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

Antiphospholipid antibodies and the risk of adverse pregnancy outcomes in patients with systemic lupus erythematosus: a systematic review and meta-analysis

OBJECTIVE

This article aims to evaluate the magnitude of adverse pregnancy outcomes (APOs) risks associated with different antiphospholipid antibody (aPL) profiles in women with systemic lupus erythematosus (SLE).

METHODS

Multiple databases were investigated to identify articles that explored the relationship between aPLs and APOs in SLE patients. A random effects model was used for calculating pooled odds ratios (OR). Stata version 15.0 was utilized to conduct the meta-analysis.

RESULTS

There were 5234 patients involved in 30 studies. Overall aPL was linked to an increased incidence of any kind of APOs, fetal loss, and preterm birth. Any kind of APOs and preterm delivery were more common in patients with lupus anticoagulant (LA) positive. Anticardiolipin antibody (aCL) was associated with an increased risk of any kind of APOs and fetal loss. The association between aCL-IgM and fetal loss was also significant. Patients with anti-beta2-glycoprotein1 antibody (antiβ2GP1) positivity had an increased risk of fetal loss.

CONCLUSIONS

Both LA and aCL were risk factors of APOs in patients with SLE. Not only ACL, particularly aCL-IgM, but antiβ2GP1 were associated with an increased risk of fetal loss, while LA appeared to indicate the risk of preterm birth.PROSPERO (CRD42023388122).

Harmonizing Motherhood: Navigating Pregnancy Outcomes in Connective Tissue Disorders

Background Connective tissue disorders encompass a diverse array of autoimmune and hereditary conditions, including systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), and antiphospholipid antibody syndrome. These disorders present unique challenges during pregnancy due to their complex pathophysiology and potential complications. Understanding their impact on pregnancy outcomes is vital for optimizing maternal and fetal health. Objective To investigate the burden, complications, maternal and fetal outcomes, and prognosis of connective tissue disorders in pregnancy. Methods The study was conducted over one year and six months at Saveetha Medical College and Hospital, Chennai, India, involving 45 pregnant women diagnosed with connective tissue disorders. Standard antenatal investigations were conducted, and participants were monitored throughout the antenatal period. Maternal and fetal outcomes were meticulously evaluated. Results Baseline characteristics revealed a heterogeneous distribution of age and parity among participants, reflecting the diverse nature of connective tissue disorders in pregnancy. Maternal medical outcomes, such as gestational hypertension (GHTN) and gestational diabetes mellitus (GDM), were prevalent, highlighting the necessity of close monitoring. Obstetric outcomes included spontaneous abortion and preterm delivery, indicating elevated risks in this population. Fetal outcomes, including fetal growth restriction and admission to the neonatal intensive care unit, underscored the impact of these disorders on fetal health. Conclusion This study examines pregnant connective tissue disorder burden, complications, maternal and fetal outcomes, and prognosis. The complicated relationship between these illnesses, and pregnancy requires specialist care and close monitoring. The participants' baseline features represent connective tissue condition heterogeneity, affecting clinical practice. Among the study subjects, 40% had RA and 20% had SLE, the most common connective tissue illness. Adverse maternal medical outcomes, like GHTN (27.27% of antiphospholipid syndrome (APS) patients and 22.22% of SLE patients) and GDM (18.18% of APS patients and 11.11% of SLE patients), highlight the need for close maternal health monitoring and management during pregnancy. Overall, this study sheds light on connective tissue abnormalities and pregnancy outcomes. Healthcare providers can improve reproductive health and well-being for various illnesses by knowing these relationships.

Pregnancy Outcomes in a Diverse US Lupus Cohort

OBJECTIVE

Although the population of patients with systemic lupus erythematosus (SLE) is racially and ethnically diverse, many study populations are homogeneous. Further, data are often lacking on critical factors, such as antiphospholipid antibodies (aPLs). We investigated live birth rates in patients with SLE at Kaiser Permanente Northern California, including race and ethnicity and aPL data.

METHODS

Electronic health records of pregnancies with outcomes observed from 2011 to 2020 were identified among patients with SLE. Prevalent SLE was defined as two or more International Classification of Diseases-coded visits seven or more days apart before the last menstrual period. We summarized patient characteristics, medication orders, health care use, and medication use. Pregnancy outcomes (live birth, stillbirth, spontaneous abortion, ectopic pregnancy, and molar pregnancy) were presented overall and stratified by race and ethnicity, aPL status, and nephritis history.

RESULTS

We identified 657 pregnancies among 453 patients with SLE. The cohort was diverse, reflecting the Northern California population (27% Asian, 26% Hispanic, 26% Non-Hispanic White, 13% Non-Hispanic Black, 5% multiracial, and approximately 2% Pacific Islander and Native American). Approximately 74% of observed pregnancies ended in live birth, 23% resulted in spontaneous abortion, 2% were ectopic or molar pregnancies, and <1% were stillbirths. There was limited variability in live births by race and ethnic group (72%-79%), aPL status (69.5%-77%), and nephritis history (71%-75%).

CONCLUSION

Our findings are consistent with previous studies; however, some methodologic differences may yield a range of live birth rates. We found that approximately 74% of pregnancies in patients with SLE ended in live birth, with modest variability in spontaneous abortion by race and ethnicity, nephritis history, and aPL status.

Determining Thrombogenicity: Using a Modified Thrombin Generation Assay to Detect the Level of Thrombotic Event Risk in Lupus Anticoagulant-Positive Patients

The aim of this study was to determine the thrombogenicity of lupus anticoagulant (LA) antibodies using a modified thrombin generation assay (TGA) with the addition of activated protein C (APC) in a group of 85 patients with LA-positive samples. Of these, 58 patients had clinical manifestations of antiphospholipid syndrome (APS) according to the Sydney criteria classification, i.e., each patient had thrombosis or foetal loss, and 27 patients did not show any clinical manifestations of APS. A comparison of the two groups' TGA results revealed statistically significant differences (Fisher's test p = 0.0016). The group of patients exhibiting clinical manifestations of APS showed higher thrombogenicity in 56.9% of patients, while the group of patients not yet exhibiting clinical manifestations of APS showed higher thrombogenicity in 25.9% of patients. There were no significant differences in the specificity of the TGA test between the groups of patients exhibiting similar clinical manifestations. Receiver operating characteristic curve analysis showed a more significant relationship (p = 0.0060) for TGA than for LA titre (p = 0.3387). These data suggest that the determination of LA thrombogenicity with the TGA assay leads to an increased prediction of the manifestation of a thromboembolic event. Our findings appear to be particularly relevant for the prediction of thrombotic events in patients with laboratory-expressed APS and no clinical manifestations.

