**Abstract**

Pregnancy in autoimmune rheumatic diseases remains a real challenge in clinical practice due to complex interplay between disease activity, pregnancy and drugs, and account for potential influence of pregnancy on rheumatic condition and the impact of disease on pregnancy outcomes. Indeed, innovative and successful therapies have dramatically improved the quality of life in immune-mediated rheumatic conditions and, subsequently, allowed more patients of reproductive age to plan a pregnancy/to conceive. The purpose of this chapter is to discuss emerging data about the interaction of pregnancy and systemic erythematosus lupus (SLE) focusing on modulation of the immune system by pregnancy, pregnancy outcomes in women with active lupus, biomarkers of adverse pregnancy outcomes (APO) including predictors of pre-eclampsia, predictors of obstetric complications in SLE, the influence of autoantibodies on fetal health, and, finally, evidence about rheumatologic and obstetric follow-up. There are still unmet needs in this new field of reproductive rheumatology and it becomes crucial that researchers, physicians (rheumatologists, specialists in maternofetal medicine, obstetricians) and midwifes share their knowledge and expertise in counseling women with SLE wishing to conceive, assisting pregnancy and managing different issues related to APO as well as drug optimization in preconception, during pregnancy and postpartum period.

**Keywords:** midwife, systemic lupus erythematosus, pregnancy

## **1. Introduction**

While documenting the role of midwifery in medical education, it is important to understand how rheumatic diseases respond to pregnancy and to allow continued development of multidisciplinary models in order to facilitate all reasonable steps in reproduction with the best available scientific evidence for health professionals.

In fact, a detailed introspection is pivotal to understand the relationship between the perception of pain, mental stress and/or physical injuries during active labor, midwife confidence and ability to handle labor.

Besides, labor quality cannot be defined by only two or three parameters; therefore, companies should consider knowledge capacities and not price whenever they decide to invest in delivery quality. These comments raise added question: "Is effort better spent at the national level to encourage labor or support for women and their babies during pregnancy?" We are optimistic about Romanian institutions supporting educational efforts that contribute to an adequate quality of labor.

Midwifes are far more important for parturient life providing optimal care based on monitoring of fetal heart, recording delivery data as well as communication with giving birth women [1–4]; also, they will provide our students clear targets for their educational and self-improvement goals.

In fact, it is well known that midwifes give support to the following events: monitor and examine women during pregnancy, breast-feeding and bathing, assist mother during labor, offer advices about still-birth, neonatal abnormality or neonatal death, make referrals to doctors, screening tests in hospital, participate in the training and supervision of youngers colleagues and students [1–4].

Continuous presence of midwifes on bed-side of parturient had positive effects, comprising a decreased risk of hemorrhage and transfusion, a decrease in urinary incontinence, reducing the delivery duration and other complications [1–4].

Pregnancy in women with immune-mediated rheumatic diseases (IMRDs) such as rheumatoid arthritis, connective tissue disorders (lupus and scleroderma), juvenile idiopathic arthritis and spondyloarthropathies is still considered a challenge in routine practice given the complex changes in the maternal immune response and the interferences between disease, pregnancy and medication [4–10].

Systemic lupus erythematosus (SLE) is commonly defined by higher maternal and fetal risk compared with pregnancy in general population, meaning that pregnant lupus patients present worse maternal as well as fetal outcomes including increased the risk of abortion, (pre)-eclampsia and placental complications [4–10].

Recent studies have shown that pregnant women with confirmed diagnosis of SLE are more likely to have hypertension, renal disease, diabetes, cerebrovascular disease, thyroid disorders, ischemic heart disease, pregnancy induced hypertension, preterm delivery, emergent caesarian sections, small for gestational age, congenital anomalies [4–11].

Clinical and/or subclinical inflammation, autoantibodies profile, hormonal dysfunction and immune abnormalities related to lupus may unquestionably contribute to pregnancy complications [5–10].

Furthermore, physiologic changes related to pregnancy are difficult to distinguish not only from disease-related manifestations but also from disease exacerbations, requiring a multidisciplinary approach with close rheumatic, obstetrical, and neonatal monitoring in order to optimize both maternal and fetal outcomes [5–10].

Although several biomarkers predicting complications in early pregnancy have already been investigated, preconception assessment is mandatory to stratify the risk in such patients. In addition to routine pregnancy labs, specific assessments should be reviewed during pregnancy comprising immune profile (total antinuclear antibodies, anti-double stranded DNA antibodies, antiphospholipid antibodies, complement level), inflammatory tests (erythrocyte sedimentation rate, C reactive protein) and proteinuria [5–10].

This review outlines detailed requirements during pre-pregnancy, pregnancy and early motherhood of reproductive-aged women diagnosed with autoimmune rheumatic diseases. We will discuss the major risks associated with pregnancy in SLE as well as management recommendations and we will focus on challenges in the delivery room by integrating the role of biomarkers to predict complications in lupus pregnancy and to foster the responsibility of midwife at parturient bed-side.

*Challenges in the Delivery Room: Integrated Analysis of Biomarkers Predicting Complications… DOI: http://dx.doi.org/10.5772/intechopen.96099*
