Lupus Activity in Pregnancy

Clowse, Megan E.B.

doi:10.1016/j.rdc.2007.01.002

Cited by 244 publications

(236 citation statements)

References 55 publications

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“…Whether SLE activity increases during pregnancy has been a matter of debate over the last years although recent studies have found a two-to threefold increase in SLE activity during pregnancy [4,[10][11][12]. Differentiation of signs and symptoms of normal pregnancy from those of exacerbations of lupus (e.g.…”

Section: Discussionmentioning

confidence: 99%

“…According to the literature, one third of pregnancies will result in a cesarean section, 33% will have preterm birth, and more than 20% will be complicated by preeclampsia [3,4,12,16]. Pregnancy outcome in SLE and the risks for these complications relate to lupus activity, antiphospholipid antibodies, renal status, hypertension, and medication complications [4,10,13,15].…”

Section: Discussionmentioning

confidence: 99%

“…Many of these complications can be attributed to SLE treatment more than to the disease itself. Several factors are believed to influence the outcome of pregnancy, namely lupus activity, antiphospholipid antibodies, renal status, hypertension and medication complications [3][4][5].…”

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

Lupus and Pregnancy—15 Years of Experience in a Tertiary Center

Ambrósio¹,

Lermann²,

Cordeiro³

et al. 2009

Clinic Rev Allerg Immunol

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This retrospective study was designed to evaluate the outcome of pregnancies in women diagnosed with systemic lupus erythematosus (SLE) followed in a tertiary fetal-maternal center. Data were collected from clinical charts between January 1993 and December 2007, with a total of 136 pregnancies (107 patients). Mean maternal age was 29 years, with the vast majority of patients being Caucasian. Most patients were in remission 6 months prior to pregnancy (93%) and the most frequently affected organs were the skin and joints. Renal lupus accounted for 14% of all cases. Twenty-nine percent of patients were positive for at least one antiphospholid antibody (aPL) and nearly 50% had positive SSa/SSb antibodies. All patients with positive aPL received low-dosage aspirin and lowmolecular-weight heparin (LMWH). There were no pregnancy complications in more than 50% of cases and hypertensive disease and intrauterine growth restriction were the most common adverse events. There were 125 live births, one neonatal death, eight miscarriages, and three medical terminations of pregnancy. Preterm delivery occurred in 25% of pregnancies. Our results are probably the conjoined result of a multidisciplinary approach together with a systematic management of SLE pregnancies, with most patients keeping their prior SLE medication combined with low-dosage aspirin and LMWH in the presence of aPL.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

See 1 more Smart Citation

Lupus and Pregnancy—15 Years of Experience in a Tertiary Center

Ambrósio¹,

Lermann²,

Cordeiro³

et al. 2009

Clinic Rev Allerg Immunol

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“…Reports of the effect of pregnancy on SLE activity are mixed, with some studies reporting a two-to three-fold increased risk of flare, whereas others indicate no increased risk (11,(13)(14)(15)(16). Measurable SLE disease activity is present in 40%-50% of pregnancies, with the most common manifestations being cutaneous disease (25%-90%), LN (up to 75%), arthritis (20%), and hematologic disease, including thrombocytopenia (10%-40%).…”

Section: Sle and Pregnancymentioning

confidence: 99%

Obstetric Nephrology

Stanhope

White

Moder

et al. 2012

Clinical Journal of the American Society of Nephrology

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Summary SLE is a multi-organ autoimmune disease that affects women of childbearing age. 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. Consequently, current recommendations advise that the affected woman achieve a stable remission of her renal disease for at least 6 months before conception. Hormonal and immune system changes in pregnancy may affect disease activity and progression, and published evidence suggests that there is an increased risk for a LN flare during pregnancy. The major goal of immunosuppressive therapy in pregnancy is control of disease activity with medications that are relatively safe for a growing fetus. Therefore, the use of mycophenolate mofetil, due to increasing evidence supporting its teratogenicity, is contraindicated during pregnancy. Worsening proteinuria, which commonly occurs in proteinuric renal diseases toward the end of pregnancy, should be differentiated from a LN flare and/or preeclampsia, a pregnancy-specific condition clinically characterized by hypertension and proteinuria. These considerations present challenges that underscore the importance of a multidisciplinary team approach when caring for these patients, including a nephrologist, rheumatologist, and obstetrician who have experience with these pregnancyrelated complications. This review discusses the pathogenesis, maternal and fetal risks, and management pertinent to SLE patients with new onset or a history of LN predating pregnancy.

