Accessible Requires Authentication Published by De Gruyter September 25, 2019

Pregnancy outcomes in systemic lupus erythematosus (SLE) women

Aida Kalok, Rizna Abdul Cader, Ima Indirayani, Abdul Kadir Abdul Karim, Shamsul Azhar Shah, Nor Azlin Mohamed Ismail, Mohd Hashim Omar and Mohamad Nasir Shafiee

Abstract

Background

Systemic lupus erythematosus (SLE) is a chronic autoimmune inflammatory condition with multi-organ involvement predominantly affecting young women. There are very limited studies in pregnancy in Asian SLE patients and therefore we embarked on this study to identify pregnancy outcomes of Malaysian women with SLE.

Materials and methods

We performed a retrospective study of pregnancy outcomes in SLE patients in our institution from January 2007 to December 2014. A total of 71 pregnancies from 44 women were analysed.

Results

The mean age of our cohort was 30.5 ± 3.9 years. The rate of active disease at conception, antiphospholipid syndrome and lupus nephritis were 22.5%, 32.4% and 57.7% respectively. SLE flare occurred in 33 out of 71 pregnancies whereas 19 pregnancies were complicated with preeclampsia. The livebirth rate for our cohort was 78.9%, whilst preterm delivery was 42.9%. On univariate analysis, active disease and flare in pregnancy were both strongly associated with foetal loss and preterm delivery. Lupus nephritis (p = 0.011), SLE flare (p = 0.008) and antiphospholipid syndrome (p = 0.032) significantly increased the risk of preeclampsia. Aspirin and hydroxychloroquine were protective against foetal loss [odds ratio (OR) 0.12] and preeclampsia (OR 0.25), respectively. On multivariate analysis, active disease was a predictor of SLE flare (p = 0.002) and foetal loss (p = 0.018) and SLE flare was the main predictor of preterm delivery (p = 0.006).

Conclusions

Pregnancies in women with SLE should be planned and aspirin and HCQ use were beneficial in reducing adverse pregnancy outcomes.

Author statement

  1. Research funding: None declared.

  2. Conflict of interest: Authors declare no conflict of interest.

  3. Ethical approval: Ethics approval was obtained from the University Research and Ethics Board (FF-2013-465).

  4. Informed consent: This is a retrospective study which involved analysis of patients data, who are being kept anonymous. Informed consent was not required.

References

[1] Pons-Estel GJ, Alarcón GS, Scofield L, Reinlib L, Cooper GS. Understanding the epidemiology and progression of systemic lupus erythematosus. Semin Arthritis Rheum. 2010;39:257–68.10.1016/j.semarthrit.2008.10.00719136143 Search in Google Scholar

[2] Clowse ME, Jamison M, Myers E, James AH. A national study of the complications of lupus in pregnancy. Am J Obstet Gynecol. 2008;199:127.e1e6. Search in Google Scholar

[3] Chakravarty EF, Nelson L, Krishnan E. Obstetric hospitalizations in the United States for women with systemic lupus erythematosus and rheumatoid arthritis. Arthr Rheum. 2005;54:899e907. Search in Google Scholar

[4] Fischer-Betz R, Specker C. Pregnancy in systemic lupus erythematosus and antiphospholipid syndrome. Best Pract Res Clin Rheumatol. 2017;31:397–414.2922468010.1016/j.berh.2017.09.011 Search in Google Scholar

[5] Yamamoto Y, Aoki S. Systemic lupus erythematosus: strategies to improve pregnancy outcomes. Int J Womens Health. 2016;8:265–72.10.2147/IJWH.S9015727468250 Search in Google Scholar

[6] Ko HS, Ahn HY, Jang DG, Choi SK, Park YG, Park IY, et al. Pregnancy outcomes and appropriate timing of pregnancy in 183 pregnancies in Korean patients with SLE. Int J Med Sci. 2011;8:577–83.2202221010.7150/ijms.8.577 Search in Google Scholar

[7] Al Arfaj AS, Khalil N. Pregnancy outcome in 396 pregnancies in patients with SLE in Saudi Arabia. Lupus. 2010;19:1665–73.10.1177/096120331037866920947541 Search in Google Scholar

[8] Teh CL, Wan SA, Cheong YK, Ling GR. Systemic lupus erythematosus pregnancies: ten-year data from a single centre in Malaysia. Lupus. 2016;26:218–23.27522092 Search in Google Scholar

[9] Phansenee S, Sekararithi R, Jatavan P, Tongsong T. Pregnancy outcomes among women with systemic lupus erythematosus: a retrospective cohort study from Thailand. Lupus. 2018;27:158–64.2870503610.1177/0961203317721353 Search in Google Scholar

[10] Hochberg MC. Updating the American College of Rheumatology revised criteria for the classification of systemic lupus erythematosus. Arthritis Rheum. 1997;40:1725.10.1002/art.17804009289324032 Search in Google Scholar

[11] Yee CS, Farewell VT, Isenberg DA, Griffiths B, Teh LS, Bruce IN, et al. The use of Systemic Lupus Erythematosus Disease Activity Index–2000 to define active disease and minimal clinically meaningful change based on data from a large cohort of systemic lupus erythematosus patients. Rheumatology (Oxford). 2011;50:982–8.10.1093/rheumatology/keq37621245073 Search in Google Scholar

[12] National Collaborating Centre for Women’s and Children’s Health (UK). Preterm Labour and Birth. London: National Institute for Health and Care Excellence (UK); 2015. Search in Google Scholar

[13] Royal College of Obstetricians and Gynaecologists. The Investigation and Treatment of Couples with Recurrent First trimester and Second-trimester Miscarriage. Green-top Guideline No. 17. RCOG (UK); 2011. Search in Google Scholar

