Pregnancy in past or present lupus nephritis: a study of 32 pregnancies from a single centre

Long-term impact of pregnancy on renal function among Egyptian women with lupus nephritis: A case control study

Few studies tackled the long-term effect of pregnancy on lupus nephritis (LNs); thus, the study aimed to explore the long-term impact of pregnancy on renal outcomes in Egyptian patients with LN. Group I patients included females who had their first pregnancy after LN onset with ≥5 years elapsing after delivery; group II patients included females who had never got pregnant for ≥7 years after LN onset. Data were retrospectively collected at baseline (T₀) and the last visit (T_last). The study included 43 patients in group I and 39 patients in group II. The comparisons between the two groups regarding the characteristics at T_last showed no significant difference regarding the serum creatinine, estimated glomerular filtration rate (eGFR), renal component of SLICC/ACR Damage Index (SDI) as well as the rate of renal flares, new-onset chronic kidney disease (CKD), progressed CKD and end-stage renal disease. Multivariate regression analysis revealed that systemic hypertension and renal flares were predictors of new-onset/progressed CKD (p = 0.019, OR [95% CI] = 4 [1.3-13]; and 0.022, 13.8 [1.5-128.8], respectively) while pregnancy was not (p = 0.363). Paired comparisons between T₀ and T_last characteristics within each group revealed significant increment of serum creatinine, renal SDI and CKD prevalence; as well as decrement of eGFR in group I (p = 0.004, <0.001, 0.001 and <0.001, respectively) and group II (p = 0.006, <0.001, 0.004 and 0.002, respectively). In conclusion, pregnancy, per se, does not affect the long-term renal outcome in LN patients; however, it is rather dependent on the existence of baseline renal damage and the development of renal flares.

The association of lupus nephritis with adverse pregnancy outcomes among women with lupus in North America

OBJECTIVES

We evaluated the association of lupus nephritis (LN) and adverse pregnancy outcomes in prospective cohorts of pregnant women with SLE (systemic lupus erythematosus).

METHODS

We conducted a patient-level pooled analysis of data from three cohorts of pregnant women with SLE. Pooled logistic regression models were used to evaluate the association of LN and adverse pregnancy outcomes. Odds ratios and 95% confidence intervals were calculated using a fixed effect model by enrolling cohort.

RESULTS

The pooled cohort included 393 women who received care at clinics in the United States and Canada from 1995 to 2015. There were 144 (37%) women with a history of LN. Compared to women without LN, those with LN had higher odds of fetal loss (OR: 1.90; 95% CI: 1.01, 3.56) and preeclampsia (OR: 2.04; 95% CI: 1.01, 4.13). Among the 31 women with active nephritis (defined as urine protein ≥ 0.5 g/24 h) there was a higher odds of poor pregnancy outcome (OR: 3.08; 95% CI: 1.31, 7.23) and fetal loss (OR: 6.29; 95% CI: 2.52, 15.70) compared to women without LN.

CONCLUSIONS

In this pooled cohort of women with SLE, a history of LN was associated with fetal loss and preeclampsia. Active nephritis was associated with poor pregnancy outcome and fetal loss.

Evaluation of red blood cell distribution width-platelet ratio as a predictor of adverse pregnancy outcomes and disease severity in systemic lupus erythematosus

OBJECTIVE

The red blood cell distribution width to platelet ratio (RPR) is known to reflect systemic inflammation. This study aimed to explore the predictive value of RPR for disease activity and adverse pregnancy outcomes (APOs) in pregnant women with systemic lupus erythematosus (SLE).

METHODS

We retrospectively evaluated case data of all pregnant women with SLE managed at the First Affiliated Hospital of Zhengzhou University from January 2014 to March 2017. Correlations between RPR and SLE clinical disease activity, organ involvement, and maternal complications were analysed. Changes in the RPR and erythrocyte sedimentation rate (ESR) were observed before and after treatment. A receiver operating characteristic (ROC) curve was used to predict disease activity and APOs based on RPR.

RESULTS

A total of 118 patients were enrolled, including 77 in the disease-active group and 41 in the disease-inactive group. The live birth rate was significantly higher in the disease-inactive group than in the disease-active group (P < 0.001). Compared to the disease-inactive group, the number of patients with elevated RPR, anti-dsDNA antibody level, and ESR was significantly higher in the disease-active group, whereas their platelet-lymphocyte ratios and complement 3 and 4 levels were significantly lower. The disease-active group was more likely to experience APOs (P < 0.001), mainly due to premature birth, low birth weight, and pregnancy loss. The ROC curve indicated that RPR had an effect on disease activity and APOs.

CONCLUSION

RPR can be used as a predictor of disease severity and APOs in pregnant women with SLE. Key Points • RPR positively correlated with SLEDAI; patients with elevated RPR have higher disease activity, more organ, and more maternal complications. • Monitoring RPR could better predict disease activity in pregnant patients with SLE and reduce the incidence of maternal complications and APOs.

Pregnancy Outcomes in Systemic Lupus Erythematosus Women: A single tertiary centre experience

Objectives

This study was conducted to assess pregnancy outcomes in women with systemic lupus erythematosus (SLE) in Oman.

Methods

A retrospective cohort study of 149 pregnancies in 98 women with SLE was conducted over 10 years to evaluate the impact of clinical and laboratory parameters in predicting adverse pregnancy outcomes.

Results

Mean maternal age was 30.6 ± 5 years ranging from 20–44 years, and the mean disease duration was 10 ± 5 years, ranging from 2–27 years. The most common maternal manifestations were joint pain in 36 (24.2%), lupus nephritis (LN) in 18 (12.08%), preeclampsia in 11 (7.4%), eclampsia in three (2%) and lupus flare in one pregnancy. The live birth rate was 139 (93.3%) with a mean gestational age of 36 ± 2 weeks ranging from 26–40 weeks. In total, 55 (39.6%) were preterm deliveries, six (4%) pregnancies ended in miscarriage, and four (2.7%) resulted in intrauterine fetal death. Intrauterine growth restriction was observed in 49 babies (35%). A significant association was found between hypertension (HTN) and miscarriage (P = 0.024) and preterm birth (P = 0.019). In addition, HTN was positively associated with preeclampsia (P = 0.004) and LN (P = 0.048). Antiphospholipid syndrome impacted preterm birth (P = 0.013) and postpartem haemorrhage (PPH) (P = 0.027) and was found to be a significant predictor for women developing deep vein thrombosis and pulmonary embolism (P <0.001 for both).

