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Extended report
Effect of pregnancy on disease flares in patients with systemic lupus erythematosus
  1. Amanda M Eudy1,2,
  2. Anna Maria Siega-Riz3,
  3. Stephanie M Engel1,
  4. Nora Franceschini1,
  5. Annie Green Howard4,
  6. Megan E B Clowse2,
  7. Michelle Petri5
  1. 1 Department of Epidemiology, University of North Carolina at Chapel Hill Gillings School of Global Public Health, Chapel Hill, North Carolina, USA
  2. 2 Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
  3. 3 School of Nursing, University of Virginia, Charlottesville, Virginia, USA
  4. 4 Department of Biostatistics, University of North Carolina at Chapel Hill Gillings School of Global Public Health, North Carolina, USA
  5. 5 Department of Rheumatology, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
  1. Correspondence to Dr Amanda M Eudy, Department of Medicine, Duke University Medical Center, Durham, NC 27710, USA; Amanda.eudy{at}


Objective Prior studies found conflicting results about whether lupus is likely to flare during or after pregnancy. Using a large cohort of pregnant and non-pregnant women with lupus, we estimated the effect of pregnancy on disease flares in systemic lupus erythematosus.

Methods Data were collected in the Hopkins Lupus Cohort 1987–2015. Women aged 14–45 years with >1 measurement of disease activity were included. The time-varying exposures were classified as pregnancy, postpartum or non-pregnant/non-postpartum periods. Flares were defined as: (1) change in Physician Global Assessment (PGA)≥1 from previous visit and (2) change in Safety of Estrogens in Lupus National Assessment-Systemic Lupus Erythematosus Disease Activity Index (SELENA-SLEDAI)≥4 from previous visit. A stratified Cox model estimated HRs with bootstrap 95% CIs.

Results There were 1349 patients, including 398 pregnancies in 304 patients. There was an increased rate of flare defined by PGA during pregnancy (HR: 1.59; 95% CI 1.27 to 1.96); however, this effect was modified by hydroxychloroquine (HCQ) use, with the HR of flares in pregnancy compared with non-pregnant/non-postpartum periods estimated to be 1.83 (95% CI 1.34 to 2.45) for patients with no HCQ use and 1.26 (95% CI 0.88 to 1.69) for patients with HCQ use. The risk of flare was similarly elevated among non-HCQ users in the 3 months postpartum, but not for women taking HCQ after delivery.

Conclusions Our study supports and extends previous findings that the incidence of flare is increased during pregnancy and within the 3 months postpartum. Continuing HCQ, however, appeared to mitigate the risk of flare during and after pregnancy.

  • systemic lupus erythematosus
  • disease activity
  • epidemiology

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  • Handling editor Josef S Smolen

  • Contributors All authors were involved in the conception and design of the study. MP contributed to the acquisition of the data. All authors contributed to analysis and interpretation of the data. All authors participated in the drafting of the manuscript or revised it critically for intellectual content. All authors read and approved the final manuscript.

  • Funding The Hopkins Lupus Cohort is supported by NIH AR 43727 and AR 69572.

  • Competing interests None declared.

  • Patient consent Detail has been removed from this case description/these case descriptions to ensure anonymity. The editors and reviewers have seen the detailed information available and are satisfied that the information backs up the case the authors are making.

  • Ethics approval Johns Hopkins University School of Medicine Institutional Review Board and University of North Carolina at Chapel Hill Institutional Review Board.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Presented at This work was previously presented as an oral presentation at the American College of Rheumatology Annual Meeting 2016 in Washington, DC, 11–16 November 2016. Eudy AM, Siega-Riz AM, Engel S, et al. Effect of Pregnancy on Disease Flares in Patients with Systemic Lupus Erythematosus (abstract). Arthritis Rheumatol 2016;68(suppl 10).