Lupus in Pregnancy

Contributor: Shelley Chapman, MD
Last Update: October 21, 2018

Systemic lupus erythematosus (SLE) has a predilection for women of childbearing age. Due to the profound disturbance of the immunologic system and the often multi-organ involvement, SLE can pose complex clinical problems during pregnancy. Diagnostic criteria for SLE can be reviewed elsewhere. A diagnosis of SLE does require a strongly positive result for antinuclear antibody and anti-DNA or anti-Smith antibody; however, the concept of “lupus–like” is accepted and managed as unequivocal lupus.

Pregnancy does not typically affect the long-term prognosis of SLE; however, pregnancy may be associated with more “lupus flares”. Additionally successive pregnancies do not necessarily affect individuals in the same way. Patients should be maintained on all pre-pregnancy medications unless a medication is contraindicated in pregnancy, as stopping them may lead to a “lupus flare”. Pregnancy concerns include the following:

• If antiphospholipid syndrome (APS) is present, this increases the risk for spontaneous miscarriage and fetal loss.
• The risk for preeclampsia is increased in patients with SLE.
• The risk for PTD is increased due to pregnancy complications.
• The risk for IUGR is increased.
• The infant is at risk for neonatal lupus syndrome (photosensitive rash, thrombocytopenia, hepatitis, and hemolytic anemia which are transient findings plus congenital heart block which is permanent). This syndrome occurs exclusively in neonates of women with high titer anti-SSA/Ro or anti-SSB/La.
• There is an increased risk of late pregnancy loss due to hypertension and renal compromise. Lupus nephritis should be inactive for at least 6 months prior to pregnancy to optimize outcomes for mother and baby.
• If no hypertension, renal impairment, or APS are present, then the prognosis for the pregnancy is good. Additionally, if the patient has been in remission from SLE for greater than 6 months pregnancy outcome is improved.
• The findings of maternal antiplatelet antibodies, serum creatinine > 1.5, creatinine clearance < 65 ml/min/m3 or proteinuria >2.4 grams/24 hours are associated with poor pregnancy outcomes.

Recommendations:

• Await six-month exacerbation free period before becoming pregnant.
• Adjust medications with the coordination of rheumatologist/internist. Avoid Methotrexate, Leflunomide, Warfarin and Mycophenolate as they are contraindicated in pregnancy.
• Initial maternal labs: 24-hour urine for creatinine clearance and total protein or a urine P:C ratio, CMP, lupus anticoagulant, beta 2 glycoprotein 1, anticardiolipin antibodies, anti- SSA/Ro and anti-SSB/La (unless previously done), and CBC with antiplatelet antibodies if low platelets. Consider ANA, complement studies (CH 50, C3and C4), and uric acid if these tests will impact care.
• Begin low dose baby aspirin 162 mg by mouth nightly by 12 weeks gestation for preeclampsia prophylaxis.
• Targeted ultrasound at 20 weeks.
• If positive anti-SSA/Ro or anti-SSB/La, recommend PR interval screening from 18-26 weeks gestation every other week. Also schedule MFM ECHO for these patients around 24 weeks.
• Serial growth scans in the third trimester.
• Began antenatal testing with weekly BPPs at 32 weeks; however, if fetal growth is abnormal twice weekly testing should be performed, starting at the time of diagnosis.
• Monitor blood pressure closely throughout pregnancy.
• If there is a history of a thromboembolic event, unfractionated heparin or Lovenox should be added as appropriate.
• Thrombophilia guidelines recommend prophylactic anticoagulation for patients with APS even without a history of VTE.
• Notify pediatric colleagues of maternal lupus.