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Lupus Eritematoso Sistémico En El Embarazo www.medigraphic.org.mx ARTÍCULO DE REVISIÓN Lupus eritematoso sistémico en el embarazo Daniela Stuht López,1 Samuel Santoyo Haro,2 Ignacio Lara Barragán3 Resumen Summary El lupus eritematoso sistémico (LES) es una enferme- Systemic lupus erythematosus (LES), is a chronic, dad crónica, multisistémica que se caracteriza por una infl ammatory and multisystemic disease characterized by respuesta autoinmune aberrante a autoantígenos con an aberrant autoimmune response to autoantigens that afección a cualquier órgano o tejido, que afecta princi- attacks any organ or tissue, affecting primarily women in palmente a mujeres en edad reproductiva. LES afecta reproductive age. In the United States of America, LES aproximadamente a 300,000 personas en los Estados affects nearly 300,000 people, primarily women with a ratio Unidos de América con relación mujer:hombre de 10:1. El female: male of 10:1. The aim of this article is to resume the objetivo de este artículo es revisar los principales riesgos primary risks of pregnancy associated to LES, as well as asociados al embarazo de pacientes con LES, así como the general recommendations for preconceptional period las recomendaciones generales en cuanto al periodo pre- and treatment during pregnancy and lactation. concepcional, el manejo general y farmacológico durante el embarazo y la lactancia. Palabras clave: Embarazo, lupus eritematoso sistémico, Key words: Pregnancy, systemic lupus erythematosus, fertilidad, tratamiento. fertility, treatment. INTRODUCCIÓN desencadenan una activación y proliferación de células inmunes innatas y linfocitos autorreactivos.2 El lupus eritematoso sistémico (LES) es una enfermedad La heterogeneidad clínica de la enfermedad constituye crónica, multisistémica que se caracteriza por una respuesta un reto diagnóstico para muchos médicos, por esta razón autoinmune aberrante a autoantígenos con afección a cual- se establecieron 11 criterios clínicos, siendo necesarios quier órgano o tejido, que afecta principalmente a mujeres cuatro para establecer el diagnóstico.3 en edad reproductiva.1,2 Diversos factores ambientales en LES afecta aproximadamente a 300,000 personas en individuos que se encuentran predispuestos genéticamente los Estados Unidos de América. La prevalencia varía según la región, oscilando en un rango de 20 a 150 casos por cada 100,000 habitantes, con la más alta prevalencia en 1 Residente de Ginecología y Obstetricia de la Facultad Mexi- brasileños.3,4 La enfermedad se presenta en todas las razas, cana de Medicina Universidad La Salle. aunque los hispanos y negros tienen una presentación de 2 Profesor titular del Curso de la Especialidad en Ginecología enfermedad más severa; la edad de presentación va de y Obstetricia. entre los 17 y 35 años, y la relación mujer:hombre es de 3 Profesor adjunto del Curso de la Especialidad en Ginecología 10:1, esta relación es menos marcada cuando la enferme- y Obstetricia. dad se presenta en los extremos de la vida. El pronóstico ha Hospital Ángeles Pedregal. mejorado en los últimos años: la supervivencia a 10 años es www.medigraphic.org.mxde alrededor del 80% y a 20 años del 65%; sin embargo, Correspondencia: la mortalidad sigue siendo tres veces mayor cuando se Dra. Daniela Stuht López compara con la población en general.5 Correo electrónico: [email protected] En México, se cuenta con el registro de que aproximada- mente 1.5 millones de personas padecen esta enfermedad, Aceptado: 30-04-2018. lo que se traduce a 20 casos por cada 100,000 habitantes, Este artículo puede ser consultado en versión completa en http:// de los cuales el 90% son mujeres de entre los 20 y 45 años www.medigraphic.com/actamedica de edad.6 La Fundación Mexicana para Enfermos Reumá- ACTA MÉDICA GRUPO ÁNGELES. Volumen 16, No. 4, octubre-diciembre 2018 331 Stuht LD y cols. ticos AC estableció que por cada nueve mujeres enfermas laboradores realizaron un estudio de cohorte para evaluar de LES, sólo hay un hombre con la enfermedad.6 incidencia de resultados perinatales adversos en mujeres Las mujeres con LES tienen las mismas tasas de fertilidad mexicanas con LES encontrando: nacimientos pretérmino en comparación con el resto de las mujeres, con excepción 41.8%, óbito 1.6%, oligohidramnios 6.6%, aborto 5.7%, de aquellas pacientes con un compromiso de la función renal rotura prematura de membranas 9.8%, hipertensión gesta- importante (tasa de filtrado glomerular < 50 mL/min), enfer- cional 5.7%, preeclampsia 24.6%, anemia 23%, restricción medad activa o amenorrea inducida por terapia citotóxica.7 del crecimiento intrauterino 14.7%, cesárea 78.2%.15 Sin embargo, las mujeres embarazadas con lupus tienen un El objetivo de este artículo es revisar los principales riesgo elevado de desenlaces adversos tanto maternos como