Pregnancy in women with systemic lupus erythematosus
- Bonnie L Bermas, MD
Bonnie L Bermas, MD
- Associate Professor of Medicine
- Harvard Medical School
- Nicole A Smith, MD, MPH
Nicole A Smith, MD, MPH
- Assistant Professor of Obstetrics, Gynecology, and Reproductive Biology
- Harvard Medical School
- Section Editors
- David S Pisetsky, MD, PhD
David S Pisetsky, MD, PhD
- Section Editor — Lupus
- Professor of Medicine and Immunology
- Duke University Medical Center
- Charles J Lockwood, MD, MHCM
Charles J Lockwood, MD, MHCM
- Section Editor — Obstetrics
- Senior Vice President, USF Health
- Dean, Morsani College of Medicine
- Professor, Obstetrics and Gynecology
- University of South Florida
Systemic lupus erythematosus (SLE) predominantly affects women of childbearing age. Fertility in SLE patients does not appear to be altered by disease, other than the decrease in ovarian reserve in women exposed to cyclophosphamide.
However, pregnancy in women with SLE carries a higher maternal and fetal risk compared with pregnancy in healthy women. The prognosis for both mother and child is best when SLE has been quiescent for at least six months prior to the pregnancy. Disease flares during SLE pregnancy pose challenges with respect to distinguishing physiologic changes related to pregnancy from disease-related manifestations. Thus, a multidisciplinary approach with close medical, obstetric, and neonatal monitoring is necessary to optimize both maternal and fetal outcomes.
This topic review will discuss the major risks associated with pregnancy in SLE patients, as well as management recommendations. Issues related to menstrual function, menopause, estrogen replacement therapy, and the use of oral contraceptives in women with systemic lupus erythematosus are presented separately (see "Menstrual function, menopause, and hormone replacement therapy in women with systemic lupus erythematosus" and "Approach to contraception in women with systemic lupus erythematosus"). Issues related to pregnancy in patients with impaired renal function or with antiphospholipid syndrome (APS) are also presented elsewhere. (See "Pregnancy in women with underlying renal disease" and "Pregnancy in women with antiphospholipid syndrome".)
Ideally, all pregnancies in women with systemic lupus erythematosus (SLE) should be planned during periods of disease quiescence for six months prior to conception. Active SLE at the time of conception is a strong predictor of adverse maternal and obstetrical outcomes [1-3]. In spite of this risk, the majority of such pregnancies still result in live births. As an example, one study of 267 pregnancies in a cohort of lupus patients found that women with high disease activity compared with low disease activity in the first and second trimesters showed a threefold increase in pregnancy loss (miscarriages and perinatal mortality) . However, overall there was no statistically significant difference in the number of live births between the women with high disease activity compared with low disease activity (77 percent versus 88 percent, respectively).
Preconception evaluation — A preconception assessment is essential in women with SLE to determine whether pregnancy may pose an unacceptably high maternal or fetal risk, to initiate interventions to optimize disease activity, and to adjust medications to those that are least harmful to the fetus.
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- PREGNANCY PLANNING
- Preconception evaluation
- - Risk assessment
- - Specific laboratory testing
- - Medications
- Selective use allowed during pregnancy
- Selective use with caution in pregnancy
- Contraindicated in pregnancy
- SPECIFIC CONSIDERATIONS DURING PREGNANCY
- Exacerbation of SLE
- Impact of lupus on pregnancy
- Fetal complications
- Special considerations
- - Lupus nephritis
- - Presence of antiphospholipid antibodies
- - Presence of anti-Ro and anti-La antibodies
- MANAGEMENT DURING PREGNANCY
- Monitoring SLE activity
- - Initial evaluation
- - Laboratory testing
- - Postpartum laboratory testing
- Maternal-fetal monitoring
- - Preeclampsia versus lupus nephritis
- Treating active SLE
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS