Women with rheumatic diseases face adverse pregnancy outcomes

Pregnancies in women with rheumatic and systemic autoimmune diseases—including systemic lupus erythematosus (SLE), spondyloarthritis (SpA), and rheumatoid arthritis (RA)—pose significant health risks and are likely to lead to unfavourable outcomes, according to several studies presented at this year’s European Alliance of Associations for Rheumatology (EULAR) Congress.

A group of New York-based researchers in the US reported that pregnancies in women with vs without SLE carried an elevated risk of foetal morbidity, such as intrauterine growth restriction (8.0 percent vs 2.7 percent) and preterm delivery (14.5 percent vs 7.3 percent). [EULAR 2022, abstract OP0124]

Moreover, women in the SLE group faced greater risks of blood transfusion, puerperal cerebrovascular disorders, acute renal failure, eclampsia or disseminated intravascular coagulation, cardiovascular and peripheral vascular disorders, and general medical issues, said lead researcher Dr Bella Mehta.

Mehta pointed out that their study, which involved 40 million delivery-related admissions and 51,161 SLE patients in the US, demonstrated that foetal morbidity and severe maternal morbidity occurred at a higher rate among women with vs without SLE.

In SpA pregnancies on the other hand, an analysis of 1,394 Swedish women with SpA and 13,932 general population comparators with singleton births showed a slight difference in several adverse outcomes.

Specifically, the SpA group were at higher risk of gestational diabetes (adjusted relative risk [RR], 1.88, 95 percent confidence interval [CI], 1.10–2.56), elective and emergency Caesarean delivery (adjusted RR, 1.54, 95 percent CI, 1.32–1.79 and 1.23, 95 percent CI, 1.02–1.48, respectively), and moderately preterm birth (adjusted RR, 1.52, 95 percent CI, 1.18–1.97). [EULAR 2022, abstract OP0126]

The SpA group also had nonsignificant increased risk of pre-eclampsia (adjusted RR, 1.32, 95 percent CI, 0.96–1.81), and infants born to mothers with SpA had a slightly higher risk of infection during their first year of life (adjusted RR, 1.23, 95 percent CI, 0.98–1.53).

Principal investigator Dr Matilda Morin of Karolinska Institutet in Stockholm, Sweden, noted that the increased risks of both emergency Caesarean delivery and spontaneous preterm birth in SpA vs the comparator could not be solely attributed to the different management of SpA pregnancies but also to other factors.

A separate France study in RA identified corticosteroid exposure during pregnancy as a risk factor for an unfavourable pregnancy outcome (odds ratio [OR], 3.2, 95 percent CI, 1.1–9.6; p=0.04). Other factors that contributed to a risk increase were nulliparity (OR, 6.2, 95 percent CI, 2.1–17.8; p=0.002) and age (per year: OR, 1.1, 95 percent CI, 1.0–1.3; p=0.02). [EULAR 2022, abstract OP0127]

The analysis was based on 92 pregnancies in women with RA, of which 43 (46.2 percent), 8 (7.9 percent), and 40 (43.5 percent) were exposed to corticosteroid, nonsteroidal anti-inflammatory drugs (NSAIDs), and biologics at least once during pregnancy, respectively.

Lead study author Sabrina Hamroun of Cochin Hospital in Paris, France, stressed the careful use of corticosteroid during pregnancy considering the findings.

Taken together, the findings from the three studies may help inform clinicians in their management of rheumatic diseases during pregnancy or in women who are planning to conceive.

High live birth rates with good medication adherence

Despite the increased risk of adverse pregnancy outcomes, women with rheumatic diseases can have successful pregnancies, owing to the use of antirheumatic drugs, according to a team of investigators from Italy. They shared their findings from a web-based longitudinal observational cohort study in 758 pregnant women with rheumatic diseases (SLE and RA predominantly) across 26 centres in Italy.

Most of the pregnancies (n=495, 89.5 percent) ended in live births; there were 54 (9.8 percent) cases of pregnancy loss (40 spontaneous, 6 voluntary terminations) and four (0.7 percent) cases of perinatal death. [EULAR 2022, abstract OP0125]

Regarding treatments, 166 (30 percent) pregnancies were exposed to corticosteroids, 239 (43 percent) to hydroxychloroquine, 59 (10.7 percent) to conventional synthetic disease-modifying antirheumatic drugs (DMARDs), 84 (15.2 percent) to tumour necrosis factor (TNF) inhibitors, one (0.2 percent) to non-TNF biologic DMARDs, 299 (54 percent) to low-dose acetylsalicylic acid, and 126 (22.8 percent) to heparin.

“Multiple factors may have contributed to the high rate of live births, including good disease control before and during pregnancy, thanks to the use of antirheumatic drugs and low frequency of general risk factors,” said first study author Prof Laura Andreoli of University of Brescia, Italy.

Andreoli and colleagues’ data add to the results of another study, which reported that adherence to prescribed medications is quite high among pregnant women with systemic autoimmune diseases.

In an analysis involving 80 pregnant women and 72 nonpregnant women with systemic autoimmune diseases, adherence score (assessed using the 8-item Morisky Medication Adherence Scale) was significantly higher in the pregnant group both for hydroxychloroquine (HCQ; p=0.039) and other DMARDs (p=0.018). [EULAR 2022, abstract OP0128]

Significantly more patients in the pregnant group showed good medication adherence for HCQ (76.0 percent vs 57.6 percent; p=0.044). For other DMARDs, the between-group difference in the number of patients with good adherence was not statistically significant (74.6 percent vs 61.7 percent).

Principal investigator Dr Dina Zucchi of University of Pisa in Italy said that anxiety was a significant determinant of low medication adherence both in pregnant and non-pregnant women.

“Conversely, depression didn’t seem to have an impact on adherence in either group,” Zucchi added.