Obstetric hospitalizations in the United States for women with systemic lupus erythematosus and rheumatoid arthritis

Managing pregnancy in inflammatory rheumatological diseases

Historically, pregnancy in women with many inflammatory rheumatic diseases was not considered safe and was discouraged. Combined care allows these pregnancies to be managed optimally, with the majority of outcomes being favorable. Disease activity at the time of conception and anti-phospholipid antibodies are responsible for most complications. Disease flares, pre-eclampsia, and thrombosis are the main maternal complications, whereas fetal loss and intrauterine growth restriction are the main fetal complications. Antirheumatic drugs used during pregnancy and lactation to control disease activity are corticosteroids, hydroxychloroquine, sulphasalzine, and azathioprine. Vaginal delivery is possible in most circumstances, with cesarean section being reserved for complications.

Rheumatic diseases and pregnancy

PURPOSE OF REVIEW

This review discusses how inflammatory rheumatic diseases [rheumatoid arthritis, ankylosing spondylitis, systemic lupus erythematosus (SLE)] of the mother can influence the course of pregnancy and the development of the fetus. Antirheumatic drug therapy of the mother and strategies to prevent fetal complications namely in SLE must be considered with care.

RECENT FINDINGS

The current literature is presented discussing hypotheses about the immunologic mechanisms leading to amelioration or exacerbation of the rheumatic symptoms in rheumatoid arthritis and ankylosing spondylitis during pregnancy. In SLE, several recent studies have been published concerning fetal complications in the antiphospholipid syndrome and in Ro/SSA-positive and La/SSB-positive mothers and how to diagnose, treat, or prevent these.

SUMMARY

Today, women with inflammatory rheumatic diseases are normally fertile and can be encouraged to become pregnant, when there is a stable and quiescent phase of the disease. This is in particular important for patients with SLE, although pregnancy outcome in SLE has improved over the last decades. Pregnancy in SLE is still a high-risk period during the disease course with the highest risk in women with active lupus nephritis. In contrast, women with rheumatoid arthritis develop amelioration of the rheumatic symptoms during the course of pregnancy in most cases; female ankylosing spondylitis patients are likely to show unaltered or aggravated symptoms of back pain and impaired function.

Fertility in women with chronic inflammatory arthritides

OBJECTIVE

To compare fertility rates in women with RA, other chronic arthritides (OCAs) and JIA with reference women from the general population.

METHODS

Each woman from a Norwegian patient registry was matched by year of birth with 100 reference women randomly selected from the National Population Registry. Data linkage of patients and references with the Medical Birth Registry of Norway (MBRN) identified all offspring in patients and references until October 2007, and indirectly also nulliparous (childless) women. Groups were compared with Mann-Whitney U-test for continuous variables and chi-squared tests for categorical variables. Poisson regression analysis was applied to calculate relative fertility rates in the diagnostic groups vs references.

RESULTS

Among 631 patients 849 children were registered in MBRN. Of these, 289 children (34.0%) were born after time of diagnosis vs 44.3% in references. Altogether, 206 of 631 patients (32.6%) were nulliparous vs 26.4% in references (P < 0.001). Among RA patients, 28.4% (96 of 338) were nulliparous vs 24.5% in references (P = 0.09), 30.7% (67 of 218) in OCA patients vs 24.5% in references (P = 0.03) and 57.3% (43 of 75) in JIA patients vs 40.9% in references (P = 0.004). Adjusted relative fertility rates in RA, OCA and JIA after diagnosis were 0.88, 0.84 and 0.84, respectively, compared with references.

CONCLUSION

A higher proportion of women with chronic inflammatory arthritides were nulliparous compared with references, and relative fertility rates were reduced in all patient groups.

Rheumatoid arthritis and birth outcomes: a Danish and Swedish nationwide prevalence study

OBJECTIVES

To examine the prevalence of preterm birth, infants with low Apgar score, small for gestational age (SGA) birth, stillbirth and congenital abnormalities in women with rheumatoid arthritis (RA) compared with women without RA.

DESIGN

Prevalence study.

