A. Systemic Lupus Erythematosus [1,4]

1. Flares probably increase during pregnancy and early post-partum [2]
   1. Renal Problems are major risk
   2. Hematologic problems also increase during pregnancy
   3. Skin disease and arthritis are most common types of flare
   4. Falling serum complement levels may be best marker for disease flare
2. Preeclampsia
   1. All patients with SLE are at much increased risk for preeclampsia
   2. Risk of renal failure requiring dialysis may be 1-2%
   3. This is particularly true in patients with SLE and clinically significant disease
   4. Proteinuria, hyperuricmia, and impaired renal function may be due to SLE and/or toxemia
3. Maternal Complications [6,8]
   1. Risks are related to severity of SLE and to glucocorticoid doses
   2. Increased risk of diabetes, hyperglycemia, hypertension, urinary tract infection, HELLP
   3. Presence of antiphospholipid antibodies increases risk for thromboembolic events
   4. Low platelets are not uncommon in normal pregnancy, but accompany SLE
   5. Congestive heart failure and pulmonary insufficiency are rare
4. Fetal Complications [8]
   1. Fetal loss
   2. Preterm birth - occurs in >30% of SLE pregnancies
   3. Low birth weight (intrauterine growth retardation, IUGR)
   4. Spontaneous Abortions
   5. Neonatal Lupus Syndrome - congenital heart block
   6. Malforation - teratogenic drug exposure (rare)
5. Spontaneous Abortions [7]
   1. Increased risk with SLE
   2. Many occur in second trimester, though may occur throughout
   3. Highest risk in antiphospholipid Ab positive patients
   4. Prednisone + aspirin therapy increases side effects and does not improve birth outcome
6. Neonatal lupus syndrome
   1. Rash, thrombocytopenia, heart block
   2. Most parents are Anti-Ro Antibody positive
   3. Many parents also have anti-La antibodies
7. Treatment of SLE in Pregnancy
   1. Glucocorticoids are safe for fetus and are mainstay of therapy
   2. Cytotoxic agents may be stopped, preferably 3-6 months before conception
   3. Hydroxychloroquine has some risks which may be acceptable in some patients [3]
   4. Flares have been treated with prednisolone and azathioprine with apparent success [6]
   5. Thromboembolic disease prophylaxis should be aspirin (low dose) + subcutaneous heparin
   6. Intravenous Ig can be used in resistant patients or patients with recurrent fetal loss
   7. Hypertension is treated with hydralazine, methyldopa, and calcium channel blockers

B. Rheumatoid Arthritis [5]

1. Generally decreased activity during pregnancy (~75% of persons)
2. Major risk is flare post-partum
3. Glucocorticoids are mainstay of therapy during pregnancy
4. Hydroxychloroquine has some risks and usually should be stopped before conception [3]
5. All cytotoxic drugs should generally be discontinued
6. Methotrexate is teratogenic and an abortifacient

C. Systemic Sclerosis (Scleroderma)

1. Skin disease (possibly other symptoms and signs) may improve during pregnancy
2. Increased risk of renal damage
3. ACE inhibitors contraindicated
4. Relaxin production during second and third trimesters may affect skin disease

References

1. Petri M. 1994. Rheum Dis Clin N Amer. 20:87
2. Petri M, Howard D, Repke J. 1991. Arthritis Rheum. 34:1538
3. Parke AL. 1988. J. Rheumatol. 15:607.
4. Boumpas DT, Fessler BJ, Austin HA III, et al. 1995. Ann Intern Med. 123(1):42
5. Masi A, Feigenbaum SL, Chatterton RT. 1995. Sem Arthritis Rheum. 25(1):1
6. Lima F, Buchanan NMM, Khamashta MA, et al. 1995. Sem Arthritis Rheum. 25(3):184
7. Laskin CA, Bombardier C, Hannah ME, et al. 1997. NEJM. 337(3):148
8. Petri M and Allbritton J. 1993. J Rheumatol. 20(4):650