Sex, Drugs, and... CKD

A PREGNANT LUPUS

Pregnancy in the setting of systemic lupus erythematosus (SLE) is associated with a higher risk of complications compared to normal women. 
Pregnancy in SLE patients should be accurately planned. First of all, you need to assess disease severity. 
Consider possible contraindications related to disease damage: severe renal failure, severe pulmonary fibrosis, cardiomiopathy, CVA, MI. In the event of severe damage, the main recommendation is for surrogacy/adoption/IVF with gestational carrier. 
If no significant damage is present, next step is to evaluate disease activity. Disease should be inactive for at least 6 months, check APL, anti-SSA/Ro, anti-SSB/La. Rate of fetal loss is up to 75% in patients with active lupus nephritis. Medications should be evaluated, if contraindicated changed to safe ones.  Do not stop HCQ: it is safe, studies show beneficial effects on pregnancy outcome, suspension increases the risk of flare.

PROMISSE study reported data on 386 pregnancies in SLE:  5% risk for severe flare, 15% for mild-moderate flare. When flares develop, they often occur during the first or second trimester or during the first few months after delivery. Disease flares during pregnancy should be treated using low-dose non fluorinated steroids, azathioprine, cyclosporine, tacrolimus, or IVIg. Use of fluorinated compounds, such as dexamethasone and betamethasone should be limited to a single course for fetal lung maturity, in cases of premature delivery. Repeated use has been associated with impaired neuro-psychological development of the child in later life.

The biggest issue is the 3-5 times higher risk of pre-eclampsia, complicating 16-30% of SLE pregnancies. 

Neonatal Lupus Syndromes (NLS) is a form of passively acquired fetal autoimmunity from maternal antibodies, anti-Ro and anti-La antibodies. Neonatal lupus typically manifests as congenital heart block or as lupus rash. In rare cases, it may manifest as hepatic or hematologic involvement. 

Risk of any manifestation of neonatal SLE is 20-25% with maternal Ro/La, congenital heart block (CHB) occurs in 2-3% but mortality is 20% and 60-80% require pacemaker. So in the event of previous CHB in neonate maternal Ro/La with, weekly fetal echo is recommended from 18 weeks.