Pregnancy Outcomes in Systemic Lupus Erythematosus with and without Previous Nephritis

The impact of different classes of lupus nephritis on maternal and fetal outcomes: a cohort study of 147 pregnancies

OBJECTIVE

To analyze the impact of different classes of lupus nephritis as risk variables for maternal and fetal adverse outcomes in a cohort of pregnant lupus patients.

METHODS

This is a cohort study with retrospective and prospective data collection, conducted at the University Hospital of State University of Rio de Janeiro, Brazil, from 2011 to 2016. A total of 147 pregnancies of 137 systemic lupus erythematosus patients of whom 66 had lupus nephritis were included. Demographic and clinical features, as well as maternal and fetal outcomes were observed for each nephritis histological class among systemic lupus erythematosus patients and compared with those without nephritis. Categorical variables were expressed as absolute and relative frequencies and numerical variables as means and standard deviation. The chi-square test with Fisher's correction and Student's t-test were used for statistical analysis. A pvalue < 0.05 was considered statistically significant.

RESULTS

Systemic lupus erythematosus patients with proliferative nephritis (classes III/IV, n = 54) presented more frequent disease flares ( p = 0.02), continuous active disease during pregnancy and puerperium ( p = 0.006), hospitalization due to systemic lupus erythematosus ( p < 0.001), hospitalization not directly associated to systemic lupus erythematosus ( p = 0.04), higher frequency of cesarean delivery ( p = 0.03) and preeclampsia ( p = 0.01) than patients without nephritis. Permanent damage measured by Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index was more frequent in classes III/IV than among the other patients. The frequency of adverse fetal outcomes such as prematurity and admission to neonatal intensive care unit were not different among systemic lupus erythematosus patients with or without nephritis. However, perinatal deaths were more frequent in patients with all classes of nephritis ( p = 0.003).

CONCLUSION

Systemic lupus erythematosus patients with proliferative nephritis (classes III/IV) have a higher frequency of adverse maternal outcomes. This is probably due to the major impact of proliferative forms of nephritis on women's global heath, which is corroborated by the higher Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index findings, although we cannot exclude the negative influence of disease activity for the maternal adverse events. The findings indicate a need for further lupus nephritis classification beyond the nonspecific term nephritis in the context of lupus pregnancy as the impact on maternal and fetal outcomes varies according to histological class.

Renal disease in pregnancy: Fetal, neonatal and long-term outcomes

Renal disease in women of childbearing age is estimated to be approximately 3%; consequently, renal disease is not an uncommon comorbidity in pregnancy. There has been considerable evidence published over the last 20 years to suggest that renal disease in pregnancy is associated with higher maternal, fetal, and offspring morbidity. Studies published are largely heterogeneous; include unmatched cohort studies; and focus on early neonatal outcomes such as prematurity, small for gestational age, and neonatal unit admission. There appears to be an inverse relationship between maternal renal function and likelihood of neonatal morbidity using these outcome measures. Overall though, data regarding medium-to long-term outcomes for children born to mothers with renal disease are scarce. However, in view of emerging epidemiological evidence regarding cardiovascular programming in intrauterine life in those born premature or small for gestational age, it is likely that this population of children remain at high risk of cardiovascular disease as adults. The scope of this review is to amalgamate and summarize existing evidence regarding the outcomes of infants born to mothers with renal disease. Focus will be given to pregnancy-related acute kidney injury, chronic kidney disease, dialysis, and transplantation.

Important considerations in pregnant patients with lupus nephritis

INTRODUCTION

In the last few decades, identification of predictors of pregnancy outcome and appropriate pregnancy planning have significantly reduced the maternal and fetal risks in pregnant women with lupus nephritis. Areas covered: Successful pregnancies have been reported even in women with chronic renal disease and renal insufficiency. However, refractory hypertension and severe renal or cardiac chronic dysfunction are still considered contraindications to pregnancy. Pre-term delivery and fetal growth restriction may still occur in SLE patients more frequently than in healthy women, even in pregnancies regularly planned and monitored by a team of nephrologists and gynaecologists. Expert commentary: Stable disease remission is the most important factor for a successful pregnancy. In case of flare-ups of lupus, timely diagnosis and appropriate management may ensure a successful outcome in the majority of pregnant women. The negative role of anti-phospholipid antibodies and of chronic arterial hypertension may be countered with appropriate anticoagulation and anti-hypertensive therapy. Further studies are needed to better assess the possible impact of pregnancy on the long-term outcome of lupus nephritis.

Management and outcomes of pregnancy with or without lupus nephritis: a systematic review and meta-analysis

Background

Although it is well established that systemic lupus erythematosus (SLE) negatively affects pregnancy outcomes, there is insufficient evidence on the effect of lupus nephritis (LN) on antenatal management and pregnancy outcomes. We performed a systematic review and meta-analysis to determine the association of LN with management and pregnancy outcomes in SLE patients.

Methods

Embase, Medline, Cochrane, and ClinicalTrials.gov were carefully searched for relevant English and Chinese language studies. A total of 2,987 articles were reviewed. Data were extracted that compared management and pregnancy outcomes in SLE pregnant women with LN vs without LN. Risk of bias was assessed by a modified version of the Newcastle-Ottawa Scale and the STROBE checklist. Combined odds ratios (OR) and 95% confidence intervals (CI) were obtained and sensitivity analysis was performed using RevMan 5.3 software.