Conclusion

Despite potential complications, most pregnancies complicated by SLE in Oman result in good outcomes. Adverse pregnancy outcomes, however, may still occur in women with SLE. In women with SLE, pregnancy planning, careful antenatal monitoring and efficient SLE treatment need to be undertaken for successful pregnancy outcomes.

Preeclampsia Risk Prediction Model for Chinese Pregnant Patients With Systemic Lupus Erythematosus

OBJECTIVE

To screen for a high risk of preeclampsia in women with systemic lupus erythematosus (SLE).

METHODS

A total of 513 antenatal care records of pregnant patients with SLE were obtained, and the data were randomly assigned to either a development set (n = 342) or a validation set (n = 171). Preeclampsia predictors were identified with stepwise regression, and a coefficient B of each variable was used to establish a prediction model and risk scoring system. Goodness-of-fit was assessed by the Hosmer-Lemeshow and Omnibus tests, and the area under the receiver operating characteristic curve (area under the curve) was used to assess discrimination. Validation was performed using the validation set.

RESULTS

The preeclampsia incidence was 14.4% in the pregnant patients with SLE. A mean arterial pressure (MAP) ≥96.5 mm Hg (odds ratio [OR] 213.15 [95% confidence interval (95% CI) 24.39-999.99]), prepregnancy hypertension (OR 18.19 [95% CI 2.67-125.01]), a hematologic disorder (OR 4.13 [95% CI 1.03-16.67]), positive IgM anticardiolipin antibodies (aCLs) (OR 19.85 [95% CI 1.11-333.33]), serum albumin <31.5 grams/liter (OR 9.88 [95% CI 2.07-47.62]), serum uric acid ≥303 μmoles/liter (OR 5.58 [95% CI 1.40-22.22]), and 24-hour urinary protein ≥0.286 grams (OR 14.39 [95% CI 2.43-83.33]) were selected for the preeclampsia prediction model. The area under the curve was 0.975. Preeclampsia prediction model scores >4 indicated a high risk of preeclampsia. For the validation set, the preeclampsia prediction accuracy was 93.6% (sensitivity 88.5%, specificity 94.5%).

CONCLUSION

A model for predicting the risk of preeclampsia in pregnant patients with SLE was established on the basis of MAP, prepregnancy hypertension, hematologic disorders, IgM aCLs, albumin, uric acid, and 24-hour urinary protein. The model had good predictive efficiency and can help clinicians improve pregnancy outcomes in high-risk women with early interventions.

Maternal and Fetal Outcomes in Iranian Patients with Systemic Lupus Erythematosus: A Five-Year Retrospective Study of 60 Pregnancies

BACKGROUND

As a multisystem autoimmune disease, Systemic Lupus Erythematosus (SLE) mainly affects women during reproductive age. This retrospective study was designed to investigate the fetal and maternal outcomes of Iranian women with SLE.

METHODS

Clinical and laboratory records of 60 pregnancies in 55 SLE patients who attended Hafez hospital, a tertiary referral center for high risk pregnancies and SLE patients affiliated with Shiraz University of Medical Science, were reviewed during April 2012 and March 2016.

RESULTS

The mean age of the patients was 29.28±4.6 years and mean disease duration was 5.09±4.2 years. Live birth rate was 83.3% after exclusion of elective abortions. There were 50 live births, 3 neonatal deaths, 3 spontaneous abortions and 7 stillbirths. 9 (15%) women developed preeclampsia and there was 1 (1.6%) case of HELLP syndrome. Lupus flares occurred in 27 (45%) patients during pregnancy. Preterm delivery occurred in 11.6% of pregnancies. Skin and joints were the most frequently affected organs. Patients with previous lupus nephritis (n=18) were associated with a higher risk of maternal complication, but fetal outcomes were similar in both groups. Cesarean rate was about 66%, mostly related to fetal indications (50%).

CONCLUSION

Pregnancies in most women with pre-existing SLE can now be managed with successful results although presence of previous lupus nephritis is still a major risk factor for adverse maternal outcomes. In our study, fetal outcome was not different between patients with lupus nephritis compared with the patients without nephritis who were under treatments. Hence, to achieve favorable long-term results, we recommend regular multispecialty treatment approaches and progestational counseling for women with SLE.

Umbilical arterial Doppler ultrasonography predicts late pregnancy outcomes in patients with lupus nephritis: a multicenter study from southern China

OBJECTIVES

To investigate the fetal adverse pregnancy outcomes (APOs) and the predictive value of umbilical arterial Doppler ultrasonography in the third trimester in pregnant women with lupus nephritis (LN).

METHODS

A retrospective cohort study enrolling 203 LN patients from 2007 to 2017 was performed. Ultrasonic parameters were recorded.

RESULTS

Fetal APOs occurred in 103 patients (103/203, 50.7%). Sixty-six pregnancies (66/203, 32.5%) ended with preterm births. The incidence rate of intrauterine growth restriction (IUGR) was 18.2% (37/203). Fetal distress was noted in 23 pregnancies (23/203, 11.3%). All the Doppler parameters elevated in patients with IUGR, fetal distress, and composite conditions. Resistance index (RI) indicated the highest risk of IUGR and composite APOs. The cutoff values were 0.66 and 0.67, respectively. Sensitivities were 51.4% and 33.7%, and specificities were 87.4% and 92.1%. Peak velocity of the umbilical arteries at end-systole (Vmax, abbreviated as S) to that at end-diastole (Vmin, abbreviated as D) (S/D) ratio was also a best predictor for IUGR, with the optimal cutoff value of 2.88. Sensitivity and specificity were comparable with RI. Pulsatility index (PI) over 0.84 was an ideal indicator for fetal distress with an optimal combination of sensitivity (89.5%) and specificity (51.6%).

CONCLUSIONS

Fetal complications were frequent in patients with LN. Umbilical arterial Doppler ultrasonography was a useful measure to predict late IUGR, fetal distress, and the composite APOs.

