Systemic lupus erythematosus (SLE) primarily affects women of childbearing age and is more likely to be diagnosed in women of color. Historically, physicians have counseled women with SLE to avoid becoming pregnant and to terminate the pregnancy if they become pregnant. However, the past two decades have resulted in treatment approaches that have reduced the mortality rates from SLE and lupus nephritis. During this same time, rheumatologists have implemented major changes in the management of pregnant women with SLE.
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Results from a large study indicate in-hospital maternal mortality and overall pregnancy outcomes have improved markedly over the past 18 years for women with SLE, as well as those without SLE. Bella Mehta, MBBS, a rheumatologist at the Hospital for Special Surgery, New York City, and colleagues performed the analysis, concluding that although improvements in pregnancy outcomes have been particularly noteworthy in women with SLE, SLE pregnancy risks still remain high. The authors published their findings online July 9 in the Annals of Internal Medicine.1
The study included a nationwide sample of hospitalized pregnant women from the National Inpatient Sample (NIS) and compared data from 1998–2000 with data from 2013–2015. The NIS contains discharge data from approximately 20% of all community hospitals in the U.S. but does not include outpatient information, such as outpatient deliveries, early pregnancy losses and miscarriages. The researchers found the percentage of pregnant patients with SLE increased significantly from 0.09% of all pregnancy-related admissions in the first period to 0.16% in the second, indicating that more women with SLE are attempting pregnancy.
In the first data period, the investigators documented in-hospital mortality in patients with SLE at 442 per 100,000 admissions. They found this rate declined dramatically to less than 50 per 100,000 admissions during the second data period. Likewise, in the first data period, SLE patients had an in-hospital mortality rate 34 times higher than patients without SLE, while the second data period revealed that the in-hospital maternal mortality rate had declined to five times higher for women with SLE than for women without SLE. The preeclampsia/eclampsia rates in patients with SLE also decreased between the same two periods from 9.5% to 9.1%, and fetal mortality rates for all women declined, but were not statistically significant.
“Our findings confirm other data showing that SLE pregnancies are associated with a greater [length of stay] and higher hospital charges. In our study, total hospitalization charges were 1.8 times higher for women with SLE than for those without,” write the authors in their discussion. “Non-delivery related hospitalizations decreased, but remained more frequent in SLE pregnancies, although [length of stay] decreased. A possibility exists that more efficient in-hospital care for pregnant patients with SLE improved maternal and fetal outcomes while lowering [length of stay].”
Other factors that have likely contributed to the improved outcomes include better diagnosis and referral of patients with mild disease to rheumatologists, as well as counseling of women to attempt pregnancy when disease is quiescent. Whatever the causes, the findings suggest that previous concerns about mortality associated with pregnancy in women with SLE are no longer applicable.
Lara C. Pullen, PhD, is a medical writer based in the Chicago area.
- Mehta B, Luo Y, Xu J, 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. 2019 Jul 9. [Epub ahead of print]