As a consequence of increased survival over the last decades, patients with systemic lupus erythematosus (SLE) and their partners have an increased wish for pregnancy. However, pregnancy in SLE is associated with an increased risk of maternal and fetal complications.^1–3 Moreover, unlike the general population where subsequent pregnancies from the same father often see a decrease in complication risk, women with SLE face a persistent elevated risk throughout all their pregnancies.¹ Furthermore, there are unanswered questions regarding the safety of medication use during conception, pregnancy and lactation. Early pre-conceptional counselling, assessment of risk factors for adverse outcomes, timely adjustment of medication, careful planning of conception, and multidisciplinary management of pregnancy are of major importance to improve the course and outcome of lupus pregnancies.^4–6

Case 2: Pregnancy wish of a 30-year-old female with SLE and a complicated obstetric history A 30-year-old white female with SLE and her husband attend the specialized pregnancy outpatient clinic in our center because of renewed pregnancy wish, but they have strong doubts because of their experience with a severely complicated first pregnancy.

Her lupus is clinically and serologically silent under treatment with hydroxychloroquine (HCQ) 400 mg/d. Her blood pressure and renal function are normal. She is severely obese (BMI >40).

At the age of 23 years, she was diagnosed with SLE when she developed photosensitivity rashes, arthritis, and a Class IV lupus nephritis (confirmed by renal biopsy) with proteinuria and glomerular erythrocyturia. Laboratory tests showed positive antinuclear antibodies, anti-dsDNA, anti-SSA and anti-SSB antibodies; antiphospholipid antibodies were negative. She was treated according to the EuroLupus regimen with IV pulses of cyclophosphamide and prednisolone, antiproteinuric agents and HCQ and maintenance therapy with mycophenolate mofetil (MMF). Complete remission of her SLE, including the lupus nephritis, was obtained. At the age of 25 years, she had a pregnancy wish. Her lupus was still in remission under treatment with MMF and prednisone 5 mg/d, and she had normal blood pressure without the use of antihypertensive agents. MMF was replaced by azathioprine, and she was encouraged to lose weight because of her obesity.

The patient became pregnant one year later while her lupus remained silent. She started low-dose aspirin and folic acid and continued calcium supplementation. Her pregnancy course was unremarkable until 23 weeks gestational age, with normal results of Doppler ultrasound investigations. However, at 23 weeks pregnancy duration, she was admitted because of pre-eclampsia with hypertension (BP 160/100 mmHg), edema, and proteinuria (2 g/24 hours) without any clinical or serological signs of lupus activity. Investigations of renal function and urine sedimentation were unremarkable. Doppler ultrasound investigation demonstrated reduced flow in the uterine arteries and fetal growth restriction. Despite bed rest and therapy with antihypertensive agents, she developed nausea, headache, and proteinuria increased to 11 g/24 hours. Treatment with IV magnesium sulphate was initiated, and after careful shared decision-making, an emergency caesarean section was performed at 24 weeks and 3 days gestational age. The patient gave birth to a live daughter with a birth weight of 500 grams who was admitted to the neonatal intensive care unit. The daughter was discharged after seven months with oxygen and tube feeding. Three years later, the daughter caught up with the growth lag but has a slight cognitive and motor development delay.

References

1. Kroese SJ, Abheiden CNH, Blomjous BS, et al. Maternal and perinatal outcome in women with systemic lupus erythematosus: A retrospective bicenter cohort study. J Immunol Res. 2017;2017:8245879. doi: 10.1155/2017/8245879.

2. 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.

3. Abheiden CNH, Blomjous BS, Slaager C, et al. Systemic lupus erythematosus is associated with an increased frequency of spontaneous preterm births: Systematic review and meta-analysis. Am J Obstet Gynecol. 2024 doi: 10.1016/j.ajog.2024.03.010.

4. Blomjous BS, Johanna IPV, Zijlstra E, et al. Desire to have children and preferences regarding to pre-pregnancy counselling in women with SLE. Rheumatology (Oxford). 2021;60(6):2706–13. doi: 10.1093/rheumatology/keaa684.

5. Zucchi D, Fischer-Betz R, Tani C. Pregnancy in systemic lupus erythematosus. Best Pract Res Clin Rheumatol. 2023:101860. doi: 10.1016/j.berh.2023.101860.

6. Davis-Porada J, Kim MY, Guerra MM, et al. Low frequency of flares during pregnancy and post-partum in stable lupus patients. Arthritis Res Ther. 2020;22(1):52. doi: 10.1186/s13075-020-2139-9.

Learning Objectives At the end of this workshop participants will be able to:

• Demonstrate knowledge of the general obstetric risk factors and lupus-specific risk factors for adverse pregnancy outcomes in patients with SLE

• Explain the importance of differentiating hypertension-related pregnancy disorders from renal flares during lupus pregnancies

• Describe the therapeutic options and limitations for prevention and treatment of hypertension-related pregnancy complications

• Describe the importance of (repeated) pre-conceptional counselling patients with SLE and their partners before planning a pregnancy

• Describe the importance of multidisciplinary management of pregnancy in women with SLE by a team of specialized healthcare providers