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Galli J, Loi E, Lazzaroni MG, Molinaro A, Andreoli L, Bendoni M, Moschetti L, Pedretti E, Visconti LM, Airò P, Franceschini F, Tincani A, Fazzi E. Neurodevelopmental profile in children born to mothers affected by systemic sclerosis. Early Hum Dev 2024; 191:105988. [PMID: 38531240 DOI: 10.1016/j.earlhumdev.2024.105988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 03/08/2024] [Accepted: 03/12/2024] [Indexed: 03/28/2024]
Abstract
BACKGROUND Systemic sclerosis (SSc) is a chronic immune-mediated connective tissue disease that can affect women of childbearing age. The long-term outcomes of their offspring remain poorly explored. Aim of this study was to detail the neurodevelopmental profile of children born to SSc mothers. METHODS Twenty children (mean age: 96 ± 4.32 months; 10 males) born to SSc mothers were enrolled. We collected data on clinical history, neurological examination, cognitive profile and adaptive behavior in all subjects. According to the chronological age, we also investigated quality of life, behavioral characteristics, psychological functioning and self-image. RESULTS All the children had normal neurological examination, cognitive profile and adaptive functioning, except for one (5 %) who suffered from Autism Spectrum Disorder. An important discrepancy was observed between parental and child opinion regarding the perception of quality of life, more compromised in the latter. We documented a risk for internalizing behavioral problems in 2 cases (10 %), for externalizing problems in 3 (15 %), for both in 1 (5 %) and for social and out-of-school activities in 5 (25 %). As regards psychological functioning, evaluated in 11 children, three (28 %) were at risk for anxiety, 1 (9 %) for depressive disorders and other 4 (36 %) for somatic disturbances. Emotional fragility and poor competence in metabolizing one's emotional experiences were observed in 9 out of the 13 subjects assessed (70 %). CONCLUSIONS Children born to SSc women exhibit normal cognitive and adaptive abilities but an increased vulnerability to psychopathological problems and fragility in social functioning. These observations might reflect that children need to feel mature to accept maternal chronic disease that, in turn, may hinder support for offspring's social and emotional development.
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Affiliation(s)
- Jessica Galli
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy; Unit of Child Neurology and Psychiatry, ASST Spedali Civili of Brescia, Brescia, Italy.
| | - Erika Loi
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy; Unit of Child Neurology and Psychiatry, ASST Spedali Civili of Brescia, Brescia, Italy.
| | - Maria Grazia Lazzaroni
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy; Rheumatology and Clinical Immunology Unit - ERN ReCONNET, ASST Spedali Civili of Brescia, Italy
| | - Anna Molinaro
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy; Unit of Child Neurology and Psychiatry, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Laura Andreoli
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy; Rheumatology and Clinical Immunology Unit - ERN ReCONNET, ASST Spedali Civili of Brescia, Italy
| | - Marzia Bendoni
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Liala Moschetti
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy; Rheumatology and Clinical Immunology Unit - ERN ReCONNET, ASST Spedali Civili of Brescia, Italy
| | - Eleonora Pedretti
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy; Rheumatology and Clinical Immunology Unit - ERN ReCONNET, ASST Spedali Civili of Brescia, Italy
| | | | - Paolo Airò
- Rheumatology and Clinical Immunology Unit - ERN ReCONNET, ASST Spedali Civili of Brescia, Italy
| | - Franco Franceschini
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy; Rheumatology and Clinical Immunology Unit - ERN ReCONNET, ASST Spedali Civili of Brescia, Italy
| | - Angela Tincani
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy; Rheumatology and Clinical Immunology Unit - ERN ReCONNET, ASST Spedali Civili of Brescia, Italy
| | - Elisa Fazzi
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy; Unit of Child Neurology and Psychiatry, ASST Spedali Civili of Brescia, Brescia, Italy
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Kawano Y, Kolstad KD, Li S, Simard JF, Chung L. Trends in adverse pregnancy outcomes among women with systemic sclerosis in the United States. Semin Arthritis Rheum 2023; 63:152252. [PMID: 37666113 DOI: 10.1016/j.semarthrit.2023.152252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Revised: 07/31/2023] [Accepted: 08/03/2023] [Indexed: 09/06/2023]
Abstract
OBJECTIVES We sought to examine temporal trends in adverse pregnancy outcomes among SSc pregnancies in a large nationwide sample. METHODS We used the National Inpatient Sample (NIS) database from 2000 - 2017 to derive national estimates of delivery-associated hospitalizations in the United States among patients with SSc. Each SSc delivery was matched to 100 non-SSc deliveries by age, delivery year, and race. We evaluated adverse pregnancy outcomes (APOs) including maternal and fetal death, cesarean delivery, hospital length of stay, preterm delivery, intrauterine growth restriction, and hypertensive disorders of pregnancy. We used multivariable regression models with an interaction term between SSc and year and adjusting for race, advanced maternal age, diabetes mellitus, and pre-existing hypertension to evaluate temporal trends in APOs among SSc and non-SSc deliveries. RESULTS From 2000 to 2017, there were 3740 delivery-associated hospitalizations for women with SSc. SSc was associated with an increased risk of all APOs compared to non-SSc deliveries. Fetal death declined in SSc deliveries from 49.0 per 1000 delivery-related admissions in 2000 - 2005 to 16.2 per 1000 in 2012 - 2017. There was a significant difference in trends for fetal death between SSc and non-SSc deliveries (p = 0.043), but the trends for other APOs did not differ between the two groups. CONCLUSIONS In this large nationwide sample, the risk of fetal death among women with SSc markedly improved over the past 18 years. The risk for other APOs remained high in SSc deliveries compared to non-SSc deliveries, and further studies are needed to determine what strategies can improve these outcomes.
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Affiliation(s)
- Yumeko Kawano
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Boston, MA, USA
| | - Kathleen D Kolstad
- Division of Rheumatology, University of California Los Angeles, Los Angeles, CA, USA
| | - Shufeng Li
- Department of Dermatology, Stanford University School of Medicine, Palo Alto, CA, USA; Department of Urology, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Julia F Simard
- Division of Immunology and Rheumatology, Stanford University School of Medicine, Palo Alto, CA, USA; Department of Epidemiology and Population Health, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Lorinda Chung
- Division of Immunology and Rheumatology, Stanford University School of Medicine, Palo Alto, CA, USA; Division of Rheumatology, Palo Alto VA Health Care System, Palo Alto, CA, USA.
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Shen G, Swaminathan M, Huang I, Louden D, Feterman D, Tahir MW, Singh N. Racial disparities in pregnancy outcomes among women with rheumatic diseases: A systematic literature review. Semin Arthritis Rheum 2023; 60:152193. [PMID: 36966601 PMCID: PMC10148907 DOI: 10.1016/j.semarthrit.2023.152193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 03/14/2023] [Indexed: 04/03/2023]
Abstract
OBJECTIVE There is a limited understanding of racial disparities in adverse pregnancy outcomes (APO) among women with rheumatic diseases. The aim of our study was to conduct a systematic literature review to evaluate the impact of race on APO in women with rheumatic diseases. METHODS Databases were searched to find reports of APO stratified by race among women with rheumatic diseases. The initial searches were conducted in July 2020 and updated in March 2021. Of the final included articles, the full text was reviewed, and data was extracted from each study using a standard data abstraction form. RESULTS Ten studies with a total of 39,720 patients met our eligibility criteria. There was a greater propensity for APO in racial minorities with rheumatic diseases compared to their White counterparts. Among women with systemic lupus erythematosus (SLE), Black women had the highest odds of APOs, particularly those with a concomitant diagnosis of antiphospholipid syndrome. Pooled meta-analysis could not be done due to multiple factors, including heterogeneity between studies. CONCLUSION Racial minorities with rheumatic diseases are more prone to APO compared to their White counterparts. One limitation is the lack of standardized criteria for APO, which prohibited direct comparison between studies. There is also a paucity of data looking at APOs among women with rheumatic diseases other than SLE. Further research is needed to explore the drivers of these racial disparities to guide targeted solutions for those in the greatest need.
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Affiliation(s)
- Gloria Shen
- University of Washington, Seattle, WA, United States
| | - Maya Swaminathan
- Division of Rheumatology, Department of Internal Medicine, University of Washington, Seattle, WA, United States
| | - Irvin Huang
- Division of Rheumatology, Department of Internal Medicine, University of Washington, Seattle, WA, United States
| | - Diana Louden
- University Libraries, University of Washington, Seattle, WA, United States
| | - Dominique Feterman
- Division of Rheumatology, Department of Internal Medicine, University of Washington, Seattle, WA, United States
| | - Muhammad Waqas Tahir
- Department of Hospital Internal Medicine, Mayo Clinic, Jacksonville, FL, United States
| | - Namrata Singh
- Division of Rheumatology, Department of Internal Medicine, University of Washington, Seattle, WA, United States.
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Andreoli L, Chighizola CB, Iaccarino L, Botta A, Gerosa M, Ramoni V, Tani C, Bermas B, Brucato A, Buyon J, Cetin I, Chambers CD, Clowse MEB, Costedoat-Chalumeau N, Cutolo M, De Carolis S, Dolhain R, Fazzi EM, Förger F, Giles I, Haase I, Khamashta M, Levy RA, Meroni PL, Mosca M, Nelson-Piercy C, Raio L, Salmon J, Villiger P, Wahren-Herlenius M, Wallenius M, Zanardini C, Shoenfeld Y, Tincani A. Immunology of pregnancy and reproductive health in autoimmune rheumatic diseases. Update from the 11 th International Conference on Reproduction, Pregnancy and Rheumatic Diseases. Autoimmun Rev 2023; 22:103259. [PMID: 36549355 DOI: 10.1016/j.autrev.2022.103259] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 12/18/2022] [Indexed: 12/24/2022]
Abstract
Autoimmune rheumatic diseases (ARD) can affect women and men during fertile age, therefore reproductive health is a priority issue in rheumatology. Many topics need to be considered during preconception counselling: fertility, the impact of disease-related factors on pregnancy outcomes, the influence of pregnancy on disease activity, the compatibility of medications with pregnancy and breastfeeding. Risk stratification and individualized treatment approach elaborated by a multidisciplinary team minimize the risk of adverse pregnancy outcomes (APO). Research has been focused on identifying biomarkers that can be predictive of APO. Specifically, preeclampsia and hypertensive disorders of pregnancy tend to develop more frequently in women with ARD. Placental insufficiency can lead to intrauterine growth restriction and small-for-gestational age newborns. Such APO have been shown to be associated with maternal disease activity in different ARD. Therefore, a key message to be addressed to the woman wishing for a pregnancy and to her family is that treatment with compatible drugs is the best way to ensure maternal and fetal wellbeing. An increasing number of medications have entered the management of ARD, but data about their use in pregnancy and lactation are scarce. More information is needed for most biologic drugs and their biosimilars, and for the so-called small molecules, while there is sufficient evidence to recommend the use of TNF inhibitors if needed for keeping maternal disease under control. Other issues related to the reproductive journey have emerged as "unmet needs", such as sexual dysfunction, contraception, medically assisted reproduction techniques, long-term outcome of children, and they will be addressed in this review paper. Collaborative research has been instrumental to reach current knowledge and the future will bring novel insights thanks to pregnancy registries and prospective studies that have been established in several Countries and to their joint efforts in merging data.
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Affiliation(s)
- Laura Andreoli
- Rheumatology and Clinical Immunology Unit, ASST Spedali Civili, Brescia, Italy; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Cecilia B Chighizola
- Paediatric Rheumatology Unit, ASST G. Pini & CTO, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Luca Iaccarino
- Rheumatology Unit, Department of Medicine-DIMED, University of Padova, Padova, Italy
| | - Angela Botta
- Department of Obstetrics, Gynaecology and Pediatrics, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Maria Gerosa
- Division of Clinical Rheumatology, ASST Gaetano Pini-CTO, Research Center for Adult and Pediatric Rheumatic Diseases, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Véronique Ramoni
- Medicina Generale Lodi, ASST Lodi-Ospedale Maggiore, Lodi, Italy
| | - Chiara Tani
- Rheumatology Unit, Azienda Ospedaliero Universitaria Pisana and Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | | | - Antonio Brucato
- Internal Medicine, Fatebenefratelli Hospital, Milan, Italy; Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
| | - Jill Buyon
- Division of Rheumatology, New York University Grossman School of Medicine, New York, NY, USA
| | - Irene Cetin
- Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy; Department of Woman, Mother and Child, Luigi Sacco and Vittore Buzzi Children Hospitals, ASST Fatebenefratelli-Sacco, Milan, Italy
| | - Christina D Chambers
- Department of Pediatrics, University of California, Herbert Wertheim School of Public Health and Longevity Science, University of California, San Diego, La Jolla, CA, USA
| | - Megan E B Clowse
- Division of Rheumatology & Immunology, Duke University School of Medicine, Durham, NC, USA
| | - Nathalie Costedoat-Chalumeau
- Internal Medicine Department, Cochin Hospital, Referral center for rare autoimmune and systemic diseases, Université de Paris, CRESS, INSERM, INRA, Paris, France
| | - Maurizio Cutolo
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal M edicine, University of Genoa, IRCSS San Martino Polyclinic, Genoa, Italy
| | - Sara De Carolis
- Department of Obstetrics, Gynaecology and Pediatrics, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Radboud Dolhain
- Department of Rheumatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Elisa M Fazzi
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy; Child Neurology and Psychiatry Unit, ASST Spedali Civili, Brescia, Italy
| | - Frauke Förger
- Department of Rheumatology and Immunology, University Hospital (Inselspitaland University of Bern, Bern, Switzerland
| | - Ian Giles
- Centre for Rheumatology, Department of Inflammation, Division of Medicine, University College London, Department of rheumatology, University College London Hospital, London, UK
| | - Isabell Haase
- Department for Rheumatology and Hiller Research Institute, Heinrich-Heine-University, Düsseldorf, Germany
| | - Munther Khamashta
- Women & Children's Health, King's College, London, UK; GlaxoSmithKline Global Medical Expert, Dubai, United Arab Emirates
| | - Roger A Levy
- Universidade do Estado de Rio de Janeiro, Rio de Janeiro, Brazil; GlaxoSmithKline Global Medical Expert, Collegeville, PA, USA
| | - Pier Luigi Meroni
- IRCCS Istituto Auxologico Italiano, Immunorheumatology Research Laboratory, Milan, Italy
| | - Marta Mosca
- Rheumatology Unit, Azienda Ospedaliero Universitaria Pisana and Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | | | - Luigi Raio
- Department of Obstetrics and Gynaecology, University Hospital (Inselspitaland University of Bern, Bern, Switzerland
| | - Jane Salmon
- Division of Rheumatology, Department of Medicine, Hospital for Special Surgery and Weill Cornell Medicine, New York, NY, USA
| | - Peter Villiger
- Rheumatology and Clinical Immunology, Medical Center Monbijou, Bern, Switzerland
| | - Marie Wahren-Herlenius
- Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Marianne Wallenius
- National Advisory Unit on Pregnancy and Rheumatic Diseases, St Olavs Hospital, Trondheim, University Hospital and Institute of Neuromedicine and Movement Science, NTNU, Norwegian University of Science and Technology, Trondheim, Norway
| | - Cristina Zanardini
- Department of Obstetrics and Gynecology, ASST Spedali Civili, Brescia, Italy
| | - Yehuda Shoenfeld
- Sackler Faculty of Medicine, Ariel University, Ariel, Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel
| | - Angela Tincani
- Rheumatology and Clinical Immunology Unit, ASST Spedali Civili, Brescia, Italy; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy.
