On the basis of standardized assessments of disease activity in a cohort of pregnant women with systemic lupus erythematosus (SLE), a team of Norwegian researchers found that disease activity at conception and during pregnancy was low to absent, but increased at 6 and 12 months after delivery.
The research team, led by Carina Götestam Skorpen, MD, from Trondheim University Hospital, Norway, wrote that the 6- and 12-month upswing was “a novel finding in women with SLE.” Results from the longitudinal follow-up study were published July 2017 in Arthritis Care & Research.1
Pregnancies in women with SLE are considered high risk because of an increased incidence of adverse maternal and fetal complications such as miscarriage, stillbirth, preeclampsia, fetal growth restriction, and preterm delivery. High disease activity (also known as “flare”) at time of conception and during pregnancy increases the risk for poor outcomes. Prior studies had suggested that 50% of pregnant women with SLE experience increased disease flare during pregnancy or in the postpartum period.
To examine variations in disease activity in women with SLE during and after pregnancy, the researchers examined data from RevNatus, a nationwide Norwegian multicenter, prospective observational register including women with an inflammatory rheumatic disease when planning pregnancy or after conception.
Women in RevNatus are assessed in visits that take place in each trimester of pregnancy and at 6 weeks, 6 months, and 12 months after birth. The study population included women in RevNatus diagnosed as having SLE by a rheumatologist before enrollment, and whose pregnancies resulted in live births. Among the 128 women who qualified for the study, there were 145 pregnancies and 757 visits. Seventeen women participated twice.
Disease activity was assessed with the Lupus Activity Index in Pregnancy (LAI-P) at the visits that took place during pregnancy and at 6 weeks after birth, and with the modified Lupus Activity Index (M-LAI) at 6 and 12 months after birth. Both the LAI-P and the M-LAI are variants of the LAI, an index that results in a global activity score that facilitates comparison among patients with different disease manifestations across 8 organ systems and allows researchers to detect changes in disease activity over time.2
More than half (51.6%) of the disease activity scores across all visits indicated remission, and 6.3% of the scores indicated moderate disease activity. Only 1 score indicated high disease activity (0.1%). However, a statistically significant change in disease activity took place over time (P =.017), with the highest activity seen at visits 5 and 6.
Summary and Clinical Applicability
“In conclusion, in our study of pregnancies in women with SLE resulting in live births, the majority of women had low or no disease activity at conception, with a statistically significant change in disease activity over time,” wrote the investigators. “Increased disease activity of clinical importance was not demonstrated during pregnancy or at 6 weeks postpartum, but at 6 and 12 months postpartum. Our study points to the importance of tight disease control in women with SLE not only before and during pregnancy, but also in the first year after birth.”
Limitations & Disclosures
The authors noted several limitations to the study:
- A lack of information on preconception disease activity in the majority of participants.
- Women planning pregnancies are recruited for the register, resulting in possible selection bias toward women with planned pregnancies.
- Physicians may not have recruited patients in remission for the register; thus, no or low disease activity may have been underreported.
- Götestam Skorpen C, Lydersen S, Gilboe I-M, et al. Disease activity during pregnancy and the first year postpartum in women with systemic lupus erythematosus [published online July 10, 2017]. Arthritis Care Res. doi: 10.1002/acr.23102
- Griffiths B, Mosca M, Gordon C. Assessment of patients with systemic lupus erythematosus and the use of lupus disease activity indices. Best Pract Res Clin Rheumatol. 2005;19(5):685-708. doi: 10.1016/j.berh.2005.03.010