Maternal and fetal factors associated with mortality and morbidity in a multi-racial/ethnic registry of anti-SSA/Ro-associated cardiac neonatal lupus

Abstract

Background: Cardiac manifestations of neonatal lupus include conduction disease and, rarely, an isolated cardiomyopathy. This study was initiated to determine the mortality and morbidity of cardiac neonatal lupus and associated risk factors in a multi-racial/ethnic US-based registry to provide insights into the pathogenesis of antibody-mediated injury and data for counseling.

Methods and results: Three hundred twenty-five offspring exposed to maternal anti-SSA/Ro antibodies with cardiac neonatal lupus met entry criteria. Maternal, fetal echocardiographic, and neonatal risk factors were assessed for association with mortality. Fifty-seven (17.5%) died, 30% in utero. The probability of in utero death was 6%. The cumulative probability of survival at 10 years for a child born alive was 86%. Fetal echocardiographic risk factors associated with increased mortality in a multivariable analysis of all cases included hydrops and endocardial fibroelastosis. Significant predictors of in utero death were hydrops and earlier diagnosis, and of postnatal death were hydrops, endocardial fibroelastosis, and lower ventricular rate. Isolated heart block was associated with a 7.8% case fatality rate, whereas the concomitant presence of dilated cardiomyopathy or endocardial fibroelastosis quadrupled the case fatality rate. There was a significantly higher case fatality rate in minorities compared with whites, who were at a lower risk of hydrops and endocardial fibroelastosis. Pacing was required in 70%; cardiac transplantation was required in 4 children.

Conclusion: Nearly one fifth of fetuses who develop cardiac neonatal lupus die of complications predicted by echocardiographic abnormalities consistent with antibody-associated disease beyond the atrioventricular node. The disparity in outcomes observed between minorities and whites warrants further investigation.

Figure 1

Figure 1A. Kaplan-Meier survival estimates of fetal cardiac-NL in utero. Of note, the exact gestational age at birth was unknown for two cases which were excluded from the analysis. The X axis represents the number of cases at the corresponding gestational age. Figure 1B. Kaplan-Meier survival estimates of children with cardiac-NL born alive.

Figure 1

Figure 1A. Kaplan-Meier survival estimates of fetal cardiac-NL in utero. Of note, the exact gestational age at birth was unknown for two cases which were excluded from the analysis. The X axis represents the number of cases at the corresponding gestational age. Figure 1B. Kaplan-Meier survival estimates of children with cardiac-NL born alive.

Figure 2

The Kaplan-Meier curves reflecting probability of pacemaker implantation. Of note, two cases of cardiac-NL that were paced in utero were omitted from the analysis.