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Systemic Lupus Erythematosus and Pregnancy: Clinical Evolution Fernanda Garanhani de Castro Systemic lupus erythematosus Surita Mary Ângela Parpinelli and pregnancy: clinical evolution, Ema Yonehara Fabiana Krupa maternal and perinatal outcomes José Guilherme Cecatti and placental fi ndings Department of Obstetrics and Gynecology, Faculdade de Ciências Médicas, Universidade Estadual de Campinas (Unicamp), Campinas, São Paulo, Brazil ORIGINAL ARTICLE INTRODUCTION OBJECTIVE ABSTRACT Systemic lupus erythematosus (SLE) is The objective of the present study was to an autoimmune disease of unknown etiology evaluate the clinical evolution, perinatal out- CONTEXT AND OBJECTIVE: Systemic lupus erythematosus is a chronic disease that is more that can affect various organs and systems. comes and most frequently observed placental frequent in women of reproductive age. The Since it predominantly affects women (in alterations among pregnant lupus patients, relationship between lupus and pregnancy is the proportions of 9 to 1) and since in the according to the presence or absence of disease problematic: maternal and fetal outcomes are worse than in the general population, and majority of cases it is diagnosed between fl are-ups. These women were receiving care the management of fl are-ups is diffi cult during the ages of 20 and 40, it is the connective tissue at a specialized prenatal clinic, Centro de this period. The aim here was to compare the disease that is most frequently associated with Atenção Integral à Saúde da Mulher (Women’s outcomes of 76 pregnancies in 67 women with pregnancy and the puerperium. Remission Full Healthcare Clinic), Universidade Estadual lupus, according to the occurrence or absence of fl are-ups. of the disease around the time of conception de Campinas (CAISM/Unicamp), over an 1,2 DESIGN AND SETTING: An observational cohort is related to favorable pregnancy outcome. eight-year period, and they gave birth at the clinical study evaluating the evolution of pregnant On the other hand, a diagnosis of SLE during same institution. women with lupus who were receiving care at the pregnancy and fl are-up around the time of prenatal outpatient clinic, Centro de Atenção In- conception or during pregnancy are related METHODS tegral à Saúde da Mulher, Universidade Estadual de Campinas (CAISM/Unicamp), between 1995 to poor prognosis for both the pregnancy and This observational cohort study was and 2002. 1 the course of the disease. carried out at the specialized prenatal clinic METHODS: Data were collected on a precoded Abortion, intrauterine growth restric- CAISM/Unicamp, which is a tertiary clinic for form. The women were divided into two groups ac- tion, prematurity, and perinatal morbidity high-risk pregnancies. The patients included cording to the occurrence or absence of fl are-ups, and mortality are among the most common in the study were followed up according to as defi ned by the systemic lupus erythematosus disease activity index (SLEDAI). The presence or adverse perinatal outcomes in pregnant lupus a specifi c protocol for the care of pregnant absence of fl are-ups and renal involvement was patients. Flare-ups, nephritis and arterial women with lupus, including investigation of considered to be the independent variable and the hypertension are factors that increase the risk of the current clinical and laboratory conditions other results were dependent variables. perinatal complications,2,3 as is an association (cardiac, immunological, renal, hematological RESULTS: Flare-ups occurred in 85.3% of cases, with antiphospholipid antibody syndrome and hepatic status). They delivered their babies and were most signifi cant when there was renal involvement. This was related to greater numbers (APS), which is present in 30-40% of SLE at the same institution between 1995 and of women with preeclampsia and poor perinatal cases.4 Although rare, neonatal lupus is also a 2002. A total of 67 women and 76 pregnancies outcome. Intrauterine growth restriction was complication that may be serious and should were included in the study. They represent all more common in the women with active disease. Placental weight was signifi cantly lower in the always be considered in this population. of the cases with SLE that were managed at women with renal involvement. The adverse perinatal outcomes resul- this service during this period. There was no CONCLUSIONS: Flare-ups and renal involve- ting from SLE are believed to occur as a loss to follow-up. ment in lupus patients during pregnancy are consequence of immunological alterations in Data were collected on a precoded form associated with increased maternal and perinatal the placenta. The histology of the placenta and data entry was performed using the Epi- complications. frequently reveals vascular abnormalities in Info software program, version 6.1. After KEY WORDS: Lupus. Pregnancy. Perinatology. the uteroplacenta or alterations in coagula- evaluating the general characteristics of the Placenta. Maternal welfare. tion. These lesions are generally similar to sample, the women were divided into two those found in preeclampsia, hypertension groups according to the presence or absence and diabetes mellitus.1,5,6 Improvements in of fl are-ups of the disease during pregnancy, the treatment and control of systemic lupus as defi ned by the systemic lupus erythemato- erythematosus have led to better quality of life sus disease activity index (SLEDAI).8 They for patients with this pathological condition were also divided into two groups according and a consequent increase in the number of to whether renal involvement with SLE was pregnancies in this population.7 detected or not. Sao Paulo Med J. 2007;125(2):91-5. 