Results

Sixteen studies, including 1,760 pregnant patients with SLE, were included. Gestational hypertension (OR=5.65, 95% CI=2.94–10.84), preeclampsia (OR=2.84, 95% CI=1.87–4.30), SLE flare (OR=2.66, 95% CI=1.51–4.70), renal flare (OR=15.18, 95% CI=5.89–39.14), proteinuria (OR=8.86, 95% CI=4.75–16.52), and hypocomplementemia (OR=2.86, 95% CI=1.68–4.87) were significantly affected in pregnant women with LN. Anti-Sjögren’s syndrome-related antigen A/Ro autoantibodies were negatively associated with pregnant women with LN (OR=0.57, 95% CI=0.33–0.98). Pregnant women with LN presented a significant decrease in live births (OR=0.62, 95% CI=0.49–0.80) and a significant increase in preterm births (OR=1.92, 95% CI=1.49–2.49) and fetal growth restriction (OR=1.43, 95% CI=1.08–1.91). Regarding antenatal management, steroids (OR=2.48, 95% CI=1.59–3.87) and immunosuppressant treatment (OR=6.77, 95% CI=3.30–13.89) were more frequently used in women with LN.

Conclusion

This review identified a significant association between the aforementioned outcomes and SLE pregnant patients with LN. In patients with SLE, LN increased the risks for adverse pregnancy outcomes and the use of medication. Therefore, special treatment and close monitoring should be allocated to pregnant women with LN.

Glomerular Disease in Women

Gender differences exist in the prevalence of glomerular diseases. Data based on histological diagnosis underestimate the prevalence of preeclampsia, which is almost certainly the commonest glomerular disease in the world, and uniquely gender-specific. Glomerular disease affects fertility via disease activity, the therapeutic use of cyclophosphamide, and underlying chronic kidney disease. Techniques to preserve fertility during chemotherapy and risk minimization of artificial reproductive techniques are considered. The risks, benefits, and effectiveness of different contraceptive methods for women with glomerular disease are outlined. Glomerular disease increases the risk of adverse outcomes in pregnancy, including preeclampsia; yet, diagnosis of preeclampsia is complicated by the presence of hypertension and proteinuria that precede pregnancy. The role of renal biopsy in pregnancy is examined, in addition to the use of emerging angiogenic biomarkers. The safety of drugs prescribed for glomerular disease in relation to reproductive health is detailed. The impact of both gender and pregnancy on long-term prognosis is discussed.

[Indirect causes of maternal deaths (except stroke, cardiovascular diseases and infections): Results from the French confidential enquiry into maternal deaths, 2010-2012]

Maternal deaths of indirect causes result of a preexisting disease or an affection appeared during the pregnancy without any relationship with obstetrical causes, but worsened by the physiological effects of pregnancy. Among the 23 deaths of indirect cause related to a preexisiting pathology, 22 (96 %) have been analyzed by the expert comity. A known or preexisting chronic disease was documented in 16 patients (sick-cell disorder, n=3, treated epilepsy, n=3, intracerebral carvenomas, n=1, multifocal glial tumor, n=1, breast cancer, n=1, systemic lupus, n=1, diabetes mellitus, n=3, antiphospholipid syndrome, n=1). For 6 women, the pathology was unknown before the pregnancy (glioblastoma, n=2, epilepsy, n=1, Ehlers-Danlos syndrome, n=1, sick-cell disorder, n=1, breast cancer, n=1). While 6 of these deaths has been evaluated as not avoidable, 13 deaths has been considered as possibly (n=12) or certainly (n=1) preventable. The main factor of avoidability was the patient's interaction with the health system (medically non advised pregnancy, lack of adherence to treatment, for example). A pre-pregnancy medical consultation with a specialist should be recommended to all patients with preexisting chronic disease, to allow a complete information about the risks of a pregnancy, treatment adaptation if needed, better adherence and multidisciplinary follow up.

Pregnancy and Glomerular Disease: A Systematic Review of the Literature with Management Guidelines

During pregnancy, CKD increases both maternal and fetal risk. Adverse maternal outcomes include progression of underlying renal dysfunction, worsening of urine protein, and hypertension, whereas adverse fetal outcomes include fetal loss, intrauterine growth restriction, and preterm delivery. As such, pregnancy in young women with CKD is anxiety provoking for both the patient and the clinician providing care, and because the heterogeneous group of glomerular diseases often affects young women, this is an area of heightened concern. In this invited review, we discuss pregnancy outcomes in young women with glomerular diseases. We have performed a systematic review in attempt to better understand these outcomes among young women with primary GN, we review the studies of pregnancy outcomes in lupus nephritis, and finally, we provide a potential construct for management. Although it is safe to say that the vast majority of young women with glomerular disease will have a live birth, the counseling that we can provide with respect to individualized risk remains imprecise in primary GN because the existing literature is extremely dated, and all management principles are extrapolated primarily from studies in lupus nephritis and diabetes. As such, the study of pregnancy outcomes and management strategies in these rare diseases requires a renewed interest and a dedicated collaborative effort.

Maternal and Perinatal Outcome in Women with Systemic Lupus Erythematosus: A Retrospective Bicenter Cohort Study

Objective

To investigate disease activity around and during pregnancy and pregnancy outcome in women with systemic lupus erythematosus (SLE) considering antiphospholipid antibody status. Moreover, differences between first and consecutive pregnancies were examined.

