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Saudi Journal of Kidney Diseases and Transplantation
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ORIGINAL ARTICLE Table of Contents   
Year : 2009  |  Volume : 20  |  Issue : 5  |  Page : 802-805
Outcome of pregnancy in patients with inactive systemic lupus erythromatosus and minimal proteinuria


Department of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia

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Date of Web Publication2-Sep-2009
 

   Abstract 

Systemic lupus erythematosus (SLE) is a multisystem disease. This study was under≠taken to assess the outcome of pregnancies in patients with inactive SLE. We prospectively studied 20 female patients with diagnosis of stable class IV Lupus nephritis followed up at King Abdul Aziz University Hospital, in Jeddah, Saudi Arabia between 1998 and 2008. Before each pregnancy all the patients had their blood pressure, serum creatinine, creatinine clearance, serology for SLE and 24-hour urine protein excretion measured and then repeated at monthly intervals during the pregnancy. Statistical analysis was performed using the Wilcoxon signed-rank test. Despite having negative antinuclear antibody (ANA) significant complications were observed during pregnancy. The daily proteinuria during 34-36 weeks' gestation was significantly higher (P< 0.05) than during 32 weeks. Two patients had abortions one stillbirth and 2 required termination of the pregnancy; one due to severe hypertension, and other due to renal impairment. One patient developed HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome. 14 patients had a successful preg≠nancy, including 4 requiring a cesarian section. In conclusion, although no clinical evidence of lupus disease activity was demonstrated pre-conception proteinuria significantly increased during pregnancy along with maternal and fetal complications. Pregnant females with diagnosis of SLE need a multidisciplinary care during the pregnancy and post-partum period.

How to cite this article:
Alshohaib S. Outcome of pregnancy in patients with inactive systemic lupus erythromatosus and minimal proteinuria. Saudi J Kidney Dis Transpl 2009;20:802-5

How to cite this URL:
Alshohaib S. Outcome of pregnancy in patients with inactive systemic lupus erythromatosus and minimal proteinuria. Saudi J Kidney Dis Transpl [serial online] 2009 [cited 2020 Jun 6];20:802-5. Available from: http://www.sjkdt.org/text.asp?2009/20/5/802/55365

   Introduction Top


Systemic Lupus Erythematosus (SLE) is an autoimmune disease that primarily affects young females of childbearing age. For social reasons, the Kingdom of Saudi Arabia has one of the highest rates of pregnancy and childbirth. Since SLE is relatively common in Saudi Arabia (per≠sonal and others experience as no true preva≠lence is known). Many patients with lupus neph≠ritis present with pregnancy, regardless of the risks for both the foetus and the mother. This becomes a challenge especially when the pa≠tient has active SLE, gross proteinuria or severe hypertension.

The data on pregnancy and lupus is variable and the recommendations about pregnancy differ between studies. Nevertheless, the consensus exists that it is safe to proceed with pregnancy if the lupus is inactive for at least one year to 6 months, especially lupus nephritis. [1],[2],[3],[4],[5],[6] This pros≠pective study evaluates 20 pregnancies in class IV lupus nephritis patients with quiescent disease for at least more than 6 months.


   Patients and Methods Top


This is a prospective study of 20 female pa≠tients with SLE, mean age of 27.2 ± 5.57 years (18-38 years) followed at King Abdul Aziz University Hospital, in Jeddah, Saudi Arabia between 1998 and 2008. All had Class IV lupus nephritis, without raised creatinine, but all of them had proteinuria of less than 1 g/day. All of the biopsies showed mild interstitial fibrosis.

Eight patients were primigravida and 12 were multigravida who had uncomplicated previous pregnancies. Prior to each pregnancy, all the pa≠tients had their blood pressure, serum creati≠nine, creatinine clearance, CBC, serology and 24-hour urine protein excretion measured. All investigations were repeated monthly till the termination of pregnancy. Pre-conception all patients were normotensive and not on any anti≠hypertensives and the pre-conception creatinine clearance was 89.2 mL/min.

