New recommendations by EULAR for women's health and pregnancy in patients with systemic lupus erythematosus (SLE) and/or antiphospholipid syndrome (APS) were presented last week at the European League Against Rheumatism Annual Congress (EULAR 2015).
Developed by expert consensus, these evidence-based recommendations provide crucial guidance to support family planning, assisted reproduction, pregnancy and the menopause in these patients.
'APS and SLE disproportionately affect women, typically starting when they are at their most fertile, and leaving women at risk of reduced fertility and pregnancy complications,' said study investigator Dr. Laura Andreoli, Rheumatology and Clinical Immunology Unit, department of clinical and experimental sciences, University of Brescia, Italy. 'Women often develop these conditions before they have had a chance to have children or complete their family; physicians must ensure that optimal management includes best-practice measures to reduce these risks from the onset of disease and throughout pregnancy.'
Antiphospholipid syndrome is an autoimmune disorder that can cause the blood to clot, leaving patients at risk of deep vein or arterial thrombosis, and pregnancy complications including pre-eclampsia, foetal growth restriction and foetal loss.
SLE is a chronic inflammatory disease that can affect any organ system, but mainly involves the joints, kidneys and skin. SLE predominately affects women, occurring 10 times more often than in men and often starting when they are in their 20s and 30s.
The EULAR recommendations state that SLE or APS patients planning a pregnancy should be counselled and managed after assessment of risk that takes into consideration disease activity, serological profile, hypertension and use of drugs (with emphasis on hydroxychloroquine). Recommendations range from topics such as preservation of fertility to assisted reproduction, and propose physicians to consider HPV immunisation in young women with stable or inactive disease.
The EULAR recommendations also include:
- SLE and/or APS women can be candidates for contraceptive measures based on their disease activity and thrombotic risk (particularly presence of antiphospholipid antibodies)
- Fertility preservation methods, including gonadotropin-releasing hormone (GnRH) analogues should be considered prior to the use of alkylating agents
- Assisted reproduction techniques can be safely used in patients with stable or inactive disease provided that preventative measures are offered to limit the risk of flare and/or thrombosis
- Disease activity, serological markers and renal function parameters are useful to monitor for obstetrical adverse outcomes and disease flares during pregnancy
Swedish population registry data investigating the impact of pregnancy and its complications (in the form of maternal-placental syndrome) on cardiovascular events in SLE were also presented today at EULAR.
The population-based retrospective study of 3,232 women with SLE (72 percent of whom had undergone childbirth), found that incidence of cardiovascular events was highest among women who had never had children (3.4 per 1,000 person-years). These data led Soh et al. to conclude that pregnancy and its complications do not accelerate CVE to the same extent as SLE-related morbidity. The authors also hypothesised that severe SLE may reduce fertility and the chances of successful pregnancy, further reinforcing the need for these EULAR recommendations.