Methods

Pregnancies > 16 weeks gestation of SLE patients receiving joint care from rheumatologists and gynecologists in two tertiary centers in the Netherlands between 2000 and 2015 were included. Disease activity, flare rate, and pregnancy outcomes and complications were assessed.

Results

Ninety-six women (84% Caucasian) with 144 pregnancies were included. The median SLE(P)DAI score was 2 before, during, and after pregnancy. Flare rates were 6.3%, 20.1%, and 15.3%, respectively. Severe hypertensive disorder of pregnancy, intrauterine fetal death, preterm birth, and small-for-gestational age infants occurred in 18.1%, 4.1%, 32.7%, and 14.8%, respectively. Complication rates were similar in the first and consecutive pregnancies. Half of the women did not experience any pregnancy complication whereas 42.7% developed a complication during all pregnancies. Mean number of pregnancies was 2.4 and live births 1.7.

Conclusion

In this SLE population with low disease activity, pregnancy complications were present irrespective of antiphospholipid antibody status. Furthermore, there were no differences in complication rates between the first and consecutive pregnancies as seen in healthy mothers. This information is useful for patient counseling.

Kidney Outcomes and Risk Factors for Nephritis (Flare/De Novo) in a Multiethnic Cohort of Pregnant Patients with Lupus

BACKGROUND AND OBJECTIVES

Kidney disease is a critical concern in counseling patients with lupus considering pregnancy. This study sought to assess the risk of renal flares during pregnancy in women with previous lupus nephritis in partial or complete remission, particularly in those with antidouble-stranded DNA antibodies and low complement levels, and the risk of new-onset nephritis in patients with stable/mildly active SLE.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We assessed active nephritis (renal flares and de novo kidney disease) and associated predictors during pregnancy in patients with lupus with urine protein ≤1000 mg and serum creatinine <1.2 mg/dl at baseline; 373 patients (52% ethnic/racial minorities) enrolled between 2003 and 2012 were prospectively followed in the Predictors of Pregnancy Outcome: Biomarkers in Antiphospholipid Syndrome and Systemic Lupus Erythematosus Study. Active nephritis was defined by proteinuria increase of >500 mg and/or red blood cell casts.

RESULTS

Of 118 patients with previous kidney disease, 13 renal flares (11%) occurred (seven of 89 in complete remission and six of 29 in partial remission) compared with four with de novo kidney involvement (2%) in 255 patients without past kidney disease (P<0.001). Active nephritis was not associated with ethnicity, race, age, creatinine, BP, or antihypertensive and other medications. In multivariable logistic regression analyses, patients with past kidney disease in complete or partial remission more often experienced active nephritis (adjusted odds ratio, 6.88; 95% confidence interval, 1.84 to 25.71; P=0.004 and adjusted odds ratio, 20.98; 95% confidence interval, 4.69 to 93.98; P<0.001, respectively) than those without past kidney disease. Low C4 was associated with renal flares/de novo disease (adjusted odds ratio, 5.59; 95% confidence interval, 1.64 to 19.13; P<0.01) but not low C3 or positive anti-dsDNA alone.

CONCLUSIONS

De novo kidney involvement in SLE, even in ethnic/racial minorities, is uncommon during pregnancy. Past kidney disease and low C4 at baseline independently associate with higher risk of developing active nephritis. Antibodies to dsDNA alone should not raise concern, even in patients with past kidney disease, if in remission.

Systemic lupus erythematosus and risk of preterm birth: a systematic review and meta-analysis of observational studies

We performed a meta-analysis to identify the association between systemic lupus erythematosus (SLE) and preterm birth. In this study, we studied the effects of SLE, SLE disease activity, a history of nephritis and active nephritis on preterm birth. Searches were conducted before 20 May 2016 of PubMed, Embase, Medline and Cochrane Library of literature and article reference lists. Eleven observational case-control studies and thirteen cohort studies met the inclusion criteria. The pooled relative risk (RR) for the risk of preterm birth in SLE patients versus controls was 2.05 (95% confidence interval (CI): 1.72-3.32); for active SLE patients versus inactive was 2.98 (95% CI: 2.32-3.83); for SLE patients with a history of lupus nephritis versus those without nephritis it was 1.62 (95% CI: 1.35-1.95); and for SLE patients with active nephritis versus those with quiescent nephritis it was 1.78 (95% CI: 1.17-2.70). In summary, this study identified a significant association in the above results. This association was more significant in active SLE patients versus inactive. With respect to SLE itself, active inflammation (such as disease activity) may be more hazardous for the management of the pregnancy. This suggests that it is essential to control disease activity in order to achieve a better outcome of SLE pregnancy.

Predictors of poor obstetric outcome in women with systemic lupus erythematosus: a 10-year experience of a university hospital

OBJECTIVE

To compare the maternal and fetal outcome in patients with systemic lupus erythematosus (SLE) by a retrospective analysis from 2005 to 2010, and a prospective follow-up of pregnant SLE patients from 2010 to 2015 to find out predictors of poor obstetric outcome.

METHODS

The study included 236 SLE pregnant females (retrospective group) whose data were viewed retrospectively from their medical records, and 214 SLE pregnant females (prospective group) who were followed prospectively to record their maternal and fetal outcome.

