Protocols for High-Risk Pregnancies: Autoimmune Disease

Synopsis: In this protocol, Dr Lockwood reviews the pathophysiology, diagnosis, and management of systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), and scleroderma. One in 2000 pregnancies are complicated by SLE, and RA is the most common autoimmune disease in women of childbearing age. Scleroderma, in contrast, is rare.

Key messages about SLE

• In 98% of patients with SLE, antinuclear antibody is positive. Diagnosis is established when 4 or more criteria for SLE from the American College of Rheumatology are met.

• Four factors determine prognosis for live birth when a pregnancy is complicated by SLE: disease activity at conception and subsequent flares during pregnancy; coexisting lupus nephritis; development of antiphospholipid antibodies (APA); and presence of anti-SSA (Ro) antibodies.

• Many women with SLE and underlying renal disease may be on angiotensin-converting enzyme (ACE) inhibitors to control hypertension and slow progress of the renal disease. ACE inhibitors are teratogenic and should be stopped prior to conception or as soon after it occurs as possible.

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• For active SLE in pregnancy, prednisone is the mainstay of therapy. It should also be used for antepartum SLE flare. Azathioprine can be added if a patient’s condition is refractory to glucocorticoids. In patients with SLE who have APA, low-molecular-weight aspirin and low-dose aspirin should be used.

• Delivery can be delayed until 40 weeks, provided that twice-weekly fetal testing at 36 weeks is reassuring, if a woman with SLE does not have SSB/ SSA antibodies, APA, worsening nephritis or hypertension, fetal growth restriction, oligohydramnios, or superimposed preeclampsia.

Key Messages About RA

• Diagnosis of RA requires that 5 different clinical features be present, including inflammatory arthritis involving 3 or more joints and symptom duration of more than 6 weeks.

• In 40% to 80% to patients with RA, the condition improves in pregnancy whereas 90% have postpartum exacerbations.

• Local steroid injections into affected joints should be part of initial treatment of RA in pregnancy. If the condition does not respond, prednisone can be given at a dose of 5 mg every morning and 2.5 mg every evening.

• Acetaminophen is recommended for RA in pregnancy and NSAIDs should be avoided after 20 weeks.