SETTING

Combined Sweden and Denmark nationwide from 1994 to 2006.

SUBJECTS

We included 871,579 women with a first-time singleton birth identified through population-based healthcare databases.

MAIN OUTCOME MEASURES

We compared the prevalence of preterm birth, low Apgar score (<7 at 5 min), SGA birth, stillbirth and congenital abnormalities amongst women with RA compared with women without RA using prevalence odds ratio (OR) with 95% confidence interval (95% CI), whilst controlling for maternal age, smoking, parental cohabitation and year. We stratified analyses by period of birth (1994-1997, 1998-2001 and 2002-2006).

RESULTS

Amongst 1199 women with RA, 7.8% gave birth between 32 and 36 gestational weeks (adjusted OR, 1.44; 95% CI, 1.14-1.82), 1.4% gave birth before gestational week 32 (adjusted OR, 1.55; 95% CI, 0.97-2.47), 1.6% had an infant with a low Apgar score (OR, 0.99; 95% CI, 0.95-1.65), 5.9% had an SGA birth (adjusted OR, 1.56; 95% CI, 1.2-2.01), 0.9% experienced stillbirth (adjusted OR, 2.07; 95% CI, 0.98-4.35) and 4.3% gave birth to an infant with congenital abnormalities (adjusted OR,1.32; 95% CI, 0.98-1.79). The OR for congenital abnormalities decreased from 2.57 (95% CI, 1.59-4.16) in 1994-1997 to 1.00 (95% CI, 0.64-1.56) in 2002-2006.

CONCLUSIONS

Women with RA had a high prevalence of most adverse birth outcomes. This could be due to inflammatory activity, medical treatment or other factors not controlled for.

Managing contraception and pregnancy in the rheumatologic diseases

Most pregnancies in women with rheumatologic disease will result in the delivery of a healthy baby. Pregnancy can be particularly risky in women with active disease or on teratogenic medications, making contraception an important issue for these women. All women with rheumatologic disease have contraceptive options, including barrier methods, the intra-uterine device and progesterone-only medications. Active inflammatory disease, whether in the form of lupus, systemic vasculitis or myositis, places the pregnancy at increased risk. Pre-eclampsia is a particular risk for women with lupus or antiphospholipid syndrome and may be decreased by daily low-dose aspirin. Rheumatoid arthritis typically improves and does not have a major impact on pregnancy outcomes. The expected post-partum arthritis flare may be avoided by restarting medications soon after delivery. Judicious use of medication and close observation may be the keys to successful pregnancy in women with rheumatologic disease.

Management of rheumatic diseases during pregnancy

Systemic rheumatic diseases commonly affect women during the childbearing years. Many women with these diseases may be contemplating pregnancy or discover an inadvertent pregnancy, leading to concerns regarding medication use, changes in disease activity during pregnancy, safety of lactation, and future ability to care for a child given the presence of chronic illnesses. There are outstanding reviews that summarize the safety and use of immunosuppressive medications during pregnancy. However, in addition to medication use, providers need to be aware of the available data regarding fertility, pregnancy outcomes, delivery, and lactation issues that may be specific to individual diseases. Optimally, women should plan pregnancies to occur around times of disease quiescence, several months after potentially teratogenic medications have been discontinued. The course of the underlying rheumatic disease during pregnancy is variable, and there are no specific clinical or laboratory variables that consistently predict disease improvement or worsening during pregnancy. Recent data suggest that increased disease activity in women with most autoimmune diseases during pregnancy may lead to increased risk of premature delivery, low-birth-weight infants, and other adverse pregnancy outcomes. Arthritis involving the cervical spine and hips may impact delivery and must be considered by both obstetricians and obstetric anesthesiologists. Data are mixed regarding the impact of breastfeeding on underlying autoimmune diseases; the choice to continue breastfeeding is a personal decision.

Neurodevelopment in the offspring of Japanese systemic lupus erythematosus patients

OBJECTIVE

To evaluate pregnancy outcome of systemic lupus erythematosus (SLE) and the neuropsychological outcomes in offspring of SLE mothers.

