“Thirty years ago, most women with SLE were advised to avoid pregnancy because of high risks for maternal and fetal morbidity and mortality. Now, this advice has shifted entirely, and most women with SLE, with careful management, can safely build a family,” Megan Clowse, MD, MPH, from Duke University Medical Center, Durham, NC, notes in an editorial published with the study online July 8 in Annals of Internal Medicine.1
Using the National Inpatient Sample database, Bella Mehta, MBBS, MS, from Hospital for Special Surgery and Weill Cornell Medicine, New York, and colleagues assessed trends and disparities in maternal and fetal complications among more than 93,000 pregnant women with SLE and 78 million without SLE hospitalized in the U.S from 1998 through 2015.
“The biggest take-home message from this study is that more lupus patients are attempting pregnancy, most of the physicians are not recommending against it, and women are having successful deliveries,” Dr. Mehta says in a news release.2
Rates of SLE-related pregnancies and deliveries steadily increased during the study period. At the same time, there was a “dramatic” decline over time in in-hospital mortality in SLE patients, from 442 per 100,000 admissions between 1998–2000 to <50 per 100,000 admissions between 2013–2015.
In women with SLE, in-hospital maternal mortality went from a rate 34 times higher in the earlier period to less than five times higher in later period, the investigators note in their paper.
In-hospital mortality also declined for patients without lupus during the same time period, but not as dramatically, from 13 to 10 per 100,000 admissions.
Fetal deaths also declined over the study period in women with SLE (268 deaths per 10,000 deliveries in 1998–2000 vs. 153 deaths per 10,000 deliveries in 2013–2015) and women without SLE (72 deaths per 10,000 deliveries in 1998-2000 vs. 66 deaths per 10,000 deliveries in 2013–2015). Although the decrease in fetal deaths appears somewhat greater in women with than without SLE, the difference in trends did not reach statistical significance (P=0.064), the investigators say.
Women with SLE also showed greater progress in rates of preeclampsia or eclampsia and length of hospital stay, but they still have worse outcomes in these measures compared with women without lupus, they point out.
“Our study provides nationwide evidence that SLE pregnancy outcomes have become markedly better in the past two decades and continue to improve. However, SLE pregnancy risks remain high, and more work is needed to ensure good pregnancy outcomes among women with SLE,” Dr. Mehta and colleagues conclude.
Dr. Clowse agrees. “Work still must be done…regarding preeclampsia and fetal and maternal mortality, each of which is several times more common in women with SLE than in those without the disease.”
“Although great advances have been made in therapy, recent analyses demonstrate that use of hydroxychloroquine (HCQ) and aspirin in SLE pregnancy is not widespread. The inaugural reproductive health guidelines soon to be published by the American College of Rheumatology will have the potential to help expand state-of-the-art approaches to the management of pregnant women with SLE seen in everyday practice,” Dr. Clowse notes.
The study had no specific funding and the authors have no relevant disclosures. Dr. Mehta did not respond to a request for comment by press time.
References
- Clowse MEB. Pregnancy in women with lupus: We have come so far and have so far to go. Ann Intern Med. 2019 Jul 9.
- 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.