riesgos asociados al embarazo de pacientes con LES, así fetales, dentro de los que se incluyen mayores tasas de parto como las recomendaciones generales en cuanto al perio- pretérmino, muerte fetal, restricción del crecimiento intrau- do preconcepcional, el manejo general y farmacológico terino, bajo peso al nacimiento, preeclampsia y hemorragia durante el embarazo y la lactancia. obstétrica.8 Aproximadamente de 10 a 25% de las pacientes con enfermedad reumática sistémica que acuden a valoración PERIODO PRECONCEPCIONAL a un servicio de urgencias, requieren ser hospitalizadas, y la mortalidad de estas pacientes varía de 47 hasta 79%, a pesar Desde la primera vez que se tiene contacto con una pa- del incremento de la supervivencia en pacientes con LES.8 ciente en edad reproductiva con diagnóstico de LES, se Las principales afecciones reportadas durante el emba- debe abordar el tema de planeación familiar con la finali- razo incluyen enfermedades hipertensivas (preeclampsia, dad de determinar el tiempo adecuado para embarazarse eclampsia), síndrome de HELLP, restricción de crecimiento (remisión de la enfermedad por lo menos seis meses antes intrauterino y pérdidas fetales recurrentes. Adicionalmente, del embarazo), así como el tratamiento compatible para el se ha reportado aumento en la actividad lúpica durante el control de la enfermedad durante el embarazo.7,16 embarazo, así como aumento en el número de cesáreas en pacientes con lupus y embarazo.9-14 Estratificación del riesgo En 2012, se realizó un estudio retrolectivo en pobla- ción mexicana que incluyó 23 mujeres con lupus activo El asesoramiento previo a la concepción es vital en mu- atendidas en una unidad de cuidados intensivos. Las prin- jeres con LES. El paso inicial en el asesoramiento consiste cipales complicaciones encontradas fueron: restricción del en la estratificación del riesgo para resultados maternos y crecimiento intrauterino en 39.1%, parto pretérmino en fetales adversos en mujeres embarazadas con LES. Diversos 78.2%, preeclampsia severa en 30.4%, y muerte materna hallazgos clínicos e inmunológicos permiten identificar en 17.4%.8 Por otro lado, más recientemente Farfan y co- embarazos de alto riesgo (Tabla 1).17 Tabla 1: Factores de riesgo a identifi car en mujeres con lupus eritematoso sistémico (LES) durante el asesoramiento preconcepcional. Relacionados con la enfermedad Generales LES activo en los últimos 6 a 12 meses o en la concepción Edad materna Nefritis lúpica (antecedente o actividad durante la concepción) Hipertensión arterial Actividad serológica (C3/C4 sérica, anti-ADN) Diabetes mellitus Resultados adversos en embarazos previos Sobrepeso/obesidad Antecedente de trombosis Enfermedad tiroidea Perfi l anticuerpos antifosfolípidos (anticoagulante lúpico, IgG/IgM Tabaquismo o alcoholismo anticuerpos anticardiolipina, IgG/IgMwww.medigraphic.org.mx anti ab2GPI) Anticuerpos anti-Ro y anti-La Inmunizaciones Daño de órgano en estadio fi nal y comorbilidades C3 = Complemento 3. C4 = Complemento 4. anti-ADN = Anticuerpos anti-ADN de doble cadena. Modifi cado de: Andreoli L, Bertsias GK, Agmon-Levin N et al. EULAR recommendations for women’s health and the management of family planning, assisted reproduction, pregnancy and menopause in patients with systemic lupus erythematosus and/or antiphospholipid syndrome. Ann Rheum Dis. 2017; 76 (3): 476-485. doi: 10.1136/annrheumdis-2016-209770. 332 ACTA MÉDICA GRUPO ÁNGELES. Volumen 16, No. 4, octubre-diciembre 2018 Lupus eritematoso sistémico en el embarazo Aunque algunos autores comentan que los embarazos las principales contraindicaciones para el embarazo en en pacientes con LES son de alto riesgo, lo que es cierto es pacientes con LES.20 que no todas las pacientes con LES tienen el mismo riesgo. Aquéllas de mayor riesgo son las que tengan una historia Medidas anticonceptivas obstétrica deficiente, compromiso renal, complicaciones cardiacas, hipertensión pulmonar, enfermedad pulmonar Se debe asesorar a las pacientes acerca de la anticoncep- intersticial, enfermedad activa, altas dosis de esteroides, ción con la finalidad de prevenir embarazos no deseados anticuerpos positivos (antifosfolípidos, anti-Ro, anti-La, en periodos de alta actividad de la enfermedad, o con la embarazo múltiple).18 ingesta de medicamentos teratogénicos.17 En mujeres con LES, la prematuridad, preeclampsia Se debe individualizar a cada paciente para poderle y eclampsia se asocian a riesgo de eventos adversos en ofrecer la mejor opción anticonceptiva. El dispositivo in- 25-35%, 10-15% y 1.0-1.5%, respectivamente. Durante trauterino (DIU) es una opción; sin embargo, cabe aclarar el embarazo, los principales factores de riesgo incluyen: que el DIU con levonorgestrel se debe considerar sólo en lupus activo, nefritis activa, hipertensión arterial, y uso de las
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