RESULTS

There was a highly significant difference between the two groups regarding abortion, venous thromboembolism, prematurity, and intrauterine fetal death (p < 0.001) with more occurrence in retrospective group. Also, the frequency of lupus flares, worsening of renal functions, blood transfusion, maternal mortality, admission to NICU, and neonatal death was higher in the retrospective group (p < 0.05). Predictors of poor obstetric outcome included Last flare before pregnancy <6 months, number of antenatal hospital admissions ≥ 6, use of immunosuppressive therapy, the presence of anti-SSA/Ro and anti-SSB/La, and SLE with nephritis (p < 0.05).

CONCLUSION

Improved maternal and fetal outcome in women with SLE has occurred following integrated multidisciplinary approach. This emphasizes the importance of postponing pregnancy when predictors of poor outcome are encountered.

Low-molecular-weight heparin and aspirin use in relation to pregnancy outcome in women with systemic lupus erythematosus and antiphospholipid syndrome: A cohort study

OBJECTIVE

To relate anticoagulant use to pregnancy complications in women with systemic lupus erythematosus (SLE) and primary antiphospholipid syndrome (APS).

METHODS

All ongoing pregnancies, 184, in two Dutch tertiary centers between 2000 and 2015.

RESULTS

LMWH and aspirin was prescribed in 15/109 SLE women without antiphospholipid antibodies (aPL), 5/14 with aPL, 11/13 with APS, 45/48 with primary APS. Main complications in the four treatment groups (no anticoagulant treatment, aspirin, LMWH, aspirin and LMWH) included hypertensive disorders of pregnancy (9.4%, 23.3%, 50%, 18.4%, respectively, p = 0.12) and preterm birth (16.7%, 34.3%, 75%, 36.8%, respectively, p < 0.001).

CONCLUSION

Maternal and perinatal complications occurred frequently, despite LMWH and aspirin use.

Pregnancy and Lupus Nephritis

The management of lupus nephritis in pregnancy presents a diagnostic and therapeutic challenge for providers. Pregnancy creates a series of physiologic changes in the immune system and kidney that may result in an increased risk of disease flare and adverse maternal and fetal outcomes, such as preeclampsia, fetal loss, and preterm delivery. Conception should be delayed until disease is in remission to ensure the best pregnancy outcomes. Maternal disease activity and fetal well-being should be monitored closely by an interdisciplinary team, including obstetricians, rheumatologists, and nephrologists throughout pregnancy. Careful attention must be paid to the dosing and potential teratogenicity of medications.

Systemic lupus erythematosus pregnancies: ten-year data from a single centre in Malaysia

We performed a retrospective study of all systemic lupus erythematosus (SLE) pregnancies during a 10-year period (2006–2015) to describe the clinical features, maternal and foetal outcomes in our centre. There were 115 pregnancies in 86 women with SLE. Our patients had a mean age of 29.1 years (SD 5.80) and a mean disease duration of 44.63 months (SD 41.17). Fifteen patients had antiphospholipid syndrome (APS). Our patients had complicated pregnancies: 26.1% had SLE flares, 13.9% had pre-eclampsia and 45.1% needed caesarean sections. There were 23.3% foetal losses and 25% preterm deliveries in our patients. There was a higher rate of unplanned pregnancies and lupus flare among pregnancies with active SLE at conception. Pregnancies in lupus nephritis have higher incidence of lupus flares during pregnancy but similar maternal and foetal outcomes compared to those without nephritis. The prognostic indicators for adverse foetal outcome in our patients were flare of SLE (HR 4.08 [CI 95% 1.65–10.13, p < 0.01]) and APS (HR 3.07 [CI 95% 1.12–8.42, p < 0.05]) and the prognostic indicator for adverse maternal outcome was hypertension (HR 3.58 [CI 95% 1.30–9.90, p < 0.05]). Lupus pregnancies in our centre remained as high-risk pregnancies with significant maternal and foetal complications.

EULAR recommendations for women's health and the management of family planning, assisted reproduction, pregnancy and menopause in patients with systemic lupus erythematosus and/or antiphospholipid syndrome

Objectives

Develop recommendations for women's health issues and family planning in systemic lupus erythematosus (SLE) and/or antiphospholipid syndrome (APS).

Methods

Systematic review of evidence followed by modified Delphi method to compile questions, elicit expert opinions and reach consensus.

Results

Family planning should be discussed as early as possible after diagnosis. Most women can have successful pregnancies and measures can be taken to reduce the risks of adverse maternal or fetal outcomes. Risk stratification includes disease activity, autoantibody profile, previous vascular and pregnancy morbidity, hypertension and the use of drugs (emphasis on benefits from hydroxychloroquine and antiplatelets/anticoagulants). Hormonal contraception and menopause replacement therapy can be used in patients with stable/inactive disease and low risk of thrombosis. Fertility preservation with gonadotropin-releasing hormone analogues should be considered prior to the use of alkylating agents. Assisted reproduction techniques can be safely used in patients with stable/inactive disease; patients with positive antiphospholipid antibodies/APS should receive anticoagulation and/or low-dose aspirin. Assessment of disease activity, renal function and serological markers is important for diagnosing disease flares and monitoring for obstetrical adverse outcomes. Fetal monitoring includes Doppler ultrasonography and fetal biometry, particularly in the third trimester, to screen for placental insufficiency and small for gestational age fetuses. Screening for gynaecological malignancies is similar to the general population, with increased vigilance for cervical premalignant lesions if exposed to immunosuppressive drugs. Human papillomavirus immunisation can be used in women with stable/inactive disease.

