Abstract
The aim of this study is to explore the clinical features and pregnancy outcomes of Chinese patients with new-onset systemic lupus erythematosus (SLE) during pregnancy or puerperium. We retrospectively evaluated the data of all pregnant women with SLE managed at the First Affiliated Hospital of Zhengzhou University between April 2013 and March 2017. Clinical characteristics, laboratory features, medication use, and pregnancy outcomes were compared between pregnant women with new-onset SLE and pregnant women with pre-existing SLE. Risk factors for adverse pregnancy outcomes were determined using binary regression analyses. Overall, 223 pregnancies in 216 patients were included; 148 (69.6%) patients had a history of SLE, and 68 (30.4%) were diagnosed with SLE during pregnancy or puerperium. Most cases of new-onset SLE (72.1%) occurred during the first and second trimesters. Thrombocytopaenia (especially severe thrombocytopaenia) (76.5% vs 54.2%, P = 0.008; 39.7% vs 15.5%, P = 0.001) and anaemia (especially moderate anaemia) (73.5% vs 56.9%, P = 0.007; 52.9% vs 35.2%, P = 0.035) were more common in women with new-onset SLE than in women with pre-existing SLE and active disease during pregnancy. Additionally, patients with new-onset SLE experienced higher rates of moderate-to-severe disease activity than patients with pre-existing SLE (P < 0.01); disease activity occurred mostly during the first and second trimesters (75.4%). Compared with pre-existing SLE patients, disease activity in new-onset SLE patients occurred mostly in the first trimester (33.3% vs 15.3%, P = 0.043) and less in the third trimester (21.1% vs 47.2%, P < 0.001). Pregnancy loss was significantly higher in patients with new-onset SLE than in patients with pre-existing SLE (62.4% vs 27.1%, P < 0.001), with most cases occurring during the first and second trimesters (95.3%). However, there were no significant differences in neonatal outcomes between new-onset and pre-existing SLE patients with active disease. Within the new-onset SLE group, active disease was an independent risk factor for pregnancy loss (odds ratio [OR] = 16.185, confidence interval [CI] = 1.895–138.232, P = 0.011), whereas disease onset at late gestation was a protective factor against pregnancy loss (OR = 0.589, CI = 0.435–0.796, P = 0.013). Patients with new-onset SLE suffered greater haematological involvement (mainly thrombocytopaenia and anaemia) and higher rates of moderate-to-severe disease activity and pregnancy loss than patients with pre-existing SLE. Controlling disease activity and extending gestational age may improve pregnancy outcomes in women with new-onset SLE.
Key Points • The clinical features of new-onset SLE during pregnancy and its impact on pregnancy outcomes have rarely been reported, especially in Chinese patients. • New-onset SLE during pregnancy in Chinese women occurred primarily during the first and second trimesters and was characterised by haematological disorders, including thrombocytopaenia and anaemia. • Women with new-onset SLE during pregnancy had significantly higher disease activity scores and pregnancy loss rates than women with pre-existing SLE, especially during the first and second trimesters; controlling disease activity and prolonging gestational age may improve pregnancy outcomes in this setting. |
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References
Stojan G, Baer AN (2012) Flares of systemic lupus erythematosus during pregnancy and the puerperium: prevention, diagnosis and management. Expert Rev Clin Immunol 8:439–453. https://doi.org/10.1586/eci.12.36
Lazzaroni M G, Dall'Ara F, Fredi M, Nalli C, Reggia R, Lojacono A, Ramazzotto F, Zatti S, Andreoli L, Tincani A. (2016). A comprehensive review of the clinical approach to pregnancy and systemic lupus erythematosus. J Autoimmun 74:106-117. https://doi.org/10.1016/j.jaut.2016.06.016
