Abstrakt
Background: Pregnancy has been reported to constitute a high risk in lupus patients. However, with the emergence of potent disease modifying antirheumatic drugs (DMARDs), pregnancy outcome has become more favorable in this group of patients. There is thus a need to report the Nigerian experience so as to add to the body of knowledge. There has been no report on pregnancy outcome among Nigerian lupus patients.
Objective: To describe the maternal and fetal outcomes among pregnant female systemic lupus erythematosus [SLE] patients attending Lagos State University Teaching Hospital (LASUTH), Lagos,
Nigeria.
Methods: A retrospective case series of pregnancy outcome in systemic lupus erythematosus (SLE) patients between the years 2011 to 2015. Data about demography, symptoms during pregnancy, blood pressure, investigations, treatment, route of delivery and pregnancy outcome were collected from patients’ case record files. Data was analyzed using descriptive statistics.
Results: The outcome of 15 pregnancies in 12 lupus patients were reported. The outcome of the pregnancies were eight live births from elective cesarean section (CS), three live births via spontaneous vaginal delivery, a stillborn following vaginal delivery, an intrauterine fetal death from intrauterine growth restriction, a spontaneous abortion, and a maternal mortality. Mean birth weight was 2.8kg (SD+/- 0.5). Active disease and hypertension were observed in 2 pregnancies each, while lupus nephritis was present in 5 pregnancies. Only one of the patients was hospitalized before delivery due to a flare of lupus nephritis. Antiphospholipid syndrome occurred in 1 of the pregnancies. There was no occurrence of a flare post-delivery, neither was there any case of neonatal lupus syndrome nor congenital heart block.
Conclusion: Pregnancy in patients with SLE is still associated with a risk of poor outcome in Nigeria, but with the appropriate timing and management, it is possible to have a good outcome. Cooperation with an Obstetrician experienced in high risk pregnancies is also essential. A high index of suspicion is recommended in patients with recurrent spontaneous abortions and/or unexplained deterioration in renal function, even in the absence of typical skin lesions of lupus and/or arthritis. Finally, since the management of SLE in pregnancy is cost intensive, the development of favorable health insurance policies by the government to enable the common man to benefit from standard health care will ease the burden of cost of management on patients.
Keywords: Systemic lupus erythematosus, pregnancy, maternal outcome and fetal outcome.
Abstrait
Contexte : La grossesse a été signalé à constituer un risque élevé chez les patientes atteintes de lupus. Cependant, avec l’émergence de médicaments antirhumatismaux (DMARD) puissants, l’issue de la grossesse est devenue plus favorable chez ce groupe de patientes. Il est donc nécessaire de rendre compte de l’expérience Nigériane afin de compléter le corpus de connaissances. Aucun résultat de grossesse n’a été signalé chez les patientes atteintes de lupus Nigérian.
Objectif : Pour décrire les résultats maternels et fœtaux chez les patientes enceintes atteintes de lupus érythémateux disséminé (LES) à l’Hôpital d’Enseignement Universitaire de l’État de Lagos
(LASUTH) à Lagos, Nigéria.
Méthodes : Une série de cas rétrospectifs sur l’issue de la grossesse chez les patientes atteintes de lupus érythémateux systémique (LES) entre 2011 et 2015. Les données sur la démographie, les
symptômes pendant la grossesse, la pression artérielle, les investigations, le traitement, la voie d’accouchement et l’issue de la grossesse ont été recueillies des dossiers des patientes. Les données ont été analysées à l’aide de statistiques descriptives.
Résultats : Les résultats de 15 grossesses chez 12 patientes atteintes de lupus ont été rapportés. Les résultats de la grossesse ont été huit naissances vivantes issues d’une césarienne élective (CS), trois naissances vivantes via un accouchement vaginal spontané, un mort-né après un accouchement vaginal, une mort fœtale intra-utérine due à une restriction de croissance intra-utérine, un avortement spontané et une mortalité maternelle. Le poids moyen à la naissance était de 2,8 kg (ET +/- 0,5). Une maladie active et une hypertension ont été observées dans 2 grossesses chacune, tandis que la néphrite lupique était présente dans 5 grossesses. Un seul des patients a été hospitalisé avant l’accouchement en raison d’une poussée de néphrite lupique. Le syndrome des anti-phospholipides est apparu dans une des grossesses. Aucune poussée n’a été constatée après l’accouchement, ni aucun syndrome de lupus néonatal ni aucun bloc cardiaque congénital.
