Skip to main content
SpringerLink
Log in

Risk factors of systemic lupus erythematosus flares during pregnancy

  • FRONTIERS IN AUTOIMMUNITY
  • Published:
Immunologic Research Aims and scope Submit manuscript

Abstract

This review examines the risk factors for the development of systemic lupus erythematosus (SLE) flares during pregnancy. In preconception, anti-DNA, hypocomplementemia, previous thrombosis, triple antiphospholipid (aPL) antibody positivity, active lupus nephritis and discontinuation of medications such as hydroxychloroquine and azathioprine are factors associated with pregnancy failure. During pregnancy, SLE flares are associated with aPL antibodies, synergic changes of pregnancy on Th1 and TH2 cytokines, other cytokines and chemokines that interact with hormones such as estrogen and prolactin that amplify the inflammatory effect. From the clinical point of view, SLE activity at pregnancy onset, thrombocytopenia, lupus nephritis, arterial hypertension, aPL syndromes, preeclampsia is associated with lupus flares and fetal complications. In puerperium, the risk factors of flares are similar to pregnancy. Hyperactivity of immune system, autoantibodies, hyperprolactinemia, active lupus nephritis, decrease in TH2 cytokines with increase in TH1 cytokines probably participate in SLE flare. The SLE flares during pregnancy make the difference between an uncomplicated pregnancy and pregnancy with maternal and fetal complications. Therefore, the knowledge of risk factors leads the best treatment strategies to reduce flares and fetal complications in SLE patients.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  1. Lateef A, Petri M. Managing lupus patients during pregnancy. Best Pract Res Clin Rheumatol. 2013;27:435–47.

    Article  PubMed  Google Scholar 

  2. Jara LJ, Medina G, Navarro C, Saavedra MA, Blanco-Favela F, Espinoza LR. Pregnancy, hormones, and autoimmune rheumatic diseases. In: Walker S, Jara LJ, editors. Endocrine manifestations of systemic autoimmune diseases. Amsterdam: Elsevier; 2008. p. 185–98.

    Chapter  Google Scholar 

  3. Peart E, Clowse ME. Systemic lupus erythematosus and pregnancy outcomes: an update and review of the literature. Curr Opin Rheumatol. 2014;26:118–23.

    Article  CAS  PubMed  Google Scholar 

  4. Warren JB, Silver RM. Autoimmune disease in pregnancy: systemic lupus erythematosus and antiphospholipid syndrome. Obstet Gynecol Clin North Am. 2004;31:345–72.

    Article  PubMed  Google Scholar 

  5. Clowse ME. Lupus activity in pregnancy. Rheum Dis Clin North Am. 2007;33:237–52.

    Article  PubMed Central  PubMed  Google Scholar 

  6. Saavedra MA, Cruz-Reyes C, Vera-Lastra O, Romero GT, Cruz-Cruz P, Arias-Flores R, et al. Impact of previous lupus nephritis on maternal and fetal outcomes during pregnancy. Clin Rheumatol. 2012;31:813–9.

    Article  PubMed  Google Scholar 

  7. Lockshin MD, Kim M, Laskin CA, Guerra M, Branch DW, Merrill J, et al. Prediction of adverse pregnancy outcome by the presence of lupus anticoagulant, but not anticardiolipin antibody, in patients with antiphospholipid antibodies. Arthritis Rheum. 2012;64:2311–8.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  8. Clowse ME, Wallace DJ, Weisman M, James A, Criscione-Schreiber LG, Pisetsky DS. Predictors of preterm birth in patients with mild systemic lupus erythematosus. Ann Rheum Dis. 2013;72:1536–9.

    Article  PubMed  Google Scholar 

  9. Zen M, Ghirardello A, Iaccarino L, Tonon M, Campana C, Arienti S, et al. Hormones, immune response, and pregnancy in healthy women and SLE patients. Swiss Med Wkly. 2010;140:187–201.

    CAS  PubMed  Google Scholar 

  10. Clowse ME, Magder LS, Petri M. The clinical utility of measuring complement and anti-dsDNA antibodies during pregnancy in patients with systemic lupus erythematosus. J Rheumatol. 2011;38:1012–6.

