Uterine Preservation in Systemic Lupus Erythematosus Complicated by Pregnancy With Diffuse Thin Myometrium: A Clinical Observation

Pregnancy complicated by systemic lupus erythematosus (SLE) is associated with adverse outcomes for both the mother and the infant, alongside increased obstetric risks.1–5 Recent case reports have highlighted the risk of thinning of the myometrium and abnormal placental implantation in patients with SLE during pregnancy, which require rigorous clinical attention. In our practice, we managed a full-term pregnancy in a patient with SLE. During a cesarean delivery, the myometrium was found to be diffusely thin and semi-transparent. Through proactive management, the uterus was preserved, and the postpartum recovery was good. There is currently a paucity of literature suggesting that SLE in pregnancy is linked to both a thin myometrium and placenta accreta. Given the rarity of this clinical presentation, this report serves as a reference to raise awareness for similar future cases. All data used in this study were approved by the ethics committee of Peking University People’s Hospital (No.: 2026PHB145-001). Written informed consent was acquired from the patient for the publication of this report and associated clinical informatio. A 29-year-old gravida 2, para 0 female patient, was admitted for a planned delivery at term (39+5 weeks of gestation). In May 2021, she had been diagnosed with SLE complicated by gastrointestinal smooth muscle involvement, serous cavity effusion, and secondary antiphospholipid syndrome. Prior to pregnancy, her regimen had included prednisone and tacrolimus; cyclophosphamide had been discontinued before conception. During pregnancy, treatment was augmented with hydroxychloroquine, aspirin, and low-molecular-weight heparin. She underwent dynamic monitoring of relevant parameters (Supplementary Table 1, https://links.lww.com/MFM/A120) alongside stringent antenatal surveillance throughout gestation. Routine checkups during pregnancy showed no obvious abnormalities. The patient had a history of penicillin hypersensitivity, but was otherwise negative for chronic, infectious, or genetic diseases. Her obstetric history was notable for a previous induction of labor due to intrauterine fetal demise at 23 weeks of gestation in 2021. After admission, physical examination revealed an immature cervix and an estimated fetal weight of 3000 g. Ultrasound examination showed a single live fetus in a cephalic presentation with no detectable abnormalities in the placenta or myometrium. Admission diagnoses included pregnancy complicated by SLE and atypical antiphospholipid antibody syndrome. After admission, relevant examinations were conducted. A consultation with the Department of Rheumatology and Immunology was initiated to guide the perinatal management of SLE. The patient’s SLE was stable, and assessment indicated suitability for a vaginal trial of labor. However, during labor induction, an abnormal fetal heart rate was detected. Owing to the presence of multiple comorbidities, the patient underwent a cesarean section via a transverse incision in the lower uterine segment under combined spinal-epidural anesthesia on May 15, 2024 (40 weeks of gestation). The procedure also included bilateral ligation of the ascending branches of the uterine artery, uterine suturing, and uterine reconstruction. Upon entry into the abdominal cavity, the uterine surface was noted to be covered with tortuous, engorged vessels, and the lower uterine segment was poorly formed. The engorged vessels were ligated. After delivery of the fetus, transient but profuse hemorrhaging occurred from the incision edges. After initial control, further exploration revealed an entirely atonic, boggy uterus with a hematoma-like consistency. Upon exteriorization, the myometrium was found to be markedly thinned and nearly translucent, resembling a flaccid sac (Supplementary Fig. 1A, https://links.lww.com/MFM/A120). The placenta was only partially adherent to the right anterior uterine wall and was separated with minimal traction. Samples from the adherent placenta were sent for pathological examination, and tissue was collected for bacterial culture. Following the placement of intrauterine gauze packing and the ligation of the bilateral ascending uterine arteries, hemostasis remained suboptimal upon tourniquet release. Consequently, a B-Lynch suture and uterine reconstruction were performed. Despite the administration of uterotonic agents, the uterus remained atonic, necessitating additional compression sutures (Supplementary Fig. 1B, https://links.lww.com/MFM/A120). After a 10-minute assessment period with no significant bleeding, the abdomen was routinely closed. Vital signs remained stable throughout the procedure, and the surgery was deemed successful, with the patient safely returned to the ward. The placental tissue was submitted for pathological examination (Supplementary Fig. 2, https://links.lww.com/MFM/A120). The newborn was a healthy, full-term female weighing 3350 g, exhibiting good general condition. On the day of surgery, based on the