Lupus erythematosus and its complications in pregnancy
Description
Systemic lupus erythematosus (Les) is a multisystemic, chronic pathology that is identified by the aberrant autoimmune response to autoantigens with damage to any tissue or organ, which usually affects women of reproduction age and is characterized by periods of reactivation and remission with a percentage of 7-33% similar to that of non-pregnant patients. Being a disease that affects women in a fertile state, pregnancy can be considered at high risk, since, during the state of gestation, great hormonal changes are generated and the increase in free steroid hormones even progesterone, glucocorticoids and estrogens are generated, which cause changes to immunocompetent cells, such as monocytes, T lymphocytes and B lymphocytes; As a consequence of this, the clinical manifestations of autoimmune pathologies that are modified according to their pathophysiology, so that some improve, others have no changes and others suffer a wake during pregnancy. The evolution of pregnancy can be threatened by the presence of autoantibodies and by damage to different organs, as mentioned above, which can cause systemic rheumatic diseases and, in addition, different degrees of vasculitis.
Complications
Lupus in pregnancy presents a series of complications among which are: prematurity, preeclampsia, delay in intrauterine growth, neonatal lupus and the one that represents the greatest risk is abortion. On the other hand, the woman in a state of gestation can present other types of risks to contract among them anemia, deep venous thrombosis, cerebral vascular accident and death, thrombocytopenia and pulmonary thromboembolism. In the case of women who have had a history of renal diseases, they can increase the risk of preeclampsia, this can be noticed by inflammation of hands, weight gain, stomach pain and blurred vision.
There are several immunological and clinical findings that can verify if pregnancy is high risk, although it is estimated that not all patients have the same risk; However, women who have had a history of pulmonary hypertension, renal damage, poor obstetric., 2018).
Influential factors
The factors that influence the lupus of pregnant women can be: environmental, genetic, toxic factors and drug consumption.
Preconceptive and prenatal period
It is important that women use family planning as a prevention measure before becoming pregnant, attending at least 6 months before the doctor to avoid future complications in the fetus, even to start some type of treatment for the control of pathology.
Women in a state of gestation should acquire monthly prenatal control until week 28, both with a gynecologist specializing in maternal-feetal medicine and with a rheumatologist with the aim of avoiding possible fetal and/or maternal complications (hair et al., 2014).
Treatment
A pregnancy with Lupus requires continuous monitoring, made by a multidisciplinary group, including an obstetrician, specialized at high risk. It is extremely important that he remains as inactive as possible for the well -being of the fetus, there are 3 primary points in the treatment which are:
- Monitor fetal development and growth
- Maintain inactive disease
- Interruption of pregnancy in the case of detecting fetal distress
As for drugs, pregnant women must have a good advice since consumption in high doses of certain medications can cause poor formation of the fetus, therefore, pharmacological treatment must be based on two fundamental pillars:
- Antipalúdico (hydroxychloroquine), this is recommended only in the case of relapses, it is used mainly for joint symptoms.
- Corticosteroids, should consume in low doses in the case of minor manifestations and high doses in the case of serious manifestations such as: nephritis, vasculitis.
Immune reaction
He is characterized by a humoral response mediated by th2 cytokines in addition to IL-10 which are protagonists in the pathogenesis of lupus and the exacerbations of the disease. Another cytokines that participate in an immune response is the IL-6 which contributes to the cell differentiation of TH0 to TH2, thus increasing cytocin levels during active disease (López et al. 2018). During pregnancy major hormonal changes occur such as the increase in free steroid hormones including glucocorticoids, progesterones and estrogen that cause changes in immunocompetent cells such as B lymphocytes, T lymphocytes and monocytes, as a consequence of clinical manifestations, therefore patients patients With lupus they have diminished concentrations of estradiol, cortisol, dehydroepiandrosterone and progesterone, this decrease, accompanied by increase in the levels of IL-10, is a sign that the disease worsens during the pregnancy period. Autoimmune diseases are modified according to their pathophysiology in such a way that some improve, others remain unchanged and others worsen during pregnancy.
By increasing Lupus activity before conception or at the beginning of pregnancy, maternal complications increase. Approximately 50% of women with some degree of lupus activity during pregnancy. The risk of an outbreak or exacerbation of moderate or severe lupus activity is around 15 to 30%, in women who have had lupus activity in the six months prior to pregnancy. For this reason it is recommended not to get pregnant until it remains without loup activity for six months (Torres and Hernández 2013).
Regulatory T cells (CD4+ CD25+ FOXP3+), suppress the immune response, preventing autoimmune disease and maintains maternal-feetal tolerance, there are also predictors of the evolution of the disease during pregnancy which are the high clinical activity and high levels of serum complement, in the same way the double-chain anti-DNA antibodies. Risk factors are when there is the presence of proteinuria, antiphospholipid antibodies (SAF), thrombocytopenia or hypertension at the beginning of pregnancy. SAFs are associated with recurring loss of pregnancies due. 2018).
