Plan Ahead: Clinical Tips for Managing Reproductive Health in Patients with Rheumatic Disease

Lupus Nephritis & Preeclampsia

Next, Dr. Soh discussed the challenging topic of differentiating lupus nephritis from preeclampsia in pregnant patients with systemic lupus erythematosus. Both lupus nephritis and preeclampsia can be associated with hypertension, proteinuria and many other similar clinical manifestations, and interpretation of lab studies can be confusing.

Example: Complement levels in active lupus nephritis may appear spuriously normal in patients who are pregnant. One lab test used to help differentiate lupus nephritis from preeclampsia is the soluble fms-like tyrosine kinase-1 (sFlt-1) to placental growth factor (PlGF) ratio. This test has a high negative predictive value, and if the ratio of sFlt-1:PlGF is <38, then preeclampsia is effectively ruled out for the subsequent seven days. (Note: In the development cohort looking at this test, the negative predictive value using this threshold was 99.3%.)⁴

In cases in which lupus nephritis is confirmed in pregnancy, cyclophosphamide can be used after 12 weeks of gestation. In contrast, Dr. Soh cautions against using mycophenolate in the treatment of lupus nephritis during pregnancy because significant safety issues may be associated with its use.

The timing of delivery for patients with possible preeclampsia is important. Considerations to make regarding this decision include the presence or absence of worsening hypertension, rising creatinine levels and/or static growth of the fetus.

In Sum

As one member of the audience stated in the question-and-answer portion of the session, this area is an important topic, and it’s crucial for rheumatologists to work together with maternal fetal medicine physicians and other women’s health providers to ensure optimal care for patients.

Jason Liebowitz, MD, is an assistant professor of medicine in the Division of Rheumatology at Columbia University Vagelos College of Physicians and Surgeons, New York.

References

1. Sammaritano LR, Bermas BL, Chakravarty EE, et al. 2020 American College of Rheumatology guideline for the management of reproductive health in rheumatic and musculoskeletal diseases. Arthritis Rheumatol. 2020 Apr;72(4):529–556.
2. Saji F, Samejima Y, Kamiura S, et al. Dynamics of immunoglobulins at the feto-maternal interface. Rev Reprod. 1999 May;4(2):81–89.
3. Soh MC, Moretto M. The use of biologics for autoimmune rheumatic diseases in fertility and pregnancy. Obstet Med. 2020 Mar; 13(1): 5–13.
4. Zeisler H, Llurba E, Chantraine F, et al. Predictive value of sFlt-1:PlGF ratio in women with suspected preeclampsia. N Engl J Med. 2016 Jan 7;374(1):13–22.