Systemic lupus erythematosus (SLE) disproportionately affects women in their reproductive age years. Pregnancy in this systemic autoimmune disease has long been associated with poor obstetric outcomes. However, the frequency of pregnancy loss in lupus has dropped to a level commensurate with that of the general US population. The outcomes of lupus pregnancies are better if conception is delayed until the disease has been inactive for at least 6 months, and the medication regimen has been adjusted in advance. Pregnancy in lupus is prone to complications, including flares of disease activity during pregnancy or in the postpartum period, preeclampsia, miscarriage, stillbirth, intrauterine growth retardation, and preterm birth. Active lupus nephritis poses the greatest risk. The recognition of a lupus flare during pregnancy may be difficult because the signs and symptoms may mimic those of normal pregnancy. Monitoring should include baseline and monthly laboratory tests, serial ultrasonography, fetal surveillance tests, and fetal m-mode echocardiography for mothers with SS-A (Ro) or SS-B (La) antibodies. In the absence of any signs or symptoms of active SLE, affected patients require no specific treatment during pregnancy. If hydroxychloroquine was in use before conception, it should be maintained throughout pregnancy. If a woman with SLE has antiphospholipid antibodies, prophylactic treatment with aspirin and/or low-molecular weight heparin is indicated to prevent fetal loss. Lupus flares during pregnancy are generally treated with hydroxychloroquine, low-dose prednisone, pulse intravenous methylprednisolone, and azathioprine. High-dose prednisone and cyclophosphamide are reserved for severe lupus complications but are associated with significant pregnancy-related complications and poor obstetrical outcomes.
Obstetricians and Gynecologists and Family Physicians
After completing the CME activity, physicians should be better able to provide preconception counseling to a woman with lupus, differentiate signs of a lupus flare from symptoms of pregnancy, differentiate preeclampsia from a flare of lupus nephritis, and differentiate the serious medical complications of pregnancy in a lupus patient.
*Associate Professor, Division of Rheumatology, Department of Medicine, †Professor, Department of Gynecology and Obstetrics, and ‡Professor, Division of Rheumatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
Chief Editor's Note: This article is part of a series of continuing education activities in this Journal through which a total of 36 AMA/PRA Category 1 Credits™ can be earned in 2011. Instructions for how CME credits can be earned appear on the last page of the Table of Contents.
Unless otherwise noted below, the authors, faculty and staff in a position to control the content of this CME activity and their spouses/life partners (if any) have disclosed that they have no financial relationships with, or financial interest in, any commercial organizations pertaining to this educational activity.
Supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases (grant R01-AR43737) and National Institute of Dental and Craniofacial Research (contract NOI DE-32636), Hopkins General Clinical Research Center (grant M01-RR-00052), and the Jerome L. Greene Foundation.
Correspondence requests to: Alan N. Baer, MD, Associate Professor of Medicine, Johns Hopkins University, Clinical Director, Division of Rheumatology, Good Samaritan Hospital, Suite 508, Russell Morgan Building, 5601 Loch Raven Boulevard, Baltimore, MD 21239. E-mail: firstname.lastname@example.org.