Middle East Fertility Society Journal (2016) 21, 168174

Middle East Fertility Society

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ORIGINAL ARTICLE

Pregnancy outcome in patients with systemic lupus

erythematosus: A single center study in the High
Risk Pregnancy unit
Eman Aly Hussein Aly a,*, Rafaat Mohamed Riyad a, Abeer Nabil Mokbel b

a
Department of Obstetrics and Gynecology, Kasr AL Aini Hospital, Cairo University, Egypt
b
Department of Rheumatology and Rehabilitation Cairo University, Egypt

Received 13 August 2015; revised 16 December 2015; accepted 28 December 2015

Available online 22 January 2016

KEYWORDS Abstract Background: Systemic Lupus Erythematosus (SLE) is a chronic autoimmune disease
Systemic lupus erythemato- that mainly affects females in the reproductive age.
sus; Objective: To investigate pregnancy course and outcome in females with SLE, to evaluate the
Pregnancy outcomes; effect of pregnancy on SLE disease activity and to investigate the predictors of adverse pregnancy
Flares outcomes.
Methods: A prospective study of 91 pregnancies (84 women) with SLE. Comparisons were done
using Chi-square test to evaluate the impact of clinical and laboratory parameters on maternal and
fetal outcomes. Logistic regression analysis was used to study the predictors of adverse pregnancy
outcome (dened as the occurrence of abortion, pre-eclampsia, prematurity, IUFD or SLE are).
Results: The most common maternal manifestations of SLE were cutaneous lesions (93%), artic-
ular (92%), lupus nephritis (53%), hypertension (39%) and secondary antiphospholipid syndrome
(APS) (38%). The incidence of abortion was (15%), IUGR (32%), prematurity (13%), pre-
eclampsia (12%), IUFD (8%), NICU (15%), and LBW (22%). SLE antenatal ares were (44%),
with 70% occurring in the second trimester, with renal ares being the most commonly reported
(21%). The incidence of postnatal ares was 7%. There was signicant association between hyper-
tension and abortion (p = 0.04), pre-eclampsia (p = 0.0001) and SLE ares (p = 0.0001). Lupus
nephritis and hypertension were predictors of preeclampsia (p = 0.01 and p = 0.002 respectively)
and SLE ares (p = 0.048 and p = 0.003 respectively). Secondary APS and aCL IgG were also
predictors of abortion (p = 0.001 and p = 0.04 respectively).

* Corresponding author at: Department of Obstetrics and Gynecology, Kasr EL Aini Hospital, Cairo University Hospitals, Egypt. Tel.: +20 2
33352214, +20 122 3518488.
E-mail address: emanalyhussein@yahoo.com (E.A. Hussein Aly).
Peer review under responsibility of Middle East Fertility Society.

