IMIDs not tied to adverse pregnancy outcomes overall; lupus, APS linked to preterm birth
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Key takeaways:
- For pregnancies at 20 weeks of gestation or greater, many IMIDs were “only weakly associated” with risk for adverse pregnancy outcomes.
- Lupus and antiphospholipid syndrome were linked to preterm birth and more likely cesarean delivery.
Pregnant patients with lupus or antiphospholipid syndrome have a higher risk for preterm birth, although immune-mediated inflammatory diseases in general are “only weakly associated” with adverse pregnancy outcomes, according to data.
“It is commonly reported that autoimmune disease increases risk for adverse pregnancy outcomes, and some patients decide to forego pregnancy because of concern for adverse birth outcomes,” Jennifer Hadlock, MD, of the Institute for Systems Biology and University of Washington, one of the co-authors of the study, told Healio. “However, autoimmune diseases are not all the same, and each patient has a unique medical history.”
To better understand how pregnancy outcomes are affected by various immune-mediated inflammatory diseases (IMIDs), Hadlock and colleagues conducted a retrospective cohort study in partnership with Providence St. Joseph Health in Washington. They collected electronic health records for 365,075 people who had live births from January 2013 through December 2022 and analyzed pregnancy outcomes in those with IMIDs vs. those without.
The cohort included 5,784 patients diagnosed with IMIDs prior to pregnancy and 359,291 people without IMIDs. The study evaluated the connections of 12 different IMIDs to preterm birth, low birth weight, small for gestational age and caesarean section. The assessed IMIDs were psoriasis, inflammatory bowel disease, rheumatoid arthritis, spondyloarthritis, multiple sclerosis, systemic lupus erythematosus, psoriatic arthritis, antiphospholipid syndrome, Sjögren's syndrome, vasculitides, sarcoidosis, and systemic sclerosis.
According to the researchers, pregnancy with a prior diagnosis of IMID has doubled in prevalence — from 1.1% to 2% — over the last decade. After adjusting for comorbidities, the researchers found that, in pregnancies at 20 weeks of gestation or greater, having at least one IMID was “only weakly associated” with risks for preterm birth (RR = 1.1; 95% CI, 1-1.3), low birth weight (RR = 1.2; 95% CI, 1-1.4), small for gestational age (RR = 1.1; 95% CI, 1-1.2) and cesarean delivery (RR = 1.1; 95% CI, 1.1-1.2).
However, adverse pregnancy outcomes did have a “strong association” with two specific conditions — SLE and antiphospholipid syndrome. According to the researchers, patients with either disease demonstrated greater risks for preterm birth and of cesarean delivery, while SLE was also associated with greater risk for low birth weight and delivering babies that are small for gestational age.
“Physicians and patients alike should know that having an autoimmune condition doesn’t necessarily mean you will have a difficult pregnancy or adverse birth outcome,” Philip J. Mease, MD, of the Swedish Medical Center in Washington, co-author of this study, told Healio. “It is important for patients to work with their entire health care team for optimal management of pregnancy, autoimmune disease and other conditions.”
This article has been edited to more accurately reflect the data.
Perspective
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This study grouped 12 different IMIDs, including non-rheumatologic IMIDs like multiple sclerosis and inflammatory bowel disease. Therefore, one of the medications that was included in the evaluation was a 5-ASA. I would have found the article more interesting from a rheumatology point of view if only rheumatologic conditions were considered, and medications other than steroids, TNF inhibitors and hydroxychloroquine were included in the evaluation.
Many patients are taking non-TNF inhibitors such as abatacept (Orencia, Bristol Myers Squibb), tocilizumab (Actemra, Genentech) and rituximab (Rituxan, Genentech), so this data would be extremely important for us to be able to advise patients about the effects of these medications on pregnancy outcomes.
Also, although the outcomes of pre-term birth, low birth weight and gestational age were included in the evaluation, I am even more interested in outcomes such as miscarriages, infertility and birth deformities. I understand that data collection is easier beginning at 20 weeks of gestation, but many of our patients are not able to become pregnant or suffer an early pregnancy loss so the effect of disease and medications on these outcomes, in my opinion, is just as important.
Only 17% of the patients in this study were on immunomodulatory medications at the time of study entry. This suggests that these patients had either milder disease or lacked access to rheumatologic care to prescribe these medications, so perhaps this data does not pertain to the patients that we see in our offices.
Finally, the authors concluded that it was the comorbid conditions that contributed to the poor pregnancy outcomes rather than the autoimmune diseases themselves. They concluded this as their study was one of the few that randomized for comorbid conditions, and demonstrated that only lupus and antiphospholipid syndrome were associated with a significant increase in poor pregnancy outcomes. I would be interested in the outcomes of other studies that randomized for comorbidities to see if their conclusions would be similar. Overall, I found the data of interest, but I have many further questions that need to be addressed.
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