Among patients with systemic lupus erythematosus (SLE) who have stable or inactive disease at conception, disease flares during and after pregnancy are typically mild and occur at similar rates, according to study results published in Arthritis Research & Therapy.1
Patients with SLE with active disease have increased risk for poor fetal outcomes, ranging from preterm birth and restricted growth to fetal loss, in addition to maternal nephritis and pre-eclampsia. As a result, current clinical guidelines call for conception after low disease activity for 6 months.2 However, the effects of lupus flares and its predictors are less widely known during and after pregnancy.
The study evaluated data from 384 patients enrolled in the multicenter prospective PROMISSE (Predictors of Pregnancy Outcome: Biomarkers in Antiphospholipid Antibody Syndrome and Systemic Lupus Erythematosus) study. Between September 2003 and December 2012, the study included consecutive patients who were pregnant and met the revised American College of Rheumatology criteria for SLE, as well as the inclusion criteria for age (18-45 years), hematocrit (>26%), and gestation (<12 weeks). The study aimed to assess the number, severity, and risk factors for flares during and after pregnancy in patients with quiescent or stable mildly active disease and avoid other known risk factors for pregnancy complications in patients with SLE. Patients were enrolled at 8 to 12 weeks gestation and had follow-ups monthly and at 2 to 6 months postpartum. Disease activity was measured using the Physician Global Assessment (PGA) and the Systemic Lupus Erythematosus Pregnancy Disease Activity Index (SLEPDAI); the Systemic Lupus Erythematosus National Assessment (SELENA)-SLEDAI flare index was used to assess patient flares.
Of the 384 patients (average age, 30.9 years), 100 (26%) experienced flares (SLEPDAI >4; PGA >1) at any point during their pregnancy. Among patients with flares, 20.8% had ≥1 mild/moderate flare and 6.25% had ≥1 severe flare. In postpartum patients, 27.7% had mild/moderate flares and 1.7% experienced severe flares. During pregnancy and postpartum, mild flares rarely required treatment.
Baseline demographic and clinical variables predictive of flares during and after pregnancy included ethnicity/race (P =.019) and age (P =.002), with black, Hispanic, and younger patients likelier to experience flares. Low C4 was also significantly associated with flares (P =.005), and higher disease activity at baseline significantly predicted flares during pregnancy. Among women who experienced flares vs those who did not experience flares, mean SLEPDAI >4 (P =.011) and mean PGA >1 (P =.005) were higher at baseline. In contrast, baseline patient characteristics had no correlations with postpartum flares. Similarly, no correlations existed between postpartum flares and laboratory values, disease activity, and medication use at the last visit during pregnancy.
Logistic regression analysis showed that the baseline variables that were independently predictive of ≥1 flare during pregnancy included age at screening (P =.003), low C4 (P =.024), and PGA score (P =.005). Overall, older patients and those with quiescent disease at baseline were at reduced risk for flares.
Study limitations included the inclusion of patients with quiescent disease at baseline and the exclusion of patients with SLE who required high-dose prednisone and with nephritis, the possibility of the researchers missing some flares because of scheduling, and the fact that postpartum visits were scheduled after 3 months and not soon after delivery.
“Based on these results, physicians can reassure their patients that if they plan their pregnancy at a time of quiescence, they are unlikely to have a flare during or in the 6 months after pregnancy,” the researchers concluded.
1. Davis-Porada J, Kim MY, Guerra MM, et al. Low frequency of flares during pregnancy and post-partum in stable lupus patients. Arthritis Res Ther. 2020;22 (1):1.
2. Skorpen CG, Lydersen S, Gilboe I-M, et al. Disease activity during pregnancy and the first year postpartum in women with systemic lupus erythematosus. Arthritis Care Res (Hoboken). 2017;69(8):1201-1208.