Cluster analysis of antiphospholipid antibodies-associated adverse pregnancy outcome patients: based on a 13-years cohort study

Antiphospholipid antibodies (aPLs) are the leading causes of adverse pregnancy outcomes (APOs). We conducted cluster analysis to identify distinct phenotypes among aPLs-associated APOs patients. This approach aims to facilitate risk stratification and improve pregnancy outcomes for obstetric APS. This was a retrospective study of persistent aPLs positive women cohort in Peking Union Medical College Hospital. Baseline demographic characteristics, clinical manifestation, previous APOs and antibodies profiles were included for hierarchical cluster analysis. Placentae from portions of patients were collected and performed the histopathologic diagnoses. Four clusters among 209 patients with 477 pregnancies were identified. Cluster 1 comprised patients with triple aPLs positivity and demonstrates a high incidence of gestational hypertension (34.92%, P < 0.05) and preterm delivery (20.63%, P < 0.05). Patients in cluster 2 were characterized by lupus anticoagulant (LA) positivity, with high risk of whole gestational APOs. Cluster 3 included patients with isolated aPLs-IgM isotype combined with early miscarriage (60.92%, P = 0.016). Patients in cluster 4 majorly presented aPLs-IgG isotype combined with placenta insufficiency (22.73%). During the follow-up, the live birth rate in cluster 1 and 2 was only 69.20%. Placenta pathology revealed the most severe impairment within cluster 1, whereas clusters 3 and 4 exhibited relatively milder damage. By cluster analysis, we identified four clinical subtypes of aPLs-associated APOs patients. Patients with triple antibodies or high-risk lupus characteristics were prone to occurred gestational hypertension and premature delivery. Isolated LA or aCL/aβ2GPI positivity were found to be more frequently associated with early-stage fetal loss.

The impact of pregnancy planning and medical readiness on reproductive outcomes in women with systemic lupus erythematosus

Women with systemic lupus erythematosus (SLE) who get pregnant while SLE is active or while on teratogens have higher risk of poor pregnancy outcomes. The American College of Rheumatology (ACR) Reproductive Health Guidelines recommend women conceive when SLE is well controlled and treated with pregnancy-compatible medications. The Healthy Outcomes in Pregnancy with SLE Through Education of Providers (HOP-STEP) Intervention was created to ascertain pregnancy interest and contraceptive use followed by a personalized pregnancy prevention and/or planning discussion (https://www.LupusPregnancy.org). All study participants were adult females enrolled in a prospective registry who met ACR or SLICC criteria. Women were defined as "not medically ready for pregnancy" if they were currently prescribed a teratogen, had proteinuria ≥500 mg, or had elevated SLE activity according to the physician's global assessment. Two time periods were assessed: 2/2018-12/2019 and 10/2020-4/2021 to evaluate pre- and post-pandemic periods, with some post-pandemic visits taking place via telehealth. The interest in pregnancy was similar between the first time period (17%) and the second time period, whether in-person (18%) or virtual (18%). Pregnancy interest was assessed significantly more frequently during in-person visits (90%) compared to virtual encounters (67%) (p = .02). Contraceptive use was not significantly different during either time period with use of a teratogen or increased SLE activity. Of the 52 women in both time periods who were not medically ready for pregnancy and were not on effective contraception, three women (5.8%) conceived. None of the women who were using moderate or highly effective contraception became pregnant. Pregnancy outcomes were similar between unintended or high-risk and well-timed pregnancies. The HOP-STEP Intervention effectively identified pregnancy interest, giving rheumatologists the opportunity to address patient reproductive goals, optimize disease activity, and adjust medication regimens prior to conception.

Lupus and recurrent pregnancy loss: the role of female sex hormones and B cells

Systemic lupus erythematosus is a debilitating autoimmune disease characterized by uncontrolled activation of adaptive immunity, particularly B cells, which predominantly affects women in a 9 to 1 ratio compared to men. This stark sex disparity strongly suggests a role for female sex hormones in the disease's onset and progression. Indeed, it is widely recognized that estradiol not only enhances the survival of autoreactive B cells but also stimulates the production of autoantibodies associated with systemic lupus erythematosus, such as anti-nuclear antibodies and anti-dsDNA antibodies. Clinical manifestations of systemic lupus erythematosus typically emerge after puberty and persist throughout reproductive life. Furthermore, symptoms often exacerbate during the premenstrual period and pregnancy, as increased levels of estradiol can contribute to disease flares. Despite being fertile, women with lupus face a heightened risk of pregnancy-related complications, including pregnancy loss and stillbirth, which significantly surpass the rates observed in the healthy population. Therefore, this review aims to summarize and discuss the existing literature on the influence of female sex hormones on B-cell activation in patients with systemic lupus erythematosus, with a particular emphasis on their impact on pregnancy loss.

Pregnancy outcomes in 1869 pregnancies in a large cohort from the Spanish Society of Rheumatology Lupus Register (RELESSER)

INTRODUCTION

Obstetric complications are more common in women with systemic lupus erythematosus (SLE) than in the general population.

OBJECTIVE

To assess pregnancy outcomes in women with SLE from the RELESSER cohort after 12 years of follow-up.

METHODS

A multicentre retrospective observational study was conducted. In addition to data from the RELESSER register, data were collected on obstetric/gynaecological variables and treatments received. The number of term pregnancies was compared between women with pregnancies before and after the diagnosis of SLE. Further, clinical and laboratory characteristics were compared between women with pregnancies before and after the diagnosis, on the one hand, and with and without complications during pregnancy, on the other. Bivariate and multivariate analyses were carried out to identify factors potentially associated with complications during pregnancy.

