Systemic Lupus Erythematosus, Pregnancy And Reproduction

Systemic lupus erythematosus, pregnancy and reproduction

Introduction

Systemic lupus erythematosus (LAS) is an autoimmune multisystemic disease that mainly affects young women of reproductive age, but will not affect their fertility. The patient with Lupus can pursue a successful pregnant woman, as long as careful control or monitoring is carried with their respective rheumatologist and gynecologist so as not to present serious complications during pregnancy. You can still find contradictory information about whether pregnancy can produce an activity outbreak. However, they are agreements with the following aspects:

If the disease has remained inactive for at least 6 months before the time of conception, the risk of reactivation of the disease is lower.

The outbreaks are more frequent in the second half of pregnancy and in the postpartum. During pregnancy, HTA can be developed and renal function is deteriorated. The exacerbation of kidney disease occurs up to 40% of cases, usually in the second half of pregnancy. Approximately 50% of proteinuria patients can suffer fetal loss.

Patients with active renal, cardiac, lung or involvement of the CNS have a higher risk of complications. Two thirds of patients with their and kidney disease develop preeclampsia, compared to 14% of patients with renal affectation. In some situations it is difficult to differentiate a preeclampsia situation from loup nephritis.

The fetal forecast is more linked to the presence of renal disease and antiphospholipid antibodies than to the activity of the disease.

Approximately 20% of patients have fetal loss.”(Pedraz Criminalva, Bernabeu Gonzálvez, & Vela Casasempere, 2019, p. eleven)

In the event that the patient is pregnant, the doctor will ask for a urine analysis to search the urine proteins, complement levels, complete hemogram, antiphospholipid antibodies to check the danger of spontaneous abortion, anti-ADN antibodies,Blood to examine the renal and hepatic function, anti-SSA/Ro and anti-SSB/the fetus antibodies to observe if the fetus has a risk of cardiac lock or neonatal lupus, if so, the doctor will ask for a fetal echocardiogram from the week from the week18. The patient should be oriented from contraceptive measures to prevent unwanted pregnancies in periods of high disease or medication administration.

Doctors should particularize the contraceptive measure in each patient to avoid or run the risk of presenting an unwanted pregnancy and adverse effects that may be presented during pregnant women through prescribed and ingested medications.

Fetal complications

There is a high risk of exacerbation or outbreaks of both maternal and fetal lou forPrevent it. Neonatal lupus is characterized by the manifestation of blood problems, skin lesions, liver disorders, cardiac blocking in which a pacemaker is placed to regulate heartbeat that normally disappears at 6 months of age.

Next, the characteristics mentioned above will be affirmed by means of a clinical case: “RN of female sex, 37 -year -old mother, from Asunción, with enough prenatal controls, without known pathologies or infection data, with full membranes,goes to caesarean section by unfavorable bishop, grade II. Born with a weight of 3.280 grams, Apgar 9/9, 40 weeks per capurro. On physical examination, it attracts attention, leather lesions of the erythematous and desquamient type, which cover face with periocular distribution in mask, scalp and anterior thorax, respecting the mucous membranes.”(Arias, Irala, Zapata, Fonseca, & More, 2019)

Antiphospholipid antibodies or antiphospholipid syndrome can be present at 10% – 40%, causing a condition to the fetus by means of the passage of these antibodies in the placenta. Causing the baby to be born with a low weight, or/and a fetal death occurs within the uterus before 20 weeks of pregnancy.

Preeclampsia occurs when the placenta has problems, producing high pressure in pregnant women, headaches, blurred vision and proteins in urine. Intrauterine growth restriction (RCIU) presents different causes, one of the most common is hypertension and presence of antiphospholipid antibodies. Renal failure is produced by the deterioration of renal function due to lupus activation.

In addition, there are possibilities that some babies face health risks such as premature birth or child.

Pharmacotherapy

A specialized doctor in rheumatology and gynecology should be consulted to suspend certain medications before and during pregnancy, thus avoiding, the bad training of the baby.

The medications that have not caused any problems and is considered a good safety profile are: hydroxychloroquine (platelet) reduces the activity of systemic lupus erythematosus, glucocorticoid requirements and prevents a lupus outbreak. In other words, through a study it was confirmed that “… neonatal morbidity (prematurity and restriction of intrauterine growth) decreases).”(Stuht López, Santoyo Haro, & Lara Barragán, 2018)

Acetylsalicylic acid or aspirin in low doses is used to prevention of high pressure called as preeclampsia, it is recommended to administer it from week 12 and 28 of pregnancy. Folic acid and vitamins should be administered three months before becoming pregnant to reduce defects in the neuro or neural tube such as spine or biffid spine and anencephaly.

The medications that must be canceled are: Metotrexate, rituximab, cyclophosphamide, mofenolate mofenolate, oral anticoagulants, angiotensin II receptor blockers and most non -steroidal anti -inflammatories (naproxen or ketoprofen, diclofenac and ibuprofen).

Pregnancy control

It must be carried out in a high specialty hospital or institution with the participation of the nephrologist, rheumatologist, gynecologist and a specialist in Maternal Fetal Medicine. In order to detect or promptly prevent complications and visits frequencies will depend on each case.

In general, in pregnant women with them that are stable, without evidence of lupus outbreaks and without increasing fetal maternal complications, it is suggested that on the first visit it will be made in week 6 of gestation. Then, the first first quarter analytics and ultrasound will be requested, which would be 11 to 14 to 14. Then visits must be made every 4 weeks until week 28, every 2 weeks until week 36 and every week until childbirth or until the baby is born.

In the stable pregnant women who have not had loup activity during pregnancy, childbirth will be scheduled between the 40s and 41. On each visit, the doctor will review the blood pressure, which there is no presence of proteins and hematuria (blood) in the urine, determine data of loup activity or some complication, consultations will have to be more frequent.

In the first quarter, the baby surveillance and growth control will be carried out by ultrasound between week 11 and 14. Morphological ultrasound will help us verify if the baby presents any malformation and is done in week 20 to 22. The baby growth control ultrasound, to observe the baby’s adequate growth and weight, will be done at week 28 and then every 4 weeks.

If the pregnancy passes without complications for the mother and for the fetus you can reach the end of pregnancy and the majority will get a normal vaginal delivery. If you specify the induction of childbirth, this can be done in the same way as in the rest of the pregnant women. Cesarean section as a way of childbirth will be carried out according to obstetric indications (podic presentation, previous placenta …) and not because of the disease itself, although the different cases must always be individualized.

Breastfeeding, as is well known, is the best food option for neonates, by providing the necessary nutrients for healthy development and growth, it is recommended up to six months to continue food supplements until two years. Most medications consumed by women with lupus appear in minimal concentrations in breast milk (Prednisone < 20 mg/día, hidroxicloroquina, AINE, heparina), por lo que de no existir contraindicación se debe de estimular a la madre a amamantar.

conclusion

Pregnancy in women with systemic lupus erythematosus is a high -risk condition, but through the appropriate indications or advice of the doctor specialized in rheumatology and gynecology, it may have a successful pregnancy making a correct and due planning to counteract complications, abortions, fetal deaths,premature birth, outbreaks or exacerbation, Lupus activity during pregnancy so that it does not affect the mother and son. In addition, perfect pharmacological management must be ensured, taking into account the security profile of the various treatments during pregnancy and breastfeeding.