Conclusion : La grossesse chez les patientes présentant un LES est toujours associée à un risque de résultats médiocres au Nigéria, mais avec un temps et une gestion appropriée, il est possible d’obtenir de bons résultats. La coopération avec un obstétricien expérimenté dans les grossesses à haut risque est également essentielle. Un indice de suspicion élevé est recommandé chez les patientes présentant des avortements spontanés récurrents et / ou une détérioration inexpliquée de la fonction rénale, même en l’absence de lésions cutanées typiques du lupus et / ou de l’arthrite. Enfin, comme la gestion de LES pendant la grossesse est coûteuse, le développement de politiques d’assurance maladie favorables par le gouvernement permettant à l’homme du commun de bénéficier de soins de santé standard allégera le fardeau des coûts de la gestion pour les patientes.
Mots clés: Lupus érythémateux disséminé , grossesse, évolution maternelle et évolution fœtale
Correspondence: Dr. Olabanke A. Olatunde, Department of Medicine, Olabisi Onabanjo University Teaching Hospital, Sagamu, Ogun State, Nigeria. E-mail: olatundeolabanke@yahoo.com
Reference
Adelowo OO and Oguntona SA. Pattern of systemic lupus erythematosus among Nigerians. Clin Rheumatol. 2009;28(6):699–703.
Bertsias G., Cevera R. and Boumpas D.T. Systemic Lupus Erythematosus: Pathogenesis and Clinical Features. EULAR textbook on rheumatic diseases, Geneva,Switzerland: European League Against Rheumatism. 2012:476–505.
Ostensen M. New insights into sexual functioning and fertility in rheumatic diseases. Best Pract Res Clin Rheumatol. 2004;18(2):219–232.
Ostensen M and Clowse M. Pathogenesis of pregnancy complications in systemic lupus erythematosus. Curr opinion in Rheumatol. 2013;25(5):591–596.
Chen C, Chen Y, Lin H, et al.. Increased risk of adverse pregnancy outcomes for hospitalisation of women with lupus during pregnancy/ : a nationwide population-based study. Clin Exp Rheumatol. 2010;28(1):49–55.
Smyth A, Oliveira GH, Lahr BD, et al. A systematic review and meta-analysis of pregnancy outcomes in patients with systemic lupus erythematosus and lupus nephritis. Clin J Am Soc Nephrol. 2010;5(11):2060–2068.
Eman Aly Husein Aly, Rafaat Mohamed Riyad ANM. Pregnancy outcome in patients with systemic lupus erythematosus: A single center study in the High Risk Pregnancy unit. Middle East Fertil Soc J. 2016;21(3):168–174.
Chakravarty EF, Colón I, Langen ES, et al. Factors that predict prematurity and preeclampsia in pregnancies that are complicated by systemic lupus erythematosus. Am J Obstet Gynecol. 2005;192(6):1897–904.
Kwok LW, Tam LS, Zhu TY, Leung YY and Li EK. Predictors of maternal and fetal outcomes in pregnancies of patients with systemic lupus erythematosus. Lupus. 2011;20(8):829–836.
Khamashta MA. Systemic lupus erythematosus and pregnancy. Best Practice & Research Clinical Rheumatology. 2006;20(4):685–694.
Ko HS, Ahn HY, Jang DG, et al. Pregnancy outcomes and appropriate timing of pregnancy in 183 pregnancies in Korean patients with SLE. Int J Med Sci. 2011;8(7):577–583.
Mok CC and Wong RW. Pregnancy in systemic lupus erythematosus. Postgr Med J. 2001;77(905):157–165.