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Pregnancy outcome in patients with systemic lupus erythematosus
Conclusion: Careful monitoring of pregnancy and efcient treatment of SLE can decrease the
risks for the mother and the fetus. However, despite improvements in pregnancy outcome of
SLE pregnant patients, adverse maternal and fetal outcomes may occur. SLE may are-up with
pregnancy.
2016 Middle East Fertility Society. Production and hosting by Elsevier B.V. This is an open access article
under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction
Systemic Lupus Erythematosus (SLE) is a chronic autoim-
mune disease that mainly affects females in the reproductive
age group. Women with SLE have the same fertility rate as
the age-matched population of healthy women (1). Histori-
cally, the general recommendation was against pregnancy in
SLE patients due to poor fetal and maternal outcomes (2).
However, over the past few years, the improved treatment
allowed better control over the disease activity resulting in a
remarkable improvement in the quality of life of these patients,
including pregnancy outcomes (3). Nevertheless, there is still a
considerable risk of fetal and maternal complications (4). Preg-
nancies for patients with SLE pose a greater risk of fetal loss,
intrauterine growth restriction (IUGR), prematurity, pre-
eclampsia, and low birth weight (LBW) (5,6).
Several studies discussed the impact of pregnancy on mater-
nal lupus with conicting results, where some studies showed
increased SLE ares during pregnancy (7), while others found
no difference in ares between pregnant and non-pregnant
patients with SLE (8,9). The aim of this study was to evaluate
the maternal and fetal outcomes of pregnancy in women with
SLE, trying to investigate the predictors of adverse pregnancy
outcomes and also to compare the results of the work done in
our department with the current literature.
Patients and methods
This was a prospective study of 91 pregnancies in 84 SLE
female patients attending the antenatal clinic at the High Risk
Pregnancy unit in the Gynecology and Obstetrics Department
at Cairo University Hospitals from October 2010 to January
2015. Each pregnancy was counted as a separate case. The
study was approved by the Institutional Review Board. All
patients were consented to participate in the study. All SLE
patients fullled at least 4 of the 11 criteria of the American
College of Rheumatology (10). Any pregnancy in a patient
with active disease or before 6 months of SLE remission was
excluded. Antiphospholipid syndrome (APS) was diagnosed
according to the recent classication criteria (11). Management
of patients in the study involved a multidisciplinary approach
including obstetrics and a rheumatology team in addition to
nephrology team for patients with renal involvement. Other
specialties were considered as needed.
All patients were followed-up since diagnosis of pregnancy
till delivery. Follow-up during postpartum period continued
for 6 weeks. During the antenatal follow-up, pregnant women
were seen once a month during the rst trimester, every three
weeks in second trimester, then twice weekly starting from the
28th week of pregnancy, and weekly starting from the 36th
week. Patients were seen twice during postpartum period.
169
Thorough history taking, clinical examination and labora-
tory assessment were done for all patients. Data recorded
included age at SLE diagnosis, duration of illness, previous
and current SLE manifestations, current and past medications
utilized, and laboratory data. At each visit, clinical evaluation
of pregnancy and SLE current condition was performed.
Investigations included antinuclear antibodies (ANA), anti-
double stranded (dsDNA) antibodies, lupus anticoagulants
(LAC), anticardiolipin antibodies via immunoglobulins G
(aCL IgG) and M (aCL IgM). Anti-Ro/SSA and anti-La/
SSB antibodies were also done. Baseline routine laboratory
tests (followed by monthly follow-up tests) included complete
blood picture, serum transaminases, alkaline phosphatase
serum albumin, creatinine, urine analysis, 24-h urine collection
for total proteinuria, Fasting and postprandial blood glucose,
serum uric acid and erythrocyte sedimentation rate.
Antenatal ultrasound and Doppler scans for fetal assess-
ment were regularly performed with detailed fetal anomaly scan
at 22 weeks of gestation. Fetal echocardiography was per-
formed in all patients with anti-SSA and/or anti-SSB antibod-
ies. Pregnancies complicated with IUGR, decreased amniotic
uid, or hypertension were followed twice weekly by Doppler
evaluation and fetal cardiotocography (CTG). All SLE preg-
nant patients received Prednisolone with dose ranging from 5
to 20 mg/day. Low dose Acetylsalicylic acid (81 mg) was
described as soon as fetal pulsations were conrmed in the rst
trimester. Anticoagulation with low molecular weight heparin
(LMWH) was used in all patients with APS and in patients with
history of thrombotic events. Flares were treated with increased
doses of Prednisolone up to 60 mg/day and/or introduction of
medications as Hydroxychloroquine or Azathioprine.
Manifestations of SLE in pregnancy were identied and
recorded. Pregnancy outcomes were assessed by occurrence
of obstetric complications as abortion, intrauterine fetal death
(IUFD), IUGR, development of preeclampsia (dened as new
onset hypertension and proteinuria after 20 weeks gestation),
and preterm labor (before 37 weeks gestation). Neonatal out-
come was assessed by live births (term and preterm), LBW
(less than 2.5 kg at birth), neonatal deaths (within 28 days after
delivery), neonatal lupus syndrome or congenital heart block,
and neonatal admission to intensive care unit (NICU).
The disease activity of SLE was evaluated using the SLE
Disease Activity Index (SLEDAI). Active disease at concep-
tion was dened as SLEDAI score P2 (12). SLE are was
dened as onset of new signs or worsening of disease during
pregnancies in patients who are previously in remission. Flares
included new or worsened cutaneous disease, arthritis, pleuri-
tis, pericarditis, nephritis, hematological abnormalities as
hemolytic anemia or platelet count below 60,000/lL, adding
new drugs (Hydroxychloroquine and/or Azathioprine), hospi-
talization for SLE-related manifestations, increased pred-
nisone dose, or increased SLEDAI score P3.
170 E.A. Hussein Aly et al.

