Table 2.
Checklist of parameters to be considered for preconception counselling and risk stratification in women with systemic lupus erythematosus (SLE) and/or antiphospholipid syndrome (APS)
| Disease-related risk factors | Prognostic implications |
| SLE activity/flares* (in the last 6–12 months or at conception) | Increased risk for (i) maternal disease activity (RR 2.1 for subsequent flare during pregnancy and puerperium);14 (ii) hypertensive complications (OR 1.8 for PE);15 (iii) fetal morbidity and mortality (OR 5.7 for pregnancy loss,16 3.5 for IUGR17 6.5 for preterm delivery)14 15 17–22 |
| Lupus nephritis (history or active at conception†) | Strong predictor of poor maternal (RR 9.0 for renal flare during/after pregnancy)23 and fetal outcome(s) (OR 7.3 for fetal loss and 18.9 for preterm delivery)24 25 |
| Serological (serum C3/C4, anti-dsDNA titres) activity | Increased risk for maternal SLE flares during pregnancy (OR 5.3)14 and pregnancy loss23 26 27 |
| Previous adverse pregnancy outcome(s) | APS: increased risk for pregnancy complications28–30 |
| History of vascular thrombosis | APS: increased risk (ORs ranging 3.6–12.7) for pregnancy morbidity31 |
| SLE diagnosis | APS: increased risk (OR 6.9) for pregnancy morbidity31 32 |
| aPL profile‡ | SLE: strong predictor of adverse maternal and fetal outcomes,19
25
27
33
34 especially for patients with persistent moderate-to-high aPL titres, LA and multiple aPL positivity (high-risk aPL profile) APS: high-risk aPL profile correlates with increased risk of maternal vascular thrombotic events during pregnancy (OR 12.1),35 (pre-)eclampsia (OR 2.3),36 37 APS-related pregnancy morbidity (OR 9.2),31 IUGR (OR 4.7),36 preterm birth38 39 |
| Anti-Ro/SSA, anti-La/SSB antibodies | Linked to development of neonatal lupus, including a low risk (0.7–2%) for CHB (especially if moderate-to-high anti-Ro titres);40–43 weak association with other pregnancy complications44 |
| End-stage organ damage and associated comorbidities | 45 46 |
| General risk factors | 47 |
| Maternal age | |
| Arterial hypertension | Increased risk for pregnancy loss (OR 2.4,33 RR 2.9),48 preterm birth18 24 27 and IUGR (OR 6.8)15 |
| Diabetes mellitus | 49 |
| Overweight/obesity | |
| Thyroid disease | 50 |
| Nicotine and alcohol use | 28 |
| Immunisations§ |
*Diagnosed by validated SLE activity indices and/or physician judgement.
†Evaluated by renal function tests (serum creatinine, blood urea nitrogen) and urinalysis (proteinuria urine sediment).
‡Includes LA, aCL IgG/IgM, aβ2GPI IgG/IgM. The level of positivity of aCL and aβ2GPI antibodies (low vs medium–high) should be defined according to the single assay's characteristics.
§If negative serology, evaluate whether immunisations can be performed prior to pregnancy (eg, rubella).
aCL, anticardiolipin antibodies; aβ2GPI, anti-β2-GPI antibodies; anti-dsDNA, anti-double-stranded DNA antibodies; aPL, antiphospholipid antibodies; CHB, congenital heart block; IUGR, intrauterine growth restriction; LA, lupus anticoagulant; PE, pre-eclampsia; RR, relative risk.