Background/Purpose: Systemic lupus erythematosus (SLE) is associated with a higher risk of fetal growth restriction and birth of small for gestational age (SGA) concepts. Fetuses with growth restriction have 10-fold higher neonatal mortality, higher risk of hypoxia, meconium aspiration, hypoglycemia, delay in neurodevelopment and cerebral palsy. In adulthood, there is a greater risk of hypertension, type 2 diabetes, hypercholesterolemia and cardiovascular disease. The present study aims to analyze the occurrence of SGA (birth weight below 10th percentile) newborns (NB) in pregnant women with SLE accompanied at a tertiary unit. We studied the association of birth of SGA infants with clinical and laboratory characteristics of maternal SLE prior to conception, during gestation and with maternal comorbidities.

Methods: This is a cohort study with retrospective and prospective data collection, with inclusion of patients with ≥ 4 SLE classification criteria (ACR), single pregnancies and deliveries after 22 weeks. Patients with fetuses with congenital malformations or aneuploidy were excluded. Data were obtained by script-oriented chart review. The comparison between groups was done using Student’s t-test or Mann-Whitney test for numerical data and chi-square test (χ2) or Fisher’s exact test for categorical data, with significance of 5%.

Results: 151 patients where included,and 28 had SGA NB (18.5%). Of the variables prior to conception, previous history of nephritis (RR = 3.01, 1.28-7.08, p=0.01) and presence of anti-RNP antibody (RR = 2.67, 1.11-6.43, p=0.02) were more frequent in patients with SGA NB. Among variables that occurred during gestation, active nephritis (RR = 4.11, 1.68-10, p=0.002), pulse therapy with methylprednisolone (RR = 20.3, 2.18-190, p=0.008) and consumption of C3 complement (RR = 2.70, 1.09-6.67, p=0.03) were associated with SGA group. When considering the SGA NB with altered fetal Doppler subgroup, the associated additional variables were the presence of permanent damage by SDI ≥ 1 (RR = 7.43, 1.50-36.7, p=0.01), previous history of neurolupus (RR = 5.16, 1.21-21.8, p=0.03), presence of lupus anticoagulant (RR = 4.58, 1.07-19.5, p=0.04), antiphospholipid syndrome (RR = 5.21, 1.26-21.5, p=0.04), activity at conception (RR = 6.27, 1.26-31.1, p=0.02) and during gestation (RR = 6.08, 1.22-30.1, p=0.02 per clinical judgment and RR = 9.67, 1.97-47.5, p=0.004 per SLEPDAI score ≥ 6), extra-renal activity (RR = 6.08, 1.22-30.1, p=0.02), presence of anti-DNA (RR = 4.58, 1.07-19.5, p=0.04) and SLE-related hospitalization during pregnancy (RR = 8.6, 1.74-42.3, p=0.006). Birth weight and gestational age at delivery were lower in the SGA group (1831g +/- 687g vs 2794g +/- 741g, p<0.0001; 36.5 vs 38 weeks, p=0.05). Fetal death and admission to neonatal ICU were 4.3 (p=0.03) and 3.2 (p<0.0001) times more frequent among the SGA NB, as were activity in the puerperium (3.9 times, p=0.02) and peripartum hemorrhage (2.3 times, p=0.04) among women with SGA NB.

Conclusion: These findings reinforce the importance of SLE remission prior to conception, since prior maternal morbidity combined with the presence of disease activity during pregnancy and treatment with high doses of steroids increase the risk of SGA birth.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/analysis-of-occurrence-of-small-for-gestational-age-infants-in-women-with-systemic-lupus-erythematosus/