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5
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Deshauer S, Junek M, Baron M, Beattie KA, Larché MJ. Effect of pregnancy on scleroderma progression. JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2023; 8:27-30. [PMID: 36743807 PMCID: PMC9896202 DOI: 10.1177/23971983221101311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 04/07/2022] [Indexed: 11/15/2022]
Abstract
Objective To explore the trajectory of scleroderma disease activity in women who experienced a pregnancy after systemic sclerosis diagnosis compared to nulliparous women. Methods We analyzed data from the Canadian Scleroderma Research Group registry by identifying nulliparous women and women with ⩾1 pregnancy after systemic sclerosis diagnosis. Patient characteristics were compared between groups at registry entry. Controlling for age, smoking, and time since systemic sclerosis diagnosis, generalized estimating equations tested the effect of pregnancy on force vital capacity, diffusing capacity of the lungs for carbon monoxide, right ventricular systolic pressure, glomerular filtration rate, antibody status, active digital ulcers, physician global assessment of activity, and severity over 9 years. Results At registry entry, numbers of women in the nulliparous and pregnancy after systemic sclerosis diagnosis groups were 153 and 45, respectively. Corresponding numbers at 6 and 9 years were 48 and 21, and 18 and 9, respectively. The prevalence of anti-topoisomerase positivity was 18.3% in nulliparous and 12.5% in pregnancy after systemic sclerosis diagnosis. Baseline differences included mean (Standard deviation) age of diagnosis (nulliparous: 38.8 (14.0), pregnancy after systemic sclerosis diagnosis: 22.6 (6.8) years, p < 0.001), disease duration (nulliparous: 9.6 (8.9), pregnancy after systemic sclerosis diagnosis: 21.9 (9.6) years; p < 0.001), and inflammatory arthritis (nulliparous: 41 (28%), pregnancy after systemic sclerosis diagnosis: 22 (49%), p = 0.009). There were no significant differences between groups in the change of any outcomes over time. Conclusion Results demonstrated that having ⩾1 pregnancy after systemic sclerosis diagnosis did not appear to significantly impact long-term renal, respiratory, or global function outcomes. While this offers a hopeful message to systemic sclerosis patients planning a pregnancy, physicians and patients should remain vigilant for potential post-partum complications.
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Affiliation(s)
- Siobhan Deshauer
- Division of Rheumatology, Department of
Medicine, McMaster University, Hamilton, ON, Canada
- Siobhan Deshauer, Division of Rheumatology,
Department of Medicine, McMaster University, 702-25 Charlton Avenue East,
Hamilton, ON L8N 1Y2, Canada.
| | - Mats Junek
- Division of Rheumatology, Department of
Medicine, McMaster University, Hamilton, ON, Canada
| | - Murray Baron
- Division of Rheumatology, Jewish
General Hospital, Department of Medicine, McGill University, Québec, QC,
Canada
| | - Karen A Beattie
- Division of Rheumatology, Department of
Medicine, McMaster University, Hamilton, ON, Canada
| | - Margaret J Larché
- Division of Rheumatology, Department of
Medicine, McMaster University, Hamilton, ON, Canada
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Systemic sclerosis and pregnancy outcomes: a retrospective study from a single center. Arthritis Res Ther 2022; 24:91. [PMID: 35477585 PMCID: PMC9044598 DOI: 10.1186/s13075-022-02783-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 04/19/2022] [Indexed: 11/23/2022] Open
Abstract
Background Pregnancy in systemic sclerosis (SSc) patients is no more an infrequent event as it used to be, but literature data on pregnancy outcomes in women with SSc are scarce. The rate of preterm deliveries and intrauterine growth restriction (IUGR) seems to be increased, while the risk of miscarriages is controversial. Moreover, no study compared pregnancy outcomes in SSc with antiphospholipid syndrome (APS) and systemic lupus erythematosus (SLE). We performed a retrospective study to compare the pregnancy and disease outcomes of women with SSc with a cohort of age-matched women with systemic lupus erythematosus (SLE), antiphospholipid syndrome (APS), and healthy controls (HC). Methods A total of 154 pregnancies from SSc, SLE, APS patients, and HC were prospectively followed at the High-Risk Pregnancy Unit of our center from 2008 to 2019. The primary outcome was a composite endpoint of miscarriages, fetal deaths, intrauterine growth restriction (IUGR), preeclampsia, neonatal deaths, preterm birth, and small-for-gestational-age (SGA) newborns. Single adverse pregnancy outcomes (APO) represented secondary endpoints. SSc activity variations in relation to pregnancy were assessed. Results The risk of APO was significantly higher in SSc patients compared to HC (60.6% vs 10.0%; OR = 14.42; 95% CI 3.70–56.18, p = 0.001) and SLE patients (60.6% vs 37.5%; OR = 3.56; 95% CI 1.29–9.83, p = 0.014). Compared to HC, women with SSc had an increased frequency of first trimester miscarriage (15% vs 0 %; p = 0.016), preeclampsia (12% vs 0%, p = 0.038), and SGA newborns (21.2% vs 0%; p = 0.003). Preterm deliveries were more frequent in SSc pregnancies in comparison with HC (24.2% vs 5%; OR = 6.08; 95% CI 1.19–31.02, p = 0.036) and SLE patients (24.2% vs 7.5%, OR = 5.68; 95% CI 1.1–29.38, p = 0.038). Disease remained stable in all SSc patients during pregnancy and up to 1 year after delivery. Conclusions We found an increased risk of APO in our SSc cohort in comparison with HC (with higher rates of miscarriages, preeclampsia, SGA newborns, and preterm deliveries) and SLE patients (presenting a higher rate of preterm deliveries). High-risk multidisciplinary management of SSc pregnant women is highly recommended.
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Nalli C, Manfredi L, Fredi M, Crisafulli F, Bertocchi S, Khizroeva J, Bitsadze V, Makatsariya A, Zatti S, Andreoli L, Franceschini F, Tincani A. Managing puerperium in patients with systemic autoimmune diseases: an update. Expert Rev Clin Immunol 2022; 18:391-399. [PMID: 35255770 DOI: 10.1080/1744666x.2022.2050216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Puerperium is a critical period for patients affected by autoimmune rheumatic diseases for the risk of disease's flares and difficulties in treating lactating mothers. We want to summarize the literature data about psychological and pharmacological management of these patients and possible risk factors of disease's flares. AREAS COVERED We made a narrative review on recent studies about puerperium in rheumatic autoimmune diseases patients. EXPERT OPINION The physicians involved in management of patients during puerperium and in the follow-up of babies need to agree on maternal treatment because they need to reassure mothers about the safety of the prescribed medications. Furthermore, women with rheumatic diseases could present some musculoskeletal limitations and psychological problems, such as postpartum depression, which can lead to a sense of inadequacy to the mother's task. Families and physicians should be aware of these possible complications and support the new mothers providing correct counseling and practical help.
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Affiliation(s)
- Cecilia Nalli
- Rheumatology and Clinical Immunology Unit, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Lucia Manfredi
- Department of Clinical and Molecular Sciences, Polytechnic University of Marche, Ancona, Italy
| | - Micaela Fredi
- Rheumatology and Clinical Immunology Unit, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Francesca Crisafulli
- Rheumatology and Clinical Immunology Unit, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Stefania Bertocchi
- Rheumatology and Clinical Immunology Unit, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Jamilya Khizroeva
- Department of Obstetrics and Gynecology, I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation, Moscow, Russian Federation
| | - Victoria Bitsadze
- Department of Obstetrics and Gynecology, I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation, Moscow, Russian Federation
| | - Alexander Makatsariya
- Department of Obstetrics and Gynecology, I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation, Moscow, Russian Federation
| | - Sonia Zatti
- Rheumatology and Clinical Immunology Unit, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Laura Andreoli
- Rheumatology and Clinical Immunology Unit, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Franco Franceschini
- Rheumatology and Clinical Immunology Unit, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Angela Tincani
- Rheumatology and Clinical Immunology Unit, ASST Spedali Civili di Brescia, Brescia, Italy
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Lazzaroni MG, Crisafulli F, Moschetti L, Semeraro P, Cunha AR, Neto A, Lojacono A, Ramazzotto F, Zanardini C, Zatti S, Airò P, Tincani A, Franceschini F, Andreoli L. Reproductive Issues and Pregnancy Implications in Systemic Sclerosis. Clin Rev Allergy Immunol 2022; 64:321-342. [PMID: 35040084 DOI: 10.1007/s12016-021-08910-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/28/2021] [Indexed: 12/26/2022]
Abstract
Systemic sclerosis (SSc) is a rare systemic autoimmune disease that can influence reproductive health. SSc has a strong female predominance, and the disease onset can occur during fertility age in almost 50% of patients. Preconception counseling, adjustment of treatment, and close surveillance during pregnancy by a multidisciplinary team, are key points to minimize fetal and maternal risks and favor successful pregnancy outcomes. The rates of spontaneous pregnancy losses are comparable to those of the general obstetric population, except for patients with diffuse cutaneous SSc and severe internal organ involvement who may carry a higher risk of abortion. Preterm birth can frequently occur in women with SSc, as it happens in other rheumatic diseases. Overall disease activity generally remains stable during pregnancy, but particular attention should be paid to women with major organ disease, such as renal and cardiopulmonary involvement. Women with such severe involvement should be thoroughly informed about the risks during pregnancy and possibly discouraged from getting pregnant. A high frequency of sexual dysfunction has been described among SSc patients, both in females and in males, and pathogenic mechanisms of SSc may play a fundamental role in determining this impairment. Fertility is overall normal in SSc women, while no studies in the literature have investigated fertility in SSc male patients. Nevertheless, some considerations regarding the impact of some immunosuppressive drugs should be done with male patients, referring to the knowledge gained in other rheumatic diseases.
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Affiliation(s)
- Maria-Grazia Lazzaroni
- Rheumatology and Clinical Immunology Unit, Department of Clinical and Experimental Sciences, ASST Spedali Civili of Brescia, University of Brescia, Brescia, Italy
| | - Francesca Crisafulli
- Rheumatology and Clinical Immunology Unit, Department of Clinical and Experimental Sciences, ASST Spedali Civili of Brescia, University of Brescia, Brescia, Italy
| | - Liala Moschetti
- Rheumatology and Clinical Immunology Unit, Department of Clinical and Experimental Sciences, ASST Spedali Civili of Brescia, University of Brescia, Brescia, Italy
| | - Paolo Semeraro
- Rheumatology and Clinical Immunology Unit, Department of Clinical and Experimental Sciences, ASST Spedali Civili of Brescia, University of Brescia, Brescia, Italy
| | - Ana-Rita Cunha
- Rheumatology Department, Centro Hospitalar do Baixo Vouga, Aveiro, Portugal
| | - Agna Neto
- Rheumatology Department, Hospital Central do Funchal, Madeira, Portugal
| | - Andrea Lojacono
- Obstetrics and Gynaecology Unit, ASST Garda Ospedale of Desenzano, Desenzano del Garda, Italy
| | | | - Cristina Zanardini
- Obstetrics and Gynaecology Unit, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Sonia Zatti
- Obstetrics and Gynaecology Unit, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Paolo Airò
- Rheumatology and Clinical Immunology Unit, Department of Clinical and Experimental Sciences, ASST Spedali Civili of Brescia, University of Brescia, Brescia, Italy
| | - Angela Tincani
- Rheumatology and Clinical Immunology Unit, Department of Clinical and Experimental Sciences, ASST Spedali Civili of Brescia, University of Brescia, Brescia, Italy.,I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russia
| | - Franco Franceschini
- Rheumatology and Clinical Immunology Unit, Department of Clinical and Experimental Sciences, ASST Spedali Civili of Brescia, University of Brescia, Brescia, Italy
| | - Laura Andreoli
- Rheumatology and Clinical Immunology Unit, Department of Clinical and Experimental Sciences, ASST Spedali Civili of Brescia, University of Brescia, Brescia, Italy.
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9
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Colbenson GA, Rose CH, Ernste FC, Ryu JH. Successful Pregnancy Outcome With Connective Tissue Disease-Associated Interstitial Lung Disease: A Case Series. J Clin Rheumatol 2022; 28:e305-e307. [PMID: 33657592 DOI: 10.1097/rhu.0000000000001725] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
| | | | | | - Jay H Ryu
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
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10
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Yang L, Sun W, Yao Q. Management of pregnancy with diffuse cutaneous systemic sclerosis: a case report and literature review. J Int Med Res 2021; 49:3000605211060160. [PMID: 34851779 PMCID: PMC8647261 DOI: 10.1177/03000605211060160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Diffuse cutaneous systemic sclerosis may occur in women of childbearing age. Pregnancies in this population are associated with a markedly increased risk of adverse obstetric and maternal outcomes even before the onset of symptoms related to sclerosis. We report a case involving the management and outcome of pregnancy in a 30-year-old woman with diffuse cutaneous systemic sclerosis. The course of her pregnancy was good and was assisted by a group consultation including obstetricians and rheumatologists. Vaginal delivery was the patient’s preferred choice because she had irregular skin tightness in her lower abdominal skin. She underwent induction of labor and combined spinal-epidural analgesia, and successfully delivered. Importantly, these pregnancies need to be planned, where possible, to allow the opportunity to counsel women and their partners in advance and to decrease any risks. These pregnancies should be considered high risk, and they require close antenatal monitoring and good supervision from an expert multidisciplinary team experienced in high-risk pregnancies. The management of delivery for patients with cutaneous systemic sclerosis is challenging, and vaginal delivery with labor analgesia is an alternative option to cesarean section.
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Affiliation(s)
- Lingyun Yang
- Department of Gynecology and Obstetrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
| | - Weiwei Sun
- Department of Gynecology and Obstetrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
| | - Qiang Yao
- Department of Gynecology and Obstetrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
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11
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Moraes DA, Oliveira MC. Life after Autologous Hematopoietic Stem Cell Transplantation for Systemic Sclerosis. J Blood Med 2021; 12:951-964. [PMID: 34785969 PMCID: PMC8590726 DOI: 10.2147/jbm.s338077] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 10/26/2021] [Indexed: 12/29/2022] Open
Abstract
Stem cell transplantation has been investigated as treatment for severe and progressive systemic sclerosis (SSc) for the past 25 years. To date, more than 1000 SSc patients have been transplanted worldwide. Overall and event-free survival have increased over the years, reflecting stricter patient selection criteria and better clinical management strategies. This review addresses long-term outcomes of transplanted SSc patients, considering phase I/II and randomized clinical trials, as well as observational studies and those assessing specific aspects of the disease. Clinical outcomes are discussed comparatively between studies, highlighting advances, drawbacks and controversies in the field. Areas for future development are also discussed.
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Affiliation(s)
- Daniela A Moraes
- Division of Clinical Immunology, Department of Internal Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Maria Carolina Oliveira
- Center for Cell-Based Therapy, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
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12
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Braun J, Balbir-Gurman A, Toledano K, Tavor Y, Braun-Moscovici Y. Favourable outcome of planned pregnancies in systemic sclerosis patients during stable disease. Scand J Rheumatol 2021; 51:513-519. [PMID: 34637666 DOI: 10.1080/03009742.2021.1964178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Objective: Studies evaluating pregnancy outcomes in systemic sclerosis (SSc) are limited. SSc is associated with maternal complications and adverse neonatal outcomes. This study investigated the impact of disease stage (stable vs active) on the maternal and neonatal outcomes of pregnancies of patients followed at an Israeli medical centre.Method: The charts of 354 SSc female patients followed during 2003-2020 were reviewed. Data on clinical and laboratory features, number of pregnancies close to SSc diagnosis, and maternal and neonatal outcomes were analysed. Patients were divided into a stable disease and an active/early disease group.Results: The active/early disease group included 26 patients [19 diffuse SSc (dSSc)], with 38 pregnancies. Median disease duration was 1 year, except for four patients who were first diagnosed during pregnancy. SSc was exacerbated in all patients during pregnancy or shortly after delivery [skin, lung, and heart involvement in dSSc; severe vasculopathy in limited SSc patients]. Six patients had hypertensive disorders of pregnancy; four pregnancies ended with foetal death. Thirty-three children were born, 60% with intrauterine growth retardation (IUGR)/low birthweight (LBW). The stable disease group included 19 patients, including seven with previously active disease, now stabilized (five dSSc), and 32 pregnancies. All pregnancies were planned and monitored closely. Disease remained stable in all patients. Four patients had hypertensive disorders of pregnancy; 12/29 newborns had LBW (41%).Conclusion: Active maternal disease during pregnancy poses an increased risk of SSc aggravation. The maternal and neonatal outcomes in planned pregnancy during stable disease are favourable. IUGR/LBW is common among neonates, even in stable disease.
