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Schenone C, Pacini G, Gotelli E, Hysa E, Campitiello R, Sammorì S, Paolino S, Sulli A, Cutolo M. Updating on pregnancy in rheumatoid arthritis. Expert Rev Clin Immunol 2024; 20:1041-1052. [PMID: 38748553 DOI: 10.1080/1744666x.2024.2356164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Accepted: 05/13/2024] [Indexed: 05/21/2024]
Abstract
INTRODUCTION Rheumatoid arthritis (RA), the most prevalent autoimmune disease in reproductive years, exhibits a higher incidence in females, suggesting involvement of estrogens, genetics and environmental factors in disease onset. Literature shows smaller families in RA patients, driving increased interest in Assisted Reproductive Techniques. AREAS COVERED This review elucidates how immunotolerance mechanisms contribute to favorable pregnancy outcomes in RA, emphasizing the need for a careful pregnancy planning to mitigate fetal complications and postnatal flares, which surpass those in the general population. A thorough medication evaluation, orchestrated by a multidisciplinary team, is imperative during pregnancy, weighing potential teratogenic effects against safer alternatives to balance medication safety with disease control. A systematic literature search on PubMed and MEDLINE, using specific terms, covered relevant academic journals up to the latest date. EXPERT OPINION This narrative review comprehensively addresses pregnancy-related considerations in RA patients, prioritizing meticulous disease management with pregnancy and breastfeeding-compatible drugs in line with the latest recommendations and registry data. The focus remains on evaluating glucocorticoids, conventional, and biological disease-modifying drugs for compatibility during pregnancy and breastfeeding. Additionally, the evolving landscape of targeted synthetic drugs during pregnancy is explored, providing insights into the latest developments in rheumatological care.
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Affiliation(s)
- Carlotta Schenone
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine and Specialties, University of Genova, Genova, Italy
| | - Greta Pacini
- Rheumatology Unit, Santa Chiara Hospital, APSS Trento, Trento, Italy
| | - Emanuele Gotelli
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine and Specialties, University of Genova, Genova, Italy
| | - Elvis Hysa
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine and Specialties, University of Genova, Genova, Italy
| | - Rosanna Campitiello
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine and Specialties, University of Genova, Genova, Italy
- IRCCS San Martino Polyclinic Hospital, Genoa, Italy
| | - Silvia Sammorì
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine and Specialties, University of Genova, Genova, Italy
- IRCCS San Martino Polyclinic Hospital, Genoa, Italy
| | - Sabrina Paolino
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine and Specialties, University of Genova, Genova, Italy
- IRCCS San Martino Polyclinic Hospital, Genoa, Italy
| | - Alberto Sulli
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine and Specialties, University of Genova, Genova, Italy
- IRCCS San Martino Polyclinic Hospital, Genoa, Italy
| | - Maurizio Cutolo
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine and Specialties, University of Genova, Genova, Italy
- IRCCS San Martino Polyclinic Hospital, Genoa, Italy
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Menekse Beser D, Oluklu D, Uyan Hendem D, Yildirim M, Serbetci H, Kara O, Sahin D. Assessment of fetal pulmonary artery Doppler indices in pregnant women with rheumatoid arthritis and ankylosing spondylitis. JOURNAL OF CLINICAL ULTRASOUND : JCU 2023. [PMID: 37119433 DOI: 10.1002/jcu.23471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 04/08/2023] [Accepted: 04/19/2023] [Indexed: 06/19/2023]
Abstract
PURPOSE To investigate fetal pulmonary artery Doppler parameters in pregnant women with rheumatoid arthritis (RA) and ankylosing spondylitis (AS). METHODS This case-control study included 24 pregnant women diagnosed with 13 AS and 11 RA and 48 healthy pregnant women at 29-30 weeks of gestation. The demographic and clinical features were recorded, including disease type and duration, attacks during pregnancy, and medications. Pulmonary artery acceleration time (AT), ejection time (ET), and pulmonary artery acceleration time to ejection time (PATET) ratio were measured by manual trace with spectral Doppler ultrasound. RESULTS A shorter pulmonary AT and lower PATET ratio were found in the case group (34.8 ± 2.3, p < 0.001, 0.18 ± 0.02, p < 0.001, respectively). When comparing the groups that had an attack during pregnancy and had not, there were no significant differences in the pulmonary artery indices. We also demonstrated a moderate correlation between maternal disease years and the PATET ratio (r = -0.562, p = 0.004). CONCLUSION This is the first study to evaluate the effect of RA and AS on fetal pulmonary indices. Maternal inflammation might affect pulmonary development and circulation. Fetal pulmonary Doppler indices can be used to obtain further information about neonatal respiratory morbidities in rheumatological disorders.
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Affiliation(s)
- Dilek Menekse Beser
- Department of Obstetrics and Gynecology, Division of Perinatology, Turkish Ministry of Health Ankara City Hospital, Ankara, Turkey
| | - Deniz Oluklu
- Department of Obstetrics and Gynecology, Division of Perinatology, Turkish Ministry of Health Ankara City Hospital, Ankara, Turkey
| | - Derya Uyan Hendem
- Department of Obstetrics and Gynecology, Division of Perinatology, Turkish Ministry of Health Ankara City Hospital, Ankara, Turkey
| | - Muradiye Yildirim
- Department of Obstetrics and Gynecology, Division of Perinatology, Turkish Ministry of Health Ankara City Hospital, Ankara, Turkey
| | - Hakkı Serbetci
- Department of Obstetrics and Gynecology, Division of Perinatology, Turkish Ministry of Health Ankara City Hospital, Ankara, Turkey
| | - Ozgur Kara
- Department of Obstetrics and Gynecology, Division of Perinatology, Turkish Ministry of Health Ankara City Hospital, University of Health Sciences, Ankara, Turkey
| | - Dilek Sahin
- Department of Obstetrics and Gynecology, Division of Perinatology, Turkish Ministry of Health Ankara City Hospital, University of Health Sciences, Ankara, Turkey
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Tegenge MA, Mahmood I, Struble EB, Sauna Z. Pharmacokinetics of antibodies during Pregnancy: Impact of pregnancy on the pharmacokinetics of antibodies (Part 2). Int Immunopharmacol 2023; 119:109915. [PMID: 36842918 DOI: 10.1016/j.intimp.2023.109915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 02/15/2023] [Accepted: 02/16/2023] [Indexed: 02/26/2023]
Abstract
In Part 1, we provided a general description of macromolecules, pharmacokinetics (PK) characteristics in non-pregnant subjects, and the physiological changes during pregnancy. Here we further elaborate on the impact of pregnancy on the PK of antibodies through illustrative case studies (immunoglobulins, infliximab, adalimumab and eculizumab). Using published data from nonclinical and clinical studies, we present measured or calculated PK parameters from pregnant subjects comparing with data from non-pregnant subjects, if available. Due to the paucity of PK data evaluating PK of antibodies during pregnancy, we also provide examples of PK studies for small molecules. Finally, we draw conclusions on the nature and direction of PK changes for both antibodies and small molecules as well as provide recommendations for areas that would benefit from further studies.
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Affiliation(s)
- Million A Tegenge
- Division of Clinical Evaluation and Pharmacology/Toxicology, Office of Tissue and Advanced Therapies, Center for Biologics Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA.
| | - Iftekhar Mahmood
- Mahmood Clinical Pharmacology Consultancy LLC, Rockville, MD, USA
| | - Evi B Struble
- Division of Plasma Protein Therapeutics, Office of Tissue and Advanced Therapies, Center for Biologics Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Zuben Sauna
- Division of Plasma Protein Therapeutics, Office of Tissue and Advanced Therapies, Center for Biologics Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
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Bae KJ, Baek GH, Lee Y, Lee J, Jo YG. Incidence and Risk Factors for Pregnancy-Related de Quervain's Tenosynovitis in South Korea: A Population-Based Epidemiologic Study. Clin Orthop Surg 2023; 15:145-152. [PMID: 36778998 PMCID: PMC9880499 DOI: 10.4055/cios22099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 05/10/2022] [Accepted: 06/06/2022] [Indexed: 11/06/2022] Open
Abstract
Background Although pregnant or lactating women have been recognized to be predisposed to de Quervain's tenosynovitis (DQT), there is a lack of epidemiologic evidence. The purpose of this study was to estimate the nationwide incidence of pregnancy-related DQT (PRDQT) and to analyze risk factors using the Korean National Health Insurance (NHI) database. Methods A retrospective epidemiologic study of pregnant women in South Korea from 2013 to 2017 was conducted using the NHI claims database. Using corresponding diagnostic codes, we identified women diagnosed with DQT during pregnancy or the postpartum period. We calculated the cumulative incidence and analyzed risk factors such as demographics, pregnancy type, delivery method, gestational complications, and comorbidities using multivariate logistic regression analysis. Results Between 2013 and 2017, 34,342 patients with PRDQT were identified among 1,601,501 pregnant women, representing a cumulative incidence of approximately 2.1%. Age ≥ 30 years, multiple gestation, cesarean delivery, hypertensive disorders in pregnancy, and underlying rheumatoid arthritis were all identified as significant risk factors for the occurrence of PRDQT, whereas diabetic disorders in pregnancy and underlying diabetes mellitus were not. Conclusions In South Korea, PRDQT was found to affect approximately 2.1 out of 100 pregnant women between 2013 and 2017. The incidence and risk factors identified in this study can be used for clinical consultations and prediction, as well as for development of national health policies.
