Pregnant women who have had a previous blood-clotting event may benefit by continuation of blood-thinning medications throughout and after pregnancy for up to six to 12 weeks, at which time the risk of clotting associated with pregnancy seems to diminish. The patient was a 37-year-old Caucasian woman who came to our pregnancy clinic for preconception counselling. Systemic lupus erythematosus and pregnancy outcomes: an update and review of the literature. These can occur at any stage, and are more difficult to diagnose, as symptoms overlap those of normal pregnancy. This is an outstanding prospective study of pregnancies in women with SLE. At physical examination, she exhibited polyarthritis of wrists and hands, and hypertension. Plaquenil has now been found to be safe for use to treat SLE during pregnancy. © 2020 Springer Nature Switzerland AG. SLE is a multi-organ autoimmune disease that affects women of childbearing age. Lupus is a chronic condition, but symptoms tend to cycle in alternate periods of "flares" (or "flares-ups") and remissions. Lupus and pregnancy delay advice. 2005;14(8):593–7. Thus, it is paramount that care begins preconception so that proper planning in terms of optimizing the medical regimen, discontinuation of fetotoxic agents, and treatment … She should initiate azathioprine, a well-known antirheumatic drug compatible with pregnancy and breastfeeding, titrated to a maximum of 2 mg/kg/day if needed to keep SLE with previous renal major involvement under control. Thus, the risks and benefits of treatment during pregnancy must be … https://doi.org/10.1182/blood-2010-07-295444. Copyright © 2020 Springer Healthcare Limited. Presented by Dr.Lim Chong Hong, Consultant Rheumatologist, Hospital Sultanah Bahiyah during High Risk Pregnancy Summit 2018 on 7th Oct 2018. Article  The pregnancy rate was 28% and the live birth rate was 85%. Coscia LA, Armenti DP, King RW, Sifonis NM, Constantinescu S, Moritz MJ. Google Scholar. Experts discuss the increasing use of telemedicine in rheumatology during the COVID-19 pandemic. Putting research into context. It may also reduce the incidence of small-for-gestational-age fetus in mothers with SLE GN, and seems able to prevent pregnancy loss and fetal damage in patients with aPL through complement inhibition. At the first visit to the pregnancy clinic, the patient was taking the following medications: prednisone 5 mg/day for 4 days/week; MMF 2 g/day; low dose acetylsalicylic acid (LDASA) 100 mg/day; ramipril 10 mg/day; omeprazole 20 mg/day; and vitamin D (1500 IU/day). Contraception and other reliable forms of pregnancy prevention is routinely advised for women with SLE, since getting pregnant during active disease was found to be harmful. Lupus. The increased risks spontaneous miscarriage fetal death pre-eclampsia preterm delivery IUGR Related to 1. In both SLE and preeclampsia, for example, women develop worsening proteinuria with hypertension and edema. Please enable JavaScript on your browser, so that you can use all features of this website. Search. Transplantation. Results: Of 50 treatment subjects performed for the 39 women (i.e. Question 3. All treatment options have risks but these risks have to be balanced against the risks of no treatment or, ‘too late’ treatment. Ovulation stimulation as a fertility treatment could theoretically induce SLE. 1965;192(3):260. https://doi.org/10.1001/jama.1965.03080160080030. Because SLE treatment may require the use of strong immunosuppressive medications that can have serious side effects, female patients must stop taking the medication before and during pregnancy to protect unborn children from harm. Urgent premature delivery is a frequent phenomenon. Learning objectives To understand how to manage pregnant women with SLE. 2014;26(2):118–23. Anti-inflammatory and immunosuppressive drugs and reproduction. Labelling all pregnancies in women with SLE as high risk is not helpful or appropriate as those with quiescent disease will, in many cases, have uncomplicated pregnancies. J Pediatr Genet. Diagnosis, treatment and lifestyle changes are important. What therapeutic modifications would you suggest in order for the patient to become pregnant? If this drug is used, ovarian protection should be offered by means of gonadotropin-releasing hormone agonists, as was performed in the case of the this patient. An association of autoimmune disease with infertility has been suggested, but the studies are not conclusive. MMWR Morb Mortal Wkly Rep. 2008;57:1–5. Article  Management of pregnant women with renal disease involves awareness of, and allowance for, physiological changes including decreased serum creatinine and increased proteinuria. Pregnancy in systemic lupus erythematosus now has favorable outcomes for the majority of women. Autoimmun Rev. Induction treatment was initiated for SLE GN according to the National Institutes of Health protocol, with monthly intravenous cyclophosphamide for 6 months (cumulative dose 8 g) together with 1 mg/kg/day of oral prednisolone, gradually tapered to 5 mg/day over 6 months. Clowse ME, Madger LS, Petri M. Cyclophosphamide for lupus during pregnancy. In addition, SLE can flare up during pregnancy, and proper treatment can maintain the health of