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Affiliation(s)
- J Braun
- Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - A Balbir-Gurman
- Rappaport Faculty of Medicine, B Shine Rheumatology Institute, Rambam Health Care Campus, Technion-Israeli Institute of Technology, Haifa, Israel
| | - K Toledano
- Rappaport Faculty of Medicine, B Shine Rheumatology Institute, Rambam Health Care Campus, Technion-Israeli Institute of Technology, Haifa, Israel
| | - Y Tavor
- Rappaport Faculty of Medicine, B Shine Rheumatology Institute, Rambam Health Care Campus, Technion-Israeli Institute of Technology, Haifa, Israel
| | - Y Braun-Moscovici
- Rappaport Faculty of Medicine, B Shine Rheumatology Institute, Rambam Health Care Campus, Technion-Israeli Institute of Technology, Haifa, Israel
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13
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Motta F, Codullo V, Ramoni V, Cesari S, Ferrario G, Fiandrino G, Beneventi F, Rampello S, Johnsson H, Montecucco C, Graham GJ. Role of placental inflammatory mediators and growth factors in patients with rheumatic diseases with a focus on systemic sclerosis. Rheumatology (Oxford) 2021; 60:3307-3316. [PMID: 33313931 PMCID: PMC8516508 DOI: 10.1093/rheumatology/keaa782] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 10/19/2020] [Indexed: 12/16/2022] Open
Abstract
Objectives Pregnancy in SSc is burdened with an increased risk of obstetric complications. Little is known about the underlying placental alterations. This study aimed to better understand pathological changes and the role of inflammation in SSc placentas. Leucocyte infiltration, inflammatory mediators and atypical chemokine receptor 2 (ACKR2) expression in SSc placentas were compared with those in other rheumatic diseases (ORD) and healthy controls (HC). Methods A case–control study was conducted on eight pregnant SSc patients compared with 16 patients with ORD and 16 HC matched for gestational age. Clinical data were collected. Placentas were obtained for histopathological analysis and immunohistochemistry (CD3, CD20, CD11c, CD68, ACKR2). Samples from four SSc, eight ORD and eight HC were analysed by qPCR for ACKR2 expression and by multiplex assay for cytokines, chemokines and growth factors involved in angiogenesis and inflammation. Results The number of placental CD3, CD68 and CD11 cells was significantly higher in patients affected by rheumatic diseases (SSc+ORD) compared with HC. Hepatocyte growth factor was significantly increased in the group of rheumatic diseases patients (SSc+ORD) compared with HC, while chemokine (C-C motif) ligand 5 (CCL5) was significantly higher in SSc patients compared with ORD and HC. CCL5 levels directly correlated with the number of all local inflammatory cells and higher levels were associated with histological villitis. Conclusions Inflammatory alterations characterize placentas from rheumatic disease patients and could predispose to obstetric complications in these subjects.
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Affiliation(s)
- Francesca Motta
- Institute of Infection, Immunity & Inflammation, College of Medical and Veterinary Life Sciences, University of Glasgow, Glasgow, UK.,Division of Rheumatology, Fondazione IRCCS Policlinico San Matteo and University of Pavia
| | - Veronica Codullo
- Division of Rheumatology, Fondazione IRCCS Policlinico San Matteo and University of Pavia
| | - Véronique Ramoni
- Division of Rheumatology, Fondazione IRCCS Policlinico San Matteo and University of Pavia
| | - Stefania Cesari
- Unit of Anatomic Pathology, Department of Molecular Medicine, Fondazione IRCCS Policlinico San Matteo
| | | | - Giacomo Fiandrino
- Unit of Anatomic Pathology, Department of Molecular Medicine, Fondazione IRCCS Policlinico San Matteo
| | - Fausta Beneventi
- Division of Obstetrics and Gynaecology, Fondazione IRCCS Policlinico San Matteo and University of Pavia, Pavia
| | - Stefania Rampello
- Division of Obstetrics and Gynaecology, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Hanna Johnsson
- Institute of Infection, Immunity & Inflammation, College of Medical and Veterinary Life Sciences, University of Glasgow, Glasgow, UK
| | | | - Gerard J Graham
- Institute of Infection, Immunity & Inflammation, College of Medical and Veterinary Life Sciences, University of Glasgow, Glasgow, UK
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14
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Hachulla E, Agard C, Allanore Y, Avouac J, Bader-Meunier B, Belot A, Berezne A, Bouthors AS, Condette-Wojtasik G, Constans J, De Groote P, Diot E, Dumas F, Jego P, Joly F, Launay D, Le Guern V, Le Quintrec JS, Lescaille G, Meune C, Moulin B, Nguyen C, Omeish N, Pene F, Richard MA, Rochefort J, Roren A, Sitbon O, Sobanski V, Truchetet ME, Mouthon L. French recommendations for the management of systemic sclerosis. Orphanet J Rare Dis 2021; 16:322. [PMID: 34304732 PMCID: PMC8310704 DOI: 10.1186/s13023-021-01844-y] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/26/2021] [Indexed: 12/13/2022] Open
Abstract
Systemic sclerosis (SSc) is a generalized disease of the connective tissue, arterioles, and microvessels, characterized by the appearance of fibrosis and vascular obliteration. There are two main phenotypical forms of SSc: a diffuse cutaneous form that extends towards the proximal region of the limbs and/or torso, and a limited cutaneous form where the cutaneous sclerosis only affects the extremities of the limbs (without passing beyond the elbows and knees). There also exists in less than 10% of cases forms that never involve the skin. This is called SSc sine scleroderma. The prognosis depends essentially on the occurrence of visceral damage and more particularly interstitial lung disease (which is sometimes severe), pulmonary arterial hypertension, or primary cardiac damage, which represent the three commonest causes of mortality in SSc. Another type of involvement with poor prognosis, scleroderma renal crisis, is rare (less than 5% of cases). Cutaneous extension is also an important parameter, with the diffuse cutaneous forms having less favorable prognosis.
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Affiliation(s)
- Eric Hachulla
- Service de Médecine Interne et Immunologie Clinique, Centre de Référence Des Maladies Autoimmunes Systémiques Rares du Nord et Nord-Ouest de France (CeRAINO), Univ. Lille, Inserm, CHU Lille, U1286 - INFINITE - Institute for Translational Research in Inflammation, 59000, Lille, France.
| | - Christian Agard
- Internal Medicine, Nantes University Hospital, University of Nantes, Nantes, France
| | - Yannick Allanore
- Rheumatology Department, Hôpital Cochin, AP-HP, Université de Paris, Paris, France
| | - Jerome Avouac
- Rheumatology Department, Hôpital Cochin, AP-HP, Université de Paris, Paris, France
| | - Brigitte Bader-Meunier
- Department of Pediatric Immunology and Rheumatology; Hospital Necker, APHP, Paris, France
| | - Alexandre Belot
- Pediatric Nephrology, Rheumatology, Dermatology, HFME, Hospices Civils de Lyon, Bron, France
| | - Alice Berezne
- Department of Internal Medicine, CHR Annecy-Genevois, Annecy, France
| | - Anne-Sophie Bouthors
- Anaesthesia Intensive Care Unit, Jeanne de Flandre Women Hospital, Academic Hospital, ULR 7365 - GRITA - Groupe de Recherche Sur Les Formes Injectables Et Les Technologies Associées, University Lille, Lille, France
| | - Geraldine Condette-Wojtasik
- Service de Médecine Interne et Immunologie Clinique, Centre de Référence Des Maladies Autoimmunes Systémiques Rares du Nord et Nord-Ouest de France (CeRAINO), Univ. Lille, Inserm, CHU Lille, U1286 - INFINITE - Institute for Translational Research in Inflammation, 59000, Lille, France
| | - Joël Constans
- Vascular Medicine Department, Bordeaux University Hospital Centre, Saint André Hospital, FCRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists) PeripherAL Artery DIsease Network (PALADIN), Bordeaux, France
| | - Pascal De Groote
- Cardiology Department, Lung-Heart Institute, CHU de Lille, 59000, Lille, France
| | | | - Florence Dumas
- Emergency Department, Cochin Hospital, Paris University, Paris, France
| | - Patrick Jego
- Internal Medicine and Clinical Immunology Unit, CHU Rennes, Rennes, France
| | - Francisca Joly
- Department of Gastroenterology, IBD and Nutrition Support, Beaujon Hospital, INSERM UMRS-1149, Assistance Publique-Hôpitaux de Paris, University of Paris, Clichy, France
| | - David Launay
- Service de Médecine Interne et Immunologie Clinique, Centre de Référence Des Maladies Autoimmunes Systémiques Rares du Nord et Nord-Ouest de France (CeRAINO), Univ. Lille, Inserm, CHU Lille, U1286 - INFINITE - Institute for Translational Research in Inflammation, 59000, Lille, France
| | - Veronique Le Guern
- Service de Médecine Interne, Centre de Référence Maladies Autoimmunes Systémiques Rares D'Ile de France, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (AP-HP), APHP-CUP, Hôpital Cochin, Université de Paris, 75014, Paris, France
| | | | - Geraldine Lescaille
- Centre d'Immunologie et Maladies Infectieuses (CIMI-Paris), Department of Odontology, Paris Diderot/Paris 07, Sorbonne Paris Cité, AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Christophe Meune
- Cardiology Department, Hôpital Avicenne, AP-HP, Université de Paris, Paris, France
| | - Bruno Moulin
- Department of Nephrology and Kidney Transplantation, Nouvel Hôpital Civil, University Hospitals of Strasbourg, Strasbourg, France
| | - Christelle Nguyen
- Physical Medicine and Rehabilitation Department, Hôpital Cochin, AP-HP, Université de Paris, Paris, France
| | - Nadine Omeish
- Oral and Dental Medicine, Hôpital Pitié-Salpêtrière, APHP, Université de Paris, Paris, France
| | - Frederic Pene
- Medical Intensive Care Unit, Hôpital Cochin, AP-HP. Centre & Université de Paris, Paris, France
| | - Marie-Aleth Richard
- Department of Dermatology, Timone Hospital, University Hospital of Marseille, Marseille, France
| | - Juliette Rochefort
- Oral and Dental Medicine, Hôpital Pitié-Salpêtrière, APHP, Université de Paris, Paris, France
| | - Alexandra Roren
- AP-HP Cochin Hospital, Université Paris Descartes Sorbonne Paris Cité, INSERM U1153, Paris, France
| | - Olivier Sitbon
- Assistance Publique-Hôpitaux de Paris, Service de Pneumologie, Hôpital Bicêtre, Laboratoire d'Excellence en Recherche Sur le Médicament et Innovation Thérapeutique, Université Paris-Sud, Le Kremlin-Bicêtre, France
| | - Vincent Sobanski
- Service de Médecine Interne et Immunologie Clinique, Centre de Référence Des Maladies Autoimmunes Systémiques Rares du Nord et Nord-Ouest de France (CeRAINO), Univ. Lille, Inserm, CHU Lille, U1286 - INFINITE - Institute for Translational Research in Inflammation, 59000, Lille, France
| | | | - Luc Mouthon
- Service de Médecine Interne, Centre de Référence Maladies Autoimmunes Systémiques Rares D'Ile de France, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (AP-HP), APHP-CUP, Hôpital Cochin, Université de Paris, 75014, Paris, France.
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15
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Long-term Outcome of Children Born to Women with Autoimmune Rheumatic Diseases: A Multicentre, Nationwide Study on 299 Randomly Selected Individuals. Clin Rev Allergy Immunol 2021; 62:346-353. [PMID: 33725262 PMCID: PMC8994724 DOI: 10.1007/s12016-021-08857-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/01/2021] [Indexed: 10/26/2022]
Abstract
The concern about the offspring's health is one of the reasons for a reduced family size of women with rheumatic diseases (RD). Increased risk of autoimmune diseases (AD) and neurodevelopmental disorders (ND) has been reported in children born to patients with RD. Within a nationwide survey about reproductive issues of women with RD, we aimed at exploring the long-term outcome of their children. By surveying 398 patients who received their diagnosis of RD during childbearing age (before the age of 45), information about the offspring were obtained from 230 women who declared to have had children. A total of 148 (64.3%) patients were affected by connective tissue diseases (CTD) and 82 (35.7%) by chronic arthritis. Data on 299 children (156 males, 52.1%; mean age at the time of interview 17.1 ± 9.7 years) were collected. Twelve children (4.0%), who were born to patients with CTD in 75% of the cases, were affected by AD (8 cases of celiac disease). Eleven children had a certified diagnosis of ND (3.6%; 6 cases of learning disabilities); 9 of them were born to mothers with CTD (5 after maternal diagnosis). No association was found between ND and prenatal exposure to either maternal autoantibodies or anti-rheumatic drugs. Absolute numbers of offspring affected by AD and ND were low in a multicentre cohort of Italian women with RD. This information can be helpful for the counselling about reproductive issues, as the health outcomes of the offspring might not be an issue which discourage women with RD from having children.
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16
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Kharbanda R, Naveen R, Misra DP, Gupta L, Agarwal V. Poor maternal and foetal outcomes in women with systemic sclerosis: an interview-based study at a tertiary centre. Rheumatol Int 2021; 41:1133-1142. [PMID: 33682026 DOI: 10.1007/s00296-021-04793-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Accepted: 01/16/2021] [Indexed: 12/15/2022]
Abstract
Poor obstetric outcomes are described in rheumatic diseases (RDs) such as systemic sclerosis (SSc). We assessed the effect of the disease in Indian women and compared with those in developed countries and other RDs. Women with SSc (ACR/EULAR 2013 criteria) registered at a tertiary care centre (2010-2016) were interviewed by teleconsultation. Pregnancies occurring after disease onset were compared with those occurring prior to it. Maternal complications included antepartum hemorrhage, postpartum hemorrhage, spontaneous abortion, preterm rupture of membrane, oligohydramnios, infection, prolonged labour, and foetal complications including low birth weight (LBW), intrauterine death (IUD), preterm delivery, and neonatal infection. Results were expressed as median (Interquartile range). Of 200 SSc, 75 patients aged 31 (22-38) years and disease duration 41 (32-50) months were interviewed. Diffuse cutaneous SSc was the most common (42.56%). 127 conceptions before the onset of SSc were compared with 15 after. Among post-diagnosis, 9 (60%) were live births, 3 (20%) spontaneous abortions 1 (6.7%) induced abortion, 2 (13.3%) IUD. Of the live births, 4 (26.7%) were preterm and 3 (20%) were LBW. Pregnancies after disease onset had a higher rate of maternal (OR - 4.9) and foetal (OR - 9.9) complications compared to pregnancies before SSc. Compared to the Italian cohort, Indian SSc patients had a higher abortion rate (OR - 5.8), frequent lower section ceaserean section (OR - 9.4) and lower live births (OR - 0.05). More frequent caesarean deliveries (OR - 93), preterm deliveries (OR - 20) when compared with lupus and favourable maternal outcomes (OR - 0.15), higher preterm deliveries (OR - 9.6) in comparison with Takayasu arteritis were noted. SSc incurs a higher risk of poor maternal as well as the foetal outcome.
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Affiliation(s)
- Rajat Kharbanda
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, 226014, India
| | - R Naveen
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, 226014, India
| | - Durga Prasanna Misra
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, 226014, India
| | - Latika Gupta
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, 226014, India.
| | - Vikas Agarwal
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, 226014, India
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17
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Eisfeld H, Glimm AM, Burmester GR, Ohrndorf S, Backhaus M. Pregnancy outcome in women with different rheumatic diseases: a retrospective analysis. Scand J Rheumatol 2021; 50:299-306. [PMID: 33622159 DOI: 10.1080/03009742.2020.1849788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Objective: Pregnancy may influence the course of inflammatory rheumatic diseases and, conversely, rheumatic and musculoskeletal diseases (RMDs) can affect the outcome of pregnancy. This study aimed to retrospectively analyse the outcome of pregnancy and disease in women with RMDs.Method: Subjects were patients with high-risk pregnancy and connective tissue diseases (CTDs) or inflammatory joint diseases (IJDs) managed at a specialized rheumatology outpatient clinic from 2007 to 2014. Data from conception to 6 months postpartum were collected from medical records and a questionnaire, and analysed regarding clinical symptoms, medications, pregnancy complications, birth outcomes, and infant development. Generalized estimating equations were used to compare the groups (CTD vs IJD).Results: The eligible 66 pregnancies in 57 RMD patients were divided into two groups by RMD type: CTD (n = 48) or IJD (n = 18). The live birth rate was 97% overall. Pregnancy complications (excluding two twin pregnancies) were incurred in 39.1%: miscarriage (n = 2), premature delivery (n = 12), small-for-gestational-age infants (n = 5), and/or pregnancy-related diseases (n = 14). Three children born to women with CTDs had affected development (autism spectrum disorder, congenital heart disease, bronchopulmonary dysplasia). CTD infants had a significantly lower mean gestational age (in weeks) (p = 0.042), weight (p = 0.009), and length (p = 0.016) at birth than IJD infants.Conclusion: Although the live birth rate was high, complications occurred in 39.1% of pregnancies in this cohort. Therefore, interdisciplinary management of pregnant women with RMDs at specialized clinics is strongly recommended.