STUDY DESIGN

Pregnancy outcomes of SLE patients from 1989 to 2006 were determined and the neuropsychological development of the children born to SLE patients was examined suited for their age; Bayley Scales of Infant Development up to four years and Kauffmann Assessment Battery for Children from four years onwards.

RESULTS

Of the 233 deliveries, 58 (24.7%) were preterm, 72 (30.9%) were low-birth-weight, and 46 (19.7%) were IUGR. Twenty-six children enrolled in this study had normal intelligence. The mean MDI and PDI were 95.8+/-10.1 and 94.6+/-14.1, respectively. The mean scores for the Sequential Processing scale, Simultaneous Processing scale, and Mental Processing composite were 103.1+/-13.3, 104.2+/-10.2, and 104.2+/-12.2, respectively. In the children with anti-Ro/SS-A antibody-positive mothers, mean gestational age and birth weight were significantly lower (p<0.05), as a result, the mean score of Sequential Processing and Mental Processing were significantly lower than that of negative mothers. The presence of maternal antiphospholipid antibody was not related to gestational age, birth weight and any score on the intelligence tests, except for the rate of IUGR.

CONCLUSION

The rates of preterm delivery and IUGR were frequent in the SLE patients and careful monitoring and management of the disease during pregnancy are still necessary. We should examine the neurodevelopment of the children born from mothers with anti-Ro/SS-A antibody prospectively.

Dysregulated complement activation as a common pathway of injury in preeclampsia and other pregnancy complications

The complement system protects the host against invading organisms, initiates inflammation and dispose of immune complexes and the products of inflammatory injury. The complement system provides an important link between the innate and adaptive immune systems. Experimental observations suggest that increased complement activation causes and/or perpetuates inflammation during pregnancy. Recent studies suggest a link between complement activation and preeclampsia. Excessive activation or insufficient regulation of complement recruits leukocytes and unleashes potent inflammatory and anti-angiogenic mediators associated with placental insufficiency and maternal endothelial dysfunction characteristic of preeclampsia. We review the animal and human studies that link complement activation and pathogenic events in preeclampsia, present evidence that activation of the complement system is associated with the development of preeclampsia and provides new targets to prevent its complications.

The management of rheumatic diseases in pregnancy

Pregnancy can create a challenge for physicians caring for women with rheumatic diseases. For many women with rheumatoid arthritis (RA), pregnancy can provide a reprieve from long-term joint pain and inflammation, but others will not experience remission and will continue to need medication. Systemic lupus erythematosus (SLE) may remain quiet in some women, but in others may become more aggressive during pregnancy, putting both mother and foetus at risk. Women with limited scleroderma can do remarkably well, but scleroderma renal crises can be difficult to manage. A third of pregnancies in women with antiphospholipid syndrome (APS) may be refractory to our best therapy. In general, active inflammation from rheumatic diseases poses a stronger threat to the well-being of both mother and foetus than many immunosuppressant medications. Therefore, continued immunosuppression with the least risky medications will allow for the most optimal pregnancy outcomes.

Systemic lupus erythematosus pregnancies: the Sarawak experience and review of lupus pregnancies in Asia

We performed a cross-sessional study of all systemic lupus erythematosus (SLE) pregnancies during a 4-year period (2006-2009) to describe the clinical features, maternal and foetal outcomes in our centre. There were 48 pregnancies in 44 women with SLE. Our patients have a mean age of 30.0 years (SD 6.36) and a mean disease duration of 40.67 months (SD 48.23). Our patients have complicated pregnancies: 32.7% have SLE flares, 17.3% have preeclampsia and 48.9% needed caesarean sections. There were 20.0% foetal losses and 17.8% preterm deliveries in our patients. SLE flares contributed to 60.0% of foetal losses in our patients. Lupus pregnancies in our centre generally have a good maternal and foetal outcome comparable to developed countries in Asia. The low incidence of APS, the high usage of hydroxychloroquine and the high SLE remission rate in our patients prior to conceptions contributed to the good outcome.

