Outcome of pregnancy in patients with systemic lupus erythematosus

Mendelian randomization reveals systemic lupus erythematosus and rheumatoid arthritis and risk of adverse pregnancy outcomes

BACKGROUND

The effect of systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA) on adverse pregnancy outcomes is a controversial topic. This study aimed to use Mendelian randomization (MR) analysis to assess the causal relationship between SLE, RA and adverse pregnancy outcomes.

METHODS

Genetic variants for SLE and RA, as well as adverse pregnancy outcomes, were derived from pooled statistics from large public genome-wide association studies. Several methods, such as inverse variance weighting (IVW), MR-Egger, weighted median and MR-Pleiotropic Residuals Sum and Outliers, were employed to estimate two-sample causality.

RESULTS

Genetic prediction of SLE was associated with higher odds of preterm labour [odds ratio (OR) 1.03, 95 % confidence interval (CI) 1.01-1.05; p = 0.008]. RA was associated with higher odds of preterm labour (OR 1.03, 95 % CI 1.01-1.06; p = 0.009), pre-eclampsia or eclampsia (OR 1.04, 95 % CI 1.01-1.07; p = 0.005), and poor fetal growth (OR 1.08, 95 % CI 1.04-1.12; p = 2.91 × 10-5). The results of bidirectional MR analysis did not indicate that SLE was associated with spontaneous abortion, pre-eclampsia or eclampsia, preterm rupture of membranes, or poor fetal growth (p-value for IVW 0.13-0.97).

CONCLUSIONS

This study found a genetic association between SLE and the risk of preterm labour, and highlights the importance of perinatal care and monitoring for patients with SLE. Furthermore, RA was found to be associated with a wide range of adverse outcomes, including preterm labour, pre-eclampsia or eclampsia, and poor fetal growth; as such, there is a need for more intensive therapeutic interventions and prenatal monitoring.

Studying Pregnancy Outcome Risk in Patients with Systemic Lupus Erythematosus Based on Cluster Analysis

Background. Pregnancy in systemic lupus erythematosus (SLE) patients is a challenge due to the potential maternal and fetal complications. Therefore, a multidisciplinary assessment of disease risk before and during pregnancy is essential to improve pregnancy outcomes. Objectives. Our purpose was to (i) define clusters of patients with similar history and laboratory features and determine the associative maternal and perinatal outcomes and (ii) evaluate the risk spectrum of maternal and perinatal outcomes of pregnancy in SLE patients, represented by our established risk-assessment chart. Methods. Medical records of 119 patients in China were analyzed retrospectively. Significant variables with $p<0.05$ were selected. The self-organizing map was used for clustering the data based on historical background and laboratory features. Results. Clustering was conducted using 21 maternal and perinatal features. Five clusters were recognized, and their prominent maternal manifestations were as follows: cluster 1 (including 27.73% of all patients): preeclampsia and lupus nephritis; cluster 2 (22.69%): oligohydramnios, uterus scar, and femoral head necrosis; cluster 3 (13.45%): upper respiratory tract infection; cluster 4 (15.97%): premature membrane rupture; and cluster 5 (20.17%): no problem. Conclusion. Pregnancy outcomes in SLE women fell into three categories, namely high risk, moderate risk, and low risk. Present manifestations, besides the medical records, are a potential assessment means for better management of pregnant SLE patients.

Maternal and perinatal outcomes of pregnancies in systemic lupus erythematosus: A nationwide population-based study

OBJECTIVES

Systemic lupus erythematosus (SLE) is an autoimmune disease that develops mainly in women of reproductive age. We aimed to explore the risk of pregnancy complications in Asian patients with SLE.

METHODS

From January 2005 to December 2014, we conducted a nationwide case-control study, using Taiwan's National Health Insurance Research Database. Obstetric complications and perinatal outcomes in SLE patients were compared with those without SLE.

RESULTS

2059 SLE offspring and 8236 age-matched, maternal healthy controls were enrolled. We found increased obstetric and perinatal complications in SLE population compared with healthy controls. SLE patients exhibited increased risk of preeclampsia/eclampsia (8.98% vs.1.98%, odds ratio [OR]: 3.87, 95% confidence interval [95% CI]: 3.08-4.87, p<0.0001). Their offspring tended to have lower Apgar scores (<7) at both 1 min (10.7% vs. 2.58%, p<0.0001) and 5 min (4.25% vs. 1.17%, p<0.0001), as well as higher rates of intrauterine growth restriction (IUGR, 9.91% vs. 4.12%, OR: 2.24, 95% CI: 1.85-2.71, p<0.0001), preterm birth (23.70% vs 7.56%, OR: 3.00, 95% CI: 2.61-3.45, p<0.0001), and stillbirth (4.23% vs. 0.87%, OR: 3.59, 95% CI: 2.54-5.06, p<0.0001). The risks of preterm birth and stillbirth were markedly increased in SLE patients with concomitant preeclampsia/eclampsia or IUGR. Preterm birth of SLE patients was 1~4 gestational weeks earlier than that of healthy controls and the peak occurrence of stillbirth in SLE population was at 20~30 gestational weeks.