Statistical analysis
Table 2 Clinical and laboratory characteristics of the 91
pregnant SLE patients included in the study.
Descriptive statistics was used to summarize data. Chi-square
Number of patients Percentage
test was used to evaluate the impact of clinical and laboratory
n = 91 (%)
characteristics on maternal and fetal outcomes. Logistic anal-
ysis was used to study the predictors of adverse pregnancy out- Planned pregnancy
Yes 65 71.4%
come (dened as the occurrence of abortion, pre-eclampsia,
No 26 28.6%
prematurity, IUFD or SLE are). Each pregnancy was consid-
ered as a separate observation. In all cases, p value < 0.05 was Gravity
considered to be statistically signicant. All statistical analyses Primigravida 30 33%
were performed using SPSS 19.0 (Statistical Package for the Multigravida 61 67%
History of abortion 42 46.2%
Social Science; SPSS Inc., Chicago, IL, USA).
History of preterm labor 35 38.5%
History of DVT 10 11.0%
Results
SLE manifestations
Cutaneous lesions 85 93.4%
Patient and disease characteristics
Articular lesions 84 92.3%
Renal aection 49 53.8%
We studied maternal and fetal outcome of 91 pregnancies in 84 Hypertension 36 39.6%
pregnant SLE patients. Mean age of patients at pregnancy was Hematological 39 42
29 (SD 4) years and mean duration of SLE disease was 8 (SD 5 abnormalities
years). Patients included in the study were all in clinical remis- Neurological manifestations 6 7
Pre-gestational diabetes 4
sion as determined by SLEDAI index. There were 65 planned
Antiphospholipid syndrome 35 38
pregnancies (71%), 42 patients (46%) had history of abortion,
(APS)
35 patients (38%) had history of preterm birth, 10 patients aCL (IgG) 38 42
(11%) had history of deep venous thrombosis and 4 patients aCL (IgM) 36 40
had pre-gestational diabetes (Table 1). LAC 39 43
Manifestations of SLE were recorded throughout preg- ANA 72 79
nancy and included cutaneous lesions in 85 patients (93%), dsDNA 73 80
articular (arthralgias and arthritis) in 84 patients (92%), and Anti-Ro/SSA antibodies 18 20
lupus nephritis in 49 patients (53%); 36 (39%) patients already Anti-La/SSB antibodies 26 29
had hypertension at the beginning of pregnancy; hematological LMWH 58 64
Hydroxychloroquine 42 46
abnormalities as anemia and thrombocytopenia were present
Azathioprine 18 20
in 39 patients (42%); and neurological manifestations in 6
patients (7%) as neuropsychiatric disorders or mild increased SLE = Systemic Lupus Erythematosus, DVT = deep venous
intracranial tension. Secondary APS was diagnosed in 35 thrombosis, aCL IgG = anti-cardiolipin antibodies immunoglob-
patients with SLE (38%). Autoantibodies were positive as ulin G, aCL IgM = anti-cardiolipin antibodies immunoglobulin
M, LAC = lupus anticoagulant, antinuclear antibodies (ANA),
follows: ANA in 72 patients (79%), anti-dsDNA in 73 patients
anti-double stranded (dsDNA) antibodies, LMWH = low molec-
(80%), aCL IgG in 38 patients (42%) and aCL IgM in 36 ular weight heparin
patients (40%) (Table 2).

Pregnancy outcome
developed severe progressive lupus nephritis at 18 and
Abortion occurred in 14 patients (15%); 9 patients with rst 20 weeks gestation). Twenty-nine pregnancies (32%) were
trimester abortions and 5 patients were therapeutically termi- complicated by IUGR, and 12 patients (13%) developed
nated in the second trimester (2 cases at 15th week because pre-eclampsia during pregnancy (all had already pre-existing
of fetal malformations; hydrocephalus and 3 patients history of hypertension before pregnancy). Twenty-nine
patients (32%) underwent vaginal delivery and 48 patients
(53%) underwent cesarean sections mainly due to obstetric
Table 1 Demographic data of the 91 pregnant SLE patients indications (previous cesarean, cephalopelvic disproportion
included in the study. and severe preeclampsia). Most pregnancies (n = 70%, 77%)
resulted in live births. There were 7 cases (8%) of IUFD
Mean age in Standard
years deviation
(between 26 and 28 gestation) (Table 3).
Preterm birth was reported in 12 pregnancies (13%), and 7
Age of patients at 28.55 4.39 cases who were electively terminated between the 32nd and
pregnancy
34th weeks of gestation (3 cases of severe uncontrolled pre-
Age at SLE onset 19.73 4.99
Age of patients at 21.88 3.602
eclampsia, 2 cases of progressive lupus nephritis with
marriage uncontrolled hypertension and 2 cases with severe IUGR
Duration of SLE disease 7.65 5.15 and deteriorating Doppler indices). The other 5 cases had
spontaneous preterm rupture of membranes. Twenty neonates
SLE = Systemic Lupus Erythematosus
suffered from LBW (22%) and 14 neonates (15%) were
Pregnancy outcome in patients with systemic lupus erythematosus 171

