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Vitamin D Repletion in SLE Requires at Least 2,000 IU Daily

VA N C O U V E R , B . C . — Monthly monitoring by rheumatologists of every pregnancy in every woman with systemic lupus erythematosus may be unnecessary, according to Dr. Michelle Petri. A relatively small list of criteria can distinguish high-risk pregnancies in women with systemic lupus erythematosus (SLE)—ones that carry a higher likelihood of miscarriage, extreme prematurity, and SLE flare—from others, and signal the need for intensive monitoring by obstetricians and rheumatologists, Dr. Petri said at the meeting. At present, however, there is little effort to make such distinctions, so most SLE pregnancies are subjected to monthly visits to rheumatologists and obstetricians, and, starting at week 26, weekly monitoring by obstetricians. That’s not always necessary; women are subjected to needless anxiety and hospital resources are wasted, Dr. Petri said. Based on the Hopkins Lupus Cohort, a database that has been tracking several thousand patients with SLE over the past 25 years, Dr. Petri and her colleague, Duke University rheumatologist Megan Clowse, have identified those factors that truly put women and fetuses at risk during SLE pregnancies. Pregnancy and the postpartum period are hard on the kidneys of women with SLE, though organ involvement elsewhere in the body tends to lessen, said Dr. Petri, professor of rheumatology at Johns Hopkins University, Baltimore. “Proteinuria from active lupus significantly increases, and this continues even after delivery,” she added. Therefore, pregnant women with lupus nephritis truly do need close monitoring. Dr. Petri recommended monthly urine protein-creatinine ratios to detect a worsening of the condition and the need for treatment. In terms of fetal health, the risk of miscarriage doubles if, at the first pregnancy visit, a woman is proteinuric, thrombocytopenic, or hypertensive, or has a history of antiphospholipid syndrome. The risk triples if two or more of these conditions are present, Dr. Petri said. The presence of antithyroid antibodies also increases the risk of miscarriage. In addition, active SLE, especially if accompanied by anti–double-stranded DNA antibody or low complement levels, predicts extreme prematurity. Autoimmune thyroid disease also appears to be associated with preterm birth. Screening for the various factors, “we can predict at the first pregnancy visit if there’s going to be a poor outcome,” Dr. Petri said. If the risk factors are present, monthly monitoring by a high-risk obstetrician, followed by weekly monitoring at week 26, are appropriate to gauge if, and when, a rescue delivery is needed. ■