Diagnosis
To diagnose this chronic autoimmune disease it is usually complicated, since, it affects different organs of the patient, for this, a specific physical and analytical examination is required. The symptoms for the suspicion of Lupus can be confused with other diseases, although in a review from 1996 to 2003 it was established that the combination of symptoms and signs can give the result of lupus, which are joint, cutaneous, hematological and serological affectation , presenting greater affectation to the central nervous system and the renal level.
As established by American Collegue of Rheumatology, (2019) The diagnostic criteria are the Malar erythema, the discoid lupus, photosensitivity, oral and nasopharyngeal ulcers, non -erosive arthritis, proteinuria> 0.5gr/24 h or cellular cylinders , seizures or psychosis, hemolytic anemia, leukopenia < 4 000 µL, la linfopenia < 1 500 µL o la trombocitopenia < 100 000 µL, al igual puede aparecer las alteraciones inmunológicas de las células LE, anti DNA nativo, anti-Sm, anticuerpos anti- nucleares y VDRL falso positivo.
In general symptoms you can see high fever, weight loss or asthenia, arthritis with a frequency of 68% up to 90% throughout the disease, mucocutaneous symptoms such as malar erythema and nose are also very frequent, on the nose, Related to photosensitive and oral ulcers, another of the symptoms is the phenomenon of Raynaud, a condition of the blood vessels that are often detected in the fingers of the hands and feet, in the kidneys it has a percentage of 30 to 70 % that are It can present a disease in the first years of evolution until reaching a terminal renal disease, it also produces a neuropsychiatric condition due to the affectation of the central nervous system, such as headache, depression, a cerebrovascular disease, frequently a thromboembolia (Prieto, 2015).
For a better Lupus diagnosis, a blood clinical laboratory analysis should be performed, which is reflected in a decrease in the three cell lines, known as pancithopenia, however, if you have negative antinuclear antibodies Ana with IFI method With HEP-2 cells it can be said that the patient does not have lupus, in the case of giving as a positive result it can be said that it is a lupus erythematosus, even more specific with the detection of antiphospholipid antibodies, specifically of IgG anticardiolipid antibodies,
lupic and antibetal anticoagulant2glycoproteic I, which frequently causes deep vein thrombosis in lower extremities which in pregnancies produce abortions, fetal death or pre -rates. Elisa’s methods are less sensitive than IFI, but they are easier to perform and lower cost, detecting ADNDC antigen, for the diagnosis of lupus (Almaraz et al., 2017).
In patients suffering from systemic lupus erythematosus the prognosis for the mother and the fetus can be adverse due to 3 conditions that are frequently presented:
- The percentage of abortion risk; The prevalence of abortion can be up to 40 %, essentially in those that have antiphospholipid antibodies22.
- Greater danger of late fetal death and premature birth, this occurs due to HTA, proteinuria and deterioration of renal function, which would indicate reaction of the les or a preeclampsia.
- The neonata lupus erythematosus is due to the transfer of IgG of the mother to the fetus, it consists of a transitory rash of the newborn, permanent complete cardiac block or blood alterations.
The fetus should be performed to rule out or confirm that it has them, the signs and symptoms that it presents is the propagation throughout the skin, not always these spots A seem only in the face, sometimes the fetus does not present symptoms until after days or weeks of birth, or when exposed to the sun, in the same way it disappears at 4 or 6 months since at this time the mother’s immunoglobulin is eliminated, and its own antibodies are developing (Sabat A et al., 2016).
Bibliography
- American Collegue of Rheumatology. (2019). CIE INFORMATIVE SHEET. March, 1.
- Hair, a., Catro, i., & Sabat, S. (2014). Original pregnant works with systemic lupus erythematosus at the Regional Clinical Hospital of Concepción, Chile. 79 (1), 21–26.
- López, d., Haro, s., & Barragán, I. (2018). Systemic lupus erythematosus in pregnancy. 4, 331–338. https: // doi.org/10.1136/ANNRHEUMDIS-2016-209770.332
- Prieto, m. (2015). Clinical practice guide on systemic lupus erythematosus. January 2015. http: // portal.Guiasalud.is/GPC/GPC_549_lupus_Sescs_comPL.PDF
- Rodríguez Almaraz, M. AND., Rabadán Rubio, and., & Lozano, F. (2017). Systemic lupus erythematosus management protocol in pregnancy. Medicine (Spain), 12 (25), 1474–1477. https: // doi.org/10.1016/J.med.2017.01.007
- Sabat A, S., Vinet M, M., Sanhueza F, C., Galdames G, A., Castro E, I., & Caballero e, to. (2016). Pregnant with systemic lupus erythematosus at the Regional Clinical Hospital of Concepción, Chile. Chilean Obstetrics and Gynecology Magazine, 79 (1), 21–26. https: // doi.org/10.4067/S0717-75262014000100004
- Torres, a., & Hernández, V. (2013). Immune and pregnancy system: general characteristics in healthy women and in patients with rheumatic diseases. Rheumatology, 76–82.
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