The overall message, Dr. Tincani said, is that complications are more common in lupus-related pregnancies, but they tend to be manageable problems if the right precautions are taken.
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Explore This IssueSeptember 2018
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“SLE disease activity has a high impact on maternal and fetal outcomes,” she said.
“Therefore, special treatments and care should be allocated to those women in order to manage adverse outcomes that might follow and to improve successful, normal delivery [of ] term infants and to reduce the risk of congenital abnormalities often linked to prematurity.”
Women with lupus who are pregnant have many therapeutic options at their disposal, Dr. Tincani said. Drugs that should be continued in pregnancy to maintain remission or to treat flares include hydroxychloroquine, chloroquine, sulfasalazine, azathioprine, cyclosporine-A, tacrolimus and colchicine.
Drugs considered teratogenic that should be withdrawn before pregnancy include methotrexate, mycophenolate mofetil and cyclophosphamide. Not enough information exists to make firm recommendations for leflunomide, mepacrine and selective COX-II inhibitors, Dr. Tincani said.
Hydroxychloroquine, especially, is known for pregnancy benefits—reducing SLE flare rate, congenital heart block risk and reducing the risk of babies small for gestational age, among other benefits in lupus nephritis patients. “It is absolutely indicated to continue [hydroxychloroquine] if [the patient is] already on treatment or to start it if pregnancy is planned,” Dr. Tincani said.
According to EULAR recommendations, rituximab can be used in “severe, exceptional cases” in the first trimester, she said. Alternatives to belimumab should be considered because of limited experience.
Clinicians need to be armed with information on long-term outcomes, Dr. Tincani said, because inevitably would-be mothers will ask their “most burning” question: “Will my baby be healthy?”
Studies have found that children born to women with SLE have a similar rate of developing rheumatic autoimmune diseases, but a higher risk of non-rheumatic autoimmune diseases, with a slightly higher risk of allergic conditions, she said.5
A long-term study of neuropsychological development in 40 children born to women with SLE, anti-phospholipid syndrome or both found they all showed normal intelligence levels, with only 7% at levels considered to be bordering impairment.
Questionnaires completed by mothers have uncovered histories that include an elevated level of epilepsy—reported for four of the children—and of sleep disorders, she said.6
“These data are interesting, but all of these things are very rare and as you have seen, are not really dangerous,” she said. “Children of SLE patients may carry some minor neuropsychological problems that we are not to ignore—because most of them can be overcome if we know them.”