Pregnancy in patients with systemic lupus erythematosus

Endocrine and immune system interactions during pregnancy

Pregnancy is known to induce a transient depression of maternal cell-mediated immunity, to prevent rejection of the fetus, while at the same time it keeps adequate maternal host defense mechanisms to fight infection. Presently, the aim of this paper was to investigate a possible endocrine and immunologic alteration observed during a successful pregnancy. This study consistently showed that plasma corticosterone levels were significantly higher (P<0.0001) in pregnant Wistar rats than in virgin female. An increased number of peritoneal macrophages was also detected in pregnant females when compared to non-pregnant ones. Macrophages play an important role in the production of bioactive proteins and lipids such as nitric oxide. Then, in support of the latter, the present study showed increased levels of endogenous NO in pregnant rats when compared to non-pregnant ones, thereby mediating the vasodilatation process of normal gestation. Furthermore, our FACS analysis clearly indicated the correlation between reduced CD161 expression on NK cells (P<0.0001) in pregnant rats when compared to virgin females. It was found that pregnancy appears to be associated with depressed cell immunity, as evidenced by a significant inhibition of lymphocyte proliferation. Understanding the immunological paradox of maternal tolerance, as well as the hormonal modulation of the immune environment during pregnancy is essential for future studies to investigate the potential for these processes to be modulated by diet or effective therapeutics during pregnancy.

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.

Onset of systemic lupus erythematosus during pregnancy

When systemic lupus erythematosus (SLE) is first suspected during pregnancy, though rare, the diagnostic criteria are not different from those for nonpregnant women. The pregnancy outcome is good if treatment with adequate immunosuppressive agents starts as soon as the diagnosis is made. There are 4 cases in this report who had SLE onset during pregnancy. Although 2 of them suffered from preeclampsia, all 4 pregnancies resulted in favorable outcomes after the lupus was controlled by medical treatment.

Cyclophosphamide for lupus during pregnancy

Severe systemic lupus erythematosus often requires the use of cyclophosphamide in women of reproductive age. As cyclophosphamide is generally avoided during pregnancy because of its teratogenic risk, its impact on fetal survival is poorly understood. This is a case series of lupus patients exposed to cyclophosphamide during pregnancy. We reviewed pregnancies in patients with lupus seen at a large university hospital between October 1986 and September 2003. The pregnancies were evaluated prospectively for cyclophosphamide exposure, lupus activity, and fetal outcome. Comparison was made between pregnancies with severe lupus requiring cyclophosphamide and those that did not. We identified four pregnancies with cyclophosphamide exposure. Two pregnancies were inadvertently exposed to cyclophosphamide early in the first trimester; both resulted in first trimester miscarriages. Two patients were administered cyclophosphamide for severe lupus nephritis and thrombocytopenia during the second trimester. Soon after the administration of cyclophosphamide, both pregnancies ended with fetal demise. Pregnancies exposed to cyclophosphamide for severe lupus flare resulted in a higher rate of fetal losses than pregnancies with severe lupus but not requiring the drug (100% versus 31.25%). In conclusion we present four pregnancies exposed to cyclphosphamide, each ending with pregnancy loss. Based on our experience, the survival of the fetus is strongly in doubt when cyclophosphamide is required to treat lupus in the mother.

Pregnancy outcomes before and after a diagnosis of systemic lupus erythematosus

OBJECTIVE

The purpose of this study was to evaluate pregnancy outcomes before and after diagnosis of lupus.

STUDY DESIGN

Successive selection criterion applied to 148 lupus and 78,905 non-lupus pregnancies, generated 3 groups: lupus group, 84 pregnancies (not-yet-diagnosed group, 15 women; already-diagnosed group, 69 women), and control group, 51,000 pregnancies. Three-way analysis of variance and the chi-squared test were used for analyses.

