Largely due to improvements in perinatal monitoring and disease management, there has been a significant decrease in pregnancy loss among women with systemic lupus erythematosus (SLE) over the past 40 years, according to new data published in the Journal of Rheumatology.¹

Moreover, the new study also showed a trend toward decreased preterm deliveries over the last 20 years in comparison to the general population. "Disease management, particularly the identification and treatment of secondary antiphospholipid syndrome (APS), may be the most significant clinical advance in the last 2 decades, although there is still debate regarding the optimum therapeutic regimen for women with a history of thrombosis and/or recurrent pregnancy loss," conclude the researchers, led by Christine A. Clark, BSc, a research associate in the department of medicine, immunology, and obstetrics and gynecology at the University of Toronto in Ontario, Canada.

"We continue to advocate that SLE pregnancies be treated as high risk; however, based upon our review of the literature, we propose that the prevailing description of pregnancy in patients with SLE be revised to reflect advances in disease and perinatal management over the last 40 years," Clark and colleagues conclude.

Patient cohort and literature review determine findings

To arrive at their findings, researchers analyzed the pregnancy outcomes of 83 SLE patients at their clinic over the past 3 years and reviewed the literature over the past 40 years.  They extracted pregnancy loss and preterm delivery data from reports of postdiagnosis SLE pregnancies.

The rate of loss in SLE pregnancies over the past 40 years decreased from a mean of 43% from 1960 to 1965 to 17% from 2000 to 2003, the study showed. The study authors point out that this approximates the pregnancy loss rate in the general US population. Specifically, 88% of pregnancies in the cohort from the clinic resulted in a live birth, the study showed.

Preterm delivery also down in SLE

Preterm deliveries were not uniformly reported and were rarely stratified into spontaneous or physician-initiated deliveries. Prior to 1980, Clark and colleagues note, it was not possible to derive group means for each time period. From 1980 to 2002, however, there was a trend toward a decrease in preterm births in SLE pregnancies, although these continue to be more frequent in SLE than in the general population, the researchers report.

"This information is in agreement with what we have been seeing clinically, and it is reassuring to see numbers and be able to relay them to patients," says Lisa R. Sammaritano, MD, assistant professor of internal medicine at Weill Medical College of Cornell University and assistant attending physician at the Hospital for Special Surgery, both in New York City.

News about live births "as good as it gets"

In an editorial accompanying the new study,² Jill P. Buyon, MD, a rheumatologist at the Hospital for Joint Diseases in New York City, agrees with the study authors that "it is quite likely that the decrease in loss may be due in large part to identification and treatment of patients with antiphospholipid antibodies."

Another potential reason for the decline, she writes, is that " it has become dogma that women with SLE are advised to consider pregnancy only when disease is stable." She points out that "the news on live births is as good as it gets."

While a more optimistic view of pregnancy in SLE may be warranted, several caveats exist; namely, that a history of arterial thrombosis, severe renal insufficiency, and pulmonary hypertension are contraindications.

"Optimism does not obviate the critical need for judicious obstetrical care and the search for biomarkers such as complement activation products that would help predict poor outcomes beyond the influence of maternal disease or specific autoantibodies," Dr. Buyon writes.

Joan T. Merrill, MD, head of the clinical pharmacology research program at the Oklahoma Medical Research Foundation in Oklahoma City and medical director of the Lupus Foundation of America, has a few caveats of her own to add when interpreting the new study data.

"This study is limited by the fact that there would have been very different definitions for lupus, people of different ethnic backgrounds, and very inconsistent methodologies for following patients and determining outcomes over all the years being assessed," she tells CIAOMed. "The data suggest that overall outcomes are improving, and it could be speculated that better prenatal care of high-risk pregnancies and better and more aggressive overall treatments for lupus could be part of the reason. However, it may be that more people (with less severe illness) are diagnosed with SLE today, so it is premature to conclude that the rate of pregnancy complications is really declining or, if it is, that we know the reasons."
                      
Pregnancy outcomes also studied  in primary Sjogren's syndrome

In related news,³ researchers found that primary Sjogren's syndrome (pSS) had no impact on pregnancy outcome before disease onset. The most important condition associated with pSS in anti-SSA-positive mothers was congenital heart block in the offspring.

Researchers reviewed data about pregnancy, birth, and status of the newborn from the Medical Birth Registry of Norway for birth order one, two, and three for 36 pSS patients and 93 controls. Pregnancy outcomes were not different in patients compared to controls. Two patients reported giving birth to a child with congenital heart block, the study showed.

References

1. Clark CA, Spitzer KA, Laskin CA. Decrease in pregnancy loss rates in patients with systemic lupus erythematosus over a 40-year period. J Rheumatol. 2005;32:1709-1712.

2. Buyon JP. Dispelling the preconceived notion that lupus pregnancies result in poor outcomes. J Rheumatol. 2005;32:1641-1642.

3. Haga HJ, Gjesdal CG, Koksvik HS, et al. Pregnancy outcome in patients with primary Sjogren's syndrome. A case-control study. J Rheumatol. 2005;32:1734-1736.