92 Statistical analysis was carried out after can College of Rheumatology (ACR), while Of the 67 women enrolled in this study, performing consistency tests. Qualitative 17 (22.4%) had probable lupus (three positive 20 (26.3%) suffered some form of hyper- variables were analyzed using the χ² test criteria) and 12 (15.8%) had possible lupus tensive syndrome during pregnancy. Nine and, when applicable, Fisher’s exact test. (two positive criteria). The ACR criteria most women (11.8%) had preeclampsia (defi ned Student’s t test was used for comparison frequently found in this population were: im- as the raising of blood pressure after the of the means of continuous quantitative munological disorders, blood abnormalities and twentieth week of pregnancy plus proteinuria variables. Statistical significance was esta- renal involvement, serositis, butterfl y-shaped above 300 mg over a 24-hour period), and all blished as p < 0.05. The study obtained rash and a positive antinuclear antibody (ANA) of these patients had some degree of renal in- prior approval from the institution’s Re- test (Table 2). volvement. Another three patients (4%) had search Ethics Committee. Although the SLEDAI criteria do not gestational hypertension and eight (10.5%) recommend any specifi c test for evalua- had chronic hypertension. Some degree of RESULTS ting the immunological profi le, the ANA lupus nephropathy was present in 32 women During the study period, there were test was positive in 73% of cases during (45.1%) and there was no statistically signifi - 23,676 deliveries at the institution, of which prenatal follow-up. There were positive cant difference in gestational loss between 76 occurred among lupus patients. There- fi ndings of anti-DNA antibodies in 19%, these patients and the women who had no fore, the rate of deliveries to lupus patients anti-Ro in 37% and anti-La in 11% of the renal alterations. However, the incidence of at this institution was 3.21:1000. The mean cases. Anticardiolipin antibodies (via im- preeclampsia was greater, and the newborn age of the lupus patients was 25.9 years munoglobulin G and immunoglobulin M infant’s weight and placental weight were (range: 18-39 years), and these patients had determination) and/or lupus anticoagulant lower in this group of women. had between one and seven pregnancies, in- (via Russell viper venom time and kaolin One maternal death occurred during cluding the current one. Around 22.4% of clotting time) were detected in 36% of the puerperium. This was a patient who had the women had previously miscarried. The the patients. Immunosuppressor treatment secondary pulmonary hypertension associated women in this study had attended a mean of for SLE was required in 93.4% of the with lupus and who had had a fl are-up during 8.5 prenatal consultations. The mean time pregnant women. The immunosuppressors a twin pregnancy. She went into premature elapsed between diagnosis of lupus and com- used included prednisone (at doses of 5 to labor and underwent cesarean section at mencement of pregnancy was 48.9 months, 80 mg/day) and azathioprine. Antihyperten- 28 weeks due to breech presentation of the i.e. four to fi ve years (Table 1). sive drugs were used by 26.7% and aspirin fi rst twin and premature labor. She developed Of the 76 cases studied, 47 (61.8%) fulfi lled and/or heparin by 14% of the women (data central nervous system vasculitis and died the diagnostic criteria established by the Ameri- not presented in table). from reentrant convulsions on the third day of the puerperium. Table 1. General characteristics and history of pregnant lupus patients. Campinas, With regard to the type of delivery, 68.6% 1995-2002 of the patients underwent cesarean section. Maternal variables Mean (n = 76) SD The principal indication for this was fetal Age (years) 25.9 5.64 distress (32 cases). Of the 76 cases studied, Number of prenatal visits 8.5 4.02 14 led to gestational loss. Of these, six were Disease duration (months) 48.9 39.0 miscarriages (7.8%), three were cases of fetal death (3.9%) and fi ve were neonatal deaths n% (6.5%) (Table 3). In all the cases in which With history of abortion 17 22.4 the woman was not a primigravida, she had First pregnancy 21 27.6 a history of at least one previous miscarriage.
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