Why obstetric and autoimmune history matter for women’s CV risk

NEW YORK – Systemic autoimmune disease is widely recognized as a major risk factor for cardiovascular disease (CVD), but less recognized as a cardiovascular risk factor is a history of pregnancy complications, including preeclampsia, and cardiologists and rheumatologists should include an obstetric history in the treatment of patients with autoimmune diseases, a reproductive health specialist in rheumatology told attendees at the 4th Annual Conference on Cardiometabolic Risk in Inflammatory Conditions.

“Autoimmune diseases, especially lupus, increase the risk of both cardiovascular disease and maternal placental syndromes,” Lisa R. Sammaritano, MD, professor at the Hospital for Special Surgery in New York City and a specialist in reproductive health issues at rheumatology patients, those present said. “For those patients who have complications during pregnancy, it increases their already increased risk of subsequent cardiovascular disease.”

CVD risk double whammy

A history of systemic lupus erythematosus (SLE) and a problematic pregnancy can be a double whammy for cardiovascular disease risk. Sammaritano cited a 2022 meta-analysis that found patients with SLE had a 2.5 times greater risk of stroke and almost three times greater risk of myocardial infarction than people without SLE.

Maternal placenta syndromes include pregnancy loss, restricted fetal growth, preeclampsia, premature membrane rupture, placental abruption and intrauterine fetal death, Sammaritano said. Hypertensive disorders of pregnancy, previously called adverse pregnancy outcomes, include gestational hypertension, preeclampsia, and eclampsia.

Pregnancy complications can adversely affect maternal cardiovascular health after delivery, Sammaritano noted, a fact borne out by cardiovascular health after a population-based retrospective maternal cohort study and a 2007 meta-analysis that found that a history of of preeclampsia the risk doubles. for venous thromboembolism, stroke and ischemic heart disease up to 15 years after pregnancy.

“It is always important to obtain a reproductive health history from patients with autoimmune diseases,” Sammaritano told Medscape Medical News in an interview. “This is an integral part of any medical history. In the usual setting, this includes not only pregnancy history, but also the use of contraception in women of childbearing age. Unplanned pregnancy can lead to adverse consequences in the context of an active or severe autoimmune disease or when teratogenic drugs are used.”

Pregnancy history can be a factor in a woman’s cardiovascular health more than 15 years after giving birth, even if a woman is no longer planning a pregnancy or is in menopause. “As such, this history is important in assessing each woman’s risk profile for cardiovascular disease, in addition to the usual traditional risk factors,” Sammaritano said.

“It is even more important for women with autoimmune diseases, who have been shown to already have an increased risk of cardiovascular disease independent of their pregnancy history, likely related to a chronic inflammatory state and other autoimmune-related factors such as the presence of antiphospholipid antibodies.” aPL) or use of corticosteroids.”

The timing of the disease’s onset is also an issue, she said. “For example, in patients with SLE, cardiovascular disease begins much earlier than in the general population,” says Sammaritano. “As a result, these patients likely need to be assessed for risk – both traditional and other risk factors – earlier than the general population, especially if an adverse obstetric history is present.”

At the younger end of the age continuum, women with autoimmune diseases, including SLE and antiphospholipid syndrome, who are pregnant should receive guideline-directed prophylaxis with low-dose aspirin preeclampsia, Sammaritano said. “Whether every patient with SLE needs this is still uncertain, but those with a history of kidney disease, hypertension or aPL antibody clearly do,” she added.

The evidence supporting hydroxychloroquine (HCQ) in these patients is controversial, but Sammaritano noted two meta-analyses, one in 2022 and the other in 2023, that found HCQ reduced the risk of preeclampsia in women.

“The clear benefit of HCQ in preventing maternal disease complications, including flares, means that we recommend it regardless of circumstances for all patients with SLE at baseline and during pregnancy (if tolerated),” said Sammaritano. “The benefit or optimal use of these medications in other autoimmune diseases is less studied and less certain.”

Sammaritano added in her presentation: ‘We really need better therapies and hopefully they are coming, but I think the message, especially for practicing rheumatologists and cardiologists, is to ask the question about the history of obstetrics. Many of us don’t. It doesn’t seem relevant at this point, but it is in terms of the patient’s long-term risk of cardiovascular disease.”

The arguments for treatment during pregnancy

Prophylaxis against pregnancy complications in patients with autoimmune disease may be feasible, told Taryn Youngstein, MBBS, rheumatologist and co-director of the Center of Excellence in Vasculitis Research, Imperial College London, London, England. Medscape Medical News after Sammaritano’s presentation. At the 2023 annual meeting of the American College of Rheumatology, her group reported the safety and effectiveness of continuing tocilizumab in pregnant women with Takayasu arteritis, a large vessel vasculitis that mainly affects women of childbearing age.

“What traditionally happens is you stop the biologic medication, especially before the third trimester because of safety and concerns that the monoclonal antibody is actively transported across the placenta, meaning the baby gets much more concentration of the drug than the mother ,” Youngstein said.

It’s a situation doctors should keep a close eye on, she said. “The mother donates their immune system to the baby, but they also donate medications.”

“In high-risk patients, we would share decision-making with the patient,” Youngstein continued. “We decided it was too much of a risk for us to stop the drug, so we continued the interleukin-6 (IL-6) inhibitor throughout the pregnancy.”

Youngstein’s group’s data showed that pregnant women with Takayasu arteritis who continued IL-6 inhibition therapy all achieved healthy births.

“We have shown that it is relatively safe to do that, but you have to be very careful when monitoring the baby,” she said. This includes not giving live vaccines to the child at birth because it will have a high degree of IL-6 inhibition, she said.

Sammaritano and Youngstein had no relevant financial relationships to disclose.