Molad Y, Borkowski T, Monselise A, Ben-Haroush A, Sulkes J, Hod M, Feldberg D, Bar J (2005) Maternal and fetal outcome of lupus pregnancy: a prospective study of 29 pregnancies. Lupus 14:145–151. https://doi.org/10.1191/0961203305lu2072oa
Lateef A, Petri M (2017) Systemic lupus erythematosus and pregnancy. Rheum Dis Clin N Am 43:215–226. https://doi.org/10.1016/j.rdc.2016.12.009
Andreoli L, Fredi M, Nalli C, Reggia R, Lojacono A, Motta M, Tincani A (2012) Pregnancy implications for systemic lupus erythematosus and the antiphospholipid syndrome. J Autoimmun 38:J197–J208. https://doi.org/10.1016/j.jaut.2011.11.010
Eudy AM, Siega-Riz AM, Engel SM, Franceschini N, Howard AG, Clowse M, Petri M (2018) Effect of pregnancy on disease flares in patients with systemic lupus erythematosus. Ann Rheum Dis 77:855–860. https://doi.org/10.1136/annrheumdis-2017-212535
Nahal SK, Selmi C, Gershwin ME (2018) Safety issues and recommendations for successful pregnancy outcome in systemic lupus erythematosus. J Autoimmun 93:16–23. https://doi.org/10.1016/j.jaut.2018.07.016
Zhao C, Zhao J, Huang Y, Wang Z, Wang H, Zhang H, Xu H, Yang N (2013) New-onset systemic lupus erythematosus during pregnancy. Clin Rheumatol 32:815–822. https://doi.org/10.1007/s10067-013-2180-z
Ku M, Guo S, Shang W, Li Q, Zeng R, Han M, Ge S, Xu G (2016) Pregnancy outcomes in Chinese patients with systemic lupus erythematosus (SLE): a retrospective study of 109 pregnancies. PLoS One 11:e159364. https://doi.org/10.1371/journal.pone.0159364
Zhongping Z, Yang Y, Yanfeng Z, Dongying C, Liang L, Yang X (2016) Analysis of clinical features and adverse pregnancy outcomes of patients with systemic lupus erythematosus at the beginning of pregnancy. Chin Med J 96:3300–3304. https://doi.org/10.3760/cma.j.issn.0376-2491.2016.41.005
Zhang C, Liang MY, Xu X, Zhang XW, Chen S (2018) Clinical features of new-onset systemic lupus erythematosus in pregnant patients. J Obstet Gynaecol Res 44:234–240. https://doi.org/10.1111/jog.13520
Jakes RW, Bae SC, Louthrenoo W, Mok CC, Navarra SV, Kwon N (2012) Systematic review of the epidemiology of systemic lupus erythematosus in the Asia-Pacific region: prevalence, incidence, clinical features, and mortality. Arthritis Care Res 64:159–168. https://doi.org/10.1002/acr.20683
Petri M, Orbai AM, Alarcon GS, Gordon C, Merrill JT, Fortin PR, Bruce IN, Isenberg D, Wallace DJ, Nived O, Sturfelt G, Ramsey-Goldman R, Bae SC, Hanly JG, Sanchez-Guerrero J, Clarke A, Aranow C, Manzi S, Urowitz M, Gladman D, Kalunian K, Costner M, Werth VP, Zoma A, Bernatsky S, Ruiz-Irastorza G, Khamashta MA, Jacobsen S, Buyon JP, Maddison P, Dooley MA, van Vollenhoven RF, Ginzler E, Stoll T, Peschken C, Jorizzo JL, Callen JP, Lim SS, Fessler BJ, Inanc M, Kamen DL, Rahman A, Steinsson K, Franks AJ, Sigler L, Hameed S, Fang H, Pham N, Brey R, Weisman MH, McGwin GJ, Magder LS (2012) Derivation and validation of the systemic lupus international collaborating clinics classification criteria for systemic lupus erythematosus. Arthritis Rheum 64:2677–2686. https://doi.org/10.1002/art.34473
Bombardier C, Gladman DD, Urowitz MB, Caron D, Chang CH (1992) Derivation of the SLEDAI. A disease activity index for lupus patients. The committee on prognosis studies in SLE. Arthritis Rheum 35:630–640. https://doi.org/10.1002/art.1780350606
2019). ACOG Practice Bulletin No. 207: Thrombocytopenia in Pregnancy. Obstet Gynecol 133:e181–e193. https://doi.org/10.1097/AOG.0000000000003100
McLean E, Cogswell M, Egli I, Wojdyla D, de Benoist B (2009) Worldwide prevalence of anaemia, WHO vitamin and mineral nutrition information system, 1993-2005. Public Health Nutr 12:444–454. https://doi.org/10.1017/S1368980008002401
