Cardiovascular Risks Associated With Pregnancy Among Women with Systemic Lupus Erythematosus Open Access

Angley, Meghan (Fall 2021)

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Systemic lupus erythematosus (SLE) primarily affects women during their reproductive years. It is three times as common among African American women compared to white women. Women may be at risk of poor birth outcomes even in the years before a clinical diagnosis of SLE. Women with SLE also have a higher incidence of cardiovascular disease (CVD) at younger ages. Adverse pregnancy outcomes have been associated with later CVD in the general population, but the relationship between pregnancy and CVD in women with SLE has not been examined. The goal of this dissertation was to characterize the associations between pregnancy and cardiovascular health among women with SLE, with a focus on African American women with SLE.


In Aim 1, we evaluated the association between SLE and preterm and small-for-gestational age (SGA) birth among African American women by timing of birth in relation to diagnosis. After adjusting for maternal age, education and parity, compared with the general population, women were at higher risk of giving birth to preterm or SGA infants within three years before their SLE diagnosis but even more so after their SLE diagnosis.

In Aim 2, we examined whether parous women with SLE were at a greater risk of hospitalization for CVD compared to nulligravid women with SLE. Our results suggested a modestly increased hazard of CVD among parous women with SLE compared with nulligravid women with SLE after adjusting for markers of SLE severity.

In Aim 3, we examined whether subclinical markers of cardiovascular health, specifically blood pressure, carotid intima media thickness (IMT) and arterial distensibility were associated with parity among African American women with SLE and without SLE. Parity was not associated with blood pressure or IMT among women with SLE, but distensibility was lower among parous women compared to nulliparous women with SLE. There was no association among women without SLE.

This work provides evidence for the need to monitor and coordinate care for all women with SLE, but especially parous women, in order to manage their risk for CVD.

Table of Contents

Chapter 1 Overview and Specific Aims. 1

Introduction. 1

Public Health Importance. 1

Specific Aims. 2

Data Sources. 3

Chapter 2 Background. 6

Description and Epidemiology of SLE.. 6

SLE and Birth Outcomes. 7

Adverse Birth Outcomes and Cardiovascular Disease. 11

SLE and Cardiovascular Health. 12

Pregnancy and Cardiovascular Disease in Women with SLE.. 13

Chapter 3 Adverse Perinatal Outcomes Before and After Diagnosis Among Women with Systemic Lupus Erythematosus. 17

Abstract 17

Introduction. 18

Methods. 19

Results. 22

Discussion. 24

Tables and Figures. 29

Appendix: Simulation accounting for covariance. 33

Chapter 4 Cardiovascular Disease After Delivery Among Women with Systemic Lupus Erythematosus. 36

Abstract 36

Introduction. 37

Methods. 38

Results. 42

Discussion. 44

Tables and Figures. 49

Appendix: Additional Tables. 53

Chapter 5 Blood Pressure, Carotid Intima Media Thickness, Distensibility and Parity Among African American Women with Systemic Lupus Erythematosus. 54

Abstract 54

Introduction. 55

Methods. 57

Results. 60

Discussion. 62

Tables. 66

Chapter 6 Conclusions, Impact & Future Research. 70

Summary of Findings. 70

Strengths and Limitations. 72

Public Health Impact 75

Future Research. 76

References. 79

Funding. 96

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