CONCLUSIONS

Asian SLE patients exhibited increased risks of maternal complications and adverse birth outcomes. Frequent antenatal visits before 20 gestational weeks are recommended in high-risk SLE patients.

Exacerbations of autoimmune diseases during pregnancy and postpartum

Autoimmune diseases represent a complex heterogeneous group of disorders that occur as a results of immune homeostasis dysregulation and loss of self-tolerance. Interestingly, more than 80% of the cases are found among women at reproductive age. Normal pregnancy is associated with remarkable changes in the immune and endocrine signaling required to tolerate and support the development and survival of the placenta and the semi-allogenic fetus in the hostile maternal immune system environment. Gravidity and postpartum represent an extremely challenge period, and likewise the general population, women suffering from autoimmune disorders attempt pregnancy. Effective preconception counseling and subsequent gestation and postpartum follow-up are crucial for improving mother and child outcomes. This comprehensive review provides information about the different pathways modulating autoimmune diseases activity and severity, such as the influence hormones, microbiome, infections, vaccines, among others, as well as updated recommendations were needed, in order to offer those women better medical care and life quality.

Pregnancy and childbirth in a patient with multiple sclerosis: A case report of successful management

OBJECTIVE

Multiple sclerosis (MS) preferentially affects females of reproductive age, making reproduction an important issue for women with MS. An increased incidence of poor labor progress often results in assisted vaginal delivery or a cesarean section. However, with good pre-pregnancy counseling and management, women with MS can conceive and give birth safely. Here, we present a case of pregnancy with MS, which was carried to term uneventfully and ended with unassisted vaginal delivery.

CASE REPORT

A 36-year-old woman was treated for MS for three years before she conceived. Because of her mild clinical presentation, medication was discontinued when her pregnancy was confirmed. Counseling was completed, and she had a smooth pregnancy course and gave birth vaginally at 38 weeks and two days.

CONCLUSION

Based on this case report, women with mild clinical presentation of MS before pregnancy can conceive and carry successfully to term with no or improved disease presentation.

Adverse pregnancy outcomes in adolescents and young women with systemic lupus erythematosus: a national estimate

BACKGROUND

Pregnant women with systemic lupus erythematosus (SLE) have increased risk of adverse outcomes including disease flare, spontaneous abortion, preeclampsia/eclampsia, premature birth and maternal death. However, pregnancy outcomes among adolescents and young women with SLE have not been well-explored. Our objective was to compare risk of adverse pregnancy outcomes in adolescents and young women with SLE to risk among peers without SLE.

METHODS

We studied the 2000-2011 Nationwide Inpatient Sample (NIS) of the Healthcare Cost and Utilization Project (HCUP) to estimate the prevalence of adverse pregnancy outcomes in women with SLE aged ≤ 21 years at time of delivery. Outcomes were compared to peers without SLE by using multivariate logistic regression to calculate odds ratios and risk differences. Additionally, differences in length of stay and total charges per hospitalization were described.

RESULTS

There were 8,791,391 unique pregnancies, of which 4002 occurred in young women with SLE. After adjustment for age, race, insurance type and quartile of median income based on patient ZIP code individuals with SLE had increased odds of pre-eclampsia/eclampsia (OR 3.2, 95% CI 2.3-4.6), maternal death (OR 80, 95% CI 10-604), preterm birth (OR 2.7, 95% CI 2-3.7), spontaneous abortion (OR 5.1, 95% CI 2.8-9.6), and induced abortion (OR 30, 95% CI 14-63). The increase in risk among women with SLE was greatest for preterm birth (RD 11%, 95% CI 6-16), pre-eclampsia/eclampsia (RD 9%, 95% CI 5-13), and spontaneous abortion (RD 4%, 95% CI 0.9-6). Risk difference for induced abortion was 2% with 95% CI 0.6-4, while the difference in risk for maternal death did not reach statistical significance (RD 0.4, 95% CI -0.4-1).

CONCLUSIONS

Adolescents and young women with SLE experience increased risk of adverse, pregnancy-specific outcomes as compared to their peers, including pre-eclampsia/eclampsia, maternal death, preterm birth, spontaneous abortion, and induced abortion. Additionally, length of stay and total charges for hospitalization are increased.

Hydroxychloroquine for the prevention of fetal growth restriction and prematurity in lupus pregnancy: A systematic review and meta-analysis

OBJECTIVES

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease that primarily affects women of childbearing age. While the impact of hydroxychloroquine (HCQ) on SLE activity and neonatal lupus occurrence has been evaluated in several studies, its role on prematurity and intrauterine growth restriction (IUGR) remains uncertain. The aim of this study was to assess the impact of HCQ exposure on prematurity and IUGR during pregnancy in women with SLE.

METHODS

We conducted a systematic review and a meta-analysis comparing prematurity and IUGR in SLE pregnancies exposed or not exposed to HCQ. The odds ratio of IUGR and prematurity were calculated and compared between pregnancies in each group according HCQ treatment.

RESULTS

Six studies were included (3 descriptive cohort studies and 3 case series) totalling 870 pregnancies. Of the SLE pregnancies, 308 were exposed to HCQ and were compared to 562 not exposed to HCQ. There was no statistical difference for prematurity or IUGR between groups.