Zhan Z, Yang Y, Zhan Y, Chen D, Liang L, Yang X (2017) Fetal outcomes and associated factors of adverse outcomes of pregnancy in southern Chinese women with systemic lupus erythematosus. PLoS One 12:e176457. https://doi.org/10.1371/journal.pone.0176457
Elenkov IJ, Hoffman J, Wilder RL (1997) Does differential neuroendocrine control of cytokine production govern the expression of autoimmune diseases in pregnancy and the postpartum period? Mol Med Today 3:379–383. https://doi.org/10.1016/s1357-4310(97)01089-7
Doria A, Iaccarino L, Arienti S, Ghirardello A, Zampieri S, Rampudda ME, Cutolo M, Tincani A, Todesco S (2006) Th2 immune deviation induced by pregnancy: the two faces of autoimmune rheumatic diseases. Reprod Toxicol 22:234–241. https://doi.org/10.1016/j.reprotox.2006.04.001
Doria A, Iaccarino L, Sarzi-Puttini P, Ghirardello A, Zampieri S, Arienti S, Cutolo M, Todesco S (2006) Estrogens in pregnancy and systemic lupus erythematosus. Ann N Y Acad Sci 1069:247–256. https://doi.org/10.1196/annals.1351.022
Salem ML (2004) Estrogen, a double-edged sword: modulation of TH1- and TH2-mediated inflammations by differential regulation of TH1/TH2 cytokine production. Curr Drug Targets Inflamm Allergy 3:97–104. https://doi.org/10.2174/1568010043483944
Munoz-Valle JF, Vazquez-Del MM, Garcia-Iglesias T, Orozco-Barocio G, Bernard-Medina G, Martinez-Bonilla G, Bastidas-Ramirez BE, Navarro AD, Bueno M, Martinez-Lopez E, Best-Aguilera CR, Kamachi M, Armendariz-Borunda J (2003) T(H)1/T(H)2 cytokine profile, metalloprotease-9 activity and hormonal status in pregnant rheumatoid arthritis and systemic lupus erythematosus patients. Clin Exp Immunol 131:377–384. https://doi.org/10.1046/j.1365-2249.2003.02059.x
Yang H, Liu H, Xu D, Zhao L, Wang Q, Leng X, Zheng W, Zhang F, Tang F, Zhang X (2014) Pregnancy-related systemic lupus erythematosus: clinical features, outcome and risk factors of disease flares--a case control study. PLoS One 9:e104375. https://doi.org/10.1371/journal.pone.0104375
Yang MJ, Cheng MH, Lin HY (2006) Onset of systemic lupus erythematosus during pregnancy. J Chin Med Assoc 69:130–133. https://doi.org/10.1016/S1726-4901(09)70191-1
Doria A, Cutolo M, Ghirardello A, Zampieri S, Vescovi F, Sulli A, Giusti M, Piccoli A, Grella P, Gambari PF (2002) Steroid hormones and disease activity during pregnancy in systemic lupus erythematosus. Arthritis Rheum 47:202–209. https://doi.org/10.1002/art.10248
Churchill D, Nair M, Stanworth SJ, Knight M (2019) The change in haemoglobin concentration between the first and third trimesters of pregnancy: a population study. BMC Pregnancy Childbirth 19:359. https://doi.org/10.1186/s12884-019-2495-0
Horowitz KM, Ingardia CJ, Borgida AF (2013) Anemia in pregnancy. Clin Lab Med 33:281–291. https://doi.org/10.1016/j.cll.2013.03.016
Cines DB, Levine LD (2017) Thrombocytopenia in pregnancy. Blood 130:2271–2277. https://doi.org/10.1182/blood-2017-05-781971
Tan EM, Cohen AS, Fries JF, Masi AT, McShane DJ, Rothfield NF, Schaller JG, Talal N, Winchester RJ (1982) The 1982 revised criteria for the classification of systemic lupus erythematosus. Arthritis Rheum 25:1271–1277. https://doi.org/10.1002/art.1780251101
Hochberg MC (1997) Updating the American College of Rheumatology revised criteria for the classification of systemic lupus erythematosus. Arthritis Rheum 40:1725. https://doi.org/10.1002/art.1780400928
Ni JD, Yao X, Pan HF, Li XP, Xu JH, Ye DQ (2009) Clinical and serological correlates of anti-Sm autoantibodies in Chinese patients with systemic lupus erythematosus: 1,584 cases. Rheumatol Int 29:1323–1326. https://doi.org/10.1007/s00296-009-0855-1
Yamamoto Y, Aoki S (2016) Systemic lupus erythematosus: strategies to improve pregnancy outcomes. Int J Women's Health 8:265–272. https://doi.org/10.2147/IJWH.S90157
Clowse ME (2007) Lupus activity in pregnancy. Rheum Dis Clin N Am 33:237–252. https://doi.org/10.1016/j.rdc.2007.01.002