Association of higher rheumatoid arthritis disease activity during pregnancy with lower birth weight: results of a national prospective study

OBJECTIVE

To determine the outcome of pregnancy in women with rheumatoid arthritis (RA) in relation to disease activity and medication use during the pregnancy.

METHODS

In a prospective study, pregnant women with RA were evaluated before conception (when possible), during each trimester of the pregnancy, and postpartum. Clinical characteristics, disease activity, medication use, and pregnancy outcome were analyzed. To examine the independent influence of prednisone use and disease activity on birth weight, regression analyses were performed, with adjustments for gestational age of the child at delivery, the sex of the newborn, and the mother's smoking status, education level, parity, and use of an assisted reproduction technique. Kaplan-Meier curve analyses were performed to examine the association between medication use and gestational age at delivery.

RESULTS

Data from 152 Caucasian RA patients with singleton pregnancies were available. Both the mean +/- SD birth weight (3,379 +/- 564 gm) and the mean +/- SD birth weight standard deviation score (SDS; +0.1 +/- 1.1), which is the birth weight adjusted for the gestational age and sex of the newborn, were comparable with those in the general population. On multiple linear regression analyses of birth weight and birth weight SDS, both of which were adjusted for covariates, only disease activity was associated with lower birth weight (P = 0.025). The gestational age at delivery was significantly lower in women who were taking prednisone (38.8 versus 39.9 weeks; P = 0.001), and their delivery was more often premature (<37 weeks; P = 0.004).

CONCLUSION

Pregnancy outcome in women with well-controlled RA is comparable with that in the general population. The effect of prednisone on birth weight is mediated by a lower gestational age at delivery, whereas a higher level of disease activity independently influences birth weight negatively, suggesting an immune-mediated mechanism.

The implications of autoimmunity and pregnancy

There are multiple epidemiological studies that document the potential adverse affects of autoimmunity on nearly every aspect of reproduction, even in the absence of clinically manifest autoimmune disease. Two decades ago, it was suggested that women with autoimmune diseases avoid pregnancy due to inordinate risks to the mother and the child. In contrast, newer epidemiological data demonstrated that advances in the treatment of autoimmune diseases and the management of pregnant women with these diseases have similarly improved the prognosis for mother and child. In particular, if pregnancy is planned during periods of inactive or stable disease, the result often is giving birth to healthy full-term babies without increased risks of pregnancy complications. Nonetheless, pregnancies in most autoimmune diseases are still classified as high risk because of the potential for major complications. These complications include disease exacerbations during gestation and increased perinatal mortality and morbidity in most autoimmune diseases, whereas fetal mortality is characteristic of the anti-phospholipid syndrome (APS). In this review, we will discuss these topics, including issues of hormones, along with potential long-term effects of the microchimerism phenomenon. With respect to pregnancy and autoimmune diseases, epidemiological studies have attempted to address the following questions: 1) Is it safe for the mother to become pregnant or are there acute or chronic effects of pregnancy on the course of the disease? 2) Does the disease alter the course and/or the outcome of a pregnancy and thereby represent an inordinate risk for the fetus and infant? And do new therapeutic and management approaches improve the pregnancy outcomes in women with autoimmune diseases? 3) Does passage of maternal autoantibodies represent a risk to the child? 4) Do pregnancy, parity, or other factors influencing hormonal status explain the female predominance of many autoimmune diseases, and is the pregnancy effect related to microchimerism? Answering these questions has taken on additional importance in recent decades as women in western countries now frequently choose to delay pregnancies and have some or all of their pregnancies after disease onset. In this paper, we primarily focus on APS, systemic lupus erythematosus (SLE), multiple sclerosis (MS), rheumatoid arthritis (RA), and type 1 diabetes (T1D).

Can tumor necrosis factor inhibitors be safely used in pregnancy?

OBJECTIVE

We review available safety data for use of currently approved tumor necrosis factor (TNF) inhibitors during pregnancy and lactation and suggest guidelines for use of these agents among women of reproductive age. Method. Although regulatory agencies encourage the inclusion of pregnant women and those of child-bearing age in randomized controlled trials, pregnant and lactating women have universally been excluded from studies because of unknown or potential risks to the fetus. Thus, strong evidence-based treatment recommendations during pregnancy are usually lacking and safety information is derived from voluntary reports of adverse events during postmarketing surveillance or via uncontrolled, observational studies, reviewed here.

