The miscarriage rate among patients treated at the Johns Hopkins Hospital lupus pregnancy center is 17 percent, a substantial improvement over the national average of 25 percent, a new study shows.
"The Hopkins rate is much less than the national average even though we feel we have very high-risk lupus patients," Dr. Michelle Petri, a lupus researcher and co-director of the lupus pregnancy center, said yesterday. "More than half are low socio-economic status black patients who have a higher risk than most of the lupus patients reported in the literature."
Petri attributes the markedly improved lupus pregnancy outcome at Hopkins to "aggressive management."
It is the same kind of aggressiveness, she said, that Hopkins specialists are now beginning to use to identify lupus patients at high risk for heart attacks in their 30s.
"We're putting lupus patients who have high blood pressure and high levels of fats in their blood on four months of diet therapy initially and, if that fails, we'll go to cholesterol reducing medications," she said.
"We're becoming much more interventionists, saying we don't have to accept a high rate of cardiovascular disease which our studies show is killing one in four lupus patients. We're starting to intervene in our very young patients so that 10 or 15 years down the road, they will escape coronary artery disease."
Prednisone, the drug that must be used to keep lupus patients alive, is also leading to life-threatening blood pressure and cholesterol levels. "Most patients are on the smallest amount of the drug that is effective, so we cannot reduce the drug," Petri said.
The miscarriage reduction rate, she said, is the result of a vigorous screening program which once a month evaluates how active the lupus of the pregnant woman is and adjusts medications to make sure the lupus is under control.
In addition, the patients are screened monthly to see if they develop two antibodies that seem to contribute to miscarriages. One of these antibodies is called anti-cardiolipin and the other the anti-lupus coagulant.
"If we feel that our patients are at high risk for miscarriage. If they have had previous miscarriages or other problems from these antibodies, we treat them to prevent the action of the antibodies," Petri said.
Lupus is a disorder in which the body's immune system turns against its own organs, attacking virtually any part of the body, from the skin to the kidneys, muscle tissue and the brain. The disease affects 1 in 250 black women and 1 in 700 white women in the United States. Most commonly, it strikes women in their late teens and early 20s.
For a long time, lupus patients were counseled against becoming pregnant. Only in the last 15 years have more women become pregnant and been able to find physicians and obstetricians who feel comfortable following their pregnancies, Petri said.
In another major finding in the lupus pregnancy study, Petri reported that one in three of live births occur prematurely. "In fact, several of the babies were born at 27 and 28 weeks and had long stays in our neo-natal intensive care unit," she said.
The studies were presented last week by Petri at the American College of Rheumatology Scientific Meeting in Seattle.
"I don't think that rheumatologists across the country realized how many of the births were premature," she said. "For example, there are parts of the country where a pregnant woman with lupus is sent to a regular obstetrician instead of to a high-risk obstetrician.
"And I still have arguments with health maintenance organizations and insurance carriers who say to lupus patients, 'No, you can't go to Hopkins or to any high-risk obstetrics center in Baltimore' because they don't consider a lupus pregnancy a high-risk situation."