Original Article
Obstetrical outcome of pregnancy in patients with systemic Lupus Erythematosus. A study of 60 cases

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Abstract

Objective: To analyze the course of maternal diseases and the outcome of pregnancy in patients with systemic Lupus Erythematosus (SLE). Study design: During a period of 11 years we prospectively followed 60 pregnancies in 46 SLE patients in a tertiary care center in Barcelona (Spain). The management protocol included: (1) planning of conception when disease was inactive; (2) frequent follow-up visits by an internist–obstetrician team; (3) use of sequential ultrasonographic, Doppler and fetal echocardiographic examinations; (4) serial evaluations of maternal immunological condition; and (5) low dose aspirin from 1 month before attempting conception and throughout pregnancy was added in women with antiphospholipid antibodies. From 1985 until 1994 prednisone prophylaxis was used in all lupus patients during the last month of pregnancy and during the first month of the puerperium; from 1995 onwards this regime was abandoned. Results: The mean (S.D.) age of patients was 28.6 (4.8) years (range 20 to 42) and the mean (S.D.) previous duration of SLE was 6.25 (4.8) years (range 0 to 17). SLE was diagnosed during the pregnancy in two cases (3.3%) and the disease was active at conception in four cases (6.7%); at that time nine patients (15%) were taking prednisone. Antiphospholipid antibodies were positive in 16 patients (30.4%) and there were 10 (16.7%) pregnancies in patients having lupus nephropathy. There were three first-trimester miscarriages (5%) and four (6.7%) voluntary abortions. Obstetric complications in the remaining 53 pregnancies included: preterm delivery, 11 cases (20.8%); intrauterine growth retardation, five cases (9.4%); hypertension, 10 patients (18.9%), five of them fulfilling the criteria of preeclampsia; premature rupture of membranes, four patients (7.5%); finally, 13 neonates had a birthweight lower than 2500 g. There were 15 lupus flares (28.3%), giving a flare rate of 0.044 per patient/month. There were five neonatal deaths (perinatal mortality rate, 94‰): one because of complete heart block, three due to severe hyaline membrane disease resulting from extreme prematurity and one intrauterine death in a patient having the Leiden mutation. Conclusion: Pregnancy in patients with SLE should not be regarded as an unacceptable high-risk condition for the mother or her baby provided that conception is accurately planned and patients are managed according to a careful multidisciplinary treatment schedule.

Introduction

Interest in the association of autoimmune conditions with pregnancy complications has grown tremendously in the past decade. It is well established that women with certain autoimmune conditions have a high frequency of fetal wastage [1]. It is also well known the association of the antiphospholipid antibodies (aPL), namely the lupus anticoagulant (LA) and anticardiolipin autoantibodies (aCL), with recurrent fetal losses [2], [3], [4], [5], [6].

Systemic lupus erythematosus (SLE) is the autoimmune disease that most frequently compromises pregnancy [1], [2]. The coexistence of SLE and pregnancy is by no means a rare event, as SLE has a predilection for women of childbearing age. Maternal morbidity may be severe during an SLE exacerbation, and treatment itself is limited by pregnancy. On the other hand, active SLE places the embryo, fetus and neonate at enormous risk [2], [3].

However, there is no agreement on the exact influence of pregnancy in the course of SLE and the complexities of the association of SLE and pregnancy have led to a call for a team approach (internists–gynaecologists) undertaking prospective studies [2]. This article summarises maternal and fetal outcome in the first 60 pregnancies in 46 SLE patients followed in our lupus pregnancy clinic, according to a careful multidisciplinary treatment schedule.

Section snippets

Patients

Between January, 1985 and December, 1996 we prospectively followed 60 consecutive pregnancies (including one twin pregnancy) in 46 SLE patients, diagnosed according to the 1982 revised criteria of the American Rheumatism Association [4].

Medical management

At the time of pregnancy diagnosis, a complete physical examination was done and visits were scheduled monthly (or more often when necessary) until the 26th week; from 27th to 35th weeks, patients were scheduled fortnightly and then, weekly until delivery. After

Patient characteristics

The mean (S.D.) age of our patients was 28.6 (4.8) years and the mean (S.D.) duration of SLE was 6.25 (4.85) years. In two cases (3.3%) SLE was diagnosed during pregnancy. Although patients were advised to become pregnant only when the disease was inactive, the disease was considered active at conception in four pregnancies (6.7%) and at that time nine patients (15%) were taking prednisone. Anti Ro (SS-A) antibodies were present in 15 (25%) cases, while 14 out of 46 women (30.4%) tested

Discussion

The topic of pregnancy in women with SLE is at present a matter of great interest, as therapy has helped more patients feel well enough to have families [12], [13]. However, there is no agreement about the exact influence of pregnancy on the course of SLE. Thus, several prospective and retrospective recent studies [13], [14], [15], [16], [17], [18], [19], [20], [21], [22], [23], [24], including some reports using a matched-non pregnant control design [14], [17], [18], [19], [20], [21], [22],

Condensation

Pregnancy in patients with SLE should not be regarded as an unacceptable high-risk condition provided that conception is accurately planned and patients are managed according to a careful multidisciplinary treatment schedule.

Acknowledgments

This work was supported in part by Grants FISS 94/0564 and FISS 94/0323 from Fondo de Investigaciones Sanitarias de la Seguridad Social of Spain.

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