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ORIGINAL RESEARCH |
From the *Department of Obstetrics and Gynecology, Brigham and Women's Hospital, and Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston; Department of Obstetrics and Gynecology, Boston Medical Center, Boston University School of Medicine, Boston; Genetics and Teratology Unit, Department of Pediatrics, Massachusetts General Hospital, Harvard Medical School, Boston; and ¶Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
Address reprint requests to: Adam Wolfberg, MD, MPH, Department of OB/GYN, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115; e-mail: awolfberg{at}partners.org.
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ABSTRACT |
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METHODS: Using an institutional database, we identified all women with diagnosed rheumatologic disease (n = 114) who delivered a baby at our institution during a 33-month period. We compared the incidence of adverse obstetric and neonatal outcomes among these women with the incidence among women without rheumatologic diseases (n = 18,534).
RESULTS: Women with rheumatologic diseases were more likely to have preeclampsia than women without rheumatologic disease (8.8% versus 2.3%, P < .001) Women with rheumatologic diseases were also at increased risk of preterm delivery (15.2% versus 7.8%, P = .002) and small-for-gestational-age infants (8.0% versus 3.1%, P = .001) compared with women without rheumatologic disease.
CONCLUSION: The finding that women with rheumatologic diseases are at increased risk of adverse obstetric outcomes suggests a need for heightened clinical vigilance and further research into the common pathophysiologic correlates.
LEVEL OF EVIDENCE: II-2
There are limited data regarding the association of rheumatologic diseases with hypertension and preeclampsia. Yasmeen et al5 found that the incidence of hypertensive disorders in pregnancy was higher among women with SLE than among those without SLE, based on an analysis of a large state database. However, the rates of hypertensive disorders among women with SLE (2.9%) and those without SLE (0.4%) in that report are both well below the commonly accepted rates of gestational hypertension and preeclampsia.9 A study of pregnant patients in Norway with rheumatologic diseases found an increased incidence of preeclampsia among women with SLE, systemic sclerosis, Sjögren's syndrome, polymyositis, and dermatomyositis, but the association was not consistent over the study period.10
Given the limited data available, we sought to determine whether there was an increased rate of preeclampsia among women with rheumatologic diseases.
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MATERIALS AND METHODS |
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We excluded women with multiple pregnancies, women transferred to our institution intrapartum, and women with diseases that are associated with preeclampsia or other adverse obstetric or neonatal outcomes, such as diabetes, thyroid disease, and infection with cytomegalovirus or parvovirus.
Information about women's prenatal course, chronic hypertension diagnosed before pregnancy, preeclampsia, intrauterine growth restriction (IUGR), SGA, intrauterine fetal demise, and coexisting medical conditions was collected. To isolate the association of preeclampsia with rheumatologic diseases, we excluded women with a diagnosis of chronic hypertension, defined as history of hypertension before pregnancy and reported in the patient's chart. We also excluded women diagnosed with hypertension during the first 20 weeks of pregnancy because hypertension that early in pregnancy could represent a preexisting hypertensive disorder rather than preeclampsia.
Preeclampsia was defined as new-onset hypertension after 20 weeks of pregnancy (systolic blood pressure greater than 140 mm Hg or diastolic blood pressure greater than 90 mm Hg) accompanied by proteinuria and/or evidence of organ involvement. Only patients diagnosed with preeclampsia before labor were included; we excluded women diagnosed with preeclampsia during labor to avoid overdiagnosing preeclampsia by mistakenly including women with a single isolated elevated blood pressure reading. An SGA infant was defined as one with birth weight below the 5th percentile, by using a United States population reference.13
Statistical comparisons were performed with 
2 or Fisher exact test, as appropriate. Logistic regression analysis was used to evaluate the association of rheumatologic conditions with preeclampsia while controlling for maternal age. The overall association was evaluated in a logistic analysis where any rheumatologic disease (yes/no) was the outcome variable. Separate logistic regressions were also performed by examining the association of each rheumatologic condition with preeclampsia. P < .05 was considered statistically significant.
The protocol was approved by our institutional review board.
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RESULTS |
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There was an almost 4-fold greater risk of preeclampsia among the overall group of women with rheumatologic diseases than among those without rheumatologic diseases (8.8% versus 2.3%; relative risk 4.3; 95% confidence interval 2.2, 8.2). When examined separately, SLE, rheumatoid arthritis, other rheumatologic diseases grouped together, and antiphospholipid antibody syndrome were each associated with a 3- to 5-fold higher rate of preeclampsia, although only the associations with SLE and the other rheumatologic diseases grouped together reached statistical significance. After adjusting for maternal age, the overall association between all rheumatologic diseases and preeclampsia remained highly significant. When examined separately, only SLE and antiphospholipid antibody syndrome were significantly associated with preeclampsia in the regression analyses (Table 1).
