pregnancy consultation 2

13. • Women who have had a previous venous
thromboembolism should receive
thromboprophylaxis with low molecular
weight heparin throughout pregnancy and
for 6 weeks postpartum
13
Pregnancy consultation 3

14. • The risk of an SLE flare in pregnancy is
increased with active disease in the 3–6
months prior to conception, with the
majority of flares occurring after the 20th
weeks of pregnancy
• Most flares are managed expectantly with
medical management and adjustments to
drug therapy
14
Pregnancy consultation 4

15. • At every antenatal visit, measure the BP,
test the urine for proteinuria, and quantify
the proteinuria by PCR or 24 hour urine
proetein estimation.
• The features of lupus nephritis include
hypertension and proteinuria with or
without haematuria and renal impairment
15
Pregnancy consultation 5

16. • The presence of hematuria or red cell casts
as well as a rise in anti-dsDNA titres or a
fall in complement levels help to distinguish
this from pre-eclampsia
16
Pregnancy consultation 7

17. • In cases of lupus nephritis that fail to
respond to increasing dosages of steroids
and azathioprine, and where there is a
deterioration of renal function and/or
hypertension, other immunosuppressive
drugs may be considered, such as
mycophenolate mofetil or tacrolimus. Such
management decisions should be
undertaken in consultation with
nephrologists and rheumatologists, 17
Pregnancy consultation 8

18. • Premature rupture of membranes is also
being more frequent in pregnancies
complicated by SLE; rates vary and are
generally quoted at ~20% and is common in
women who are on steroids
18
Pregnancy consultation 9

19. SLE and fetal risks
• Increased risks of congenital heart block,
fetal growth restriction and increased rates
of preterm delivery
• Scanning at least every 4 weeks to screen
for fetal growth restriction in those women
at risk is generally accepted and fetal
echocardiography referral should be
arranged for those with anti-Ro/La
antibodie 19

20. • Doppler studies can be used to estimate
placental function A uterine artery Doppler
should be first carried out at 20 weeks and
repeated 4 weeks later if any abnormality is
found A raised pulsatility index or diastolic
notching are associated with increased risk
for developing pre-eclampsia, as they can
indicate underlying placental dysfunction
20
SLE and fetal risks

21. • Congenital heart block is associated with maternal
anti-Ro/La autoantibodies. usual presentation is a
fixed fetal bradycardia of 60–80 beats per minute
on ultrasound scan. It occurs in 2–3% of fetuses of
women with the anti-Ro/La antibody CHB is
associated with significant perinatal morbidity and
mortality, with about half of infants requiring
pacing by the first year of life.
21
SLE and fetal risks

22. • Congenital heart block develops between
18– 28 weeks of gestation and fetal
echocardiography should be performed
around this period to detect it. Hydrops
fetalis can occur in utero and is thought to
be due to the degree of endomyocardial
fibrosis and associated myocarditis.
22
SLE and fetal risks

23. Drug treatment in pregnant SLE
patient
• Glucocorticoids, mainly in the form of
prednisolone, are frequently but not
exclusively used as one of the first-line
treatments in pregnancy Women on
moderate to high dosages of steroids should
should be screened regularly for gestational
diabetes.
23

24. • Immunosuppressants that are used and are
generally considered safe during pregnancy
include azathioprine and
hydroxychloroquine. There is no need to
discontinue them during pregnancy
24
Drug treatment in pregnant SLE
patient

25. •To consider thromboprophylaxis
•Manage hypertension
25
Postpartum management