CONCLUSION

This meta-analysis failed to prove the efficacy of HCQ in the prevention of prematurity as well as IUGR during SLE pregnancies. Due to the heterogeneity of the studies, these results should be interpreted cautiously.

Long-Term Outcomes of Systemic Lupus Erythematous Patients after Pregnancy: A Nationwide Population-Based Cohort Study

Background

Data on long-term maternal outcomes in patients with systemic lupus erythematosus (SLE) are lacking. The study aimed to explore the relationships among SLE, pregnancy, outcomes of end-stage renal disease (ESRD), and overall mortality.

Methods

We established a retrospective cohort study consisting of four cohorts: pregnant (case cohort) and nonpregnant SLE patients, as well as pregnant and nonpregnant non-SLE patients. One case cohort and three comparison cohorts were matched by age at first pregnancy and index date of pregnancy by using the Taiwan National Health Insurance Research Dataset. All study subjects were selected based on the index date to the occurrence of ESRD or overall death. Cox proportional hazard regression models and Kaplan–Meier curves were used in the analysis.

Results

SLE pregnant patients exhibited significantly increased risk of ESRD after adjusting for other important confounders, including immunosuppressant and parity (HR = 3.19, 95% CI: 1.35–7.52 for pregnant non-SLE; and HR = 2.77, 95% CI: 1.24–6.15 for nonpregnant non-SLE patients). No significant differences in ESRD incidence were observed in pregnant and nonpregnant SLE patients. Pregnant SLE patients exhibited better clinical condition at the baseline and a significantly lower risk of overall mortality than nonpregnant SLE patients.

Conclusions

Our data support current recommendations for SLE patients to avoid pregnancy until disease activity is quiescent. Multicenter recruitment and clinical information can be used to further examine the association of SLE and ESRD (or mortality) after pregnancy.

A clinical decision support system for prediction of pregnancy outcome in pregnant women with systemic lupus erythematosus

OBJECTIVE

Pregnancy among systemic lupus erythematosus (SLE)-affected women is highly associated with poor obstetric outcomes. Predicting the risk of foetal outcome is essential for maximizing the success of pregnancy. This study aimed to develop a clinical decision support system (CDSS) to predict pregnancy outcomes among SLE-affected pregnant women.

METHODS

We performed a retrospective analysis of 149 pregnant women with SLE, who were followed at Shariati Hospital (104 pregnancies) and a specialized clinic (45 pregnancies) from 1982 to 2014. We selected significant features (p<0.10) using a binary logistic regression model performed in IBM SPSS (version 20). Afterward, we trained several artificial neural networks (multi-layer perceptron [MLP] and radial basis function [RBF]) to predict the pregnancy outcome. In order to evaluate and select the most effective network, we used the confusion matrix and the receiver operating characteristic (ROC) curve. We finally developed a CDSS based on the most accurate network. MATLAB 2013b software was applied to design the neural networks and develop the CDSS.

RESULTS

Initially, 45 potential variables were analysed by the binary logistic regression and 16 effective features were selected as the inputs of neural networks (P-value<0.1). The accuracy (90.9%), sensitivity (80.0%), and specificity (94.1%) of the test data for the MLP network were achieved. These measures for the RBF network were 71.4%, 53.3%, and 79.4%, respectively. Having applied a 10-fold cross-validation method, the accuracy for the networks showed 75.16% accuracy for RBF and 90.6% accuracy for MLP. Therefore, the MLP network was selected as the most accurate network for prediction of pregnancy outcome.

CONCLUSION

The developed CDSS based on the MLP network can help physicians to predict pregnancy outcomes in women with SLE.

Predictors of poor obstetric outcome in women with systemic lupus erythematosus: a 10-year experience of a university hospital

OBJECTIVE

To compare the maternal and fetal outcome in patients with systemic lupus erythematosus (SLE) by a retrospective analysis from 2005 to 2010, and a prospective follow-up of pregnant SLE patients from 2010 to 2015 to find out predictors of poor obstetric outcome.

METHODS

The study included 236 SLE pregnant females (retrospective group) whose data were viewed retrospectively from their medical records, and 214 SLE pregnant females (prospective group) who were followed prospectively to record their maternal and fetal outcome.

RESULTS

There was a highly significant difference between the two groups regarding abortion, venous thromboembolism, prematurity, and intrauterine fetal death (p < 0.001) with more occurrence in retrospective group. Also, the frequency of lupus flares, worsening of renal functions, blood transfusion, maternal mortality, admission to NICU, and neonatal death was higher in the retrospective group (p < 0.05). Predictors of poor obstetric outcome included Last flare before pregnancy <6 months, number of antenatal hospital admissions ≥ 6, use of immunosuppressive therapy, the presence of anti-SSA/Ro and anti-SSB/La, and SLE with nephritis (p < 0.05).

CONCLUSION

Improved maternal and fetal outcome in women with SLE has occurred following integrated multidisciplinary approach. This emphasizes the importance of postponing pregnancy when predictors of poor outcome are encountered.