RESULTS

A total of 809 women were included, with 1869 pregnancies, of which 1395 reached term. Women with pregnancies before the diagnosis of SLE had more pregnancies (2.37 vs 1.87) and a higher rate of term pregnancies (76.8% vs 69.8%, p < 0.001) compared to those with pregnancies after the diagnosis. Women with pregnancies before the diagnosis were diagnosed at an older age (43.4 vs 34.1 years) and had more comorbidities. No differences were observed between the groups with pregnancies before and after diagnosis in antibody profile, including anti-dsDNA, anti-Sm, anti-Ro, anti-La, lupus anticoagulant, anticardiolipin or anti-beta-2-glycoprotein. Overall, 114 out of the 809 women included in the study experienced complications during pregnancy, including miscarriage, preeclampsia/eclampsia, foetal death, and/or preterm birth. Women with complications had higher rates of antiphospholipid syndrome (40.5% vs 9.9%, p < 0.001) and higher rates of positivity for IgG anticardiolipin (33.9% vs 21.3%, p = 0.005), IgG anti-beta 2 glycoprotein (26.1% vs 14%, p = 0.007), and IgM anti-beta 2 glycoprotein (26.1% vs 16%, p = 0.032) antibodies, although no differences were found regarding lupus anticoagulant. Among the treatments received, only heparin was more commonly used by women with pregnancy complications. We did not find differences in corticosteroid or hydroxychloroquine use.

CONCLUSIONS

The likelihood of term pregnancy is higher before the diagnosis of SLE. In our cohort, positivity for anticardiolipin IgG and anti-beta-2- glycoprotein IgG/IgM, but not lupus anticoagulant, was associated with a higher risk of poorer pregnancy outcomes.

Preconception clinical factors related to adverse pregnancy outcomes in patients with systemic lupus erythematosus or primary Sjögren's syndrome: a retrospective cohort study

OBJECTIVE

To identify preconception clinical factors associated with adverse pregnancy outcomes (APO) in patients with systemic lupus erythematosus (SLE) or primary Sjögren's syndrome (pSS).

METHODS

A single-centre, retrospective cohort study was conducted, which included pregnant women treated at the University Medical Center Groningen between January 2010 and August 2021 who fulfilled classification criteria for SLE or pSS. Demographic data, relevant comorbidities, disease duration, disease activity before and during pregnancy, APO, laboratory parameters and treatment regimens were recorded. Associations between the presence of APO and preconception characteristics were evaluated.

RESULTS

Our study population included 48 (70%) SLE and 21 (30%) pSS pregnancies concerning 70 fetuses (one twin). Preterm birth (n=9, 19%) was the most frequent APO in SLE pregnancies, while in pSS pregnancies this was miscarriages (n=3, 14%). There were no associations between the presence of APO in SLE pregnancies and clinical parameters, laboratory parameters or medication use prior to conception. In the pSS group, significant associations were found between the presence of APO and body mass index (p=0.010), parity (p=0.046), C4 (p=0.021) and low C4 levels (p=0.002).

CONCLUSIONS

No preconception risk factors related to APO were found in SLE pregnancies, whereas preconception complement levels were associated with APO development in patients with pSS.

A systematic literature review to examine the considerations around pregnancy in women of child-bearing age with myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) or aquaporin 4 neuromyelitis optica spectrum disorder (AQP4+ NMOSD)

BACKGROUND

Aquaporin-4 antibody positive (AQP4+) neuromyelitis optica spectrum disorder (NMOSD) and myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) are rare autoimmune diseases with overlapping phenotypes. Understanding their clinical manifestation prior to, during and after pregnancy may influence the management of women of child-bearing age (WOCBA) with these diseases.

METHODS

This systematic review identified relevant MEDLINE-indexed publications dated between 01 January 2011 and 01 November 2021, and congress materials from key conferences between 01 January 2019 and 01 November 2021. These were manually assessed for relevance to AQP4+ NMOSD and/or MOGAD in WOCBA, with selected data extracted and considered.

RESULTS

In total, 107 articles were retrieved and reviewed for relevancy, including 65 clinical studies. Limited evidence was found regarding a conclusive impact of either disease on female fertility, sexual function or menarche, and impact on maternal outcomes requires further investigation in both conditions to establish risk for pre-eclampsia, gestational diabetes and other complications relative to the general population. Collated data for pregnancy outcomes show clear risks in AQP4+ NMOSD to healthy delivery and a rise in annualised relapse rate postpartum that may require adaptation of treatment regimens. Disease activity appears to be attenuated during pregnancy in MOGAD patients with an increased risk of relapse during the postpartum months, but strong conclusions cannot be made due to a paucity of available data.

CONCLUSIONS

This review brings together the literature on AQP4+ NMOSD and MOGAD in WOCBA. The potential impact of pregnancy and the postpartum period on disease activity suggest a proactive management strategy early on may improve maternal and infant outcomes, but more clinical data are needed, particularly for MOGAD.

Pregnancy outcomes among Egyptian women with systemic lupus erythematosus: A prospective cohort study

Pregnant patients with systemic lupus erythematosus (SLE) represent a high-risk group. The aim of this study is to describe the pregnancy outcomes among SLE patients who were followed prospectively at a conjoint high-risk pregnancy/rheumatology clinic from 2007 to 2021 and to identify predictors of adverse maternal and fetal outcomes. This study included 201 singleton pregnancies of 123 women with SLE. Their mean age was 27.16 ± 4.80 years, and their mean disease duration was 7.35 ± 5.46 years. Secondary antiphospholipid syndrome (APS) was diagnosed in 77 (38.3%) pregnancies. The pregnancy was planned in 104 (51.7%) pregnancies. Flares occurred in 83 (41.3%) and pre-eclampsia in 15 (7.5%) pregnancies. Full-term pregnancy occurred in 93 (46.3%), fetal loss (miscarriage and intra-uterine fetal death) in 41 (20.4%), and prematurity in 67 (33.3%) of the pregnancies, respectively. Seven neonates died from complications of prematurity, and another one died from cardiac congenital anomalies. In the multivariate analyses, unplanned pregnancy was associated with eight times higher risk of disease flare OR = 7.92 (p < 0.001), lupus nephritis flare during pregnancy increased the odds of pre-eclampsia occurrence four times OR = 3.98 (p = 0.02), while disease flares during pregnancy predicted prematurity OR = 2.49, p = 0.049. Patients with secondary APS had three times increased risk of fetal loss OR = 2.97, p = 0.049. To conclude, unplanned pregnancy, disease flares, and APS have been identified as predictors for adverse maternal and/or fetal outcomes. Pregnancy planning is necessary to reduce maternal and fetal complications.