    Article  CAS  PubMed  Google Scholar 

  11. Minamiguchi S, Mikami Y, Nakajima N, Salah A, Kondoh E, Tatsumi K, et al. Complement split product C4d deposition in placenta in systemic lupus erythematosus and pregnancy-induced hypertension. Pathol Int. 2013;63:150–7.

    Article  CAS  PubMed  Google Scholar 

  12. Kobayashi N, Yamada H, Kishida T, Kato EH, Ebina Y, Sakuragi N, et al. Hypocomplementemia correlates with intrauterine growth retardation in systemic lupus erythematosus. Am J Reprod Immunol. 1999;42:153–9.

    Article  CAS  PubMed  Google Scholar 

  13. Buyon JP. Updates of lupus and pregnancy. Bull NYU Hosp Jt Dis. 2009;67:271–5.

    PubMed Central  PubMed  Google Scholar 

  14. Doria A, Ghirardello A, Iaccarino L, Zampieri S, Punzi L, Tarricone E, et al. Pregnancy, cytokines, and disease activity in systemic lupus erythematosus. Arthritis Rheum. 2004;51:989–95.

    Article  CAS  PubMed  Google Scholar 

  15. Iaccarino L, Ghirardello A, Zen M, Villalta D, Tincani A, Punzi L, et al. Polarization of TH2 response is decreased during pregnancy in systemic lupus erythematosus. Reumatismo. 2012;64:314–20.

    Article  CAS  PubMed  Google Scholar 

  16. Muñoz-Valle JF, Vázquez-Del Mercado M, García-Iglesias T, Orozco-Barocio G, Bernard-Medina G, Martínez-Bonilla G, et al. T(H)1/T(H)2 cytokine profile, metalloprotease-9 activity and hormonal status in pregnant rheumatoid arthritis and systemic lupus erythematosus patients. Clin Exp Immunol. 2003;131:377–84.

    Article  PubMed Central  PubMed  Google Scholar 

  17. Björkander S, Bremme K, Persson JO, van Vollenhoven RF, Sverremark-Ekström E, Holmlund U. Pregnancy-associated inflammatory markers are elevated in pregnant women with systemic lupus erythematosus. Cytokine. 2012;59:392–9.

    Article  PubMed  Google Scholar 

  18. Kuchroo VK, Meyers JH, Umetsu DT, DeKruyff RH. TIM family of genes in immunity and tolerance. Adv Immunol. 2006;91:227–49.

    Article  CAS  PubMed  Google Scholar 

  19. Zhoa J, Lei Z, Liu Y, Li B, Zhang L, Fang H, et al. Human pregnancy up-regulates Tim-3 in innate immune cells for systemic immunity. J Immunol. 2009;182:6618–24.

    Article  Google Scholar 

  20. Zenclussen AC, Kokeny G, Thimm O, Sollwedel A, Godo M, Casalis PA, et al. Mechanisms behind flare of renal lupus during murine pregnancy. Reprod Biomed Online. 2008;17:114–26.

    Article  CAS  PubMed  Google Scholar 

  21. Andersen T, Munthe-Fog L, Garred P, Jacobsen S. Serum levels of ficolin-3 (Hakata antigen) in patients with systemic lupus erythematosus. J Rheumatol. 2009;36:757–9.

    Article  CAS  PubMed  Google Scholar 

  22. Halmos A, Rigó J. Jr, J Szijártó, G Füst, Z Prohászka, A Molvarec. Circulating ficolin-2 and ficolin-3 in normal pregnancy and pre-eclampsia. Clin Exp Immunol. 2012;169:49–56.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  23. Cohen-Solal JF, Jeganathan V, Hill L, Kawabata D, Rodriguez-Pinto D, Grimaldi C, et al. Hormonal regulation of B-cell function and systemic lupus erythematosus. Lupus. 2008;17:528–32.

    Article  CAS  PubMed  Google Scholar 

  24. Grimaldi CM, Michael DJ, Diamond B. Cutting edge: expansion and activation of a population of autoreactive marginal zone B cells in a model of estrogen-induced lupus. J Immunol. 2001;167:1886–90.

