Prof. Hatem Abu Hshim,Professor of Obstetrics and gynecology Mansoura University Hydroxychloroquine is well tolerated and, when dosed appropriately, ocular toxicity is very rare. The patient’s pregnancy was unremarkable. To understand the importance of pre-pregnancy counselling for women with SLE. Tedeschi SK, Guan H, Fine A, Costenbader KH, Bermas B. Organ-specific systemic lupus erythematosus activity during pregnancy is associated with adverse pregnancy outcomes. Article  In some cases, there is a reduction in lupus symptoms during pregnancy. 1988;296(6625):825. https://doi.org/10.1136/bmj.296.6625.825. … Clowse ME, Madger LS, Petri M. Cyclophosphamide for lupus during pregnancy. Registries of CHB cases do not provide evidence that the prompt use of fluorinated steroids in cases of isolated CHB significantly alters fetal/neonatal morbidity or mortality. Supus. Ovulation stimulation as a fertility treatment could theoretically induce SLE. The cesarean delivery rate is thus 59.57 %. You can access the Systemic lupus erythematosus tutorial for just £48.00 inc VAT. https://doi.org/10.1191/0961203305lu2169oa. Br Med J. Women pregnant and known to have anti-Ro (SSA) or anti-La antibodies (SSB) often have echocardiograms during the 16th and 30th weeks of pregnancy to monitor the health of the heart and surrounding vasculature. LDASA, which is also compatible with gestation and breastfeeding, should be continued during pregnancy considering the presence of aPL antibodies and its proven role in preventing pregnancy adverse outcomes such as preeclampsia and preterm delivery. Pre-pregnancy counselling should also include a discussion regarding medications (see Drug therapy in SLE). She was diagnosed with SLE at the age of 33 years, when she presented to our hospital complaining of a 6-month clinical picture of intermittent fever, asthenia, inflammatory peripheral arthralgia, facial and extremities morning edema, and foamy urine. Correspondence to Pickrell MD, Sawers R, Michael J. Pregnancy after renal transplantation: severe intra-uterine growth retardation during treatment with cyclosporine. Venkataramanan R, Koneru B, Wang CCP, et al. N Engl J Med. In anticipation of pregnancy, such medications should be discontinued and replaced with immunosuppressive medications … Top of Page. What contraceptive measures would you recommend in this situation? Rheum Dis Clin N Am. The patient then began maintenance treatment with mycophenolate mofetil (MMF) 1 g twice a day and reached complete remission after 18 months (no symptoms, no cytopenia, no proteinuria, negative anti-dsDNA, and normal complement levels – SLEDAI 0). Lupus. 16-10-2018 | Pregnancy | Editorial | Article, 09-07-2019 | Systemic lupus erythematosus | Highlight | News, 16-04-2020 | Systemic lupus erythematosus | News. Pregnancy should start after a period of at least 6–12 months of stable low disease activity or remission. Predictors and outcomes of renal flares after successful cyclophosphamide treatment for diffuse proliferative lupus glomerulonephritis. Some medications are safe to take while you’re pregnant however others, like methotrexate, shouldn’t be taken. SLE in the mother may also cause lupus or heart problems to develop in the newborn. We will describe the patient’s journey regarding family planning, which will showcase the preconception counselling and risk stratification suggested for women with ARD. Question 2. If your lupus is active or if you experience a flare-up, however, your medical team will work with you to treat your disease in a way that's safest for you and your growing baby. 2004;31(12):2360–5. During pregnancy, lupus improves in a … This case highlights that having a rheumatic autoimmune disease and being treated with immunosuppressive drugs does not represent a contraindication to pregnancy. 2011;117(5):1499–506. Some women with lupus should delay pregnancy and discuss their plan with their treating doctor when they are planning to have a baby. https://doi.org/10.1002/ajmg.a.32685. Renal involvement in the form of either active lupus nephritis (LN) at the time of conception, or a LN new onset or flare during pregnancy increases the risks of preterm delivery, pre-eclampsia, maternal mortality, fetal/neonatal demise, and intrauterine growth restriction. Curr Treat Options in Rheum 4, 110–118 (2018). Lupus flares following delivery are treated similarly to those in a non-pregnant patient. Putting research into context. https://doi.org/10.1016/j.rdc.2016.12.003. The successful live-birth rate in the whole series was 94 % (47/50). This is a very well written review article on the use of calcinurin inhibitors for lupus nephritis by one of the worldwide experts in the field. 2016;35(7):1725–32. In women of reproductive age, the ideal time for this evaluation is close to diagnosis, in order to set the timing for a future pregnancy and to avoid, if possible, drugs that can lead to premature gonadal failure such as cyclophosphamide. Urgent premature delivery is a frequent phenomenon. Treating active SLE — The treatment of active SLE during pregnancy is guided by the severity and degree of organ involvement, similar to patients in the non-pregnant state. © 2020 Springer Nature Switzerland AG. 2015;42(4):728–30. Obstetric neprhology: lupus and lupus nephritis in pregnancy. CAS  However, over the last 10-20 years, advancing technology, a better understanding of the disease and changes in medical practice mean that in many cases pregnancy is possible with close supervision, and advice will be tailored according to individual cases. University of Oklahoma School of Medicine, Oklahoma City, OK, USA, Arthritis and Clinical Immunology, Oklahoma Medical Research Foundation, 825 NE 13th Street, Oklahoma City, OK, 73104, USA, You can also search for this author in Provision of proper preconception counseling and risk stratification should be timely (since the very first visit, if the patient is of childbearing potential), ideally by a multidisciplinary team composed of rheumatologists and obstetricians. Coscia LA, Constantinescu S, Davison JM, Moritz MJ, Armenti VT. Immunosuppressive drugs and fetal outcome. 