1. Introduction
Systemic lupus erythematosus (SLE), a complex autoimmune disease, can present particular challenges for pregnant women. Although the management of these pregnancies has improved, they remain at risk, exposing both maternal and fetal complications [1]. Optimal management of these pregnancies requires close collaboration among various specialists, including internists, rheumatologists, obstetricians, anesthesiologists, and pediatricians. Preconception counseling is recommended to address these crucial aspects before pregnancy begins. A management and follow-up plan is established, facilitating prompt intervention in case of potential flares, directly impacting the well-being of both the mother and the fetus [2]. Our study aimed to examine the effects of pregnancy on lupus as well as the impact of lupus on the course of pregnancy.
2. Results
The average age of our parturients was 31.4 years, with extremes ranging from 22 to 38 years, and a predominance in the age group of 34 to 38 years. The median gravidity and parity were 2 and 1, respectively, with 39% being multiparous. One patient (3%) underwent voluntary termination of pregnancy (abortion) due to lupus. Four (13%) patients had a history of spontaneous miscarriage <10 weeks of gestation, with antiphospholipid antibody syndrome associated in one case. One (3%) patient had a history of intrauterine fetal death. Multiple miscarriages were observed in five (16%) patients, with four (13%) cases having antiphospholipid antibody syndrome. Among 31 parturients, three (10%) had a family history of lupus. The duration of the disease in all our patients exceeded three years, with remission lasting one to three years, except in five (16%) cases that required medical termination of pregnancy. Clinical manifestations related to lupus in our patients included chronic arthralgia in 11 (35%) cases, nine (29%) cases of malar rash, five (16%) cases of photosensitivity, four (13%) cases of discoid lupus, four (13%) cases of pleurisy or pericarditis, and one case (3%) of oral ulceration. Other clinical manifestations included one case (3%) of lupus chorea, two cases (6.45%) of Raynaud’s syndrome, one case (3%) of urticaria, one case (3%) of dry syndrome, one case (3%) of alopecia, and one case (3%) of lymphadenopathy. Hypertension was found in eight (26%) patients. Lower limb edema was found in four (13%) cases. One patient was admitted for threatened preterm labor at 23 weeks of gestation with an examination revealing a long cervix open to two centimeters; this patient was treated with tocolysis (calcium channel blockers “nifedipine”) and her pregnancy was carried to term. Among our patients, 23 cases had a normal obstetric ultrasound at admission, seven patients had oligohydramnios, and one patient had intrauterine fetal death at 28 weeks of gestation (Table 1). Renal insufficiency was found in five (16%) patients. Proteinuria was positive in 13 (45%) patients. Hematological abnormalities (anemia, thrombocytopenia) were present in 16 (52%) patients. Syphilitic serology was performed in 23 patients, returning positive in two (6%) patients. Eleven (35%) patients had positive anti-DNA antibodies. Antinuclear antibodies were positive in 13 (46%) patients. Antiphospholipid antibodies were positive in eight (28%) patients. Complement levels were not assessed. Among our patients, 17 (55%) cases were on corticosteroid therapy with adjuvant treatment and antiplatelet aspirin. Antihypertensive treatment was prescribed in nine (32%) patients; eight patients had hypertension and one case of lupus nephropathy stage II. Hydroxychloroquine was continued in eight (26%) patients. The five patients with antiphospholipid antibody syndrome were treated with aspirin and heparin in combination preconceptionally; intrauterine fetal death occurred at 28 weeks of gestation in one of them. Among our 31 patients, 16 (52%) experienced progressive flares, including six (19%) cases during the first trimester; skin flares in four (13%) cases, cutaneous and articular flares in two (6.45%) cases, pericarditis in one (3%) case, and renal flare in one (3%) case (Table 2). These parturients were not on any treatment and responded well to corticosteroid therapy. One (3%) patient who developed superimposed preeclampsia and had a renal relapse in the third trimester required premature termination of pregnancy at 32 weeks of gestation with three sessions of hemodialysis. In the postpartum period, four (13%) patients experienced relapses, and their corticosteroid dose was not increased. Among our 31 parturients, we noted: Six (19%) cases of medical termination of pregnancy were performed at 5, 10, 12, 14, 15, and 18 weeks of gestation, one (3%) case of intrauterine fetal death occurred at 28 weeks of gestation, five (16%) cases of preterm delivery occurred at 29 and 32 weeks of gestation; two cases at 33 weeks of gestation and one case at 35 weeks of gestation, and 19 (61%) cases of term pregnancies (Figure 1). Cesarean section indications are summarized in Table 3. Among the 31 cases; one (3%) case of intrauterine fetal death and 24 (77%) cases resulted in live births, among which five (16%) newborns were premature, four (13%) newborns had intrauterine growth retardation, and 15 (48%) newborns were normal. The four (13%) newborns whose mothers were maintained on hydroxychloroquine throughout pregnancy had no cardiac malformations. All 31 (100%) patients had normal postpartum outcomes. The five patients who required therapeutic termination of pregnancy did not experience any complications. Three multiparous parturients and another with lupus nephropathy stage II underwent tubal ligation, representing a frequency of 13%, and 27 (87%) patients were placed on micro-progestins postpartum.
