Pregnancy outcomes in women with systemic lupus erythematosus (SLE) have improved significantly in the past two decades, including a marked decrease in maternal mortality, according to a large U.S. study.
The research, “Trends in Maternal and Fetal Outcomes Among Pregnant Women With Systemic Lupus Erythematosus in the United States: A Cross-sectional Analysis,” was published in the journal Annals of Internal Medicine.
Women with SLE traditionally were advised to avoid having children due to frequent complications. Yet, between 1960 and 2003, studies showed that miscarriages dropped from 40% to 17% in these women.
In the past 20 years, improved knowledge of disease processes, treatment developments, and updated guidelines have collectively improved outcomes in SLE patients. However, whether pregnant women with SLE also have benefited remained unclear.
To address that gap, a team from the Hospital for Special Surgery (HSS), the Icahn School of Medicine at Mount Sinai, Weill Cornell Medicine and the New York-Presbyterian/Weill Cornell Medical Center used the National Inpatient Sample database, which has discharge data from nearly 20% of U.S. community hospitals.
The data revealed that, from 1998 to 2015, a total of 93,820 pregnant women with SLE and more than 78 million pregnant women without this disease were hospitalized. Comparing 1998-2000 to 2013-2015, in-hospital maternal mortality per 100,000 admissions declined in people with or without SLE, from 442 to less than 50 in patients and from 13 to 10 women in the control group.
This means the higher risk for in-hospital mortality in SLE patients lowered from 34-times higher to only 2.5-5 times higher. Although not statistically significant, the team also found a trend toward a larger decline in fetal mortality in patients with SLE than in women without the disorder.
“For lupus patients who are young and who are thinking of pregnancies, they should know that many other patients with lupus over the past two decades have successfully become pregnant and delivered, and mortality is minimal,” Bella Mehta, MD, the study’s lead author, said in a press release. “This is encouraging for young women with lupus. If they decide to have children, they can.”
Other improvements in SLE patients included lower rates of preeclampsia (high blood pressure in mothers, reducing blood supply to the fetus) and eclampsia (seizures or coma in women with preeclampsia) from 9.5% to 9.1%, and shorter hospital stays from a mean of 4.3 days to 3.8 days.
In contrast, women without SLE showed an increase in preeclampsia/eclampsia rates from 3.3% to 4.1% and in-hospital stays from a mean of 2.5 to 2.7 days.
The data further showed that the percentage of women with SLE in all pregnancy-related admissions increased significantly from 0.09% to 0.16% and from 0.08% to 0.14% in delivery-related admissions.
“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,” Mehta said. “However,” the team cautioned, “improvement is still needed, because SLE pregnancy risks remain high.”
Other factors likely contributing to better outcomes include improved diagnosis, more common referral to rheumatologists, counseling to attempt pregnancy when disease is inactive, and use of low-dose aspirin and heparin in patients with antiphospholipid syndrome, an immune disorder common in SLE patients that increases the risk of blood clots.
“The times are changing,” commented Said Ibrahim, MD, the study’s senior author. “It is okay for women with lupus to get pregnant, as long as they are under the care of a rheumatologist and high risk obstetrics.”
According to Ibrahim, senior associate dean for diversity and inclusion at Weill Cornell Medicine, the findings also suggest that improving care is a successful strategy to address healthcare inequities in women with SLE, “a disease that largely affects women and most particularly women of color.”
“It is a hopeful message,” he said.
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