Conclusions

Recommendations for women's health issues in SLE and/or APS were developed using an evidence-based approach followed by expert consensus.

Pregnancy in women with systemic lupus erythematosus (SLE)

For many years pregnancy has been contraindicated in patients with SLE, particularly when kidney involvement was present. Today, pregnancy is no longer considered impossible in women with lupus. Yet, lupus pregnancies are still considered high-risk. The prognosis has considerably improved for pregnant women but the fetal risk, although progressively reduced, is still higher in pregnancies of patients with SLE than in pregnancies of healthy women. Miscarriage, premature delivery, and preeclampsia, as well as heart problems in the baby are the major complications that can occur. In this paper we will review the outcome of pregnant women with SLE, the influence of lupus on fetal outcome, the effects of pregnancy on lupus, and the management of pregnant lupus patients based on our personal experience and the revision of the most recent and significant papers on the subject.

A best practice position statement on pregnancy in chronic kidney disease: the Italian Study Group on Kidney and Pregnancy

Pregnancy is increasingly undertaken in patients with chronic kidney disease (CKD) and, conversely, CKD is increasingly diagnosed in pregnancy: up to 3 % of pregnancies are estimated to be complicated by CKD. The heterogeneity of CKD (accounting for stage, hypertension and proteinuria) and the rarity of several kidney diseases make risk assessment difficult and therapeutic strategies are often based upon scattered experiences and small series. In this setting, the aim of this position statement of the Kidney and Pregnancy Study Group of the Italian Society of Nephrology is to review the literature, and discuss the experience in the clinical management of CKD in pregnancy. CKD is associated with an increased risk for adverse pregnancy-related outcomes since its early stage, also in the absence of hypertension and proteinuria, thus supporting the need for a multidisciplinary follow-up in all CKD patients. CKD stage, hypertension and proteinuria are interrelated, but they are also independent risk factors for adverse pregnancy-related outcomes. Among the different kidney diseases, patients with glomerulonephritis and immunologic diseases are at higher risk of developing or increasing proteinuria and hypertension, a picture often difficult to differentiate from preeclampsia. The risk is higher in active immunologic diseases, and in those cases that are detected or flare up during pregnancy. Referral to tertiary care centres for multidisciplinary follow-up and tailored approaches are warranted. The risk of maternal death is, almost exclusively, reported in systemic lupus erythematosus and vasculitis, which share with diabetic nephropathy an increased risk for perinatal death of the babies. Conversely, patients with kidney malformation, autosomal-dominant polycystic kidney disease, stone disease, and previous upper urinary tract infections are at higher risk for urinary tract infections, in turn associated with prematurity. No risk for malformations other than those related to familiar urinary tract malformations is reported in CKD patients, with the possible exception of diabetic nephropathy. Risks of worsening of the renal function are differently reported, but are higher in advanced CKD. Strict follow-up is needed, also to identify the best balance between maternal and foetal risks. The need for further multicentre studies is underlined.

Pregnancy across the spectrum of chronic kidney disease

Management of the pregnant woman with chronic kidney disease is difficult for both nephrologists and obstetricians. Prepregnancy counselling with respect to risk stratification, optimization of maternal health prior to pregnancy, as well as management of the many potential pregnancy-associated complications in this complex patient population remains challenging due to the paucity of large, well-designed clinical studies. Furthermore, the heterogeneity of disease and the relative infrequency of pregnancy, particularly in more advanced stages of chronic kidney disease, leaves many clinicians feeling ill prepared to manage these pregnancies. As such, counselling is imprecise and management varies substantially across centers. All pregnancies in women with chronic kidney disease can benefit from a collaborative multidisciplinary approach with a team that consists of nephrologists experienced in the management of kidney disease in pregnancy, maternal-fetal medicine specialists, high-risk pregnancy nursing staff, dieticians, and pharmacists. Further access to skilled neonatologists and neonatal intensive care unit support is essential given the risks for preterm delivery in this patient population. The goal of this paper is to highlight some of the data that currently exist in the literature, provide management strategies for the practicing nephrologist at all stages of chronic kidney disease, and explore some of the knowledge gaps where future multinational collaborative research efforts should concentrate to improve pregnancy outcomes in women with kidney disease across the globe.

The role of second trimester uterine artery Doppler in pregnancies with systemic lupus erythematosus

OBJECTIVE

The aim of this article is to assess the predictive value of second trimester mean uterine artery Doppler pulsatility index (mUtA PI) for pregnancy complications in women with systemic lupus erythematosus (SLE).

METHODS

Cohort study of consecutive pregnancies complicated with SLE during a period of 12 years is used. SLE diagnosis was made before pregnancy. mUtA PI was measured between 23 + 0 and 26 + 6 weeks' gestation. Pregnancy and neonatal outcomes were collected. Small for gestational age (SGA) was defined as birth weight <10th percentile. Adverse pregnancy outcome (APO) was defined as one of the following: pre-eclampsia (PE), SGA, placental abruption, stillbirth, or neonatal death. Differential diagnosis between PE and renal flare was made according to SLE-disease activity index.

