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Mehta B, Jannat-Khah D, Glaser KK, Luo Y, Sammaritano LR, Branch DW, Goodman SM, Lockshin M, Wang F, Ibrahim S, Salmon JE. Fetal and maternal morbidity in pregnant patients with Lupus: a 10-year US nationwide analysis. RMD Open 2023; 9:e002752. [PMID: 37185223 PMCID: PMC10255159 DOI: 10.1136/rmdopen-2022-002752] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 12/12/2022] [Indexed: 05/17/2023] Open
Abstract
OBJECTIVE To evaluate and quantify the indicators of fetal and maternal morbidity in deliveries for patients with systemic lupus erythematosus (SLE) compared with deliveries in patients without SLE. METHODS We used retrospective data from the National Inpatient Sample (NIS) to identify all delivery related hospital admissions of patients with and without SLE from 2008 to 2017 using ICD-9/10 codes. Fetal morbidity indicators included pre-term delivery and intrauterine growth restriction (IUGR). 21 indicators of severe maternal morbidity were identified using standard Centers for Disease Control and Prevention (CDC) definitions. Descriptive statistics, including 95% confidence intervals, were calculated using sample weights from the NIS dataset. RESULTS Among the 40 million delivery-related admissions, 51 161 patients were reported to have SLE. Patients with SLE had a higher risk of fetal morbidity, including IUGR (8.0% vs 2.7%) and pre-term delivery (14.5% vs 7.3%), than patients without SLE. During delivery, mothers with SLE were nearly four times as likely to require a blood transfusion or develop a cerebrovascular disorder, and 15 times as likely to develop acute renal failure than those without SLE. CONCLUSION Our study demonstrates that fetal morbidity and severe maternal morbidity occur at a higher rate in patients with SLE compared with those without. This quantitative work can help inform and counsel patients with SLE during pregnancy and planning.
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Affiliation(s)
- Bella Mehta
- Hospital for Special Surgery, New York, New York, USA
- Weill Cornell Medicine, New York, New York, USA
| | - Deanna Jannat-Khah
- Hospital for Special Surgery, New York, New York, USA
- Weill Cornell Medicine, New York, New York, USA
| | | | - Yiming Luo
- Columbia University Irving Medical Center, New York, New York, USA
| | - Lisa R Sammaritano
- Hospital for Special Surgery, New York, New York, USA
- Weill Cornell Medicine, New York, New York, USA
| | - D Ware Branch
- University of Utah Health, Salt Lake City, Utah, USA
| | - Susan M Goodman
- Hospital for Special Surgery, New York, New York, USA
- Weill Cornell Medicine, New York, New York, USA
| | - Michael Lockshin
- Hospital for Special Surgery, New York, New York, USA
- Weill Cornell Medicine, New York, New York, USA
| | - Fei Wang
- Weill Cornell Medicine, New York, New York, USA
| | | | - Jane E Salmon
- Hospital for Special Surgery, New York, New York, USA
- Weill Cornell Medicine, New York, New York, USA
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Chandramouli S, Alvarez C, Englund TR, Silverstein RG, Sheikh SZ. Teratogenic medication use associated with favourable odds of contraception counselling in a cohort of women with systemic lupus erythematosus at a large tertiary academic medical centre. Lupus Sci Med 2022; 9:9/1/e000823. [PMID: 36418076 PMCID: PMC9685263 DOI: 10.1136/lupus-2022-000823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 10/31/2022] [Indexed: 11/24/2022]
Abstract
OBJECTIVE SLE primarily affects women of childbearing age, who have an increased risk of pregnancy complications, especially in the setting of active disease. Contraception counselling is particularly important given the teratogenicity of some medications used for SLE treatment. Our study describes the frequency of contraception counselling provided by multiple subspecialties to women with SLE and investigates associations between teratogenic medication use and receiving contraception counselling. METHODS This was a cross-sectional retrospective study of women (aged 15-46 years) diagnosed with SLE who were seen in various outpatient clinics at a large tertiary academic medical centre over a 2-year period. Demographic data were retrieved via the university-affiliated central data repository, and additional data, including documentation of contraception counselling, were obtained via manual chart abstraction. Univariable associations between variables and contraception counselling were assessed to produce unadjusted ORs and 95% CIs. Multivariable models were generated to evaluate independent associations between variables and contraception counselling. RESULTS Data from 478 women (52% African American, 25% Caucasian) with SLE were included. Rheumatology was the subspecialty to document contraception counselling most frequently (57%). Nearly 80% of women received counselling from at least one subspecialty, 44% from at least two. Factors associated with having lower odds of receiving contraception counselling were older age and Caucasian race. Women on teratogenic medications (methotrexate, mycophenolate mofetil/mycophenolic acid, cyclophosphamide) had higher odds of receiving contraception counselling from at least one subspecialty (OR 2.01; 95% CI 1.23 to 3.26), from two or more subspecialties (OR 2.18; 95% CI 1.50 to 3.17), and from rheumatology (OR 1.86; 95% CI 1.27 to 2.73). CONCLUSIONS In this study, women with SLE on teratogenic medications had higher odds of receiving contraception counselling from rheumatology and from at least two subspecialties. Multidisciplinary approaches to enhance contraception counselling should be encouraged.
