Lupus Flare in Pregnancy - Symptoms, Complications and Management.

Introduction

Many patients with lupus have a successful pregnancy. As lupus patients are more likely to develop pregnancy complications, therefore it is essential to consult the rheumatologist and an obstetrician regarding pregnancy, delivery, lactation, and assisted reproductive techniques before becoming pregnant. Before pregnancy, an assessment is critical for therapy, pregnancy management, and outcomes, as the risk for pregnancy-related problems in lupus patients will depend on disease activity, damage, and medication. It is also essential to plan the delivery at the hospital, where there is a neonatal intensive care unit and other advanced facilities that will provide the specialized care that the mother and the baby may require. The risk of lupus flare is not increased in pregnant women, and it can occur during pregnancy or immediately following delivery. Most of these flares are not life-threatening to both the baby and the mother and can be treated with steroids.

What Are the Symptoms of Lupus Flare during Pregnancy?

The disease flares in pregnant lupus patients might be challenging to recognize as many bodily functions change during pregnancy and may overlap with features of active disease, which makes differentiation difficult. Most patients with flaring during pregnancy might have symptoms such as fatigue, body aches, fever, butterfly-shaped redness across the cheeks and nose, or patchy hair loss. There is also joint pain and joint swelling, which is commonly reported. When there is heart or lung involvement, patients report symptoms such as breathing problems or chest pain. The common discomforts of pregnancy that mimic the symptoms of lupus flare are:

• Swelling of joints.

• Pain in the joint.

• Swelling of feet, ankles, or hands.

• The redness of the face is known as pregnancy blush.

• Fatigue.

• Loss of hair.

• Shortness of breath.

If any of the above symptoms are experienced, it is essential to report them to the physician. Lupus flares detected early are easier to treat and will cause less harm to the mother and the baby.

What Complications Can Lupus Cause in Pregnancy?

Lupus patients have a higher risk of increased blood pressure, which occurs after twenty weeks of pregnancy in a previously normal woman, known as preeclampsia. There is also the risk of developing HELLP syndrome ( Hemolysis, Elevated Liver Enzymes, Low Platelets), renal insufficiency, hypertension, blood clots, abnormal blood counts, preterm delivery, urinary tract infections, and diabetes. During pregnancy, women taking steroids, diabetes, and hypertension are very common. The indications for the rise in blood pressure are headaches, blurry vision, abdominal pain, and decreased frequency of urination. Approximately one-fifth of lupus pregnancies, miscarriages, or pregnancy loss can happen. They are likely to occur in women with high blood pressure, active kidney disease, or antiphospholipid antibodies.

What Is Antiphospholipid Syndrome?

One autoimmune disorder is antiphospholipid syndrome caused by antiphospholipid antibodies attacking vascular structures in the body. This will lead to an increased tendency in the arteries and veins of the legs, lungs, or placenta to form abnormal blood clots. Therefore, lupus patients must be screened for antiphospholipid antibodies, especially in women who have experienced miscarriage previously. Aspirin is commonly prescribed to women with a history of miscarriage and antiphospholipid antibodies to prevent recurrence.

Preterm delivery is common in lupus patients, and they are at higher risk for delivering before completing thirty-seven weeks of pregnancy. Also, preterm delivery happens in one-third of lupus mothers. Lupus patients should be careful with premature labor symptoms such as backache, pelvic pressure, abdominal cramps, blood or clear fluid leaking from the vagina, and the contractions that will occur every ten minutes before thirty-seven weeks of pregnancy completion.

How Are Lupus Flares Managed during Pregnancy?

The management of lupus flares in pregnancy necessitates a collaborative effort between rheumatologists, obstetricians, and other specialists. Medications that may have been effective before pregnancy might need adjustment to ensure maternal well-being and fetal health. Corticosteroids, immunosuppressants, and anti-malarial drugs are commonly used with careful consideration of their potential impact on the developing fetus.

Which Lupus Medications Can Be Safely Used during Pregnancy?

During pregnancy, some medications are safe, but it is advisable to review the medication list with the physician during the pregnancy planning phase. Selected medications include:

• Steroids: During pregnancy, steroids that can be given safely are prednisone, prednisolone, and methylprednisolone, as they do not cross the placenta, and hence the baby is not affected. That should be given at the lowest possible dose. Steroids such as dexamethasone and betamethasone do not cross the placenta and are specifically used to treat the baby. Although the steroids are considered safe for the baby, they can be associated with certain side effects like preeclampsia, increased blood pressure, diabetes, kidney problems, low birth weight babies, water breaking early, and intrauterine growth retardation.

• Hydroxychloroquine: During pregnancy, all women with lupus should take hydroxychloroquine if possible, as it is commonly used to prevent lupus flares and improve the outcome for mothers with lupus kidney disease. When hydroxychloroquine is discontinued during pregnancy by the women, it can more likely cause exacerbation of lupus disease activity and usually require higher doses of steroids.

• Heparin: During pregnancy, heparin is safe for use, but it should be stopped before delivery to decrease the risk of bleeding.

How Does Lupus Flares Impact on Fetal Health during Pregnancy?

Lupus flares during pregnancy raise concerns about potential complications for both the mother and the fetus. Uncontrolled inflammation may contribute to adverse outcomes, which include preterm birth, preeclampsia, and low birth weight. Regular monitoring through ultrasounds, blood tests, and other diagnostic measures helps detect issues early, allowing timely interventions.

Specific lupus-related antibodies such as anti-Ro/SSA and anti-La/SSB may cross the placenta and impact the fetal heart, which leads to congenital heart block. It is essential to closely monitor and collaborate between rheumatologists and pediatric cardiologists to detect and manage such complications.

Conclusion

The intersection of lupus and pregnancy requires a comprehensive and individualized approach. Advancements in medical knowledge and ongoing research contribute to refining strategies for managing lupus flares during pregnancy, offering hope for improved outcomes.