Pregnancy outcome in women with active and inactive lupus nephritis: A prospective cohort study

Several studies have emphasized poor pregnancy outcomes associated with active lupus nephritis at the onset of conception. A few controversial studies have compared pregnancy outcome in patients with inactive lupus nephritis at conception and those without a history of lupus nephritis. This study aimed to find out if quiescent lupus nephritis at the onset of conception carries an increased risk of pregnancy complications compared to pregnancies without a history of lupus nephritis. This is a prospective cohort study carried out at the Rheumatology/Obstetrics Conjoint Clinic of Kasr Al-Ainy Hospital between January 2006 and December 2017. A total of 119 pregnancies were included: 72 pregnancies in group I (with a history of lupus nephritis) and 47 pregnancies in group II (non-renal systemic lupus erythematosus). They were subjected to full history taking, monthly clinical examination and laboratory investigations. In total, 16 (22.2%) renal pregnancies had renal flares at the onset of conception. Maternal complications, specifically renal flares, were reported in 36 (50%) pregnancies in group I and 13 (27.7) pregnancies in group II, with a significant difference ( p = 0.015). No significant differences were found concerning the frequency of pregnancy-related maternal and fetal complications between the two groups. When data were re-analyzed after excluding patients experiencing renal flares during the 6 months preceding pregnancy, there were no significant differences regarding the frequency of maternal and fetal complications between renal and non-renal pregnancies. In conclusion, lupus nephritis, per se, is not a risk factor for poor pregnancy outcome; rather, it is the lupus nephritis activity at the onset of pregnancy.

Important considerations in pregnant patients with lupus nephritis

INTRODUCTION

In the last few decades, identification of predictors of pregnancy outcome and appropriate pregnancy planning have significantly reduced the maternal and fetal risks in pregnant women with lupus nephritis. Areas covered: Successful pregnancies have been reported even in women with chronic renal disease and renal insufficiency. However, refractory hypertension and severe renal or cardiac chronic dysfunction are still considered contraindications to pregnancy. Pre-term delivery and fetal growth restriction may still occur in SLE patients more frequently than in healthy women, even in pregnancies regularly planned and monitored by a team of nephrologists and gynaecologists. Expert commentary: Stable disease remission is the most important factor for a successful pregnancy. In case of flare-ups of lupus, timely diagnosis and appropriate management may ensure a successful outcome in the majority of pregnant women. The negative role of anti-phospholipid antibodies and of chronic arterial hypertension may be countered with appropriate anticoagulation and anti-hypertensive therapy. Further studies are needed to better assess the possible impact of pregnancy on the long-term outcome of lupus nephritis.

Management and outcomes of pregnancy with or without lupus nephritis: a systematic review and meta-analysis

Background

Although it is well established that systemic lupus erythematosus (SLE) negatively affects pregnancy outcomes, there is insufficient evidence on the effect of lupus nephritis (LN) on antenatal management and pregnancy outcomes. We performed a systematic review and meta-analysis to determine the association of LN with management and pregnancy outcomes in SLE patients.

Methods

Embase, Medline, Cochrane, and ClinicalTrials.gov were carefully searched for relevant English and Chinese language studies. A total of 2,987 articles were reviewed. Data were extracted that compared management and pregnancy outcomes in SLE pregnant women with LN vs without LN. Risk of bias was assessed by a modified version of the Newcastle-Ottawa Scale and the STROBE checklist. Combined odds ratios (OR) and 95% confidence intervals (CI) were obtained and sensitivity analysis was performed using RevMan 5.3 software.

Results

Sixteen studies, including 1,760 pregnant patients with SLE, were included. Gestational hypertension (OR=5.65, 95% CI=2.94–10.84), preeclampsia (OR=2.84, 95% CI=1.87–4.30), SLE flare (OR=2.66, 95% CI=1.51–4.70), renal flare (OR=15.18, 95% CI=5.89–39.14), proteinuria (OR=8.86, 95% CI=4.75–16.52), and hypocomplementemia (OR=2.86, 95% CI=1.68–4.87) were significantly affected in pregnant women with LN. Anti-Sjögren’s syndrome-related antigen A/Ro autoantibodies were negatively associated with pregnant women with LN (OR=0.57, 95% CI=0.33–0.98). Pregnant women with LN presented a significant decrease in live births (OR=0.62, 95% CI=0.49–0.80) and a significant increase in preterm births (OR=1.92, 95% CI=1.49–2.49) and fetal growth restriction (OR=1.43, 95% CI=1.08–1.91). Regarding antenatal management, steroids (OR=2.48, 95% CI=1.59–3.87) and immunosuppressant treatment (OR=6.77, 95% CI=3.30–13.89) were more frequently used in women with LN.

Conclusion

This review identified a significant association between the aforementioned outcomes and SLE pregnant patients with LN. In patients with SLE, LN increased the risks for adverse pregnancy outcomes and the use of medication. Therefore, special treatment and close monitoring should be allocated to pregnant women with LN.

Systemic lupus erythematosus pregnancies: ten-year data from a single centre in Malaysia

We performed a retrospective study of all systemic lupus erythematosus (SLE) pregnancies during a 10-year period (2006–2015) to describe the clinical features, maternal and foetal outcomes in our centre. There were 115 pregnancies in 86 women with SLE. Our patients had a mean age of 29.1 years (SD 5.80) and a mean disease duration of 44.63 months (SD 41.17). Fifteen patients had antiphospholipid syndrome (APS). Our patients had complicated pregnancies: 26.1% had SLE flares, 13.9% had pre-eclampsia and 45.1% needed caesarean sections. There were 23.3% foetal losses and 25% preterm deliveries in our patients. There was a higher rate of unplanned pregnancies and lupus flare among pregnancies with active SLE at conception. Pregnancies in lupus nephritis have higher incidence of lupus flares during pregnancy but similar maternal and foetal outcomes compared to those without nephritis. The prognostic indicators for adverse foetal outcome in our patients were flare of SLE (HR 4.08 [CI 95% 1.65–10.13, p < 0.01]) and APS (HR 3.07 [CI 95% 1.12–8.42, p < 0.05]) and the prognostic indicator for adverse maternal outcome was hypertension (HR 3.58 [CI 95% 1.30–9.90, p < 0.05]). Lupus pregnancies in our centre remained as high-risk pregnancies with significant maternal and foetal complications.

