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REVIEW
Lupus and pregnancy: ten questions and some answersG
Ruiz-Irastorza1 and MA Khamashta2
1Service and Department of Internal Medicine, Hospital De
Cruces, University of The Basque Country, Bizkaia, Spain; and
2Lupus Research Unit,The Rayne Institute, St
Thomas’ Hospital, King’s College, London, UK
Pregnancy and systemic lupus erythematosus (SLE)are closely
related. Most patients with lupus areyoung women with the
possibility of getting pregnantduring the course of the disease.
Mutual interactions
between lupus and pregnancy can occur. Patients withSLE are at a
higher risk for obstetric complications,such as miscarriage and
hypertensive disorders, anddrugs for the treatment of SLE can
affect the foetus.
As a result, questions regarding pregnancy are usu-ally
formulated by women with lupus. We have cho-sen 10 frequent
questions and tried to offer practicalanswers.
How does pregnancy affect SLE?
Observational studies point to a higher degree of lupus
activity during pregnancy in unselectedpopulations.1,2 Flare rates
are highest among thosewomen, who were active at conception.3
Flares are also more common in those women,who stop taking
hydroxychloroquine.4,5 Conversely,women on prolonged remission are
less likely toexperience an increase of lupus activity
duringpregnancy.6,7 In fact, due to a better selection
of patients, recent series have found a low frequency
of flares.7 Most authors agree that flares are usuallymild and
can occur any time during pregnancy andthe puerperium.8
Measuring lupus activity during pregnancy is notstraightforward.
Common laboratory tests that areuseful in non-pregnant patients are
less reliable duringpregnancy.9 Mild anaemia and thrombocytopenia
arecommon during this period, due to the expansion
of circulating volume.
Residual proteinuria in women with past lupusnephritis can also
rise as the glomerular filtrationincreases during pregnancy.
Erythrocyte sedimenta-
tion rate is physiologically elevated during
pregnancy.Complement determinations are less useful duringpregnancy
due to a natural increase of C3 and C4levels.9 Activity scales
specific for pregnancy, which
take into account these issues, have beenestablished.10 One of
them, the Lupus Activity Indexin Pregnancy is actually validated,
showing high sen-sitivity, specificity and predictive values for
detectinglupus flares during pregnancy.11 However, such scalesare
meant for research purposes and physicians haveto take therapeutic
decisions based on clinicalgrounds.
How does SLE affect pregnancy?
Lupus can adversely influence pregnancy in severalways.
Antiphospholipid antibodies (aPL) are themain predictors of
pregnancy complications inpatients with SLE, including miscarriage,
foetaldeath, prematurity and preeclampsia. Of note, notall aPL
confer the same risk, lupus anticoagulant(LA) being the most
strongly associated withmiscarriage.12 Disease activity has shown a
clear asso-ciation with foetal loss and prematurity.13,14
Renaldisease, past or present, can also affect the course
of pregnancy. In fact, women with severe renalimpairment
(serum creatinine over 2.8 mg/dl) have achance lower than 30% of
having a successful preg-
nancy,15 with a high risk of associated complicationssuch as
hypertension or worsening of renal function.
What makes lupus pregnancy ‘high risk’?
Not all women with SLE have the same risk of com-plications
during pregnancy. Thus, pre-pregnancycounselling is essential to
estimate the chance of bothfoetal and maternal problems (Table 1).
High-riskpatients are shown in Table 2. A previous
complicatedpregnancy is, by itself, an important adverse
prognos-
tic variable.16
Likewise, the presence of aPL is closely
Lupus (2008) 17, 416–420
http://lup.sagepub.com
© 2008 SAGE Publications Los Angeles, London, New Delhi and
Singapore 10.1177/0961203308090027
Correspondence to: Munther A Khamashta, Research Unit, The
Rayne
Institute, St Thomas’ Hospital, London SE1 7EH, UK.
Email: [email protected]
at BROWN UNIVERSITY on November 24,
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Lupus and pregnancy: ten questions and some answersG
Ruiz-Irastorza and MA Khamashta
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Lupus
at BROWN UNIVERSITY on November 24,
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