RESULTS

Uncommon adverse pregnancy outcomes observed with TNF inhibitor therapy appear to approximate those seen in women not receiving such therapy and may include premature birth, miscarriage, low birthweight, hypertension, and preeclampsia. There are rare reports of fetal malformations or congenital anomalies in patients exposed to TNF inhibitors during conception or pregnancy. However, the incidence of these events appears to be far below the 3% rate of congenital anomalies in the general population.

CONCLUSION

If the activity or disease severity precludes the cessation of a TNF inhibitor and/or DMARD, uncontrolled observations suggest that conception and early pregnancy are not adversely affected by use of TNF inhibitors. Nearly 70% of pregnant patients can discontinue their TNF inhibitor early in the pregnancy (or with determination of pregnancy) without augmenting maternal or fetal risks.

Pregnancy and catastrophic antiphospholipid syndrome

Antiphospholipid syndrome (APS) is clearly related to maternal morbidity. The most characteristic feature is pregnancy loss; however, several other serious complications had been reported including fetal growth restriction, uteroplacental insufficiency, fetal distress, pre-eclampsia, and HELLP syndrome. Herein, we review the different aspects of obstetric APS features, with special emphasis on its life-threatening variant known as catastrophic APS (Asherson's syndrome) and its relationship with a thrombotic microangiopathy such as HELLP syndrome.

Systemic lupus erythematosus pregnancies: a case series from a tertiary, East Malaysian hospital

We performed a retrospective study of all systemic lupus erythematosus (SLE) pregnancies during a two-year period (2006–2007) to describe the clinical features, maternal and foetal outcomes in our centre. There were 17 pregnancies in 16 women with SLE. Our patients have a mean age of 28.31 years (SD 5.24) and a mean disease duration of 38.62 months (SD 38.03). Our patients have complicated pregnancies: 35.3% have SLE flares, 21.1% have preeclampsia and 47.4% needed caesarean sections. There were 15.8% foetal losses and 12.5% preterm deliveries in our patients. All the foetal losses occurred in patients with severe SLE flares during pregnancies. Lupus pregnancies in our centre generally have a good maternal and foetal outcome comparable with developed countries. The low incidence of antiphospholipid syndrome, the high usage of hydroxychloroquine and the high SLE remission rate in our patients before conceptions are the possible factors contributing to the good outcome.

Risk of unintended pregnancy among women with systemic lupus erythematosus

OBJECTIVE

It is recommended that women with systemic lupus erythematosus carefully time their pregnancies, but little is known about use of contraception and risk of unintended pregnancy in this population. The goal of this study was to estimate the proportion of women with lupus at risk for unintended pregnancy.

METHODS

We surveyed 309 women with lupus, ages 18-50 years, seen at the University of Pittsburgh lupus center between January and May 2007.

RESULTS

Of the women surveyed, 212 (69%) completed the survey. In the past 3 months, 97 (46% of 212) had faced some risk of unintended pregnancy. Of these, 53 (55% of 97) reported >or=1 occasion on which they had unprotected sex and 22 (23% of 97) reported that in the last 3 months they had unprotected sex "most of the time." No women reported having used emergency contraception after unprotected sex. A desire to "discuss birth control with a health care provider at the lupus center" was reported by 22 (10% of 212) respondents and 16 (17% of 94) women <or=35 years old.

CONCLUSION

Many women cared for by our lupus center are at risk of unintended pregnancy and are interested in discussing birth control with a health care provider.