Fetal outcome and recommendations of pregnancies in lupus nephritis in the 21st century. A prospective multicenter study

The aim of this multicenter study was to assess the present risk of fetal complications and the inherent risk factors in pregnant women with lupus nephritis. Seventy-one pregnancies in 61women (59 Caucasians and 2 Asians) with lupus nephritis were prospectively followed between October 2006 and December 2013. All patients received a counselling visit within 3 months before the beginning of pregnancy and were followed by a multidisciplinary team. At baseline mild active nephritis was present in 15 cases (21.1%). Six pregnancies (8.4%) resulted in fetal loss. Arterial hypertension at baseline (P = 0.003), positivity for lupus anticoagulant (P = 0.001), anticardiolipin IgG antibodies (P = 0.007), antibeta2 IgG (P = 0.018) and the triple positivity for antiphospholipid antibodies (P = 0.004) predicted fetal loss. Twenty pregnancies (28.2%) ended pre-term and 12 newborns (16.4%) were small for gestational age. Among the characteristics at baseline, high SLE disease activity index (SLEDAI) score (P = 0.027), proteinuria (P = 0.045), history of renal flares (P = 0.004), arterial hypertension (P = 0.009) and active lupus nephritis (P = 0.000) increased the probability of preterm delivery. Odds for preterm delivery increased by 60% for each quarterly unit increase in SLEDAI and by 15% for each quarterly increase in proteinuria by 1 g per day. The probability of having a small for gestational age baby was reduced by 85% in women who received hydroxychloroquine therapy (P = 0.023). In this study, the rate of fetal loss was low and mainly associated with the presence of antiphospholipid antibodies. Preterm delivery remains a frequent complication of pregnancies in lupus. SLE and lupus nephritis activity are the main risk factors for premature birth. Arterial hypertension predicted both fetal loss and preterm delivery. Based on our results the key for a successful pregnancy in lupus nephritis is a multidisciplinary approach with close medical, obstetric and neonatal monitoring. This entails: a) a preconception evaluation to establish and inform women about pregnancy risks; b) planning pregnancy during inactive lupus nephritis, maintained inactive with the lowest possible dosage of allowed drugs; c) adequate treatment of known risk factors (arterial hypertension, antiphospholipid and antibodies); d) close monitoring during and after pregnancy to rapidly identify and treat SLE flares and obstetric complications.

Pregnancy Outcomes in Chinese Patients with Systemic Lupus Erythematosus (SLE): A Retrospective Study of 109 Pregnancies

Systemic lupus erythematosus (SLE) is a multisystem autoimmune disease that primarily affects women during their reproductive years. The interaction between SLE and pregnancy remains debated. The objective of this study was to analyze the fetal and maternal outcomes of Chinese women with SLE. A total of 109 pregnancies in 83 SLE patients from June 2004 to June 2014 at a tertiary university hospital were reviewed retrospectively. Patients' characteristics, clinical and laboratory data during pregnancy were obtained from electronic medical records. After exclusion of elective abortions, the live birth rate was 61.5%. Significantly, APS (antiphospholipid syndrome), disease activity, hypertension, hypocomplementemia, thrombocytopenia, and anemia during pregnancy were more commonly observed in fetal loss pregnancies than in live birth pregnancies. Compared to the 64 women with a history of SLE, 19 women with new-onset lupus during pregnancy had worse pregnancy outcome. Furthermore, the 64 patients with a history of SLE were divided into lupus nephritis group and SLE group (non-renal involvement). We found that the lupus nephritis group had worse maternal outcome than the SLE group. We conclude that new-onset lupus during pregnancy predicts both adverse maternal and fetal outcomes, while a history of lupus nephritis predicts adverse maternal outcomes. It is essential to provide SLE women with progestational counseling and regular multispecialty care during pregnancy.

Seronegative systemic lupus erythematosus: etiology of nephrotic syndrome and acute renal failure in early postpartum period

Systemic lupus erythematosus (SLE) is an autoimmune syndrome that occurs most commonly in women during their reproductive years. Nephritis is known to be one of the most serious complications of SLE. Lupus nephropathy is frequently associated with ANA and anti-dsDNA antibodies. Rarely, serological markers may be initially absent, and in many cases, they become positive after sometime.

We present a 28-year old, otherwise healthy female who admitted to our clinic with edema, hypertension, proteinuria and acute renal failure following her fourth delivery. Serum immunological markers were negative and renal biopsy showed histopathological changes consistent with systemic lupus erythematosus as the etiology of nephrotic syndrome. A dramatic therapeutic response was achieved by pulse steroid and cyclophosphamide treatment following oral steroid therapy.

In women with new onset nephrotic syndrome or renal function deterioration in postpartum period, even if the patient is asymptomatic or seronegative, it is crucial to exclude SLE for a rapid diagnosis and prompt treatment in the case of lupus nephritis. Renal biopsy is of diagnostic importance in such cases in which there is no other clinical, biochemical and serological evidence of the disease.

Efficacy and safety of Etanercept, high-dose intravenous gammaglobulin and plasmapheresis combined therapy for lupus diffuse proliferative nephritis complicating pregnancy

We report one case of pregnancy-onset severe diffuse proliferative nephritis in a patient with systemic lupus erythematosus (SLE), who was successfully treated with a combination of anti-tumour necrosis factor (TNF)-alpha, plasmapheresis and high-dose intravenous gammaglobulin. No flares were observed either in clinical symptoms or in laboratory examinations during pregnancy or after delivery. Her autoantibodies except fluorescent anti-nuclear antibodies were negative. We suggest that a combination of anti-TNF-alpha, plasmapheresis and high-dose intravenous gammaglobulin may be a safe and effective therapy for pregnant patients suffering severe lupus nephritis.

Pregnancy in women with systemic lupus erythematosus (SLE)

For many years pregnancy has been contraindicated in patients with SLE, particularly when kidney involvement was present. Today, pregnancy is no longer considered impossible in women with lupus. Yet, lupus pregnancies are still considered high-risk. The prognosis has considerably improved for pregnant women but the fetal risk, although progressively reduced, is still higher in pregnancies of patients with SLE than in pregnancies of healthy women. Miscarriage, premature delivery, and preeclampsia, as well as heart problems in the baby are the major complications that can occur. In this paper we will review the outcome of pregnant women with SLE, the influence of lupus on fetal outcome, the effects of pregnancy on lupus, and the management of pregnant lupus patients based on our personal experience and the revision of the most recent and significant papers on the subject.

