Preeclampsia in women with lupus – Influence of aspirin and hydroxychloroquine on pregnancy outcome

ElsevierVolume 31, March 2023, Pages 14-16Pregnancy HypertensionAuthor links open overlay panelAbstract

Systemic lupus erythematosus is associated with increased rates of preeclampsia. Both aspirin and hydroxychloroquine are recommended for preeclampsia prophylaxis in women with lupus but there are no studies examining related outcomes in an Australian cohort. This was a single centre retrospective study of lupus affected pregnancies. The association between hydroxychloroquine, aspirin and preeclampsia was examined using adjusted logistic regression models. In 95 pregnancies, hydroxychloroquine was associated with a significantly lower risk of preeclampsia (adjusted OR 0.16, 95 % CI 0.04–0.64) but there was no association between aspirin and preeclampsia (adjusted OR 1.34, 95 % CI 0.33–5.40).

Introduction

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease which disproportionately affects women of childbearing age [1], [2]. Preeclampsia occurs in approximately 25 % of SLE affected pregnancies and is associated with increased maternal and fetal complications [1], [3].

Hydroxychloroquine (HCQ) has anti-inflammatory, antioxidant, and anti-thrombotic effects with several potential mechanisms to explain its impact on pregnancy outcomes [4]. International guidelines recommend continuing it through pregnancy in women with SLE, as it is associated with a reduced risk of disease flare [5]. The influence of hydroxychloroquine on the development of preeclampsia in this group is more uncertain with two recent meta-analyses reporting conflicting results [5], [6].

In a systematic review and meta-analysis, aspirin use was associated with a significant reduction in preterm preeclampsia in high-risk women [7]. Aspirin is recommended for preeclampsia prophylaxis in women with SLE because of its theoretical pro-angiogenic effect but there are no studies demonstrating a significant risk reduction in this population [8], [9], [10]. The true effect of aspirin on preeclampsia risk in women with SLE and the interaction with HCQ remains undefined.

Section snippetsMethods

Women aged 18 years or older with SLE who had one or more pregnancies managed at a single centre in Western Australia between 2010 and 2020 were included in the study. Patients were identified through hospital coding system entries for SLE and pregnancy. Women were excluded if most of their pregnancy care was undertaken elsewhere, they delivered before 20 weeks or had a multiple pregnancy. Women were also excluded if they had isolated discoid lupus or if the diagnosis of SLE was in doubt using

Statistical method

Continuous data were summarised using median and interquartile range (IQR) and categorical data using frequency distributions. Logistic and linear regression analyses were conducted to assess the effects of HCQ and aspirin use on preeclampsia, preterm delivery, birth weight (continuous outcome) and small for gestational age; variance estimation accounted for the intra-group correlation among women who had more than one pregnancy in the study period. Pre-specified adjustments were made for BMI,

Baseline patient characteristics

There were a total of 95 pregnancies in 71 women over the 11 year study period. Baseline demographic and SLE characteristics are as seen in Table 1. 51 pregnancies were exposed to HCQ, and 63 to aspirin. Both aspirin and HCQ were used in 41 pregnancies.

Pregnancy outcomes

A total of 17 pregnancies were affected by preeclampsia, 6/51 (11.8 %) in the HCQ exposed group and 11/44 (25 %) in the HCQ unexposed group (OR 0.40, 95 % CI 0.14–1.15). When adjusted for aspirin use, BMI, lupus nephritis, lupus flare in

Discussion

HCQ use was independently associated with a significantly lower rate of preeclampsia after adjustment for confounders. This supports the findings of the 2021 meta-analysis by Duan et al in an Australian cohort [6]. The rate of preeclampsia in women not exposed to HCQ was consistent with the previously documented rates of preeclampsia in SLE pregnancies. However, our findings are limited by retrospective data collection and small patient numbers which prevented adjustment for more potential

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

References (11)

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© 2022 International Society for the Study of Hypertension in Pregnancy. Published by Elsevier B.V. All rights reserved.

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