Higher Risk for Maternal and Fetal Adverse Outcomes Among Pregnant Patients With SLE With Irreversible Damage Accrual

Pregnant woman
Pregnant African American mother holding her stomach
Researchers assessed the effect of irreversible damage accrual in women with systemic lupus erythematosus and adverse maternal and/or fetal and neonatal outcomes.

Pregnant women with systemic lupus erythematosus (SLE) who present with irreversible damage accrual may have a higher risk for maternal and fetal adverse outcomes, independent of disease activity, according to results of a study published in Lupus.

The researchers sought to assess the potential effect of irreversible damage accrual on adverse maternal and fetal/neonatal outcomes in women with SLE.

An observational, single-center, retrospective cohort study was conducted among pregnant patients with SLE between 2011 and 2020 at the Hospital University Pedro Ernesto of the State University of Rio de Janeiro, Brazil. SLE disease activity was defined as Systemic Lupus Erythematosus Pregnancy Disease Activity Index (SLEPDAI) of 4 or more during pregnancy and/or the consensual judgment of a rheumatologist and obstetrician for the need to increase steroid and/or azathioprine doses. Systemic Lupus International Collaborating Clinic/American College of Rheumatology (SLICC/ACR) Damage Index (SDI) was used to evaluate irreversible organ damage.

Data from 260 women in their first pregnancies following an SLE diagnosis were included in the current study. Overall, 67 women had a score of at least 1 point on the SDI scale at the onset of prenatal care.

Women with vs without an SDI score presented significantly more often with adverse maternal events, including disease activity during pregnancy (P =.004) and puerperium (P =.001), active lupus nephritis (P =.04), and hospitalizations (P =.004).

Risks for adverse fetal and neonatal outcomes were also significantly higher among women with an SDI of at least1 than those without an SDI score (59.7% vs 38.3%, respectively; P =.001), even after controlling for disease activity (ie, SLEPDAI score

>4). Women with an SDI of at least 1 vs those without an SDI score had significantly more frequent preterm deliveries (46.3% vs 31.6%, respectively; P =.01), small for gestational age infants (28.3% vs 18.1%, respectively; P =.04), and admissions to neonatal intensive care units (26.9% vs 1.5%, respectively; P <.001).

Multivariate analysis showed that an SDI of at least 1 was an independent risk factor of hospitalization for obstetric complications (P =.0008) and preterm delivery (P =.009).

Study limitations included that fact that it was retrospective analysis and its single-center design; inability to assess modifiable risk factors such as smoking; patients with an SDI score of greater than 1 were not included in the analysis; and the evaluation of SDI at the beginning of prenatal care, therefore not considering any modifications to the score during the course of pregnancy.

The researchers concluded, “Despite these limitations, [the] study is quite relevant as it demonstrates for the first time that SDI can influence adverse pregnancy outcomes and, in addition, it helps understand pregnancy in women [with SLE] in developing countries like Brazil, with low rate of family planning, low adherence to contraceptive methods, and a significant number of patients with severe and active lupus since conception.”

Disclosure: One study author declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of the author’s affiliations.


Lacerda MI, de Jesús GRR, dos Santos FC, de Jesús NR, Levy RA, Klumb EM. The SLICC/ACR Damage Index (SDI) may predict adverse obstetric events in patients with systemic lupus erythematosus. Lupus. Published online September 16, 2021. doi:10.1177/09612033211045061