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VBCR - April 2017, Vol 6, No 1 - Lupus
Sophie Granger

The majority of patients affected by systemic lupus erythematosus (SLE) and/or antiphospholipid syndrome (APS) are women of childbearing age. Personal relationships and family planning among these patients suffer because of gaps in the management of reproductive concerns (eg, pregnancy’s effect on maternal disease, effects of the disease on the fetus, and medication safety during pregnancy and breast-feeding) and other women’s health issues. In response to these unmet needs, the European League Against Rheumatism (EULAR) has published evidence-based recommendations for the management of women’s health issues and family planning among patients with SLE and/or APS (Andreoli L, et al. Ann Rheum Dis. 2017;76:476-485).

“These recommendations have been devised with the intention of helping physicians involved in the care of patients with SLE and/or APS and facilitating physician–patient communication. They recognise an implicit need for change in the mindset of health professionals, shifting from caution against pregnancy towards embracement of pregnancy,” lead author Laura Andreoli, MD, PhD, Unit of Rheumatology and Clinical Immunology, Spedali Civili, Brescia, Italy, and colleagues explained in the published report of the EULAR guidelines.

Using a modified Delphi approach, a multidisciplinary committee of experts that included Dr Andreoli carefully chose and amended 12 research questions for use in a systematic literature review. The committee observed EULAR standardized operating procedures, and used the Appraisal of Guidelines for Research and Evaluation instrument.

After classifying evidence based on the design and validity of existing literature, each statement was graded for strength. Ultimately, the committee members reached a consensus on 12 final statements. These statements, which range in level of agreement from 9.2 to 10, offer recommendations for the management of health issues, and cover a number of topics relevant to women with SLE and/or APS.

Risk Assessment and Preconception Counseling

Preconception counseling and the implementation of suitable preventive strategies and patient-specific monitoring plans for before and during pregnancy require the evaluation of risk factors for adverse outcomes to the mother and fetus.

Contraception Techniques

Contraception counseling should be given to women with SLE and/or APS, especially with regard to the prevention of undesired pregnancies during periods of high disease activity and teratogenic drug intake. Risk factors should be assessed on an individual basis, and include general- (eg, obesity) and disease-related factors (eg, thrombotic risk).

Risks for Diminished Fertility

Although there is no solid evidence that points to SLE and/or APS decreasing fertility, active disease (particularly lupus nephritis) and immunosuppressive therapy use may negatively impact fertility. As such, just like with the population at large, women with SLE and/or APS should be given fertility counseling, especially with regard to the negative impact of increasing age and certain lifestyle factors (eg, tobacco use, alcohol consumption).

Fertility Conservation

Methods for preserving fertility (particularly gonadotropin-releasing hormone analogs) should be explored for women with SLE who are menstruating and who will be given alkylating agents.

Methods of Assisted Reproduction

The use of assisted reproduction techniques (eg, ovulation induction treatments and in vitro fertilization protocols) are safe for women with SLE who have stable or inactive disease. Patients who test positive for antiphospholipid antibodies or APS should be given anticoagulants and/or low-dose aspirin.

Predictive Biomarkers of Disease Activity

Assess for disease activity (eg, renal function parameters and serologic markers) among pregnant women with SLE to stay vigilant of obstetrical adverse outcomes and disease flares.

Monitoring During Pregnancy

Supplementary fetal surveillance should be conducted with Doppler ultrasonography and biometric parameters in women with SLE and/or APS, especially when they are in their third trimester. When fetal dysrhythmia or myocarditis is suspected, particularly in patients who test positive for anti-Ro/SSA and/or anti-La/SSB antibodies, fetal echocardiography is recommended.

Drugs for Preventing and Managing SLE Flares During Pregnancy

During pregnancy, prevent or manage SLE flares with hydroxychloroquine, oral glucocorticoids, azathioprine, cyclosporin A, and tacrolimus. For moderate-to-severe flares, glucocorticoids, intravenous pulse therapy, intravenous immunoglobulin, and plasmapheresis are potential therapies that can be used for management. It is recommended that mycophenolic acid, cyclophosphamide, leflunomide, and methotrexate be avoided.

Supplementary Treatments During Pregnancy

Before conception and during pregnancy, hydroxychloroquine is recommended for women with SLE. Low-dose aspirin is recommended for use in women with SLE who are at risk for preeclampsia, and as combination treatment with heparin for women with SLE-associated APS or primary APS. Just as with the general population, calcium, vitamin D, and folic acid should be provided as supplementation. Consider measuring vitamin D levels in the blood once pregnancy is established.

Hormone Replacement Therapy and Menopause

Hormone replacement therapy may be used to manage severe vasomotor menopausal manifestations in women with SLE who have stable or inactive disease and negative antiphospholipid antibodies. Carefully consider the risk for thrombosis and cardiovascular disease with the use of hormone replacement therapy in patients with positive antiphospholipid antibodies.

Malignancy Screenings

As with the general population, women with SLE and/or APS should be screened for malignancies, including breast, ovarian, and endometrial cancer. The risk for developing cervical premalignant lesions is higher among women with SLE—especially those receiving immunosuppressive drugs—so this patient population should be monitored carefully.

Vaccinations for Human Papillomavirus

All women with SLE and/or APS that is stable or inactive can be considered candidates for human papillomavirus immunizations.

Dr Andreoli and colleagues also stressed the need for family planning to be discussed during the initial encounter between the physician and patient, and subsequently reinforced.

“Reproductive issues are of paramount importance for women with systemic lupus erythematosus and/or antiphospholipid syndrome and should be addressed on a regular basis by healthcare providers,” they said.

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Last modified: May 18, 2017
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