Clinical outcomes and predictors of maternal and fetal complications in pregnancies of patients with systemic lupus erythematosus

ABSTRACT

Introduction: Systemic Lupus Erythematosus (SLE) mostly affects women during their childbearing years. Fertility is preserved in SLE patients, but pregnancy is often characterized by a high number of maternal and fetal complications. Adverse pregnancy outcomes (APO) have been widely studied over the last decades and several investigators have focused on the potential clinical and serological predictors of maternal and fetal complications.

Areas covered: In this review, we analyzed maternal and fetal complications in SLE patients and predictors of APO. Active disease in the 6 months before conception, lupus nephritis, anti-phospholipid (aPL), anti-SSA/Ro and/or anti-SSB/La antibodies have been identified as the most consistent predictors of maternal and fetal complications to date. However, molecular mechanisms and underlying immunological pathways involved in APO still remain elusive.

Expert opinion: Difficulties in assessing prevalence and predictors of APO in SLE patients are due to lack of uniformity in the definitions and methods used in the different studies. In addition, some maternal and fetal complications are difficult to diagnose and to differentiate from each other. Preconception counseling is paramount to prevent APO, and it should consider four main factors: disease activity/lupus nephritis, safety of drugs, aPL, anti-SSA/Ro, and/or anti-SSB/La antibodies.

KEYWORDS:

• SLE
• pregnancy
• adverse pregnancy outcomes
• predictors
• biomarkers
• disease activity
• preconception-counselling

Article highlights

1. SLE is a chronic autoimmune disease which mostly affects women during their childbearing years; despite pregnancy outcomes in SLE women have consistently improved in the last few decades, pregnancy is still challenging either for patients or clinicians.

2. Adverse pregnancy outcomes (APO) include maternal and fetal/neonatal complications.

3. Maternal complications encompass hypertensive disorders (gestational hypertension, preeclampsia/eclampsia, Hemolysis Elevated Liver Enzymes, Low Platelets – HELLP – syndrome) and disease flares.

4. Fetal/neonatal complications include cesarean section, preterm delivery, intrauterine growth restriction, small for gestational age, fetal loss and intrauterine fetal death.

5. Predictors of APO have been widely analyzed for many years; however, specific biomarkers have not been identified yet.

6. Novel predictors of APO include pro-angiogenic and anti-angiogenic factors, complement activation products, and uterine and umbilical artery Doppler abnormalities.

7. Some predictive factors could also consist in some drugs, i.e. hydroxychloroquine and low dose aspirin seem to be protective against neonatal lupus and preeclampsia/fetal loss, respectively; however, their efficacy is still under evaluation and need further investigations.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.