Expression pattern of glucocorticoid receptor α gene and associations with clinicolaboratory features in patients with systemic lupus erythematosus

Background

Glucocorticoid receptor α (GRα) gene is a transcription factor with clinically significant immune-modulating properties in various autoimmune diseases. However, the expression pattern of the GRα gene and associations with clinical features in patients with systemic lupus erythematosus (SLE) is controversial. This study aimed to assess the correlation between the GRα expression and different clinical and laboratory-related parameters in SLE patients.

Methods

A total of 45 women with newly diagnosed SLE and 31 gender and age-matched healthy controls were enrolled in this cross-sectional study. The real-time quantitative PCR (qRT-PCT) method evaluated the differences in GRα expression in peripheral blood mononuclear cells from cases and controls. The correlation between the GRα gene expression levels, clinicolaboratory features, and potential prognostic application was also analyzed.

Results

Compared to the healthy individuals, the GRα gene expression in newly diagnosed SLE patients who did not receive any treatment was numerically reduced, but this reduction did not achieve statistical significance (P=0.87). No significant correlation was also found with the activity and severity of SLE according to SLEDAI2K (P=0.41). The GRα gene expression showed a negative correlation with CRP (P=0.034) and a positive correlation with lupus anticoagulant (P=0.039) levels in SLE. The receiver operating characteristic (ROC) curve analysis indicated that the GRα expression level might be a predictor biomarker for low CRP and positive lupus anticoagulant in SLE, respectively.

Conclusion

This study proposed that expression of the GRα in newly diagnosed lupus patients has no statistically significant difference with healthy age and sex-matched controls. Besides, its expression does not correlate with lupus disease activity according to SLEDAI2k. However, further studies in this area are required.

Alternative pathway activation in pregnancy, a measured amount "complements" a successful pregnancy, too much results in adverse events

During pregnancy, the maternal host must adapt in order to enable growth of the fetus. These changes affect all organ systems and are designed both to protect the fetus and to minimize risk to the mother. One of the most prominent adaptations involves the immune system. The semi-allogenic fetoplacental unit has non-self components and must be protected against attack from the host. This requires both attenuation of adaptive immunity and protection from innate immune defense mechanisms. One of the key innate immune players is complement, and it is important that the fetoplacental unit is not identified as non-self and subjected to complement attack. Adaptation of the complement response must, however, be managed in such a way that maternal protection against infection is not compromised. As the complement system also plays a significant facilitating role in many of the stages of a normal pregnancy, it is also important that any necessary adaptation to accommodate the semi-allogenic aspects of the fetoplacental unit does not compromise this. In this review, both the physiological role of the alternative pathway of complement in facilitating a normal pregnancy, and its detrimental participation in pregnancy-specific disorders, are discussed.

A Comparative Analysis of Anticardiolipin, Anti-Β2-Glycoprotein-1, and Lupus Anticoagulants in Saudi Women with Recurrent Spontaneous Abortions

Association and pathogenesis of antiphospholipid antibodies (APAs) in patients with Antiphospholipid syndrome (APS) as well as systemic lupus erythematosus (SLE) suffering from unexplained spontaneous abortions is controversial. Moreover, the majority of the published evidence is based on the patient histories rather than the study groups. The main objective of the present study is to do a comparative analysis of the high levels of antiphospholipid antibodies (APAs) including anticardiolipin (ACA), anti-β2-glycoprotein-1 (β2 GP1), and Lupus anticoagulants (LA) and their association with the gestational age of abortion and duration past abortion in Saudi women. In this study, 100 women living in Makkah city, located in the Western region of Saudi Arabia, with a mean age of 30.5 ± 12.60 years (mean ± standard deviation), having a previous history of recurrent spontaneous abortions were enrolled as case group and 100 healthy pregnant women previously having one or more successful pregnancies were selected as control group. Based on the gestational age of the patient’s miscarriages, our results revealed consistently and significantly high levels of ACA, β2 GP1, and LA, being greatest at more than 15 weeks when compared with 10 weeks and 11−15 weeks, respectively. Based on duration of past miscarriages, a slightly increased level was observed at ≤4 years after their first miscarriage. In addition, less or more equal levels of these antibodies were observed at 5−12 and more than 12 years in all the cases of miscarriages. We concluded an elevated pattern of APAs in these patients with an increase in the age of abortion. A comparison between the levels of ACA, β2 GP1, and LA further indicated a highly significant level of LA in all the cases of abortions (p < 0.0005).

Pregnancy outcomes in antiphospholipid antibody positive patients: prospective results from the AntiPhospholipid Syndrome Alliance for Clinical Trials and InternatiOnal Networking (APS ACTION) Clinical Database and Repository ('Registry')

OBJECTIVES

To describe the outcomes of pregnancies in antiphospholipid antibody (aPL)-positive patients since the inception of the AntiPhospholipid Syndrome Alliance for Clinical Trials and InternatiOnal Networking Registry.

METHODS

We identified persistently aPL-positive patients recorded as 'pregnant' during prospective follow-up, and defined 'aPL-related outcome' as a composite of: (1) Preterm live delivery (PTLD) at or before 37th week due to pre-eclampsia (PEC), eclampsia, small-for-gestational age (SGA) and/or placental insufficiency (PI); or (2) Otherwise unexplained fetal death after the 10th week of gestation. The primary objective was to describe the characteristics of patients with and without aPL-related composite outcomes based on their first observed pregnancies following registry recruitment.

RESULTS

Of the 55 first pregnancies observed after registry recruitment among nulliparous and multiparous participants, 15 (27%) resulted in early pregnancy loss <10 weeks gestation. Of the remaining 40 pregnancies: (1) 26 (65%) resulted in term live delivery (TLD), 4 (10%) in PTLD between 34.0 weeks and 36.6 weeks, 5 (12.5%) in PTLD before 34th week, and 5 (12.5%) in fetal death (two associated with genetic anomalies); and (2) The aPL-related composite outcome occurred in 9 (23%). One of 26 (4%) pregnancies with TLD, 3/4 (75%) with PTLD between 34.0 weeks and 36.6 weeks, and 3/5 (60%) with PTLD before 34th week were complicated with PEC, SGA and/or PI. Fifty of 55 (91%) pregnancies were in lupus anticoagulant positive subjects, as well as all pregnancies with aPL-related composite outcome.

