Risks Quantified in Medically Optimized Pregnancy With Lupus

SAN DIEGO — In pregnant women with systemic lupus erythematosus (SLE), those with ill-timed pregnancies had poorer pregnancy outcomes, including preeclampsia and preterm birth.

Dr Catherine Sims

Women with autoimmune conditions are at an increased risk for pregnancy complications, including pregnancy loss, preterm delivery, and increased need for cesarean delivery, said Catherine Sims, MD, a rheumatologist at Duke Health in Durham, North Carolina, who is focused on reproductive rheumatology. "The natural question, both clinically and from a research perspective, is, 'what can we do in order to mitigate or minimize these complications?' " she said during a presentation at the American College of Rheumatology 2023 Annual Meeting.

While research suggests that patients who plan their pregnancies during times of well-controlled disease have the "best chances of improved pregnancy outcomes," Sims and her colleagues wanted to quantify how planning for pregnancy affected reproductive outcomes.

Sims recruited pregnant women with SLE and assessed if the women were medically optimized for pregnancy, if the pregnancy was intended, or both. Intended pregnancy was assessed by using a validated self-reported survey called the London Measure of Unplanned Pregnancy. Pregnant women were considered "medically optimized" for pregnancy if they were not on teratogenic medication, had continued pregnancy-compatible SLE medications, and had a urine protein-creatinine ratio of less than 1 gram in the 6 months prior to or during the first trimester. Intended pregnancies that were medically optimized were classified as "well-timed."

Of the 115 women enrolled in the study, about half had well-timed pregnancies, 20% were neither intended nor medically optimized, 17% were not intended but medically optimized, and 13% were intended but not medically optimized.

Women with ill-timed pregnancy — either not medically optimized and/or unintended — were generally younger and more likely to be single, on Medicare or Medicaid, and on income of less than $50,000 per year.

Ill-timed pregnancies had higher rates of mycophenolate exposure and higher physician-reported SLE disease activity. While patient-reported SLE activity was higher in patients who were not personally ready for pregnancy, in patients who had an intended pregnancy, there was no difference in self-reported SLE activity between those that were medically optimized and those not medically optimized.

"About a third of our patients are actually underestimating their true disease activity level when they are preparing for pregnancy," Sims said. For example, while persistent proteinuria in a patient would drive up physician assessment of disease activity, the patient may not be experiencing any symptoms and is unaware of her condition, Sims explained.

In terms of pregnancy outcomes, women with unintended pregnancies had a 2.5 times higher incidence of preeclampsia compared with those with intended pregnancies. Patients with unplanned pregnancies were also significantly more likely to experience stillbirth.

Women who were not medically optimized for pregnancy were three times as likely to experience preterm birth and preeclampsia compared with those with optimized pregnancies.

These outcomes drive home the importance of optimizing patients for pregnancy, Sims said, and effectively communicating this importance to patients, especially when they might not be perceiving their disease activity.

The study's findings show providers "what we thought we knew, which is that there are some patients that are not as aware of their risk," commented Lisa R. Sammaritano, MD, Hospital for Special Surgery, New York City, who moderated the session where the research was presented. "It brings home the importance of counselling our patients about contraception [as well as] the importance of planning," she said.

Sims added that it is "crucial" to make this information easily accessible and digestible to patients. One important resource she mentioned is the HOP-STEP program, which stands for Healthy Outcomes in Pregnancy with SLE Through Education of Providers. The program, directed by researchers at Duke University, is designed to improve pregnancy planning in people with lupus. Direct-to-patient resources are key, she said, as patients can often be nervous to ask about pregnancy planning during appointments.

"They won't want to bring a pregnancy with me in clinic because they're afraid I'm just going to say, 'don't do it,' " Sims said. "But we are making decisions with the patient. Our patients are not asking for permission, but telling us what they want, and we need to meet them where they are at."

Medscape Medical News © 2023 

Cite this: Risks Quantified in Medically Optimized Pregnancy With Lupus - Medscape - Nov 21, 2023.