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Affiliation(s)
- Shruti Chandramouli
- Department of Medicine, Division of Rheumatology, Allergy & Immunology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Carolina Alvarez
- Thurston Arthritis Research Center, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Tessa R Englund
- Thurston Arthritis Research Center, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - R Gina Silverstein
- Department of Obstetrics & Gynecology, The University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Saira Z Sheikh
- Department of Medicine, Division of Rheumatology, Allergy & Immunology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA,Thurston Arthritis Research Center, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
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Preparing for Pregnancy in Women with Systemic Lupus Erythematosus—A Multidisciplinary Approach. Medicina (B Aires) 2022; 58:medicina58101371. [DOI: 10.3390/medicina58101371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 09/22/2022] [Accepted: 09/23/2022] [Indexed: 11/17/2022] Open
Abstract
Pregnancy is one of the most challenging processes the human body is exposed to: the healthy mother can carry to term a genetically different new-born, while her immune system adapts to tolerate this new status and avoids rejection. In autoimmune disorders, motherhood is even more challenging, with additional medical counselling, mother care, and foetus development checks being necessary. While the aspects of supplementary mother care and pregnancy progress tracking are associated with well-established medical procedures and protocols, counselling, be it pre- or post-conception, is still underestimated and scarcely applied. Indeed, over the past decades, medical counselling for this particular population has changed significantly, but from a healthcare’s provider point of view, more is required to ensure a smooth, controllable pregnancy evolution. One of the most frequent autoimmune diseases affecting young females during their fertile years is Systemic Lupus Erythematosus (SLE). Like other heterogenous diseases, it exposes the mother to severe, organ-threatening complications and unpredictable evolution. Both the disease and its treatment can significantly affect the mother’s willingness to engage in a potentially risky pregnancy, as well as the likeliness to carry it to term without any impairments. A good collaboration between the patient’s rheumatologist and obstetrician is therefore mandatory in order to: (a) allow the mother to make an informed decision on pursuing with the pregnancy; (b) ensure a perfect synchronization between pregnancy terms and treatment; and (c) avoid or minimize potential complications. The best approach to achieve these outcomes is pregnancy planning. Moreover, knowing one desired prerequisite for a successful pregnancy evolution in SLE mothers is a stable, inactive, quiescent disease for at least six months prior to conception, planning becomes more than a recommended procedure. One particular aspect that requires attention before conception is the treatment scheme applied before delivery as autoantibodies can influence significantly the course of pregnancy. In this view, future SLE mothers should ideally benefit from preconception counselling within their agreed care pathway. A multidisciplinary team including at least the rheumatologist and obstetrician should be employed throughout the pregnancy, to decide on the appropriate timing of conception and compatible medication with respect to disease activity, as well as to monitor organ involvement and foetus development progress.
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Predictors Associated with Adverse Pregnancy Outcomes in a Cohort of Women with Systematic Lupus Erythematosus from Romania-An Observational Study (Stage 2). J Clin Med 2022; 11:jcm11071964. [PMID: 35407573 PMCID: PMC9000014 DOI: 10.3390/jcm11071964] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 03/16/2022] [Accepted: 03/30/2022] [Indexed: 12/16/2022] Open
Abstract
Background: Pregnancy in women with systemic lupus erythematosus (SLE) is accompanied by adverse pregnancy outcomes (APOs). We aimed to investigate the association between clinical, sonographic, and laboratory parameters and APOs (preeclampsia, intrauterine growth restriction, premature birth, and maternal mortality). Methods: This observational retrospective study included all pregnancies in women with SLE who attended two tertiary maternity hospitals from Romania between January 2013 and December 2020. Clinical, sonographic, and laboratory variables were examined. Bivariate associations of APO status and each predictor variable were evaluated, and significant predictors were further included in a classification model based on discriminant analysis. Results: Predictors of APOs included BMI > 25 kg/m2, personal history of lupus nephritis or chronic hypertension, proteinuria, low C3, SLE Disease Activity Index 2000 (SLEDAI-2k score ≥ 4 and physician’s global-assessment (PGA) score ≥ 1 throughout pregnancy, increased mean uterine arteries pulsatility index in the first and second trimesters, cerebroplacental ratio < 1 in the second and third trimesters, and small fetal abdominal circumference in the third trimester. Glucocorticoids, methyldopa, and aspirin use appeared to be protective against APOs. Conclusions: This study provides a comprehensive analysis of the most important predictors for APOs in pregnant patients with SLE, which could constitute a basis for further research.