RESULTS

Stillbirth outcome was increased in the lupus group compared with the control group (odds ratio, 4.84 [95% CI, 1.72,11.08]); the not-yet-diagnosed group (odds ratio, 9.89 [95% CI, 1.09,42.63]), and the already-diagnosed group (odds ratio, 3.85 [95% CI, 1.02,10.31]). Considering >1 pregnancy per patient would have overestimated the stillbirth rate. Stillbirth risk was increased significantly in severe maternal disease that was marked by central nervous system involvement. The already-diagnosed group had more hypertensive complications (P = .001 and .0001). Both lupus groups showed a significantly greater proportion of preterm births (P = .03), growth restriction (P = .019), and infants in the very low birth weight category (P = .021) compared with the control group.

CONCLUSION

Poor fetal outcomes are seen in pregnancies that are complicated by lupus, even before clinical appearance of disease, which supports a predisease state.

Pregnancy outcome in women with pre-existing lupus nephritis

The aim of the present study was to assess the fetal and maternal outcome in a cohort of patients with lupus nephritis. Twenty-four pregnancies in 22 women with lupus nephritis occurring between 1991 and 2000 were analysed retrospectively. Lupus nephritis was biopsy proven before pregnancy in all cases. Women were followed from the beginning of pregnancy up to 6 months postpartum. Close fetal-maternal monitoring and frequent laboratory investigations were applied routinely to all patients. All women were prescribed steroid therapy from the beginning of the pregnancy. There were 18 live births, four spontaneous abortions and two stillbirths. Of the 18 live births, 14 were premature and four were term deliveries, representing a 25% fetal loss rate and 58% prematurity rate. There were two fetuses with congenital heart block. We recorded hypertension in 42%, proteinuria in 50% and pre-eclampsia in 25% of our patients. Proteinuria was irreversible in four cases. No maternal deaths or postpartum exacerbation of the disease were recorded in the study period. All renal flares were reversed postpartum. Patients positive for antiphospholipid antibodies had a worse perinatal outcome. Hypertension, proteinuria and antiphospholipid antibodies appear to be associated with adverse perinatal outcome and pregnancy complications. Pregnancy is not contraindicated in women with lupus nephritis, but is associated with significant fetal and maternal risks.

Autoimmune disease in pregnancy: systemic lupus erythematosus and antiphospholipid syndrome

Autoimmune diseases most commonly occur in women of childbearing age. Although some conditions such as ankylosing spondylitis are more common in men, over 70% of individuals with autoimmune diseases are women. This article focuses on SLE,which is often considered to be the "classic" autoimmune disease,and antiphospholipid syndrome (APS), which is associated with pregnancy loss and placental insufficiency.

Pregnancy in patients with systemic lupus erythematosus

We reviewed the obstetrical performance and outcome of 15 pregnancies in patients with systemic lupus erythematosus (SLE) (study group) and compared them with 45 age and parity-matched normal pregnancies (control group). Eleven women (73.8%) were in remission phase and 4 (26.7%) had active disease at the time of conception. The time interval between disease diagnosis and the index pregnancy was 4.2 +/- 2.5 years. Two patients with renal involvement had lupus flare-up during the antenatal period. There was no case of lupus flare-up in the postpartum period. Gestational age at delivery was significantly lower in SLE patients (35.9 +/- 2.5 weeks) compared to the control group (37.4 +/- 2.2 weeks). The incidence of intrauterine growth retardation was significantly higher in the SLE patients (40%). There was no case of neonatal lupus or congenital heart block.

Immune dysfunction in patients with unexplained repeated abortions

OBJECTIVES

To examine the immunological profiles by antiphospholipid antibodies IgG, IgM, IgA immunoglobulins ACA, as well as C3, C4 complement component levels.

METHODS

A group of 44 women with a history of three or more consecutive pregnancy losses was compared with 34 normal women.