CONCLUSION

In our multicentre, international, aPL-positive cohort, of 55 first pregnancies observed prospectively, 15 (27%) were complicated by early pregnancy loss. Of the remaining 40 pregnancies, composite pregnancy morbidity was observed in 9 (23%) pregnancies.

Physician Global Assessment International Standardisation COnsensus in Systemic Lupus Erythematosus: the PISCOS study

The Physician Global Assessment International Standardisation COnsensus in Systemic Lupus Erythematosus (PISCOS) study aimed to obtain an evidence-based and expert-based consensus standardisation of the Physician Global Assessment (PGA) scoring of disease activity in systemic lupus erythematosus (SLE). An international panel of 79 SLE experts participated in a three-round Delphi consensus process, in which 41 statements related to the PGA in SLE were rated, using a 0 (strongly disagree) to 10 (strongly agree) numerical rating scale. Statements with agreement of 75% or greater were selected and further validated by the expert panel. Consensus was reached on 27 statements, grouped in 14 recommendations, for the use of the PGA in SLE, design of the PGA scale, practical considerations for PGA scoring, and the relationship between PGA values and levels of disease activity. Among these recommendations, the expert panel agreed that the PGA should consist of a 0-3 visual analogue scale for measuring disease activity in patients with SLE in the preceding month. The PGA is intended to rate the overall disease activity, taking into account the severity of active manifestations and clinical laboratory results, but excluding organ damage, serology, and subjective findings unrelated to disease activity. The PGA scale ranges from "no disease activity" (0) to the "most severe disease activity" (3) and incorporates the values 1 and 2 as inner markers to categorise disease activity as mild (≥0·5 to 1), moderate (>1 and ≤2) and severe (>2 to 3). Only experienced physicians can rate the PGA, and it should be preferably scored by the same rater at each visit. The PISCOS results will allow for increased homogeneity and reliability of PGA ratings in routine clinical practice, definitions of remission and low disease activity, and future SLE trials.

Potential genetic biomarkers predict adverse pregnancy outcome during early and mid-pregnancy in women with systemic lupus erythematosus

BACKGROUND

Effectively predicting the risk of adverse pregnancy outcome (APO) in women with systemic lupus erythematosus (SLE) during early and mid-pregnancy is a challenge. This study was aimed to identify potential markers for early prediction of APO risk in women with SLE.

METHODS

The GSE108497 gene expression dataset containing 120 samples (36 patients, 84 controls) was downloaded from the Gene Expression Omnibus database. Weighted gene co-expression network analysis (WGCNA) was performed, and differentially expressed genes (DEGs) were screened to define candidate APO marker genes. Next, three individual machine learning methods, random forest, support vector machine-recursive feature elimination, and least absolute shrinkage and selection operator, were combined to identify feature genes from the APO candidate set. The predictive performance of feature genes for APO risk was assessed using area under the receiver operating characteristic curve (AUC) and calibration curves. The potential functions of these feature genes were finally analyzed by conventional gene set enrichment analysis and CIBERSORT algorithm analysis.

RESULTS

We identified 321 significantly up-regulated genes and 307 down-regulated genes between patients and controls, along with 181 potential functionally associated genes in the WGCNA analysis. By integrating these results, we revealed 70 APO candidate genes. Three feature genes, SEZ6, NRAD1, and LPAR4, were identified by machine learning methods. Of these, SEZ6 (AUC = 0.753) showed the highest in-sample predictive performance for APO risk in pregnant women with SLE, followed by NRAD1 (AUC = 0.694) and LPAR4 (AUC = 0.654). After performing leave-one-out cross validation, corresponding AUCs for SEZ6, NRAD1, and LPAR4 were 0.731, 0.668, and 0.626, respectively. Moreover, CIBERSORT analysis showed a positive correlation between regulatory T cell levels and SEZ6 expression (P < 0.01), along with a negative correlation between M2 macrophages levels and LPAR4 expression (P < 0.01).

CONCLUSIONS

Our preliminary findings suggested that SEZ6, NRAD1, and LPAR4 might represent the useful genetic biomarkers for predicting APO risk during early and mid-pregnancy in women with SLE, and enhanced our understanding of the origins of pregnancy complications in pregnant women with SLE. However, further validation was required.

Outcomes of pregnancy and associated factors in sub-Saharan African women with systemic lupus erythematosus: a scoping review

Objective

To scope and summarise available literature on the outcomes of pregnancy and associated factors in sub-Saharan African women with SLE.

Methods

Electronic databases and reference lists of retrieved articles were searched to identify relevant studies published from 1 January 2000 to 28 October 2019. Data were combined through narrative synthesis.

Results

We included four studies retrospectively reporting a total of 137 pregnancies in 102 women over a 26-year period. Mean age at conception ranged from 27.2 to 39.9 years. Kidney damage, the predominant organ manifestation before conception, was reported in 43 (42.2%) patients. Ninety-seven (70.8%) pregnancies resulted in 98 live births. SLE flares occurred in 44 (32.2%) pregnancies, mainly skin (20.4%) and renal (18.2%) flares. Major adverse pregnancy outcomes (APOs) were preterm birth 38.8%, low birth weight 29.8%, pregnancy loss 29.2% and pre-eclampsia 24.8%. The main factors associated with APOs were nephritis and SLE flares.

Conclusion

Over two-thirds of pregnancies resulted in live birth in this cohort of sub-Saharan African women with SLE. The main APOs and associated factors described in other parts of the world are also seen in this region, but with high rates of APOs. A large prospective multinational study is warranted for more compelling evidence.

Use of Physician Global Assessment in systemic lupus erythematosus: a systematic review of its psychometric properties

OBJECTIVE

The Physician Global Assessment (PGA) is a visual analogue score that reflects the clinician's judgement of overall SLE disease activity. The aim of this systematic literature review is to describe and analyse the psychometric properties of the PGA.