Pregnancy Outcomes in Chinese Patients with Systemic Lupus Erythematosus (SLE): A Retrospective Study of 109 Pregnancies

Systemic lupus erythematosus (SLE) is a multisystem autoimmune disease that primarily affects women during their reproductive years. The interaction between SLE and pregnancy remains debated. The objective of this study was to analyze the fetal and maternal outcomes of Chinese women with SLE. A total of 109 pregnancies in 83 SLE patients from June 2004 to June 2014 at a tertiary university hospital were reviewed retrospectively. Patients' characteristics, clinical and laboratory data during pregnancy were obtained from electronic medical records. After exclusion of elective abortions, the live birth rate was 61.5%. Significantly, APS (antiphospholipid syndrome), disease activity, hypertension, hypocomplementemia, thrombocytopenia, and anemia during pregnancy were more commonly observed in fetal loss pregnancies than in live birth pregnancies. Compared to the 64 women with a history of SLE, 19 women with new-onset lupus during pregnancy had worse pregnancy outcome. Furthermore, the 64 patients with a history of SLE were divided into lupus nephritis group and SLE group (non-renal involvement). We found that the lupus nephritis group had worse maternal outcome than the SLE group. We conclude that new-onset lupus during pregnancy predicts both adverse maternal and fetal outcomes, while a history of lupus nephritis predicts adverse maternal outcomes. It is essential to provide SLE women with progestational counseling and regular multispecialty care during pregnancy.

Systemic lupus erythematosus: strategies to improve pregnancy outcomes

Systemic lupus erythematosus (SLE) is a chronic autoimmune inflammatory disease with a high prevalence in females of childbearing age. Thus, reproduction in SLE patients is a major concern for clinicians. In the past, SLE patients were advised to defer pregnancy because of poor pregnancy outcomes and fear of SLE flares during pregnancy. Investigations to date show that maternal and fetal risks are higher in females with SLE than in the general population. However, with appropriate management of the disease, sufferers may have a relatively uncomplicated pregnancy course. Factors such as appropriate preconception counseling and medication adjustment, strict disease control prior to pregnancy, intensive surveillance during and after pregnancy by both the obstetrician and rheumatologist, and appropriate interventions when necessary play a key role. This review describes the strategies to improve pregnancy outcomes in SLE patients at different time points in the reproduction cycle (preconception, during pregnancy, and postpartum period) and also details the neonatal concerns.

Lupus nephritis is associated with poor pregnancy outcomes in pregnant SLE patients in Cape Town: a retrospective analysis

Introduction

Systemic lupus erythematosus (SLE) is a multi-system auto-immune disease common in females of child-bearing age. The effect of pregnancy on SLE and vice versa have not been well characterised in Africans. The aim of this study is to describe the pregnancy outcomes of patients with SLE presenting to the maternity department of Groote Schuur Hospital, Cape Town.

Methods

This study was designed as a retrospective review of records of pregnant women known with SLE and followed-up at the maternity section of Groote Schuur Hospital. The duration of survey was from the 1^st January 2003 to 31^st December 2013.

Results

There were 61 pregnancies reviewed in 49 patients; 80.3% of the pregnancies were in patients of mixed ancestry and the rest (19.7%) in black African patients. The mean age at presentation of the current pregnancy was 27.2±5.0 years. Mean gestational age at presentation and delivery was 13.0 ± 6.0 weeks and 28.9 ± 9.8 weeks respectively and 47.5% of the pregnancies were in patients with lupus nephritis (LN). Thirty nine (63.9%) pregnancies reached the third trimester and 11.5% of all pregnancies ended in the first trimester. There was a lower number of live births to mothers of African ancestry than to those of mixed ancestry (p=0.001). In 55.7% of the pregnancies, no flare was reported while a renal flare was reported in 23%. Pregnancies in patients with LN had higher frequencies of flares (58.6% vs 31.3%; p=0.032), pre-eclampsia (34.5% vs 12.5%; p=0.041), longer stay in hospital (12.0 ± 9.1 days vs 6.1 ± 5.1 days; p=0.004) and low birth weight babies (1.94 ± 1.02 kg vs 2.55±0.95 kg; p=0.046) than in patients without LN. Only 36 (59%) of the neonates were discharged home alive and of these 2 (5.6%) were to mothers of black African ancestry (p=0.001).

Conclusion

Increased lupus activity in pregnant SLE patients may account for the increased deaths of neonates born to SLE mothers. Patients of black African descent and those with LN tend to have a poorer outcome. A multi-disciplinary approach to the management of SLE patients (of child-bearing age or pregnant) needs to be further assessed for better outcomes.

Lupus anticoagulant, disease activity and low complement in the first trimester are predictive of pregnancy loss

Introduction

Multiple factors, including proteinuria, antiphospholipid syndrome, thrombocytopenia and hypertension, are predictive of pregnancy loss in systemic lupus erythematosus (SLE). In the PROMISSE study of predictors of pregnancy loss, only a battery of lupus anticoagulant tests was predictive of a composite of adverse pregnancy outcomes. We examined the predictive value of one baseline lupus anticoagulant test (dilute Russell viper venom time) with pregnancy loss in women with SLE.

