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Pregnancy in Women With Systemic Lupus Erythematosus: Messages for the ClinicianPregnancy in Women With Systemic Lupus Erythematosus

Bevra H. Hahn, MD
[+] Article, Author, and Disclosure Information

This article was published online first at www.annals.org on 23 June 2015.

From David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California.

Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M15-1301.

Requests for Single Reprints: Bevra H. Hahn, MD, Distinguished Professor of Medicine (Emeritus), Division of Rheumatology, David Geffen School of Medicine, University of California, Los Angeles, Room 31-75, 1000 Veteran Avenue, Los Angeles, CA 90095.

Ann Intern Med. 2015;163(3):232-233. doi:10.7326/M15-1301
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In this issue, Buyon and colleagues report findings from a large prospective study of pregnancy outcomes in ethnically diverse women with SLE. The editorialist discusses the study and concludes that the findings can help guide clinicians counseling patients with SLE who are contemplating pregnancy or are already pregnant.

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Comment to Editorial by Hahn
Posted on August 4, 2015
Jill P. Buyon, Mimi Y. Kim, Jane E. Salmon
New York University School of Medicine, Albert Einstein College of Medicine, Hospital for Special Surgery, and Weill Cornell Medical College, New York, New York
Conflict of Interest: Dr. Buyon and Dr. Kim report grants from the National Institutes of Health and the National Institute of Arthritis and Musculoskeletal and Skin Diseases during the conduct of the study. Dr. Salmon reports grants from the National Institutes of Health, the National Institute of Arthritis and Musculoskeletal and Skin Diseases, and Rheuminations during the conduct of the study.
For women with Systemic Lupus Erythematosus faced with a disease which surfaces coincident with the child bearing years, new knowledge regarding pregnancy outcomes both for mother and baby is essential. We would like to clarify several points raised by Dr. Hahn (1). Although PROMISSE enrolled patients who were not highly active in accord with current recommendations, a third had past renal disease, a third had serologic activity, a third were on low dose prednisone and a fifth were continued on azathioprine (2). Many of our patients had serious manifestations of SLE, but their disease was inactive or mildly/moderately active at enrollment. The “very good news” for such patients was not just that pregnancy outcomes were favorable in 81%, but contrary to many prior studies, flares were much less frequent than the 50% referenced in the Clowse (3) paper cited by Hahn (1); severe flares occurred in 3% and mild/moderate in <13%. A major directive of PROMISSE was to identify risk factors predictive of poor outcomes. A smaller increase in serum complement levels was significantly predictive of an adverse pregnancy outcome after 23 weeks but owing to the smaller number of patients did not reach statistical significance after 35 weeks. In contrast, the presence of anti-dsDNA antibodies was not informative. Surely we need to take a closer look at first trimester flares, especially those who have heeded the advice to forestall conception until disease stability and those with intermediate renal insufficiency. However, continued discouragement of pregnancy in patients with heavy proteinuria and or high activity, would seem prudent.

Second, while Hahn points to the “not-so-good” news for African Americans and Hispanic Americans, there is an important qualifier to the message for these lupus patients regarding the non-modifiable risk factors of ethnicity and race. For African Americans and Hispanics without any identified risk factors (not on hypertensive, LAC-negative, Platelets ≥100K, PGA ≤1) poor pregnancy outcomes occurred in 13.7% and 15.0%, respectively, lower than the overall frequencies of 25.6% and 25.9% in these groups provided in Table 2 and emphasized by Dr. Hahn. In comparison, the frequency of poor outcomes in non-Hispanic Whites without risk factors was 7.8%. The basis for this underlying disparity warrants further exploration.

1. Hahn BH. Pregnancy in Women With Systemic Lupus Erythematosus: Messages for the Clinician. Ann Intern Med. 2015;163(3):232-3.
2. Buyon JP, Kim MY, Guerra MM, Laskin CA, Petri M, Lockshin MD, et al. Predictors of Pregnancy Outcomes in Patients With Lupus: A Cohort Study. Ann Intern Med. 2015;163(3):153-63.
3. Clowse ME, Jamison M, Myers E, James AH. A national study of the complications of lupus in pregnancy. Am J Obstet Gynecol. 2008;199(2):127 e1-6.
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