RESULTS

Our results showed lower levels of IgG immunoglobulins for the patient group (P < 0.001) while the C3, C4 complement component levels remained unaltered. Anticardiolipin antibodies were positive in ten patients for IgG or IgM isotypes or for both presenting a prevalence of 22.7% while none of the control subjects had ACA positive titers. The lupus anticoagulant was not detected in either group. Ten patients (22.7%) presented positive autoantibody tests as compared with only 3 (8.8%) of the control group. No statistical differences were found between the two groups when the frequency of each autoantibody's positive tests were examined separately.

CONCLUSIONS

An inconsistent immune derangement seems to be present in recurrent aborters with the presence of anticardiolipin antibodies as the stronger representative marker of immune alteration.

Antinuclear and antiphospholipid antibodies in healthy women with recurrent spontaneous abortion

PROBLEM

To determine the presence of absence of subclinical autoimmunity in healthy women with first trimester recurrent spontaneous abortion (RSA), the sera of 72 healthy women with a history of three or more consecutive abortions were analyzed for the presence of antibodies to phospholipid and nuclear antigens.

METHOD

Lupus anticoagulant was determined, as were antibodies to cardiolipin. An indirect immunofluorescent antinuclear test was performed and specific antinuclear antibodies to double-stranded DNA, ribonucleoprotein, Smith antigen, and Sjogren's syndrome A and B antigens were tested.

RESULTS

Nine women (13.2%) had low levels of antinuclear antibodies, none of which were specific. Four women (5.6%) had moderate to high levels of aCL antibodies.

CONCLUSION

We conclude that the prevalence of aCLs and antinuclear antibodies in healthy women with first trimester RSA is low. Subclinical autoimmunity is not a common cause of first trimester RSA.

The effect of systemic lupus erythematosus on pregnancy and pregnancy outcome

This review provides an analysis of reports published since 1980 on the effect of systemic lupus erythematosus (SLE) on pregnancy and pregnancy outcome. The question whether pregnancy increases clinical flares and the severity of flares in patients with SLE during pregnancy has not been resolved because of difficulty in defining exacerbations of SLE and of preeclampsia. An analysis of major detailed reports indicates that maternal complications are reduced in patients who are in clinical remission prior to the onset of pregnancy compared with women with persistent disease activity. Complications are observed in 30%-50% of patients with inactive disease at onset of gestation. After exclusion of spontaneous abortions during the first trimester, fetal survival was 85%-90% in most reported case series. The best outcomes were reported in patients with inactive disease at onset of pregnancy. It seems likely that some maternal complications and fetal wastage in this population are related to anticardiolipin antibodies.

Systemic lupus erythematosus and pregnancy

This article critically analyses the data in the literature on pregnancy in women with systemic lupus erythematosus. Based on the results of recent controlled prospective studies, it is apparent that the long-standing opinion that pregnancy induces exacerbation of the disease should be revised. The presence of active disease and/or a significant loss of renal function at conception are not only associated with a high risk of maternal complications, but also with high frequencies of loss of the fetus, as well as pre- and dysmaturity. Recently, the presence of antiphospholipid antibodies, notably the lupus anticoagulant and anticardiolipin antibodies, has been recognized as being important for the occurrence of death of the fetus, in particular, late in the pregnancy. This is probably due to thrombosis occurring in the placental vessels. However, the results of randomized studies on treatment with antithrombotic drugs and/or procedures lowering, antibody levels must be available before we will know whether the presence of these antibodies should be coupled to specific instructions or not. Although there is a strong association between the neonatal lupus syndrome and the presence of anti-SSA antibodies in maternal blood, the finding of anti-SSA antibodies has up to now had no therapeutic implications. It is concluded that pregnancy in SLE deserves extensive preconceptional counseling and close cooperation between the internist, rheumatologist, obstetrician and the neonatologist.