    Article  CAS  PubMed  Google Scholar 

  25. Thompson CB. Apoptosis in the pathogenesis and treatment of disease. Science. 1995;267:1456–62.

    Article  CAS  PubMed  Google Scholar 

  26. Walker SE. Estrogen and autoimmune disease. Clin Rev Allergy Immunol. 2011;40:60–5.

    Article  CAS  PubMed  Google Scholar 

  27. Doria A, Iaccarino L, Sarzi-Puttini P, Ghirardello A, Zampieri S, Arienti S, et al. Estrogens in pregnancy and systemic lupus erythematosus. Ann N Y Acad Sci. 2006;1069:247–56.

    Article  CAS  PubMed  Google Scholar 

  28. Petri M. Prospective study of systemic lupus erythematosus pregnancies. Lupus. 2004;13:688–9.

    Article  CAS  PubMed  Google Scholar 

  29. Doria A, Tincani A, Lockshin M. Challenges of lupus pregnancies. Rheumatology (Oxford). 2008;47(Suppl 3):iii9–12.

    Google Scholar 

  30. Tincani A, Faden D, Biasini-Rebaioli C. Pregnancy in SLE (2): it is possible to predict gestational outcome? Arthritis Rheum. 2002;812:S322.

    Google Scholar 

  31. Jara-Quezada L, Graef A, Lavalle C. Prolactin and gonadal hormones during pregnancy in systemic lupus erythematosus. J Rheumatol. 1991;18:349–53.

    CAS  PubMed  Google Scholar 

  32. Costenbader K, Feskanich D, Stampfer M, Karlson E. Reproductive and menopausal factors and risk of systemic lupus erythematosus in women. Arthritis Rheum. 2007;56:1251–62.

    Article  PubMed  Google Scholar 

  33. Hughes GC. Progesterone and autoimmune disease. Autoimmun Rev. 2012;11:A502–14.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  34. Medeiros PB, Febrônio MV, Bonfá E, Borba EF, Takiuti AD, Silva CA. Menstrual and hormonal alterations in juvenile systemic lupus erythematosus. Lupus. 2009;18:38–43.

    Article  CAS  PubMed  Google Scholar 

  35. Doria A, Cutolo M, Ghirardello A, Zampieri S, Vescovi F, Sulli A, et al. Steroid hormones and disease activity during pregnancy in systemic lupus erythematosus. Arthritis Rheum. 2002;47:202–9.

    Article  CAS  PubMed  Google Scholar 

  36. Ragusa A, de Carolis C, dal Lago A, Miriello D, Ruggiero G, Brucato A, et al. Progesterone supplement in pregnancy: an immunologic therapy? Lupus. 2004;13:639–42.

    Article  CAS  PubMed  Google Scholar 

  37. Ostensen M. Sex hormones and pregnancy in rheumatoid arthritis and systemic lupus erythematosus. Ann N Y Acad Sci. 1999;876:131–43.

    Article  CAS  PubMed  Google Scholar 

  38. Walker SE, Jacobson JD. Roles of prolactin and gonadotropin-releasing hormone in rheumatic diseases. Rheum Dis Clin North Am. 2000;26:713–36.

    Article  CAS  PubMed  Google Scholar 

  39. Vera-Lastra O, Mendez C, Jara LJ, Cisneros M, Medina G, Ariza R, et al. Correlation of prolactin serum concentrations with clinical activity and remission in patients with systemic lupus erythematosus. Effect of conventional treatment. J Rheumatol. 2003;30:2140–6.

    CAS  PubMed  Google Scholar 

  40. Jara LJ, Vera-Lastra O, Miranda JM, Alcala M, Alvarez-Nemegyei J. Prolactin in human systemic lupus erythematosus. Lupus. 2001;10:748–56.

    Article  CAS  PubMed  Google Scholar 

  41. Jara LJ, Pacheco-Reyes H, Medina G, Angeles U, Cruz-Cruz P, Saavedra MA. Prolactin levels are associated with lupus activity, lupus anticoagulant, and poor outcome in pregnancy. Ann N Y Acad Sci. 2007;1108:218–26.