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Affiliation(s)
- Kee Jeong Bae
- Department of Orthopedic Surgery, Seoul National University Boramae Medical Center, Seoul, Korea
| | - Goo Hyun Baek
- Department of Orthopedic Surgery, Seoul National University Hospital, Seoul, Korea
| | - Yohan Lee
- Department of Orthopedic Surgery, Seoul National University Boramae Medical Center, Seoul, Korea
| | - Joonha Lee
- Department of Orthopedic Surgery, Seoul National University Boramae Medical Center, Seoul, Korea
| | - Yong Gil Jo
- Department of Orthopedic Surgery, Seoul National University Boramae Medical Center, Seoul, Korea
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Arleevskaya M, Takha E, Petrov S, Kazarian G, Renaudineau Y, Brooks W, Larionova R, Korovina M, Valeeva A, Shuralev E, Mukminov M, Kravtsova O, Novikov A. Interplay of Environmental, Individual and Genetic Factors in Rheumatoid Arthritis Provocation. Int J Mol Sci 2022; 23:ijms23158140. [PMID: 35897715 PMCID: PMC9329780 DOI: 10.3390/ijms23158140] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 07/18/2022] [Accepted: 07/19/2022] [Indexed: 02/05/2023] Open
Abstract
In this review, we explore systemization of knowledge about the triggering effects of non-genetic factors in pathogenic mechanisms that contribute to the development of rheumatoid arthritis (RA). Possible mechanisms involving environmental and individual factors in RA pathogenesis were analyzed, namely, infections, mental stress, sleep deprivation ecology, age, perinatal and gender factors, eating habits, obesity and smoking. The non-genetic factors modulate basic processes in the body with the impact of these factors being non-specific, but these common challenges may be decisive for advancement of the disease in the predisposed body at risk for RA. The provocation of this particular disease is associated with the presence of congenital loci minoris resistentia. The more frequent non-genetic factors form tangles of interdependent relationships and, thereby, several interdependent external factors hit one vulnerable basic process at once, either provoking or reinforcing each other. Understanding the specific mechanisms by which environmental and individual factors impact an individual under RA risk in the preclinical stages can contribute to early disease diagnosis and, if the factor is modifiable, might be useful for the prevention or delay of its development.
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Affiliation(s)
- Marina Arleevskaya
- Central Research Laboratory, Kazan State Medical Academy, 420012 Kazan, Russia; (E.T.); (S.P.); (G.K.); (R.L.); (M.K.); (A.V.); (E.S.); (M.M.)
- Institute of Fundamental Medicine and Biology, Kazan (Volga Region) Federal University, 420008 Kazan, Russia;
- Correspondence: ; Tel.: +7-89172-886-679; Fax: +7-843-238-5413
| | - Elena Takha
- Central Research Laboratory, Kazan State Medical Academy, 420012 Kazan, Russia; (E.T.); (S.P.); (G.K.); (R.L.); (M.K.); (A.V.); (E.S.); (M.M.)
| | - Sergey Petrov
- Central Research Laboratory, Kazan State Medical Academy, 420012 Kazan, Russia; (E.T.); (S.P.); (G.K.); (R.L.); (M.K.); (A.V.); (E.S.); (M.M.)
- Institute of Environmental Sciences, Kazan (Volga Region) Federal University, 420008 Kazan, Russia
| | - Gevorg Kazarian
- Central Research Laboratory, Kazan State Medical Academy, 420012 Kazan, Russia; (E.T.); (S.P.); (G.K.); (R.L.); (M.K.); (A.V.); (E.S.); (M.M.)
| | - Yves Renaudineau
- Department of Immunology, CHU Toulouse, INSERM U1291, CNRS U5051, University Toulouse IIII, 31000 Toulouse, France;
| | - Wesley Brooks
- Department of Chemistry, University of South Florida, Tampa, FL 33620, USA;
| | - Regina Larionova
- Central Research Laboratory, Kazan State Medical Academy, 420012 Kazan, Russia; (E.T.); (S.P.); (G.K.); (R.L.); (M.K.); (A.V.); (E.S.); (M.M.)
| | - Marina Korovina
- Central Research Laboratory, Kazan State Medical Academy, 420012 Kazan, Russia; (E.T.); (S.P.); (G.K.); (R.L.); (M.K.); (A.V.); (E.S.); (M.M.)
- Institute of Fundamental Medicine and Biology, Kazan (Volga Region) Federal University, 420008 Kazan, Russia;
| | - Anna Valeeva
- Central Research Laboratory, Kazan State Medical Academy, 420012 Kazan, Russia; (E.T.); (S.P.); (G.K.); (R.L.); (M.K.); (A.V.); (E.S.); (M.M.)
| | - Eduard Shuralev
- Central Research Laboratory, Kazan State Medical Academy, 420012 Kazan, Russia; (E.T.); (S.P.); (G.K.); (R.L.); (M.K.); (A.V.); (E.S.); (M.M.)
- Institute of Environmental Sciences, Kazan (Volga Region) Federal University, 420008 Kazan, Russia
| | - Malik Mukminov
- Central Research Laboratory, Kazan State Medical Academy, 420012 Kazan, Russia; (E.T.); (S.P.); (G.K.); (R.L.); (M.K.); (A.V.); (E.S.); (M.M.)
- Institute of Environmental Sciences, Kazan (Volga Region) Federal University, 420008 Kazan, Russia
| | - Olga Kravtsova
- Institute of Fundamental Medicine and Biology, Kazan (Volga Region) Federal University, 420008 Kazan, Russia;
| | - Andrey Novikov
- Mathematical Center, Sobolev Instiute of Mathematics, Siberian Branch of Russian Academy of Sciences, 630090 Novosibirsk, Russia;
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Kocatürk E, Podder I, Zenclussen AC, Kasperska Zajac A, Elieh-Ali-Komi D, Church MK, Maurer M. Urticaria in Pregnancy and Lactation. FRONTIERS IN ALLERGY 2022; 3:892673. [PMID: 35873599 PMCID: PMC9300824 DOI: 10.3389/falgy.2022.892673] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 06/09/2022] [Indexed: 11/13/2022] Open
Abstract
Chronic urticaria (CU) is a mast cell-driven chronic inflammatory disease with a female predominance. Since CU affects mostly females in reproductive age, pregnancy is an important aspect to consider in the context of this disease. Sex hormones affect mast cell (MC) biology, and the hormonal changes that come with pregnancy can modulate the course of chronic inflammatory conditions, and they often do. Also, pregnancy-associated changes in the immune system, including local adaptation of innate and adaptive immune responses and skewing of adaptive immunity toward a Th2/Treg profile have been linked to changes in the course of inflammatory diseases. As of now, little is known about the effects of pregnancy on CU and the outcomes of pregnancy in CU patients. Also, there are no real-life studies to show the safety of urticaria medications during pregnancy. The recent PREG-CU study provided the first insights on this and showed that CU improves during pregnancy in half of the patients, whereas it worsens in one-third; and two of five CU patients experience flare-ups of their CU during pregnancy. The international EAACI/GA2LEN/EuroGuiDerm/APAAACI guideline for urticaria recommends adopting the same management strategy in pregnant and lactating CU patients; starting treatment with standard doses of second-generation (non-sedative) H1 antihistamines, to increase the dose up to 4-folds in case of no response, and to add omalizumab in antihistamine-refractory patients; but also emphasizes the lack of evidence-based information on the safety and efficacy of urticaria treatments during pregnancy. The PREG-CU study assessed treatments and their outcomes during pregnancy. Here, we review the reported effects of sex hormones and pregnancy-specific immunological changes on urticaria, we discuss the impact of pregnancy on urticaria, and we provide information and guidance on the management of urticaria during pregnancy and lactation.
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Affiliation(s)
- Emek Kocatürk
- Department of Dermatology, Koç University School of Medicine, Istanbul, Turkey
- *Correspondence: Emek Kocatürk
| | - Indrashis Podder
- Department of Dermatology, Venereology and Leprosy, College of Medicine and Sagore Dutta Hospital, Kolkata, India
| | - Ana C. Zenclussen
- Department of Environmental Immunology, Helmholtz Centre for Environmental Research (UFZ) and Saxonian Incubator for Clinical Translation (SIKT), University of Leipzig, Leipzig, Germany
| | - Alicja Kasperska Zajac
- European Center for Diagnosis and Treatment of Urticaria/Angioedema (GA2LEN UCARE /ACARE Network), Zabrze, Poland
- Department of Clinical Allergology, Urticaria Center of Medical University of Silesia, Katowice, Poland
| | - Daniel Elieh-Ali-Komi
- Institute of Allergology, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Allergology and Immunology, Berlin, Germany
| | - Martin K. Church
- Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Allergology and Immunology, Berlin, Germany
| | - Marcus Maurer
- Institute of Allergology, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Allergology and Immunology, Berlin, Germany
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Edens C. The Impact of Pediatric Rheumatic Diseases on Sexual Health, Family Planning, and Pregnancy. Rheum Dis Clin North Am 2021; 48:113-140. [PMID: 34798942 DOI: 10.1016/j.rdc.2021.09.016] [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: 11/30/2022]
Abstract
A comprehensive review of reproductive health subtopics, including sexual intercourse, romantic relationships, contraception, sexually transmitted infections, pregnancy, and infertility, as they pertain to patients with pediatric rheumatic diseases and those who care for them.
