**7. Maternal and fetal complications during lupus pregnancy**

Maternal and fetal complications are more frequent in lupus pregnancy than in healthy ones. So, even if new treatment strategies have been incorporated in guidelines for managing this complex situation, SLE is still a severe risk factor for pregnancy.

As discussed, SLE pregnancy is related to an increased risk of miscarriage, stillbirth, neonatal death, premature delivery and FGR [33, 34]. Cesarean section due to pregnancy complications is also more prevalent in lupus patients. A large nationwide study revealed that maternal mortality rate in SLE patients reaches 325/100,000 live births, meaning more than 20-fold higher than in non-SLE population [35]. The risk for other maternal complications includes thrombosis, hypertension, infection, thrombocytopenia, and transfusion, being each 3- to 7-fold

**91**

20–30% [44].

50% [31].

*Systemic Lupus Erythematosus Pregnancy DOI: http://dx.doi.org/10.5772/intechopen.99008*

disease [34].

**7.1 Lupus flare**

higher in SLE population. Gestational hypertension, apart from pre-eclampsia, may provoke long-term complications related to cardiovascular and peripheral artery

The risk of gestational diabetes is also increased in SLE pregnancy [22, 36]. It is mainly related to glucocorticoid therapy during pregnancy. About 10% of gestational diabetes result from autoimmune activity (GADA, IA2A, IAA and ZnT8-A antibodies) [37]. Nevertheless, the prevalence of SLE and autoimmune gestational

During lupus pregnancies, there is an increased risk of maternal and fetal morbidity and mortality, but a stable disease prior to conception can act as predictor of a good outcome [38]. The onset of new symptoms or signs as arthritis, discoid or subacute cutaneous lupus lesions, oral ulcers, vasculitis, polyserositis, lymphadenopathy, positive direct Coombs, myocarditis, pneumonitis, proteinuria, leucopenia, thrombocytopenia, complement consumption or raised anti-DNA antibody expression must arise the suspicion about an ongoing lupus flare [12, 38].

During a healthy pregnancy, complement levels are usually raised, as it acts as acute phase reactant [31]. So, normal or lower range of complement suggests serum consumption due inflammatory process [38]. The coexistence of hypocomplementemia and high SLE activity usually predicts a poor pregnancy outcome. Proteinuria

Recently, the PROMISSE (Predictors of Pregnancy Outcome: Biomarkers in Antiphospholipid Antibody Syndrome and Systemic Lupus Erythematosus) study revealed that up to 20.8% lupus pregnancies experience mild to moderate flares but only 6.25% have severe ones [39]. Patients at risk were the ones with younger age, low C4 and higher physician global assessment at baseline as independent risk factors for having at least one flare during pregnancy. This study is remarkable and unique in that it has a multicenter, multiethnic and multiracial sample included. Hence, non-white race was also identified as a risk factor for lupus flare. According to the authors, there were no medications associated with flare, including hydroxy-

SLE patients with central nervous system (CNS) involvement during pregnancy

As mentioned on Section 5.1, lupus patients can also have APS. Although rare, catastrophic APS (CAPS) can occur in up to 1% of patients and mortality reaches

Lupus nephritis (LN) is severe and independent risk factor for both maternal and fetal outcomes. It is related to preterm birth, hypertension and pre-eclampsia [42]. Pre-eclampsia have an increased risk in SLE pregnancy and can appear in up to 25% of SLE patients [31, 33]. Active LN at the time of conception has been pointed as the major risk factor for pre-eclampsia in SLE pregnancies [43]. LN activates in 4–30% of patients; those who had previous recurrence of LN are at a higher risk

have higher risk for maternal and fetal complications and poor prognosis [40]. Preterm birth incidence can be 60% higher than in other lupus pregnancies and extreme prematurity can reach 40% of the newborns. CNS lupus pregnancies have higher risk for complications, whether neurological symptoms are present or not. In contrast, in cutaneous lupus erythematosus the pregnancy outcomes are

diabetes, and the relationship between them, needs further research.

and leukopenia are also associated to a worse prognosis [31, 38].

chloroquine, in contrast to other studies.

comparable to those of healthy populations [41].

**7.2 Pre-eclampsia and lupus nephritis**

#### *Systemic Lupus Erythematosus Pregnancy DOI: http://dx.doi.org/10.5772/intechopen.99008*

higher in SLE population. Gestational hypertension, apart from pre-eclampsia, may provoke long-term complications related to cardiovascular and peripheral artery disease [34].

The risk of gestational diabetes is also increased in SLE pregnancy [22, 36]. It is mainly related to glucocorticoid therapy during pregnancy. About 10% of gestational diabetes result from autoimmune activity (GADA, IA2A, IAA and ZnT8-A antibodies) [37]. Nevertheless, the prevalence of SLE and autoimmune gestational diabetes, and the relationship between them, needs further research.
