Lúpus eritematoso sistêmico e fatores de risco para eventos adversos na gestação: uma coorte retrospectiva no Estado do Amazonas

Abstract

Background: Systemic lupus erythematosus (SLE) is an immune-mediated disease that predominates in women of childbearing age and directly interferes with pregnancy outcomes. It is associated with higher incidences of preeclampsia, fetal death, prematurity, and an increase in the incidence and worsening of SLE activity. Although SLE and pregnancy is a widely studied topic, there are few studies conducted in Brazil. Objectives: To describe the incidence and risk factors for maternal, fetal, and/or perinatal complications in pregnancies of patients with SLE in a tertiary service in the State of Amazonas. Methods: A retrospective descriptive and analytical study was conducted, observing the periods before, during, and after pregnancy in relation to medications, disease activity, and maternal and fetal outcomes. Descriptive analysis was performed using absolute and relative frequencies, means with standard deviations, or medians with interquartile ranges. Categorical associations used chi-square, Fisher, or McNemar tests, and continuous variables were analyzed using Wilcoxon, Mann-Whitney, or Student's T-tests. The adjustment of odds ratios and the determination of risk factors were performed using binary logistic regression. Results: The study included 155 pregnancies from 109 patients, with an average age of 28.2 (±5.5) years at the time of pregnancy. Seventy-six (49%) had a history of nephritis, 93 (60%) had immunological alterations, 94 (60.4%) had a history of chronic kidney disease, 45 (29%) had hypertension, and 18 (11.6%) had antiphospholipid syndrome (APS). In 131 (88.5%) pregnancies, immunosuppressive medication was used before the gestational period, and in 56 (36.1%), the mother had active SLE, with renal, cutaneous, and hematological activity being the most frequent. During pregnancy, there was an increase of 12.3% (p=0.004) in the proportion of patients with active disease and 32.7% (p<0.001) in hypertension; 22.9% of pregnancies resulted in gestational loss, 15.7% resulted in spontaneous abortion, and 7.2% in stillbirths. Preeclampsia occurred in 16.8%, prematurity in 37.3%, low birth weight for gestational age in 16.2%, and intrauterine growth restriction in 15.6%. Immunological alterations (OR=3.02 [1.11; 8.21], p=0.031), renal involvement (OR=3.74 [1.25; 11.21], p=0.018), and disease activity before pregnancy (OR=1.3 [1.04; 1.64], p=0.023) were risk factors for adverse maternal events, while the use of hydroxychloroquine before pregnancy was a protective factor (OR=0.23 [0.08; 1.64], p=0.007). For fetal and perinatal events, the risk factors were the use of ASA (OR=5.22 [1.33; 20.54], p=0.018) and disease activity during pregnancy (OR=1.31 [1.14; 1.52], p<0.001). The use of hydroxychloroquine before and during pregnancy was a protective factor (OR=0.14 [0.04; 0.44], p=0.001). Conclusion: In pregnancies where SLE was active before and during pregnancy, there was a higher incidence of adverse maternal, fetal, and perinatal events. The management of pregnancy in patients with SLE continues to be a challenge and should be conducted in a multidisciplinary manner. Disease activity should be carefully monitored before, during, and after pregnancy, with hydroxychloroquine being maintained throughout the pregnancy period.