RESULTS

There are 70 pregnancies in 64 women. PE was observed in four cases (6%), SGA in five cases (7%), and APO in seven cases (10%). mUtA PI showed a sensitivity and a specificity of 1.0 (95% CI 0.5-1.0) and 1.0 (95% CI 0.95-1.0) for PE, 0.40 (95% CI 0.12-0.77) and 0.97 (95% CI 0.89-0.99) for SGA, and 0.57 (95% CI 0.25-0.84) and 1.0 (95% CI 0.94-1.0) for APO, respectively.

CONCLUSION

Our findings suggest that uterine artery Doppler is confirmed to be a high sensitivity and a high specificity test for predicting PE even in SLE patients.

Fertility and pregnancy in rheumatoid arthritis and systemic lupus erythematosus

Background

Rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE) are disorders that commonly impact reproductive aged women.

Findings

Both women with RA and SLE have smaller sized families than do controls. In the case of RA factors other than fertility contribute, while in women with SLE there may be diminished ovarian reserve due to cyclophosphamide therapy and advanced maternal age. RA pregnancies can be complicated by preterm birth and small-for-gestational aged infants. SLE pregnancies have higher rates of fetal loss, in particular in those patients with co-existing antiphospholipid syndrome. SLE pregnancies are also more likely to be complicated by pre-eclampsia and hypertension and to result in preterm birth and small-for-gestational aged infants.

Conclusion

Appropriate fertility evaluation and careful pregnancy planning with coordinated obstetrical care help ensure better outcomes in these patient populations.

Predictors of Pregnancy Outcomes in Patients With Lupus: A Cohort Study

BACKGROUND

Because systemic lupus erythematosus (SLE) affects women of reproductive age, pregnancy is a major concern.

OBJECTIVE

To identify predictors of adverse pregnancy outcomes (APOs) in patients with inactive or stable active SLE.

DESIGN

Prospective cohort.

SETTING

Multicenter.

PATIENTS

385 patients (49% non-Hispanic white; 31% with prior nephritis) with SLE in the PROMISSE (Predictors of Pregnancy Outcome: Biomarkers in Antiphospholipid Antibody Syndrome and Systemic Lupus Erythematosus) study. Exclusion criteria were urinary protein-creatinine ratio greater than 1000 mg/g, creatinine level greater than 1.2 mg/dL, prednisone use greater than 20 mg/d, and multifetal pregnancy.

MEASUREMENTS

APOs included fetal or neonatal death; birth before 36 weeks due to placental insufficiency, hypertension, or preeclampsia; and small-for-gestational-age (SGA) neonate (birthweight below the fifth percentile). Disease activity was assessed with the Systemic Lupus Erythematosus Pregnancy Disease Activity Index and the Physician's Global Assessment (PGA).

RESULTS

APOs occurred in 19.0% (95% CI, 15.2% to 23.2%) of pregnancies; fetal death occurred in 4%, neonatal death occurred in 1%, preterm delivery occurred in 9%, and SGA neonate occurred in 10%. Severe flares in the second and third trimesters occurred in 2.5% and 3.0%, respectively. Baseline predictors of APOs included presence of lupus anticoagulant (LAC) (odds ratio [OR], 8.32 [CI, 3.59 to 19.26]), antihypertensive use (OR, 7.05 [CI, 3.05 to 16.31]), PGA score greater than 1 (OR, 4.02 [CI, 1.84 to 8.82]), and low platelet count (OR, 1.33 [CI, 1.09 to 1.63] per decrease of 50 × 109 cells/L). Non-Hispanic white race was protective (OR, 0.45 [CI, 0.24 to 0.84]). Maternal flares, higher disease activity, and smaller increases in C3 level later in pregnancy also predicted APOs. Among women without baseline risk factors, the APO rate was 7.8%. For those who either were LAC-positive or were LAC-negative but nonwhite or Hispanic and using antihypertensives, the APO rate was 58.0% and fetal or neonatal mortality was 22.0%.

LIMITATION

Patients with high disease activity were excluded.

CONCLUSION

In pregnant patients with inactive or stable mild/moderate SLE, severe flares are infrequent and, absent specific risk factors, outcomes are favorable.

PRIMARY FUNDING SOURCE

National Institutes of Health.

Understanding and Managing Pregnancy in Patients with Lupus

Systemic lupus erythematosus (SLE) is a chronic, multisystemic autoimmune disease that occurs predominantly in women of fertile age. The association of SLE and pregnancy, mainly with active disease and especially with nephritis, has poorer pregnancy outcomes, with increased frequency of preeclampsia, fetal loss, prematurity, growth restriction, and newborns small for gestational age. Therefore, SLE pregnancies are considered high risk condition, should be monitored frequently during pregnancy and delivery should occur in a controlled setting. Pregnancy induces dramatic immune and neuroendocrine changes in the maternal body in order to protect the fetus from immunologic attack and these modifications can be affected by SLE. The risk of flares depends on the level of maternal disease activity in the 6–12 months before conception and is higher in women with repeated flares before conception, in those who discontinue useful medications and in women with active glomerulonephritis at conception. It is a challenge to differentiate lupus nephritis from preeclampsia and, in this context, the angiogenic and antiangiogenic cytokines are promising. Prenatal care of pregnant patients with SLE requires close collaboration between rheumatologist and obstetrician. Planning pregnancy is essential to increase the probability of successful pregnancies.

Systemic lupus erythematosus and outcomes in first and subsequent births based on data from a national birth registry

OBJECTIVE

To examine the associations between systemic lupus erythematosus (SLE) and outcomes in first and subsequent births.

