Embedded Files
preterm birth (66% preterm birth with active SLE vs. 33% with inactive SLE) (29). Some of these deliveries may be induced to protect the health of the mother, but the majority are spontaneous preterm deliveries. Pre-eclampsia, the combination of hypertension and proteinuria in the third trimester, is a dangerous pregnancy complication that is common in women with SLE. Studies estimate that up to one in four women with SLE will develop pre-eclampsia (10, 33). This risk is particularly high for women with pre-existing hypertension or a prior history of lupus nephritis (36). The risk for pre-eclampsia might be reduced with daily dosing of low-dose aspirin (LDA). Studies on non-SLE high-risk pregnancies show that aspirin can decrease the risk for pre-eclampsia by 20% and is a safe medication for both mother and baby (37). Studies of the effect of lupus on pregnancy outcomes (38–42) are summarized in Table 2 and studies of the effect of prior and current lupus nephritis on pregnancy outcomes (43–45) are presented in .Although scleroderma was once considered a strict contraindication for pregnancy, with careful timing of pregnancy and close monitoring, successful pregnancies can be achieved with good outcomes for both the mother and infant (2). Studies have shown no increase in miscarriage rate, with the exception of women with long-standing diffuse scleroderma [42% with long-standing diffuse scleroderma vs. 13% of all other subjects; relative risk (RR) 2.8, 95% confidence interval (CI) 1.23–6.37, p < 0.05] (46). Another study found the live birth rate was 84% for women with limited scleroderma, 77% for women with diffuse scleroderma, and 84% in a historical control group (46). An increased risk for premature births has been reported in case series and a recent prospective study (47–49). Low birth weight (< 2500 g at term) was also common (48–50). Scleroderma disease activity does not change in pregnancy (46–48). In one study there seemed to be no change in 10-year cumulative survival between those women with scleroderma who became pregnant after diagnosis and those who did not (48). Raynaud's phenomenon may improve with pregnancy secondary to a physiological increase in cardiac output, while gastroesophageal reflux disease (GERD) worsens, especially during the latter part of pregnancy. Scleroderma renal crisis is a feared complication during pregnancy. Angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers are life-saving treatments for scleroderma renal crisis, but carry significant risk for foetal anomalies (51). These risks occur late in pregnancy and include renal atresia, pulmonary hypoplasia, and foetal death (52). A prior episode of renal crisis is not a strict contraindication for future pregnancy, but it is recommended that a woman wait several years until her disease is stable before trying to conceive. A trial without ACE inhibitors prior to pregnancy is recommended to determine if blood pressure can be adequately controlled with alternative anti-hypertensive medications. APS and pregnancy APS is characterized by the presence of antiphospholipid antibodies (aPL) in the setting of either vascular thrombosis or pregnancy complication as defined in the classification criteria for APS (Table 4) (53). The pregnancy complications include repeated early pregnancy losses, a single late-term loss, or early severe pre-eclampsia. APS is the leading cause of miscarriage and infertility among patients with either hereditary or acquired thrombophilia (54). Additionally, patients with APS can have multiple pregnancy complications including foetal growth retardation, infertility, and maternal thrombosis. Untreated,
Report abuse