Cortés-Hernández J, Ordi-Ros J, Paredes F, et al. Clinical predictors of fetal and maternal outcome in systemic lupus erythematosus: a prospective study of 103 pregnancies. Rheumatology. 2002;41(6):643–650.
Clowse ME, Magder LS, Witter F and Petri M. The impact of increased lupus activity on obstetric outcomes. Arthritis Rheum. 2005;52(2):514–521.
Adelowo OO, Ojo O and Oduenyi I. Auto antibodies in Nigerian lupus patients. Afr J Med Med Sci. 2012;41(2):171–181.
Tan EM, Cohen AS, Fries JF, et al. The 1982 revised criteria for the classification of systemic lupus erythrematosus. Arthritis Rheum. 1982;25(11):1271–1277.
Helewa ME, Burrows RF, Smith J, et al. Report of the Canadian Hypertension Society Consensus Conference:1. Definitions, evaluation and classification of hypertensive disorders in pregnancy. Can Med Assoc Journal. 1997;157(6):715–725.
Gifford RW. Report of the National High Blood Pressure Education Program Working Group on High Blood Pressure in Pregnancy. Am J Obs Gynecol. 2000;183:1–5.
Hahn BH, Mcmahon MA, Wilkinson A, et al. American College of Rheumatology Guidelines for Screening , Treatment , and Management of Lupus Nephritis. Arthritis care Res. 2012;64(6):797–808.
Petri M, Buyon J and Kim M. Classification and definition of major flares in SLE clinical trials 1. Lupus. 1999;8(8):685–691.
Johansen KS and Hod M. Quality development in perinatal care/ : the OBSQID project. Int J Gynaecol Obs. 1999;64(2):167–172.
Cartlidge PH and Stewart JH. Effect of changing the stillbirth definition on evaluation of perinatal mortality rates.The Lancet. 1995;346(8973):486–488.
Miyakis S, Lockshin MD, Atsumi T, et al. International consensus statement on an update of the classification criteria for definite antiphospholipid syndrome(APS). J Thromb Haemost. 2006;4(2):295–306.
Dey ID, Coleman J, Kwarko H and Mate-Kole M. Outcome of pregnancy in patients with systemic lupus erythematosus at Korle-bu Teaching Hospital. Ghana Med J. 2016;50(2):72–77.
Georgiou PE, Politi EN, Katsimbri P, Sakka V and Drosos AA. Outcome of lupus pregnancy: a controlled study. Rheumatology. 2000;39(9):1014–1019.
Chandran, V., Aggarwal, A. and Misra R. Active disease during pregnancy is associated with poor foetal outcome in Indian patients with systemic lupus erythematosus. Rheumatol Int. 2005;26(2):152–156.
Whitelaw DA, Hall D and Kotze T. Pregnancy in systemic lupus erythematosus: a retrospective study from a developing community. Clin Rheumatol. 2008;27(5):577.
Mbuli L, Mapiye D and Okpechi I. Lupus nephritis is associated with poor pregnancy outcomes in pregnant SLE patients in cape town: A retrospective analysis. Pan Afr Med J. 2015;22(1):1–10.
Rahman P, Gladman DD and Urowitz MB. Clinical predictors of fetal outcome in systemic lupus erythematosus. J Rheumatol. 1998;25(8):1526–1530.
Lateef A and Petri M. Managing lupus patients during pregnancy. Best Pract Res Clin Rheumatol. 2013;27(3):435–447.
Ruiz-Irastorza G and Khamashta M A. Lupus and pregnancy: Integrating clues from the bench and bedside. Eur J Clin Invest. 2011;41(6):672–678.
Izmirly PM, Costedoat-Chalumeau N, Pisoni C, et al. Maternal use of hydroxychloroquine is associated with a reduced risk of recurrent anti-SSA/Ro associated cardiac manifestations of neonatal lupus. Circulation. 2012;126(1):76–82.
Adelowo OO and Oguntona S. Anti-phospholipid syndrome in Nigeria: Report of five cases. East Afr Med J. 2009;86(2):94–96.