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As systemic lupus erythematosus (SLE) and/or antiphospholipid syndrome (APS) can cause complications during pregnancy, investigators believe it is imperative that women follow the clinical practice guidelines and receive multidisciplinary counseling before trying to conceive.
Patients with systemic lupus erythematosus (SLE) and/or antiphospholipid syndrome (APS) who wish to become pregnant may benefit from a multidisciplinary clinical pathway that includes pre-pregnancy counseling, according to a study published in Lupus Science and Medicine.1
Both SLE and APS are autoimmune diseases that mainly affect women of childbearing age. As these conditions can cause complications during pregnancy, it is imperative that women follow the clinical practice guidelines and receive multidisciplinary counseling before trying to conceive.
Patients with SLE/APS are at an increased risk of flares and thromboembolic events (TEE), gestational hypertensive disease, and miscarriage. Children have an increased risk of prematurity, fetal grown restriction, stillbirth, and neonatal death. Additionally, mothers with SLE who have anti-Ro/SSA or anti-La/SSB antibodies have a slightly elevated risk (1-2%) of a congenital heart block that is associated with neonatal lupus erythematosus (NLE).
“While clinical practice guidelines have emerged as rigorous means to make clinical studies and research more accessible for practitioners, they are not always sufficient to change practice behavior, especially in complex diseases such as SLE/APS,” explained investigators. “Therefore, clinical pathways are an important strategy to improve effective knowledge transfer and sharing, promote standardized evidence-based practices and are internationally recognized as a form of quality improvement.”
In this retrospective analysis, investigators compared patients with SLE/APS that were managed in a multidisciplinary clinical pathway, which included pre-pregnancy counseling, with patients who were not managed within a clinical pathway. Eligible patients were pregnant and had a confirmed diagnosis of SLE and/or APS. Information was collected between January 2008 and February 2020. SLE/APS pregnancies that were managed within the clinical pathway (from May 2014 onwards) were labeled the “pathway cohort” and those who were managed before the initiation of the clinical pathway were referred to as the “historical cohort.” The primary outcome was disease flares for patients with SLE and TEE for patients with APS. Secondary outcomes included any complications, both maternal and fetal, during the pregnancy.
Patients in the pathway cohort were consulted by individual specialists of the multidisciplinary team and assigned a dedicated nurse. Specialists were included from the Department of Obstetrics, Nephrology, Rheumatology, Thrombosis, and Haemostasis. A pulmonologist, cardiologist, radiologist, and social worker were also available if needed. Every 2 weeks, both before and during pregnancy, patients were evaluated in a multidisciplinary meeting in which the timing of pregnancy, medications, medical check-ups, and diagnostics were discussed. The women received extensive counseling and advice, as well as routine ultrasounds, throughout pregnancy. Pediatricians screened the newborns of patients with SLE for neonatal lupus. Weekly screenings for congenital heart block were performed between 18 and 26 weeks of gestation for patients who were positive for anti-RO/SS-A or anti-LA/SS-B. Finally, all enrolled patients in the pathway cohort were recommended to take 80 mg acetylsalicylic acid from 8 weeks until 36 weeks of gestation.
A total of 78 patients with 112 pregnancies were analyzed during the study. The pathway cohort was made up of 30 patients and 41 pregnancies (12 patients with SLE and 18 patients with APS). Of those patients awaiting pregnancy, 6 patients had disease flares during the follow-up period, 2 had active disease and were told to postpone conception, and 1 patient conceived against the advice of her doctors. In the historical cohort, 47 patients and 71 pregnancies were included (33 patients with SLE and 15 patients with APS).
Results showed that the pathway cohort had significantly fewer composite end point disease related SLE and TEE flares (7% vs 28%) during pregnancy. The odds ratio (OR) was 0.20 (95% confidence interval [CI] 0.06 to 0.73) in favor of participants in the pathway group and patients in this cohort had a significant reduction in SLE flares (13% vs 40%). Maternal and fetal outcomes were comparable in both groups (respectively, aOR 0.91 [95% CI 0.38 to 2.17] and aOR 1.26 [95% CI 0.55 to 2.88]). Further, only 1 patient in the pathway group (4%) had a TEE, compared with 3 (11%) in this historical cohort.
While the study size was small, disease outcome improvement indicated the effectiveness of a clinical pathway. Investigators believe these results could be generalized to other hospitals since no exclusion criteria were used. However, it is possible that knowledge of how to treat SLE/APS has improved over time, leading to more effective management practices and potentially skewing results.
“Altogether, it remains noteworthy to establish the high incidences of pregnancy and disease complications in patients with SLE/APS, that is, flares, TEEs, severe hypertensive disease, preterm birth and FGR, re-affirming the need of specialized care in a tertiary, academic center,” concluded investigators.
Wind M, Hendriks M, van Brussel BTJ, et al. Effectiveness of a multidisciplinary clinical pathway for women with systemic lupus erythematosus and/or antiphospholipid syndrome. Lupus Sci Med. 2021;8(1):e000472. doi:10.1136/lupus-2020-000472