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Affiliation(s)
- H Eisfeld
- Department of Rheumatology and Clinical Immunology, Charité University Hospital, Berlin, Germany
| | - A M Glimm
- Department of Rheumatology and Clinical Immunology, Charité University Hospital, Berlin, Germany
| | - G R Burmester
- Department of Rheumatology and Clinical Immunology, Charité University Hospital, Berlin, Germany
| | - S Ohrndorf
- Department of Rheumatology and Clinical Immunology, Charité University Hospital, Berlin, Germany
| | - M Backhaus
- Department of Rheumatology and Clinical Immunology, Charité University Hospital, Berlin, Germany.,Department of Internal Medicine, Rheumatology and Clinical Immunology, Parkklinik Weißensee, Berlin, Germany
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18
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Radin M, Schreiber K, Cecchi I, Bortoluzzi A, Crisafulli F, de Freitas CM, Bacco B, Rubini E, Foddai SG, Padovan M, Gallo Cassarino S, Franceschini F, Andrade D, Benedetto C, Govoni M, Bertero T, Marozio L, Roccatello D, Andreoli L, Sciascia S. A multicentre study of 244 pregnancies in undifferentiated connective tissue disease: maternal/fetal outcomes and disease evolution. Rheumatology (Oxford) 2021; 59:2412-2418. [PMID: 31943123 DOI: 10.1093/rheumatology/kez620] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 11/07/2019] [Indexed: 01/29/2023] Open
Abstract
OBJECTIVES To investigate fetal/perinatal and maternal outcomes from a large multicentre cohort of women diagnosed with UCTD. METHODS This multicentre retrospective cohort study describes the outcomes of 224 pregnancies in 133 consecutive women with a diagnosis of UCTD, positive for ANA and aged <45 years old at study inclusion. RESULTS Of the 224 pregnancies analysed, 177 (79%) resulted in live births, 45 (20.1%) in miscarriages (defined as pregnancy loss before 12 weeks' gestation), 2 (0.9%) in stillbirths (pregnancy loss after 20 weeks' gestation) and 6 (2.7%) cases showed intrauterine growth restriction. Miscarriages and stillbirths were strongly associated with the presence of aPL and ENA antibodies (P < 0.05). Maternal pregnancy complications were as follows: 5 (2.2%) cases developed pre-eclampsia, 11 (4.9%) cases gestational hypertension and 12 (5.4%) cases gestational diabetes. Joint involvement represented the most frequent clinical manifestation of the cohort (57.9%), followed by RP (40.6%), photosensitivity (32.3%) and haematological manifestations (27.1%). The rate of disease evolution of our cohort from a diagnosis of UCTD to a diagnosis of definite CTD was 12% within a mean time of 5.3 ± 2.8 years. With a total follow-up after first pregnancy of 1417 patient-years, we observed the evolution to a defined CTD in one out of every 88 patient- years. CONCLUSION In our multicentre cohort, women with UCTD had a live birth rate of 79%. Women with UCTD should be referred to specialist follow-up when planning a pregnancy. ENA profiling and aPL testing should be mandatory in this setting, and further therapeutic approaches and management should be planned accordingly.
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Affiliation(s)
- Massimo Radin
- Center of Research of Immunopathology and Rare Diseases - Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences, and SCDU Nephrology and Dialysis, S. Giovanni Bosco Hospital, Turin, Italy
| | - Karen Schreiber
- Department of Thrombosis and Haemophilia, Guy's and St Thomas' Hospital, London, UK.,Copenhagen Lupus and Vasculitis Clinic, Center for Rheumatology and Spine Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Irene Cecchi
- Center of Research of Immunopathology and Rare Diseases - Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences, and SCDU Nephrology and Dialysis, S. Giovanni Bosco Hospital, Turin, Italy
| | - Alessandra Bortoluzzi
- Department of Medical Sciences, University of Ferrara and Azienda Ospedaliero-Universitaria Sant'Anna, Cona (Ferrara)
| | - Francesca Crisafulli
- Department of Clinical and Experimental Sciences, University of Brescia, Unit of Rheumatology and Clinical Immunology, ASST Spedali Civili, Brescia, Italy
| | - Cristiano M de Freitas
- Department of Rheumatology, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Beatrice Bacco
- Clinical Immunology Department, University of Turin, AO Mauriziano
| | - Elena Rubini
- Center of Research of Immunopathology and Rare Diseases - Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences, and SCDU Nephrology and Dialysis, S. Giovanni Bosco Hospital, Turin, Italy
| | - Silvia G Foddai
- Center of Research of Immunopathology and Rare Diseases - Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences, and SCDU Nephrology and Dialysis, S. Giovanni Bosco Hospital, Turin, Italy
| | - Melissa Padovan
- Department of Medical Sciences, University of Ferrara and Azienda Ospedaliero-Universitaria Sant'Anna, Cona (Ferrara)
| | | | - Franco Franceschini
- Department of Clinical and Experimental Sciences, University of Brescia, Unit of Rheumatology and Clinical Immunology, ASST Spedali Civili, Brescia, Italy
| | - Danieli Andrade
- Department of Rheumatology, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Chiara Benedetto
- Department of Surgical Sciences, Obstetrics and Gynecology, Sant'Anna, University Hospital, University of Turin, Turin, Italy
| | - Marcello Govoni
- Department of Medical Sciences, University of Ferrara and Azienda Ospedaliero-Universitaria Sant'Anna, Cona (Ferrara)
| | - Tiziana Bertero
- Clinical Immunology Department, University of Turin, AO Mauriziano
| | - Luca Marozio
- Department of Surgical Sciences, Obstetrics and Gynecology, Sant'Anna, University Hospital, University of Turin, Turin, Italy
| | - Dario Roccatello
- Center of Research of Immunopathology and Rare Diseases - Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences, and SCDU Nephrology and Dialysis, S. Giovanni Bosco Hospital, Turin, Italy
| | - Laura Andreoli
- Department of Clinical and Experimental Sciences, University of Brescia, Unit of Rheumatology and Clinical Immunology, ASST Spedali Civili, Brescia, Italy
| | - Savino Sciascia
- Center of Research of Immunopathology and Rare Diseases - Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences, and SCDU Nephrology and Dialysis, S. Giovanni Bosco Hospital, Turin, Italy
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Gupta L, Balakrishnan A, Mehta P. Pregnancy counseling in rheumatic diseases: Where science meets the steps. INDIAN JOURNAL OF RHEUMATOLOGY 2021. [DOI: 10.4103/injr.injr_79_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Chung MP, Kolstad KD, Dontsi M, Postlethwaite D, Manwani P, Zhao H, Kesh S, Simard JF, Chung L. Increased Rates of Obstetric Complications Prior to Systemic Sclerosis Diagnosis. Arthritis Care Res (Hoboken) 2020; 74:912-917. [PMID: 33290624 DOI: 10.1002/acr.24533] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 11/03/2020] [Accepted: 12/03/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To investigate whether obstetric complications prior to systemic sclerosis (SSc) diagnosis are more common compared to the general obstetric population. METHODS A case-control study was performed at Kaiser Permanente Northern California to compare prior obstetric complications in adult women who later developed SSc (cases) with women from the general obstetric population who did not develop SSc (controls; matched 10:1 by age and year of delivery) from 2007-2016. Exposures included past hypertensive disorders of pregnancy (preeclampsia, eclampsia, gestational hypertension), premature rupture of membranes (PROM), intrauterine growth restriction (IUGR), maternal infections, neonatal intensive care unit (NICU) admission, and preterm birth. Fischer's exact tests were used to compare categorical variables. Conditional logistic regression models estimated the odds ratio (OR) and corresponding 95% confidence intervals for the outcome SSc. RESULTS Seventeen SSc cases and 170 non-SSc controls were identified, with median maternal age at delivery 34 years (range 23-46 years) and median time from delivery to SSc diagnosis 2 years (range 0.2-7.3 years). SSc cases were more likely to be Hispanic and Black. Prior obstetric complications appeared higher in women with an eventual SSc diagnosis compared to controls (70.6% vs. 50%), including hypertensive disorders (17.7% vs. 9.4%), PROM (11.8% vs. 4.1%), IUGR (5.9% vs 1.8%), maternal infection (29.4% vs. 14.1%), NICU admissions (23.5% vs. 7.7%), and preterm delivery (29.4% vs. 21.8%). Cases had a higher odds of delivering infants requiring NICU admission (OR=4.7, 95% CI 1.2-18.8). CONCLUSIONS Women who eventually develop SSc had trends towards more complicated pregnancy histories before overt diagnosis.
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Affiliation(s)
- Melody P Chung
- Department of Internal Medicine, Kaiser Permanente Santa Clara, Santa Clara, CA, USA.,Division of Immunology and Rheumatology, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Kathleen D Kolstad
- Division of Immunology and Rheumatology, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Makdine Dontsi
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | | | - Poonam Manwani
- Department of Internal Medicine, Kaiser Permanente Santa Clara, Santa Clara, CA, USA
| | - Hongyu Zhao
- Department of Internal Medicine, Kaiser Permanente Santa Clara, Santa Clara, CA, USA
| | - Sumana Kesh
- Department of Internal Medicine, Kaiser Permanente Santa Clara, Santa Clara, CA, USA
| | - Julia F Simard
- Division of Immunology and Rheumatology, Stanford University School of Medicine, Palo Alto, CA, USA.,Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| | - Lorinda Chung
- Division of Immunology and Rheumatology, Stanford University School of Medicine, Palo Alto, CA, USA.,Division of Immunology and Rheumatology, Palo Alto Health Care System, Palo Alto, CA, USA
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21
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Nasca MR, Giuffrida G, Micali G. The Influence of Pregnancy on the Clinical Evolution and Prognosis of Pre-Existing Inflammatory and Autoimmune Skin Disorders and Their Management. Dermatology 2020; 237:771-785. [PMID: 32950977 DOI: 10.1159/000509726] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Accepted: 06/24/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Although the possible occurrence of typical dermatoses during pregnancy is well recognized, little is known about the influence of pregnancy on the clinical evolution and prognosis of different pre-existing chronic dermatological disorders. SUMMARY In this study a comprehensive search of the available literature and reviews has been undertaken in order to collect and analyze articles reporting pre-existing chronic skin disorders in pregnant women and report current knowledge on their particular clinical and therapeutic aspects.
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22
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Borba VV, Zandman-Goddard G, Shoenfeld Y. Exacerbations of autoimmune diseases during pregnancy and postpartum. Best Pract Res Clin Endocrinol Metab 2019; 33:101321. [PMID: 31564626 DOI: 10.1016/j.beem.2019.101321] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Autoimmune diseases represent a complex heterogeneous group of disorders that occur as a results of immune homeostasis dysregulation and loss of self-tolerance. Interestingly, more than 80% of the cases are found among women at reproductive age. Normal pregnancy is associated with remarkable changes in the immune and endocrine signaling required to tolerate and support the development and survival of the placenta and the semi-allogenic fetus in the hostile maternal immune system environment. Gravidity and postpartum represent an extremely challenge period, and likewise the general population, women suffering from autoimmune disorders attempt pregnancy. Effective preconception counseling and subsequent gestation and postpartum follow-up are crucial for improving mother and child outcomes. This comprehensive review provides information about the different pathways modulating autoimmune diseases activity and severity, such as the influence hormones, microbiome, infections, vaccines, among others, as well as updated recommendations were needed, in order to offer those women better medical care and life quality.
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Affiliation(s)
- Vânia Vieira Borba
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel
| | - Gisele Zandman-Goddard
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel; Department of Medicine C, Wolfson Medical Center, Tel Aviv, Israel
| | - Yehuda Shoenfeld
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel; I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), Russia.
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23
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Tincani A, Nalli C, Khizroeva J, Bitsadze V, Lojacono A, Andreoli L, Shoenfeld Y, Makatsariya A. Autoimmune diseases and pregnancy. Best Pract Res Clin Endocrinol Metab 2019; 33:101322. [PMID: 31542218 DOI: 10.1016/j.beem.2019.101322] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Pregnancy in autoimmune diseases remains an argument of debate. In last years great improvements were done and with the correct medical support women with disease such as Systemic Lupus Erythematosus or Antiphospholipid Syndrome can afford a pregnancy and have healthy babies. The starting point is a good counselling. Women should be informed about risks that can occur taking some medications while pregnant and, on the other hand, that there are medications that can be safety assumed during pregnancy. Furthermore, there are known maternal risks factor such as the presence of antiphospholipid antibodies or anti-Ro/SSA antibodies that must be carefully manage by both rheumatologists and obstetrics. In addition, also disease activity during pregnancy can represent an issue. For all these reason, a multidisciplinary approach is mandatory in order to give our patients an optimal medical support, before, during and after pregnancy.
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Affiliation(s)
- Angela Tincani
- Rheumatology and Immunology Unit, Department of Clinical and Experimental Sciences, University of Brescia, ASST Spedali Civili, Brescia, Italy; I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), Russia.
| | - Cecilia Nalli
- Rheumatology and Immunology Unit, Department of Clinical and Experimental Sciences, University of Brescia, ASST Spedali Civili, Brescia, Italy
| | - Jamilya Khizroeva
- Department of Obstetrics and Gynecology of I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russia
| | - Victoria Bitsadze
- Department of Obstetrics and Gynecology of I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russia
| | - Andrea Lojacono
- Obstetric and Gynecology Unit, Department of Clinical and Experimental Science, University of Brescia, ASST Spedali Civili, Brescia, Italy
| | - Laura Andreoli
- Rheumatology and Immunology Unit, Department of Clinical and Experimental Sciences, University of Brescia, ASST Spedali Civili, Brescia, Italy
| | - Yehuda Shoenfeld
- I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), Russia; Department of Medicine 'B', The Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Ramat Gan, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv-Yafo, Israel
| | - Alexander Makatsariya
- Department of Obstetrics and Gynecology of I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russia
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Kolstad KD, Mayo JA, Chung L, Chaichian Y, Kelly VM, Druzin M, Stevenson DK, Shaw GM, Simard JF. Preterm birth phenotypes in women with autoimmune rheumatic diseases: a population-based cohort study. BJOG 2019; 127:70-78. [PMID: 31571337 DOI: 10.1111/1471-0528.15970] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/19/2019] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To investigate preterm birth (PTB) phenotypes in women with different autoimmune rheumatic diseases in a large population-based cohort. DESIGN Retrospective cohort study. SETTING California, USA. POPULATION All live singleton births in California between 2007 and 2011 were analysed. Patients with autoimmune disease at delivery were identified by International Classification of Diseases, Ninth Revision , Clinical Modification (ICD-9-CM), codes for systemic lupus erythematosus (SLE), systemic sclerosis (SSc), rheumatoid arthritis (RA), polymyositis/dermatomyositis (DM/PM), and juvenile idiopathic arthritis (JIA). METHODS Maternally linked hospital and birth certificate records of 2 481 516 deliveries were assessed (SLE n = 2272, RA n = 1501, SSc n = 88, JIA n = 187, DM/PM n = 38). Multivariable Poisson regression models estimated the risk ratios (RRs) for different PTB phenotypes (relative to term deliveries) for each autoimmune disease compared with the general obstetric population, adjusting for maternal age, race/ethnicity, body mass index, smoking, education, payer, parity, and prenatal care. MAIN OUTCOME MEASURES Preterm birth (PTB) was assessed overall (20-36 weeks of gestation) and by subphenotype: preterm prelabour rupture of membranes (PPROM), spontaneous birth, or medically indicated PTB. The risk of PTB overall and for each phenotype was partitioned by gestational age: early (20-31 weeks of gestation) and late (32-36 weeks of gestation). RESULTS Risks for PTB were elevated for each autoimmune disease evaluated: SLE (RR 3.27, 95% CI 3.01-3.56), RA (RR 2.04, 95% CI 1.79-2.33), SSc (RR 3.74, 95% CI 2.51-5.58), JIA (RR 2.23, 95% CI 1.54-3.23), and DM/PM (RR 5.26, 95% CI 3.12-8.89). These elevated risks were observed for the majority of PTB phenotypes as well. CONCLUSIONS Women with systemic autoimmune diseases appear to have an elevated risk of various PTB phenotypes. Therefore, preconception counselling and close monitoring during pregnancy is crucial. TWEETABLE ABSTRACT This study found that women with systemic autoimmune diseases have an elevated risk of preterm birth phenotypes.
