Pregnancies in Lupus: Monitoring and Metrics

Abstract

Systemic lupus erythematosus (SLE) predominantly affects women during their reproductive years, occurring in about 1/1000 women aged between 15 and 45 years. SLE pregnancies are associated with higher maternal and fetal morbidity and mortality. As such, these pregnancies are high-risk, requiring close and careful monitoring by the rheumatologist and maternal-fetal medicine specialist, and sometimes others, throughout pregnancy and postpartum. Adverse pregnancy outcomes can be decreased if conception occurs during a time of SLE disease remission or low disease activity, on medications and dosages compatible with pregnancy. Thus, pregnancies in women with SLE need to be planned well in advance, which requires discussion between patients and their rheumatologists. Anti-SSA, anti-SSB, and antiphospholipid antibodies should be measured prior to conception. During pregnancy and postpartum, lupus disease activity should be followed closely. However, how best to monitor for disease flares and the frequency of monitoring have not been established; current practice is heterogeneous and not necessarily evidence-based. Further, the specific SLE disease activity tools modified for pregnancy have not been validated. Lupus flares in pregnancy can be difficult to distinguish from other complications of pregnancy, such as preeclampsia which occurs in SLE pregnancies more commonly than in women not affected. Newer imaging modalities for monitoring high-risk pregnancies such as umbilical and uterine artery Doppler studies are believed to be useful in monitoring pregnancies at high risk for placental insufficiency which can complicate SLE pregnancies, but there are no guidelines for the use of these modalities in SLE pregnancies. Because of the relative infrequency of pregnancy in SLE women, collection of reliable datasets of sufficient size can be challenging. Administrative databases, registries, and prospective cohort studies are important data sources to address research questions on reproduction in women with SLE, and each has its own advantages and disadvantages. There are factors unique to SLE and pregnancy that create special challenges when attempting to study this area. These include early pregnancy complications and loss, determination of the timing of gestation related to events, parity and repeated pregnancies, measurement of drug exposures, ascertaining congenital malformations, immortal time bias, and the timing of SLE diagnosis in relation to pregnancy. More and better studies that address these factors will facilitate the development of evidence-based guidelines for the optimal monitoring and management of the SLE patient while planning pregnancy, during pregnancy, and postpartum as well as monitoring the fetus and neonate to achieve the best possible outcomes.