Objective To investigate the effect of hydroxychloroquine (HCQ) in pregnant women with systemic lupus erythematosus (SLE). Methods In SLE pregnancies of a single Dutch center (2000–2015), lupus activity and flares before and during pregnancy and postpartum were assessed using the SLE Disease Activity Index (SLEDAI)/SLEPDAI (SLEDAI adjusted for pregnancy). The association between HCQ use and pregnancy outcomes (early spontaneous abortion, fetal death, and preterm and term live birth) was analyzed using generalized estimating equations (GEE) accounting for the occurrence of multiple pregnancies per patient. Analyses were adjusted for antiphospholipid antibody (aPL) status. Results 110 pregnancies (63 mostly Caucasian patients) were included, of which, in 30, HCQ was used; overall occurrence of flares was low (non-HCQ group: 5 mild (6.4%) and 2 severe (2.6%); HCQ group: 2 mild (6.7%) and no severe flares). The HCQ group showed a trend towards lower dosage of prednisone (OR 0.2 (95% CI 0.0–1.4); p = 0.10). Pregnancy outcomes were comparable between groups. Among preterm live births, pregnancy duration was significantly longer in HCQ users (2.4 weeks (95% CI 1.0–3.8; p ≤ 0.001)). Conclusion HCQ use was associated with longer pregnancy duration in the vulnerable preterm birth population, underscoring the beneficial effect of HCQ use during pregnancy.

Objective To investigate disease activity around and during pregnancy and pregnancy outcome in women with systemic lupus erythematosus (SLE) considering antiphospholipid antibody status. Moreover, differences between first and consecutive pregnancies were examined. Methods Pregnancies > 16 weeks gestation of SLE patients receiving joint care from rheumatologists and gynecologists in two tertiary centers in the Netherlands between 2000 and 2015 were included. Disease activity, flare rate, and pregnancy outcomes and complications were assessed. Results Ninety-six women (84% Caucasian) with 144 pregnancies were included. The median SLE(P)DAI score was 2 before, during, and after pregnancy. Flare rates were 6.3%, 20.1%, and 15.3%, respectively. Severe hypertensive disorder of pregnancy, intrauterine fetal death, preterm birth, and small-for-gestational age infants occurred in 18.1%, 4.1%, 32.7%, and 14.8%, respectively. Complication rates were similar in the first and consecutive pregnancies. Half of the women did not experience any pregnancy complication whereas 42.7% developed a complication during all pregnancies. Mean number of pregnancies was 2.4 and live births 1.7. Conclusion In this SLE population with low disease activity, pregnancy complications were present irrespective of antiphospholipid antibody status. Furthermore, there were no differences in complication rates between the first and consecutive pregnancies as seen in healthy mothers. This information is useful for patient counseling.

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Background: Systemic lupus erythematosus (SLE) predominantly affects women during their fertile period. During pregnancy SLE patients are prone to pregnancy complications and may experience increased disease activity. Objectives: To investigate disease activity around/during pregnancy and pregnancy complications in a European cohort according to antiphospholipid antibody (aPL) status. Additionally data on lifetime pregnancy outcomes and comparison of first and consecutive pregnancies were analyzed. Methods: All ongoing pregnancies of >16 weeks gestation of SLE patients (according to the ACR revised criteria) receiving joint care from rheumatologists and gynecologists in two tertiary centers in the Netherlands between 2000-2015 were included. Disease activity (using SELENA-SLE(P)DAI around and during pregnancy), flare rate according to the SELENA-SLEDAI definitions and pregnancy complications were assessed by medical chart review. Results: From 96 women (84% Caucasian) 144 pregnancies were included. Before (<6 months), during and after pregnancy (<6 months) the median SELENA-SLE(P)DAI score was 2 and mild/moderate flare rates were 6.3%, 18.8% and 13.9% respectively. Three patients developed a severe flare during pregnancy, 2 patients postpartum; all were aPL negative. Severe maternal complications (preeclampsia, eclampsia or HELLP-syndrome) occurred in 16.2% of aPL negative, 21.4% of aPL positive SLE patients, and in 30.8% of SLE patients with antiphospholipid syndrome (APS) (GEE; no significant differences between groups). HELLP-syndrome occurred in 23.1% of SLE patients with APS and in 3.1% of SLE patients without APS (Chi-Square; p<0.01). The perinatal complications intrauterine fetal death, preterm birth, small-for-gestational age and neonatal lupus occurred in 4.1%, 32.7%, 14.8%, 1.4%, respectively (GEE; no significant differences between groups). Maternal and perinatal complication rates were similar in first (18.5% and 41.4%) and consecutive (17.6% and 35.1%) pregnancies (Chi-Square; p=0.88 and p=0.44). Of all patients, 42.7% developed a complication during all of their pregnancies (obstetrical history included). Conclusions: This is the first study in patients with SLE demonstrating that incidence rates of pregnancy complications do not decrease in consecutive pregnancies compared to first pregnancies, in contrast to findings in the general population. Except for HELLP-syndrome, pregnancy complications were not significant different between aPL groups. Despite overall low disease activity and the absence of aPL in the majority of patients, almost half of the patients developed a complication during their pregnancies.

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