Cross-sectional analysis of adverse outcomes in 1,029 pregnancies of Afro-Caribbean women in Trinidad with and without systemic lupus erythematosus

The objective of the study was to examine pregnancy outcomes in women with systemic lupus erythematosus (SLE) and population controls in Trinidad. We performed a cross-sectional analysis of adverse outcomes in pregnancies of Afro-Caribbean women with SLE and without SLE. One hundred and twenty-two female adult cases of SLE and 203 neighbourhood age-matched women without SLE were interviewed concerning details of their reproductive history, and the anticardiolipin antibody (ACL) status was established for women with SLE. A total of 1,029 pregnancies were reported (356 by women with SLE, 673 by women without SLE). In women with ≥ 1 pregnancy the total number of pregnancies was similar in women with a diagnosis of SLE and women without; however, a lower proportion of women with SLE had ever been pregnant compared with women without SLE (80% versus 91%, P = 0.002). In multivariate logistic regression analyses adjusted for maternal age, district of residence, pregnancy order and smoking, SLE pregnancies were more than twice as likely to end in foetal death than non-SLE pregnancies (odds ratio (OR), 2.4; 95% confidence interval (CI), 1.2–4.7). This effect was driven by a large increase in the odds of stillbirth (OR, 8.5; 95% CI, 2.5–28.8). The odds of early miscarriage (OR, 1.4; 95% CI, 0.6–3.1) and of mid-trimester miscarriage (OR, 1.9; 95% CI, 0.4–9.5) were higher, but were not statistically significantly different, in SLE pregnancies than in non-SLE pregnancies. The odds of ectopic pregnancy (OR, 7.5; 95% CI, 0.9–62.5) and of preterm birth (OR, 3.4; 95% CI, 1.2–10.0) were higher in SLE pregnancies conceived after diagnosis than in non-SLE pregnancies. There was no evidence of raised levels of IgG or IgM ACL among the majority (93/97 women, 96%) of SLE cases who reported sporadic mid-trimester miscarriage or stillbirth, although there was evidence of high levels of IgM and IgG ACL among women reporting three or more miscarriages and three consecutive miscarriages, and of raised IgG ACL among those experiencing ectopic pregnancy. In conclusion, we found evidence for a large increase in risk of stillbirth in the pregnancies of Afro-Caribbean Trinidadian women with SLE (not accounted for by high ACL status). There was some evidence of an increased risk of preterm delivery and ectopic pregnancy in pregnancies conceived after a diagnosis of maternal SLE.

Lupus activity in pregnancy

Pregnancy in a woman with systemic lupus erythematosus (SLE) can be complicated by both lupus activity and pregnancy mishaps. The majority of recent studies found an increase in lupus activity during pregnancy, perhaps exacerbated by hormonal shifts required to maintain pregnancy. Increased lupus activity, in turn, prompts an elevated risk for poor pregnancy outcomes, including stillbirth, preterm birth, low birth weight, and preeclamspsia. Fortunately, the majority of pregnancies in women with SLE are successful. However, the interaction between pregnancy and SLE activity can lead to complications for both mother and baby.

Rheumatoid arthritis and reproduction

Additional research is needed to establish the safety of biologic agents in pregnancy and lactation. The practitioner should convey information regarding the natural history of rheumatoid arthritis during pregnancy and safety issues related to pharmacotherapies to every woman of childbearing age with RA, well before conception and pregnancy, to ensure optimal outcomes.

Etanercept: long-term clinical experience in rheumatoid arthritis and other arthritis

Etanercept is a dimeric fusion protein based on the p75 TNF-alpha receptor. It binds to TNF-alpha and blocks its biologic activity. In randomized, double-blind, placebo-controlled trials, etanercept has therapeutic activity in rheumatoid arthritis, psoriatic arthritis, polyarticular-course juvenile idiopathic arthritis and ankylosing spondylitis. Etanercept improves joint inflammation, physical function and slows/halts structural damage, especially when combined with methotrexate. A sustained response is observed in a substantial percentage of patients. Although some safety issues should be considered before starting etanercept treatment, in general terms, etanercept is a well tolerated drug with an acceptable safety profile. The use of any TNF-alpha antagonist must be in agreement with the National Recommendations for Biologic Therapy, and in difficult clinical situations, a balance between risk/benefit needs to be obtained.