Systemic lupus erythematosus and pregnancy at the Royal Women's Hospital, Brisbane 1979-1989

The management and obstetric outcome of 17 patients with systemic lupus erythematosus (SLE) complicating 42 pregnancies is presented. Similar to world figures there was a 14.3% incidence of therapeutic abortion, a 4.8% incidence of ectopic pregnancy, a 16.7% incidence of spontaneous abortion, a 23.8% incidence of prematurity, a 4.8% incidence of fetal death in utero (FDIU) and a 9.5% incidence of intrauterine growth retardation (IUGR). In patients with antiphospholipid antibodies the obstetric outcome was significantly worse. Pregnancies complicated by preexisting renal compromise all concluded with an adverse outcome to the conceptus. In light of the experiences at the Royal Women's Hospital and a review of the world literature, the need for a standardized approach to SLE in pregnancy and more importantly the need for a large, prospective randomized trial of low dose aspirin in these pregnancies is highlighted.

Maternal and fetal complications in pregnant women with systemic lupus erythematosus

Recent studies provide important insights into maternal complications in patients with systemic lupus erythematosus (SLE) established before onset of pregnancy. Exacerbations or relapse occur during the course of pregnancy and immediately postpartum in 25% to 60% of pregnancies. However, the likelihood of increased clinical activity of SLE during pregnancy is influenced by signs of activity present at onset of pregnancy. In the absence of signs of clinical activity for at least 6 months before conception, relapses occur in about one third, whereas in patients with clinical activity at onset of pregnancy, persistent activity or exacerbations occur in approximately two thirds. Fetal survival in these patients parallels the incidence of SLE activity: 85% to 95% in the group with inactive disease at conception and 50% to 80% in subjects with active disease at onset of pregnancy. The introduction of an assay for anticardiolipids has led to a new concept for the pathogenesis of autoimmune disease, namely immune-related thrombosis. Recent studies suggest that this mechanism may play an important role in clinical episodes in SLE, involving late fetal death and maternal arterial and venous thrombosis.

Antinuclear antibodies in sera of patients with recurrent pregnancy wastage

Four groups of women were studied to determine whether low-level antinuclear antibody titers are associated with a higher risk for pregnancy loss. Group A consisted of 30 patients with a history of unexplained fetal losses. Group B consisted of 30 women with "explained" fetal losses (e.g., uterine septum or luteal phase defect). Ages and number of losses were comparable between the women in groups A and B. Group C consisted of 61 healthy pregnant women. Group D involved 61 healthy nonpregnant women of reproductive age. In groups A and B, 40% and 53.3% of the respective patients had antinuclear antibody titers greater than or equal to 1:40. In groups C and D the frequencies of positive antinuclear antibody titers were 8.2% and 5.6%, respectively. This study demonstrates a high prevalence of low-titer antinuclear antibody-positive serum in patients with explained and unexplained pregnancy losses.

Pregnancy in the patient with rheumatic disease: the obstetrician's perspective

Patients with rheumatic diseases who become pregnant are justifiably categorized as having high-risk pregnancies. Utilizing a multidisciplinary approach, including perinatologists, rheumatologists and anaesthetists, successful pregnancies have become the rule rather than the exception. However, women with rheumatic disease are particularly prone to develop serious obstetric problems which often result in early hospitalization and delivery. Although vigilant obstetric care improves perinatal outcome, prematurity will continue to be a major problem complicating pregnancies in women with rheumatic disease.

Postpartum subsidence of hepatitis B viral replication in HBeAg-positive carrier mothers