A best practice position statement on pregnancy in chronic kidney disease: the Italian Study Group on Kidney and Pregnancy

Pregnancy is increasingly undertaken in patients with chronic kidney disease (CKD) and, conversely, CKD is increasingly diagnosed in pregnancy: up to 3 % of pregnancies are estimated to be complicated by CKD. The heterogeneity of CKD (accounting for stage, hypertension and proteinuria) and the rarity of several kidney diseases make risk assessment difficult and therapeutic strategies are often based upon scattered experiences and small series. In this setting, the aim of this position statement of the Kidney and Pregnancy Study Group of the Italian Society of Nephrology is to review the literature, and discuss the experience in the clinical management of CKD in pregnancy. CKD is associated with an increased risk for adverse pregnancy-related outcomes since its early stage, also in the absence of hypertension and proteinuria, thus supporting the need for a multidisciplinary follow-up in all CKD patients. CKD stage, hypertension and proteinuria are interrelated, but they are also independent risk factors for adverse pregnancy-related outcomes. Among the different kidney diseases, patients with glomerulonephritis and immunologic diseases are at higher risk of developing or increasing proteinuria and hypertension, a picture often difficult to differentiate from preeclampsia. The risk is higher in active immunologic diseases, and in those cases that are detected or flare up during pregnancy. Referral to tertiary care centres for multidisciplinary follow-up and tailored approaches are warranted. The risk of maternal death is, almost exclusively, reported in systemic lupus erythematosus and vasculitis, which share with diabetic nephropathy an increased risk for perinatal death of the babies. Conversely, patients with kidney malformation, autosomal-dominant polycystic kidney disease, stone disease, and previous upper urinary tract infections are at higher risk for urinary tract infections, in turn associated with prematurity. No risk for malformations other than those related to familiar urinary tract malformations is reported in CKD patients, with the possible exception of diabetic nephropathy. Risks of worsening of the renal function are differently reported, but are higher in advanced CKD. Strict follow-up is needed, also to identify the best balance between maternal and foetal risks. The need for further multicentre studies is underlined.

Pregnancy outcomes of women with coexisting systemic lupus erythematosus flare and preeclampsia

OBJECTIVES

Systemic lupus erythematosus (SLE) flare and preeclampsia are difficult to differentiate from each other and occasionally coexist; This study aimed to analyze cases requiring termination of pregnancy due to SLE flare or preeclampsia and to elucidate the association between these two conditions; Methods. Out of 71 pregnancies in 60 women managed for SLE-complicated pregnancies who delivered at or after 22 weeks' gestation at a tertiary center, 7 pregnancies were terminated due to uncontrollable severe SLE flare or severe preeclampsia We retrospectively analyzed the clinical courses and laboratory findings of these 7 cases to determine whether their pathological conditions were attributable to SLE flare alone, preeclampsia alone, or the coexistence of these two conditions.

RESULTS

One of the 7 cases had preeclampsia alone, two had SLE alone, and four had both conditions. The coexistence of preeclampsia and SLE was thus the most common condition. In cases with both conditions, SLE flare had preceded preeclampsia, thereby making treatment after delivery difficult.

CONCLUSION

Severe SLE flare often preceded severe preeclampsia and worsened after delivery. When differentiating severe SLE flare from severe preeclampsia is difficult during pregnancy, women should be regarded as having SLE flare rather than preeclampsia and aggressively treated.

Circulating Angiogenic Factors and the Risk of Preeclampsia in Systemic Lupus Erythematosus Pregnancies

OBJECTIVE

To investigate whether angiogenic factors are associated with risk of developing preeclampsia in pregnant women with systemic lupus erythematosus (SLE).

METHODS

We performed a nested case-control study within a cohort of SLE women with singleton pregnancies. The study included 42 patients with SLE who eventually developed preeclampsia and 75 normal SLE pregnancies. Serum samples were collected at 4-week intervals (from weeks 12 to 36). Serum samples were analyzed for soluble fms-like tyrosine kinase-1 (sFlt-1), placental growth factor (PlGF), and soluble endoglin (sEng).

RESULTS

Women destined to develop preeclampsia had lower PlGF levels and higher sFlt-1 and sEng levels, and a higher sFlt-1/PlGF ratio than normal pregnancies. These changes became significant at 12 weeks in patients destined to develop either early onset (< 34 weeks, p ≤ 0.003) or late-onset preeclampsia (≥ 34 weeks, p ≤ 0.02). The risk to develop preeclampsia was higher among patients with PlGF concentration values in the lowest quartile or with sFlt-1 and sEng levels, and sFlt-1/PlGF ratio, in the highest quartile of the normal SLE pregnancies distribution. The OR were higher and appeared earlier in patients destined to develop early onset preeclampsia (OR ≥ 16.2, from Week 12 onward) than in patients who presented preeclampsia later (OR ≥ 8.9, from Week 24 onward).

CONCLUSION

Changes in circulating concentrations of sFlt-1, PlGF, sEng, and the sFlt-1/PlGF ratio precede the onset of preeclampsia in SLE pregnancies. The risk profile of circulating angiogenic factors for developing preeclampsia distinctly evolves depending on whether this condition is manifested earlier or later.

Related factors of fetal loss in Chinese women with systemic lupus erythematosus: data from Chinese SLE Treatment and Research Group registry IV

OBJECTIVE

To study the factors associated with fetal loss in Chinese women with systemic lupus erythematosus (SLE) in a large cohort of SLE patients in the CSTAR (Chinese SLE Treatment and Research Group) registry.

METHODS

We compared the clinical characteristics and auto-antibody profiles between SLE patients with fetal loss and SLE patients with normal pregnancies. The relationship between selected variables and fetal loss was examined by univariate analysis and binary logistic regression analysis.

RESULTS

A total of 992 patients with 2026 pregnancies were recruited. Fifty women experienced fetal loss, including 49 spontaneous abortion, eight stillbirths and three neonatal deaths. The overall fetal loss rate was 3.0% (60/2026). Arthritis and serositis were observed significantly more frequently (P < 0.05) in normal pregnancy women. The rate of thrombocytopenia was significantly increased in patients with fetal loss (30.0% vs. 16.1%, P = 0.010), while there was no statistically significant difference in the frequency of nephropathy, central nervous system involvement between the normal pregnancy group and fetal loss group. Factors that associated with fetal loss included anti-phospholipid antibodies (aPL) (OR 2.299; 95% CI 1.058-4.993; P = 0.035) and anti-Sjögren syndrome antigen A (SSA) antibody (OR 2.283; 95% CI 1.275-4.088; P = 0.005), and thrombocytopenia (OR 2.241; 95% CI 1.192-4.213; P = 0.012). However, arthritis (OR 0.544, 95% CI 0.307-0.965, P = 0.037) was associated with favorable fetal outcome.