the mother longer. Hits on the points. Heartbeat irregularities can be successfully treated. Knight CL, Nelson-Piercy C. Management of systemic lupus erythematosus during pregnancy: challenges and solutions. Renal biopsy was compatible with class IV lupus glomerulonephritis (GN). To understand the features and associated risk factors which increase the chance of adverse pregnancy outcome in women with SLE. If your lupus is active or if you experience a flare-up, however, your medical team will work with you to treat your disease in a way that's safest for you and your growing baby. https://doi.org/10.1055/s-0035-1556743. After our preconception visit, the patient began to take hydroxychloroquine, alternating 200 and 400 mg every other day. If your lupus is active or if you experience a flare-up, however, your medical team will work with you to treat your disease in a way that's safest for you and your growing baby. Effect of SLE on pregnancy 1. 2006;8(3):209. https://doi.org/10.1186/ar1957. Smyth RM, Aflaifel N, Bamigboye AA. This article does not contain any studies with human or animal subjects performed by any of the authors. The management of SLE and pregnancy should be undertaken in a multidisciplinary setting. To identify known teratogenic medications that may be used to treat SLE and discuss alternative therapeutics that can be used throughout pregnancy in order to manage maternal autoimmune diseases. Nephrol Dial Trans. Drug Saf. Google Scholar. Learn more about Institutional subscriptions. N Engl J Med. Lewden B, Vial T, Elefant E, Nelva A, Carlier P, Descotes J, et al. Sign up ; Research; Policy; About us; Contact us; Helpline 0800 5200 520; Menu Versus Arthritis. Interventions for varicose veins and leg oedema in pregnancy. This is a preview of subscription content, log in to check access. The study was designed to exclude pregnancies with known risk factors so that the role of underlying SLE on pregnancy outcomes could be examined more closely. Pregnancy should be managed in a multidisciplinary setting – ideally in a joint clinic composed of rheumatologists, obstetricians and other specialists as needed, with clinical expertise in following pregnant patients with ARD. Queries regarding the risk of disease flares during pregnancy, chance of fetal loss, and the safety of various drugs are often raised. This is a very well written review article on the use of calcinurin inhibitors for lupus nephritis by one of the worldwide experts in the field. OBJECTIVES • Describe adverse events observed in SLE patients who become pregnant • Discuss the management of lupus pregnancies • Discuss briefly the management of Anti-Phospholipid Syndrome (APS) in pregnancy 3. Pro: The use of calcinurin inhibitors in the treatment of lupus nephritis. SLE (or lupus for short) is a multisystem, autoimmune disease, involving complex pathogenetic mechanisms that can present at any age. Prednisolone at a low dose of up to 7.5 mg/day or less may be required for maintenance therapy. How would you counsel her? PubMed Google Scholar. https://doi.org/10.1007/s40264-013-0034-x. Birth Defects Res A ClinMolTeratol. Once there are definite signs of fetal harm this cannot always be corrected and late management decisions can only institute rescue. What therapeutic modifications would you suggest in order for the patient to become pregnant?Question 3. Corticosteroid use and risk of orofacial clefts. Differentiating between lupus activity and pregnancy-related complications presents a major challenge in the management of SLE pregnancies. Management of SLE in pregnancy. Hematologic abnormalities In general, pregnancy does not cause flares of SLE. https://doi.org/10.1002/ajmg.a.34037. Many women have common complaints throughout their pregnancy. The patient decided to breastfeed and maintained the same therapeutic regime as during pregnancy. This means that you get to put up with a whole lot of symptoms ranging from morning sickness to severe pain in the legs, paired with swelling, which may even prevent you from engaging in daily tasks. Tettambel MA. If you are pregnant, your name may be listed on a pregnancy registry to track the effects of Benlysta on the baby. What should be your main concern in the presence of this antibody profile?Question 4. Use of HCQ is recommended in women with SLE preconceptionally and throughout pregnancy.33, 56, 60 A beneficial role has also been suggested for APS pregnancies,119–121 but at present there is insufficient data to recommend its routine use in these patients. Some women with lupus should delay pregnancy and discuss their plan with their treating doctor when they are planning to have a baby. 93. PubMed Central  On the other hand, antirheumatic drugs such as cyclophosphamide have the potential to decrease gonadal function. 