2015;4(2):42–55. Eliza F. Chakravarty MD, MS. Erin Shirley declares that she has no conflict of interest. Because SLE treatment may require the use of strong immunosuppressive medications that can have serious side effects, female patients must stop taking the medication before and during pregnancy to protect unborn children from harm. Transplantation. PubMed  This article does not contain any studies with human or animal subjects performed by any of the authors. While it does not discuss pregnancy per se, it provides an excellent guideline of how to use the medications in SLE. Question 2. For most women with lupus, a successful pregnancy is possible. Article  Reproductive issues including contraception, fertility, and pregnancy are important components of the comprehensive care of women with systemic lupus erythematosus (SLE). Cytotoxic drugs (such as cyclophosphamide) are potent immunosuppressive agents that are used to treat serious manifestations of SLE, especially kidney inflammation (glomerulonephritis). Make sure you discuss the options for birth control with your doctor. Levy RA, Vilela VS, Cataldo MJ, Ramos RC, et al. Current Treatment Options in Rheumatology Question 1. Am J ObstetGynecol. Additionally, obstetric risk stratification must take into account general and disease-specific risk factors (see Table 2). 2001;10(6):401–4. Am J Med Genet. 2014;28(8):1174–87. However, the impact of HCQ on pregnancy outcomes remains controversial. SLE pregnancies are complicated due to risk for maternal disease exacerbation and potential for fetal and neonatal complications. If your SLE remains in remission throughout the course of your pregnancy, you'll likely not need any special treatment during your nine months. CurrOpinRheumatol. https://doi.org/10.1007/s40264-013-0034-x. Management and Monitoring. Open Access Rheumatol 2017; Nar 10. https://doi.org/10.2147/OARRR.S878(. For advice about the use of drugs in pregnant lupus patients there is a separate BSR guideline on the use of drugs in rheumatic diseases in pregnancy and breastfeeding . Labelling all pregnancies in women with SLE as high risk is not helpful or appropriate as those with quiescent disease will, in many cases, have uncomplicated pregnancies. Monoclonal antibodies, systemic lupus erythematosus, and pregnancy: insights from an open label study. Caring for Yourself During Pregnancy. Ostensen M, Khamashta M, Lockshin M, Parke A, et al. Pregnancy is an important aspect to women’s lives, and a diagnosis of SLE should not necessarily preclude the ability to bear children. Article  The outlook for most people with lupus is good. Google Scholar. Although ARD do not represent a cause of infertility in themselves, they may be related to a decrease in parity for multifactorial reasons such as the concern of having a child with ARD, or being unable to care for a child due to the structural damage that may arise. After this time, considering that her disease remained in remission, she received the “green light” to conceive. A diagnosis of SLE with renal major involvement was made. 14-05-2020 | Pregnancy | Case study | Article. In anticipation of pregnancy, such medications should be discontinued and replaced with immunosuppressive medications including azathioprine and cyclosporine and assessed for disease stability. Treatment should not be withheld due to pregnancy; however, some medications used to treat SLE may cross the placenta and cause fetal harm. An association of autoimmune disease with infertility has been suggested, but the studies are not conclusive. As SLE can flare during pregnancy, it is important for the patient to be under a doctor’s care during pregnancy. However, pregnancy with the most common – and serious – type of the disease of lupus called systemic lupus erythematosus involves special implications for prenatal care. Sufficient time should be allowed for proper washout (at least 6 weeks for MMF). Treatment of Systemic Lupus Erythematosus (SLE) in Pregnancy. Low dose weekly methotrexate in the first trimester of pregnancy: results of a French collaborative study. JAMA. Use of HCQ is recommended in women with SLE preconceptionally and throughout pregnancy.33, 56, 60 A beneficial role has also been suggested for APS pregnancies,119–121 but at present there is insufficient data to recommend its routine use in these patients. https://doi.org/10.1002/art.20364. https://doi.org/10.1016/0002-9378(73)90559-0. The patient decided to breastfeed and maintained the same therapeutic regime as during pregnancy. Transplantation. Pregnancy after treatment for breast cancer with BRCA mutations is safe, with excellent fetal outcomes and no increase in cancer recurrence, say researchers reporting a … Oocyte cryopreservation can be another option, although not widely available. Saarikoski S, Seppala M. Immunosuppression during pregnancy: transmission of azathioprine and its metabolites from mother to fetus. Renal biopsy was compatible with class IV lupus glomerulonephritis (GN). She was advised to wait at least 6 months after this change of antirheumatic immunosuppressive drugs to allow proper monitoring of disease, with monthly evaluation of renal parameters and bimonthly evaluation of anti-dsDNA titres and levels of C3 and C4. 2002;9:161–4. 2006;82(12):1698–702. If your lupus is active or if you experience a flare-up, however, your medical team will work with you to treat your disease in a way that's safest for you and your growing baby. This article is part of the Topical Collection on Lupus, Shirley, E., Chakravarty, E.F. Pregnancy and its outcome is a major concern to most SLE patients. The treatments may include: anti-inflammatory medications for … To minimize complications in pregnancy, SLE ideally should be well controlled for at least 4-6 months before conception. 27. Anderka MT, Lin AE, Abuelo DN, Mitchell AA, Rasmussen SA. 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