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SLE and Pregnancy and Prognosis?

The news from the PROMISSE study on pregnancy outcome in women with systemic lupus erythematosus is good for non-Hispanic white women and not so good for Hispanic white and African-American in women.

Buyon JP, Kim MY, Guerra MM, et al. Original Research: Predictors of Pregnancy Outcomes in Patients With Lupus: A Cohort Study. Ann Intern Med. Published online 23 June 2015 doi:10.7326/M14-2235

Hahn BH. Editorial: Pregnancy in Women With Systemic Lupus Erythematosus: Messages for the Clinician. Ann Intern Med. Published online 23 June 2015 doi:10.7326/M15-1301

 

The good news: Among pregnant women with systemic lupus erythematosus (SLE), 81% had a good outcome.

The bad news: Among Hispanic white and African-American women, only 74% had a good outcome.

(“Good outcome” means not having an adverse pregnancy outcome (APO), which includes fetal or neonatal death, birth <36 weeks due to placental insufficiency, hypertension, pre-eclampsia, and <5th percentile of birth weight.)

 

Total

No APOs

APOs

Non-Hispanic white

184

157 (85%)

27 (15%)

Hispanic white

58

43 (74%)

15 (26%)

African-American

78

58 (74%)

20 (26%)

Other/No answer

65

54 (83%)

11 (17%)

Total

385

312 (81%)

73 (19%)

APO = adverse pregnancy outcome. P=0.053

That’s the result of the Predictors of Pregnancy Outcome: Biomarkers in Antiphospholipid Antibody syndrome and Systemic Lupus Erythematosus (PROMISSE) study, the largest study to date, with 385 patients and 198 healthy controls.

The best results (92%) were achieved by non-Hispanic white women with negative lupus anticoagulant test results, no treatment for hypertension, no or low disease activity, and platelet counts of at least 100 x 109 cells/L. Fetal or neonatal deaths occurred in only 3.9%, which is similar to healthy control participants.

Among all 385 pregnancies, 5% ended in fetal or neonatal death.

PROMISSE identified characteristics of US women who had good and bad outcomes. Multivariant analysis revealed several predictors of poor fetal outcomes.

Being non-Hispanic white had an odds ratio of 0.45 (confidence interval 0.24-0.84) for having an APO at any time during pregnancy. Other characteristics were:

-- Anti-hypertensive use at baseline

-- Presence of lupus anticoagulant

-- Clinical flare at any time during pregnancy

-- Moderate clinical disease at baseline

APOs were not associated with anti-dsDNA.

In an editorial, Bevra Hahn suggests:

-- Pregnancies should be planned as much as possible and timed to occur when disease activity is lowest.

-- Every pregnancy during SLE is high-risk, and a high-risk obstetrician should be involved.

-- SLE should be controlled as tightly as possible. Flares occur in approximately 50% of pregnant women. Nonfluorinated glucocorticoids are the mainstay of treatment, and hydroxychloroquine seems to be safe for the fetus. For the approximately 40% of patients positive for anticardiolipin, low-dose aspirin plus heparin is recommended.