Methods

From the Hopkins Lupus Cohort, there were 202 pregnancies from 175 different women after excluding twin pregnancies and pregnancies for which we did not have a first trimester assessment of lupus anticoagulant. We determined the percentage of women who had a pregnancy loss in groups defined by potential risk factors. The lupus anticoagulant was determined by dilute Russell viper venom time with appropriate mixing and confirmatory testing. Generalised estimating equations were used to calculate p values, accounting for repeated pregnancies in the same woman.

Results

The age at pregnancy was <20 years (2%), 20–29 (53%), 30–39 (41%) and >40 (3%). 55% were Caucasian and 34% African-American. Among those with lupus anticoagulant during the first trimester, 6/16 (38%) experienced a pregnancy loss compared with only 16/186 (9%) of other pregnancies (p=0.003). In addition, those with low complement or higher disease activity had a higher rate of pregnancy loss than those without (p=0.049 and 0.005, respectively). In contrast, there was no association between elevated anticardiolipin in the first trimester and pregnancy loss.

Conclusions

The strongest predictor of pregnancy loss in SLE in the first trimester is the lupus anticoagulant. In addition, moderate disease activity by the physician global assessment and low complement measured in the first trimester were predictive of pregnancy loss. These data suggest that treatment of the lupus anticoagulant could be considered, even in the absence of history of pregnancy loss.

[Lupus and pregnancy: study of 26 cases, an internal medicine department experience and review of the literature]

OBJECTIVE

To study the maternal and fetal outcomes in women with systemic lupus erythematosus.

PATIENTS AND METHODS

A retrospective study of 26 pregnancies in 15 systemic erythematosus patients diagnosed before or during pregnancy regarding to American College of Rheumatology criteria in a single reference center.

RESULTS

The mean patient age was 31.52 years (24-39 years). The mean interval from the diagnosis of the systemic lupus erythematosus to pregnancy was 4.2 years. Eight pregnancies were planned. The flare rate of lupus during pregnancy was 31%, life birth rate was 65% and fetal loss rate was 35%.

DISCUSSION AND CONCLUSION

As an increase in disease activity can occur during pregnancy and because of a higher rate of obstetrical complications in patients with lupus, it is important to carefully plan pregnancy. Pregnancy in lupus patients must be closely monitored by a multispeciality care of the patients.

Pregnancy and renal outcomes in lupus nephritis: an update and guide to management

Systemic lupus erythematosis (SLE) commonly affects women of child bearing-age, and advances in treatment have resulted in an increasing number of women with renal involvement becoming pregnant. Knowledge of the relationship of the condition with respect to fertility and pregnancy is important for all clinicians involved in the care of women with lupus nephritis because they have complicated pregnancies. Presentation of lupus nephritis can range from mild asymptomatic proteinuria to rapidly progressive renal failure and may occur before, during, or after pregnancy. The timing of diagnosis may influence pregnancy outcome. Pregnancy may also affect the course of lupus nephritis. All pregnancies in women with lupus nephritis should be planned, preferably after more than six-months of quiescent disease. Predictors of poor obstetric outcome include active disease at conception or early pregnancy, baseline poor renal function with Creatinine >100 μmol/L, proteinuria >0.5 g/24 hours, presence of concurrent antiphospholipid syndrome and hypertension. In this review the most recent studies of pregnancies in women with lupus nephritis are discussed and a practical approach to managing women prepregnancy, during pregnancy and post-partum is described.

Risk factors for blood transfusion in singleton pregnancy deliveries in Taiwan

OBJECTIVE

To investigate risk factors for blood transfusion in pregnancy.

METHODS

In a population-based study, data from all women with singleton pregnancies (n=225 304) admitted for delivery in Taiwanese hospitals in 2002 were obtained from the National Health Insurance claims database. To identify risk factors for blood transfusion, a logistic regression model with generalized estimating equation was used to calculate the adjusted odds ratio (OR) and 95% confidence intervals (CI) for characteristics of the pregnant women, hospitals, clinics, and obstetricians.

RESULTS

The incidence of blood transfusion was 1.43%. Cesarean delivery, vaginal birth after cesarean (VBAC), and repeat cesarean delivery had higher rates of blood transfusion than vaginal delivery, with an OR of 7.2 (95% CI, 6.38-8.02), 4.2 (95% CI, 2.52-6.87), and 5.9 (95% CI, 5.06-6.80), respectively. Other risk factors included extremes of age; pregnancies complicated by prepartum hemorrhage, placenta previa, pre-eclampsia, eclampsia, anemia, or systemic lupus erythematosus; and obstetricians with low or mid-to-low numbers of deliveries.

CONCLUSION

The study has identified risk factors for blood transfusion in pregnancy on the basis of a nationwide database and provides useful information for obstetric practice. For women with a history of cesarean delivery, vaginal delivery might be considered owing to its lower incidence of transfusion.

Maternal deaths in women with lupus nephritis: a review of published evidence

BACKGROUND AND OBJECTIVES

Pregnancies in women with systemic lupus erythematosus (SLE) and lupus nephritis are considered high-risk due to high rates of maternal and fetal complications. However, there has not been a formal analysis addressing the issue of maternal deaths in these women. The aim of this study was to perform a literature review of the maternal deaths in women with SLE and lupus nephritis to: (1) identify the main causes of death and (2) discuss possible reasons for these causes, and strategies that may improve patient care and outcomes. DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENT: We performed an extensive electronic literature search from 1962 to 2009 using online databases (PubMed, Embase, Lilacs, Cochrane Controlled Trials Register, Medline, and Science Citation Index). Studies were included if they reported pregnancies in patients with SLE and lupus nephritis with at least one reported maternal death.