Table 1. Demographic, clinical, and paraclinical data of parturients.
|
Number |
Percentage (%) |
Age (Standard Deviation) |
31.4 (±4.35) |
22 - 25 |
4 |
13 |
26 - 29 |
6 |
19 |
30 - 33 |
9 |
29 |
34 - 38 |
12 |
39 |
Antiphospholipid Syndrome |
5 |
16 |
Recurrent Miscarriage |
5 |
16 |
Gestational Hypertension |
8 |
26 |
Lower Limb Edema |
4 |
13 |
Chronic Arthralgia |
11 |
35 |
Malar Rash |
9 |
29 |
Photosensitivity |
5 |
16 |
Discoid Lupus |
4 |
13 |
Pleurisy or Pericarditis |
4 |
13 |
Oral Ulceration |
1 |
3 |
Obstetric Ultrasound |
|
|
Normal |
23 |
74 |
Oligohydramnios |
7 |
23 |
Intrauterine Fetal Death |
1 |
3 |
Positive Proteinuria |
13 |
45 |
Lupus Nephritis |
10 |
32 |
Renal Insufficiency |
5 |
16 |
Hemodialysis |
2 |
6 |
Native Anti-DNA Antibodies |
11 |
35 |
ANA |
13 |
46 |
Anemia |
16 |
52 |
Thrombocytopenia |
10 |
33 |
Treatment |
|
|
Corticosteroids |
17 |
55 |
Low-dose Aspirin |
21 |
72 |
LMWH |
3 |
10 |
Hydroxychloroquine |
8 |
26 |
Azathioprine |
1 |
4 |
Antihypertensive Medication |
9 |
32 |
ANA: Antinuclear antibodies; LMWH: Low molecular weight heparin.
Table 2. Distribution of lupus flare-up cases associated with pregnancy based on the time of onset.
Timing of flare |
Number of cases |
Percentage (%) |
First trimester |
6 |
19 |
Second trimester |
2 |
7 |
Third trimester |
4 |
13 |
Postpartum |
4 |
13 |
No flare |
15 |
48 |
Figure 1. Distribution of lupus associated with pregnancy based on pregnancy outcome.
Table 3. Indications for cesarean section.
Cesarean Indications |
Number of Cases |
Percentage (%) |
Oligohydramnios |
3 |
10 |
Eclampsia |
1 |
3 |
Severe Pre-eclampsia |
1 |
3 |
Persistent Occiput Posterior |
1 |
3 |
Vaginal Delivery |
25 |
81 |
3. Discussion
Systemic lupus erythematosus (SLE) can significantly affect pregnancy, and pregnancy can affect lupus activity. In our series, 52% of pregnant women experienced lupus flares, with 19% occurring in the first trimester. The timing of flares varies between trimesters and in the postpartum period [1]-[3]. Renal disease is a risk factor for poor fetal and maternal outcomes. It is recommended to wait at least six months after a lupus flare, especially a renal flare, before conceiving, although one study suggests that a four-month delay may be sufficient. High-risk pregnancies require multidisciplinary collaboration and essential preconception counselling [4] [5]. The fetal prognosis is poor when lupus is diagnosed during pregnancy, with high rates of fetal loss [6]. Complications such as placental insufficiency and thrombosis are common, often exacerbated by antiphospholipid antibodies [7]-[9]. Hydroxychloroquine reduces flares when used during pregnancy. Despite advances, rates of fetal loss, prematurity, and intrauterine growth retardation remain high [10] [11]. Preventive therapies, including hydroxychloroquine and azathioprine, are accepted, but the addition of corticosteroids in late pregnancy is controversial because of potential risks to both mother and fetus [5] [12].
4. Conclusion
Systemic lupus erythematosus, a disease that typically affects young women of childbearing age, highlights the importance of pregnancy for women with lupus, emphasizing the psychological and emotional dimensions of this period. Pregnancy and the postpartum period can reveal previously unrecognized lupus, and a lupus flare can occur at any time during pregnancy, especially if lupus is active at conception. When lupus is inactive for at least six months before conception, remission persists in most cases, particularly with adequate management. Advances in understanding the factors influencing the course of lupus during pregnancy have improved the treatment and monitoring of pregnant lupus patients. Combined with advances in fetal surveillance techniques and assessment of fetal well-being, this offers a reasonably favorable outlook for both mother and child in most cases. Nevertheless, our findings align with the literature in terms of the possibility of serious maternal and fetal complications, underscoring the importance of coordinated multidisciplinary surveillance to early detect disease flares and promptly adjust treatment.
Ethics Approval and Consent to Participate
The original article was approved by the Ethics Committee of the University Hospital of Ibn Rochd.
Consent for Publication
The patients’ written consent was obtained.
Availability of Data and Material
Data concerning the patient’s record are available from the corresponding author on reasonable request.
Authors’ Contributions
SZ: conception, data curation, interpretation, and writing of the manuscript. HB, KN, NS, SJ: conception, data curation, and supervision of the draft.