Breastfeeding in women with systemic lupus erythematosus: results from a Norwegian quality register

BACKGROUND

Knowledge on breastfeeding among women with systemic lupus erythematosus (SLE) is sparse. We wanted to identify the frequency of breastfeeding in SLE, and to compare breastfeeding women with SLE to non-breastfeeding women to examine possible differences in disease characteristics and self-reported health data between the groups.

METHODS

Prospective data on women with SLE from RevNatus, a consent-based Norwegian nationwide quality register was used for this study. Data were collected during January 2016 to September 2021. We used data registered at inclusion when planning pregnancy or in 1^st trimester, and 6 weeks, 6 and 12 months after delivery. Breastfeeding and non-breastfeeding patients were compared according to demographic, serological and obstetric data as well as disease activity, medication, self-reported pain, and fatigue.

RESULTS

A total of 114 pregnancies in 101 SLE women were included in the analysis. A majority of the women (78%) breastfed six weeks postpartum. Six and 12 months after delivery, breastfeeding rates were 54% and 30% respectively. Six weeks postpartum, non-breastfeeding women showed higher prevalence of emergency caesarean delivery (p = 0.038), preeclampsia (p = 0.056) and lower educational level (p = 0.046) compared to breastfeeding women. 12 months after delivery, we observed a higher frequency of multiparity among breastfeeding women (p = 0.017) compared to non-breastfeeding. Overall, we found low disease activity in both groups at all registrations in the follow-up, and disease activity did not differ between the groups. More than 70% of both breastfeeding and non-breastfeeding women used hydroxychloroquine (HCQ).

CONCLUSIONS

Breastfeeding rate in women with SLE was high six weeks postpartum. Multiparous women breastfed longer than primiparas. Disease activity, use of HCQ, and self-reported health data were comparable between the groups. Our data indicate that health professionals should encourage women with SLE to breastfeed.

Perspectives of Adult Rheumatologists Regarding Family Planning Counseling and Care: A Qualitative Study

OBJECTIVE

Little is known about whether and how rheumatologists provide family planning counseling and reproductive health care (FPCC) to reproductive-age women with rheumatic diseases. This qualitative study sought to assess rheumatologists' perspectives, attitudes, and practices regarding FPCC.

METHODS

Semistructured interviews were conducted with a geographically diverse US sample of rheumatologists (n = 12). Interviews were transcribed verbatim, and a code book was inductively developed based on transcript content. Two coders applied the code book to all transcripts, and coding differences were adjudicated to full agreement. The finalized coding was used to conduct a thematic analysis.

RESULTS

Six themes were identified across interviews. Rheumatologists said that they 1) feel responsible for providing some FPCC to patients, 2) experience tension between respecting patients' autonomy and their own anxieties about managing high-risk pregnancies, 3) view patient-initiated conversations as FPCC facilitators, and they regard lack of guidelines and the presence of competing clinical priorities as barriers to FPCC, 4) are reluctant to prescribe contraception, 5) desire greater access to resources to help guide FPCC, and 6) recognize the benefits of multidisciplinary collaboration with gynecologists.

CONCLUSION

Rheumatologists feel a sense of responsibility to provide some aspects of FPCC to reproductive-age female patients. However, their own apprehensions about managing complicated pregnancies may negatively influence how they advise patients about pregnancy planning or avoidance. Rheumatologists do not prescribe contraception but rarely refer patients to gynecologists for contraceptive care. Future work should focus on eliminating barriers and identifying solutions that support rheumatologists' efforts to provide high-quality FPCC to patients.

Update on pregnancy complications in systemic lupus erythematosus

PURPOSE OF REVIEW

This review summarizes recent research in the field of systemic lupus erythematosus (SLE) and pregnancy with focus on clinical and biochemical predictors of adverse pregnancy outcomes (APOs), accumulating evidence for the safety and efficacy of hydroxychloroquine (HCQ) in pregnancy, and the importance of preconception counseling.

RECENT FINDINGS

Ongoing research from PROMISSE investigators (Predictors of Pregnancy Outcome: Biomarkers in Antiphospholipid Antibody Syndrome and Systemic Lupus Erythematosus) adds to the understanding of risk factors for APOs in SLE pregnancies, including aberrant complement activation, incomplete downregulation of lupus-associated transcription factors, and lower socioeconomic status. Evidence supporting numerous advantages for continuing HCQ in pregnancy, as well as support for low-dose aspirin in preeclampsia prevention is reviewed. Practice gaps exist among rheumatologists in ensuring effective contraception when women of childbearing age are undergoing therapy with potentially fetotoxic medications. The publication of organizational guidelines provides evidence-based recommendations on lupus pregnancy management.

SUMMARY

Outcomes of lupus pregnancies continue to improve with understanding of risk factors that predict APOs as well as improvements in disease management. Rheumatologists caring for women with SLE should be familiar with the most up-to-date research in order to optimize pregnancy outcomes in this population.