Al AA, Khalil N (2010) Pregnancy outcome in 396 pregnancies in patients with SLE in Saudi Arabia. Lupus 19:1665–1673. https://doi.org/10.1177/0961203310378669
Larosa M, Del RT, Calligaro A, Favaro M, Zanatta E, Iaccarino L, Doria A (2019) Clinical outcomes and predictors of maternal and fetal complications in pregnancies of patients with systemic lupus erythematosus. Expert Rev Clin Immunol 15:617–627. https://doi.org/10.1080/1744666X.2019.1601557
Palma DRC, Cardoso G, Carvalho C, Nogueira I, Borges A, Serrano F (2019) Prediction of adverse pregnancy outcomes in women with systemic lupus erythematosus. Clin Rev Allergy Immunol. https://doi.org/10.1007/s12016-019-08762-9
Lockshin MD, Kim M, Laskin CA, Guerra M, Branch DW, Merrill J, Petri M, Porter TF, Sammaritano L, Stephenson MD, Buyon J, Salmon JE (2012) Prediction of adverse pregnancy outcome by the presence of lupus anticoagulant, but not anticardiolipin antibody, in patients with antiphospholipid antibodies. Arthritis Rheum 64:2311–2318. https://doi.org/10.1002/art.34402
Sciascia S, Murru V, Sanna G, Roccatello D, Khamashta MA, Bertolaccini ML (2012) Clinical accuracy for diagnosis of antiphospholipid syndrome in systemic lupus erythematosus: evaluation of 23 possible combinations of antiphospholipid antibody specificities. J Thromb Haemost 10:2512–2518. https://doi.org/10.1111/jth.12014
Chen D, Lao M, Cai X, Li H, Zhan Y, Wang X, Zhan Z (2019) Hypertensive disorders of pregnancy associated with adverse pregnant outcomes in patients with systemic lupus erythematosus: a multicenter retrospective study. Clin Rheumatol 38:3501–3509. https://doi.org/10.1007/s10067-019-04696-x
Stagnaro-Green A, Akhter E, Yim C, Davies TF, Magder L, Petri M (2011) Thyroid disease in pregnant women with systemic lupus erythematosus: increased preterm delivery. Lupus 20:690–699. https://doi.org/10.1177/0961203310394894
Ruffatti A, Tonello M, Visentin MS, Bontadi A, Hoxha A, De Carolis S, Botta A, Salvi S, Nuzzo M, Rovere-Querini P, Canti V, Mosca M, Mitic G, Bertero MT, Pengo V, Boffa MC, Tincani A (2011) Risk factors for pregnancy failure in patients with anti-phospholipid syndrome treated with conventional therapies: a multicentre, case-control study. Rheumatology (Oxford) 50:1684–1689. https://doi.org/10.1093/rheumatology/ker139
Xu J, Chen D, Duan X, Li L, Tang Y, Peng B (2019) The association between antiphospholipid antibodies and late fetal loss: a systematic review and meta-analysis. Acta Obstet Gynecol Scand 98:1523–1533. https://doi.org/10.1111/aogs.13665
Latino JO, Udry S, Aranda FM, Perés WS, Fernández RD, de Larrañaga GF (2017) Pregnancy failure in patients with obstetric antiphospholipid syndrome with conventional treatment: the influence of a triple positive antibody profile. Lupus 26:983–988. https://doi.org/10.1177/0961203317692432
Duan H, Li X, Liu C, Ge Y, Deng X (2020) Risk factors for pregnancy failure in patients with antiphospholipid antibody positivity and prior pregnancy losses: a retrospective study. J Reprod Immunol 141:103171. https://doi.org/10.1016/j.jri.2020.103171
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This work was supported by the National Natural Science Foundation of China (grant no. 71673254), National Key R&D Program of China (grant no. 2017YFC0909900), and Provincial Health Planning Commission (grant no. Wjlx2016060).
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He, X., Jiang, D., Wang, Z. et al. Clinical features of new-onset systemic lupus erythematosus during pregnancy in Central China: a retrospective study of 68 pregnancies. Clin Rheumatol 40, 2121–2131 (2021). https://doi.org/10.1007/s10067-020-05452-2
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DOI: https://doi.org/10.1007/s10067-020-05452-2