To elucidate the effects of pregnancy and delivery on hepatitis B e antigen (HBeAg)-positive carrier mothers, 31 HBeAg-positive carrier mothers were followed-up postpartum 1 year, with 30 HBeAg-positive nonpregnant female carriers as controls. Serum hepatitis B surface antigen (HBsAg), HBeAg titer, and hepatitis B virus (HBV)-DNA concentration were studied at defined intervals. The results revealed that in the control group HBeAg titers and HBV-DNA concentrations fluctuated, whereas the HBsAg titers showed little change, but HBeAg clearance or seroconversion to anti-HBe were not noted on follow-up. In contrast, one carrier mother seroconverted to anti-HBe during pregnancy and the antibody persisted thereafter. Five of the remaining 30 carrier mothers cleared HBeAg postpartum, and among these five cases, one also seroconverted to anti-HBe. In addition, in another five of the 30 cases, the HBV-DNA fell to undetectable level (less than 0.04 ng/ml). All these ten cases had a common tendency of showing a decrease in HBeAg titers and/or HBV-DNA concentrations 1-2 months after delivery. The HBeAg titers and HBV-DNA concentrations in the other 11 cases remained unchanged, whereas the remaining nine cases had increased levels. It is concluded that subsidence of HBV replication is precipitated by delivery in one-third of HBeAg-positive carrier mothers in Taiwan, and this occurs most frequently 1-2 months postpartum.

Autoimmune disease in pregnancy

Autoimmunity, whether present in a recognized syndrome such as systemic lupus erythematosus or represented by the production of subclasses of autoantibodies, adversely affects reproduction. While fertility of patients with autoimmune disorders is generally unimpaired, important exceptions exist. Recent data regarding the impact of intercurrent pregnancy upon women with SLE suggest that the overall course of this disorder is not affected. The impact of SLE and related autoimmune phenomena during pregnancy primarily relates to adverse fetal outcome. Pregnancy wastage is excessive, and premature delivery and poor fetal growth are commonly encountered. The occurrence of fetal complications correlates with the level of maternal disease activity and the presence of specific autoantibodies. Management of pregnancy complicated by SLE or the production of autoantibodies associated with poor reproductive outcome should be directed at maintaining maternal disease quiescence. The adverse effect of the maternal disorder on fetal growth and development far outweighs actual or theoretical risks attributable to maternal drug therapy.

Antinuclear antibody, lupus anticoagulant, and anticardiolipin antibody in women with idiopathic habitual abortion. A controlled, prospective study of forty-four women

In a controlled, prospective study of 44 consecutive women with idiopathic habitual abortion, only 5% had symptoms of rheumatic disease. Patients did not differ from control subjects in the frequency of positive results on tests for antinuclear antibody or anti-double-stranded DNA. Levels of C3 and C4 were higher in the habitual aborters. No patients had anti-Ro. The antiphospholipid antibody results were analyzed using 2 methods: the frequency of antiphospholipid antibodies was 9% by lupus anticoagulant using the Russell viper venom time (95% confidence interval 22-2.5) and 11% by anticardiolipin antibody assay (95% confidence interval 25-3.7), which was not significantly different from that in control subjects. However, the mean levels in the aborters (although within the normal range) were significantly higher than those in control subjects for anti-double-stranded DNA (P = 0.004), lupus anticoagulant (by Russell viper venom time; P = 0.05), and anticardiolipin antibody (P = 0.0007), when examined by multiple linear regression analysis corrected for age and concurrent pregnancy. Of the 3 patients with antiphospholipid antibodies and subsequent successful pregnancies, only 1 was treated with prednisone and aspirin. We conclude that, in the majority of women, subclinical lupus, anti-Ro, the lupus anticoagulant, and anticardiolipin antibodies are not associated with idiopathic habitual abortion.

Passively acquired autoimmunity and the maternal fetal dyad in systemic lupus erythematosus