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Affiliation(s)
- Cuoghi Edens
- Department of Pediatrics, Section of Pediatric Rheumatology, University of Chicago Medicine, 5841 South Maryland Avenue, C104-A, MC5044, Chicago, IL 60637, USA; Department of Internal Medicine, Section of Rheumatology, University of Chicago Medicine, 5841 South Maryland Avenue, C104-A, MC5044, Chicago, IL 60637, USA.
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Couillard S, Connolly C, Borg C, Pavord I. Asthma in pregnancy: An update. Obstet Med 2021; 14:135-144. [PMID: 34646341 PMCID: PMC8504309 DOI: 10.1177/1753495x20965072] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 09/16/2020] [Indexed: 01/13/2023] Open
Abstract
AIM To update obstetric care providers about asthma management. SUMMARY Asthma is the most frequent comorbid chronic illness in pregnancy. Convincing evidence shows that uncontrolled asthma magnifies the risk of maternal, fetal and neonate complications. Unfortunately, one in four women take no inhaler during pregnancy, and it is likely that decreased adherence, rather than changes in pathology, explains uncontrolled maternal asthma. Patient surveys reveal a need for information and reassurance. Although some molecules are preferred in pregnancy, there is currently no basis to withhold any asthma medication - old or new. Biomarkers such as blood eosinophils and fractional exhaled nitric oxide are an effective way to assess the risk of asthma attacks and the likelihood of responding to inhaled steroids. Furthermore, practice-changing trials in mild asthma show that switching reliever-only regimens to as-needed 'controller-and-reliever' therapy is effective. We suggest that applying these changes can alleviate women's concerns and improve outcomes.
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Affiliation(s)
- Simon Couillard
- Respiratory Medicine Unit and Oxford Respiratory NIHR BRC, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Faculté de Médecine et des Sciences de la Santé, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Clare Connolly
- Respiratory Medicine Unit and Oxford Respiratory NIHR BRC, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Catherine Borg
- Respiratory Medicine Unit and Oxford Respiratory NIHR BRC, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Ian Pavord
- Respiratory Medicine Unit and Oxford Respiratory NIHR BRC, Nuffield Department of Medicine, University of Oxford, Oxford, UK
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The positive effect of pregnancy in rheumatoid arthritis and the use of medications for the management of rheumatoid arthritis during pregnancy. Inflammopharmacology 2021; 29:987-1000. [PMID: 33844107 DOI: 10.1007/s10787-021-00808-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Accepted: 03/30/2021] [Indexed: 01/30/2023]
Abstract
Rheumatoid arthritis (RA) is an autoimmune systemic inflammatory disorder that is mostly characterised by progressive symmetrical joint destruction, particularly in the wrist and fingers, while it may also affect additional joints and several organs, such as the skin, heart, blood vessels, and lungs. It is identified by raised anti-rheumatoid factor and anti-cyclic citrullinated peptide antibodies. The chemical mediators involved in the activity of RA are IL-1β, TNF-α, and IL-6. Pregnancy exerts a positive effect on RA that helps to modulate the disease condition. Different hypotheses are recommended to explain the ameliorating effect of pregnancy in RA. RA cannot be completely cured. The treatment goal is the attrition of pain and inflammation and the further progression of the disease. Long-term management of RA is carried out using disease-modifying antirheumatic drugs (DMARDs). Therapy of acute flares can be done with Non-steroidal anti-inflammatory drugs (NSAIDs) accompanied by ad interim usage of glucocorticoids. Biologic response modifiers are also available; they act by abolishing the activity of T- cells. However, it is necessary to select the correct treatment regimen when it comes to the management of RA in pregnancy.
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Jeong H, Bae EK, Hwang J, Park EJ, Lee J, Jeon CH, Koh EM, Cha HS. The Effects of Sex and Estrogen on Radiographic Progression of Ankylosing Spondylitis in Korean Patients. JOURNAL OF RHEUMATIC DISEASES 2021; 28:76-84. [PMID: 37476018 PMCID: PMC10324893 DOI: 10.4078/jrd.2021.28.2.76] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 12/09/2020] [Accepted: 12/14/2020] [Indexed: 07/22/2023]
Abstract
Objective Ankylosing spondylitis (AS) is a chronic inflammatory disease with obvious male preponderance Males show more severe radiographic manifestations compared with females This study aimed to evaluate the effects of sex and estrogen on the radiographic progression of AS. Methods A total of 101 patients with AS were included in this study All of the radiographs were scored using the modified Stoke AS Spine Score (mSASSS) Serum levels of 17β-estradiol (E2), dickkopf-1 (Dkk1), and leptin were detected by enzyme-linked immunosorbent assay The generalized estimating equations model was used to evaluate factors associated with spinal radiographic progression. Results The mean age at disease onset was 273±107 years, and 16 patients (158%) were female In the multivariable analysis, body mass index (β-coefficient=012; p=0047) and levels of Dkk1 (β-coefficient=-011; p<0001), and female (β-coefficient=-140; p=0001) were associated with radiographic progression Among male patients with AS, baseline C-reactive protein (β=011; p=0005) and mSASSS (β=021; p=0030) were also associated with radiographic progression E2 and leptin levels were not significantly related to the radiographic progression. Conclusion Although female patients were associated with less radiographic progression in AS, there was no significant relationship between serum estrogen level and radiographic progression Results of current study suggests that genetic factors or other environmental factors associated with female may influence radiographic progression in patients with AS.
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Affiliation(s)
- Hyemin Jeong
- Division of Rheumatology, Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
| | | | - Jiwon Hwang
- Department of Internal Medicine, Samsung Changwon Hospital, Changwon, Korea
| | - Eun-Jung Park
- Department of Internal Medicine, National Medical Center, Seoul, Korea
| | - Jaejoon Lee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Chan Hong Jeon
- Division of Rheumatology, Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
| | - Eun-Mi Koh
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hoon-Suk Cha
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Nalli C, Galli J, Lini D, Merlini A, Piantoni S, Lazzaroni MG, Bitsadze V, Khizroeva J, Zatti S, Andreoli L, Fazzi E, Franceschini F, Makatsariya A, Shoenfeld Y, Tincani A. The Influence of Treatment of Inflammatory Arthritis During Pregnancy on the Long-Term Children's Outcome. Front Pharmacol 2021; 12:626258. [PMID: 33815108 PMCID: PMC8013697 DOI: 10.3389/fphar.2021.626258] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 01/29/2021] [Indexed: 12/16/2022] Open
Abstract
The management of reproductive issues in women with inflammatory arthritis has greatly changed over decades. In the 1980–1990s, women with refractory forms of arthritis were either not able to get pregnant or did choose not to get pregnant because of their disabling disease. Hence, the traditional belief that pregnancy can induce a remission of arthritis. The availability of biologic agents has allowed a good control of aggressive forms of arthritis. The main topic of discussion during preconception counselling is the use of drugs during pregnancy and breastfeeding. Physicians are now supported by international recommendations released by the European League Against Rheumatism and the American College of Rheumatology, but still they must face with cultural reluctance in accepting that a pregnant woman can take medications. Patient-physician communication should be centered on the message that active maternal disease during pregnancy is detrimental to fetal health. Keeping maternal disease under control with drugs which are not harmful to the fetus is the best way to ensure the best possible outcome for both the mother and the baby. However, there might be concerns about the influence of the in utero exposure to medications on the newborn’s health conditions. Particularly, studies suggesting an increased risk of autism-spectrum-disorders in children born to women with rheumatoid arthritis has raised questions about neuropsychological impairment in the offspring of women with chronic arthritis. As a multidisciplinary group of rheumatologists and child neuropsychiatrists, we conducted a study on 16 women with chronic forms of arthritis whose diagnosis was determined before pregnancy and their 18 school-age children. The children underwent a complete neurological examination and validated tests/questionnaires. Behavioral aspects of somatization and anxiety/depression (internalizing problem) or an “adult profile” were found in nearly one third of children. Children at a high risk of neurodevelopmental problems were born to mothers with a longer history of arthritis and were breastfeed for less than 6 months of age or were not breastfeed at all. No association was found with other maternal characteristics such as autoantibody existence and disease activity during and after the pregnancy.