Maternal and fetal outcomes of 72 pregnancies in Argentine patients with systemic lupus erythematosus (SLE)

The purpose of the following study was to analyze maternal and fetal outcomes in pregnant patients with systemic lupus erythematosus (SLE) and the influence of SLE exacerbations on those pregnancies. Seventy-two pregnancies in 61 SLE patients treated between January 1986 and February 2004 in Hospital de Clínicas "José de San Martin" were reviewed retrospectively. Patient age was 28.1 +/- 6.2 years (mean+/-standard deviation [SD]). Mean SLE duration was 4.5 +/- 3.2 years (range 6 months-10 years). No patient acquired the disorder during gestation. Four (5.5%) patients had signs of active disease at the beginning of her pregnancy. Sixteen patients, accounting for 20 pregnancies, had a history of lupus nephritis. Nine patients met secondary antiphospholipid syndrome criteria and had 13 pregnancies. There were 14 exacerbations of the disease during pregnancy (19.4%), with most flares being mild. The most common obstetric complications were gestational hypertension in 15 pregnancies (20.8%) and preeclampsia in 8 pregnancies (11%). Forty-six percent of pregnancies ended in preterm deliveries. There were 62 live births (1 twin birth; 85%), 6 stillbirths (8%), and 5 spontaneous abortions (7%). Thirty-nine percent of newborns had low birth weight. Adequate pregnancy follow-up and delivery care by an interdisciplinary team in Argentine SLE patients with no pre-gestational preparation resulted in maternal and fetal outcomes similar to those seen in world reference centers.

Pregnancy and puerperium are high susceptibility periods for the development of catastrophic antiphospholipid syndrome

It is well known that antiphospholipid syndrome (APS) is associated with recurrent pregnancies losses, but is also associated with other obstetric features such as preeclampsia, uteroplacental insufficiency and preterm birth. Pregnancy is a hypercoagulable state than can be complicated by thrombosis, especially in those patients with an underlying thrombophilic disorder. Catastrophic APS is a rare form of presentation of the APS. Several trigger factors have been related with the catastrophic APS, including infections, anticoagulation withdrawal, surgery, neoplasms and lupus "flares". In around 6% of the cases, the catastrophic APS can appear during pregnancy or puerperium. We review this specific subset of the catastrophic APS and propose a therapeutical approach for this particular situation.

Systemic lupus erythematosus and pregnancy

PURPOSE OF REVIEW

Pregnancy in patients with systemic lupus erythematosus is associated with a high risk of maternal disease exacerbation and adverse fetal outcome. This review summarizes recent published findings on lupus pregnancy.

RECENT FINDINGS

The literature is in agreement that for most women with inactive and stable systemic lupus erythematosus, pregnancy is safe for both mother and fetus. The main risk factors for adverse pregnancy course and outcome are active disease, nephritis with proteinuria, hypertension, and maternal serum antibodies to SS-A/Ro, SS-B/La, cardiolipin, beta2-glycoprotein I, and lupus anticoagulant. Recent studies have broadened our understanding of the immunological mechanism underlying congenital heart block induced by anti-Ro/La antibodies. In addition, the approach to oral contraceptives has been modified on the basis of two well controlled studies suggesting that they do not cause exacerbation of inactive or mild disease.

SUMMARY

Pregnancy in patients with systemic lupus erythematosus is safe and manageable provided the disease is stable. Patients should be evaluated before pregnancy for pregestational risk factors and be closely followed during pregnancy. In most cases of lupus flare during pregnancy, the disease can be safely managed.

Lupus and pregnancy: complex yet manageable

Systemic lupus erythematosus is a chronic multi-system autoimmune disease that occurs predominantly in women of childbearing age. The risk of complications and adverse fetal outcomes in pregnant women with lupus is high. Moreover, pregnancy can cause flares of lupus disease activity necessitating maternal immunosuppressive intervention. Interestingly, many potential complications of pregnancy present as symptoms of lupus making diagnosis and treatment a challenge. Advancing technology and better understanding of the maternal-fetal dyad in lupus have improved outcomes in lupus pregnancies over the last 40 years. This article will briefly review the important issues in pregnancies complicated by lupus and provide a general guideline to physicians for monitoring and treatment.