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Birru Talabi M, Eudy AM, Jayasundara M, Haroun T, Nowell WB, Curtis JR, Crow-Hercher R, White W, Ginsberg S, Clowse MEB. Tough Choices: Exploring Medication Decision-Making During Pregnancy and Lactation Among Women With Inflammatory Arthritis. ACR Open Rheumatol 2021; 3:475-483. [PMID: 34114738 PMCID: PMC8281053 DOI: 10.1002/acr2.11240] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Accepted: 01/27/2021] [Indexed: 01/04/2023] Open
Abstract
Objective This study explored how women’s beliefs about drug safety and interactions with their health care providers influenced their decisions to continue arthritis medications during pregnancy and lactation. Methods We collaborated with ArthritisPower, a patient‐powered research network, and CreakyJoints, its partner online community, to develop and disseminate a survey among members with inflammatory arthritis who had at least one pregnancy after diagnosis. Participants’ free‐text responses were evaluated by using thematic analysis. Results Women in the sample were 40 years old on average (N = 66). Nineteen of their pregnancies had ended in fetal loss. Fifteen percent of all pregnancies were exposed to methotrexate. Among women who used safe arthritis medications, up to 80% discontinued treatment either in preparation for pregnancy or during pregnancy or lactation. Women’s decisions to continue medications during pregnancy were influenced by their perceptions of safety and advisement from health care providers, although they often described that advice about medication safety was inconsistent between providers. Conclusion Women often chose to endure active inflammatory arthritis rather than to use disease‐modifying antirheumatic drugs because of concerns about medication safety during pregnancy and lactation. Conflicting medical advice from health care providers undermined patients’ trust in their providers and in the safety of their medications. The high rate of peripartum exposure to methotrexate, a fetotoxic drug, underscores the need for better family planning care for women with childbearing potential.
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Affiliation(s)
| | - Amanda M Eudy
- Duke University Medical Center, Durham, North Carolina
| | | | | | - W Benjamin Nowell
- Global Healthy Living Foundation, CreakyJoints, Upper Nyack, New York
| | | | | | - Whitney White
- Global Healthy Living Foundation, CreakyJoints, Upper Nyack, New York
| | - Seth Ginsberg
- Global Healthy Living Foundation, CreakyJoints, Upper Nyack, New York
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Abstract
OBJECTIVE In seeking new approaches to improve lupus pregnancy outcomes, we study the association between pregnancy planning, behaviors recommended by American College of Rheumatology's Reproductive Health Guideline 2020, and pregnancy and infant outcomes. METHODS Lupus pregnancies in a prospective registry (1/1/2018 to 4/1/2020) were classified as planned or not-planned using the patient-reported London Measure of Unplanned Pregnancy. These groups were compared for demographics, pre-pregnancy disease activity, pregnancy planning behaviors, and delivery outcomes. RESULTS Among 43 women with 43 singleton pregnancies the average age was 29.4 years and 42% were Black. Overall, 60% were planned pregnancies and 40% were not-planned (16 ambivalent, 1 unplanned). Women with not-planned pregnancies had lower age, income, and education, and more required Medicaid. Women with not-planned pregnancies were more likely to conceive when lupus activity was higher (p = 0.001), less likely to receive pre-pregnancy counseling with a rheumatologist (p = 0.02), and less likely to continue pregnancy-compatible medications (p = 0.03). Severe PROMISSE adverse pregnancy outcomes (APOs) and severe neonatal outcomes were higher among women with not-planned than planned pregnancies (43% vs 0% p = 0.003; 70% vs 30% p = 0.06). CONCLUSION This study identifies pregnancy intention as a potentially modifiable risk factor for poor outcomes in women with lupus. It highlights a unique population of women with lupus at high risk for pregnancy and infant complications: those ambivalent about pregnancy. These women may not be effectively engaging in health behaviors that prevent pregnancy nor those that will prepare for a safe pregnancy. With effective pregnancy planning and contraception guidance, we may decrease their risk for maternal-fetal morbidity and mortality.
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