CONCLUSIONS

Both univariate analysis and binary logistic regression analysis suggest that thrombocytopenia, aPL antibodies and anti-SSA antibody are associated with fetal loss in Chinese SLE women, while arthritis may be a possible factor related to favorable pregnancy outcome.

Preconception care: screening and management of chronic disease and promoting psychological health

INTRODUCTION

A large proportion of women around the world suffer from chronic diseases including mental health diseases. In the United States alone, over 12% of women of reproductive age suffer from a chronic medical condition, especially diabetes and hypertension. Chronic diseases significantly increase the odds for poor maternal and newborn outcomes in pregnant women.

METHODS

A systematic review and meta-analysis of the evidence was conducted to ascertain the possible impact of preconception care for preventing and managing chronic diseases and promoting psychological health on maternal, newborn and child health outcomes. A comprehensive strategy was used to search electronic reference libraries, and both observational and clinical controlled trials were included. Cross-referencing and a separate search strategy for each preconception risk and intervention ensured wider study capture.

RESULTS

Maternal prepregnancy diabetic care is a significant intervention that reduces the occurrence of congenital malformations by 70% (95% Confidence Interval (CI): 59-78%) and perinatal mortality by 69% (95% CI: 47-81%). Furthermore, preconception management of epilepsy and phenylketonuria are essential and can optimize maternal, fetal and neonatal outcomes if given before conception. Ideally changes in antiepileptic drug therapy should be made at least 6 months before planned conception. Interventions specifically targeting women of reproductive age suffering from a psychiatric condition show that group-counseling and interventions leading to empowerment of women have reported non-significant reduction in depression (economic skill building: Mean Difference (MD) -7.53; 95% CI: -17.24, 2.18; counseling: MD-2.92; 95% CI: -13.17, 7.33).

CONCLUSION

While prevention and management of the chronic diseases like diabetes and hypertension, through counseling, and other dietary and pharmacological intervention, is important, delivering solutions to prevent and respond to women's psychological health problems are urgently needed to combat this leading cause of morbidity.

Primigravida is associated with flare in women with systemic lupus erythematosus

The objective of this study was to identify risk factors associated with flare during pregnancy in women with systemic lupus erythematosus (SLE). We performed a retrospective analysis of pregnant women with SLE in a referral hospital. Flare was considered according to predetermined definitions. We analyzed 15 clinical, biochemical and immunological variables with a potential predictive value for relapse during pregnancy. We included 124 lupus pregnancies in 120 women. The relapse rate during pregnancy was 37.9% (47 episodes). The most common manifestations of flare were renal, joint, cutaneous and hematological. Patients with flare during pregnancy developed a higher frequency of preeclampsia and preterm delivery. In multivariate analysis, primigravida was a risk factor associated with any type of flare during pregnancy (OR 2.3, 95% CI 0.99-5.52, p = 0.05); on the other hand, primigravida (OR 3.6, 95% CI 1.19-11.3, p = 0.02), activity prior to pregnancy (OR 3.7, 95% CI 0.97-14.1, p = 0.05), and previous renal disease (OR 5.8, 95% CI 1.95-17.6, p = 0.001) were the principal risk factors associated with renal flare. The first pregnancy in women with SLE is associated with any type of flare. Disease activity is associated with preeclampsia and preterm delivery. Close monitoring is mandatory to identify relapses and timely treatment.

[Lupus and pregnancy: study of 26 cases, an internal medicine department experience and review of the literature]

OBJECTIVE

To study the maternal and fetal outcomes in women with systemic lupus erythematosus.

PATIENTS AND METHODS

A retrospective study of 26 pregnancies in 15 systemic erythematosus patients diagnosed before or during pregnancy regarding to American College of Rheumatology criteria in a single reference center.

RESULTS

The mean patient age was 31.52 years (24-39 years). The mean interval from the diagnosis of the systemic lupus erythematosus to pregnancy was 4.2 years. Eight pregnancies were planned. The flare rate of lupus during pregnancy was 31%, life birth rate was 65% and fetal loss rate was 35%.

DISCUSSION AND CONCLUSION

As an increase in disease activity can occur during pregnancy and because of a higher rate of obstetrical complications in patients with lupus, it is important to carefully plan pregnancy. Pregnancy in lupus patients must be closely monitored by a multispeciality care of the patients.

The role of lupus nephritis in development of adverse maternal and fetal outcomes during pregnancy

BACKGROUND

We aimed to investigate the relationship of lupus nephritis (LN) with fetal and maternal outcomes of pregnant patients with systemic lupus erythematosus (SLE).

METHODS

In a retrospective study, profiles of pregnant women with SLE were selected. Before pregnancy and at the end of first, second and third trimesters, SLE disease activity index-2K was assessed. Clinical and laboratory evaluations were carried out regularly. Maternal and fetal outcomes were recorded. Assessments of the crude effects of statistically significant variables on pregnancy outcomes were performed through multivariate regression analysis.

RESULTS

72 pregnancies in 65 patients were recorded. The mean age of LN patients was 28.7 years, whereas the mean age of patients with clinical nephritis was 26.1 years. No woman with LN experienced pre-term labor or stillbirth. 16 pregnancies either ended in abortion or experienced preeclampsia of which seven had LN. Multivariate logistic regression analyses showed that LN and positive antinuclear antibody were related to preeclampsia, whereas age of SLE development was associated with pre-term labor. Combined maternal and fetal outcomes were associated with the past history of abortion and LN. LN was associated with preeclampsia and SLE flare.

CONCLUSIONS

Absence of LN was in favor of prevention of SLE flare and preeclampsia.

Low risk of renal flares and negative outcomes in women with lupus nephritis conceiving after switching from mycophenolate mofetil to azathioprine

OBJECTIVE

MMF is teratogenic and needs to be replaced before pregnancy. This change may lead to flares. Our aim was to determine the risk of renal flares in women with LN who switched treatment from MMF to AZA before conception and to evaluate the outcome of their pregnancies.

METHODS

Medical records of women with LN counselled for pregnancy wish were reviewed. Women receiving treatment with either MMF or AZA (control group), with inactive lupus (SLEDAI ≤ 4) and quiescent LN (serum creatinine <1.5 mg/dl, inactive sediment and proteinuria <1 g/24 h for the preceding 6 months) were eligible for this study.

