Maternal and fetal complications of systemic lupus erythematosus Matthew Cauldwell MBBS BSc, a, * Catherine Nelson-Piercy FRCP FRCOG b a Guy’s and St Thomas’ NHS Foundation Trust, Maternity Services, St Thomas’ Hospital, 10th Floor, North Wing, Westminster Bridge Rd, London SE1 7EH, UK b Guy’s and St Thomas’ NHS Foundation Trust, London, UK *Correspondence: Matthew Cauldwell. Email: matthew.cauldwell@imperial.ac.uk Key content  Systemic lupus erythematosus (SLE) is an autoimmune condition that has multi-organ involvement.  It is approximately ten times more common in women than in men and is often diagnosed during the childbearing years.  SLE is known to increase the risk of spontaneous miscarriage; it can also cause fetal growth restriction and increased rates of sudden intrauterine death, pre-eclampsia and preterm delivery.  Management of women with lupus nephritis can be difficult, as the disease may mimic and overlap significantly with pre-eclampsia.  Multidisciplinary management of pregnant women with SLE ensures optimal surveillance of both mother and fetus. Learning objectives  To understand how to manage pregnant women with SLE.  To understand the importance of pre-pregnancy counselling for women with SLE.  To understand the features and associated risk factors which increase the chance of adverse pregnancy outcome in women with SLE.  To understand which therapies for SLE can be used safely in pregnancy and while breastfeeding.  To understand the role of the multidisciplinary team in the care of women with SLE, particularly those with underlying organ impairment. Ethical issues  When should women with SLE be advised against pregnancy?  At what point should termination of pregnancy be considered if there is deterioration in maternal health in early pregnancy? Keywords antiphospholipid syndrome / drug therapy / fetal growth restriction / perinatal complications / pre-conception counselling / pre-eclampsia / thromboembolism Please cite this paper as: Cauldwell M, Nelson-Piercy C. Maternal and fetal complications of systemic lupus erythematosus. The Obstetrician & Gynaecologist 2012;14:167–174. Introduction Systemic lupus erythematosus (SLE) is an idiopathic autoimmune condition which has multi-organ involvement. Diagnosis is based on both clinical manifestations and laboratory indices. The disease course can be sporadic and unpredictable but is typically characterised by periods of relapse and remission. This article discusses both the maternal and fetal complications of SLE and management of the disease during pregnancy. Incidence The literature quotes variable rates of SLE, which may be due to improvements in diagnostic testing. 1 The American Rheumatism Association first devised a framework for SLE in 1971; this has had several subsequent revisions and the most recent is outlined in Box 1. 2 The disease affects women and men in a ratio of 10:1. In the UK, population-based studies have shown that the disease tends to affect Afro-Caribbean people most frequently, followed by Asian people. 3 The mean age of diagnosis also varies in the literature, but most women seem to be diagnosed during the childbearing years. 1 The prevalence of SLE in women of childbearing years is around 1 in 500. Pathophysiology The exact cause of SLE remains unknown, but it has been proposed that an environmental trigger such as ultraviolet light or a viral infection; for example, the Epstein–Barr virus, 4 combined with a genetic predisposition, forms the basis of the disease process. 5 There is a 25% concordance for SLE among monozygotic twins. 5 The disease is characterised by immune complex deposition which causes inflammation in vascular beds. There is polyclonal B-cell activation which is thought to result in antinuclear antibody production. There is also an associated impairment of T-cell regulation and deficiencies in complement which leads to a failure to remove these immune complexes. ª 2012 Royal College of Obstetricians and Gynaecologists 167 DOI: 10.1111/j.1744-4667.2012.00113.x The Obstetrician & Gynaecologist http://onlinetog.org 2012;14:167–174 Review