Abstract
Pregnancy poses a unique challenge in systemic lupus erythematosus (SLE), with potentially increased rates of maternal and fetal complications and poorer obstetric outcomes.1–5 Women with SLE can flare during pregnancy, particularly those who have active disease at conception or underlying renal disease. Disease control and maternal benefits must be balanced against fetal safety, and judicious use of medications and close multidisciplinary management are essential for optimal outcomes.
Case 1: A 29-year-old female with unplanned pregnancy A 29-year-old female with SLE presented with an unplanned pregnancy at 12 weeks gestational age while on prednisone, hydroxychloroquine (HCQ) and mycophenolate mofetil (MMF) for severe mucocutaneous flare; MMF was immediately replaced with azathioprine with the patient determined to continue her pregnancy despite the risks for MMF teratogenicity. At 28 weeks gestation, she was admitted for management of infected skin lesions, periodontitis, Pseudomonas sepsis, and COVID-19 pneumonia. Two weeks following admission, she went into preterm labour and spontaneously delivered a live baby boy with cleft palate and aural atresia; the newborn eventually succumbed to sepsis, thrombocytopenia and intra-cranial hemorrhage a few hours after birth. The patient’s multidisciplinary treatments consisted of parenteral antimicrobials, glucocorticoids and tocilizumab, and required intensive care admission and transient mechanical ventilation. Despite a stormy and complicated hospital course, she made a remarkable recovery and was discharged after 2 months with minimal sequelae.
Over the next two years, follow up by telemedicine (during COVID-19 pandemic) revealed mild-to-moderate mucocutaneous flares with hypocomplementemia and elevated anti-dsDNA titres, that were responsive to transient increases in prednisone 5–15 mg/day while maintaining HCQ. Disease activity was stable on HCQ and prednisone 5 mg/day, when a third pregnancy was diagnosed at 4 weeks gestational age. Work-up showed positive tests for SSA(Ro) and SSB(La) antibodies; normal blood counts, urinalysis, renal, liver and thyroid functions, complement and lupus anticoagulant, and negative antibodies to dsDNA, Smith, RNP, cardiolipin, and beta-2-glycoprotein 1. In close coordination with obstetrics/perinatology, she was started on low dose aspirin, and fetal echocardiogram was monitored weekly from gestational age 16–26 weeks, all showing normal results. The pregnancy course was uneventful, and she delivered a live baby girl by C-Section at 37 weeks with low birth weight and APGAR 8,9; there were no congenital defects and baby continues to thrive well on breastfeeding.
[Background: Diagnosed SLE at age 19 years, her disease had been relatively stable on HCQ, with occasional mucocutaneous and musculoskeletal flares that were controlled with prednisone dose increase, intermittently combined with methotrexate or MMF. She had an uneventful term pregnancy during a period of remission at age 22 years, while maintained only on HCQ.]
References
Buyon JP, Kim MY, Guerra MM, et al. Predictors of pregnancy outcomes in patients with lupus: A cohort study. Ann Intern Med. 2015;163(3):153–63. doi: 10.7326/M14-2235.
Sammaritano LR, Bermas BL, Chakravarty EE, et al. 2020 American College of Rheumatology guideline for the management of reproductive health in rheumatic and musculoskeletal diseases. Arthritis Rheumatol. 2020;72(4):529–56. doi: 10.1002/art.41191.
Dao KH, Bermas BL. Systemic lupus erythematosus management in pregnancy. Int J Womens Health. 2022;14:199–211. doi: 10.2147/IJWH.S282604.
Bundhun PK, Soogund MZ, Huang F. Impact of systemic lupus erythematosus on maternal and fetal outcomes following pregnancy: A meta-analysis of studies published between years 2001–2016. J Autoimmun. 2017;79:17–27. doi: 10.1016/j.jaut.2017.02.009.
Lucas A, Eudy AM, Gladman D, et al. The association of lupus nephritis with adverse pregnancy outcomes among women with lupus in North America. Lupus. 2022;31(11):1401–07. doi: 10.1177/09612033221123251.
Learning Objectives At the end of this workshop participants will be able to:
Discuss predictors of adverse maternal and fetal outcomes in SLE pregnancy
Review guidelines in medication use during pregnancy and lactation
Discuss special considerations in the management approach to anti-SS-A(Ro)/anti-SS-B(La) positive pregnancy