    Article  CAS  PubMed  Google Scholar 

  42. Jara LJ, Cruz-Cruz P, Saavedra MA, Medina G, García-Flores A, Angeles U, et al. Bromocriptine during pregnancy in systemic lupus erythematosus: a pilot clinical trial. Ann N Y Acad Sci. 2007;1110:297–304.

    Article  CAS  PubMed  Google Scholar 

  43. Yang XY, Liang LQ, Xu HS, MS He, Yao SZ, Zhan ZP, et al. Efficacy of oral bromocriptine in protecting the postpartum systemic lupus erythematosus patients from disease relapse. Zhonghua Nei Ke Za Zhi. 2003;42:621–4.

    PubMed  Google Scholar 

  44. Leaños-Miranda A, Cárdenas-Mondragón G, Ulloa-Aguirre A, Isordia-Salas I, Parra A, Ramírez-Peredo J. Anti-prolactin autoantibodies in pregnant women with systemic lupus erythematosus: maternal and fetal outcome. Lupus. 2007;16:342–9.

    Article  PubMed  Google Scholar 

  45. Iozza I, Cianci S, Di Natale A, Garofalo G, Giacobbe AM, Giorgio E, et al. Update on systemic lupus erythematosus pregnancy. J Prenat Med. 2010;4:67–73.

    PubMed Central  PubMed  Google Scholar 

  46. Alvarez-Nemegyei J, Domínguez-Vallejo S, Saavedra-Déciga ME, Marín-Ordóñez J, Avila-Zapata F, Diego-Rodríguez N, et al. Relapsing risk and obstetric-neonatal outcome in pregnancy and systemic lupus erythematosus. Rev Med Inst Mex Seguro Soc. 2012;50:355–61.

    PubMed  Google Scholar 

  47. Clark CA, Spitzer KA, Nadler JN, Laskin CA. Preterm deliveries in women with systemic lupus erythematosus. J Rheumatol. 2003;30:2127–32.

    PubMed  Google Scholar 

  48. Chakravarty EF, Colón I, Langen ES, Nix DA, El-Sayed YY, Genovese MC, et al. Factors that predict prematurity and preeclampsia in pregnancies that are complicated by systemic lupus erythematosus. Am J Obstet Gynecol. 2005;192:1897–904.

    Article  PubMed  Google Scholar 

  49. Clowse ME, Magder LS, Witter F, Petri M. The impact of increased lupus activity on obstetric outcomes. Arthritis Rheum. 2005;52:514–21.

    Article  PubMed  Google Scholar 

  50. Cortés-Hernández J, Ordi-Ros J, Paredes F, Casellas M, Castillo F, Vilardell-Tarres M. Clinical predictors of fetal and maternal outcome in systemic lupus erythematosus: a prospective study of 103 pregnancies. Rheumatology (Oxford). 2002;41:643–50.

    Article  Google Scholar 

  51. Clowse ME, Magder L, Witter F, Petri M. Hydroxychloroquine in lupus pregnancy. Arthritis Rheum. 2006;54:3640–7.

    Article  PubMed  Google Scholar 

  52. Gladman DD, Tandon A, Ibañez D, Urowitz MB. The effect of lupus nephritis on pregnancy outcome and fetal and maternal complications. J Rheumatol. 2010;37:754–8.

    Article  PubMed  Google Scholar 

  53. Moroni G, Quaglini S, Banfi G, Caloni M, Finazzi S, Ambroso G, et al. Pregnancy in lupus nephritis. Am J Kidney Dis. 2002;40:713–20.

    Article  PubMed  Google Scholar 

  54. Tandon A, Ibanez D, Gladman DD, Urowitz MB. The effect of pregnancy on lupus nephritis. Arthritis Rheum. 2004;50:3941–6.

    Article  PubMed  Google Scholar 

  55. Imbasciati E, Tincani A, Gregorini G, Doria A, Moroni G, Cabiddu G, et al. Pregnancy in women with pre-existing lupus nephritis: predictors of fetal and maternal outcome. Nephrol Dial Transplant. 2009;24:519–25.

    Article  PubMed  Google Scholar 

  56. Saavedra M, Sánchez A, Morales S, Navarro-Zarza J, Angeles U, Jara L. Primigravida is associated with flare in women with systemic lupus erythematosus. Lupus. 2014. doi:10.1177/0961203314552116.