Neonatal lupus syndromes consist of transient cutaneous and hematologic abnormalities and permanent cardiac disorders all of which result from a common pathogenetic mechanism, the passive transfer of maternal autoantibodies. Detrimental antibodies such as SSA/Ro and SSB/La gain access to the fetal circulation via the normal active transport system of the trophoblast tissue which is operative after 20 weeks gestation. Despite functional maturation of the cardiac conduction system by 16 weeks gestation, fetal bradycardias are most often encountered after this time. Several lines of evidence are advanced in this review to support the role of myocarditis as the initial consequence of autoantibody attack on the fetal heart. The end result of this inflammatory insult is permanent fibrosis manifest as complete congenital heart block (CCHB). Despite the clearly demonstrated presence of SSA/Ro and SSB/La in fetal tissues as well as their fluctuation in quantity during the cell cycle, the precise accessibility of these antigens to their respective autoantibodies in unknown at the present time. However, ultraviolet light is reported to induce cell surface expression of SSA/Ro on cultured keratinocytes. The recognition of CCHB by fetal echocardiogram is presented. The rationale for the use of dexamethasone which crosses the placenta in an active form to treat fetal immune effector functions is discussed. Intense maternal plasmapheresis in an attempt to rapidly decrease maternal autoantibodies may provide another approach to the management of CCHB. Through increasing knowledge of this model of "passively acquired pure" systemic lupus erythematosus, insights into mechanisms of tissue injury and strategies for treatment will emerge.

Lupus pregnancy. II. Unusual pattern of hypocomplementemia and thrombocytopenia in the pregnant patient

To explore the causes of complications in pregnant women with systemic lupus erythematosus (SLE), we prospectively evaluated 34 pregnancies in 28 SLE patients, and 2 additional pregnancies in patients with lupus anticoagulant and positive antinuclear antibody, but no other manifestations of SLE. Nineteen pregnancies (55%) were complicated by marked proteinuria, thrombocytopenia, and/or lupus anticoagulant. Hypocomplementemia occurred in 18 pregnancies (52%). Neither thrombocytopenia-anticoagulant nor proteinuria was accompanied by an increase in antibody to double-stranded DNA or by clinical signs of active SLE. Antibody to Ro antigen did not predict fetal death. Both thrombocytopenia and proteinuria appeared abruptly during pregnancy and disappeared quickly after delivery. Fetal death was the result in 7 of 9 (77%) pregnancies in patients with anticoagulant, 6 of 10 (60%) in patients with thrombocytopenia, 6 of 18 (33%) in patients with hypocomplementemia, and 3 of 11 (27%) in patients with proteinuria. Twenty of 29 (68%) children were identified as male. The pathogenesis of hypocomplementemia was evaluated by a new assay, C1s-C1 inhibitor complex, which is thought to measure rate of complement activation by the classical pathway. Most pregnant patients with low CH50 levels and proteinuria had normal levels of C1s-C1 inhibitor complex, whereas nonpregnant patients with equivalent proteinuria and hypocomplementemia had high levels, as did pregnant patients with hypocomplementemia who did not have SLE. Pregnant and nonpregnant hypocomplementemic patients with proteinuria had similar levels of C3 and C4. In pregnant patients with SLE, C1s-C1 inhibitor complex was independent of CH50; in nonpregnant patients a linear relationship between C1s-C1 inhibitor complex and CH50 was seen.(ABSTRACT TRUNCATED AT 250 WORDS)

Lupus pregnancy. Case-control prospective study demonstrating absence of lupus exacerbation during or after pregnancy

To assess whether pregnancy is associated with exacerbation of systemic lupus erythematosus (SLE), a variety of clinical markers of disease activity in 28 pregnant patients with SLE (33 pregnancies) were compared with the same markers in age-, race-, organ system-, and disease severity-matched nonpregnant women with SLE. Both groups were followed up for periods of up to one year after delivery. Eight patients elected abortion for nonmedical reasons. In all patient groups, there were no differences between pregnant and nonpregnant patient groups in frequency of any disease activity marker studied including therapy. However, new proteinuria occurred in four pregnant patients compared with one nonpregnant patient, and thrombocytopenia attributable to SLE occurred in five pregnant patients and one nonpregnant patient. Renal disease, when it occurred, more closely resembled pregnancy-induced hypertension than lupus nephritis. It is concluded that pregnancy complications are frequent, but the assertion that pregnancy causes exacerbation of SLE remains unproved.