RESULTS

We identified 13 studies that reported a total of 17 deaths in the 6 week post-partum period that were attributable to SLE and lupus nephritis. In all cases, death occurred in the setting of active disease, and was attributed either to infection in 41.2% (n = 7), or disease activity in 29.4% (n = 5). The remaining deaths were due to pulmonary embolus in 11.8% (n = 2), pregnancy-associated cardiomyopathy in 5.9% (n = 1), adrenal failure due to abrupt steroid withdrawal in 5.9% (n = 1), and undefined in 5.9% (n = 1).

CONCLUSIONS

All maternal deaths in patients with SLE and lupus nephritis occurred in those with active disease, with disease activity/complications and infections (mainly opportunistic) being the two major causes. The presented evidence further supports timing of pregnancy relative to SLE activity, and the judicious use of immunosuppressive agents in pregnant patients.

Pregnancy related complications in patients with systemic lupus erythematosus, an egyptian experience

Background

Systemic Lupus Erythematosus (SLE) has a tendency to occur in women in their reproductive years, causing complications during pregnancy and labour. Conversely, pregnancy can cause flares of disease activity, often necessitating immediate intervention.

Aim of study

to study pregnancy related complications in patients with SLE.

Patients and methods

The study included 48 SLE pregnant females. 27 patients with 38 pregnancies, their data viewed retrospectively from medical records, and 21 patients with 21 pregnancies followed up prospectively. The laboratory data included ANA, DNA, APL antibodies and anti Ro/SSA. The disease activity was calculated according to the Systemic Lupus Activity Measure. Ultrasound was performed to confirm gestational age and assess for the presence of any congenital fetal malformations, and then repeated monthly to detect any abnormality including intrauterine growth restriction. At 30 weeks gestation and onwards, assessment of fetal wellbeing including daily fetal kick chart and once weekly non stress test was performed. Doppler blood flow velocimetry was done for those with abnormal fetal heart rate pattern. After labour, the neonate was examined for complications including complete heart block and neonatal lupus.

Results

Anti dsDNA was found in 95% of the patients, anti Ro/SSA in 6% and anti APL in 30%. 57% of the patients followed up prospectively had active disease in the 1st trimester, 24% in the 2nd and 62% in the 3rd trimester. The most common maternal complication was preeclampsia 33%, followed by spontaneous abortion 20%. Prematurity was the most common fetal complication 37%, followed by intrauterine growth restriction 29%. 2 neonates were born with congenital heart block and 1 with neonatal lupus.

Conclusion

Pregnancy in SLE patients is associated with a higher risk of obstetric complications affecting both the mother and the fetus. Preeclampsia was the most common complication followed by prematurity. Preeclampsia was significantly associated with third trimester disease activity.

A systematic review and meta-analysis of pregnancy outcomes in patients with systemic lupus erythematosus and lupus nephritis

BACKGROUND AND OBJECTIVES

Studies of the impact of systemic lupus erythematosus (SLE) and its pregnancy complications have yielded conflicting results. Major limitations of these studies relate to their small numbers of patients and retrospective designs. The aim of this study was to perform a systematic literature review of pregnancy outcomes in women with SLE and a meta-analysis of the association of lupus nephritis with adverse pregnancy outcomes.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We searched electronic databases from 1980 to 2009 and reviewed papers with validity criteria. Random-effects analytical methods were used to evaluate pregnancy complications rates.

RESULTS

Thirty-seven studies with 1842 patients and 2751 pregnancies were included. Maternal complications included lupus flare (25.6%), hypertension (16.3%), nephritis (16.1%), pre-eclampsia (7.6%), and eclampsia (0.8%). The induced abortion rate was 5.9%, and when excluded, fetal complications included spontaneous abortion (16.0%), stillbirth (3.6%), neonatal deaths (2.5%), and intrauterine growth retardation (12.7%). The unsuccessful pregnancy rate was 23.4%, and the premature birth rate was 39.4%. Meta-regression analysis showed statistically significant positive associations between premature birth rate and active nephritis and increased hypertension rates in subjects with active nephritis or a history of nephritis. History of nephritis was also associated with pre-eclampsia. Anti-phospholipid antibodies were associated with hypertension, premature birth, and an increased rate of induced abortion.

CONCLUSIONS

In patients with SLE, both lupus nephritis and anti-phospholipid antibodies increase the risks for maternal hypertension and premature births. The presented evidence further supports timing of pregnancy relative to SLE activity and multispecialty care of these patients.

Pregnancy outcome in systemic lupus erythematosus: Asia's largest single centre study

AIM

To evaluate pregnancy outcome in women with systemic lupus erythematosus (SLE).

METHODS

A total of 71 pregnancies in 35 women with SLE were evaluated for maternal and perinatal outcomes in a tertiary centre of Northern India. Thirty-five pregnancies were evaluated prospectively while details of previous 36 pregnancies in the same women were studied retrospectively.