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Affiliation(s)
- Cecilia Nalli
- Rheumatology and Clinical Immunology Unit, ASST Spedali Civili and University of Brescia, Brescia, Italy
| | - Jessica Galli
- Child Neurology and Psychiatry Unit, Department of Clinical and Experimental Sciences, ASST Spedali Civili and University of Brescia, Brescia, Italy
| | - Daniele Lini
- Rheumatology and Clinical Immunology Unit, ASST Spedali Civili and University of Brescia, Brescia, Italy.,Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Angela Merlini
- Child Neurology and Psychiatry Unit, Department of Clinical and Experimental Sciences, ASST Spedali Civili and University of Brescia, Brescia, Italy
| | - Silvia Piantoni
- Rheumatology and Clinical Immunology Unit, ASST Spedali Civili and University of Brescia, Brescia, Italy.,Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Maria Grazia Lazzaroni
- Rheumatology and Clinical Immunology Unit, ASST Spedali Civili and University of Brescia, Brescia, Italy.,Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Victoria Bitsadze
- Department of Obstetrics and Gynecology, I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russia
| | - Jamilya Khizroeva
- Department of Obstetrics and Gynecology, I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russia
| | - Sonia Zatti
- Obstetric and Gynecology Unit, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Laura Andreoli
- Rheumatology and Clinical Immunology Unit, ASST Spedali Civili and University of Brescia, Brescia, Italy.,Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Elisa Fazzi
- Child Neurology and Psychiatry Unit, Department of Clinical and Experimental Sciences, ASST Spedali Civili and University of Brescia, Brescia, Italy
| | - Franco Franceschini
- Rheumatology and Clinical Immunology Unit, ASST Spedali Civili and University of Brescia, Brescia, Italy.,Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Alexander Makatsariya
- Department of Obstetrics and Gynecology, I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russia
| | - Yehuda Shoenfeld
- 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.,I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russia
| | - Angela Tincani
- Rheumatology and Clinical Immunology Unit, ASST Spedali Civili and University of Brescia, Brescia, Italy.,Department of Clinical and Experimental Sciences, 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
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Mokbel A, Lawson DO, Farrokhyar F. Pregnancy outcomes in women with ankylosing spondylitis: a scoping literature and methodological review. Clin Rheumatol 2021; 40:3465-3480. [PMID: 33464430 DOI: 10.1007/s10067-021-05588-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 01/05/2021] [Accepted: 01/11/2021] [Indexed: 10/22/2022]
Abstract
In this scoping review, we sought to summarize the types of outcomes collected in pregnant patients with ankylosing spondylitis (AS), and to identify some methodological limitations related to pregnancy research in these patients. A comprehensive search was done to identify relevant articles in MEDLINE and Embase. We included 21 studies assessing pregnancy outcomes in AS. Most studies reported disease flare during pregnancy, and few reported improved disease activity or stable disease. Disease flare occurred in 25-80% of patients during pregnancy and in 30-100% during the postpartum. There was no increased risk of pre-eclampsia across all studies. Based on two case-control studies, there was an increased risk for prematurity and small for gestational age in AS pregnancies, pooled odds ratio (95% confidence interval) 1.99 (1.30-3.05) and 2.41 (1.22-4.77), respectively. The etiologies of cesarean section were not related to joint issues from AS but were related to other causes like pre-eclampsia and prematurity. Some key methodological issues were related to the study design, selection of study participants, disease classification, choice of control participants, and outcome measures. Based on the current literature review, some key areas for future research should evaluate the disease state at conception, effects of pharmacological treatment for AS during pregnancy, and long-term outcomes of children born to women with AS. The use of pregnancy registers and validated measurement tools in pregnancy will help to improve the state and quality of evidence in this field. Key Points • Disease flare during pregnancy in patients with ankylosing spondylitis (AS) occurred in 25-80% of the cases in the various studies, and in 30-100% of the cases during the postpartum period. • There was an increased risk for prematurity, and no increased risk of pre-eclampsia or small for gestational age. Etiologies of cesarean section were not related to the hip or sacroiliac joint affection of the disease but to other causes like pre-eclampsia and prematurity. • This study provides a comprehensive overview of issues related to research on pregnant women with ankylosing spondylitis (AS). We addressed methodological issues related to the study design, selection of study participants, disease classification, control choice, assessment of outcomes measures, and statistical analysis. • The use of pregnancy registers and validated disease activity measurement tools for pregnancy can enhance pregnancy research in women with AS.
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Affiliation(s)
- Abir Mokbel
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada. .,Department of Rheumatology, Cairo University, Giza, Egypt.
| | - Daeria O Lawson
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.,Division of Rheumatology, Toronto Western Hospital, Toronto, ON, Canada
| | - Forough Farrokhyar
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.,Department of Surgery, McMaster University, Hamilton, ON, Canada
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13
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Wright M, Smed MK, Nelson JL, Olsen J, Hetland ML, Zoffmann V, Jawaheer D. Is gene expression among women with rheumatoid arthritis dysregulated during a postpartum flare? Arthritis Res Ther 2021; 23:30. [PMID: 33461591 PMCID: PMC7812735 DOI: 10.1186/s13075-021-02418-w] [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] [Received: 08/12/2020] [Accepted: 01/04/2021] [Indexed: 11/22/2022] Open
Abstract
Background To evaluate our hypotheses that, when rheumatoid arthritis (RA) flares postpartum, gene expression patterns are altered compared to (a) healthy women, (b) RA women whose disease activity is low or in remission postpartum, and (c) pre-pregnancy expression profiles. Methods Twelve women with RA and five healthy women were included in this pilot study. RA disease activity and postpartum flare were assessed using the Clinical Disease Activity Index (CDAI). Total RNA from frozen whole blood was used for RNA sequencing. Differential gene expression within the same women (within-group) over time, i.e., postpartum vs. third trimester (T3) or pre-pregnancy (T0), were examined, using a significance threshold of q < 0.05 and fold-change ≥ 2. Results Nine of the women with RA experienced a flare postpartum (RAFlare), while three had low disease activity or were in remission (RANoFlare) during that time frame. Numerous immune-related genes were differentially expressed postpartum (vs. T3) during a flare. Fold-changes in expression from T3 to postpartum were mostly comparable between the RAFlare and healthy groups. At 3 months postpartum, compared to healthy women, several genes were significantly differentially expressed only among the RAFlare women, and not among the RANoFlare women. Some of these genes were among those whose “normal” expression was significantly modulated postpartum, and the postpartum expression patterns were significantly altered during the RA flare. There were also some genes that were significantly differentially expressed in RAFlare compared to both healthy and RANoFlare women, even though their expression was not significantly modulated postpartum. Furthermore, while postpartum expression profiles were similar to those at pre-pregnancy among healthy women, significant differences were found between those time points among the RAFlare women. Conclusions The large majority of gene expression changes between T3 and 3 months postpartum among RA women who flared postpartum reflected normal postpartum changes also seen among healthy women. Nonetheless, during a postpartum flare, a set of immune-related genes showed dysregulated expression compared to healthy women and women with RA whose disease activity was low or in remission during the same time frame, while other genes demonstrated significant differences in expression compared to RA pre-pregnancy levels. Supplementary Information The online version contains supplementary material available at 10.1186/s13075-021-02418-w.
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Affiliation(s)
- Matthew Wright
- Children's Hospital Oakland Research Institute, UCSF Benioff Children's Hospital Oakland, 5700 Martin Luther King Jr. Way, Oakland, CA, 94609, USA
| | - Mette K Smed
- Juliane Marie Center, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - J Lee Nelson
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA.,University of Washington, Seattle, WA, USA
| | - Jørn Olsen
- University of California Los Angeles, Los Angeles, CA, USA.,Aarhus University Hospital, Aarhus, Denmark
| | - Merete L Hetland
- DANBIO Registry and Copenhagen Centre for Arthritis Research, Centre for Rheumatology and Spine Diseases VRR, Rigshospitalet, Glostrup, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Vibeke Zoffmann
- Juliane Marie Center, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Damini Jawaheer
- Children's Hospital Oakland Research Institute, UCSF Benioff Children's Hospital Oakland, 5700 Martin Luther King Jr. Way, Oakland, CA, 94609, USA. .,University of California San Francisco, San Francisco, CA, USA.
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Cutolo M, Straub RH. Sex steroids and autoimmune rheumatic diseases: state of the art. Nat Rev Rheumatol 2020; 16:628-644. [PMID: 33009519 DOI: 10.1038/s41584-020-0503-4] [Citation(s) in RCA: 68] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/01/2020] [Indexed: 12/16/2022]
Abstract
In autoimmune rheumatic diseases, oestrogens can stimulate certain immune responses (including effects on B cells and innate immunity), but can also have dose-related anti-inflammatory effects on T cells, macrophages and other immune cells. By contrast, androgens and progesterone have predominantly immunosuppressive and anti-inflammatory effects. Hormone replacement therapies and oral contraception (and also pregnancy) enhance or decrease the severity of autoimmune rheumatic diseases at a genetic or epigenetic level. Serum androgen concentrations are often low in men and in women with autoimmune rheumatic diseases, suggesting that androgen-like compounds might be a promising therapeutic approach. However, androgen-to-oestrogen conversion (known as intracrinology) is enhanced in inflamed tissues, such as those present in patients with autoimmune rheumatic diseases. In addition, it is becoming evident that the gut microbiota differs between the sexes (known as the microgenderome) and leads to sex-dependent genetic and epigenetic changes in gastrointestinal inflammation, systemic immunity and, potentially, susceptibility to autoimmune or inflammatory rheumatic diseases. Future clinical research needs to focus on the therapeutic use of androgens and progestins or their downstream signalling cascades and on new oestrogenic compounds such as tissue-selective oestrogen complex to modulate altered immune responses.
