Predictors of pregnancy outcomes in patients with lupus: A cohort study

Jill P. Buyon, Mimi Y. Kim, Marta M. Guerra, Carl A. Laskin, Michelle Petri, Michael D. Lockshin, Lisa Sammaritano, D. Ware Branch, T. Flint Porter, Allen Sawitzke, Joan T. Merrill, Mary D. Stephenson, Elisabeth Cohn, Lamya Garabet, Jane E. Salmon

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Abstract

Background: Because systemic lupus erythematosus (SLE) affects women of reproductive age, pregnancy is a major concern. Objective: To identify predictors of adverse pregnancy outcomes (APOs) in patients with inactive or stable active SLE. Design: Prospective cohort. Setting: Multicenter. Patients: 385 patients (49% non-Hispanic white; 31% with prior nephritis) with SLE in the PROMISSE (Predictors of Pregnancy Outcome: Biomarkers in Antiphospholipid Antibody Syndrome and Systemic Lupus Erythematosus) study. Exclusion criteria were urinary protein-creatinine ratio greater than 1000 mg/g, creatinine level greater than 1.2 mg/dL, prednisone use greater than 20 mg/d, and multifetal pregnancy. Measurements: APOs included fetal or neonatal death; birth before 36 weeks due to placental insufficiency, hypertension, or preeclampsia; and small-for-gestational-age (SGA) neonate (birthweight below the fifth percentile). Disease activity was assessed with the Systemic Lupus Erythematosus Pregnancy Disease Activity Index and the Physician's Global Assessment (PGA). Results: APOs occurred in 19.0% (95% CI, 15.2% to 23.2%) of pregnancies; fetal death occurred in 4%, neonatal death occurred in 1%, preterm delivery occurred in 9%, and SGA neonate occurred in 10%. Severe flares in the second and third trimesters occurred in 2.5% and 3.0%, respectively. Baseline predictors of APOs included presence of lupus anticoagulant (LAC) (odds ratio [OR], 8.32 [CI, 3.59 to 19.26]), antihypertensive use (OR, 7.05 [CI, 3.05 to 16.31]), PGA score greater than 1 (OR, 4.02 [CI, 1.84 to 8.82]), and low platelet count (OR, 1.33 [CI, 1.09 to 1.63] per decrease of 50 × 109 cells/L). Non-Hispanic white race was protective (OR, 0.45 [CI, 0.24 to 0.84]). Maternal flares, higher disease activity, and smaller increases in C3 level later in pregnancy also predicted APOs. Among women without baseline risk factors, the APO rate was 7.8%. For those who either were LACpositive or were LAC-negative but nonwhite or Hispanic and using antihypertensives, the APO rate was 58.0% and fetal or neonatal mortality was 22.0%. Limitation: Patients with high disease activity were excluded. Conclusion: In pregnant patients with inactive or stable mild/ moderate SLE, severe flares are infrequent and, absent specific risk factors, outcomes are favorable.

Original languageEnglish (US)
Pages (from-to)153-163
Number of pages11
JournalAnnals of internal medicine
Volume163
Issue number3
DOIs
StatePublished - Aug 4 2015

ASJC Scopus subject areas

  • Internal Medicine

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    Buyon, J. P., Kim, M. Y., Guerra, M. M., Laskin, C. A., Petri, M., Lockshin, M. D., Sammaritano, L., Branch, D. W., Porter, T. F., Sawitzke, A., Merrill, J. T., Stephenson, M. D., Cohn, E., Garabet, L., & Salmon, J. E. (2015). Predictors of pregnancy outcomes in patients with lupus: A cohort study. Annals of internal medicine, 163(3), 153-163. https://doi.org/10.7326/M14-2235