RESULTS

We identified 54 women [23 treated with MMF (group 1) and 31 treated with AZA (group 2)]. MMF dosage was tapered and subsequently transferred to AZA, which was maintained throughout pregnancy. Three (13%) patients (group 1) vs none (group 2) developed a renal flare 3-6 months after transitioning from MMF to AZA (P = 0.14) before pregnancy ensued. The only parameter with a significant difference in those with flare compared with those without was younger age (median 27 vs 30 years; P = 0.03). Risk for adverse outcome within 48 pregnancies (pre-eclampsia 9%, preterm delivery 20.5%) increased with every milligramme of prednisone dosage [odds ratio (OR) 2.03] and every single unit of SLEDAI score (OR 3.92). Renal flares occurred post-partum in two women. No patient developed worsening of renal function.

CONCLUSION

Replacing MMF with AZA in patients with quiescent LN for pregnancy planning rarely leads to renal flares. Pregnancy outcome was favourable.

Pregnancy and renal outcomes in lupus nephritis: an update and guide to management

Systemic lupus erythematosis (SLE) commonly affects women of child bearing-age, and advances in treatment have resulted in an increasing number of women with renal involvement becoming pregnant. Knowledge of the relationship of the condition with respect to fertility and pregnancy is important for all clinicians involved in the care of women with lupus nephritis because they have complicated pregnancies. Presentation of lupus nephritis can range from mild asymptomatic proteinuria to rapidly progressive renal failure and may occur before, during, or after pregnancy. The timing of diagnosis may influence pregnancy outcome. Pregnancy may also affect the course of lupus nephritis. All pregnancies in women with lupus nephritis should be planned, preferably after more than six-months of quiescent disease. Predictors of poor obstetric outcome include active disease at conception or early pregnancy, baseline poor renal function with Creatinine >100 μmol/L, proteinuria >0.5 g/24 hours, presence of concurrent antiphospholipid syndrome and hypertension. In this review the most recent studies of pregnancies in women with lupus nephritis are discussed and a practical approach to managing women prepregnancy, during pregnancy and post-partum is described.

Subfertility treatment in women with systemic lupus erythematosus

This study comprised of 65 infertile patients with systemic lupus erythematosus (SLE). The aim was to study causes and different modalities used for the management of subfertile patients with SLE. All patients were diagnosed to have SLE according to the standard criteria of diagnosis. All patients were scheduled to expectant treatment, ovulation induction and timed intercourse, intrauterine insemination (IUI), intracytoplasmic sperm injection (ICSI). Anovulation was in 20 patients (20%), due to PCOS in 10 cases and due to other causes in three patients. A total of 28 patients (43.1%) needed laparoscopy for their work-up of infertility. Male factor for infertility was present in nine couples (16.7%). Ovulation induction and timed intercourse was adopted for a maximum 6 cycles and IUI for 3 cycles. In vitro fertilisation (IVF)/ICSI was needed in five cases using standard long agonist protocol. Four cases were complicated by significant ovarian hyperstimulation syndrome after conventional ovarian stimulation and cycles were cancelled. Pregnancy occurred in 20 women. Ovarian stimulation for ovulation induction and IVF seems to be safe and successful in well selected women with non-complicated SLE.

Joint European League Against Rheumatism and European Renal Association-European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis

OBJECTIVES

To develop recommendations for the management of adult and paediatric lupus nephritis (LN).

METHODS

The available evidence was systematically reviewed using the PubMed database. A modified Delphi method was used to compile questions, elicit expert opinions and reach consensus.

RESULTS

Immunosuppressive treatment should be guided by renal biopsy, and aiming for complete renal response (proteinuria <0.5 g/24 h with normal or near-normal renal function). Hydroxychloroquine is recommended for all patients with LN. Because of a more favourable efficacy/toxicity ratio, as initial treatment for patients with class III-IV(A) or (A/C) (±V) LN according to the International Society of Nephrology/Renal Pathology Society 2003 classification, mycophenolic acid (MPA) or low-dose intravenous cyclophosphamide (CY) in combination with glucocorticoids is recommended. In patients with adverse clinical or histological features, CY can be prescribed at higher doses, while azathioprine is an alternative for milder cases. For pure class V LN with nephrotic-range proteinuria, MPA in combination with oral glucocorticoids is recommended as initial treatment. In patients improving after initial treatment, subsequent immunosuppression with MPA or azathioprine is recommended for at least 3 years; in such cases, initial treatment with MPA should be followed by MPA. For MPA or CY failures, switching to the other agent, or to rituximab, is the suggested course of action. In anticipation of pregnancy, patients should be switched to appropriate medications without reducing the intensity of treatment. There is no evidence to suggest that management of LN should differ in children versus adults.

CONCLUSIONS

Recommendations for the management of LN were developed using an evidence-based approach followed by expert consensus.

Maternal deaths in women with lupus nephritis: a review of published evidence

BACKGROUND AND OBJECTIVES

Pregnancies in women with systemic lupus erythematosus (SLE) and lupus nephritis are considered high-risk due to high rates of maternal and fetal complications. However, there has not been a formal analysis addressing the issue of maternal deaths in these women. The aim of this study was to perform a literature review of the maternal deaths in women with SLE and lupus nephritis to: (1) identify the main causes of death and (2) discuss possible reasons for these causes, and strategies that may improve patient care and outcomes. DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENT: We performed an extensive electronic literature search from 1962 to 2009 using online databases (PubMed, Embase, Lilacs, Cochrane Controlled Trials Register, Medline, and Science Citation Index). Studies were included if they reported pregnancies in patients with SLE and lupus nephritis with at least one reported maternal death.

RESULTS

We identified 13 studies that reported a total of 17 deaths in the 6 week post-partum period that were attributable to SLE and lupus nephritis. In all cases, death occurred in the setting of active disease, and was attributed either to infection in 41.2% (n = 7), or disease activity in 29.4% (n = 5). The remaining deaths were due to pulmonary embolus in 11.8% (n = 2), pregnancy-associated cardiomyopathy in 5.9% (n = 1), adrenal failure due to abrupt steroid withdrawal in 5.9% (n = 1), and undefined in 5.9% (n = 1).

CONCLUSIONS

All maternal deaths in patients with SLE and lupus nephritis occurred in those with active disease, with disease activity/complications and infections (mainly opportunistic) being the two major causes. The presented evidence further supports timing of pregnancy relative to SLE activity, and the judicious use of immunosuppressive agents in pregnant patients.

