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Objectives Pregnancy outcomes of women with SLE are worse compared to those with other or no immune-mediated inflammatory diseases (IMID). Factors may include concomitant corticosteroid or other medication use and active disease in the peripartum period. Uptake of SLE treatments (eg. hydroxychloroquine), remain suboptimal during pregnancy. We examined medication use and maternal/neonatal outcomes in a contemporary, population-level, pregnancy-birth cohort.Methods The study population included all singleton pregnancies with 22+ weeks of gestation, between July 2008 and December 2024 in Alberta, Canada. Previously validated algorithms based on ICD-10 codes identified women with SLE and IMID. We compared maternal characteristics, comorbidities and neonatal outcomes between no IMID and SLE groups. Dispensation of SLE-related medication use during pregnancy was evaluated over time. Proportion of days covered (PDC) during pregnancy for each medication was calculated to estimate adherence. Logistic regression was used to calculate the odds of developing preterm labour when exposed to SLE-related medications after adjusting for maternal factors.Results Among 787,346 pregnancies of 474,197 women, 994 women had SLE and 786,352 had no IMID. Pregnant women with SLE were more likely to have renal disease (10.4%), pre-existing hypertension (23.5%), pre-eclampsia/eclampsia (9.9%) than those with no IMID [ table 1]. Neonates in mothers with SLE had more congenital anomalies (13%), were smaller for gestational age (16.1%) and had more NICU admissions (20.2%). Prescription dispensations in the SLE group included corticosteroids 21%, NSAIDs 5.5%, antimalarials 46.6%, and pregnancy safe DMARDs 9.5%. Mean PDC for anti-malarials increased from 60.6 (SD 30.3) to 72.2 (SD 27.4) between 2008-2016 and 2017-2024 [table 2]. In multivariable models, factors significantly associated with higher risk of preterm labour in women with SLE included: low PDC (< 40%) of anti-malarials (compared to high PDC (> 80%)); high PDC of corticosteroids (compared to no use); active disease, and pre-eclampsia/eclampsia [table 3].Abstract S16:01 Table 1–3Conclusions Pregnancy-safe medication use has increased over time but peripartum outcomes remain poor for women with SLE. Corticosteroid use continues to have a complex relationship with peripartum outcomes in this population. Adherence to anti-malarial use during pregnancy may improve outcomes . Further patient education and close disease monitoring in the peripartum period is recommended.