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Early Risk Factors for Pregnancy Loss in Lupus

From the ¹Department of Medicine, Division of Rheumatology, Duke University Medical Center, Durham, North Carolina; ²Department of Biostatistics, University of Maryland School of Medicine, Baltimore, and ³Departments of Gynecology and Obstetrics, and ⁴Medicine, Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, Maryland.

OBJECTIVE: To identify early risk factors for pregnancy loss in lupus pregnancies.

METHODS: We conducted a cohort study of all pregnancies seen in the first trimester in lupus patients followed from 1987 to 2002 at the Hopkins Lupus Center. At each visit, vital signs, a complete blood count, a urinalysis, and a 24-hour urine collection for total protein, if the dipstick revealed proteinuria, were obtained. Proteinuria was defined as protein greater than 500 mg in a 24-hour urine collection. Secondary antiphospholipid syndrome was diagnosed by using the Sapporo criteria. Thrombocytopenia was defined as platelets under 150,000. Hypertension was defined as blood pressure over 140/90 mm Hg during the first trimester. Pregnancies electively terminated were excluded from this study.

RESULTS: One hundred sixty-six pregnancies in 125 women were followed in the Hopkins Lupus Cohort from the first trimester onward. Twenty-seven pregnancies (16%) ended with a loss. Pregnancy loss was increased 2.6 times in women with first-trimester proteinuria (P = .04). A diagnosis of secondary antiphospholipid syndrome led to a 3.1-fold increase in pregnancy loss, predominantly after 20 weeks of gestation (P = .004). Thrombocytopenia in the first trimester led to an increase in pregnancy loss by 3.3 fold (P .001). First-trimester hypertension led to a 2.4-fold increase in pregnancy loss (P = .027). Each risk factor was independent in raising pregnancy loss risk.

CONCLUSION: The acronym PATH can help remind clinicians to monitor for Proteinuria, Antiphospholipid syndrome, Thrombocytopenia, and Hypertension early in pregnancy. Close observation, with frequent laboratory analysis and appropriate therapy, is important to pregnancy success in women with lupus.

LEVEL OF EVIDENCE: II-2

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