Risk for adverse pregnancy outcomes greater in systemic sclerosis than lupus
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Pregnant patients with systemic sclerosis demonstrate a higher risk for adverse pregnancy outcomes, including preterm delivery, than those with lupus and healthy controls, according to data published in Arthritis Research & Therapy.
“Until now, even though the overall obstetric result reported in the literature was good, there is no uniformity among the different studies, with discordant findings of different adverse pregnancy outcomes,” Gerard Espinosa, MD, PhD, of the Hospital Clínic de Barcelona, told Healio.
To examine the prevalence of adverse pregnancy outcomes in pregnant patients with SSc, compared with those with systemic lupus erythematosus or antiphospholipid syndrome, Espinosa and colleagues prospectively followed 154 pregnancies in healthy individuals as well as patients with SSc, SLE and APS.
Researchers identified 21 patients who became pregnant following the onset of SSc symptoms between 2008 and 2019. Comparator groups consisting of 26 pregnant patients with SLE and 31 pregnant patients with antiphospholipid syndrome in the same period were also selected and followed. Finally, a group of 40 pregnant patients were selected for the healthy control. Patients were followed throughout the pregnancy and for up to 1 year post-delivery.
During the observational period, the researchers assessed heart rate, blood pressure, signs of organ or system involvement attributable to SSc, and kidney involvement at each visit. When there was high suspicion of a specific disease manifestation, such as Raynaud’s syndrome, specific tests were performed for confirmation.
A composite of adverse pregnancy outcomes served as the study’s primary endpoint. These outcomes were defined as miscarriages, fetal death, neonatal death before hospital discharge, preeclampsia, preterm birth, intrauterine growth restrictions and small-for-gestational-age newborns.
According to the researchers, the risk for adverse pregnancy outcomes was significantly higher in patients with SSc, compared with patients in the healthy control group — 60.6% vs. 10% (OR = 14.42; 95% CI, 3.7-56.18). Patients with SSc also had a higher likelihood of adverse pregnancy outcomes compared with patients with SLE — 60.6% vs. 37.5% (OR = 3.56; 95% CI, 1.29-9.83).
Patients with SSc were more likely than healthy controls to have a first-trimester miscarriage — 15% vs. 0% (P = .016) — preeclampsia — 12% vs. 0% (P = .038) — and small-for-gestational-age newborns — 21.2% vs. 0% (P = .003). In addition, preterm deliveries were more common in patients with SSc, at 24.2%, compared with the healthy control cohort, at 5% (OR = 6.08; 95% CI, 1.19-31.02, and SLE cohort, at 7.5% (OR – 5.68; 95% CI, 1.1-29.38).
“Pregnant women with SSc present with an increased risk of APO in our SSc cohort in comparison with healthy controls (with higher rates of miscarriages, preeclampsia, SGA newborns, and preterm deliveries) and SLE patients,” Espinosa said. “In my opinion, the take home message is that a high-risk multidisciplinary management of SSc pregnant women is recommended and, although it was not an objective of our work, the pre-gestational assessment is mandatory.”
Perspective
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The autoimmune diseases we treat every day have implications across the patient’s lifespan. Women in their childbearing years are faced with a problem that doesn’t have an easy solution. Do they risk adverse pregnancy outcomes and their own health to have a baby, knowing they have a complex and sometimes difficult-to-treat disease? Many providers discourage women from becoming pregnant, but they lack the data to support their position. Studies like this one are essential so that the real risks and potential outcomes to the baby and the mother can be discussed.
In my practice, when the patient begins discussing the desire to become pregnant, we immediately send her to a high-risk pregnancy provider so that all the expectations can be discussed up front and she can get the needed support.
Pre-pregnancy counseling, referrals to high-risk pregnancy providers, multidisciplinary management of her disease and medications, and close monitoring especially during the first trimester are critical pieces of the care plan.
Perspective
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Although there are a multitude of studies regarding pregnancy outcomes in patients with anti-phospholipid syndrome and systemic lupus erythematosus, little data are available for pregnancy outcomes in systemic sclerosis. Studies to date have had conflicting data and the more recent studies, including prospective data from two published studies, concluded successful outcomes similar to the general population, with no increase in maternal mortality. Older studies, mainly observational case studies, showed poor outcomes, both maternal and fetal, with increased infertility, miscarriage and maternal complications.
This study was designed to retrospectively compare pregnancy and disease outcomes of women with SSc with those of patients with APS and SLE, including a healthy control group, all followed prospectively through their pregnancies.
Prior data showed discordant risk for preterm birth, intrauterine growth restriction (IUGR), small for gestational age (SGA) newborns and preeclampsia. Some data suggest higher risk for progression in women with early onset — less than 4 years — diffuse cutaneous scleroderma and positive anti-topoisomerase antibodies.
In general, APS and SLE are frequently associated with poor outcomes including recurring fetal loss, preeclampsia, placental insufficiency and IUGR.
Demographics included 21 pregnant women with SSc, 26 pregnant women with SLE, 31 pregnant women with APS and 40 healthy controls who were all age matched.
Results included 21 patients with SSc, with a total of 33 pregnancies, four of which were conceived through assisted reproductive technology. A total of 121 control pregnancies included 40 pregnancies from 26 patients with SLE, 41 pregnancies from 31 patients with APS, and 40 healthy controls. Mean disease duration at conception in SSc was 6 years, 9.4 years for SLE and 2.5 years for APS.
Results showed an increased risk overall for adverse pregnancy outcomes for SSc including miscarriage, SGA newborns, preeclampsia and premature deliveries.
I would agree with the authors that the main strength of the study was that patients were followed prospectively with real-time assessments as compared to prior studies where data were collected through questionnaires or database information. The limitations include small study size and the retrospective analysis.
There is a significant need for larger cohort population studies in patients with SSc, who represent an increasing population of pregnancies in autoimmune disease. Additionally, there is a need for pre-pregnancy counseling and management by high-risk maternal fetal medicine clinicians.
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