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 Pregnancy in Autoimmune Disease550: National Study of Medical Complications in SLE PregnanciesAuthors: Megan E. B. Clowse, Margaret G. Jamison, Evan Myers, Andra H. James. Duke University, Durham, NC Using the Nationwide Inpatient Sample, a federally administered database encompassing 20% of all hospital admissions in the United States from 2000 to 2002, the authors identified over 18.3 million pregnancy-related admissions, 17,262 of which were to women with SLE. This resulted in 13,555 deliveries to women with SLE. By comparing the pregnancies of women with lupus to the general population, this study identified several pregnancy and medical complications for which the lupus patients were are particularly increased risk. Over one third of women with lupus delivered by cesarean section, 2.6 times more frequently than healthy women. Over one in five women with lupus suffered from preeclampsia, which is 3-fold higher than expected. Eclampsia was 4.4 times more common among lupus patients, but was fortunately quite rare (0.5% of all SLE pregnancies). The most shocking statistic was that women with lupus have a 20-fold increase in the risk for death, however the absolute number of deaths was low – averaging out to about 15 deaths per year nationwide, or 3 in 1000 lupus pregnancies. Other medical complications, including strokes, blood clots, and infections were also increased several-fold among lupus patients. Women with lupus were more likely to have low blood counts, including anemia and low platelets, during pregnancy. This likely prompted the 3.4-fold increase in transfusions required by women with lupus. Beyond having a systemic autoimmune disease, women with lupus have several important co-morbid conditions that may place them at higher risk than the general population. They tend to be older when they get pregnant, and more of them have high blood pressure or diabetes prior to pregnancy. Also, some women with lupus may have a higher risk for blood clots, may have kidney failure, and may have pulmonary hypertension – each of these diseases makes carrying a pregnancy very difficult. Editorial: This is the largest study, to date, of lupus pregnancies. Due to the large size of the cohort, the authors were able to identify the risks associated with rare complications such as death, stroke, and eclampsia. Prior single-center cohorts have not had enough patients to provide reliable information about these risks. The most alarming finding in this study is the dramatic increase in the risk of death among women with lupus over that of healthy pregnant women. This elevation, however, is not surprising as a woman with lupus who is NOT pregnant is also at an increased risk for death – studies estimate that about 2% of lupus patients will die each year. In this study, the maternal mortality was 0.3% per pregnancy. Therefore, though the 20-fold increase in maternal mortality is certainly a wake-up call to all of us caring for women with lupus, it is NOT an increase over the risk that lupus patients live with every day. This study does have several drawbacks. Primarily, the information included in this database is from hospital discharges – while hospitalized, these patients were primarily cared for by obstetricians, who have not been specifically trained in the diagnosis of lupus. There is undoubtedly some error in the diagnosis of lupus in this cohort – both over and under diagnosis. However, for the diagnosis of SLE will be more accurate for women with serious complications as a rheumatologist was more likely to be involved in the case. The elevated risks identified in this study mandate that women with lupus be followed closely by a rheumatologist and a high-risk obstetrician throughout pregnancy. | |