RESULTS

The Mean age of pregnant women with SLE was 26.89 ± 2.7 years and 14.57% were nulliparous. The presenting event was arthritis in 60% of the patients; others presented with febrile illness, renal manifestation and cutaneous manifestation. One woman was lupus anticoagulant positive. All women conceived while on disease quiescence period and were continued on the same pre-pregnancy dose of pharmacological agents. Hypertensive disorders of pregnancy were seen in 28.5% while chronic hypertension was seen in 5.6%. The incidence of abortion, preterm deliveries and perinatal loss was 33.8, 29.57 and 12.67%, respectively. Vaginal delivery rate was 47.88 and 18.3% underwent caesarean section. There was no case of neonatal lupus and none had disease flare-up in the postpartum period.

CONCLUSION

A better pregnancy outcome can be expected if clinical remission is achieved and disease activity is adequately controlled prior to pregnancy.

The lowest surviving birth weight infant delivered from a systemic lupus erythematosus mother with antiphospholipid syndrome

We report the intact surviving case of a newborn with a birth weight of 412 g delivered from an active systemic lupus erythematosus (SLE) mother with antiphospholipid syndrome. A review of the literature revealed that our infant is the lowest surviving birth weight in newborns from SLE mothers to date.

Systemic lupus erythematosus pregnancies: the Sarawak experience and review of lupus pregnancies in Asia

We performed a cross-sessional study of all systemic lupus erythematosus (SLE) pregnancies during a 4-year period (2006-2009) to describe the clinical features, maternal and foetal outcomes in our centre. There were 48 pregnancies in 44 women with SLE. Our patients have a mean age of 30.0 years (SD 6.36) and a mean disease duration of 40.67 months (SD 48.23). Our patients have complicated pregnancies: 32.7% have SLE flares, 17.3% have preeclampsia and 48.9% needed caesarean sections. There were 20.0% foetal losses and 17.8% preterm deliveries in our patients. SLE flares contributed to 60.0% of foetal losses in our patients. Lupus pregnancies in our centre generally have a good maternal and foetal outcome comparable to developed countries in Asia. The low incidence of APS, the high usage of hydroxychloroquine and the high SLE remission rate in our patients prior to conceptions contributed to the good outcome.

The implications of autoimmunity and pregnancy

There are multiple epidemiological studies that document the potential adverse affects of autoimmunity on nearly every aspect of reproduction, even in the absence of clinically manifest autoimmune disease. Two decades ago, it was suggested that women with autoimmune diseases avoid pregnancy due to inordinate risks to the mother and the child. In contrast, newer epidemiological data demonstrated that advances in the treatment of autoimmune diseases and the management of pregnant women with these diseases have similarly improved the prognosis for mother and child. In particular, if pregnancy is planned during periods of inactive or stable disease, the result often is giving birth to healthy full-term babies without increased risks of pregnancy complications. Nonetheless, pregnancies in most autoimmune diseases are still classified as high risk because of the potential for major complications. These complications include disease exacerbations during gestation and increased perinatal mortality and morbidity in most autoimmune diseases, whereas fetal mortality is characteristic of the anti-phospholipid syndrome (APS). In this review, we will discuss these topics, including issues of hormones, along with potential long-term effects of the microchimerism phenomenon. With respect to pregnancy and autoimmune diseases, epidemiological studies have attempted to address the following questions: 1) Is it safe for the mother to become pregnant or are there acute or chronic effects of pregnancy on the course of the disease? 2) Does the disease alter the course and/or the outcome of a pregnancy and thereby represent an inordinate risk for the fetus and infant? And do new therapeutic and management approaches improve the pregnancy outcomes in women with autoimmune diseases? 3) Does passage of maternal autoantibodies represent a risk to the child? 4) Do pregnancy, parity, or other factors influencing hormonal status explain the female predominance of many autoimmune diseases, and is the pregnancy effect related to microchimerism? Answering these questions has taken on additional importance in recent decades as women in western countries now frequently choose to delay pregnancies and have some or all of their pregnancies after disease onset. In this paper, we primarily focus on APS, systemic lupus erythematosus (SLE), multiple sclerosis (MS), rheumatoid arthritis (RA), and type 1 diabetes (T1D).

Maternal and foetal outcomes in pregnant patients with active lupus nephritis

The objective of this study was to determine the impact of lupus nephritis disease activity on maternal and foetal outcomes in pregnant patients with systemic lupus erythematosus (SLE). Medical records of all pregnant patients with SLE treated at our institution between 1976 and 2007 were reviewed. All patients met American College of Rheumatology classification criteria for SLE. Demographic data, history of lupus nephritis, nephritis disease activity and maternal and foetal outcomes of pregnancy were abstracted. Active lupus nephritis was defined as the presence of proteinuria >0.5 g/day and/or active urinary sediment with or without an elevation in serum creatinine (Cr). Quiescent lupus nephritis was confirmed in the presence of proteinuria <0.5 mg/day and inactive urinary sediment. We identified 58 patients with 90 pregnancies. Compared with pregnancies in SLE patients without renal involvement (n = 47), pregnancies in patients with active lupus nephritis (n = 23) were associated with a higher incidence of maternal complications (57% vs 11%, P < 0.001), whereas those with quiescent lupus nephritis (n = 20) were not (35% vs 11%, P = 0.10). Women with active lupus nephritis were more likely to deliver preterm than women without lupus nephritis, median of 34 weeks vs 40 gestational weeks, respectively (P = 0.002) and were more likely to suffer foetal loss (35% vs 9%, P = 0.031). Active, but not quiescent, lupus nephritis during pregnancy is associated with a higher incidence of maternal and foetal complications compared with pregnancies in SLE patients without renal involvement.