METHODS

This systematic literature review was conducted by two independent reviewers in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. All articles published through 1 July 2019 in PubMed were screened, with no limitation on year of publication, language or patients' age. Psychometric properties data were analysed according to the OMERACT Filter methodology version 2.1.

RESULTS

The literature search identified 91 studies. Face validity was reported in all the articles retrieved in which the PGA was used alone or as part of composite indices (Systemic Responder Index, Safety of Estrogen in Lupus Erythematosus National Assessment Flare Index, Lupus Low Disease Activity State, Definitions of Remission in Systemic Lupus Erythematosus criteria). Content validity was reported in 89 studies. Construct validity was demonstrated by a good correlation (r ≥ 0.50) between the PGA with the SLEDAI (12 studies), SLAM (4 studies), LAI, BILAG and ECLAM (2 studies each). Criterion validity was assessed exploring the PGA correlation with quality of life measurements, biomarker levels and treatment changes in 28 studies, while no study has evaluated correlation with damage. A good responsiveness for PGA was shown in eight studies. A high variability in scales was found, causing a wide range of reliability (intraclass correlation coefficient 0.67-0.98).

CONCLUSION

PGA is a valid, responsive and feasible instrument, though its reliability was impacted by the scale adopted, suggesting the major need for standardization of its scoring.

Pregnancy rates and perinatal outcomes in women with systemic lupus erythematosus: data from the Korean national health claims database

INTRODUCTION/OBJECTIVES

The pregnancy rate in systemic lupus erythematosus (SLE) is not fully understood and comparisons of adverse pregnancy outcomes (APOs) with SLE versus the general population are limited. This study aimed to estimate the pregnancy rate and APOs in Korean SLE compared to those without SLE.

METHOD

Pregnant women were identified using the ICD-10 codes for delivery and abortion in the Korean national health claims database (2013-2015). APOs were classified as fetal loss, intrauterine growth retardation (IUGR), pre-eclampsia/eclampsia, and gestational diabetes. Annual incidence rates (IRs) of pregnancy and APOs were calculated in women with SLE and the general population without SLE and the two groups were compared using age-adjusted incidence rate ratios (IRRs). Age-stratified IRRs were further analyzed.

RESULTS

The annual IRs of pregnancy in SLE were 29.54-30.70 per 1000 persons. The IRRs were lower in women with SLE than in the general population: 0.68 (0.61-0.76), 0.66 (0.60-0.74), and 0.74 (0.66-0.82) in each respective year. The IRRs of fetal loss, IUGR, and pre-eclampsia/eclampsia were 1.30 (1.14-1.49), 4.65 (3.55-6.09), and 3.43 (2.70-4.36), respectively. However, the IRR of gestational diabetes in SLE did not significantly differ from that of women without SLE. Among the APOs, fetal loss, IUGR, and pre-eclampsia/eclampsia showed decreasing tendencies as age increased.

CONCLUSIONS

Pregnancy rates in SLE were approximately 30% lower than those in the general population. Except for gestational diabetes, fetal loss, IUGR, and pre-eclampsia/eclampsia were higher in SLE and showed a decreasing tendency with age. Key Points • This population-based cohort study showed that pregnancy rates in SLE were approximately 30% lower than those in the general population. • SLE had a 1.3-fold higher rate of fetal loss, more than 4-fold higher IUGR rate, and more than 3-fold pre-eclampsia or eclampsia rate compared with the general population. • Adverse pregnancy outcomes in SLE showed a decreasing tendency with age.

Pregnancy in systemic lupus erythematosus

OBJECTIVES

Systemic lupus erythematosus (SLE) is a chronic illness that often affects women of reproductive age. The objectives of this article are to review the impact of SLE on pregnancy and current management strategies, including commonly used therapies.

METHODS

We conducted a review of available literature on the clinical course of SLE, diagnosis, management and pregnancy complications.

RESULTS

SLE has a variable clinical course characterized by flares and periods of remission and can present unique challenges in the management of obstetric patients. Pregnancy in patients with SLE is associated with multiple risks, including fetal loss, preterm birth, fetal growth restriction, and hypertensive disease. With advancements in disease treatment, many women have favorable pregnancy outcomes, but appropriate preconception counseling and disease management remain important tools in reducing complications.

CONCLUSION

Given the implications SLE can have on women of reproductive age and in pregnancy, understanding the disease course and management is important in order to optimize pregnancy outcomes.

Adverse pregnancy outcomes among multi-ethnic systemic lupus erythematosus patients in Malaysia

BACKGROUND

Despite the improvement in the live birth rate among patients with systemic lupus erythematosus (SLE), they are still at an increased risk of adverse pregnancy outcomes (APOs).

OBJECTIVE

To determine the prevalence and factors associated with APOs in the multi-ethnic SLE populations in Malaysia.Methodology: This was a retrospective review of the consecutive SLE patients who attended the outpatient clinic in two major rheumatology centres from January 2016 until December 2019 with complete pre-pregnancy, antenatal and intra-partum records. APOs include pregnancy loss, prematurity, pre-eclampsia, intra-uterine growth restriction (IUGR) and maternal death. Univariate and multivariable logistic regression with generalised estimating equation (GEE) analyses were performed to determine the factors associated with APOs.

RESULTS

A total of 153 patients with 240 pregnancies were included and the majority of the patients were Malay (69.9%), followed by Chinese (24.2%) and Indian (5.9%). The prevalence of APOs was 61.7% with the commonest complication being prematurity (28.3%), followed by pregnancy loss (24.6%) and pre-eclampsia (21.8%). Logistic regression model-based GEE analysis revealed that the independent predictors of APOs were active haematological system during pregnancy, pre-pregnancy active disease, Indian patients and positive lupus anticoagulant. Hydroxychloroquine use was associated with lower APOs including pre-eclampsia, prematurity and IUGR in the univariate analyses but it was no longer significant in the GEE analysis.

CONCLUSION

The prevalence of APOs was high particularly among the Indian patients. Positive lupus anticoagulant and pre-pregnancy active disease were the factors strongly associated with APOs in our multi-ethnic cohort. Hydroxychloroquine may protect against APOs but further larger studies are needed to confirm this.

The antiphospholipid syndrome - often overlooked cause of vascular occlusions?