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Affiliation(s)
- Maurizio Cutolo
- Research Laboratories and Academic Division of Clinical Rheumatology, Postgraduate School of Rheumatology, Department of Internal Medicine DIMI, University of Genova, IRCCS San Martino Polyclinic, Genoa, Italy.
| | - Rainer H Straub
- Laboratory of Experimental Rheumatology and Neuroendocrine Immunology, Division of Rheumatology, Department of Internal Medicine, University Hospital of Regensburg, Regensburg, Germany
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15
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Raine C, Austin K, Giles I. Mechanisms determining the amelioration of rheumatoid arthritis in pregnancy: A systematic review. Semin Arthritis Rheum 2020; 50:1357-1369. [PMID: 32224046 DOI: 10.1016/j.semarthrit.2020.03.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 02/17/2020] [Accepted: 03/13/2020] [Indexed: 01/21/2023]
Abstract
BACKGROUND The phenomenon of pregnancy-induced remission of rheumatoid arthritis (RA) was first reported by Philip Hench in 1938. Despite extensive efforts, the underlying scientific basis has remained elusive. A number of different potential mechanisms have been investigated. We have undertaken a systematic review of the available peer-reviewed articles involving pregnant patients with RA in order to establish the depth of current scientific understanding of this important topic. METHODS This review was conducted according to guidelines of preferred reporting items for systematic reviews and meta-analyses. Studies were identified by a thorough search of multiple databases including Medline, PubMed and EMBASE. Search terms used were different combinations of the keywords: rheumatoid arthritis, inflammatory arthritis, pregnancy, mechanisms, disease activity, relapse and remission. Non-English language articles and studies that were not directly relevant were excluded. Two independent reviewers (CR and KA) screened the retrieved articles by reading the title and abstract to identify studies that addressed potential mechanisms determining RA activity in pregnancy. Articles were further refined after reading the full text. A data extraction sheet was developed for the purpose of this review and used by the independent reviewers. RESULTS After exclusion of irrelevant, duplicate and foreign language articles, a final total of 37 original articles were identified. The largest body of literature concerned glycosylation of immunoglobulins, with 9 published articles. There is evidence of an association between increasing levels of galactosylation of immunoglobulins and reduced RA disease activity in pregnancy. Other identified articles comprised 5 on cytokine changes in pregnancy, 5 on human leucocyte antigen (HLA) incompatibility, 5 on changes in peripheral blood mononuclear cell (PBMC) gene expression; 4 on changes in corticosteroids; 3 on pregnancy associated α2-glycoprotein; 2 on changes in rheumatoid factor (RF)/anti-citrullinated protein antibody (ACPA); and 1 each on microchimerism, gamma delta T cells, regulatory T cells, and mannose-binding lectin. The results of these studies were heterogenous and occasionally conflicting. Selected studies varied greatly in terms of population size, methodology and use of controls and disease activity assessments. CONCLUSION This systematic review has found that the cause of the pregnancy-induced amelioration of RA remains to be determined, despite extensive efforts. It is unclear which of the various transitory changes in pregnancy may be responsible for initiating downstream anti-inflammatory immunological mechanisms. We discuss limitations of the current literature and suggest areas for future study.
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Affiliation(s)
- Charles Raine
- Rayne Institute, University College London Centre for Rheumatology Research, University Street, London WC1E 6JF, United Kingdom.
| | - Keziah Austin
- Department of Rheumatology, University College London Hospital, 250 Euston Rd, London NW1 2PG, United Kingdom.
| | - Ian Giles
- Rayne Institute, University College London Centre for Rheumatology Research, University Street, London WC1E 6JF, United Kingdom.
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16
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Immunological adaptations in pregnancy that modulate rheumatoid arthritis disease activity. Nat Rev Rheumatol 2020; 16:113-122. [PMID: 31932747 DOI: 10.1038/s41584-019-0351-2] [Citation(s) in RCA: 65] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/28/2019] [Indexed: 02/08/2023]
Abstract
During pregnancy, the fetus that grows within the maternal uterus is not rejected by the maternal immune system. To enable both tolerance towards the fetus and defence against pathogens, modifications of the maternal immune system occur during gestation. These modifications are able to bring about a natural improvement in disease activity of some autoimmune diseases, such as rheumatoid arthritis (RA). Various mechanisms of the immune system contribute to the phenomenon of pregnancy-related improvement of RA, and the cessation of these immunomodulatory mechanisms after delivery correlates with postpartum disease flare. HLA disparity between mother and fetus, glycosylation of IgG, immunoregulatory pathways, and alterations in innate and adaptive immune cells and their cytokines have important roles in pregnancy and in pregnancy-related amelioration of RA.
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17
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Unal C, Fadiloglu E, Tanacan A, Zaim OC, Beksac MS. Retrospective evaluation of pregnancies with ankylosing spondylitis in a tertiary center in Turkey. Int J Rheum Dis 2019; 23:101-105. [PMID: 31713329 DOI: 10.1111/1756-185x.13746] [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: 07/02/2019] [Revised: 10/09/2019] [Accepted: 10/18/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND To evaluate obstetrical and perinatal outcomes of pregnancies with ankylosing spondylitis (AS). METHODS This was a retrospective study evaluating obstetric outcomes of 52 patients with AS who were followed up at our institution between 2006 and 2019. Patients were classified as having disease greater than or less than 5 years, and according to disease-related medical treatment during pregnancy, as drug free, single medication or multiple medication. RESULTS Overall rates of preterm delivery, intrauterine growth retardation and preeclampsia were 17.3%, 13.4% and 7.7%, respectively. Thirty-three of the patients were followed up without any medication, while 19 patients used drugs during pregnancy. Seven patients used a single drug and 12 patients had multiple drugs. There was no significant difference in terms of obstetrical and neonatal outcomes. However, a higher rate of neonatal intensive care unit (NICU) admission was observed in the group using medication for AS, despite a lack of statistical significance (31.5% vs 15%, P = .162). On the other hand, patients having disease more than 5 years had higher rates of Apgar scores less than <7 and admission to the NICU despite a lack of statistical significance (4% vs 7.4% and 16% vs 26%; P = .267 and P = .297, respectively). CONCLUSION In conclusion, pregnancies of patients with AS must be considered as high risk due to increased rates of adverse outcomes such as preterm delivery, intrauterine growth retardation or preeclampsia.
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Affiliation(s)
- Canan Unal
- Division of Perinatology, Department of Obstetrics and Gynecology, Hacettepe University, Ankara, Turkey
| | - Erdem Fadiloglu
- Division of Perinatology, Department of Obstetrics and Gynecology, Hacettepe University, Ankara, Turkey
| | - Atakan Tanacan
- Division of Perinatology, Department of Obstetrics and Gynecology, Hacettepe University, Ankara, Turkey
| | - Onur Can Zaim
- Division of Perinatology, Department of Obstetrics and Gynecology, Hacettepe University, Ankara, Turkey
| | - Mehmet Sinan Beksac
- Division of Perinatology, Department of Obstetrics and Gynecology, Hacettepe University, Ankara, Turkey
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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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Jethwa H, Lam S, Smith C, Giles I. Does Rheumatoid Arthritis Really Improve During Pregnancy? A Systematic Review and Metaanalysis. J Rheumatol 2018; 46:245-250. [PMID: 30385703 DOI: 10.3899/jrheum.180226] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/24/2018] [Indexed: 11/22/2022]
Abstract
OBJECTIVE We performed a systematic review and metaanalysis to assess rheumatoid arthritis (RA) disease activity during pregnancy using objective disease activity scoring systems. METHODS A systematic review of PubMed, EMBASE/Medline, Cochrane, and LactMed databases was performed. Our inclusion criteria for analysis were prospective studies, more than 5 patients per study, and data on RA using an objective scoring system conducted by a clinician/health professional. RESULTS Ten studies were eligible for final analysis, which included 237 patients, of which prepartum data were available for 204 patients. Postpartum disease activity was recorded in 135 pregnancies. CONCLUSION Disease activity improved in 60% of patients with RA in pregnancy and flared in 46.7% postpartum.
