Systemic lupus erythematosus (SLE) primarily affects women of child-bearing age. Recent diagnostic and treatment advances have resulted in improved overall survival in patients with SLE, but whether similar improvements in outcomes have occurred among pregnant women with SLE is unclear. This analysis compares trends in pregnancy outcomes over 17 years in a nationwide sample of pregnant women with and without SLE.
Background:
Although pregnancy in systemic lupus erythematosus (SLE) carries a high risk for mother and fetus, outcomes may be improving.
Objective:
To assess nationwide trends and disparities in maternal and fetal complications among pregnant women with SLE.
Design:
Retrospective cohort study.
Setting:
United States, 1998 to 2015.
Patients:
Adult pregnant women with and without SLE who had hospitalizations recorded in the National Inpatient Sample (NIS) database.
Measurements:
Outcome measures were in-hospital maternal mortality, fetal mortality, preeclampsia or eclampsia, caesarean sections, non–delivery-related admissions, and length of stay. To assess whether trends in outcomes over time differed between patients with SLE and those without SLE, logistic or linear regression with an interaction term between year and SLE (yes or no) was used. Nationwide population estimates incorporating sampling and poststratification weights were obtained.
Results:
An estimated 93 820 pregnant women with SLE and 78 045 054 without SLE were hospitalized in the United States from 1998 through 2015. Outcomes improved during those 18 years. In-hospital maternal deaths (per 100 000 admissions) declined among patients with as well as those without SLE (442 vs. 13 for 1998 to 2000 and <50 vs. 10 for 2013 to 2015), although the decrease was greater in women with SLE (difference in trends, P < 0.002). The percentage of patients with SLE in all pregnancy-related, as well as delivery-related, admissions increased significantly.
Limitations:
The sample for this analysis was identified by using diagnostic codes; detailed information on hospital-specific trends, SLE disease activity, and medications was not available. Race trends could not be analyzed. Given that NIS uses weighted estimates, the incidence of outcomes reported may not be exact.
Conclusion:
In this large study examining SLE and non-SLE pregnancies over 18 years, in-hospital maternal mortality and overall outcomes improved markedly, particularly among women with SLE. However, improvement is still needed, because SLE pregnancy risks remain high.
Primary Funding Source:
None.
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Author, Article and Disclosure Information
Hospital for Special Surgery and Weill Cornell Medicine, New York, New York (B.M., L.S., J.S., M.L., S.G.)
Mount Sinai St. Luke's, Mount Sinai West, and Icahn School of Medicine, New York, New York (Y.L.)
Weill Cornell Medicine, New York, New York (J.X.)
Weill Cornell Health Policy and Research, New York, New York (S.I.)
Grant Support: Dr. Mehta is supported by the C. Ronald MacKenzie Young Scientist Endowment Award. Dr. Ibrahim is supported by grant K24AR055259 from the National Institute of Arthritis and Musculoskeletal and Skin Diseases.
Disclosures: Authors have disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M19-0120.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that her spouse has stock options/holdings with Targeted Diagnostics and Therapeutics. Darren B. Taichman, MD, PhD, Executive Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Catharine B. Stack, PhD, MS, Deputy Editor, Statistics, reports that she has stock holdings in Pfizer, Johnson & Johnson, and Colgate-Palmolive. Christina C. Wee, MD, MPH, Deputy Editor, reports employment with Beth Israel Deaconess Medical Center. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Yu-Xiao Yang, MD, MSCE, Deputy Editor, reports that he has no financial relationships or interest to disclose.
Reproducible Research Statement: Study protocol: Not available. Statistical code: Available from Dr. Luo (e-mail, [email protected]
Corresponding Author: Bella Mehta, MBBS, MS, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021; e-mail, [email protected]
Current Author Addresses: Drs. Mehta, Salmon, and Goodman: Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021.
Dr. Luo: Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, New York, NY 10029.
Ms. Xu and Dr. Ibrahim: New York–Presbyterian Hospital/Weill Cornell Medical Center, Weill Department of Medicine, 525 East 68th Street, Box 130, New York, NY 10065.
Drs. Sammaritano and Lockshin: Barbara Volcker Center, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021.
Author Contributions: Conception and design: B. Mehta, Y. Luo, M. Lockshin.
Analysis and interpretation of the data: B. Mehta, Y. Luo, J. Xu, L. Sammaritano, J. Salmon, M. Lockshin, S. Goodman, S. Ibrahim.
Drafting of the article: B. Mehta, Y. Luo, L. Sammaritano, M. Lockshin, S. Goodman, S. Ibrahim.
Critical revision for important intellectual content: B. Mehta, Y. Luo, J. Xu, L. Sammaritano, J. Salmon, M. Lockshin, S. Goodman, S. Ibrahim.
Final approval of the article: B. Mehta, Y. Luo, J. Xu, L. Sammaritano, J. Salmon, M. Lockshin, S. Goodman, S. Ibrahim.
Statistical expertise: J. Xu.
Administrative, technical, or logistic support: B. Mehta, S.M. Goodman
Collection and assembly of data: B. Mehta, Y. Luo.
This article was published at Annals.org on 9 July 2019.
* Drs. Mehta and Luo share first authorship.
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