postoperative laboratory results, supportive treatments were administered, including blood transfusion, anti-inflammatory therapy, and fluid replacement. On the third postoperative day, 20 mg of methylprednisolone was administered once daily, and on the fourth day, the original oral regimen was resumed. The patient was discharged on postoperative day 6 and continued the aforementioned treatment outside the hospital, with follow-up care provided by the department of rheumatology and immunology. The primary discharge diagnoses included postpartum hemorrhage secondary to uterine atony, placenta previa with hemorrhage, elective cesarean section resulting in single fetal delivery, and postpartum anemia. Six months after childbirth, the patient’s physical condition remains stable, with normal menstruation occurring three times. She regularly attends follow-up appointments at the department of rheumatology, where her condition is currently well controlled. The newborn is healthy and shows no signs of discomfort. In this case, optimal outcomes were achieved through collaborative efforts with the department of rheumatology and immunology during pregnancy, prompt intervention during surgery, and exemplary teamwork throughout. In response to unforeseen complications during the procedure, the rescue personnel were well-prepared and strategically positioned, ensuring the timely management of postpartum hemorrhage. SLE is a chronic, multisystem inflammatory autoimmune disease that predominantly affects women of reproductive age.1 While its pathophysiology is complex and incompletely understood, it is known to primarily involve the breakdown of T-cell and B-cell tolerance to self-antigens, along with abnormalities in innate and adaptive immune processes.6 In clinical practice, pregnancies complicated by SLE are relatively common; however, cases in which SLE leads to thinning of the uterine myometrium and abnormal placental implantation are rare and warrant further attention. Research indicates that several high-risk factors contribute to the thinning of the uterine muscle layer during placental implantation.7 However, evidence regarding diffuse thinning of the entire uterine muscle layer due to SLE remains limited to isolated case reports. Prednisone and hydroxychloroquine constitute the basic therapeutic regimen for SLE. However, prednisone impairs the maturation of spiral arteries during placenta formation.8 Furthermore, long-term use of glucocorticoids can lead to the inhibition of estrogen receptors and may also negatively impact protein synthesis, leading to the thinning of the uterine muscle layer.9,10 SLE may also lead to thinning of the entire uterine muscle layer and abnormal placental implantation, resulting in severe postpartum hemorrhage. Routine prenatal ultrasound monitoring prioritizes the placenta and the fetus, often overlooking the integrity of the uterine muscle layer. While this omission may be inconsequential for patients whose uterine muscle layer is not significantly thin or does not cause serious obstetric complications, abnormal placental implantation and diffuse thinning of the uterine muscle layer should be explicitly considered in pregnant women with SLE. In late pregnancy, timely communication with the sonographer is necessary to properly evaluate the uterine surface, the uterine muscle layer, and placental implantation, thereby minimizing the risk of missed diagnosis. Moreover, adequate preparations must be made to manage significant perioperative bleeding. In cases of severe postpartum hemorrhage—precipitated by an inability to detach the placenta due to aberrant placental implantation and a thinned myometrium, resulting in atonic uterine contraction insufficiency—the first choice for clinical management is typically subtotal or total hysterectomy to ensure the safety of the mother’s life. However, given the success of our case, alternative management strategies also merit consideration. For pregnant patients with SLE, a collaborative, multidisciplinary approach involving the departments of obstetrics, ultrasound, and rheumatology is essential for managing the condition. Preconception counseling and comprehensive risk assessments are necessary to determine the optimal timing for pregnancy. During pregnancy, treatment regimens must be dynamically adjusted to mitigate the risk of adverse delivery outcomes. Through effective team management of SLE patients both before and during pregnancy, the disease progression can be controlled, ensuring a good pregnancy outcome, and providing a guarantee for the safety of both the mother and the fetus. Funding This work was funded by the 2025 Beijing Municipal Clinical Key Specialty Construction Program with support from the government budget. Author Contributions Guoli Liu, Kunkun Sun and Yuntao Li conceived and designed the study, and critically revised the manuscript. Linyan Zhang and Jinfang Wang was responsible for data collection, analysis, and the initial drafting of the manuscript. Conflicts of Interest None. Data Availability The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.