2014;13(2):206–14. She stopped MMF and started azathioprine 100 mg/day. Ostensen M. Preconception counseling. Enoxaparin at a prophylactic dosage can be initiated as soon as the patient becomes pregnant in order to prevent first maternal event and/or obstetric adverse outcome in a patient carrying a high risk aPL profile (triple positivity). If this tutorial is part of the member benefit package, Fellows, Members, registered Trainees and Associates should sign in to access the tutorial. They were prescribed low dose Aspirin (ASA, 100 mg per day) when another new pregnancy was achieved and in those ended up again with early pregnancy loss (less than 12 complete weeks of gestation), these patients were enrolled in this cohort and would be given daily anti-coagulant treatment in the injection starting from when next pregnancy is established. This is a well performed, prospective study of pregnant outcomes following early exposure to methotrexate at doses typically used for rheumatic diseases, CAS  Serositis 6. Multidisciplinary management of pregnant women with SLE ensures optimal surveillance of both mother and fetus. ClinRheumatol. Adjunct treatment during pregnancy. 1988;296(6625):825. https://doi.org/10.1136/bmj.296.6625.825. Teratogenic immunosuppressive medications include methotrexate, mycophenolatemofetil, and cyclophosphamide. She had been in sustained complete remission for the past two and a half years, and desired to conceive a child. In women of reproductive age, the ideal time for this evaluation is close to diagnosis, in order to set the timing for a future pregnancy and to avoid, if possible, drugs that can lead to premature gonadal failure such as cyclophosphamide. Additionally, obstetric risk stratification must take into account general and disease-specific risk factors (see Table 2). One of these complaints, often overlooked, is foot pain. Several immunosuppressive therapies that are compatible with pregnancy are available to treat flares that may occur during pregnancy. A healthy male baby was born at 39 weeks of gestation by spontaneous vaginal delivery, with adequate weight for gestational age (2680 g). Caring for Yourself During Pregnancy. A randomized study of the effect of withdrawing hydroxychloroquine sulfate in systemic lupus erythematosus. Corticosteroids, such as Treatments for mild non-organ threatening disease include the disease modifying drugs hydroxychloroquine and methotrexate, and short courses of NSAIDs for symptomatic control. 4.2 In patients with adverse prognostic factors (acute deterioration in renal function, substantial cellular crescents and/or fibrinoid necrosis), similar regimens may be used, but CYC can also be prescribed monthly at higher doses (0.75–1 g/m 2) for 6 months or orally (2–2.5 mg/kg/day) for 3 … Prof. Hatem Abu Hshim,Professor of Obstetrics and gynecology Mansoura University Monoclonal antibodies, systemic lupus erythematosus, and pregnancy: insights from an open label study. Nearly all IVF cycles were supervised by an internist. Treatment can vary depending on how severe your symptoms are and which parts of your body SLE affects. PubMed  Management of SLE during pregnancy. Google Scholar. https://doi.org/10.1191/0961203305lu2169oa. PubMed  2011;155A(7):1723–8. https://doi.org/10.1002/ajmg.a.32685. Open Access Rheumatol 2017; Nar 10. https://doi.org/10.2147/OARRR.S878(. Pregnancy leads to lasting change in foot structure Am J Phys Med Rehabil. We would like to clarify the opening statement in this article that states that treatment of Systemic Lupus Erythematosus (SLE) disease activity in pregnancy may harm the baby. 2009;149A(6):1241–8. Sifonis NM, Coscia LA, Constantinescu S, Lavelanet AF, Moritz MJ, Armenti VT. Pregnancy outcomes in solid organ transplant recipients with exposure to mycophenolatemofetil or sirolimus. https://doi.org/10.1016/j.rdc.2016.12.003, https://doi.org/10.1097/01.tp.0000252683.74584.29, https://doi.org/10.1016/j.bpobgyn.2014.07.020, https://doi.org/10.1191/0961203305lu2169oa, https://doi.org/10.1016/0002-9378(73)90559-0, https://doi.org/10.1016/j.autrev.2013.10.013, https://doi.org/10.1097/00007890-198809000-00032, https://doi.org/10.1007/s40264-013-0034-x, https://doi.org/10.1182/blood-2010-07-295444, https://doi.org/10.1001/jama.1965.03080160080030, https://doi.org/10.1007/s40674-018-0085-3. Successful pregnancies are feasible in ARD patients in the presence of the conditions listed below. Treatment for SLE and APS most commonly included steroids, hydroxychloroquine, aspirin, and low molecular weight heparin. LDASA, which is also compatible with gestation and breastfeeding, should be continued during pregnancy considering the presence of aPL antibodies and its proven role in preventing pregnancy adverse outcomes such as preeclampsia and preterm delivery. Queries regarding the risk of disease flares during pregnancy, chance of fetal loss, and the safety of various drugs are often raised. During pregnancy, lupus improves in a … These drugs allow for the avoidance of or dose reduction of corticosteroids. In anticipation of pregnancy, such medications should be discontinued and replaced with immunosuppressive medications including azathioprine and cyclosporine and assessed for disease stability. Although most pregnancies are successful, all SLE patients should be considered “high risk” due to potential maternal and fetal complications. https://doi.org/10.1002/bdra.23248. Levy RA, Vilela VS, Cataldo MJ, Ramos RC, et al. Search close. However, flares of disease activity, preeclampsia, fetal loss, intrauterine growth retardation and preterm birth are established risks of such pregnancies. Using integrative therapies to