Maternal Health Insights in Patients with SLE
The impact of pregnancy readiness on lupus activity, maternal mental health & pregnancy outcomes
By Ceshae Harding, MD, & Megan Clowse, MD, MPH
Why was this study done? Patients with systemic lupus erythematosus (SLE) who are pregnant have increased risks of risks maternal and fetal mortality, preeclampsia and cesarean sections than do members of the general population. Helping women with SLE time their pregnancy to coincide with minimal lupus activity, use of pregnancy-compatible medications and when they desire conception may improve health and well-being for both the mother and infant. In this study among individuals with SLE who became pregnant, we explored the impact of medical readiness for pregnancy and personal readiness for pregnancy on the following: provider-reported disease activity, patient-perceived disease activity, mood symptoms, pregnancy-related health behaviors and pregnancy outcomes.
What were the study methods? All study participants were enrolled in a prospective registry, met Systemic Lupus Collaborating Clinics (SLICC) criteria for SLE and had at least one pregnancy. Being medically ready for pregnancy was defined as: <1 g of proteinuria, no rheumatic teratogens at conception and continuing pregnancy-compatible SLE medications after conception. Being personally ready for pregnancy was defined as a planned pregnancy based on a London Measure of Unplanned Pregnancy ≥10. Multivariable logistic regression models estimated the association of pregnancy readiness with each outcome of interest.
What were the key findings? In patients with SLE, not being medically ready for pregnancy was associated with significantly higher provider-reported disease activity; however, these patients did not perceive themselves as having higher disease activity. Not being personally ready for pregnancy was associated with significantly higher patient-perceived disease activity and higher maternal symptoms of depression. Being both medically and personally ready for pregnancy was associated with lower rates of preeclampsia and improved gestational length.
What were the main conclusions? For maternal mental health and quality of life among individuals with SLE, greater focus is needed on decreasing the incidence of unplanned pregnancy. To improve pregnancy outcomes, greater focus is needed on improving medical optimization prior to conception in this higher risk population.
What are the implications for patients & clinicians? Reproductive-aged individuals with chronic disease are a unique population in whom disease management should always account for reproductive potential and personal goals.
This study speaks to the critical need for provider-initiated discussions around pregnancy planning, which allows individuals with SLE to make informed decisions with regard to family planning. To improve maternal health in patients with SLE, we must work toward increasing the proportion of pregnancies that are planned and medically optimized.
The study: Harding CC, Eudy AM, Sims CA, et al. The impact of pregnancy readiness on lupus activity, maternal mental health & pregnancy outcomes. Arthritis Care Res (Hoboken). 2024 Sep 8. Online ahead of print.
Pregnancy Outcomes from a Multidisciplinary Obstetric-Medicine/Rheumatology Clinic
A 5-year retrospective analysis
By Griffin Reed, MD, & Joanne S. Cunha, MD
Why was this study done? Rheumatic illnesses frequently affect women of childbearing age and treatment decisions affect the patient’s health, fertility and pregnancy outcomes. Multi-disciplinary clinics combining obstetric-medicine internists and rheumatologists are scarce, with only four known programs of this kind in the U.S.
What were the study methods? We performed a five-year retrospective chart review of patients seen in our combined obstetric-medicine/rheumatology clinic, from Jan. 1, 2016, through Dec. 31, 2021. Comprehensive demographic data on medication exposures and pregnancy outcomes were collected into an electronic database to characterize the mother’s rheumatologic diagnosis and identify comorbidities, medications and pregnancy outcomes.
What were the key findings? Eighty-one patients were seen at this clinic, and 61 were pregnant during at least one visit. The most common rheumatologic diagnoses were systemic lupus erythematosus (SLE), at 22%, and rheumatoid arthritis (RA), at 12%.
Details on the medications initiated, changed or discontinued in 87 patient visits (preconception, prenatal and postpartum encounters) can be found in Table 2 of the article. Fifty-four percent of patients received conventional synthetic disease-modifying anti-rheumatic drugs (DMARDs) and 17% received biologic DMARDs.
Low-dose aspirin was given in the antepartum period or during pregnancy in 28% of patients.
What were the main conclusions? Hydroxychloroquine, prednisone and certolizumab pegol were the most commonly prescribed medications during the preconception or pregnancy periods, which underscores the safety and efficacy of these medications during pregnancy.
Aspirin prophylaxis is recommended for patients with high-risk pregnancies, including those with SLE or antiphospholipid syndrome. Of pregnancies in our patients, 8% were complicated by preeclampsia, compared with 4% of the general U.S. population. This confirmed the higher rate of preeclampsia seen in patients with systemic autoimmune diseases and supports the need for aspirin prophylaxis in this patient population.
What are the implications for patients & clinicians? This study illustrates the advantages of a combined obstetric-medicine and rheumatology clinic in managing patients with rheumatologic disorders during the prenatal and perinatal periods. This multi-disciplinary approach allows for complex treatment decisions to be made with the goal of optimizing rheumatologic disease control as well as maternal and fetal outcomes.
The study: Reed G, Deeb M, Mathew J, et al. Pregnancy outcomes from a multidisciplinary obstetric-medicine/rheumatology clinic in the United States: A five-year retrospective analysis. Arthritis Care Res (Hoboken). 2024 Dec;76(12):1744–1750.
Coordinated Ophthalmic & Rheumatologic Care
Measurable outcomes of a coordinated care clinic
By Catherine Lavallee, MD, & Melissa Lerman, MD, PhD, MSCE
Why was this study done? Non-infectious uveitis often requires treatment with systemic immunosuppression. For expertise with these drugs, ophthalmologists frequently rely on rheumatologists to co-manage care. Coordinated clinics have been recommended to decrease barriers to communication and visit burden that arise when being cared for by two specialists. Yet there is a knowledge gap in the literature as to whether coordinated clinics provide improved care over that provided to patients who see both physicians separately.
What were the study methods? The study examined patients with anterior uveitis cared for by rheumatologists at a single institution, Children’s Hospital of Philadelphia, between 2013 and 2022. The study compared outcomes between patients who primarily received treatment in either a coordinated care or a traditional care arrangement. Survival analyses explored differences in cohort disease activity and biologic disease-modifying anti-rheumatic drug (DMARD) use. Steroid use, disease complication and absolute number of visits were compared.
What were the key findings? The traditional care cohort included 170 patients, and the combined care cohort included 45 patients. The median time until disease control differed (combined vs. traditional, 77 vs. 136 days, respectively, P<0.01). The median time until biologic initiation for the traditional cohort was 662 days and 98 days for the coordinated care cohort (P<0.01). The rate of topical corticosteroid use per appointment was 96% lower for the combined care cohort within the first year. Rates of total visits were 67% lower for patients receiving coordinated care, when controlling for the patients’ total complications.
What were the main conclusions? In this study, we demonstrate that coordinated care improved important uveitis outcomes, including reduced time to disease control, minimized corticosteroid use and accelerated initiation of biologic DMARDs in our single-center cohort.
What are the implications for patients & clinicians? Coordinated care clinics can provide better care—improved outcomes and fewer total appointments. Improved outcomes may have been positively impacted by increased expertise of clinicians in the coordinated clinic and the extent to which these physicians also provide traditional care at Children’s Hospital of Philadelphia. In future work from this population, we will assess visual outcomes, best corrected visual acuity and glaucoma.
The study: Lavallee C, Ahrens M, Davidson SL, et al. Measurable outcomes of an ophthalmology & rheumatology coordinated care clinic. Arthritis Care Res (Hoboken). 2024 Sep 15. Online ahead of print.
