One very important complication of systemic lupus erythematosus (SLE) is infertility problem. Some patients may have children; others may have difficulty to sustain the pregnancy. In fact, some patients only come for medical attention due to recurrent abortion. The abortion usually occurs at first trimester. However, there is also possibility of intrauterine death (IUD).
In terms of in vitro fertilization (IVF) in SLE patients, although ovulation induction (OI) and IVF can be successful in SLE and primary antiphospholipid syndrome (APS) patients, rates of fetal and maternal complications are high (1). However, it found that ovarian stimulation for ovulation induction and IVF seems to be safe and successful in well-selected women with SLE and antiphospholipid syndrome.
There are some highlighted situations where assisted reproductive technology (ART) should be discouraging (2). The situations include SLE in acute flares, badly controlled arterial hypertension and pulmonary hypertension. Others situations are advanced renal disease, severe valvulopathy or heart disease, and major previous thrombotic events. However, most flares are manageable and we should not deny the treatment option for selected patients (3).
If safety approach is taken during the IVF, it will ensure better outcome of IVF among SLE patients (2).The safest approaches include friendly ovarian stimulation, single embryo transfer and avoidance of ovarian hyperstimulation syndrome (OHSS). Other approaches include administration of coadjuvant therapy and use of natural estrogen or progesterone through a non oral route (3).
The conclusion is we should not deny assisted reproductive technology among this group of patients. IVF is worth to be considered in selected patients and safe measures should be taken during the procedure. However, for those who are not suitable for ART, adoption should come next to their mind.
Other related articles:
Reference:
- Guballa N, Sammaritano L, Schwartzman S, Buyon J, Lockshin MD. Ovulation induction and in vitro fertilization in systemic lupus erythematosus and antiphospholipid syndrome Arthritis & Rheumatism. 1999; 43(3): 550-556.
- Bellver J. Ovarian stimulation for ovulation induction and in vitro fertilization in patients with systemic lupus erythematosus and antiphospholipid syndrome. 2009 Jul 24
- Handa R, Kumar U, Wali JP, Systemic Lupus Erythematosus and Pregnancy.Supplement to JAPI. 2006 June; 54:19-21.
Having your own baby is so special. Every parent will agree with me that pregnancy is never easy. Bringing up one child is difficult. Bringing up twin is often very very difficult. Bringing up triplets is more difficult than anyone can ever imagine. Let’s not start with quadruplet… As interesting as it may sound, let’s have more knowledge about it so you can decide for yourself which one is the best decision when the time comes. If the time still not coming and you really want to get pregnant, don’t worry, if there is a will, there is a way, but we are not discussing it here. I’ll write another article for that.
Multiple pregnancy is a pregnancy where more than one fetus develops at the same time in the womb. The incidence of multiple births in the United States and other developed countries has been steadily increasing with advances in reproductive technologies. The frequency of multiple births in the United States for 2002 was as follows:
- twins, one in 32
- triplets, one in 583
- quadruplets, one in 9,267
- quintuplets and up, one in 58,286
Predisposing factors:
- Previous history of twin pregnancy
- Family history of twins (dizygotic only) – Twinning seems to run in some families, is mainly confined to fraternal (dizygotic twins) and seems to be entirely a property of the mother, not the father. The primary cause is an increased chance of multiple ovulation (a woman releases two or more eggs).
- Increasing maternal age – some researchers have found that women >30 years of age have more chance to have multiple pregnancy.
- High parity – have more previous pregnancy
- Induced ovulation (usually due to treatment that we give to infertility patients – i.e.: clomiphene citrate or Follicle Stimulating Hormone)
- In vitro fertilization and other type of advance reproductive technologies
- Race origin – American and African women have more chance to have multiple fetuses in comparison to other races.
Diagnose:
- Clinical examination – uterus is large for gestational age
- Ultrasound – the main diagnostic test. Nowadays, there are 3-D and 4-D ultrasounds that can see the fetus better. An ultrasound is usually performed early following positive pregnancy test to look for successful implantation and to make sure that it is intra uterine, the multiple gestation would be revealed at that time. Following the birth of multiples, the placenta is carefully examined to determine if they are fraternal or identical. One placenta indicates identical twins.
- Selective fetocide (e.g.: with intracardiac potassium chloride) – can be used if indicated (best used before 20 weeks gestation)
- serial ultrasounds to monitor the growth of the babies
- amniocentesis may be indicated to check for lung development
- close monitoring is needed for preterm labor
Complications during pregnancy:
- Polyhydramnios (too much amniotic fluid – Amniotic Fluid Index or AFI > 25)
- Pre ecclampsia ( a condition with proteinuria and hypertension) is more common (30% in twin pregnancies, 10% in singletons)
- Anemia (the problem is more common because in multiple pregnancy, iron and folate requirements are increased)
- Antepartum hemorrhage (6% for twins versus 4.7% for singletons) – this is due to placental abruption and placental praevia (in multiple pregnancy, the placenta is larger)
- Multiple pregnancy usually lead to caesarean delivery and the particular pregnant mothers may have complications of surgery as well
- incompetent cervix (cervix opens due to pressure) – this may lead to preterm labor or spontaneous abortion
- preterm labor also more common due to overstretched uterus
- premature rupture of membranes (bag of water) – which also can give rise to many problem like premature labor, chorioamnionitis (inflammation of the placenta) , cross infection to the fetus and may also lead to intrauterine death
Fetal complications:
- Increase increased rate of spontaneous abortion and perinatal mortality
- Prematurity – this is the main problem they might encounter
- Small babies (small for gestational age) – growth rate is equal with singletons up to 24 weeks but become slower there-after)
- intrauterine growth restriction of one or more fetuses
- abnormal fetal presentations which may cause problem during delivery
- Malformations (including conjoined twin) are more common (2-4 times higher rate – especially in monozygotic twins)
- In monozygotic twins, the intermingling blood supply may result in different twin size. One of the might be anemic and the other might be plethoric ( hence later become jaundice baby)
- If one of the fetus die in utero (in uterus), it may become a fetus papyraceous. Later, it will be aborted or delivered prematurely
- rare complications with twins, such as twin-to-twin-transfusion syndrome (one fetus receives more nutrients than the other due to more blood vessels perfusing one baby)
Complications of labor:
- Post partum hemorrhage – excessive per vaginal bleeding followed delivery
- Malpresentation (40% is cephalic/cephalic; 40% is cephalic/breech; 10% is breech/breech; 5% is cephalic/transverse; 4% is breech/transverse; 1% is transverse/transverse)
- Rupture vasa praevia
- Increased incidence of cord prolapse (0.6% singleton, 2.3% twins)
Conclusions
So, you can see that there are so many complications of multiple pregnancy. It can involve either the mother or the fetus (baby), or maybe both. The complications might happen during pregnancy, during delivery or even many years after delivery. Let’s not forget the psychological aspects of both parents and relatives. As fun as it might be, the price is very high. Anything can go wrong, anytime, anywhere. Think wisely and make the best decision for both of you.
Reference:
- Oxford Handbook of Clinical Specialties. 5th edition. 2001.
- http://www.pregnancy.ayurvediccure.com/multiple-pregnancy.html
- http://www.answers.com/topic/multiple-pregnancy
- http://www.healthofchildren.com/M/Multiple-Pregnancy.html