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Affiliation(s)
- Hannah Jethwa
- From the Rheumatology Department, London North West Healthcare National Health Service (NHS) Trust; General Medicine, Croydon University Hospital; Statistics Department, Royal Free Hospital; Centre for Rheumatology Research, Rayne Institute, University College London, London, UK. .,H. Jethwa, Specialist Registrar in Rheumatology, BSc, MBChB, MRCP, Rheumatology Department, London North West Healthcare NHS Trust; S. Lam, General Practitioner Trainee, BSc, MBBS, General Medicine, Croydon University Hospital; C. Smith, Research Statistician, PhD, Statistics Department, Royal Free Hospital; I. Giles, Consultant Rheumatologist, PhD, FRCP, Centre for Rheumatology Research, Rayne Institute, University College London.
| | - Suzanne Lam
- From the Rheumatology Department, London North West Healthcare National Health Service (NHS) Trust; General Medicine, Croydon University Hospital; Statistics Department, Royal Free Hospital; Centre for Rheumatology Research, Rayne Institute, University College London, London, UK.,H. Jethwa, Specialist Registrar in Rheumatology, BSc, MBChB, MRCP, Rheumatology Department, London North West Healthcare NHS Trust; S. Lam, General Practitioner Trainee, BSc, MBBS, General Medicine, Croydon University Hospital; C. Smith, Research Statistician, PhD, Statistics Department, Royal Free Hospital; I. Giles, Consultant Rheumatologist, PhD, FRCP, Centre for Rheumatology Research, Rayne Institute, University College London
| | - Colette Smith
- From the Rheumatology Department, London North West Healthcare National Health Service (NHS) Trust; General Medicine, Croydon University Hospital; Statistics Department, Royal Free Hospital; Centre for Rheumatology Research, Rayne Institute, University College London, London, UK.,H. Jethwa, Specialist Registrar in Rheumatology, BSc, MBChB, MRCP, Rheumatology Department, London North West Healthcare NHS Trust; S. Lam, General Practitioner Trainee, BSc, MBBS, General Medicine, Croydon University Hospital; C. Smith, Research Statistician, PhD, Statistics Department, Royal Free Hospital; I. Giles, Consultant Rheumatologist, PhD, FRCP, Centre for Rheumatology Research, Rayne Institute, University College London
| | - Ian Giles
- From the Rheumatology Department, London North West Healthcare National Health Service (NHS) Trust; General Medicine, Croydon University Hospital; Statistics Department, Royal Free Hospital; Centre for Rheumatology Research, Rayne Institute, University College London, London, UK.,H. Jethwa, Specialist Registrar in Rheumatology, BSc, MBChB, MRCP, Rheumatology Department, London North West Healthcare NHS Trust; S. Lam, General Practitioner Trainee, BSc, MBBS, General Medicine, Croydon University Hospital; C. Smith, Research Statistician, PhD, Statistics Department, Royal Free Hospital; I. Giles, Consultant Rheumatologist, PhD, FRCP, Centre for Rheumatology Research, Rayne Institute, University College London
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20
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Konečná B, Lauková L, Vlková B. Immune activation by nucleic acids: A role in pregnancy complications. Scand J Immunol 2018; 87:e12651. [PMID: 29479732 DOI: 10.1111/sji.12651] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Accepted: 02/15/2018] [Indexed: 12/25/2022]
Abstract
Cell-free self-DNA or RNA may induce an immune response by activating specific sensing receptors. During pregnancy, placental nucleic acids present in the maternal circulation further activate these receptors due to the presence of unmethylated CpG islands. A higher concentration of cell-free foetal DNA is associated with pregnancy complications and a higher risk for foetal rejection. Cell-free foetal DNA originates from placental trophoblasts. It appears in different forms: free, bound to histones in nucleosomes, in neutrophil extracellular traps (NETs) and in extracellular vesicles (EVs). In several pregnancy complications, cell-free foetal DNA triggers the production of proinflammatory cytokines, and this production results in a cellular and humoral immune response. This review discusses preeclampsia, systemic lupus erythematosus, foetal growth restriction, gestational diabetes, rheumatoid arthritis and obesity in pregnancy from an immunological point of view and closely examines the different pathways that result in maternal inflammation. Understanding the role of cell-free nucleic acids, as well as the biogenesis of NETs and EVs, will help us to specify their functions or targets, which seem to be important in pregnancy complications. It is still not clear whether higher concentrations of cell-free nucleic acids in the maternal circulation are the cause or consequence of various complications. Therefore, further clinical studies and, even more importantly, animal experiments that focus on the involved immunological pathways are needed.
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Affiliation(s)
- B Konečná
- Faculty of Medicine, Institute of Molecular Biomedicine, Comenius University, Bratislava, Slovakia
| | - L Lauková
- Faculty of Medicine, Institute of Molecular Biomedicine, Comenius University, Bratislava, Slovakia
| | - B Vlková
- Faculty of Medicine, Institute of Molecular Biomedicine, Comenius University, Bratislava, Slovakia
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21
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Perng P, Zampella JG, Okoye GA. Considering the impact of pregnancy on the natural history of hidradenitis suppurativa. Br J Dermatol 2017; 178:e13-e14. [PMID: 28718895 DOI: 10.1111/bjd.15735] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- P Perng
- School of Medicine, Johns Hopkins University, Baltimore, MD, U.S.A
| | - J G Zampella
- Department of Dermatology, Johns Hopkins Medical Institutions, Baltimore, MD, U.S.A
| | - G A Okoye
- Department of Dermatology, Johns Hopkins Medical Institutions, Baltimore, MD, U.S.A
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22
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Blazkova J, Gupta S, Liu Y, Gaudilliere B, Ganio EA, Bolen CR, Saar-Dover R, Fragiadakis GK, Angst MS, Hasni S, Aghaeepour N, Stevenson D, Baldwin N, Anguiano E, Chaussabel D, Altman MC, Kaplan MJ, Davis MM, Furman D. Multicenter Systems Analysis of Human Blood Reveals Immature Neutrophils in Males and During Pregnancy. JOURNAL OF IMMUNOLOGY (BALTIMORE, MD. : 1950) 2017; 198:2479-2488. [PMID: 28179497 PMCID: PMC5337813 DOI: 10.4049/jimmunol.1601855] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Accepted: 01/11/2017] [Indexed: 12/22/2022]
Abstract
Despite clear differences in immune system responses and in the prevalence of autoimmune diseases between males and females, there is little understanding of the processes involved. In this study, we identified a gene signature of immature-like neutrophils, characterized by the overexpression of genes encoding for several granule-containing proteins, which was found at higher levels (up to 3-fold) in young (20-30 y old) but not older (60 to >89 y old) males compared with females. Functional and phenotypic characterization of peripheral blood neutrophils revealed more mature and responsive neutrophils in young females, which also exhibited an elevated capacity in neutrophil extracellular trap formation at baseline and upon microbial or sterile autoimmune stimuli. The expression levels of the immature-like neutrophil signature increased linearly with pregnancy, an immune state of increased susceptibility to certain infections. Using mass cytometry, we also find increased frequencies of immature forms of neutrophils in the blood of women during late pregnancy. Thus, our findings show novel sex differences in innate immunity and identify a common neutrophil signature in males and in pregnant women.
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Affiliation(s)
- Jana Blazkova
- Division of Translational Medicine, Department of Systems Biology, Sidra Medical and Research Center, 26999 Doha, Qatar
| | - Sarthak Gupta
- Systemic Autoimmunity Branch, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD 20892
| | - Yudong Liu
- Systemic Autoimmunity Branch, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD 20892
| | - Brice Gaudilliere
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA 94305
| | - Edward A Ganio
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA 94305
| | - Christopher R Bolen
- Department of Microbiology and Immunology, Stanford University School of Medicine, Stanford, CA 94305
| | - Ron Saar-Dover
- Department of Microbiology and Immunology, Stanford University School of Medicine, Stanford, CA 94305
| | - Gabriela K Fragiadakis
- Department of Microbiology and Immunology, Stanford University School of Medicine, Stanford, CA 94305
| | - Martin S Angst
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA 94305
| | - Sarfaraz Hasni
- Systemic Autoimmunity Branch, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD 20892
| | - Nima Aghaeepour
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA 94305
| | - David Stevenson
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA 94305
| | | | | | - Damien Chaussabel
- Division of Translational Medicine, Department of Systems Biology, Sidra Medical and Research Center, 26999 Doha, Qatar
| | - Matthew C Altman
- Benaroya Research Institute at Virginia Mason, Seattle, WA 98101
| | - Mariana J Kaplan
- Systemic Autoimmunity Branch, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD 20892
| | - Mark M Davis
- Department of Microbiology and Immunology, Stanford University School of Medicine, Stanford, CA 94305
- Institute for Immunity, Transplantation of Infection, Stanford University School of Medicine, Stanford, CA 94305; and
- Howard Hughes Medical Institute, Stanford University School of Medicine, Stanford, CA 94305
| | - David Furman
- Division of Translational Medicine, Department of Systems Biology, Sidra Medical and Research Center, 26999 Doha, Qatar;
- Department of Microbiology and Immunology, Stanford University School of Medicine, Stanford, CA 94305
- Institute for Immunity, Transplantation of Infection, Stanford University School of Medicine, Stanford, CA 94305; and
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23
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Guzman-Genuino RM, Diener KR. Regulatory B Cells in Pregnancy: Lessons from Autoimmunity, Graft Tolerance, and Cancer. Front Immunol 2017; 8:172. [PMID: 28261223 PMCID: PMC5313489 DOI: 10.3389/fimmu.2017.00172] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Accepted: 02/03/2017] [Indexed: 12/26/2022] Open
Abstract
The success of pregnancy is contingent on the maternal immune system recognizing and accommodating a growing semi-allogeneic fetus. Specialized subsets of lymphocytes capable of negative regulation are fundamental in this process, and include the regulatory T cells (Tregs) and potentially, regulatory B cells (Bregs). Most of our current understanding of the immune regulatory role of Bregs comes from studies in the fields of autoimmunity, transplantation tolerance, and cancer biology. Bregs control autoimmune diseases and can elicit graft tolerance by inhibiting the differentiation of effector T cells and dendritic cells (DCs), and activating Tregs. Furthermore, in cancer, Bregs are hijacked by neoplastic cells to promote tumorigenesis. Pregnancy therefore represents a condition that reconciles these fields-mechanisms must be in place to ensure maternal immunological tolerance throughout gravidity to allow the semi-allogeneic fetus to grow within. Thus, the mechanisms underlying Breg activities in autoimmune diseases, transplantation tolerance, and cancer may take place during pregnancy as well. In this review, we discuss the potential role of Bregs as guardians of pregnancy and propose an endocrine-modulated feedback loop highlighting the Breg-Treg-tolerogenic DC interface essential for the induction of maternal immune tolerance.