  57. Wallenius M, Salvesen KA, Daltveit AK, Skomsvoll JF. SLE and outcomes in first and subsequent births based on data from a national birth registry. Arthritis Care Res (Hoboken). 2014. doi:10.1002/acr.22373.

  58. Smyth A, Oliveira GH, Lahr BD, Bailey KR, Norby SM, Garovic VD. A systematic review and meta-analysis of pregnancy outcomes in patients with systemic lupus erythematosus and lupus nephritis. Clin J Am Soc Nephrol. 2010;5:2060–8.

    Article  PubMed Central  PubMed  Google Scholar 

  59. Ruffatti A, Salvan E, Del Ross T, Gerosa M, Andreoli L, Maina A, et al. Treatment strategies and pregnancy outcomes in antiphospholipid syndrome patients with thrombosis and triple antiphospholipid positivity. A European multicentre retrospective study. Thromb Haemost. 2014;112:727–35.

    Article  PubMed  Google Scholar 

  60. Stagnaro-Green A, Akhter E, Yim C, Davies TF, Magder L, Petri M. Thyroid disease in pregnant women with systemic lupus erythematosus: increased preterm delivery. Lupus. 2011;20:690–9.

    Article  CAS  PubMed  Google Scholar 

  61. Ritchie J, Smyth A, Tower C, Helbert M, Venning M, Garovic V. Maternal deaths in women with lupus nephritis: a review of published evidence. Lupus. 2012;21:534–41.

    Article  CAS  PubMed  Google Scholar 

  62. Salmon JE, Heuser C, Triebwasser M, Liszewski MK, Kavanagh D, Roumenina L, et al. Mutations in complement regulatory proteins predispose to preeclampsia: a genetic analysis of the PROMISSE cohort. PLoS Med. 2011;8:e1001013.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  63. Stojan G, Baer AN. Flares of systemic lupus erythematosus during pregnancy and the puerperium: prevention, diagnosis and management. Expert Rev Clin Immunol. 2012;8:439–53.

    Article  CAS  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Direction of Education and Research, Hospital de Especialidades, Centro Médico La Raza, Instituto Mexicano del Seguro Social, Universidad Nacional Autónoma de México, Seris/Zaachila s/n, Colonia La Raza, 02990, Mexico City, Mexico

    Luis J. Jara

  2. Clinical Research Unit, Hospital de Especialidades, Centro Médico La Raza, Instituto Mexicano del Seguro Social, Universidad Nacional Autónoma de México, Mexico City, Mexico

    Gabriela Medina

  3. Division of Research, Hospital de Especialidades, Centro Médico La Raza, Instituto Mexicano del Seguro Social, Universidad Nacional Autónoma de México, Mexico City, Mexico

    Pilar Cruz-Dominguez

  4. Hospital de Especialidades, Centro Médico La Raza, Instituto Mexicano del Seguro Social, Universidad Nacional Autónoma de México, Mexico City, Mexico

    Carmen Navarro

  5. Internal Medicine Department, Hospital de Especialidades, Centro Médico La Raza, Instituto Mexicano del Seguro Social, Universidad Nacional Autónoma de México, Mexico City, Mexico

    Olga Vera-Lastra

  6. Rheumatology Department, Hospital de Especialidades, Centro Médico La Raza, Instituto Mexicano del Seguro Social, Universidad Nacional Autónoma de México, Mexico City, Mexico

    Miguel A. Saavedra

  7. Instituto Nacional de Enfermedades Respiratorias, Mexico City, Mexico

    Carmen Navarro

Authors
  1. Luis J. Jara
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Gabriela Medina
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Pilar Cruz-Dominguez
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Carmen Navarro
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Olga Vera-Lastra
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Miguel A. Saavedra
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Luis J. Jara.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Jara, L.J., Medina, G., Cruz-Dominguez, P. et al. Risk factors of systemic lupus erythematosus flares during pregnancy. Immunol Res 60, 184–192 (2014). https://doi.org/10.1007/s12026-014-8577-1

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s12026-014-8577-1

Keywords

Search

Navigation