[Pregnancy and systemic lupus erythematosus]

B Wechsler, D Lê Thi Huong, J C Piette
Annales de Médecine Interne 1999, 150 (5): 408-18
Acute disseminated lupus erythematosus primarily affects young women. The highly unfavorable influence of sex hormones is well known and women are advised against pregnancy. Therapeutic termination of pregnancy has been considered necessary. Regular progress in patient management has however completely changed the short, mid and long-term prognosis, although severe forms still resist treatment. As life expectancy improves, better disease control would allow revisiting the possibility of pregnancy. The spontaneous risk of an acute flare-up during pregnancy is debated but estimated in the 60% range. The risk would be about the same whatever the term, but some suggest risk predominates in the third trimester or in the post partum period. The risk of spontaneous abortion is high, partly due to poor disease control and/or the presence of an associated antiphopholipid syndrome. In such cases, preventive therapy (antiaggregates and/or heparin) has greatly improved fetal prognosis. The risk of neonatal lupus (skin eruptions, atrioventricular block) is essentially related to the presence of anti-Ro (SSA) and anti-La (SSB) antibodies. It cannot be well predicted and prevention must be conducted on an individual basis. Overall prognosis of pregnancy can be improved by authorizing pregnancy when the lupus has reached in a well-controlled quiescent phase for at least one year. A multidisciplinary surveillance associating the medical and obstetric teams is required. Preexisting hypertension and renal involvement are unfavorable factors; serum creatinine above 150 mumol/l is considered a contraindication. When good clinical conditions can be achieved, and possibly with low-dose corticosteroids (10 mg/d), the risk of a flare-up is reduced and the rate of fetal survival is almost the same as in the non-lupus female population. The rates of fetal adrenal insufficiency and infection are not significantly higher. Infants are sometimes hypertrophic at birth and are usually born prematurely. Acute pediatric care must be planned. Prognosis in case of "de novo" lupus during pregnancy or pregnancy in a woman with uncontrolled or poorly-controlled lupus remains poor and can be life-threatening for the mother.

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