Pre-Eclampsia Risk & Rheumatic Disease

ACR CONVERGENCE 2021—Using data from the Swedish and Danish nationwide clinical and health registers, Secher et al. conducted a cohort study of single pregnancies in women with rheumatoid arthritis (RA), axial spondylarthritis (axSpA) and psoriatic arthritis (PsA), matching patients to pregnant women who did not have RA, axSpA or PsA to assess the effect of disease activity and disease-modifying anti-rheumatic drugs (DMARDs) on the risk of pre-eclampsia.¹ Anne Emilie Secher, MD, DANBIO registry and Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre of Head and Orthopedics, Copenhagen University Hospital Rigshospitalet, Glostrup, Denmark, and the North Zealand Hospital, Hillerød, Denmark, presented the study’s findings during ACR Convergence 2021.

Pre-eclampsia can have potentially fatal outcomes. High disease activity in patients with RA has been associated with adverse pregnancy outcomes (e.g., preterm birth, low birth weight). However, the risk of pre-eclampsia relative to disease activity and DMARD use in women with chronic inflammatory arthritis has not been extensively assessed. Secher et al. set out to evaluate the overall risk of pre-eclampsia in pregnant women with RA, axSpA and PsA, and the effect of disease activity and DMARD use on that risk.

Methods

Secher et al. linked medical birth registers to rheumatology registers for women with RA, axSpA and PsA and singleton pregnancies from 2006 to 2018 in Sweden and Denmark. Control pregnancies from the medical birth registers were matched in a 1:10 ratio for age, birth year and parity. The researchers obtained data on DMARDs used in the nine months before pregnancy (e.g., pre-pregnancy) and during pregnancy, as well as disease activity during pregnancy (e.g., Disease Activity Score 28 for Rheumatoid Arthritis with C-Reactive Protein [DAS28-CRP], Health Assessment Questionnaire [HAQ] and CRP). Pre-eclampsia information was acquired from national patient registers.

Logistic regression was used to estimate the pre-eclampsia risk, presented by adjusted odds ratio (aOR) with a 95% confidence interval (CI). Adjustments were made for country, body mass index (BMI), educational level, maternal age, parity (e.g., the number of previous pregnancies of >20 weeks), smoking and year.

The Results

A total of 3,047 singleton pregnancies were identified (n=1,739 for RA; n=819 for axSpA; n=489 for PsA). No major maternal characteristic differences were found in the pregnant women with RA and axSpA compared with the control group. Pregnant women with PsA were more likely to be obese, smokers and less educated than pregnant women with RA or axSpA, or patients in the control group. No increased risk of pre-eclampsia was found in patients with RA or axSpA. Pregnant patients with PsA had an overall increased risk of pre-eclampsia compared with the control group (aOR 1.85; 95% CI 1.10, 3.12).

Women who received pre-pregnancy combination therapy with a conventional synthetic DMARD (csDMARD), a biologic DMARD and/or glucocorticoids in any combination of at least two had a moderately increased risk of developing pre-eclampsia compared with controls. Patients did not have an increased risk of pre-eclampsia if they had no treatment or if they received monotherapy with a csDMARD, a bDMARD or a glucocorticoid. For patients with PsA, pre-pregnancy monotherapy with a csDMARD, a bDMARD or a glucocorticoid was associated with pre-eclampsia.

When stratifying the risk on the basis of treatment during pregnancy, no significant increased risk of pre-eclampsia was observed for any of the groups with rheumatic disease. A doubled pre-eclampsia risk was associated with high disease activity in patients with RA (n=756; 43%) compared with the control group. Patients with axSpA and PsA had no increased risk of pre-eclampsia, and the event numbers were low. Three patients with axSpA had pre-eclampsia, and five patients with PsA had pre-eclampsia.

Overall, this study showed that pregnant women with PsA, but not patients with axSpA, are at increased risk of pre-eclampsia. Pregnant women with RA and severe disease who have combination therapy before pregnancy and high disease activity during pregnancy also have an increased risk of developing pre-eclampsia.

Reference

1. Secher A, Hellgren K, Glintborg B, et al. Risk of pre-eclampsia and impact of disease activity and anti-rheumatic treatment in women with rheumatoid arthritis, axial spondylarthritis and psoriatic arthritis—a collaborative matched cohort study from Sweden and Denmark [abstract 1722]. Arthritis Rheumatol. 2021 Oct; 73 (suppl 10).