The antiphospholipid syndrome (APS) was fully recognized as a clinical entity in the early 1980s. Still, more than 30 years later, the epidemiology of APS is not well described, and furthermore, APS remains a challenge in terms of both diagnostic issues and clinical praxis involving a wide range of specialties. To date, there are no diagnostic criteria for APS. The present classification criteria rely on a combination of clinical manifestations and persistently positive tests for antiphospholipid antibodies (aPL). Clinical symptoms comprise vascular thrombosis, which can affect any vascular bed, including venous, microvascular and arterial vessels, and a set of pregnancy morbidities including early and late miscarriages, foetal death and preeclampsia. APS is more frequent among patients with other autoimmune diseases, and it is especially common in systemic lupus erythematosus (SLE). Importantly, APS symptoms can present in almost any medical specialty, but general knowledge and most previous clinical studies have essentially been confined to haematology, rheumatology and obstetrics/gynaecology. However, recent data demonstrate a relatively high prevalence of aPL also in patients from the general population who suffer from vascular occlusions or pregnancy complications. It is important that these patients are recognized by the general health care since APS is a treatable condition. This review aims to summarize the present knowledge on the history, pathogenesis, clinical manifestations and treatment of APS in order to urge a wide range of clinicians to consider comprehensive assessment of all patients where the diagnosis APS may be conceivable.

Pregnancy and Systemic Lupus Erythematosus

As SLE onset is often in young adulthood, pregnancy is common and is usually successful. Pregnancy, though, is considered high-risk due to a combination of maternal (lupus flare, diabetes, pre-eclampsia) and fetal (miscarriage, intrauterine fetal demise, preterm birth, intrauterine growth restriction, congenital heart block) risks. Pregnancy should be planned for a time of good control of SLE (on allowable medications). The antimalarial hydroxychloroquine should be continued. The only permitted immunosuppressive drugs are azathioprine and tacrolimus. Of the antiphospholipid antibodies, only the lupus anticoagulant has been associated with adverse pregnancy outcomes in the largest prospective multicenter study, Predictors of Pregnancy Outcome: Biomarkers in Antiphospholipid Antibody Syndrome and Systemic Lupus Erythematosus (PROMISSE). Management of antiphospholipid syndrome in pregnancy is low molecular weight heparin and aspirin, although only 75% of pregnancies are successful.

2020 American College of Rheumatology Guideline for the Management of Reproductive Health in Rheumatic and Musculoskeletal Diseases

OBJECTIVE

To develop an evidence-based guideline on contraception, assisted reproductive technologies (ART), fertility preservation with gonadotoxic therapy, use of menopausal hormone replacement therapy (HRT), pregnancy assessment and management, and medication use in patients with rheumatic and musculoskeletal disease (RMD).

METHODS

We conducted a systematic review of evidence relating to contraception, ART, fertility preservation, HRT, pregnancy and lactation, and medication use in RMD populations, using Grading of Recommendations Assessment, Development and Evaluation methodology to rate the quality of evidence and a group consensus process to determine final recommendations and grade their strength (conditional or strong). Good practice statements were agreed upon when indirect evidence was sufficiently compelling that a formal vote was unnecessary.

RESULTS

This American College of Rheumatology guideline provides 12 ungraded good practice statements and 131 graded recommendations for reproductive health care in RMD patients. These recommendations are intended to guide care for all patients with RMD, except where indicated as being specific for patients with systemic lupus erythematosus, those positive for antiphospholipid antibody, and/or those positive for anti-Ro/SSA and/or anti-La/SSB antibodies. Recommendations and good practice statements support several guiding principles: use of safe and effective contraception to prevent unplanned pregnancy, pre-pregnancy counseling to encourage conception during periods of disease quiescence and while receiving pregnancy-compatible medications, and ongoing physician-patient discussion with obstetrics/gynecology collaboration for all reproductive health issues, given the overall low level of available evidence that relates specifically to RMD.

CONCLUSION

This guideline provides evidence-based recommendations developed and reviewed by panels of experts and RMD patients. Many recommendations are conditional, reflecting a lack of data or low-level data. We intend that this guideline be used to inform a shared decision-making process between patients and their physicians on issues related to reproductive health that incorporates patients' values, preferences, and comorbidities.

Effect of hypocomplementemia on perinatal outcomes of pregnancies with autoimmune disorders

OBJECTIVE

To demonstrate the effect of preconceptional complement levels on perinatal outcomes of pregnancies with autoimmune disorders.

METHODS

Pregnant women with autoimmune disorders (autoimmune disease and/or autoimmune antibody positivity) who were screened for complement levels (C3 and C4) prior to their pregnancies were enrolled in a special antenatal care program. These patients were administered low-dose low-molecular-weight heparin (enoxaparine, 1 × 2000 Anti-XA IU/0.2 mL/day), low-dose salysilic acid (100 mg/day) and low-dose corticosteroid (methylprednisolone, 1 × 4 mg/day orally) as soon as their pregnancies were confirmed according to the institutional protocol. We have compared hypo- and normocomplement pregnancies with autoimmune disorders in terms of their obstetric and perinatal outcomes. We have also used Beksac Obstetric Index (BOI) which is "[living child + (π/10)]/gravidity" for the comparison of their previous obstetric histories.

RESULTS

Obstetric and neonatal outcomes showed no significant difference between hypocomplement patients (n= 38) and control group (n= 157) (p> 0.05). "Composite obstetric and perinatal adverse outcome" rates were 26.2% and 27.3% in study and control groups, respectively (p> 0.05). BOI was significantly lower in hypocomplement patients (p: 0.002). Then, we have classified hypocomplement patients into 3 subgroups according to the type of complement (C3, C4 or both). Comparison inbetween these groups revealed no statistical significance in any of the analyzed parameters (p> 0.05).

CONCLUSION

Low complement levels in pregnant women with autoimmune disorders may be associated with gestational problems and poor obstetric history. Immunomodulatory treatment modalities such as ours may be beneficial for improving the obstetric and neonatal outcomes.

B cell depletion and pregnancy: Review and applications for MS treatment

Multiple sclerosis (MS) is a chronic autoimmune condition primarily affecting young adults. As there are numerous uncertainties faced by young women of childbearing age who are living with this chronic condition and the gender ratio is increasingly skewed towards women, it has become critical to define a clear approach to questions of disease management prior to and during pregnancy. With the approval of B cell depletion therapy for treatment of relapsing remitting and primary progressive MS, we explore the available data on using this type of therapy in the setting of pregnancy. We also provide recommendations regarding use of B-cell depleting therapies for patients who are considering or attempting conception.