METHODS

Data from the Medical Birth Registry of Norway during the period December 1, 1998 to December 31, 2009 were used to assess maternal and perinatal outcomes in women diagnosed with SLE compared with the general population. Outcomes of first and subsequent births were analyzed separately. Associations between SLE and pregnancy outcomes were assessed in logistic regression analyses and are shown as adjusted odds ratios (aORs) after adjustment for maternal age, gestational age, smoking habits, and previous cesarean section (CS), when relevant.

RESULTS

We analyzed 95 first and 145 subsequent births in patients and compared them with references. The risk of CS was two-fold higher in SLE patients in first and subsequent births. More newborns of patients had a birth weight <2,500 gm (aOR 5.00 [95 % confidence interval (95% CI) 3.02, 8.27] in first births and aOR 4.33 [95% CI 2.64, 7.10] in subsequent births). Additionally, preterm birth was more frequent among SLE patients (aOR 4.04 [95% CI 2.45, 6.56] in first births and aOR 3.13 [95% CI 1.97, 4.98] in subsequent births). Congenital malformations were more prevalent among children of patients than references (aOR 2.71 [95% CI 1.25, 5.86] in first births and aOR 3.13 [95% CI 1.69, 5.79] in subsequent births). Perinatal death was more frequent in first births among patients (aOR 7.34 [95% CI 2.69, 20.03]), but no difference was observed in subsequent births.

CONCLUSION

Pregnancy complications were more frequent in SLE patients than references, and the greatest differences between groups were observed in first births.

[Pregnancy and inflammatory rheumatic diseases]

Pregnancy in women with rheumatic diseases represents a challenge for patients and physicians and requires optimal shared decision-making strategies. However, the majority of women can have a successful pregnancy and the vast majority of babies are born healthy. Specific preconception care should be offered to women with rheumatic diseases to optimize and increase the chances of a successful pregnancy. A careful assessment of possible risks and the justified use of antirheumatic drugs before, during and after pregnancy are key issues.

Aspirin for prevention of preeclampsia in lupus pregnancy

Preeclampsia, the onset of hypertension and proteinuria during pregnancy, is a common medical disorder with high maternal and fetal mortality and morbidity. The underlying pathology remains poorly understood and includes inflammation, endothelial dysfunction, and an unbalanced thromboxane A₂/prostacyclin ratio. For women with systemic lupus erythematosus (SLE), particularly those with preexisting renal disease or with active lupus, the risk of developing preeclampsia is up to 14% higher than it is among healthy individuals. The mechanism is still unknown and the data for preventing preeclampsia in lupus pregnancies are rare. Modulating the impaired thromboxane A₂/prostacyclin ratio by administration of low-dose aspirin appears to be the current best option for the prevention of preeclampsia. After providing an overview of the pathogenesis of preeclampsia, preeclampsia in lupus pregnancies, and previous trials for prevention of preeclampsia with aspirin treatment, we recommend low-dose aspirin administration for all lupus patients starting prior to 16 weeks of gestation. Patients with SLE and antiphospholipid syndrome should receive treatment with heparin and low-dose aspirin during pregnancy.

The management of lupus nephritis

Lupus nephritis is one of the most devastating complications of systemic lupus erythematosus. New treatment approaches and recommendations aim to decrease mortality and improve quality of life and outcomes. The role of the primary care provider is essential to help manage complications of treatment and avoid organ damage.

Managing lupus patients during pregnancy

Systemic lupus erythematosus (SLE) is an auto-immune disease, primarily affecting young females. Pregnancy in a woman with SLE remains a high-risk situation with higher maternal and foetal mortality and morbidity. Although live births are achieved in majority of the pregnancies, active disease and major organ involvement can negatively affect the outcomes. A higher risk of foetal loss, pre-term birth, intra-uterine growth restriction (IUGR) and neonatal lupus syndromes (NLSs) are major foetal issues. Mothers are faced with disease flares, pre-eclampsia and other complications. Disease flares during SLE pregnancy pose the unique issue of recognition and differentiation between physiologic changes and disease state. Similarly, pre-eclampsia and lupus nephritis may lead to diagnostic confusion. Treatment choices during pregnancy are limited to a few safe drugs, further restricting the options. Refractory pregnancy loss associated with anti-phospholipid antibodies (aPLs) and complete heart block associated with anti-Ro antibodies remain unresolved issues. A multidisciplinary approach, with close monitoring, is essential for optimal outcomes.

Connective tissue disease in pregnancy

Connective tissue diseases (CTD) include a variety of chronic multisystem disorders with a high percentage of autoimmune conditions. Many of these conditions affect women of childbearing age and, therefore, pregnancy poses an important challenge for doctors looking after such women. Knowledge of medication safety, the effect of pregnancy on such diseases and vice versa, together with preconception counselling and multidisciplinary team care, are the basic pillars needed to provide the best obstetric and medical care to these women. In this review, we discuss the management of the most common autoimmune CTD before, during and after pregnancy, along with the most relevant issues regarding appropriate medication.