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“…There is no mention of the widely suggested option of waiting for at least 6 months of disease remission before planning pregnancy. Some examples from the literature include: "the best prevention of SLE flares during pregnancy is the delay of conception until a woman has had quiescent SLE for at least 6 months" (16), "pregnancy should be planned in advance, following a pre-conception visit in which the specific risk for complications can be assessed and pregnancy should be discouraged in women with recent serious lupus activity" (17), and "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" (18). In fact, in the third scenario of pregnancy during "clinically active LN," pregnancy may progress, but often with a high price to be paid for both the mother and baby (16 -24).…”

Section: Lettersmentioning

confidence: 99%

The other side of the risk equation: Exploring the dangers of unplanned pregnancy in women with lupus nephritis. Comment on the article by Hahn et al

Stratta¹,

Quaglia²

2012

Arthritis Care & Research

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Should cyclophosphamide be a first-line medication for class V lupus nephritis? Comment on the article by Hahn et al To the Editor:We read with interest the guidelines for the screening, treatment, and management of lupus nephritis (LN) recently published in Arthritis Care & Research (1). This article provided insightful guidance on the management of LN. However, there are some comments we would like to make.Class V LN occurs in one-fifth of biopsy-proven cases of systemic lupus erythematosus. In the Recommendations for Induction of Improvement in Patients With Class V "Pure Membranous" LN section of the guidelines, the Task Force Panel recommended that patients with pure class V LN with nephrotic range proteinuria be started on prednisone plus mycophenolate mofetil (MMF; level A evidence, defined as evidence representing data derived from multiple randomized controlled trials or a meta-analysis). However, cyclophosphamide (CYC) is not recommended and graded in the guidelines. In an analysis of 2 large randomized controlled multicenter trials of patients with class V LN, MMF taken orally at a total daily dose of 2-3 gm plus daily prednisone for 6 months resulted in improvement similar to that of intravenous CYC plus prednisone, with 0 -30% of patients having nephrotic range proteinuria after 6 months (2). These results are from a pooled analysis of patients with class V LN from the 2 prospective randomized controlled multicenter trails (2-4), not a retrospective analysis as mentioned by the guideline authors. The authors of this pooled analysis even argue that retrospective power analyses are very controversial and should be avoided (2). If this study is a retrospective analysis, the evidence level should not be level A, but rather level C (defined as evidence representing data from consensus, expert opinion, or case series) at most. The Kidney Disease: Improving Global Outcomes (KDIGO) Glomerulonephritis Work Group published guidelines for glomerulonephritis almost simultaneously in June 2012 (5), and in section 12.5: Class V LN (membranous LN), MMF is graded level 2D (defined as a suggestion based on a very low quality of evidence) after CYC (level 2C, a suggestion based on a low quality of evidence) and calcineurin inhibitors (level 2C). In fact, the KDIGO Glomerulonephritis Work Group missed the evidence level A pooled analysis study (2), and it was not included in the reference list (5). Moreover, a recent mini review concluded that MMF and CYC should now be considered standard first-line therapy for severe LN

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Lupus Activity in Pregnancy

Cited by 244 publications

References 55 publications

Lupus and Pregnancy—15 Years of Experience in a Tertiary Center

Lupus and Pregnancy—15 Years of Experience in a Tertiary Center

Obstetric Nephrology

The other side of the risk equation: Exploring the dangers of unplanned pregnancy in women with lupus nephritis. Comment on the article by Hahn et al

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