Systemic lupus erythematosus (SLE) is a multi-organ autoimmune disease and causes a wide range of serious complications. It more commonly affects young women in the reproductive years, and among other organ-systems, it also affects the reproductive system.
While the chances of a successful pregnancy have significantly improved in the past few decades, it remains a difficult prospect for a number of women suffering from SLE. This condition can affect both, the mother and the fetus. About one in ten pregnancies result in a miscarriage. The underlying cause of miscarriage is the antiphospholipid antibody syndrome, which is characterized by the development of antiphospholipid antibodies which act against the body’s own phospholipids are result in blood clotting.
All women with lupus, even if they do not have a previous history of miscarriage, should be screened for antiphospholipid and anticardiolipin antibodies. Those women who have a history of venous or arterial clotting should be therapeutically anticoagulated during the next pregnancy. And those who have had one or more late pregnancy losses, three or more first trimester losses, or severe pre-eclampsia or placental insufficiency, should be treated with prophylactic doses of heparin and a baby aspirin during the next pregnancy. A combination of heparin and aspirin is better than aspirin alone.
These pregnancies are considered high risk, and there should be fetal monitoring (ultrasounds to monitor growth and placental development), and biophysical profiles. If there are indeed signs of severe placental insufficiency, delivering through a Cesarean section should be considered.
For the fetus, there is a risk of preterm birth, primarily occurring due to pre-eclampsia and premature rupture of membranes. Maternal hypertension in the second trimester is a good predictor of the forthcoming preterm birth. But it needs to be treated carefully, as suddenly reducing maternal blood pressure could reduce placental blood flow and compromise the viability of the fetus. The fetus of an SLE, the fetus is also at risk for intrauterine growth retardation (IUGR).
Pregnant women with IUGR are at an increased for a condition known as the Lupus flare, which is worsening of the lupus activity likely due to prolactin release. These women are also more likely to have other complications of pregnancy, including diabetes, urinary tract infections, and pre-eclampsia.
The first thing that can be done is to try and time the pregnancy to coincide with a period of good disease control if possible. It is definitely problematic if the pregnancy occurs during the flare-up. General screening tests should include antiphospholipid antibodies, anti-Ro, and anti-La. Being positive for those increases the risk of congenital heart block in the baby, and warrants a 4-chamber fetal cardiac echo monitoring of the fetal cardiac conduction system. The mother’s health needs to be closely monitored as well.
Overall, pregnancy is a high-risk condition for a patient with lupus and warrants careful monitoring and counseling. If not managed properly, it can lead to serious complications for the mother and the fetus, and in some cases miscarriages as well.