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Affiliation(s)
- K D Kolstad
- Division of Immunology and Rheumatology, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - J A Mayo
- March of Dimes Prematurity Research Center at Stanford University School of Medicine, Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - L Chung
- Division of Immunology and Rheumatology, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA.,Palo Alto VA and Stanford University Division of Immunology and Rheumatology, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Y Chaichian
- Division of Immunology and Rheumatology, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - V M Kelly
- Department of Rheumatology, Palo Alto Medical Foundation, Palo Alto, California, USA
| | - M Druzin
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, California, USA
| | - D K Stevenson
- March of Dimes Prematurity Research Center at Stanford University School of Medicine, Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - G M Shaw
- March of Dimes Prematurity Research Center at Stanford University School of Medicine, Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Stanford, California, USA.,Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, California, USA.,Division of Epidemiology, Department of Health Research and Policy, Stanford University School of Medicine, Stanford, California, USA
| | - J F Simard
- Division of Immunology and Rheumatology, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA.,Division of Epidemiology, Department of Health Research and Policy, Stanford University School of Medicine, Stanford, California, USA
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25
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Clark KE, Etomi O, Ong VH. Systemic sclerosis in pregnancy. Obstet Med 2019; 13:105-111. [PMID: 33093861 DOI: 10.1177/1753495x19878042] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 08/31/2019] [Indexed: 01/08/2023] Open
Abstract
Systemic sclerosis is a rare multisystem connective tissue disease. It predominantly affects women and poses a significant risk to mother and baby during pregnancy if not managed appropriately. The commonest manifestations are skin fibrosis and Raynaud's phenomenon. Subgroups of women have an increased risk of organ involvement, especially interstitial lung disease, pulmonary arterial hypertension and renal crises. Pregnancy increases the risk to the mother, especially those with established organ involvement, but also the development of new organ dysfunction; and risks to the fetus. Optimising these women prior to conception, along with careful management and surveillance during pregnancy, is vital for optimising pregnancy outcome. Women with scleroderma need to be managed in a specialised centre with coordinated care from the multi-disciplinary teams including physicians, obstetricians, anaesthetists, neonatologists and midwives. This review aims to describe the risks associated with systemic sclerosis and pregnancy, with management advice for physicians looking after pregnant women with this chronic condition.
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Affiliation(s)
- Kristina En Clark
- Centre of Rheumatology and Connective Tissue Diseases, UCL Royal Free Medical School, London, UK
| | - Oseme Etomi
- Department of Obstetric Medicine, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Voon H Ong
- Centre of Rheumatology and Connective Tissue Diseases, UCL Royal Free Medical School, London, UK
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26
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Pregnancy in myositis and scleroderma. Best Pract Res Clin Obstet Gynaecol 2019; 64:59-67. [PMID: 31928915 DOI: 10.1016/j.bpobgyn.2019.10.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 10/04/2019] [Accepted: 10/06/2019] [Indexed: 11/22/2022]
Abstract
Myositis and scleroderma are both rare autoimmune diseases with female predominance and often occur before and during reproductive years. The rarity of diseases explains the low frequency of concurrent disease and pregnancy. Like other autoimmune diseases, myositis and scleroderma may be more active during pregnancy as well. To date, many patients with myositis and scleroderma can have favorable pregnancy outcomes with careful management. This chapter provides a current overview of pregnancy outcomes in myositis and scleroderma. A major theme that appears to have emerged across these inflammatory diseases is that active maternal disease during pregnancy is associated with adverse pregnancy outcomes, and thus, personalized management is necessary depending on the disease state and comorbidities.
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27
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Blagojevic J, AlOdhaibi KA, Aly AM, Bellando-Randone S, Lepri G, Bruni C, Moggi-Pignone A, Guiducci S, Mecacci F, Matucci-Cerinic M, Furst DE. Pregnancy in Systemic Sclerosis: Results of a Systematic Review and Metaanalysis. J Rheumatol 2019; 47:881-887. [PMID: 31474594 DOI: 10.3899/jrheum.181460] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/15/2019] [Indexed: 01/02/2023]
Abstract
OBJECTIVE Through a systematic literature search (SLR) and metaanalysis, to determine maternal and fetal outcomes in pregnancies involving systemic sclerosis (SSc), to analyze the effect of pregnancy on disease activity, and to examine predictors of fetal and maternal outcomes. METHODS An SLR was performed for articles on SSc and pregnancy published between 1950 and February 1, 2018. Reviewers double-extracted articles to obtain agreement on > 95% of predefined critical outcomes. RESULTS Out of 461 publications identified, 16 were included in the metaanalysis. The metaanalysis showed that pregnancies involving SSc were at higher risk of miscarriage (OR 1.6, 95% CI 1.22-2.22), fetuses with intrauterine growth retardation (IUGR; OR 3.2, 95% CI 2.21-4.53), preterm births (OR 2.4, 95% CI 1.14-4.86), and newborns with low birth weight (OR 3.8, 95% CI 2.16-6.56). Patients with SSc had a 2.8 times higher chance of developing gestational hypertension (HTN; OR 2.8, 95% CI 2.28-3.39) and a 2.3 times higher chance of cesarean delivery compared to controls (OR 2.3, 95% CI 1.37-3.8). The definitions of disease worsening/new visceral organ involvement were too inexact to have any confidence in the results, although worsening or new disease manifestations during pregnancy in 44/307 cases (14.3%) and 6 months postpartum in 32/306 cases (10.5%) were reported. The data did not permit definition of predictors of disease progression and of maternal and fetal outcomes. CONCLUSION Pregnancies involving SSc have increased frequency of miscarriages, IUGR, preterm deliveries, and newborns with low birth weight compared to healthy controls. Women with SSc were more prone to develop gestational HTN and to undergo cesarean delivery. Disease manifestations seem to remain stable or improve in most patients.
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Affiliation(s)
- Jelena Blagojevic
- From the Department of Experimental and Clinical Medicine, University of Florence, and the Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, Azienda Ospedaliero Universitaria Careggi (AOUC), Florence, Italy; Department of Family Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia; Faculty of Medicine, Alexandria University, Alexandria, Egypt; Department of Emergency Medicine, Division of Medicine IV AOUC; Department of Maternal-Neonatal Caref, Careggi University Hospital, Florence, Italy; University of California at Los Angeles, Los Angeles, California; University of Washington, Seattle, Washington, USA; University of Florence, Florence, Italy. .,J. Blagojevic, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; K.A. AlOdhaibi, MD, Department of Family Medicine, King Faisal Specialist Hospital and Research Centre; A.M. Aly, MBBch, Faculty of Medicine, Alexandria University; S. Bellando-Randone, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; G. Lepri, MD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; C. Bruni, MD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; A. Moggi-Pignone, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Emergency Medicine, Division of Medicine IV, AOUC; S. Guiducci, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; F. Mecacci, MD, PhD, Department of Maternal-Neonatal Care, Careggi University Hospital; M. Matucci-Cerinic, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; D.E. Furst, MD, UCLA (Emeritus), and University of Washington.
| | - Khitam Abdullah AlOdhaibi
- From the Department of Experimental and Clinical Medicine, University of Florence, and the Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, Azienda Ospedaliero Universitaria Careggi (AOUC), Florence, Italy; Department of Family Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia; Faculty of Medicine, Alexandria University, Alexandria, Egypt; Department of Emergency Medicine, Division of Medicine IV AOUC; Department of Maternal-Neonatal Caref, Careggi University Hospital, Florence, Italy; University of California at Los Angeles, Los Angeles, California; University of Washington, Seattle, Washington, USA; University of Florence, Florence, Italy.,J. Blagojevic, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; K.A. AlOdhaibi, MD, Department of Family Medicine, King Faisal Specialist Hospital and Research Centre; A.M. Aly, MBBch, Faculty of Medicine, Alexandria University; S. Bellando-Randone, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; G. Lepri, MD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; C. Bruni, MD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; A. Moggi-Pignone, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Emergency Medicine, Division of Medicine IV, AOUC; S. Guiducci, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; F. Mecacci, MD, PhD, Department of Maternal-Neonatal Care, Careggi University Hospital; M. Matucci-Cerinic, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; D.E. Furst, MD, UCLA (Emeritus), and University of Washington
| | - Aly M Aly
- From the Department of Experimental and Clinical Medicine, University of Florence, and the Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, Azienda Ospedaliero Universitaria Careggi (AOUC), Florence, Italy; Department of Family Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia; Faculty of Medicine, Alexandria University, Alexandria, Egypt; Department of Emergency Medicine, Division of Medicine IV AOUC; Department of Maternal-Neonatal Caref, Careggi University Hospital, Florence, Italy; University of California at Los Angeles, Los Angeles, California; University of Washington, Seattle, Washington, USA; University of Florence, Florence, Italy.,J. Blagojevic, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; K.A. AlOdhaibi, MD, Department of Family Medicine, King Faisal Specialist Hospital and Research Centre; A.M. Aly, MBBch, Faculty of Medicine, Alexandria University; S. Bellando-Randone, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; G. Lepri, MD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; C. Bruni, MD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; A. Moggi-Pignone, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Emergency Medicine, Division of Medicine IV, AOUC; S. Guiducci, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; F. Mecacci, MD, PhD, Department of Maternal-Neonatal Care, Careggi University Hospital; M. Matucci-Cerinic, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; D.E. Furst, MD, UCLA (Emeritus), and University of Washington
| | - Silvia Bellando-Randone
- From the Department of Experimental and Clinical Medicine, University of Florence, and the Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, Azienda Ospedaliero Universitaria Careggi (AOUC), Florence, Italy; Department of Family Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia; Faculty of Medicine, Alexandria University, Alexandria, Egypt; Department of Emergency Medicine, Division of Medicine IV AOUC; Department of Maternal-Neonatal Caref, Careggi University Hospital, Florence, Italy; University of California at Los Angeles, Los Angeles, California; University of Washington, Seattle, Washington, USA; University of Florence, Florence, Italy.,J. Blagojevic, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; K.A. AlOdhaibi, MD, Department of Family Medicine, King Faisal Specialist Hospital and Research Centre; A.M. Aly, MBBch, Faculty of Medicine, Alexandria University; S. Bellando-Randone, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; G. Lepri, MD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; C. Bruni, MD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; A. Moggi-Pignone, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Emergency Medicine, Division of Medicine IV, AOUC; S. Guiducci, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; F. Mecacci, MD, PhD, Department of Maternal-Neonatal Care, Careggi University Hospital; M. Matucci-Cerinic, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; D.E. Furst, MD, UCLA (Emeritus), and University of Washington
| | - Gemma Lepri
- From the Department of Experimental and Clinical Medicine, University of Florence, and the Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, Azienda Ospedaliero Universitaria Careggi (AOUC), Florence, Italy; Department of Family Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia; Faculty of Medicine, Alexandria University, Alexandria, Egypt; Department of Emergency Medicine, Division of Medicine IV AOUC; Department of Maternal-Neonatal Caref, Careggi University Hospital, Florence, Italy; University of California at Los Angeles, Los Angeles, California; University of Washington, Seattle, Washington, USA; University of Florence, Florence, Italy.,J. Blagojevic, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; K.A. AlOdhaibi, MD, Department of Family Medicine, King Faisal Specialist Hospital and Research Centre; A.M. Aly, MBBch, Faculty of Medicine, Alexandria University; S. Bellando-Randone, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; G. Lepri, MD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; C. Bruni, MD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; A. Moggi-Pignone, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Emergency Medicine, Division of Medicine IV, AOUC; S. Guiducci, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; F. Mecacci, MD, PhD, Department of Maternal-Neonatal Care, Careggi University Hospital; M. Matucci-Cerinic, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; D.E. Furst, MD, UCLA (Emeritus), and University of Washington
| | - Cosimo Bruni
- From the Department of Experimental and Clinical Medicine, University of Florence, and the Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, Azienda Ospedaliero Universitaria Careggi (AOUC), Florence, Italy; Department of Family Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia; Faculty of Medicine, Alexandria University, Alexandria, Egypt; Department of Emergency Medicine, Division of Medicine IV AOUC; Department of Maternal-Neonatal Caref, Careggi University Hospital, Florence, Italy; University of California at Los Angeles, Los Angeles, California; University of Washington, Seattle, Washington, USA; University of Florence, Florence, Italy.,J. Blagojevic, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; K.A. AlOdhaibi, MD, Department of Family Medicine, King Faisal Specialist Hospital and Research Centre; A.M. Aly, MBBch, Faculty of Medicine, Alexandria University; S. Bellando-Randone, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; G. Lepri, MD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; C. Bruni, MD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; A. Moggi-Pignone, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Emergency Medicine, Division of Medicine IV, AOUC; S. Guiducci, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; F. Mecacci, MD, PhD, Department of Maternal-Neonatal Care, Careggi University Hospital; M. Matucci-Cerinic, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; D.E. Furst, MD, UCLA (Emeritus), and University of Washington
| | - Alberto Moggi-Pignone
- From the Department of Experimental and Clinical Medicine, University of Florence, and the Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, Azienda Ospedaliero Universitaria Careggi (AOUC), Florence, Italy; Department of Family Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia; Faculty of Medicine, Alexandria University, Alexandria, Egypt; Department of Emergency Medicine, Division of Medicine IV AOUC; Department of Maternal-Neonatal Caref, Careggi University Hospital, Florence, Italy; University of California at Los Angeles, Los Angeles, California; University of Washington, Seattle, Washington, USA; University of Florence, Florence, Italy.,J. Blagojevic, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; K.A. AlOdhaibi, MD, Department of Family Medicine, King Faisal Specialist Hospital and Research Centre; A.M. Aly, MBBch, Faculty of Medicine, Alexandria University; S. Bellando-Randone, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; G. Lepri, MD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; C. Bruni, MD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; A. Moggi-Pignone, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Emergency Medicine, Division of Medicine IV, AOUC; S. Guiducci, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; F. Mecacci, MD, PhD, Department of Maternal-Neonatal Care, Careggi University Hospital; M. Matucci-Cerinic, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; D.E. Furst, MD, UCLA (Emeritus), and University of Washington
| | - Serena Guiducci
- From the Department of Experimental and Clinical Medicine, University of Florence, and the Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, Azienda Ospedaliero Universitaria Careggi (AOUC), Florence, Italy; Department of Family Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia; Faculty of Medicine, Alexandria University, Alexandria, Egypt; Department of Emergency Medicine, Division of Medicine IV AOUC; Department of Maternal-Neonatal Caref, Careggi University Hospital, Florence, Italy; University of California at Los Angeles, Los Angeles, California; University of Washington, Seattle, Washington, USA; University of Florence, Florence, Italy.,J. Blagojevic, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; K.A. AlOdhaibi, MD, Department of Family Medicine, King Faisal Specialist Hospital and Research Centre; A.M. Aly, MBBch, Faculty of Medicine, Alexandria University; S. Bellando-Randone, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; G. Lepri, MD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; C. Bruni, MD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; A. Moggi-Pignone, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Emergency Medicine, Division of Medicine IV, AOUC; S. Guiducci, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; F. Mecacci, MD, PhD, Department of Maternal-Neonatal Care, Careggi University Hospital; M. Matucci-Cerinic, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; D.E. Furst, MD, UCLA (Emeritus), and University of Washington
| | - Federico Mecacci
- From the Department of Experimental and Clinical Medicine, University of Florence, and the Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, Azienda Ospedaliero Universitaria Careggi (AOUC), Florence, Italy; Department of Family Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia; Faculty of Medicine, Alexandria University, Alexandria, Egypt; Department of Emergency Medicine, Division of Medicine IV AOUC; Department of Maternal-Neonatal Caref, Careggi University Hospital, Florence, Italy; University of California at Los Angeles, Los Angeles, California; University of Washington, Seattle, Washington, USA; University of Florence, Florence, Italy.,J. Blagojevic, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; K.A. AlOdhaibi, MD, Department of Family Medicine, King Faisal Specialist Hospital and Research Centre; A.M. Aly, MBBch, Faculty of Medicine, Alexandria University; S. Bellando-Randone, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; G. Lepri, MD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; C. Bruni, MD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; A. Moggi-Pignone, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Emergency Medicine, Division of Medicine IV, AOUC; S. Guiducci, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; F. Mecacci, MD, PhD, Department of Maternal-Neonatal Care, Careggi University Hospital; M. Matucci-Cerinic, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; D.E. Furst, MD, UCLA (Emeritus), and University of Washington
| | - Marco Matucci-Cerinic
- From the Department of Experimental and Clinical Medicine, University of Florence, and the Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, Azienda Ospedaliero Universitaria Careggi (AOUC), Florence, Italy; Department of Family Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia; Faculty of Medicine, Alexandria University, Alexandria, Egypt; Department of Emergency Medicine, Division of Medicine IV AOUC; Department of Maternal-Neonatal Caref, Careggi University Hospital, Florence, Italy; University of California at Los Angeles, Los Angeles, California; University of Washington, Seattle, Washington, USA; University of Florence, Florence, Italy.,J. Blagojevic, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; K.A. AlOdhaibi, MD, Department of Family Medicine, King Faisal Specialist Hospital and Research Centre; A.M. Aly, MBBch, Faculty of Medicine, Alexandria University; S. Bellando-Randone, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; G. Lepri, MD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; C. Bruni, MD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; A. Moggi-Pignone, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Emergency Medicine, Division of Medicine IV, AOUC; S. Guiducci, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; F. Mecacci, MD, PhD, Department of Maternal-Neonatal Care, Careggi University Hospital; M. Matucci-Cerinic, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; D.E. Furst, MD, UCLA (Emeritus), and University of Washington
| | - Daniel E Furst
- From the Department of Experimental and Clinical Medicine, University of Florence, and the Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, Azienda Ospedaliero Universitaria Careggi (AOUC), Florence, Italy; Department of Family Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia; Faculty of Medicine, Alexandria University, Alexandria, Egypt; Department of Emergency Medicine, Division of Medicine IV AOUC; Department of Maternal-Neonatal Caref, Careggi University Hospital, Florence, Italy; University of California at Los Angeles, Los Angeles, California; University of Washington, Seattle, Washington, USA; University of Florence, Florence, Italy.,J. Blagojevic, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; K.A. AlOdhaibi, MD, Department of Family Medicine, King Faisal Specialist Hospital and Research Centre; A.M. Aly, MBBch, Faculty of Medicine, Alexandria University; S. Bellando-Randone, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; G. Lepri, MD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; C. Bruni, MD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; A. Moggi-Pignone, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Emergency Medicine, Division of Medicine IV, AOUC; S. Guiducci, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; F. Mecacci, MD, PhD, Department of Maternal-Neonatal Care, Careggi University Hospital; M. Matucci-Cerinic, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; D.E. Furst, MD, UCLA (Emeritus), and University of Washington
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Birru Talabi M, Clowse MEB, Blalock SJ, Moreland L, Siripong N, Borrero S. Contraception Use Among Reproductive-Age Women With Rheumatic Diseases. Arthritis Care Res (Hoboken) 2019; 71:1132-1140. [PMID: 30106516 DOI: 10.1002/acr.23724] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Accepted: 08/07/2018] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To determine contraception use among a cohort of reproductive-age women (ages 18-50 years) with rheumatic diseases. METHODS We conducted a study of administrative data from a single, large medical center between the years 2013 and 2014. Women who had 1 of 21 possible rheumatic disease diagnoses and had at least 2 outpatient rheumatology visits were included in this analysis. We used logistic regression analyses to evaluate adjusted associations between the use of prescription contraception, use of potentially fetotoxic medications, and visits with rheumatologists, primary care providers, and gynecologists. RESULTS Of 2,455 women in this sample, 32.1% received any prescription contraception, and 7.9% of women used highly effective prescription methods (intrauterine devices, implants, and surgical sterilization). More than 70% of women took ≥1 type of fetotoxic medication during the 2-year study timeframe. Fetotoxic medication use was not associated with overall use of prescription contraception, but was associated with the use of highly effective contraceptive methods (adjusted odds ratio [OR] 2.26 [95% confidence interval (95% CI) 1.44-3.54]). Women who saw gynecologists or primary care providers were more likely to use prescription contraception overall (adjusted OR 3.35 [95% CI 2.77-4.05] and 1.43 [95% CI 1.18-1.73], respectively). Women who saw gynecologists were more likely to use highly versus moderately effective contraceptive methods (adjusted OR 2.35 [95% CI 1.41-3.94]). Rheumatology visits were not associated with use of prescription contraception in any models. CONCLUSION This is the largest study to date to describe contraceptive use among reproductive-age women with rheumatic diseases, and the findings reveal low use of prescription contraception. Urgent efforts are needed to improve contraceptive care and access for some women with rheumatic diseases.