Statistical analysis was done using the following tests: Shapiro-Wilk, Anderson-Darling, Martinez≠Iglewicz, Kolmogorov-Smirnov, D'Agostino Skewness, D'Agostino Kurtosis and D'Agos≠tino Omnibus tests. P value of < 0.05 was taken as significant. Patients serum creatinine, crea≠tinine clearance, hemoglobin, 24 hour urine pro≠teinuria and serology was evaluated before and after the pregnancy.


   Results Top


[Table 1] shows the 24-hour urine protein excre≠tion, creatinine clearance, serum creatinine and hemoglobin levels during pregnancy.

All of the patients were ANA negative before the pregnancy and remained negative till the delivery.

The results in [Table 1] show that daily pro≠teinuria during 34-36 weeks of gestation was significantly higher (P< 0.05) than at 32 weeks. The mean creatinine clearance was 79.85 ± 4.47 mL/min and the serum creatinine was 83 ± 7.26 µmol/L. The mean hemoglobin level was 10.59 ± 0.41 g/dL, ranging from 10 to 11.02 g/dL.

Two patients had abortions, one had a stillbirth, one required a termination of the pregnancy due to severe hypertension, and another due to renal impairment. One patient developed haemolysis and elevated liver enzymes, due to HELLP syndrome. In total fourteen (70%) patients had a successful pregnancy, four of them requiring a cesarian section. None of the 14 successful pregnancies ended in a still birth or in pre≠mature delivery (defined as gestational age of < 37 weeks). The mean birth weight was 3.1 kg with none of the babies being of low birth weight (defined as birth weight of < 2.5 Kg) and all had normal Apgar score at 1 and 5 minutes. The average hospital stay post delivery was 10 days.

All the patients had negative anti DNA and normal complement levels prior to pregnancy and remained so in the 14 patients who had un≠eventful pregnancy. The other 6 patients did develop positive DNA. Only one patient had acute renal failure with low complement levels suggesting lupus nephritis resulting in termi≠nation of pregnancy.


   Discussion Top


Majority of our patients had successful preg≠nancy outcome still complications were observed in 30% of patients. In general the unsuccessful pregnancies were mainly related to the ob≠served complications in any pregnancy and only one pregnancy could be directly related to the relapse of lupus nephritis. Retrospective and prospective data describes successful outcomes close to general population when SLE is not active especially lupus nephritis. [1],[2],[3],[4],[5],[6] In pregnant women daily proteinuria in excess of 300 mg at any time during gestation is considered abnor≠mal. [7] The increase of the mean daily proteinuria [Table 1] could indicate a lupus flare, however other clinical and serological data did not su≠pport this finding in our successful preg≠nancies. [8] Only one of our patient had flare of Lupus nephritis. Pregnancy in general remains uneventful except in minority where flare up of SLE is observes and especially in patients with some disease activity at the start of pregnancy. [2],[3],[4],[5],[8],[9] In pregnant women creatinine clearance is usually more than 100 mL/min, and a serum creatinine level greater than 0.8 mg/dL (70.72 µmol/L) is indicative of renal impairment. [9] In the present study pre-conception creatinine clea≠rance decreased from 89.2 mL/min to 79.85 ± 4.47 mL/min, together with a mean serum crea≠tinine level of 83 ± 7.26 µmol/L, although not statistically significant.

Hematological abnormalities are common in patients with SLE, and about 50% of them are usually anemic [10],[11] defined as haemoglobin of 12 g/dL or less for women. [5] However, during normal pregnancy the plasma volume increases [9] causing hemodilution which can give an artificially low hemoglobin level. Nevertheless, in this study 65% (13/20) of patients had an ab≠normally low haemoglobin level of less than 11 g/dL.

