Hot topics in lupus pregnancy

Table 1 Contraindications to pregnancy in women with systemic lupus erythematosus

Severe pulmonary hypertension (estimated systolic PAP > 50 mmHg or symptomatic)

Severe restrictive lung disease (FVC < 1 L)

Heart failure

Chronic renal failure (Cr > 2.8 mg/dL)

Previous severe preeclampsia or HELLP syndrome despite therapy with aspirin and heparin

Stroke within the previous 6 mo

Severe lupus flare within the previous 6 mo

PAP: Pulmonary arterial pressure; FVC: Forced vital capacity.

Table 2 Diferences between lupus flare and normal pregnancy

	Lupus flare	Normal pregnancy
Clinical features	Malar rash	Palmar and facial erythema
	Inflammatory arthritis	Arthralgia/Joint effusions
	Lymphadenopathy	Fatigue
	Fever	Hair loss
	Oral ulcerations
	Raynaud phenomenon
Laboratory features	ESR increased	ESR increased
	Leukopenia/lymphopenia
	Anemia	Anemia due to hemodilution
	Complement levels drop	Complement levels increased
	dsDNA antibodies rising	dsDNA antibodies stable
	Hematuria
	Proteinuria ≥ 300 mg/dL	Proteinuria ≤ 300 mg/dL

ESR: Erythrocyte sedimentation rate.

Table 3 Obstetric complications of systemic lupus erythematosus

Spontaneous abortion

Late miscarriage

Intrauterine growth retardation

Preterm delivery

Prematurity

Table 4 Differences between preeclampsia and active lupus nephritis

	Pre eclampsia	Lupus nephritis
Backgrounds	Chronic hypertension, antiphospholipid syndrome, diabetes mellitus, past preeclampsia
Hypertension	Onset after 20 wk	Onset before 20 wk
Proteinuria	++	++
Urinary sediment	Inactive	Active (red cells, white cells and cellular casts)
Complement levels	Normal	↓↓
Anti DNA antibodies	Stable	↑↑
Uric acid levels	↑
Urinary calcium excretion	↓
Extrarenal manifestations		Present

Table 5 Pregnancy morbidity of antiphospholipid syndrome

Classification criteria of APS in pregnancy

One or more unexplained deaths of a morphologically normal fetus at or beyond the 10th week of gestation, with normal fetal morphology documented by ultrasound or by direct examination of the fetus, or (b) One or more premature births of a morphologically normal neonate before the 34th week of gestation because of: (1) eclampsia or severe preeclampsia defined according to standard definitions[11], or (2) recognized features of placental insufficiency-, or (c) Three or more unexplained consecutive spontaneous abortions before the 10th week of gestation, with maternal anatomic or hormonal abnormalities and paternal and maternal chromosomal causes excluded.

Others obstetric manifestations of APS

Increased risks of intrauterine growth retardation

HELLP syndrome

Utero-placental insufficiency

Preeclampsia

Risk of thrombosis in the mother

APS: Antiphospholipid syndrome.

Table 6 Medications use during systemic lupus erythematosus pregnancy

Medication	Permitted	Not allowed
Corticosteroids	Prednisolone, Dexamethasone, Betamethasone, Pulses methylprednisolone
Antimalarials	Hydroxychloroquine
Immunosuppressives	Cyclosporine	Cyclophosphamide
	Azathioprine	Methotrexate
	Tacrolimus	Leflunomide
		Mycophenolate mofetil
Anticoagulants	Unfractionated heparin	Warfarin
	Low-molecular-weight heparin	Acenocumarol
Antiplatelets	Aspirin	Clopidogrel
		Ticlopidine
Non-steroidal anti-inflammatory drugs and analgesics	NSAIDs (until week 32)	COX-2 inhibitors
	Acetaminophen
Biologics		Rituximab
		Belimumab
Miscellaneous	Intravenous immunoglobulin

NSAID: Non-steroidal non steroidal antiinflammatory drugs.