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Affiliation(s)
| | | | - Susan J Blalock
- University of North Carolina Eshelman School of Pharmacy, Chapel Hill
| | | | | | - Sonya Borrero
- University of Pittsburgh and Center for Health Equity Research and Promotion, Veterans Administration Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
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De Carolis S, Moresi S, Rizzo F, Monteleone G, Tabacco S, Salvi S, Garufi C, Lanzone A. Autoimmunity in obstetrics and autoimmune diseases in pregnancy. Best Pract Res Clin Obstet Gynaecol 2019; 60:66-76. [PMID: 31133364 DOI: 10.1016/j.bpobgyn.2019.03.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Accepted: 03/01/2019] [Indexed: 12/15/2022]
Abstract
Autoimmune diseases (AIDs) are associated with strong female preponderance and often present before or during the reproductive years; consequently, pregnancy and breastfeeding are topics of major interest for these patients. AIDs show different responses to pregnancy: some ameliorate, while others remain unchanged, and several AIDs aggravate. The response of the AIDs to the hormonal and immunological alterations of pregnancy reflects the different pathophysiology of each disease. Systemic lupus erythematosus (SLE) and antiphospholipid syndrome (APS) are associated with multiple autoantibodies, multiorgan involvement, more aggressive therapy, and increased impact on pregnancy outcome. For the management of pregnancy in patients with SLE and/or APS, it is important to individuate the correct risk profile for each woman and timing for treatment. The optimal timing for starting or modulating treatment is at preconception assessment to influence the placentation. In this chapter, we discuss the management of pregnancy in patients with AIDs.
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Affiliation(s)
- Sara De Carolis
- UOC di Patologia Ostetrica, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy; Istituto di Clinica Ostetrica e Ginecologica, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Sascia Moresi
- UOC di Patologia Ostetrica, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Francesca Rizzo
- UOC di Patologia Ostetrica, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Giuseppina Monteleone
- UOC di Patologia Ostetrica, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Sara Tabacco
- Department of Gynecological and Obstetric Sciences and Urological Sciences, Sapienza Università di Roma, Umberto I Hospital, Rome, Italy
| | - Silvia Salvi
- UOC di Patologia Ostetrica, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy.
| | - Cristina Garufi
- Lupus Clinic, Dipartimento di Medicina Interna e Specialità Mediche, Sapienza Università di Roma, Umberto I Hospital, Rome, Italy
| | - Antonio Lanzone
- UOC di Patologia Ostetrica, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy; Istituto di Clinica Ostetrica e Ginecologica, Università Cattolica del Sacro Cuore, Roma, Italy
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Tardif ML, Mahone M. Mixed connective tissue disease in pregnancy: A case series and systematic literature review. Obstet Med 2019; 12:31-37. [PMID: 30891090 PMCID: PMC6416686 DOI: 10.1177/1753495x18793484] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 07/16/2018] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To investigate the impact of medical and obstetric complications associated with mixed connective tissue disease (MCTD) in pregnancy. METHOD We analyzed 68 pregnancies from a systematic literature review and 12 pregnancies affected by MCTD at our centre between 1986 and 2015 for medical and obstetric complications. RESULTS During pregnancy 37.1% had active MCTD and 26.7% had relapsed. Maternal complications included caesarean section (31.1%, n = 19), preeclampsia (17.6%, n = 13), thromboembolism events, and death (2.5%, n = 2 for each). Fetal complications included prematurity (48.1%, n = 25), intrauterine growth restriction (38.3%, n = 19), and neonatal lupus (28.6%, n = 18, including chondrodysplasia punctata). More than half (n = 10) of the neonatal lupus cases were explained by anti-U1RNP only. The perinatal mortality rate was 17.7% (n = 14). Pregnant women with active disease had higher rates of prematurity (OR = 7.60; 95%CI [1.93; 29.95]) and perinatal death (OR = 16.83; 95%CI [1.90; 147.70]). CONCLUSION MCTD in pregnancy puts women at risk of medical and obstetric complications, and disease activity probably increases this risk.
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Affiliation(s)
- Marie-Lou Tardif
- Internal Medicine Division, Department of Medicine,
Centre
Hospitalier de l’Université de Montréal
(CHUM), Montréal, QC, Canada
| | - Michèle Mahone
- Internal Medicine Division, Department of Medicine,
Centre
Hospitalier de l’Université de Montréal
(CHUM), Montréal, QC, Canada
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Brucato A, Pluymaekers N, Tombetti E, Rampello S, Maestroni S, Lucianetti M, Valenti A, Adler Y, Imazio M. Management of idiopathic recurrent pericarditis during pregnancy. Int J Cardiol 2019; 282:60-65. [PMID: 30773267 DOI: 10.1016/j.ijcard.2019.02.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 01/26/2019] [Accepted: 02/04/2019] [Indexed: 01/30/2023]
Abstract
BACKGROUND Data concerning idiopathic recurrent pericarditis in pregnancy are scarce. OBJECTIVES To evaluate the management and outcome of idiopathic recurrent pericarditis during pregnancy. METHODS AND RESULTS Twenty-one pregnancies were evaluated in fourteen women with a history of recurrent idiopathic pericarditis (mean maternal age 31.5 years, mean gestational age 39.0 weeks), and subdivided in 2 cohorts: eight pregnancies were analyzed retrospectively (2002-2010), thirteen (2011-2017) prospectively and followed according a predefined management protocol. Ten pregnancies were uneventful, three ended in spontaneous early abortion, one fetal death occurred at 19 weeks. Recurrences of pericarditis occurred in eight and were treated by adding NSAIDs in two cases; in five cases the dose of corticosteroids was increased and in two cases aspirin was started/increased; paracetamol was always allowed. Colchicine was used in two cases in the prospective cohort. HELLP syndrome occurred in one patient, which resolved after delivery, and one patient experienced arterial hypertension and elevated transaminase. All infants had a good outcome (mean birth weight 3114 g, 10 males). Birth weight was significantly lower in the retrospective cohort (respectively 2806 g vs. 3320 g, p-value 0.017) in which higher doses of corticosteroids were used (median dose respectively 10.0 mg vs. 2.5 mg, p-value 0.048). Five recurrences of pericarditis occurred after delivery, easily treated with standard therapy. CONCLUSION General outcomes of pregnancy in patients with idiopathic recurrent pericarditis is good, especially when patients are carefully followed by multidisciplinary teams according to standardized protocols.
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Affiliation(s)
- Antonio Brucato
- Department of Biomedical and Clinical Science "L. Sacco", University of Milano, Italy
| | - Nikki Pluymaekers
- Department of Cardiology, Maastricht University Medical Center (MUMC+) and Cardiovascular Research Institute Maastricht (CARIM), Maastricht, the Netherlands.
| | - Enrico Tombetti
- Department of Biomedical and Clinical Science "L. Sacco", University of Milano, Italy
| | - Stefania Rampello
- Department of Obstetrics and Gynaecology, Ospedale Papa Giovanni XXIII, Bergamo, Italy
| | - Silvia Maestroni
- Department of Internal Medicine, Ospedale Papa Giovanni XXIII, Bergamo, Italy
| | - Marzia Lucianetti
- Department of Obstetrics and Gynaecology, Ospedale Papa Giovanni XXIII, Bergamo, Italy
| | - Anna Valenti
- Department of Internal Medicine, Ospedale Papa Giovanni XXIII, Bergamo, Italy
| | - Yehuda Adler
- The Gertner Institute, Sheba Medical Center, affiliated to Sackler Medical school, Tel Aviv University and the College for Academic Studies, Israel
| | - Massimo Imazio
- University Cardiology AOU, Città della Salute e della Scienza di Torino, Torino, Italy
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Prolactin, autoimmunity, and motherhood: when should women avoid breastfeeding? Clin Rheumatol 2019; 38:1263-1270. [PMID: 30635855 DOI: 10.1007/s10067-018-04415-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 12/25/2018] [Indexed: 01/22/2023]
Abstract
The sexual dimorphic prevalence of autoimmunity represents one of the most alluring observations among the mosaic of autoimmunity. Sex hormones are believed to be a mainstay of this asymmetry. The greater prevalence of autoimmunity among fertile women, disease onset/relapses during pregnancy, and postpartum are some of the points that support this theory. Undeniably, motherhood represents one of the most remarkable challenges for the immune system that not only has to allow for the conceptus but also deal with extraordinary hormonal alterations. Prolactin has a recognized immune-stimulatory effect, mainly inhibiting the negative selection of autoreactive B lymphocytes. In accordance, hyperprolactinemia has been associated with several autoimmune diseases, interfering with its pathogenesis and activity. During the pregnancy and lactation period, assorted autoimmune patients experience relapses, suggesting an active interference from increased levels of prolactin. This association was found to be significant in systemic lupus erythematosus, rheumatoid arthritis, and peripartum cardiomyopathy. Furthermore, treatment with bromocriptine has shown beneficial effects specially among systemic lupus erythematosus patients. In this review, we attempt to provide a critical overview of the link between prolactin, autoimmune diseases, and motherhood, emphasizing whether breastfeeding should be avoided among women, both with diagnosed disease or high risk for its development.
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Andreoli L, Gerardi MC, Fernandes M, Bortoluzzi A, Bellando-Randone S, Brucato A, Caporali R, Chighizola CB, Chimenti MS, Conigliaro P, Cutolo M, Cutro MS, D'Angelo S, Doria A, Elefante E, Fredi M, Galeazzi M, Gerosa M, Govoni M, Iuliano A, Larosa M, Lazzaroni MG, Matucci-Cerinic M, Meroni M, Meroni PL, Mosca M, Patanè M, Pazzola G, Pendolino M, Perricone R, Ramoni V, Salvarani C, Sebastiani GD, Selmi C, Spinelli FR, Valesini G, Scirè CA, Tincani A. Disease activity assessment of rheumatic diseases during pregnancy: a comprehensive review of indices used in clinical studies. Autoimmun Rev 2018; 18:164-176. [PMID: 30572134 DOI: 10.1016/j.autrev.2018.08.008] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Accepted: 08/24/2018] [Indexed: 01/30/2023]
Abstract
Pregnancy requires a special management in women with inflammatory rheumatic diseases (RDs), with the aim of controlling maternal disease activity and avoiding fetal complications. Despite the heterogeneous course of RDs during pregnancy, their impact on pregnancy largely relates to the extent of active inflammation at the time of conception. Therefore, accurate evaluation of disease activity is crucial for the best management of pregnant patients. Nevertheless, there are limitations in using conventional measures of disease activity in pregnancy, as some items included in these instruments can be biased by symptoms or by physiological changes related to pregnancy and the pregnancy itself may influence laboratory parameters used to assess disease activity. This article aims to summarize the current literature about the available instruments to measure disease activity during pregnancy in RDs. Systemic lupus erythematosus is the only disease with instruments that have been modified to account for several adaptations which might interfere with the attribution of signs or symptoms to disease activity during pregnancy. No modified-pregnancy indices exist for women affected by other RDs, but standard indices have been applied to pregnant patients. The current body of knowledge shows that the physiologic changes that occur during pregnancy need to be either adapted from existing instruments or developed to improve the management of pregnant women with RDs. Standardized instruments to assess disease activity during pregnancy would be helpful not only for clinical practice but also for research purposes.