Maternal and environmental risk factors for neonatal AKI and its long-term consequences

Acute kidney injury (AKI) is a common and life-threatening complication in critically ill neonates. Gestational risk factors for AKI include premature birth, intrauterine growth restriction and low birthweight, which are associated with poor nephron development and are often the consequence of pre-gestational and gestational factors, such as poor nutritional status. Our understanding of how to best optimize renal development and prevent AKI is in its infancy; however, the identification of pre-gestational and gestational factors that increase the risk of adverse neonatal outcomes and the implementation of interventions, such as improving nutritional status early in pregnancy, have the potential to optimize fetal growth and reduce the risk of preterm birth, thereby improving kidney health. The overall risk of AKI among critically ill and premature neonates is exacerbated postnatally as these infants are often exposed to dehydration, septic shock and potentially nephrotoxic medications. Strategies to improve outcomes - for example, through careful evaluation of nephrotoxic drugs - may reduce the incidence of AKI and its consequences among this population. Management strategies and updated technology that will support neonates with AKI are greatly needed. Extremely premature infants and those who survive an episode of AKI should be screened for chronic kidney disease until early adulthood. Here, we provide an overview of our current understanding of neonatal AKI, focusing on its relationship to preterm birth and growth restriction. We describe factors that prevent optimal nephrogenesis during pregnancy and provide a framework for future explorations designed to maximize outcomes in this vulnerable population.

Influence of disease activity and medications on offspring birth weight, pre-eclampsia and preterm birth in systemic lupus erythematosus: a population-based study

Objectives

Exploring the associations between disease activity and medications with offspring birth weight, pre-eclampsia and preterm birth in systemic lupus erythematosus (SLE).

Methods

Data from the Medical Birth Registry of Norway (MBRN) were linked with data from RevNatus, a nationwide observational register recruiting women with inflammatory rheumatic diseases. Singleton births in women with SLE included in RevNatus 2006–2015 were cases (n=180). All other singleton births registered in MBRN during this time (n=498 849) served as population controls. Z-score for birth weight adjusted for gestational age and gender was calculated. Disease activity was assessed using Lupus Activity Index in Pregnancy. We compared z-scores for birth weight, pre-eclampsia and preterm birth in cases with inactive disease, cases with active disease and population controls.

Results

Z-scores for birth weight in offspring were lower in inactive (−0.64) and active (−0.53) diseases than population controls (−0.11). Inactive disease did not predict pre-eclampsia while active disease yielded OR 5.33 and OR 3.38 compared with population controls and inactive disease, respectively. Preterm birth occurred more often in inactive (OR 2.57) and active (OR 8.66) diseases compared with population controls, and in active compared with inactive disease (OR 3.36).

Conclusions

SLE has an increased odds for low birth weight and preterm birth, amplified by active disease. The odds for pre-eclampsia is elevated in active, but not inactive disease. This calls for tight follow-up targeting inactive disease before and throughout pregnancy.

Pregnancy and infant outcomes including major congenital malformations among women with chronic inflammatory arthritis or psoriasis, with and without etanercept use

PURPOSE

Objectives were to quantify prevalence estimates of pregnancy and infant outcomes including major congenital malformations (MCMs) by etanercept (ETN) exposure among infants born to women with chronic inflammatory arthritis (cIA) or psoriasis (PsO).

METHODS

Claims-based data delineated pregnancy exposures and outcomes of live or nonlive births among women with cIA and PsO (ETN exposed, unexposed) and general population (GP) comparators. Infant outcomes were determined for live-born infants covered by the mother's insurer. Medical records were obtained from all accessible mother-infant pairs with claims for MCMs and a random sample of mothers. Multivariable logistic regression estimated the odds ratios (ORs) of having at least one algorithm-defined MCM in the ETN-exposed cohorts versus unexposed comparators.

RESULTS

Prevalence estimates for pregnancy outcomes were comparable across cIA and PsO cohorts. Algorithm-defined prevalence estimates of having at least one MCM were 6.1% (ETN exposed), 5.5% (unexposed), and 5.7% (GP cohort) for the cIA cohort; PsO cohort estimates were 2.0%, 4.2%, and 4.7%, respectively. The ETN-exposure ORs for having at least one algorithm-defined MCM among infants of cIA mothers was 1.03 (95%CI: 0.51-2.10) and 0.39 (95%CI: 0.05-2.98) among infants of PsO mothers. Logistic regression with inverse probability of treatment weighting that included disease state resulted in an OR of 0.65 (0.24, 1.72).

CONCLUSIONS

Overall, this study did not identify any new safety concerns associated with the use of etanercept during pregnancy. Etanercept, along with the other TNFis, remains a treatment without well-controlled clinical trials in pregnant women. Patients should continue to consult their doctor regarding benefit risk decisions of TNFi therapy during pregnancy.

Management of Systemic Lupus Erythematosus During Pregnancy

Reproductive issues including contraception, fertility, and pregnancy are important components of the comprehensive care of women with systemic lupus erythematosus (SLE). SLE pregnancies are complicated due to risk for maternal disease exacerbation and potential for fetal and neonatal complications. Pre-pregnancy assessment is important to identify patients with severe disease-related damage who should avoid pregnancy, counsel patients to conceive when disease has been stable and inactive on appropriate medications, and assess relevant risk factors including renal disease, antiphospholipid antibody, and anti-Ro/SS-A and anti-La/SS-B antibodies. With careful planning, monitoring, and care, most women with SLE can anticipate a successful pregnancy.