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Affiliation(s)
- Ruth Marian Guzman-Genuino
- Experimental Therapeutics Laboratory, School of Pharmacy and Medical Science, Hanson Institute and Sansom Institute for Health Research, University of South Australia , Adelaide, SA , Australia
| | - Kerrilyn R Diener
- Experimental Therapeutics Laboratory, School of Pharmacy and Medical Science, Hanson Institute and Sansom Institute for Health Research, University of South Australia, Adelaide, SA, Australia; Robinson Research Institute and Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
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24
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Doden T, Sekijima Y, Ikeda J, Ozawa K, Ohashi N, Kodaira M, Hineno A, Tachibana N, Ikeda SI. Postpartum Anti-N-methyl-D-aspartate Receptor Encephalitis: A Case Report and Literature Review. Intern Med 2017; 56:357-362. [PMID: 28154283 PMCID: PMC5348463 DOI: 10.2169/internalmedicine.56.7442] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
We describe a 24-year-old woman with anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis that developed 3 weeks after normal delivery. She was treated with methylprednisolone, intravenous immunoglobulin, and plasmapheresis, in addition to teratoma excision. However, her recovery was slow, and dysmnesia and mental juvenility persisted even two years after onset. To date, five patients with postpartum anti-NMDAR encephalitis have been reported. All of those patients showed psychotic symptoms and were suspected of having postpartum psychosis in the early period of the encephalitis. Changes in hormonal factors, modification of immune tolerance, or retrograde infection of the ovary may be contributing factors for postpartum anti-NMDAR encephalitis.
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Affiliation(s)
- Tadashi Doden
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Japan
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25
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Micheloud D, Nuño L, Rodríguez-Mahou M, Sánchez-Ramón S, Ortega MC, Aguarón A, Junco E, Carbone J, Fernández-Cruzl E, Carreño L, López-Longo FJ. Efficacy and safety of Etanercept, high-dose intravenous gammaglobulin and plasmapheresis combined therapy for lupus diffuse proliferative nephritis complicating pregnancy. Lupus 2016; 15:881-5. [PMID: 17211995 DOI: 10.1177/0961203306070970] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We report one case of pregnancy-onset severe diffuse proliferative nephritis in a patient with systemic lupus erythematosus (SLE), who was successfully treated with a combination of anti-tumour necrosis factor (TNF)-alpha, plasmapheresis and high-dose intravenous gammaglobulin. No flares were observed either in clinical symptoms or in laboratory examinations during pregnancy or after delivery. Her autoantibodies except fluorescent anti-nuclear antibodies were negative. We suggest that a combination of anti-TNF-alpha, plasmapheresis and high-dose intravenous gammaglobulin may be a safe and effective therapy for pregnant patients suffering severe lupus nephritis.
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Affiliation(s)
- D Micheloud
- Immunology Department, University General Hospital Gregorio Marañón, Madrid, Spain
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26
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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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27
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Atta DS, Girbash EF, Abdelwahab SM, Abdeldayem HM, Tharwat I, Ghonaim R. Maternal cytokines and disease severity influence pregnancy outcomes in women with rheumatoid arthritis. J Matern Fetal Neonatal Med 2016; 29:3358-63. [PMID: 26629845 DOI: 10.3109/14767058.2015.1127342] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES To assess the influence of maternal cytokine levels, disease activity and severity on preterm delivery, small for gestational age (SGA) and cesarean delivery in pregnant women with rheumatoid arthritis (RA). METHODS A prospective study in 47 pregnant women with RA and 22 healthy pregnant controls. The main outcome measures were birth weight in relation to maternal serum levels of interleukin-6 (IL-6), interleukin-10 (IL-10), and RA activity and severity at three different time points: preconception and during the first and third trimesters. RESULTS During the third trimester, IL-10 was detectable in 23.4% of patients with RA, IL-6 in 76.6%. Mean birth weight born to mothers with RA was higher when IL-10 level was high compared with low (p = 0.001), and lower when IL-6 was high compared with low (p = 0.035). Also increase in disease activity score-28 (in 60.1%, p = 0.001), Health Assessment Questionnaire-Disability Index (in 87.5%, p = 0.013), and pain score (56.9 ± 11.4, p = 0.003) associated with increased risk of SGA. High patient's global scale was associated with unfavorable pregnancy outcome (preterm, SGA, and cesarean). CONCLUSION High maternal IL-10 levels are associated with higher birth weight and high IL-6 levels are associated with lower birth weight (SGA). Among women with RA, disease activity and severity are predictive of unfavorable pregnancy outcomes suggesting that better disease management early in the pregnancy could improve pregnancy outcomes.
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Affiliation(s)
- Doaa S Atta
- a Rheumatology and Rehabilitation, Faculty of Medicine, Zagazig University , Zagazig , Egypt
| | - Ehab F Girbash
- b Obstetrics and Gynecology, Faculty of Medicine, Zagazig University , Zagazig , Egypt .,c Najd Consulting Hospital , Riyadh , Saudi Arabia , and
| | - Shaimaa M Abdelwahab
- a Rheumatology and Rehabilitation, Faculty of Medicine, Zagazig University , Zagazig , Egypt
| | - Hussein M Abdeldayem
- b Obstetrics and Gynecology, Faculty of Medicine, Zagazig University , Zagazig , Egypt
| | - Ibrahim Tharwat
- a Rheumatology and Rehabilitation, Faculty of Medicine, Zagazig University , Zagazig , Egypt
| | - Rania Ghonaim
- d Clinical Pathology, Faculty of Medicine, Zagazig University , Zagazig , Egypt
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28
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Pikwer M, Orellana C, Källberg H, Pikwer A, Turesson C, Klareskog L, Alfredsson L, Saevarsdottir S, Bengtsson C. Parity influences the severity of ACPA-negative early rheumatoid arthritis: a cohort study based on the Swedish EIRA material. Arthritis Res Ther 2015; 17:358. [PMID: 26653988 PMCID: PMC4704530 DOI: 10.1186/s13075-015-0869-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Accepted: 11/20/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In women with rheumatoid arthritis (RA) it has been observed that during pregnancy a majority of patients experience amelioration, but after delivery a relapse of the disease is common. However, there are few studies, with diverging results, addressing the effect of parity on the severity of RA over time. Our aim was to explore the impact of parity, with stratification for anti-citrullinated protein antibody (ACPA) status as well as for onset during reproductive age or not. METHODS Female RA cases aged 18-70 years were recruited for the Epidemiological Investigation of Rheumatoid Arthritis (EIRA). Information on disease severity (the health assessment questionnaire (HAQ) and the disease activity score 28 (DAS28)) was retrieved from the Swedish Rheumatology Quality Register at inclusion and 3, 6, 12 and 24 months after diagnosis. Mixed models were used to compare mean DAS28 and HAQ scores over time in parous and nulliparous women. Mean differences at individual follow-up visits were compared using analysis of covariance. The odds of having DAS28 or HAQ above the median in parous verus nulliparous women were estimated in logistic regression models. RESULTS A total of 1237 female cases (mean age 51 years, 65 % ACPA-positive) were included. ACPA-negative parous women, aged 18-44 years, had on average 1.17 units higher DAS28 (p < 0.001) and 0.43 units higher HAQ score (p < 0.001) compared to nulliparous women during the follow-up time, adjusted for age. In this subgroup, the average DAS28 and HAQ scores were significantly higher in parous women at all follow-up time points. Younger parous ACPA-negative women were significantly more likely to have DAS28 and HAQ values above the median compared to nulliparous women at all follow-up visits. No association between parity and severity of ACPA-positive disease was observed. CONCLUSIONS Parity was a predictor of a more severe RA among ACPA-negative younger women, which might indicate that immunomodulatory changes during and after pregnancy affect RA severity, in particular for the ACPA-negative RA phenotype.
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Affiliation(s)
- Mitra Pikwer
- Rheumatology Unit, Mälarsjukhuset Hospital, Eskilstuna, Sweden. .,Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden. .,Centre for Clinical Research Sörmland, Uppsala University, Eskilstuna, Sweden. .,Rheumatology, Department of Clinical Sciences, Malmö, Lund University, Malmö, Sweden.
| | - Cecilia Orellana
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.
| | - Henrik Källberg
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.
| | - Andreas Pikwer
- Centre for Clinical Research Sörmland, Uppsala University, Eskilstuna, Sweden.
| | - Carl Turesson
- Rheumatology, Department of Clinical Sciences, Malmö, Lund University, Malmö, Sweden.
| | - Lars Klareskog
- Rheumatology Unit, Department of Medicine, Karolinska Institutet and Karolinska University Hospital Solna, Stockholm, Sweden.
| | - Lars Alfredsson
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden. .,Centre of Occupational and Environmental Medicine, Stockholm County Council, Stockholm, Sweden.
| | - Saedis Saevarsdottir
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden. .,Rheumatology Unit, Department of Medicine, Karolinska Institutet and Karolinska University Hospital Solna, Stockholm, Sweden.
| | - Camilla Bengtsson
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.