Systemic lupus erythematosus pregnancies: a case series from a tertiary, East Malaysian hospital

We performed a retrospective study of all systemic lupus erythematosus (SLE) pregnancies during a two-year period (2006–2007) to describe the clinical features, maternal and foetal outcomes in our centre. There were 17 pregnancies in 16 women with SLE. Our patients have a mean age of 28.31 years (SD 5.24) and a mean disease duration of 38.62 months (SD 38.03). Our patients have complicated pregnancies: 35.3% have SLE flares, 21.1% have preeclampsia and 47.4% needed caesarean sections. There were 15.8% foetal losses and 12.5% preterm deliveries in our patients. All the foetal losses occurred in patients with severe SLE flares during pregnancies. Lupus pregnancies in our centre generally have a good maternal and foetal outcome comparable with developed countries. The low incidence of antiphospholipid syndrome, the high usage of hydroxychloroquine and the high SLE remission rate in our patients before conceptions are the possible factors contributing to the good outcome.

Pregnancy outcome in systemic lupus erythematosus (SLE) is improving: Results from a case control study and literature review

OBJECTIVES

For women who suffer from systemic lupus erythematosus (SLE), pregnancy can be a concern, placing the mother and fetus at risk. Our objectives were to assess the risk of adverse pregnancy outcome, disease flares, fertility rate, and co-morbidities in SLE women compared to healthy controls. We also systematically reviewed the literature available on pregnancy outcome in SLE to compare our results to other published data. Our hypothesis was that pregnancy outcome in SLE is improving over time.

METHODS

A case-control study comparing self-report of the above-mentioned parameters in SLE (N=108) vs healthy controls or patients with non-inflammatory musculoskeletal (MSK) disorders (N=134) was performed. Data were collected using a self-administered questionnaire. Proportions, means and odds ratios were calculated. We searched and quantified the literature on pregnancy outcome, lupus reactivation and fertility rate. Data were summarized and presented in mean % ± SEM and median % with interquartile range (IQR).

RESULTS

Gynecological history, fertility rate and age at first pregnancy in SLE patients were comparable to controls. Eighteen percent of SLE patients reported a flare and 18% reported an improvement of symptoms during pregnancy. Twenty-four percent of lupus patients had at least one preterm delivery vs 5% in controls (OR =8.32, p = 0.0008), however other pregnancy outcomes (miscarriage, therapeutic abortion, stillbirth and neonatal death rate) did not differ between the groups. Thyroid problems were reported to be more likely in SLE patients (p = 0.02), but the prevalence of other co-morbidities was similar to controls. A literature review demonstrated that fertility was not affected in SLE patients. Lupus reactivations are common during pregnancy (36.5% ± SEM 3.3%). Most agreed that SLE pregnancies had more fetal loss (19.5% ± SEM 1.6%) and preterm births (25.5% ± SEM 2.2%) when compared to the general population. Over time, the rate of SLE peripartum flares has improved (p = 0.002) and the proportion of pregnancies resulting in live birth has increased (p = 0.024). The frequency of fetal death has not significantly changed. Our findings from the case-control study were, in general, consistent with the literature including the frequency of fetal death, neonatal death, live births and pregnancy rate.

CONCLUSION

Prematurity (25.5% ± SEM 2.2%) and fetal death (19.5% ± SEM 1.6%) in SLE pregnancy are still a concern. However, new strategies with respect to pregnancy timing and multidisciplinary care have improved maternal and fetal outcome in SLE.

What can epidemiology tell us about systemic lupus erythematosus?

Systemic lupus erythematosus (SLE) is an often-severe autoimmune rheumatic disease most commonly diagnosed in women in their childbearing years. It is thought to develop when genetically predisposed individuals are exposed to one or more environmental triggers. This review outlines the epidemiologic evidence for several putative risk factors including cigarette smoke, hormonal and reproductive factors, environmental silica and infectious exposures, as well as many yet to be identified. We also review the evidence for factors associated with increased disease activity and adverse outcomes in SLE. We review the literature on the epidemiology of SLE, its distribution, potential risk factors for its onset and for adverse outcomes. The information considered in this review was gathered through extensive review of the literature. Online Pubmed literature searches, previous reviews of the epidemiology of SLE and original studies were employed. Epidemiologic studies have helped to identify some of these potential risk factors, including exogenous hormone use, cigarette smoking, infections such as Epstein-Barr virus (EBV) and crystalline silica exposure, but many more have yet to be studied. These exposures may interact with multiple genetic factors in determining susceptibility to SLE. While epidemiologic research has contributed an enormous amount to our understanding of the disease and its pathogenesis, there are many more avenues of epidemiologic research that deserve to be pursued.