Table 3 Pregnancy outcomes of the 91 pregnancies compli- Table 4 Distribution of antenatal and postpartum SLE ares.
cated with SLE. Manifestations Antenatal SLE ares Postpartum SLE
SLE pregnancies n = 91 Percentage (%) n = 40 (%) ares n = 6 (%)
Abortion 14 15 Renal 19 (21) 1 (1)
IUGR 29 32 Anemia 5 (6) 1 (1)
Pre-eclampsia 12 13 Thrombocytopenia 4 (4) 1 (1)
Cesarian sections 48 53 Serositis 3 (3) 2 (1)
Vaginal deliveries 29 32 Cutaneous 2 (2) 0
IUFD 7 8 Articular 2 (2) 0
Live births 77 76 Renal-anemia 1 (1) 0
Full term delivery 65 71 Renal-articular 1 (1) 1 (1)
Preterm birth 12 13 Anemia-articular 3 (3) 0
LBW 20 22 SLE = Systemic Lupus Erythematosus, n = number.
Neonatal deaths 3 3
NICU 14 15
Antenatal SLE are 40 44
Postpartum are 6 7
SLE = Systemic Lupus Erythematosus, n = number, Table 5 Comparison of pregnancy outcomes between 55
IUFD = intrauterine growth retardation, IUFD = intrauterine pregnant patients without hypertension and 36 pregnant
fetal death, LBW = low birth weight, NICU: neonatal intensive hypertensive patients.
care unit.
Variables No hypertension Hypertension p-value
n = 55 (%) n = 36 (%)
Abortion 5 (9) 9 (25) 0.04*
Preterm 18 (33) 17 (42) 0.165
admitted to the NICU due to prematurity, respiratory distress
birth
syndrome or LBW. There were 3 neonatal deaths (3%); 2 cases
Pre- 0 (0) 12 (33) 0.0001*
due to prematurity and respiratory problems, and one case of eclampsia
intracranial hemorrhage. There was only one case of neonatal IUGR 19 (36) 10 (28) 0.498
photosensitive rash interpreted as cutaneous manifestation of IUFD 4 (7) 3 (8) 0.853
lupus. We recorded no neonatal cases with congenital heart LBW 10 (18) 10 (27) 0.280
block. Also there was no maternal mortality recorded. NICU 7 (13) 7 (19) 0.385
admission
SLE pregnancy-associated flare Neonatal 1 (2) 2 (6) 0.329
deaths
SLE ares 15 (27) 25 (69) 0.0001*
Forty patients (44%) developed SLE ares during pregnancy *
(most of which occurred in the 2nd trimester n = 28%, Signicant p-value (<0.05).
70%) while 6 patients suffered from post-partum ares (7%).
Renal ares were the most frequent (n = 19 cases, 21%). Prior
renal involvement was present in all cases with the renal ares.
Serositis was present in 3 cases (3%), where 2 cases developed
pleurisy and one case developed pericarditis. We reported no ares (OR = 0.17, 95% CI = 0.030.99, and p value = 0.05).
cases of neurological manifestations or increased intracranial Hypertension was found to be a predictor for the development
tension. Other systems involved in SLE ares are demon- of preeclampsia (OR = 19, 95% CI = 824, and p = 0.002)
strated in Table 4. and of SLE ares (OR = 8, 95% CI = 230 and,
The association between pre-existing hypertension and p = 0.003). Secondary APS and aCL IgG were signicantly
several pregnancy outcomes was assessed. We found a signi- associated with abortion (OR = 18, 95% CI = 4327 and
cant association between hypertension and development of p = 0.001 and OR = 19, 95% CI = 1329 and p = 0.04
pre-eclampsia (p = 0.0001), hypertension and development respectively). We did not nd any signicant predictors of pre-
of SLE ares (p = 0.0001). However, hypertension was not maturity or IUFD (Table 6).
signicantly associated with other outcomes (Table 5).
Discussion
Predictors of adverse pregnancy outcome
Despite the advent in the management of SLE pregnant
Logistic regression analysis was used to evaluate the predictors patients, SLE poses a higher risk of perinatal morbidity and
of adverse pregnancy outcome. The analysis included age at mortality when compared to normal pregnant females (13).
pregnancy, duration of SLE, presence of lupus nephritis, preg- We investigated the maternal and fetal outcomes of SLE preg-
nancy being planned or not, presence of hematological mani- nancies and the effect of pregnancy on SLE ares. Our results
festations, hypertension or APS. We found that the presence showed that the incidence of abortion was 15%. Several stud-
of lupus nephritis was a predictor for the development of ies reported abortion incidence in SLE pregnancies between
preeclampsia (Odds ratio [OR] = 0.003, 95% condence inter- 11% and 24% (14). Three patients had therapeutic abortion
val [CI] = 0.0000.248, and p value = 0.01) and also of SLE as they developed progressive uncontrolled renal ares during
172 E.A. Hussein Aly et al.