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Women with rheumatologic disorders were at a greater risk than women without rheumatologic disease of having chronic hypertension (5.6% versus 1.2%, P < .001), SGA infants (8.0% versus 3.1%), and preterm delivery (15.2% versus 7.8%, P = .002). There was a somewhat higher rate of IUGR in women with rheumatologic disease, although the difference did not reach statistical significance (P = .1) There was no increased risk of intrauterine fetal demise or congenital anomalies among women with rheumatologic disease compared with women without rheumatologic disease (Table 2).
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DISCUSSION |
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Our data demonstrate a consistent, increased incidence of preeclampsia in all rheumatologic diseases. We find it reassuring that the rate of preeclampsia among women without rheumatologic diseases was consistent with population estimates of the disease (2–7%),9 suggesting a valid diagnosis of preeclampsia among all women studied. This finding contrasts with one of the other studies that suggests an association between SLE and preeclampsia but reports a prevalence of preeclampsia below the generally accepted rates for patients both with and without SLE.5
Our data also show that women with rheumatologic diseases have an approximately 2-fold greater risk of adverse pregnancy outcomes including preterm delivery, SGA, and IUGR than women without rheumatologic diseases.
We show an increased rate of chronic hypertension among women with rheumatologic disorders, a finding that is not surprising, given that hypertension has been associated with rheumatologic disorders in patients who are not pregnant.
The reason for the association of IUGR and SGA with rheumatologic disease is unclear. A possible explanation may be found in a common autoimmune process linking the patient's pregnancy (a process of autoimmune tolerance), rheumatologic disease, and preeclampsia, and consequently compromising the uteroplacental unit. Further research to elucidate the commonalities between these conditions may be fruitful.
Our study does have certain limitations. To the extent that women with rheumatologic diseases may undergo heightened prenatal attention and blood-pressure screening, they may be more likely to be diagnosed with preeclampsia than patients with uncomplicated pregnancies whose elevated blood pressure or proteinuria go unnoticed. In addition, the fact that proteinuria is a common finding in SLE and a diagnostic criterion for preeclampsia complicates interpretation of our results. Whether the finding of proteinuria makes patients with SLE more likely to be diagnosed with preeclampsia or less likely to be diagnosed with preeclampsia because their proteinuria is attributed to SLE is unclear.
Clinically, these findings suggest that women with rheumatologic diseases deserve extremely close monitoring during the antepartum and intrapartum periods. From a pathophysiologic perspective, however, these data suggest the possibility of a common autoimmunologic link between preeclampsia and rheumatologic disorders that is worthy of further research.
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Footnotes |
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Received December 5, 2003. Received in revised form February 13, 2004. Accepted February 18, 2004.
10.1097/01.AOG.0000126279.87151.e1
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REFERENCES |
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2. Kiss E, Bhattoa HP, Bettembuk P, Balogh A, Szegedi G. Pregnancy in women with systemic lupus erythematosus. Eur J Obstet Gynecol Reprod Biol 2002;101:129–34.[Medline]
3. Gimovsky ML, Montoro M, Paul RH. Pregnancy outcome in women with systemic lupus erythematosus. Obstet Gynecol 1984;63:686–92.
4. Mintz G, Niz J, Gutierrez G, Garcia-Alonso A, Karchmer S. Prospective study of pregnancy in systemic lupus erythematosus: results of a multidisciplinary approach. J Rheumatol 1986;13:732–9.[Medline]
5. Yasmeen S, Wilkins EE, Field NT, Sheikh RA, Gilbert WM. Pregnancy outcomes in women with systemic lupus erythematosus. J Matern Fetal Med 2001;10:91–6.[Medline]
6. Mavragani CP, Dafni UG, Tzioufas AG, Moutsopoulos HM. Pregnancy outcome and anti-Ro/SSA in autoimmune diseases: a retrospective cohort study. Br J Rheumatol 1998;37:740–5.
7. Brucato A, Doria A, Frassi M, Castellino G, Franceschini F, Faden D, et al. Pregnancy outcome in 100 women with autoimmune diseases and anti-Ro/SSA antibodies: a prospective controlled study. Lupus 2002;11:716–21.
8. Steen VD, Medsger TA Jr. Fertility and pregnancy outcome in women with systemic sclerosis. Arthritis Rheum 1999;42:763–8.[Medline]
9. Sibai B. The diagnosis and management of gestational hypertension and preeclampsia. Obstet Gynecol 2003;102:181–92.
10. Skomsvoll JF, Ostensen M, Irgens LM, Baste V. Pregnancy complications and delivery practice in women with connective tissue disease and inflammatory rheumatic disease in Norway. Acta Obstet Gynecol Scand 2000;79:490–5.[Medline]
11. Nelson K, Holmes LB. Malformations due to presumed spontaneous mutations in newborn infants. N Engl J Med 1989;320:19–23.Table 2)[Abstract]
12. McGuirk CK, Westgate MN, Holmes LB. Limb deficiencies in newborn infants. Pediatrics 2001;108:E64.
13. Alexander GR, Himes JH, Kaufman RB, Mor J, Kogan M. A United States national reference for fetal growth. Obstet Gynecol 1996;87:163–8.[Abstract]
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