Ethnic differences in the number of miscarriages, number of children, perceived family support and the impact of the disease on daily living in patients with systemic lupus erythematosus

Our aim was to test for ethnic differences in the number of children, number of miscarriages, family support and the impact of the disease on daily living among patients with systemic lupus erythematosus (SLE). Patients with SLE (n = 54) who attended two hospitals in Essex, UK, were asked to complete a semi-structured, validated questionnaire. The number of children and the number of miscarriages were reported numerically. The level of family support and the impact of the disease on daily living were reported using 10 cm visual analogue scales (VAS) in which 10 cm represented the maximum support and worst effect on daily living, respectively. There were 20 Caucasian, 22 Asian and 12 African/Afro-Caribbean patients. There were 50 females and four males. The mean ± standard deviation (SD) age was 45.9 ± 12.2 years, and the mean ± SD age at disease onset was 35.6 ± 11.1 years. Overall, 34/50 female patients (68 %) reported having children of their own, while 17/50 female patients (34 %) reported one or more miscarriages. The miscarriages were mostly reported by Caucasian patients (45 % versus 18.1 % for Asian and 33.3 % for African/Afro-Caribbean patients; P < 0.05). All of the groups received support from their families (90.7 % overall), but the level of support was greater for Caucasian (mean ± SD VAS, 6.6 ± 3.4 cm) than for Asian (5.4 ± 3.9 cm) and African/Afro-Caribbean (5.4 ± 4.9 cm) patients (P = 0.06). More than half of the patients (53.7 %) reported a severe impact of SLE on daily living, while 13 % reported a moderate impact, 22.2 % reported a mild impact and 11.1 % reported no impact. The impact of SLE on daily living was significantly worse for African/Afro-Caribbean patients compared with Asian patients (P < 0.05). Overall, one in two patients with SLE reported having children of their own, while one in three patients reported having at least one miscarriage. Ninety percent of the patients received family support for their disease. Miscarriages and family support were more frequently reported by Caucasian patients. Asian patients had more children and experienced fewer miscarriages, while African/Afro-Caribbean patients reported a worse impact of the disease on daily living compared with the other ethnic groups.

Low risk of renal flares and negative outcomes in women with lupus nephritis conceiving after switching from mycophenolate mofetil to azathioprine

OBJECTIVE

MMF is teratogenic and needs to be replaced before pregnancy. This change may lead to flares. Our aim was to determine the risk of renal flares in women with LN who switched treatment from MMF to AZA before conception and to evaluate the outcome of their pregnancies.

METHODS

Medical records of women with LN counselled for pregnancy wish were reviewed. Women receiving treatment with either MMF or AZA (control group), with inactive lupus (SLEDAI ≤ 4) and quiescent LN (serum creatinine <1.5 mg/dl, inactive sediment and proteinuria <1 g/24 h for the preceding 6 months) were eligible for this study.

RESULTS

We identified 54 women [23 treated with MMF (group 1) and 31 treated with AZA (group 2)]. MMF dosage was tapered and subsequently transferred to AZA, which was maintained throughout pregnancy. Three (13%) patients (group 1) vs none (group 2) developed a renal flare 3-6 months after transitioning from MMF to AZA (P = 0.14) before pregnancy ensued. The only parameter with a significant difference in those with flare compared with those without was younger age (median 27 vs 30 years; P = 0.03). Risk for adverse outcome within 48 pregnancies (pre-eclampsia 9%, preterm delivery 20.5%) increased with every milligramme of prednisone dosage [odds ratio (OR) 2.03] and every single unit of SLEDAI score (OR 3.92). Renal flares occurred post-partum in two women. No patient developed worsening of renal function.

CONCLUSION

Replacing MMF with AZA in patients with quiescent LN for pregnancy planning rarely leads to renal flares. Pregnancy outcome was favourable.

Management of pregnancy in systemic lupus erythematosus

Systemic lupus erythematosus (SLE) is an autoantibody-mediated systemic autoimmune disease, predominantly affecting young females. Pregnancy is increasingly common in the setting of SLE, as survival and quality of life of patients improve. Although live births can be achieved in the most cases, pregnancy in patients with SLE remains a high-risk condition. Maternal and fetal mortality and morbidity are considerably increased, compared with the general population. Aberrations in pregnancy-related maternal immune adaptations are likely contributors. Active maternal disease, renal involvement, specific autoantibody subsets and advanced organ damage are predictors of poor outcome. Therapeutic options are limited during pregnancy as maternal benefit has to be weighed against fetal risk. Prevention of preterm birth and refractory pregnancy loss, as well as management of established neonatal heart block remain unmet needs. Further research should address these important issues that affect young patients with SLE and their babies.

Pregnancy and renal outcomes in lupus nephritis: an update and guide to management

Systemic lupus erythematosis (SLE) commonly affects women of child bearing-age, and advances in treatment have resulted in an increasing number of women with renal involvement becoming pregnant. Knowledge of the relationship of the condition with respect to fertility and pregnancy is important for all clinicians involved in the care of women with lupus nephritis because they have complicated pregnancies. Presentation of lupus nephritis can range from mild asymptomatic proteinuria to rapidly progressive renal failure and may occur before, during, or after pregnancy. The timing of diagnosis may influence pregnancy outcome. Pregnancy may also affect the course of lupus nephritis. All pregnancies in women with lupus nephritis should be planned, preferably after more than six-months of quiescent disease. Predictors of poor obstetric outcome include active disease at conception or early pregnancy, baseline poor renal function with Creatinine >100 μmol/L, proteinuria >0.5 g/24 hours, presence of concurrent antiphospholipid syndrome and hypertension. In this review the most recent studies of pregnancies in women with lupus nephritis are discussed and a practical approach to managing women prepregnancy, during pregnancy and post-partum is described.