[14] National Collaborating Centre for Women’s and Children’s Health (UK). Hypertension in pregnancy: diagnosis and management. Clinical Guideline [CG107]. London: National Institute for Health and Care Excellence (UK); 2010. Search in Google Scholar

[15] National Collaborating Centre for Women’s and Children’s Health (UK). Diabetes in pregnancy: management from preconception to the postnatal period. London: National Institute for Health and Care Excellence (UK); 2015. Search in Google Scholar

[16] Ideguchi H, Ohno S, Uehara T, Ishigatsubo Y. Pregnancy outcomes in Japanese patients with SLE: retrospective review of 55 pregnancies at a university hospital. Clin Rev Allergy Immunol. 2013;44:57–64.10.1007/s12016-011-8269-8 Search in Google Scholar

[17] Liu J, Zhao Y, Song Y, Zhang W, Bian X, Yang J, et al. Pregnancy in women with systemic lupus erythematosus: a retrospective study of 111 pregnancies in Chinese women. J Matern Fetal Neonatal Med. 2012;25:261–6.2150433710.3109/14767058.2011.572310 Search in Google Scholar

[18] Kalok A, Peraba P, Shah SA, Mahdy ZA, Jamil MA, Kampan N, et al. Screening for gestational diabetes in low-risk women: effect of maternal age. Horm Mol Biol Clin Investig. 2017. DOI: 10.1515/hmbci-2017-0071. Search in Google Scholar

[19] Idris N, Hatikah CC, Murizah M, Rushdan M. Universal versus selective screening for detection of gestational diabetes mellitus in a Malaysian population. Malays Fam Physician. 2009;4:83–7. Search in Google Scholar

[20] Stanhope TJ, White WM, Moder KG, Smyth A, Garovic VD. Obstetric nephrology: lupus and lupus nephritis in pregnancy. Clin J Am Soc Nephrol. 2012;l7:2089–99. Search in Google Scholar

[21] Buyon JP, Kim MY, Guerra MM, Laskin CA, Petri M, Lockshin MD, et al. Predictors of pregnancy outcomes in patients with lupus: a cohort study. Ann Intern Med. 2015;163:153–63.10.7326/M14-223526098843 Search in Google Scholar

[22] Gladman DD, Tandon A, Ibañez D, Urowitz MB. The effect of lupus nephritis on pregnancy outcome and fetal and maternal complications. J Rheumatol. 2010;37:754–8.10.3899/jrheum.09087220231194 Search in Google Scholar

[23] Saavedra MA, Cruz-Reyes C, Vera-Lastra O, Romero GT, Cruz-Cruz P, Arias-Flores R, et al. Impact of previous lupus nephritis on maternal and fetal outcomes during pregnancy. Clin Rheumatol. 2012;31:813–9.10.1007/s10067-012-1941-422278163 Search in Google Scholar

[24] Clowse ME, Magder LS, Petri M. The clinical utility of measuring complement and anti-dsDNA antibodies during pregnancy in patients with systemic lupus erythematosus. J Rheumatol. 2011;38:1012–16.2140649610.3899/jrheum.100746 Search in Google Scholar

[25] Smyth A, Oliveira GH, Lahr BD, Bailey KR, Norby SM, Garovic VD. A systematic review and meta-analysis of pregnancy outcomes in patients with systemic lupus erythematosus and lupus nephritis. Clin J Am Soc Nephrol. 2010;5:2060–8.2068888710.2215/CJN.00240110 Search in Google Scholar

[26] Miyakis S, Lockshin MD, Atsumi T, Branch DW, Brey RL, Cervera R, et al. International consensus statement on an update of the classification criteria for definite antiphospholipid syndrome (APS). J Thromb Haemost. 2006;4:295–306.10.1111/j.1538-7836.2006.01753.x16420554 Search in Google Scholar

[27] Abou-Nassar K, Carrier M, Ramsay T, Rodger MA. The association between antiphospholipid antibodies and placenta mediated complications: a systematic review and meta-analysis. Thromb Res. 2011;128:77–85.10.1016/j.thromres.2011.02.00621420151 Search in Google Scholar

[28] Mak A, Cheung MW-L, Cheak AA, Ho RC. Combination of heparin and aspirin is superior to aspirin alone in enhancing live births in patients with recurrent pregnancy loss and positive anti-phospholipid antibodies: a meta-analysis of randomized controlled trials and meta-regression. Rheumatol Oxf Engl. 2010;49:281–8.10.1093/rheumatology/kep373 Search in Google Scholar

[29] Imbasciati E, Tincani A, Gregorini G, Doria A, Moroni G, Cabiddu G, et al. Pregnancy in women with pre-existing lupus nephritis: predictors of fetal and maternal outcome. Nephrol Dial Transplant. 2009;24:519–25.18565977 Search in Google Scholar

[30] Koh JH, Ko HS, Kwok SK, Ju JH, Park SH. Hydroxychloroquine and pregnancy on lupus flares in Korean patients with systemic lupus erythematosus. Lupus. 2015;24:210–17.10.1177/096120331455535225305214 Search in Google Scholar

[31] Clowse ME. Lupus activity in pregnancy. Rheum Dis Clin North Am. 2007;33:237–52.10.1016/j.rdc.2007.01.00217499705 Search in Google Scholar

[32] Jung H, Bobba R, Su J, Shariati-Sarabi Z, Gladman DD, Urowitz M, et al. The protective effect of antimalarial drugs on thrombovascular events in systemic lupus erythematosus. Arthritis Rheum. 2010;62:863–8.2013123210.1002/art.27289 Search in Google Scholar

Received: 2019-03-04
Accepted: 2019-07-11
Published Online: 2019-09-25

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