Impact of previous lupus nephritis on maternal and fetal outcomes during pregnancy

Previous reports suggest that renal involvement before pregnancy or active renal disease during pregnancy may be associated with poor fetal and maternal outcomes in systemic lupus erythematosus (SLE) women. We report our experience of fetal and maternal complications in pregnant lupus women with and without previous lupus nephritis. We analyzed the clinical records of pregnant SLE patients attended in a tertiary reference center during a 5-year period. Patients were allocated into two groups according to the presence or absence of previous lupus nephritis. Women were evaluated monthly during pregnancy and at least 1 month postpartum. Maternal and fetal outcomes of pregnancy were abstracted. We included 95 pregnancies in 92 patients. Compared with pregnant women without lupus nephritis (n = 60), pregnancies with previous lupus nephritis (n = 35) were associated with a higher risk of maternal complications (88.5% vs. 43.3%, p = 0.00001), higher rate of lupus flares (54.2% vs. 25%, p = 0.004), and renal flares (45.7% vs. 6.6%, p = 0.00001), but most of which in most instances were reversible. On the other hand, fetal outcome was similar in both groups. Multivariate analysis showed that previous lupus nephritis and active lupus at conception were predictors of adverse maternal outcome. Pregnancies in women with previous lupus nephritis had a higher rate of maternal complications in comparison with those without. However, fetal prognosis was similar in both groups.

Pregnancy Outcomes in Systemic Lupus Erythematosus with and without Previous Nephritis

Objective.

To compare rates and predictors of pregnancy complications in mothers with systemic lupus erythematosus (SLE) with and without previous nephritis (PN).

Methods.

Retrospective analysis of 107 pregnancies in 83 women with SLE diagnosed prepregnancy.

Results.

Mothers with PN had higher rates of preterm delivery (< 37/40, 30% vs 11%, p = 0.029) than those without PN. Women with PN had earlier onset of preeclampsia [median 34.5 weeks (IQR 32–37) vs 37.5 weeks (IQR 35–38, p = 0.047)] that was more frequently complicated by preterm delivery (p = 0.02). Risk factors for preeclampsia in women with PN include 10–13 weeks’ gestation diastolic blood pressure > 80 mmHg and proteinuria, and prepregnancy estimated glomerular filtration rate (eGFR) < 90 ml/min/1.73 m2. In women with PN, midtrimester uterine-artery-Doppler notching had low negative predictive value (47%). After 39 months followup, eGFR was stable in women with or without PN.

Conclusion.

In SLE, preterm deliveries are more frequent and preeclampsia occurs earlier in women with PN, but longterm eGFR is preserved.

Pregnancy outcomes and appropriate timing of pregnancy in 183 pregnancies in Korean patients with SLE

This study was undertaken to investigate the pregnancy outcomes in patients with systemic lupus erythematosus (SLE) and the appropriate timing of pregnancy. We performed a retrospective evaluation of 183 pregnancies with SLE at Catholic University Medical Center during the 13-year period from 1998 to 2010. Pregnancy outcomes were compared according to SLE characteristics. The predictive value of the different cut-off points of the stable period before conception on adverse pregnancy outcomes was calculated by ROC (Receiver operating characteristics) curve analysis. In multivariate analysis, the presence of antiphospholipid antibodies (aPLs) increased the risk of pregnancy loss (p<0.0001) and premature birth (p=0.0040). Active disease at conception increased the risk of premature birth (p< 0.0001) and complications (IUGR, PIH, or both) (p= 0.0078). The other predictor of complications was found to be lupus flare (p=0.0252). At a cut-off level of stable period of 4 months before conception, sensitivity and specificity were 70.8% and 53.2%, 71.4% and 61.5%, and 63.6 % and 59.8 %, respectively on reducing pregnancy loss, premature birth, and complications. Pregnancies with aPLs, active disease at conception and SLE flares are at a higher risk of adverse outcomes. It is essential that disease activity remains stable at least 4 months before conception, for favorable pregnancy outcomes.

Pregnancy outcome in 396 pregnancies in patients with SLE in Saudi Arabia

The aim of this study was to examine the pregnancy outcomes in patients with systemic lupus erythematosus (SLE) and the effect of SLE flare and treatment on pregnancy outcomes. We performed a retrospective evaluation of all pregnancies occurring in patients with SLE during the 27-year period from 1980 to 2006. Of the 319 women with SLE planning pregnancy after SLE onset, 176 (55.2%) conceived resulting in 396 pregnancies. Live births were significantly lower in proportion (70.2% vs. 85.7%) and more likely to end in fetal deaths (29.7% vs. 14.2%) and preterm births (26.7% vs. 5.8 %) in pregnancies occurring after SLE onset than in pregnancies occurring before SLE onset (p < 0.0001). With respect to different disease manifestations, we found that fetal loss was significantly higher in patients with antiphospholipid (aPL) antibodies than without (p < 0.001). Preterm deliveries were significantly more frequent in patients with lupus nephritis, anti-Ro/SSA antibodies, hypertension, history of intravenous cyclophosphamide treatment and aPL than those without these features (p < 0.05). Neonates with intrauterine growth retardation (IUGR) neonates were more common in hypertensive and Raynaud's-positive pregnancies (p < 0.05). SLE flares occurred in 30.8% pregnancies. There was increased risk of fetal loss, preterm births and IUGR in pregnancies with SLE exacerbations than without (p < 0.05). Prednisolone was found to improve the rate of live births, although it was also a predictor of prematurity. The predictors of pregnancy loss were lupus nephritis (odds ratio (OR) 7.3), aPL (OR 3.9), and SLE flares in pregnancy (OR 1.9). There was higher risk of preterm deliveries in patients with lupus nephritis (OR 18.9), anti-Ro antibodies (OR 13.9), hypertension (OR 15.7) and SLE flares (OR 2.5). IUGR was found to be associated with hypertension (OR 37.7), Raynaud's (OR 12.3), and SLE flares (OR 4.2). In conclusion, pregnancies in SLE patients with active lupus nephritis, anti-Ro/SSA antibodies, aPL, hypertension, Raynaud's phenomenon, active disease at conception and SLE exacerbations are at a higher risk of adverse pregnancy outcomes. It is important to carefully plan pregnancy, and experienced rheumatologists and obstetricians should monitor SLE patients in pregnancy and postpartum.