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Affiliation(s)
- Laura Andreoli
- Rheumatology and Clinical Immunology, Spedali Civili and Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy.
| | - Maria Chiara Gerardi
- Rheumatology and Clinical Immunology, Spedali Civili and Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Melissa Fernandes
- Department of Internal Medicine, Autoimmune Disease Unit, Hospital Curry Cabral/Centro Hospitalar Lisboa Central, Lisbon, Portugal
| | - Alessandra Bortoluzzi
- Department of Medical Sciences, Rheumatology Unit, S. Anna Hospital, University of Ferrara, Ferrara, Italy
| | - Silvia Bellando-Randone
- Department of Experimental and Clinical Medicine, Division of Rheumatology AOUC, University of Florence, Florence, Italy
| | - Antonio Brucato
- Internal Medicine Division, Ospedale Papa Giovanni XXIII, Bergamo, Italy
| | - Roberto Caporali
- Division of Rheumatology, University and IRCCS Policlinico S. Matteo Foundation, Pavia, Italy
| | - Cecilia Beatrice Chighizola
- Department of Clinical Sciences and Community Health, Experimental Laboratory of Immunological and Rheumatologic Researches, IRCCS Istituto Auxologico Italiano, University of Milan, Cusano Milanino, Milan, Italy
| | - Maria Sole Chimenti
- Department of Medicina dei Sistemi, Rheumatology, Allergology and Clinical Immunology, University of Rome Tor Vergata, Rome, Italy
| | - Paola Conigliaro
- Department of Medicina dei Sistemi, Rheumatology, Allergology and Clinical Immunology, University of Rome Tor Vergata, Rome, Italy
| | - Maurizio Cutolo
- Department of Internal Medicine, Research Laboratory and Academic Division of Clinical Rheumatology, IRCCS San Martino Polyclinic Hospital, University of Genova, Genova, Italy
| | - Maria Stefania Cutro
- Rheumatology Department of Lucania, San Carlo Hospital of Potenza, Madonna delle Grazie of Matera, Matera, Italy
| | - Salvatore D'Angelo
- Rheumatology Department of Lucania, San Carlo Hospital of Potenza, Madonna delle Grazie of Matera, Matera, Italy
| | - Andrea Doria
- Division of Rheumatology, University of Padova, Padova, Italy
| | - Elena Elefante
- Department of Clinical and Experimental Medicine, Rheumatology Unit, University of Pisa, Pisa, Italy
| | - Micaela Fredi
- Rheumatology and Clinical Immunology, Spedali Civili and Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Mauro Galeazzi
- Rheumatology Unit, Department of Medical Sciences, Surgery and Neurosciences, Azienda ospedaliera Universitaria Senese, Siena, Italy
| | - Maria Gerosa
- Department of Clinical Sciences and Community Health, Department of Rheumatology, ASST Istituto Gaetano Pini & CTO, University of Milan, Milan, Italy
| | - Marcello Govoni
- Department of Medical Sciences, Rheumatology Unit, S. Anna Hospital, University of Ferrara, Ferrara, Italy
| | | | | | - Maria Grazia Lazzaroni
- Rheumatology and Clinical Immunology, Spedali Civili and Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Marco Matucci-Cerinic
- Department of Experimental and Clinical Medicine, Division of Rheumatology AOUC, University of Florence, Florence, Italy
| | - Marianna Meroni
- Rheumatology & Clinical Immunology, Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Pier Luigi Meroni
- Experimental Laboratory of Immunological and Rheumatologic Researches, IRCCS Istituto Auxologico Italiano, Cusano Milanino, Milan, Italy
| | - Marta Mosca
- Department of Clinical and Experimental Medicine, Rheumatology Unit, University of Pisa, Pisa, Italy
| | - Massimo Patanè
- Department of Internal Medicine, Research Laboratory and Academic Division of Clinical Rheumatology, IRCCS San Martino Polyclinic Hospital, University of Genova, Genova, Italy
| | - Giulia Pazzola
- Rheumatology Unit, Azienda USL-IRCCS di Reggio Emilia, Università di Modena e Reggio Emilia, Modena, Italy
| | - Monica Pendolino
- Department of Internal Medicine, Research Laboratory and Academic Division of Clinical Rheumatology, IRCCS San Martino Polyclinic Hospital, University of Genova, Genova, Italy
| | - Roberto Perricone
- Department of Medicina dei Sistemi, Rheumatology, Allergology and Clinical Immunology, University of Rome Tor Vergata, Rome, Italy
| | - Véronique Ramoni
- Division of Rheumatology, University and IRCCS Policlinico S. Matteo Foundation, Pavia, Italy
| | - Carlo Salvarani
- Rheumatology Unit, Azienda USL-IRCCS di Reggio Emilia, Università di Modena e Reggio Emilia, Modena, Italy
| | | | - Carlo Selmi
- Rheumatology & Clinical Immunology, Humanitas Research Hospital, Rozzano, Milan, Italy; BIOMETRA Department, University of Milan, Milan, Italy
| | - Francesca Romana Spinelli
- Dipartimento di Medicina Interna e Specialità Mediche-Reumatologia, Sapienza University of Rome, Rome, Italy
| | - Guido Valesini
- Dipartimento di Medicina Interna e Specialità Mediche-Reumatologia, Sapienza University of Rome, Rome, Italy
| | - Carlo Alberto Scirè
- Department of Medical Sciences, Rheumatology Unit, S. Anna Hospital, University of Ferrara, Ferrara, Italy; Epidemiology Unit, Italian Society for Rheumatology (SIR), Milan, Italy
| | - Angela Tincani
- Rheumatology and Clinical Immunology, Spedali Civili and Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy; Department of Clinical and Experimental Medicine, Rheumatology Unit, University of Pisa, Pisa, Italy
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Decision making and outcome of pregnancies in female patients with inflammatory bowel disease: findings from a community-based practice. Eur J Gastroenterol Hepatol 2018. [PMID: 29543610 DOI: 10.1097/meg.0000000000001117] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION The aim of this study was to evaluate information provided on pregnancy, personal decision making, disease course, and outcome of pregnancy from a patient's perspective in a population of patients with inflammatory bowel disease (IBD) attending two general hospitals. PATIENTS AND METHODS A questionnaire was sent to all female patients with IBD in two general hospitals in the Netherlands. The questionnaire comprised four sections: (i) demographic data and medication use (ii) details on previous pregnancies and reasons for not becoming pregnant, (iii) outcome of pregnancies before IBD diagnosis, and (iv) outcome of pregnancies after IBD diagnosis. If necessary, medical records were reviewed to verify responses or for further medical details. RESULTS In total, 385 women returned the questionnaire, 501 completed pregnancies were reported, and 113 women had never been pregnant. In 272 women with at least one pregnancy, 334 pregnancies occurred before IBD diagnosis, 157 after IBD diagnosis, and in 10 cases, IBD was diagnosed during pregnancy. Medication for IBD was used in 67% of pregnancies after IBD diagnosis, mainly 5-ASA preparations (54%). Women with ulcerative colitis experienced more IBD-related complaints during pregnancy compared with women with Crohn's disease (25 vs. 14%, P=0.016). Additional medication (n=21) or surgery (n=2) for IBD during pregnancy was indicated in 14% of cases. Most women reported an uneventful pregnancy course (79%). Preterm birth occurred in 13% of pregnancies. CONCLUSION Pregnancy in women with IBD seen in a general hospital can be managed with a good outcome. Step-up therapy is needed in a minority of cases, and severe complications are rare.
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Borba VV, Zandman-Goddard G, Shoenfeld Y. Prolactin and Autoimmunity. Front Immunol 2018; 9:73. [PMID: 29483903 PMCID: PMC5816039 DOI: 10.3389/fimmu.2018.00073] [Citation(s) in RCA: 109] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2017] [Accepted: 01/11/2018] [Indexed: 12/17/2022] Open
Abstract
The great asymmetry of autoimmune diseases between genders represents one of the most enigmatic observations among the mosaic of autoimmunity. Sex hormones are believed to play a crucial role on this dimorphism. The higher prevalence of autoimmunity among women at childbearing ages, disease onset/relapses during pregnancy, and post-partum are some of the arguments that support this hypothesis. Certainly, motherhood represents one of the most remarkable challenges for the immune system, which not only has to allow for the conceptus, but also has to deal with complex endocrine alterations. Hormonal homeostasis is known to exert a crucial influence in achieving a competent and healthy immune system. Prolactin (PRL) has a bioactive function acting as a hormone and a cytokine. It interferes with immune system modulation, mainly inhibiting the negative selection of autoreactive B lymphocytes. Likewise, hyperprolactinemia has been described in relation to the pathogenesis and activity of several autoimmune disorders. Dopamine is an effective inhibitor of PRL secretion due to either a direct influence on the hypophysis or stimulation of postsynaptic dopamine receptors in the hypothalamus, arousing the release of the PRL inhibitory factor. Hence, dopamine agonists have proven to offer clinical benefits among autoimmune patients and represent a promising therapy to be explored. In this review, we attempt to provide a critical overview of the link between PRL, autoimmune diseases, and motherhood.
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Affiliation(s)
- Vânia Vieira Borba
- Department "A" of Internal Medicine, Coimbra University Hospital Centre, Coimbra, Portugal.,Faculty of Medicine, University of Coimbra, Coimbra, Portugal.,Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel
| | | | - Yehuda Shoenfeld
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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Betelli M, Breda S, Ramoni V, Parisi F, Rampello S, Limonta M, Meroni M, Brucato A. Pregnancy in systemic sclerosis. JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2018; 3:21-29. [PMID: 35382124 PMCID: PMC8892876 DOI: 10.1177/2397198317747440] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/08/2017] [Indexed: 09/06/2023]
Abstract
This comprehensive review summarizes retrospective and prospective studies on pregnancy in systemic sclerosis in order to educate physicians on critical management issues. Fertility is normal in women with established systemic sclerosis. Their rates of spontaneous losses are comparable to the general population, except for patients with late diffuse systemic sclerosis and severe internal organ involvement who may have higher risks of abortion. Prematurity is clearly higher among systemic sclerosis women, similarly to other rheumatic diseases such as systemic lupus erythematosus and anti-phospholipid antibody syndrome. A placental vasculopathy has been observed in some women with systemic sclerosis. Overall, the disease generally remains stable in most pregnancies. Women with pulmonary hypertension should avoid pregnancy on account of the high maternal mortality risk. Management of systemic sclerosis patients before and during pregnancy includes evaluation of organ involvement and autoantibody analysis, preconceptional folic acid, and discontinuation of drugs with teratogenic potential (bosentan, mycophenolate mofetil, methotrexate, etc.). Management by high-risk pregnancy teams including neonatologists is very important to ensure the best outcomes.
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Affiliation(s)
- Mauro Betelli
- Internal Medicine, Bolognini Hospital,
Bergamo - Italy
| | - Silvia Breda
- Internal Medicine, Papa Giovanni XXIII
Hospital, Bergamo - Italy
| | - Veronique Ramoni
- Rheumatology, IRCCS Policlinico San
Matteo Foundation, Pavia - Italy
| | - Federico Parisi
- Internal Medicine, Papa Giovanni XXIII
Hospital, Bergamo - Italy
| | - Stefania Rampello
- Gynecology and Obstetrics, Papa Giovanni
XXIII Hospital, Bergamo - Italy
| | | | - Marianna Meroni
- Rheumatology, University of Genoa and
A.O.S.S. Arrigo, Alessandria - Italy
| | - Antonio Brucato
- Internal Medicine, Papa Giovanni XXIII
Hospital, Bergamo - Italy
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37
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Iijima S. Fetal and neonatal involvement in maternal rheumatologic disease. J Matern Fetal Neonatal Med 2017; 31:2079-2085. [DOI: 10.1080/14767058.2017.1334048] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Shigeo Iijima
- Department of Pediatrics, Hamamatsu University School of Medicine, Hamamatsu, Japan
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Kah Teik C, Ahmad MF, Soon Leong Y, Mohamed Ismail NA. Pulmonary hypertension complicating systemic sclerosis: A successful pregnancy outcome. J OBSTET GYNAECOL 2017; 37:677-678. [PMID: 28350528 DOI: 10.1080/01443615.2017.1284774] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Chew Kah Teik
- a Department of Obstetrics and Gynaecology, Faculty of Medicine , Universiti Kebangsaan Malaysia Medical Centre , Kuala Lumpur , Malaysia
| | - Mohd Faizal Ahmad
- a Department of Obstetrics and Gynaecology, Faculty of Medicine , Universiti Kebangsaan Malaysia Medical Centre , Kuala Lumpur , Malaysia
| | - Yong Soon Leong
- a Department of Obstetrics and Gynaecology, Faculty of Medicine , Universiti Kebangsaan Malaysia Medical Centre , Kuala Lumpur , Malaysia
| | - Nor Azlin Mohamed Ismail
- a Department of Obstetrics and Gynaecology, Faculty of Medicine , Universiti Kebangsaan Malaysia Medical Centre , Kuala Lumpur , Malaysia
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Pregnancy-Related Challenges in Systemic Autoimmune Diseases. JOURNAL OF INFUSION NURSING 2017; 38:360-8. [PMID: 26339942 DOI: 10.1097/nan.0000000000000124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The awareness of pregnancy-related physiologic changes and complications is critical for the appropriate assessment and management of pregnant patients with systemic autoimmune diseases. The overlapping features of physiologic and pathological changes, selected autoantibodies, and the use of potentially teratogenic medications can complicate their management during pregnancy. While pregnancy in lupus patients presents an additional risk to an already complex situation, in patients with no disease activity, the risk of a future pregnancy-related complication is relatively low. Anti-Ro and anti-La antibodies increase the risk of neonatal lupus erythematosus, eg, photosensitive rash and irreversible congenital heart block. Antiphospholipid antibodies increase the risk of pregnancy morbidity, eg, fetal loss and early preeclampsia. Pregnancy usually has a positive effect on rheumatoid arthritis; however, a disease flare is common during the postpartum period. Both the rheumatologist and the obstetrician should partner throughout the pregnancy to manage patients for successful outcomes.
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40
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Levy RA, de Jesús GR, de Jesús NR, Klumb EM. Critical review of the current recommendations for the treatment of systemic inflammatory rheumatic diseases during pregnancy and lactation. Autoimmun Rev 2016; 15:955-63. [PMID: 27490204 DOI: 10.1016/j.autrev.2016.07.014] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2016] [Accepted: 07/07/2016] [Indexed: 02/08/2023]
Abstract
The crucial issue for a better pregnancy outcome in women with autoimmune rheumatic diseases is appropriate planning, with counseling of the ideal timing and treatment adaptation. Drugs used to treat rheumatic diseases may interfere with fertility or increase the risk of miscarriages and congenital abnormalities. MTX use post-conception is clearly linked to abortions as well as major birth defects, so it should be stopped 3months before conception. Leflunomide causes abnormalities in animals even in low doses. Although in humans, it does not seem to be as harmful as MTX, when pregnancy is detected in a patient on leflunomide, cholestyramine is given for washout. Sulfasalazine can be used safely and is an option for those patients who were on MTX or leflunomide. Azathioprine is generally the immunosuppressive of choice in many high-risk pregnancy centers because of the safety profile and its steroid-sparing property. Cyclosporine and tacrolimus can also be used as steroid-sparing agents, but experience is smaller. Although prednisone and prednisolone are inactivated in the placenta, we try to limit the dose to the minimal effective one, to prevent side effects. Antimalarials have been broadly studied and are safe during pregnancy and breastfeeding. Among biologic disease modifying anti-rheumatic agents (bDMARD), the anti-TNFs that have been used for longer are the ones with greater experience. The large monoclonal antibodies do not cross the placenta in the first trimester, and after conception, the decision to continue medication should be taken individually. The experience is larger in women with inflammatory bowel diseases, where anti-TNF is generally maintained at least until 30weeks to reduce fetal exposure. Live vaccines should not be administrated to the infant in the first 6months of life. Pregnancy data for rituximab, abatacept, anakinra, tocilizumab, ustekinumab, belimumab, and tofacitinib are limited and their use in pregnancy cannot currently be recommended.
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Affiliation(s)
- Roger A Levy
- Department of Rheumatology, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil; Pós-graduação em Ciências Médicas (PGCM), Faculdade de Ciências, Médicas, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil.
| | - Guilherme R de Jesús
- Department of Obstetrics, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil; Department of Obstetrics, Instituto Fernandes Figueira, FIOCRUZ, Rio de Janeiro, Brazil; Pós-graduação em Ciências Médicas (PGCM), Faculdade de Ciências, Médicas, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Nilson R de Jesús
- Department of Obstetrics, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Evandro M Klumb
- Department of Rheumatology, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil; Pós-graduação em Ciências Médicas (PGCM), Faculdade de Ciências, Médicas, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil
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Tincani A, Dall'Ara F, Lazzaroni MG, Reggia R, Andreoli L. Pregnancy in patients with autoimmune disease: A reality in 2016. Autoimmun Rev 2016; 15:975-7. [PMID: 27481037 DOI: 10.1016/j.autrev.2016.07.017] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Accepted: 07/08/2016] [Indexed: 10/21/2022]
Abstract
Autoimmune rheumatic diseases are chronic systemic conditions often affecting young women during their reproductive years, so that pregnancy is a major issue in their management. For a long time pregnancy has been discouraged in these women, mainly for two reasons: gestation could aggravate maternal disease and, vice versa, the disease could negatively influence the gestational outcome. The great improvement in the approach to pregnancy done in the past few decades has allowed a progressively increasing number of affected women to fulfill their family plan. Women should be informed about potential risks related to their disease, but they should also be reassured that a good pregnancy outcome is possible if conception occurs in a stable remission state, teratogenic medications have been properly withdrawn and "safe" drugs have been mantained to prevent disease flare. A brief excursus regarding the main issues regarding SLE/APS, Systemic Sclerosis and Systemic Vasculitis is provided, in the attempt to delineate the main risk factors for adverse pregnancy outcome, the onset of maternal complications and the role played by a close multi-specialistic monitoring.