treat women with chronic pelvic pain. CAS  You do not currently have access to this tutorial. • Mok CC. Br Med J. Pregnancy consultation (symbolic image with models)/© M_a_y_a/iStock, Telemedicine_allFloorbox, This site is intended for healthcare professionals only, Case study: Pregnancy in systemic lupus erythematosus | rheumatology.medicinematters.com, decrease in parity for multifactorial reasons, discuss family planning at the time of diagnosis, active disease before conception represents the main predictor of adverse pregnancy outcomes. Article  Tax calculation will be finalised during checkout. Nineteen livebirths delivered vaginally whereas 28 delivered by cesarean section. Article  Early pregnancy loss occurs in SLE patients with aPLs. In this patient’s case, since SLE disease activity has been in remission for more than a year and she did not have any other comorbidity, she should be advised that she may get pregnant after stopping teratogenic drugs, in this case MMF. The treatments may include: anti-inflammatory medications for … In anticipation of pregnancy, such medications should be discontinued and replaced with immunosuppressive medications … Hydroxychloroquine is an effective treatment in SLE, especially for arthritis and rash. Treatment can vary depending on how severe your symptoms are and which parts of your body SLE affects. Lupus flares following delivery are treated similarly to those in a non-pregnant patient. At the time of her pregnancy the disease was quiescent, controlled with a combination of azathioprine and prednisolone. A diagnosis of SLE with renal major involvement was made. 2001;10(6):401–4. The partnership of maternal-fetal medicine, high-risk obstetrics, and rheumatology is essential to maximize the chance of … Top of Page. Am J Med Genet. 2015;4(2):42–55. Pregnancy and its outcome is a major concern to most SLE patients. Although ARD do not represent a cause of infertility in themselves, they may be related to a decrease in parity for multifactorial reasons such as the concern of having a child with ARD, or being unable to care for a child due to the structural damage that may arise. https://doi.org/10.1007/s40674-018-0085-3, DOI: https://doi.org/10.1007/s40674-018-0085-3, Over 10 million scientific documents at your fingertips, Not logged in Part of Springer Nature. Vasculitis 9. 2002;9:161–4. Peart E, Clowse ME. Treatment of SLE in pregnancy and use of Chloroquine. What should be your main concern in the presence of this antibody profile? Preconception counseling and risk stratification should be performed for all women with ARD, ideally at a pregnancy clinic with both rheumatologists and obstetricians. 2015;163(3):153–63. Blood. Sufficient time should be allowed for proper washout (at least 6 weeks for MMF). Objective: We aimed to investigate the effect of HCQ on pregnancy outcomes in patients with SLE. Women with lupus can safely get pregnant and most will have normal pregnancies and … Hydroxychloroquine use throughout pregnancy is associated with improved outcomes for both mother and infant. Due to the natural weight gain during pregnancy, a woman’s center of gravity is completely altered. Ruiz-Irastorza G, Danza A, Perales I, Villar I, Garcia M, Delgado S, et al. Pregnancy is an important aspect to women’s lives, and a diagnosis of SLE should not necessarily preclude the ability to bear children. After this time, considering that her disease remained in remission, she received the “green light” to conceive. Risks of medication use need to be balanced with risks of active maternal disease. Best Pract Res Clin Obstet Gynecol. Registries of CHB cases do not provide evidence that the prompt use of fluorinated steroids in cases of isolated CHB significantly alters fetal/neonatal morbidity or mortality. 11 women enrolled twice for two pregnancies), 46 singletons and one twin achieved livebirths. To understand the importance of pre-pregnancy counselling for women with SLE. SLE pregnancies are complicated due to risk for maternal disease exacerbation and potential for fetal and neonatal complications. As SLE is a disease with onset in young adulthood, it is not surprising that management of pregnancy is a common occurrence. Pre-pregnancy counselling should also include a discussion regarding medications (see Drug therapy in SLE). Glomerulonephritis 8. Here, we present a case of a patient with systemic lupus erythematosus (SLE) with previous major-organ involvement, who was on treatment with teratogenic immunosuppressive drugs and desired to have a child. Cochraine Database Syst Rev.2015 Oct 19;(10):CD001066. However, pregnancy with the most common – and serious – type of the disease of lupus called systemic lupus erythematosus involves special implications for prenatal care. Rheum Dis Clin N Am. Pregnancy in a woman with SLE may lead to higher rates of disease flares. Lupus (SLE) is an autoimmune disease causing your immune system to attack your body's own tissues - causing inflammation. Chakravarty EF, Murray ER, Kelman A, Farmer P. Pregnancy outcomes after maternal exposure to rituximab. For women with systemic lupus erythematosus (SLE), pregnancy increases likelihood of flare. 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