1. This lecture was conducted during the Nephrology Unit Grand Ground by Medical Student rotated under Nephrology Division under the supervision and administration of Prof. Jamal Al Wakeel, Head of Nephrology Unit, Department of Medicine and Dr. Abdulkareem Al Suwaida, Chairman of the Department of Medicine. Nephrology Division is not responsible for the content of the presentation for it is intended for learning and /or education purpose only.

2. Presented by: Nora Al Kheraiji Medical Student December 24, 2008

3. Systemic lupus erythromatosus(SLE) is one of the most common autoimmune disorders that affect women during their childbearing years (ages 15 and 45 years).

4. Gravida--- (number of pregnancies) para --- (number of births >24 W) Abortions--- (<24 W) Full Term--- (38-42W)

5. Preterm--- (24-37) IUGR--- (snography parameters are decreased) Still birth=IUFD--- (fetal death >20 but befor labor)

6. 50% (active/inactive lupus) have a normal outcome. 25% deliver healthy babies prematurely. The foetal outcome in lupus pregnancy: abortions still-births intra-uterine growth retardation (IUGR). Lupus patients have an increased risk of pre-eclampsia (5 ‑ 38%) as compared to women without SLE.

7. active lupus nephritis previous history of foetal death for foetal wastage Maternal hypertension high dose steroids for prematurity and IUGR

8. The pathophysiology of disease activity during pregnancy remains unknown. Increased SLE disease activity is expected during pregnancy because of increased levels of estrogen, prolactin(ie, proinflammatory hormone), and T–helper cell 2 cytokines.

9. Nausea, vomiting, and morning sickness can occur during the first trimester absorption of medications. Most patients with lupus report fatigue during pregnancy. (fatigue Lupus/pregnancy ? ) Differentiate malar rash from chloasma. Pedal edema and fluid accumulation in joints, especially the knees, can occur in the late stages of pregnancy and should be differentiated from the arthritis of systemic lupus erythematosus (SLE). Differentiate proteinuria secondary to preeclampsia from proteinuria due to lupus nephritis.

11. ** The likelihood of developing renal disease during pregnancy is not increased if the patient was in remission at the time of conception. Pregnancy + active lupus risk of fetal loss and worsening of the renal and extrarenal manifestations.

12. women with lupus nephritis should be encouraged to delay pregnancy until the disease can be rendered inactive for at least 6 months.

13. In a retrospective study from 2000–2005 done on 84 pregnancies in 84 SLE patients to evaluate the influence of LN on maternal and fetal outcome in patients with histologically proven LN compared with patients without LN (Pacheco-Reyes.H et al; 2006).

14. Conclusion: Pregnant women with LN have poor outcome than pregnant patients without LN. These patients require close follow-up for the best pregnancy outcome.

15. ProteinuriaLupus nephritis active urine sediment (RBCs, WBCs, and cellular casts) PreeclampsiaNO

16. complement levels + anti- DNA antibodies Lupus nephritis anti-DNA complement Preeclampsia anti-DNA (No) complement

17. In pregnant + renal disease preeclampsia or active lupus nephritis differentiation on clinical grounds is not possible renal biopsy Platelet + liver enzymes/uric acid + urinary excretion of calcium,these are more prominent in preeclampsia than in lupus nephritis.

18. Note : thrombocytopenia may also be associated with :  antiphospholipid antibodies  thrombotic thrombocytopenic purpura (TTP)  immune thrombocytopenia each of which may complicate pregnancy in women with SLE.

19. Pregnancy + postpartum period (especially) the thrombotic risk in SLE patients who have antiphospholipid antibodies. Patients on warfarin (because of a past venous or arterial thrombotic event) switch to heparin as soon as the pregnancy is recognized. Patients who had fetal losses or other pregnancy morbidity due to antiphospholipid antibody syndrome are treated with prophylactic doses of heparin and low-dose aspirin (81 mg) during subsequent pregnancies (no past morbidity, many consider the use of low-dose aspirin).

20. Neonatal lupus (3.5%) congenital heart block /lupus rash, it is associated with +ve maternal anti-Ro (usually anti-La) (rash may occur with anti-RNP antibodies.) In rare cases hepatic or hematologic involvement. So what should be done? fetal 4-chamber cardiac echocardiography performed at 16-28 weeks' gestation is recommended. If heart block of any degree is found, dexamethasone 4 mg/day is given to the mother because it crosses the placenta.

22. pregnancy loss in SLE compared with control groups. Fetal loss is possible in any trimester. First-trimester losses antiphospholipid antibodies and with lupus activity (eg, low complement concentrations and increased anti–double-stranded DNA [anti-dsDNA] antibodies). Late losses antiphospholipid antibodies. Note : hypercoagulable states other than antiphospholipid antibody syndrome are also associated with increased fetal loss.

23. SLE is not associated with infertility unless the woman has been treated with cyclophosphamide, which leads to premature ovarian failure.

24. Patients may need to be reminded about the importance of using contraception while they are taking methotrexate, cyclophosphamide, and mycophenolate. Counsel patients about the teratogenicity of medications used to treat systemic lupus erythematosus (SLE) before therapy is initiated.

25. Educate patients that, because of prolonged half-lives, some medications may need to be discontinued several months before the planned conception. Women with lupus and the antiphospholipid antibody syndrome require more frequent monitoring than those with SLE alone.

26. AZATHIOPRINE(2.5 mg/kg/d) and STEROIDS(Prednisone, 5-60 mg/d PO) (safe in pregnancy) anti-phospholipid antibody syndrome add aspirin and/or low-molecular weight heparin CYCLOPHOSPHAMIDE : causes birth defects, especially during the 1st trimester MYCOPHENOLATE MOFETIL : recently has been shown to result in ear and other facial malformations such as cleft lip and cleft palate.

27. PACHECO-REYES, H; MEDINA, G; ANGELES, U; CRUZ, P; JARA, L J. THE IMPACT OF LUPUS NEPHRITIS ON PREGNANCY OUTCOME.JOURNAL OF CLINICAL RHEUMATOLOGY. VOLUME 12(4) SUPPLEMENT, AUGUST 2006, PP S64-S65. KHURANA.R, WOLF.R. SYSTEMIC LUPUS ERYTHEMATOSUS AND PREGNANCY. EMEDICINE FROM WEB MD. UPDATED: FEB 14, 2008 TREATING LUPUS NEPHRITIS DURING PREGNANCY.RENAL FELLOW NETWORK. OCTOBER 14, 2008 HANDA.R, KUMAR.U, WALI.J. SYSTEMIC LUPUS ERYTHEMATOSUS AND PREGNANCY. SUPPLIMENT TO JAPI. New Delhi. JUNE 2006. VOL. 54. P 19