Table 6 Predictors of adverse pregnancy outcomes by binary logistic regression analysis.

Abortion Preeclampsia Prematurity IUFD SLE ares
OR; p-Value OR; p-Value OR; p-value OR; p-value OR; p-Value
(95% CI) (95% CI) (95% CI) (95% CI) (95% CI)
Age at pregnancy 0.939; 0.093 0.985; 0.843 0.980; 0.261 0.919; 0.351 1.085; 0.084
(0.8721.011) (0.8441.149) (0.9461.015) (0.7711.097) (0.9891.191)
Duration of SLE 0.988; 0.892 0.976; 0.598 1.135; 0.061 0.900; 0.065
(0.8301.176) (0.8931.067) (0.9941.296) (0.8051.007)
Lupus nephritis 0.003, 0.010* 0.171; 0.048*
(0.0000.248) (0.0300.986)
Planned pregnancy 0.719; 0.702 1.361; 0.726 1.243, 0.802 3.285; 0.091
(0.1323.902) (0.2427.662) (0.2266.843) (0.8263.064)
Hematological manifestations 5.221; 0.121 1.456; 0.479
(0.64642.169) (0.5154.117)
Hypertension 0.209; 0.077 308.820;0.002* 7.670; 0.003*
(0.0371.184) (8.06623.761) (1.97429.797)
APS 37.728; 0.001* 1.203; 0.671 1.261; 0.672
(4.357326.703) (0.5122.830) (0.4323.685)
aCL IgG 19.224; 0.041*
(1.124328.653)
aCL IgM 0.100; 0.163
(0.0042.538)
LAC 3.577; 0.073
(0.88614.441)
CI = condence interval, OR = odds ratio, IUFD = intrauterine fetal death, APS = antiphospholipid syndrome, HTN = hypertension, aCL
IgG = anti-cardiolipin antibodies immunoglobulin G, aCL IgM = anti-cardiolipin antibodies immunoglobulin M, LAC = Lupus
anticoagulant.
*
Signicant p-value (<0.05).

