Systemic lupus erythematosus (SLE) is an autoimmune disease which was historically perceived to confer an unacceptably high risk to both mother and child during pregnancy. As a result, most women with the condition were counseled to avoid pregnancy or to terminate their pregnancy. However, this is no longer the case, as a new study published in the journal Annals of Internal Medicine reveals.
Study author Bella Mehta says, “More lupus patients are attempting pregnancy, most of the physicians are not recommending against it, and women are having successful deliveries.”
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SLE affects about 240 people out of every 100,000 in North America alone. Most of these are women in the reproductive age bracket. The complications of carrying a pregnancy with SLE include the dreaded hypertensive disorders of pregnancy, pre-eclampsia and eclampsia, which endanger both the woman and the fetus. However, in the years between 1960 and 2003, the study found that pregnancy losses went down from 40% to 17%. The rates of other complications also remain higher than in other women, but the decreasing trend is encouraging.
While the last 20 years have seen scientists making breakthroughs on what exactly causes the features of SLE, its treatment, and how to predict complications more accurately, the study sought to find out how this knowledge has benefited women with SLE with respect to pregnancy. Researchers from several New York City medical centers searched the National Inpatient Sample (NIS) database to retrieve the records of all adult pregnant women who had been hospitalized, with or without SLE, from 1998 through 2015. The NIS represents about a fifth of all patients discharged from community hospitals in the US.
The data was then analyzed for maternal death while in hospital, fetal death, the occurrence of pre-eclampsia and eclampsia, Cesarean section delivery, admissions not related to delivery, and duration of hospital stay.
Important findings include a steep drop in the number of pregnant women with SLE who died in hospital, from 442/100,000 in the years 1998-2000, to below 50/100,000 in the period 2013-2015. The corresponding rates for non-SLE patients were 13 and 10 respectively. This means that women with SLE were about 35 times more likely to die during pregnancy as a result of disease-related complications during 1998-2000. By 2013-2015, this had fallen to about 5 times as high as non-SLE patients. The difference in fetal death rates was also observable but didn’t achieve statistical significance.
The rates of pre-eclampsia and eclampsia fell in lupus patients from 9.5% to 9.1% while it increased in non-lupus patients, from 3.3% to 4.1%. Hospital stays durations for women with lupus also went down, from 4.3 days on average to 3.8 days, while in non-lupus women, it went up slightly from 2.5 to 2.7 days.
Only about 0.15% of all pregnant women in hospital or undergoing delivery have lupus, but the percentage has gone up from about 0.08% in both groups, showing that more women with this condition are now becoming pregnant and successfully delivering their babies.
The reasons for this marked improvement are likely to include better diagnosis of the condition, with early referral of patients to specialists before the disease becomes severe; encouraging patients to become pregnant when the disease activity is low; and the emergence of better treatments for SLE and for its complications during pregnancy. This also includes preventive use of hydroxychloroquine in pregnancy, and the use of blood thinners like heparin and low-dose aspirin in women who have the anti-phospholipid syndrome (APS), a pregnancy complication more common in SLE and which carries a higher risk of early and late pregnancy loss.
While the risks of SLE pregnancies still remain markedly higher than in pregnancies without SLE, advances in diagnosis and management are showing good results. While more improvement is mandatory, the final word from the study is, in Dr. Mehta’s words: “For lupus patients who are young and who are thinking of pregnancies, they should know that many other patients with lupus over the past two decades have successfully become pregnant and delivered, and mortality is minimal. In the 1980s, there were clinicians who advised young women with lupus not to get pregnant because they were so worried about mortality. What this study proves is this is no longer applicable. It is okay for women with lupus to get pregnant, as long as they are under the care of a rheumatologist and high risk obstetrics.”
Mehta B, Luo Y, Xu J, Sammaritano L, Salmon J, Lockshin M, et al. Trends in Maternal and Fetal Outcomes Among Pregnant Women With Systemic Lupus Erythematosus in the United States: A Cross-sectional Analysis. Ann Intern Med. [Epub ahead of print 9 July 2019] doi: 10.7326/M19-0120, https://annals.org/aim/article-abstract/2737824/trends-maternal-fetal-outcomes-among-pregnant-women-systemic-lupus-erythematosus?doi=10.7326%2fM19-0120