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Affiliation(s)
- A Tincani
- Rheumatology and Clinical Immunology, Spedali Civili and University of Brescia, Brescia, Italy.
| | - F Dall'Ara
- Rheumatology and Clinical Immunology, Spedali Civili and University of Brescia, Brescia, Italy
| | - M G Lazzaroni
- Rheumatology and Clinical Immunology, Spedali Civili and University of Brescia, Brescia, Italy
| | - R Reggia
- Rheumatology and Clinical Immunology, Spedali Civili and University of Brescia, Brescia, Italy
| | - L Andreoli
- Rheumatology and Clinical Immunology, Spedali Civili and University of Brescia, Brescia, Italy
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Pregnancy and autoimmune connective tissue diseases. Best Pract Res Clin Rheumatol 2016; 30:63-80. [PMID: 27421217 DOI: 10.1016/j.berh.2016.05.002] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Revised: 05/24/2016] [Accepted: 05/29/2016] [Indexed: 12/28/2022]
Abstract
Autoimmune connective tissue diseases predominantly affect women and often occur during the reproductive years. Thus, specialized issues in pregnancy planning and management are commonly encountered in this patient population. This chapter provides a current overview of pregnancy as a risk factor for onset of autoimmune disease, considerations related to the course of pregnancy in several autoimmune connective tissue diseases, and disease management and medication issues before pregnancy, during pregnancy, and in the postpartum period. A major theme that has emerged across these inflammatory diseases is that active maternal disease during pregnancy is associated with adverse pregnancy outcomes, and that maternal and fetal health can be optimized when conception is planned during times of inactive disease and through maintaining treatment regimens compatible with pregnancy.
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Martínez López JA, García Vivar ML, Cáliz R, Freire M, Galindo M, Hernández MV, López Longo FJ, Martínez Taboada V, Pego Reigosa JM, Rubio E, Trujillo E, Vela-Casasempere P. Recommendations for the evaluation and management of patients with rheumatic autoimmune and inflammatory diseases during the reproductive age, pregnancy, postpartum and breastfeeding. ACTA ACUST UNITED AC 2016; 13:264-281. [PMID: 27321859 DOI: 10.1016/j.reuma.2016.05.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Revised: 05/02/2016] [Accepted: 05/07/2016] [Indexed: 01/18/2023]
Abstract
OBJECTIVE To develop recommendations on the evaluation and management of patients with rheumatic autoimmune and inflammatory diseases during the reproductive age, pregnancy, post-partum and breastfeeding based on the best evidence and experience. METHODS Recommendations were generated using nominal group and Delphi techniques. An expert panel of 12 rheumatologists was established. A systematic literature review and a narrative review (websites, clinical guidelines and other relevant documentation) were performed and presented to the panel in its 1st meeting to be discussed and to help define recommendations. A first draft of recommendations was generated and circulated for comments and wording refinement. A national survey analyzing different aspects of this topic was undertaken separately, followed by a Delphi process (2 rounds). Agreement with each recommendation was ranked on a scale of 1 (total disagreement) to 10 (total agreement), and was considered to be achieved if at least 70% voted≥7. The level of evidence and grade of recommendation were assessed using the Oxford Centre for Evidence-based Medicine Levels of Evidence. RESULTS A total of 14 recommendations were generated for the preconception period (oral and hormonal contraception, reproductive techniques), pregnancy (planning, treatment and follow-up), and breastfeeding (treatment and follow-up). High-risk situations such as lupus or antiphospholipid syndrome were included. A consensus>90% was reached for all but one recommendation. CONCLUSIONS These recommendations are intended to provide rheumatologists, patients, families and other stakeholders with a consensus on the evaluation and management of patients with autoimmune and inflammatory diseases during the reproductive age, pregnancy, postpartum and breastfeeding.
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Affiliation(s)
| | - M Luz García Vivar
- Servicio de Reumatología, Hospital Universitario Basurto, Bilbao, España
| | - Rafael Cáliz
- Unidad de Gestión de Reumatología, Complejo Hospitalario Universitario de Granada, Granada, España
| | - Mercedes Freire
- Servicio de Reumatología, Complexo hospitalario Universitario A Coruña (CHUAC), A Coruña, España
| | - María Galindo
- Servicio de Reumatología, Hospital Universitario 12 de Octubre, Madrid, España
| | | | | | - Víctor Martínez Taboada
- Servicio de Reumatología, Hospital Universitario Marqués de Valdecilla, Santander, España; Facultad de Medicina, Universidad de Cantabria, Santander, España
| | - Jose María Pego Reigosa
- Servicio de Reumatología, Hospital Meixoeiro-Complexo Hospitalario Universitario de Vigo, Vigo, España
| | - Esteban Rubio
- Servicio de Reumatología, Hospital Universitario Virgen del Rocío, Sevilla, España
| | - Elisa Trujillo
- Servicio de Reumatología, Hospital Universitario de Canarias, Santa Cruz de Tenerife, España
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Abstract
A very critical feature in women's health is the identification of risk factors for pregnancy and adverse fetal outcome. Primary biliary cirrhosis is an autoimmune disease of the liver that predominantly affects older women. However, the serologic onset of this disease appears to precede clinical manifestations by many years. The goal of this case controlled study was to analyze fertility in primary biliary cirrhosis (PBC) and investigate the outcome of pregnancy, and the influence of pregnancy on the course of the disease. The study included 233 consecutive female patients with PBC seen between 1987 and 2012. Among them, 186 had at least one conception and were matched for age with a 1:2 group of controls (367 healthy women with at least one conception in their life). PBC patients experienced 507 pregnancies as opposed to 700 pregnancies among controls (mean 1.91 vs 2.73, p < 0.05). The two groups' life history was similar in terms of miscarriages, voluntary interruptions of pregnancy, and term and preterm deliveries. The rates for one or more cesarean deliveries were lower for PBC patients (5.7 vs 11.7 %, p < 0.05). Pruritus during pregnancy was recorded in 15 pregnancies involving 13 PBC patients (3.0 %) and none of the controls. Perinatal and postnatal deaths and complications at childbirth were only recorded in the PBC patients, involving a total of 11 babies (2.7 %, p < 0.05). Eight pregnancies occurred after PBC was diagnosed in six patients, all of which had a favorable course at term, with no complications at childbirth. Ursodeoxycholic acid was continued during pregnancy and no exacerbation of the disease was observed. In conclusion, successful completion of pregnancy is a realistic expectation for PBC patients, though pregnancy and delivery must be monitored for the potentially higher than normal risk of childbirth complications.
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Quantitative Skeletal Muscle MRI: Part 2, MR Spectroscopy and T2 Relaxation Time Mapping-Comparison Between Boys With Duchenne Muscular Dystrophy and Healthy Boys. AJR Am J Roentgenol 2015. [PMID: 26204310 DOI: 10.2214/ajr.14.13755] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVE The purpose of this study is to validate the use of MR spectroscopy (MRS) in measuring muscular fat and to compare it with T2 maps in differentiating boys with Duchenne muscular dystrophy (DMD) from healthy boys. SUBJECTS AND METHODS Forty-two boys with DMD and 31 healthy boys were evaluated with MRI with (1)H-MRS and T2 maps. Grading of muscle fat and edema on conventional images, calculation of fat fractions ([fat / fat] + water) on MRS, and calculation of T2 fat values on T2 maps of the gluteus maximus and vastus lateralis muscles were performed. Group comparisons were made. The 95% reference interval (RI) of fat fraction for the control group was applied and compared with T2 map results. RESULTS Minimal fat on T1-weighted images was seen in 90.3% (gluteus maximus) and 71.0% (vastus lateralis) of healthy boys, versus 33.3% (gluteus maximus) and 52.4% (vastus lateralis) of boys with DMD. Muscle edema was seen in none of the healthy boys versus 52.4% (gluteus maximus) and 57.1% (vastus lateralis) of the boys with DMD. Fat fractions were higher in the DMD group (52.7%, gluteus maximus; 27.3%, vastus lateralis) than in the control group (12.8%, gluteus maximus; 13.7%, vastus lateralis) (p < 0.001). The 95% RI for gluteus maximus (38.7%) resulted in 61.9% sensitivity and 100% specificity for differentiating boys with DMD from healthy boys, whereas the value for vastus lateralis (17.8%) resulted in 76.2% sensitivity and 100% specificity; both had lower accuracy than did T2 maps (100% sensitivity and specificity). There was a positive correlation between T2 fat values and fat fractions (p < 0.0001). CONCLUSION In differentiation of the two groups, T2 maps were more accurate than MRS. Fat fractions can underestimate the actual amount of fat because of coexisting muscle edema in DMD.
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Autoimmune connective tissue diseases. Best Pract Res Clin Obstet Gynaecol 2015; 29:658-70. [DOI: 10.1016/j.bpobgyn.2015.03.003] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Revised: 03/02/2015] [Accepted: 03/06/2015] [Indexed: 11/17/2022]
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Moaveni D, Cohn J, Brodt J, Hoctor K, Ranasinghe J. Scleroderma and pulmonary hypertension complicating two pregnancies: use of neuraxial anesthesia, general anesthesia, epoprostenol and a multidisciplinary approach for cesarean delivery. Int J Obstet Anesth 2015; 24:375-82. [PMID: 26119257 DOI: 10.1016/j.ijoa.2015.05.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2014] [Revised: 05/01/2015] [Accepted: 05/03/2015] [Indexed: 10/23/2022]
Abstract
Literature regarding the anesthetic care of patients with scleroderma during labor and delivery is limited to remote case reports. No recent publications provide information on the anesthetic management of patients with coexisting pulmonary hypertension. This report describes the anesthetic and multidisciplinary management of two pregnant patients with concomitant scleroderma and pulmonary hypertension undergoing cesarean delivery; one with neuraxial anesthesia and one with general anesthesia. Considerations for neuraxial and general anesthesia in patients with concurrent scleroderma and pulmonary hypertension are discussed.
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Affiliation(s)
- D Moaveni
- University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL, USA.
| | - J Cohn
- University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL, USA
| | - J Brodt
- University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL, USA
| | - K Hoctor
- University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL, USA
| | - J Ranasinghe
- University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL, USA
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Systemic vasculitis and pregnancy: a multicenter study on maternal and neonatal outcome of 65 prospectively followed pregnancies. Autoimmun Rev 2015; 14:686-91. [PMID: 25858351 DOI: 10.1016/j.autrev.2015.03.009] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Accepted: 03/31/2015] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Systemic vasculitis (SV) are uncommon diseases that rarely affect women during their reproductive age; little data, mainly retrospective, is available on this topic. The aim of our study was to evaluate maternal/neonatal outcome and disease course before, during and after pregnancy. METHODS Sixty-five pregnancies in 50 women with SV were followed by a multispecialistic team in 8 institutions between 1995 and 2014. Clinical data on pregnancy, 1year before and 1year after delivery was retrospectively collected. The rate of pregnancy complications was compared to that of a General Obstetric Population (GOP) of 3939 women. RESULTS In 2 patients the diagnosis of SV was done during pregnancy; 59 out of the remaining 63 started when maternal disease was quiescent. We recorded 56 deliveries with 59 live births, 8 miscarriages and 1 fetal death. In SV, preterm, particularly early preterm (<34weeks) deliveries and cesarean sections appeared significantly more frequent than in GOP (11.3% vs 5.0%, p=0.049 and 48.2% vs 31.0%, p=0.009). Vasculitis-related complications occurred in 23 pregnancies (35.4%), with 5 severe events (7.7%) including 3 cases of transient ischemic attack (TIA). Data about the post-partum period were available for 56 pregnancies: 12 flares (21.4%) occurred, with 1 severe event (1.8%). CONCLUSION SV patients can have successful pregnancies (especially during a disease remission phase) despite an increased rate of preterm delivery. Severe flares were limited, but the occurrence of 3 TIA suggests that particular attention should be given to possible thrombotic complications in SV patients during pregnancy and puerperium.
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Østensen M, Andreoli L, Brucato A, Cetin I, Chambers C, Clowse MEB, Costedoat-Chalumeau N, Cutolo M, Dolhain R, Fenstad MH, Förger F, Wahren-Herlenius M, Ruiz-Irastorza G, Koksvik H, Nelson-Piercy C, Shoenfeld Y, Tincani A, Villiger PM, Wallenius M, von Wolff M. State of the art: Reproduction and pregnancy in rheumatic diseases. Autoimmun Rev 2014; 14:376-86. [PMID: 25555818 DOI: 10.1016/j.autrev.2014.12.011] [Citation(s) in RCA: 129] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Accepted: 12/23/2014] [Indexed: 12/13/2022]
Abstract
Throughout the last decade, increasing awareness has been raised on issues related to reproduction in rheumatic diseases including basic research to clarify the important role of estrogens in the etiology and pathophysiology of immune/inflammatory diseases. Sub- or infertility is a heterogeneous condition that can be related to immunological mechanisms, to pregnancy loss, to disease burden, to therapy, and to choices in regard to family size. Progress in reproductive medicine has made it possible for more patients with rheumatic disease to have children. Active disease in women with rheumatoid arthritis (RA) affects their children's birth weight and may have long-term effects on their future health status. Pregnancy complications as preeclampsia and intrauterine growth restriction are still increased in patients with systemic lupus erythematosus (SLE) and antiphospholipid syndrome (APS), however, biomarkers can monitor adverse events, and several new therapies may improve outcomes. Pregnancies in women with APS remain a challenge, and better therapies for the obstetric APS are needed. New prospective studies indicate improved outcomes for pregnancies in women with rare diseases like systemic sclerosis and vasculitis. TNF inhibitors hold promise for maintaining remission in rheumatological patients and may be continued at least in the first half of pregnancy. Pre-conceptional counseling and interdisciplinary management of pregnancies are essential for ensuring optimal pregnancy outcomes.
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Affiliation(s)
- Monika Østensen
- National Advisory Unit on Pregnancy and Rheumatic Diseases, Department of Rheumatology, St. Olavs Hospital, University Hospital of Trondheim, Norway.
| | - Laura Andreoli
- Rheumatology and Clinical Immunology, Spedali Civili of Brescia, Department of Clinical and Experimental Sciences, University of Brescia, Italy
| | - Antonio Brucato
- Department of Internal Medicine, Ospedale papa Giovanni XXIII Bergamo, Italy
| | - Irene Cetin
- Department of Mother and Child, Hospital Luigi Sacco, University of Milano, Italy
| | - Christina Chambers
- Department of Pediatrics, University of California San Diego, La Jolla, CA 92093-0828, USA
| | - Megan E B Clowse
- Division of Rheumatology, Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Nathalie Costedoat-Chalumeau
- Université Paris-Descartes, Paris, France; AP-HP, Hôpital Cochin, Centre de référence maladies auto-immunes et systémiques rares, Service de médecine interne, Paris, France
| | - Maurizio Cutolo
- Research Laboratories and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, Genova, Italy
| | - Radboud Dolhain
- Department of Rheumatology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - M H Fenstad
- Department of Immunology and Transfusion Medicine, St. Olavs Hospital, Trondheim, Norway
| | - Frauke Förger
- Department of Rheumatology and Clinical Immunology/Allergology, University Hospital of Bern, CH-3010 Bern, Switzerland
| | - Marie Wahren-Herlenius
- Department of Medicine, Centre for Molecular Medicine, Karolinska Universitetssjukhuset, Stockholm, Sweden
| | - Guillermo Ruiz-Irastorza
- Autoimmune Diseases Research Unit, Department of Internal Medicine, Biocruces Health Research Institute, Hospital Universitario Cruces, University of the Basque Country, Bizkaia, Spain
| | - Hege Koksvik
- National Advisory Unit on Pregnancy and Rheumatic Diseases, Department of Rheumatology, St. Olavs Hospital, University Hospital of Trondheim, Norway
| | | | - Yehuda Shoenfeld
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Aviv University, Tel-Hashomer, Israel
| | - Angela Tincani
- Department of Rheumatology and Clinical Immunology, Ospedale Civile and University of Brescia, Brescia, Italy
| | - Peter M Villiger
- Department of Rheumatology and Clinical Immunology/Allergology, University Hospital of Bern, Bern, Switzerland
| | - Marianne Wallenius
- National Service for Pregnancy and Rheumatic Diseases, Department of Rheumatology, Trondheim University Hospital, Trondheim, Norway; Dept of Neuroscience, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Michael von Wolff
- University Women's Hospital, Division of Gynaecological Endocrinology and Reproductive Medicine, University of Berne, Berne, Switzerland
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