Obstetric antiphospholipid syndrome

The present clinical and laboratory classification criteria for antiphospholipid syndrome (APS) were established in Sydney, Australia, in 2006. In this review, we focus on the obstetric subset of APS (OAPS), defined by persistent positivity for antiphospholipid antibodies together with either early recurrent pregnancy loss, early fetal death, stillbirth or premature birth <34 gestational weeks due to pre-eclampsia, eclampsia and placental insufficiency. It is important to diagnose these cases since most women suffering from OAPS can, when given appropriate treatment, have successful pregnancies. Furthermore, patients with OAPS may, depending on the antibody profile, be at enhanced risk of thrombotic events later in life. We present an update on the present knowledge of possible underlying pathogenesis, risk factors and risk estimations for adverse pregnancy outcomes before and during pregnancy, current treatment concepts, and long-term outcomes for women with OAPS and their children.

Systemic Lupus Erythematosus and Pregnancy

Systemic lupus erythematosus (SLE) is an autoimmune disease with a strong female predilection. Pregnancy remains a commonly encountered but high-risk situation in this setting. Both maternal and fetal mortality and morbidity are still significantly increased despite improvements in outcomes. Maternal morbidity includes higher risk of disease flares, preeclampsia and other pregnancy-related complications. Fetal issues include higher rates of preterm birth, intrauterine growth restriction, and neonatal lupus syndromes. Treatment options during pregnancy are also limited and maternal benefit has to be weighed against fetal risk. A coordinated approach, with close monitoring by a multidisciplinary team, is essential for optimal outcomes.

Complement inhibition by hydroxychloroquine prevents placental and fetal brain abnormalities in antiphospholipid syndrome

Placental ischemic disease and adverse pregnancy outcomes are frequently observed in patients with antiphospholipid syndrome (APS). Despite the administration of conventional antithrombotic treatment a significant number of women continue to experience adverse pregnancy outcomes, with uncertain prevention and management. Efforts to develop effective pharmacological strategies for refractory obstetric APS cases will be of significant clinical benefit for both mothers and fetuses. Although the antimalarial drug, hydroxychloroquine (HCQ) is increasingly used to treat pregnant women with APS, little is known about its efficacy and mechanism of action of HCQ. Because complement activation plays a crucial and causative role in placental ischemia and abnormal fetal brain development in APS we hypothesised that HCQ prevents these pregnancy complications through inhibition of complement activation. Using a mouse model of obstetric APS that closely resembles the clinical condition, we found that HCQ prevented fetal death and the placental metabolic changes -measured by proton magnetic resonance spectroscopy in APS-mice. Using 111In labelled antiphospholipid antibodies (aPL) we identified the placenta and the fetal brain as the main organ targets in APS-mice. Using this same method, we found that HCQ does not inhibit aPL binding to tissues as was previously suggested from in vitro studies. While HCQ did not affect aPL binding to fetal brain it prevented fetal brain abnormal cortical development. HCQ prevented complement activation in vivo and in vitro. Complement C5a levels in serum samples from APS patients and APS-mice were lower after treatment with HCQ while the antibodies titres remained unchanged. HCQ prevented not only placental insufficiency but also abnormal fetal brain development in APS. By inhibiting complement activation, HCQ might also be an effective antithrombotic therapy.

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.

Management of Systemic Lupus Erythematosus During Pregnancy

Reproductive issues including contraception, fertility, and pregnancy are important components of the comprehensive care of women with systemic lupus erythematosus (SLE). SLE pregnancies are complicated due to risk for maternal disease exacerbation and potential for fetal and neonatal complications. Pre-pregnancy assessment is important to identify patients with severe disease-related damage who should avoid pregnancy, counsel patients to conceive when disease has been stable and inactive on appropriate medications, and assess relevant risk factors including renal disease, antiphospholipid antibody, and anti-Ro/SS-A and anti-La/SS-B antibodies. With careful planning, monitoring, and care, most women with SLE can anticipate a successful pregnancy.

Systemic lupus erythematosus pregnancies: ten-year data from a single centre in Malaysia

We performed a retrospective study of all systemic lupus erythematosus (SLE) pregnancies during a 10-year period (2006–2015) to describe the clinical features, maternal and foetal outcomes in our centre. There were 115 pregnancies in 86 women with SLE. Our patients had a mean age of 29.1 years (SD 5.80) and a mean disease duration of 44.63 months (SD 41.17). Fifteen patients had antiphospholipid syndrome (APS). Our patients had complicated pregnancies: 26.1% had SLE flares, 13.9% had pre-eclampsia and 45.1% needed caesarean sections. There were 23.3% foetal losses and 25% preterm deliveries in our patients. There was a higher rate of unplanned pregnancies and lupus flare among pregnancies with active SLE at conception. Pregnancies in lupus nephritis have higher incidence of lupus flares during pregnancy but similar maternal and foetal outcomes compared to those without nephritis. The prognostic indicators for adverse foetal outcome in our patients were flare of SLE (HR 4.08 [CI 95% 1.65–10.13, p < 0.01]) and APS (HR 3.07 [CI 95% 1.12–8.42, p < 0.05]) and the prognostic indicator for adverse maternal outcome was hypertension (HR 3.58 [CI 95% 1.30–9.90, p < 0.05]). Lupus pregnancies in our centre remained as high-risk pregnancies with significant maternal and foetal complications.

Systemic lupus erythematosus and pregnancy

Although most women with systemic lupus erythematosus can achieve a successful pregnancy, fetal (fetal loss, preterm birth) and maternal (lupus flares, worsening renal function) morbidity remain major problems. Predictors of fetal loss and preterm birth have been identified and are reviewed. Modern management of lupus pregnancy includes identification of high-risk pregnancies with appropriate monitoring and treatment (when indicated) for anti-Ro and antiphospholipid antibodies, frequent assessment of and control of maternal lupus activity, adjustment of medications to avoid those associated with fetal teratogenicity, and the appropriate use of fetal assessment tests to guide intervention for the fetus at risk of intrauterine death.