Effectiveness of a multidisciplinary clinical pathway for women with systemic lupus erythematosus and/or antiphospholipid syndrome

Abstract

ObjectivesSLE and/or antiphospholipid syndrome (SLE/APS) are complex and rare systemic autoimmune diseases that predominantly affect women of childbearing age. Women with SLE/APS are at high risk of developing complications during pregnancy. Therefore, clinical practice guidelines recommend that patients with SLE/APS should receive multidisciplinary counselling before getting pregnant. We investigated the clinical effectiveness of implementing a multidisciplinary clinical pathway including prepregnancy counselling of patients with SLE/APS.MethodsA clinical pathway with specific evaluation and prepregnancy counselling for patients with SLE/APS was developed and implemented in a tertiary, academic hospital setting. Patients were prospectively managed within the clinical pathway from 2014 onwards and compared with a retrospective cohort of patients that was not managed in a clinical pathway. Primary outcome was a combined outcome of disease flares for SLE and thromboembolic events for APS. Secondary outcomes were maternal and fetal pregnancy complications.ResultsSeventy-eight patients with 112 pregnancies were included in this study. The primary combined outcome was significantly lower in the pathway cohort (adjusted OR (aOR) 0.20 (95% CI 0.06 to 0.75)) which was predominantly determined by a fivefold risk reduction of SLE flares (aOR 0.22 (95% CI 0.04 to 1.09)). Maternal and fetal pregnancy complications were not different between the cohorts (respectively, aOR 0.91 (95% CI 0.38 to 2.17) and aOR 1.26 (95% CI 0.55 to 2.88)).ConclusionsThe outcomes of this study suggest that patients with SLE/APS with a pregnancy wish benefit from a multidisciplinary clinical pathway including prepregnancy counselling.

Preparing for Pregnancy in Women with Systemic Lupus Erythematosus—A Multidisciplinary Approach

“…Since some are contraindicated during pregnancy, switching to an approved class in preconception will allow for adapting treatment before pregnancy. In these situations, metoprolol and angiotensin converting enzyme inhibitors should be switched to methyldopa, nifedipine, or labetalol, where available, and oral anticoagulants to low molecular weight heparin (LMWH) [ 47 , 48 ].…”

“…Pre-pregnancy counselling has a favourable impact on both maternal and foetal outcomes, as already outlined in this review. As shown in Figure 3 , a multidisciplinary clinical pathway for SLE women who desire to conceive is shown to reduce disease-related flares during pregnancy compared with pre-conception counselling only [ 48 ]. In this view, a team formed by the obstetrician, rheumatologist, and, on indication, nephrologist, cardiologist, pneumologist, and anaesthesiologist allow a thorough health check of the SLE mother as well as a good assessment of appropriate timing, medication, comorbidities, or vaccinations that are in line with approved recommendations.…”

“…Secondary/tertiary healthcare facilities with expertise in attending SLE patients and SLE pregnancies is advised. Follow-up evaluation should be completed every two weeks, preferable in a multidisciplinary meeting until conception and during pregnancy [ 48 ]. Such a setup enables a correct differential diagnosis between SLE flares during pregnancy, pregnancy complications (lupus nephritis versus PE), and foetal complications related to autoantibodies.…”

“…Pre-conception evaluation performed in a multidisciplinary clinical pathway, with obstetricians, rheumatologists, and other specialists as needed and with the dedicated help of the general practitioner will contribute to an improved outcome, both for the mother and the child [ 48 ].…”

Pregnancy outcomes of a joint obstetric and rheumatology clinic in a tertiary centre: a 2-year retrospective study of 98 pregnancies

“…The importance of the multidisciplinary team in the management of high-risk pregnancies in patients with SLE and other rheumatological conditions is well established [ 3 , 15 ]. However, in clinical practice, there are a variety of service models that implement multidisciplinary teams in different ways.…”