Even though all our patients had inactive lu≠pus, there were still significant complications for both the mother and the foetus, nevertheless, none of the born issues were premature or had growth retardation. Although, our results show that inactive SLE in pregnant patients still gave rise to serious complications for both mother and foetus it however, does not refrain such pa≠tients from becoming pregnant. In agreement with the literature, our study supports the pre≠diction of an adverse foetal outcome if the SLE patients have a history of nephritis. [1],[2],[3],[4],[5],[6],[7],[8] Protei≠nuria > 0.5g/day was also associated with com≠plications during pregnancy. [6] It's important to understand the pregnancy-lupus interaction, be≠cause many potential complications during preg≠ nancy can be confused as symptoms of lupus disease activity, which is challenging for both diagnosis and treatment.

In conclusion, despite the inactivity of the di≠sease proteinuria increased in general and signi≠ficant complications in 30% of our patients were noted. Pregnancy in SLE patients should therefore be considered a high-risk pregnancy.For optimal pregnancy outcome it is advisable to plan conception when SLE is inactive and a multidisciplinary care during the pregnancy and post partum.

 
   References Top

1.Yuen SY, Krizova A, Ouimet JM, Pope JE. Pregnancy outcome in systemic lupus erythe≠matosus (SLE) is improving: Results from a case control study and literature review. Open Rheumatol J 2008;2:89-98.  Back to cited text no. 1    
2.Wagner SJ, Craici I, Reed D, et al. Maternal and foetal outcomes in pregnant patients with active lupus nephritis. Lupus 2009;18(4):342-7  Back to cited text no. 2    
3.Ambrosio P, Lermann R, Cordeiro A, Borges A, Nogueira I, Serrano F. Lupus and Pregnancy-15 Years of Experience in a Tertiary Center. Clin Rev Allergy Immunol 2009 [Epub ahead of print]  Back to cited text no. 3    
4.Le Huong D, Wechsler B, Vauthier-Brouzes D, et al. Outcome of planned pregnancies in sys≠temic lupus erythematosus: a prospective study on 62 pregnancies. Br J Rheumatol 1997;36(7): 772-7  Back to cited text no. 4    
5.Tan LK, Tan HK, Lee CT, Tan AS. Outcome of pregnancy in Asian women with systemic lupus erythematosus: experience of a single perinatal centre in Singapore .Ann Acad Med Singapore 2002 ;31(3):290-5  Back to cited text no. 5    
6.Moroni G, Quaglini S, Banfi G, et al. Pregnancy in lupus nephritis. Am J Kidney Dis 2002;40: 713-20.  Back to cited text no. 6  [PUBMED]  [FULLTEXT]
7.Weinstein L, Airoldi J. Clinical significance of proteinuria in pregnancy. Obstet Gynecol Surv 2007;62(2):117-24.  Back to cited text no. 7    
8.Khamashta MA. Systemic lupus erythematosus and pregnancy. Best Pract Res Clin Rheumatol 2006;20(4):685-94.  Back to cited text no. 8    
9.Dhar JP, Sokol RJ. Lupus and Pregnancy: Complex Yet Manageable. Clin Med Res 2006; 4(4):310-21.  Back to cited text no. 9    
10.Giannouli S, Voulgarelis M, Ziakas PD, Tzioufas AG. Anaemia in systemic lupus erythematosus: from pathophysiology to clinical assessment. Ann Rheum Dis 2006;65(2):144-8.  Back to cited text no. 10    
11.Voulgarelis M, Kokori S, Ioannidis J, Tzioufas A, Kyriaki D, Moutsopoulos H. Anaemia in systemic lupus erythematosus: aetiological profile and the role of erythropoietin. Ann Rheum Dis 2000;59(3):217-22.  Back to cited text no. 11    

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Correspondence Address:
Saad Alshohaib
Faculty of Medicine, King Abdulaziz University, Jeddah
Saudi Arabia
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PMID: 19736477

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Lupus. 2010; 19(14): 1665-1673
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