pregnancy. Studies showed that fetal loss ranges from 10% in
mild renal disease up to 60% in severe lupus nephritis (13).
SLE pregnant patients carry a higher risk of IUGR when
compared to normal females (28.5% vs. 17.5%) (15). We
observed an incidence of 32% of IUGR in our cohort, which
is higher than other SLE cohorts (16,17). However this can
be explained by the high proportion of hypertensive patients
included in our study (39%). In our cohort, the incidence of
pre-eclampsia was 19%. Similar studies reported a wide range
of pre-eclampsia in SLE pregnancies from 3% to 26% (18). All
pre-eclampsia patients had history of pre-existing hypertension
before pregnancy and our results demonstrated signicant
relation between pre-eclampsia and hypertension
(p = 0.0001). Prematurity rate in SLE pregnancies ranges
between 17% and 54% (19), which is higher than our observa-
tion (13%). SLE complicated with aggressive renal disease,
hypertension, preeclampsia or IUGR, which are at risk of
iatrogenic preterm delivery (20). We had 7 cases of iatrogenic
preterm birth due to severe pre-eclampsia, severe lupus nephri-
tis and severe IUGR, while 5 cases had spontaneous rupture of
membranes and preterm delivery.
Studies reported an incidence of live births in SLE pregnan-
cies of 7289% (18,21) while other studies reported a much
lower incidence between 45% and 50% (16). The incidence
of live births in our study was 76%. This can be attributed that
all our patients were at clinical remission, strict monitoring of
patients, drug regimens to control ares and nally the use of
modern obstetric fetal monitoring.
Several studies showed that pregnancy increased the inci-
dence of SLE ares with rates up to 35% (7,14,22), while
others reported no difference (9). However, there is still uncer-
tainty about the exact effect of pregnancy on the course of SLE
disease activity (30). Similarly, we reported an incidence of
44%, while the incidence of postpartum ares was about
7%. Our ndings reported predominance of renal ares during
pregnancy (21%). This may be explained by the high percent-
age of pregnant patients with history of lupus nephritis (53%)
enrolled in the study. Approximately 70% of ares during
pregnancy occurred during second trimester. SLE ares may
occur in the rst trimester but they are usually more during
the second trimester. This goes in hand with some studies that
reported higher incidence of ares in the second than the third
trimester as some authors suggested that lower levels of estro-
gens in the last trimester of pregnancy may account for the
lower SLE relapses reported in the third trimester (2325).
Post partum SLE ares are usually mild to moderate, with a
predominance of cutaneous and articular manifestations
(2426). We had 6 patients with postpartum ares but with
no serious maternal complications.
It has been shown that renal ares and hypertension are
factors that increase the risk of perinatal complications (13).
One study reported higher rates of pre-eclampsia in SLE
patients with active renal disease (14). The effect of hyperten-
sion on pregnancy outcome was investigated. Univariate anal-
ysis showed signicant association between hypertension and
abortion (p = 0.04), pre-eclampsia (p = 0.0001) and develop-
ment of SLE ares (p = 0.0001).
Predictors of adverse pregnancy outcome were analyzed.
We found a signicant association between lupus nephritis
and preeclampsia (p value = 0.01) and SLE ares p
(value = 0.048) (OR = 0.003 and OR = 0.171 respectively),
there was a signicant association between hypertension and
preeclampsia (p = 0.002), were hypertensive patients were 19
times more likely to develop pre-eclampsia (OR = 19).
Pregnancy outcome in patients with systemic lupus erythematosus
However, this should be treated with caution as 95% CI is
wide (824). Hypertensive patients were 8 times more likely
to develop SLE ares (OR = 8) (p = 0.003) despite the wide
CI = 230. There is signicant relation between APS and
abortion (p = 0.001) despite the large CI = 4327. Our nd-
ings were similar to several studies that documented the asso-
ciation of APS and fetal loss. SLE patients with APS had
almost two-fold increase in fetal loss when compared to SLE
patients with negative APS (27). Although some studies corre-
lated active lupus nephritis and younger maternal age to pre-
maturity (28), we did not observe a similar trend. A study
was done by Hamed et al in 2013 on 201 pregnant patients
over a three year period in two university maternity centers
in Saudi Arabia and Egypt, pregnancy outcomes were com-
pared in patients with cutaneous lupus and those with systemic
disease to those of healthy controls. The authors concluded
that patients with cutaneous lupus erythematosis had almost
comparable pregnancy outcomes to those of healthy controls
and that lupus ares and positive anti-phospholipid antobod-
ies were signicant independent factors for adverse outcome
(29). This study has several strengths: the prospective study
design and large number of planned pregnancies; however,
we think that our limitations may be related to the type of
patients included, as many SLE patients were hypertensive
with renal affection. Although hypertension and lupus nephri-
tis were predictors of pre-eclampsia and SLE ares, yet the 95
CI was large. We concluded that careful monitoring of preg-
nancy coupled with efcient treatment of SLE decreased the
risks for the mother and the fetus. However, despite the
improvements in pregnancy outcome of SLE pregnant
patients, there is still adverse maternal and fetal outcomes.
Also SLE ares may increase with pregnancy.
Declaration of conflicting interests
The authors have no conict of interests.
Ethics and consent
The study was approved by the Institutional Review Board.
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