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Timur H, Tokmak A, Türkmen GG, Ali İnal H, Uygur D, Danışman N. Pregnancy outcome in patients with ankylosing spondylitis. J Matern Fetal Neonatal Med 2015; 29:2470-4. [DOI: 10.3109/14767058.2015.1089432] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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30
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Abstract
Fertility is impaired in female patients with rheumatoid arthritis (RA), which is related to disease activity and the use of certain medication. During pregnancy, disease activity usually improves, but less than previously thought. Especially in women with high disease activity, the pregnancy outcome is also impaired. All of this underscores the importance of strict control of disease activity in RA patients who wish to conceive. Management of RA disease activity during pregnancy might be a challenge as the treatment options are limited. Evidence is accumulating that tumor necrosis factor (TNF) blockers can be safely used during pregnancy, particularly during the first trimester and the beginning of the second trimester. Far less is known about the problems faced by male RA patients who wish to conceive, in terms of not only fertility and pregnancy outcome but also the safety of medication. In this paper, the fertility issues in patients with RA, the pregnancy-associated improvement of RA, the pregnancy outcomes, including the long-term effects on the offspring, and treatment options, including those during lactation and for male patients wishing to conceive, will be reviewed.
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Affiliation(s)
- Hilal Ince-Askan
- Department of Rheumatology, Erasmus Medical Center, Rotterdam, The Netherlands
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31
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Elevated Serum Levels of Soluble CD30 in Ankylosing Spondylitis Patients and Its Association with Disease Severity-Related Parameters. BIOMED RESEARCH INTERNATIONAL 2015; 2015:617282. [PMID: 26273636 PMCID: PMC4529931 DOI: 10.1155/2015/617282] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/12/2014] [Revised: 12/14/2014] [Accepted: 12/28/2014] [Indexed: 11/28/2022]
Abstract
Soluble CD30 (sCD30), a transmembrane glycoprotein that belongs to the tumor necrosis factor receptor (TNFR) superfamily, has been shown to be associated with various pathological conditions. This study was designed to measure the levels of serum sCD30 in patients with ankylosing spondylitis (AS) and to evaluate the relationships between serum sCD30 levels and other disease severity-related indexes, including bath ankylosing spondylitis disease activity index (BASDAI), ankylosing spondylitis disease activity score (ASDAS), and bath ankylosing spondylitis functional index (BASFI). Our results demonstrated significantly elevated sCD30 levels in AS patients compared to healthy controls (HCs) with mean values of 32.0 ± 12.2 and 24.9 ± 8.0 ng/mL, respectively (P** = 0.007), suggesting a potential role of sCD30 in the pathogenesis of AS. However, no significant correlations of sCD30 with BASDAI, ASDAS, or BASFI were detected in our study (P > 0.05). Therefore, sCD30 cannot be used as a reliable marker for reflecting disease activity and functional ability of AS patients.
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32
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Mahendira D, Thavaneswaran A, Carty A, Haroon N, Anton A, Passalent L, Alnaqbi KA, Savage L, Aslanyan E, Inman RD. Analysis of the effect of the oral contraceptive pill on clinical outcomes in women with ankylosing spondylitis. J Rheumatol 2015; 41:1344-8. [PMID: 24931958 DOI: 10.3899/jrheum.130996] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVE There are unexplained sex-specific changes in the clinical expression of ankylosing spondylitis (AS). We sought to examine the potential effect of exogenous estrogen in the form of oral contraceptive pills (OCP) on AS initiation and severity. METHODS This cross-sectional study consisted of women with AS from the membership of the Spondylitis Association of America. Measures of disease severity included use of biological agents and hip replacement surgery, while Bath AS Functional Index (BASFI) scores served as a surrogate marker of disability. Information was obtained using a patient questionnaire on patient demographics, OCP use, pregnancy history, AS duration, medication use, and hip replacement. RESULTS There were 571 women with AS who participated in our study, consisting of 448 OCP ever-users and 123 non-OCP users. The mean age of OCP users was 42.7 yrs (± 11.5) and of non-OCP users, 48.4 yrs (± 12.1). No difference was noted in the age at initial onset of back pain. However, OCP users were significantly younger at the time of diagnosis of AS (36.5 yrs vs 39.1 yrs, p = 0.02). There were no significant differences between the 2 groups in tumor necrosis factor inhibitor or opioid use, BASFI scores, pregnancy complications, or hip surgery. CONCLUSION The use of exogenous estrogens in the form of OCP is not associated with a measurable effect on initiation or severity of AS. Biologic and social factors may contribute to earlier diagnosis of AS in OCP users. This is the largest study to date investigating the potential effect of exogenous estrogens in women with AS.
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Affiliation(s)
- Dharini Mahendira
- From the Division of Rheumatology, University of Toronto, St. Michael's Hospital (SMH), and the Division of Rheumatology, University of Toronto, Toronto Western Hospital (TWH), Toronto, Ontario, Canada; the Division of Rheumatology, Al Ain Hospital, United Arab Emirates; and the Spondylitis Association of America (SAA), Van Nuys, California, USA.D. Mahendira, MD, MSc, FRCPC, SMH; A. Thavaneswaran, MMath, BSc; A. Carty, BPH; N. Haroon, MD, PhD, DM; A. Anton, BSc; L. Passalent, BScPT, MHSc, TWH; K.A. Alnaqbi, MD, MSc, FRCPC, TWH, and Division of Rheumatology, Al Ain Hospital; L. Savage, MS; E. Aslanyan, BA, SAA; R.D. Inman, MD, FRCPC, TWH.
| | - Arane Thavaneswaran
- From the Division of Rheumatology, University of Toronto, St. Michael's Hospital (SMH), and the Division of Rheumatology, University of Toronto, Toronto Western Hospital (TWH), Toronto, Ontario, Canada; the Division of Rheumatology, Al Ain Hospital, United Arab Emirates; and the Spondylitis Association of America (SAA), Van Nuys, California, USA.D. Mahendira, MD, MSc, FRCPC, SMH; A. Thavaneswaran, MMath, BSc; A. Carty, BPH; N. Haroon, MD, PhD, DM; A. Anton, BSc; L. Passalent, BScPT, MHSc, TWH; K.A. Alnaqbi, MD, MSc, FRCPC, TWH, and Division of Rheumatology, Al Ain Hospital; L. Savage, MS; E. Aslanyan, BA, SAA; R.D. Inman, MD, FRCPC, TWH
| | - Adele Carty
- From the Division of Rheumatology, University of Toronto, St. Michael's Hospital (SMH), and the Division of Rheumatology, University of Toronto, Toronto Western Hospital (TWH), Toronto, Ontario, Canada; the Division of Rheumatology, Al Ain Hospital, United Arab Emirates; and the Spondylitis Association of America (SAA), Van Nuys, California, USA.D. Mahendira, MD, MSc, FRCPC, SMH; A. Thavaneswaran, MMath, BSc; A. Carty, BPH; N. Haroon, MD, PhD, DM; A. Anton, BSc; L. Passalent, BScPT, MHSc, TWH; K.A. Alnaqbi, MD, MSc, FRCPC, TWH, and Division of Rheumatology, Al Ain Hospital; L. Savage, MS; E. Aslanyan, BA, SAA; R.D. Inman, MD, FRCPC, TWH
| | - Nigil Haroon
- From the Division of Rheumatology, University of Toronto, St. Michael's Hospital (SMH), and the Division of Rheumatology, University of Toronto, Toronto Western Hospital (TWH), Toronto, Ontario, Canada; the Division of Rheumatology, Al Ain Hospital, United Arab Emirates; and the Spondylitis Association of America (SAA), Van Nuys, California, USA.D. Mahendira, MD, MSc, FRCPC, SMH; A. Thavaneswaran, MMath, BSc; A. Carty, BPH; N. Haroon, MD, PhD, DM; A. Anton, BSc; L. Passalent, BScPT, MHSc, TWH; K.A. Alnaqbi, MD, MSc, FRCPC, TWH, and Division of Rheumatology, Al Ain Hospital; L. Savage, MS; E. Aslanyan, BA, SAA; R.D. Inman, MD, FRCPC, TWH
| | - Ammepa Anton
- From the Division of Rheumatology, University of Toronto, St. Michael's Hospital (SMH), and the Division of Rheumatology, University of Toronto, Toronto Western Hospital (TWH), Toronto, Ontario, Canada; the Division of Rheumatology, Al Ain Hospital, United Arab Emirates; and the Spondylitis Association of America (SAA), Van Nuys, California, USA.D. Mahendira, MD, MSc, FRCPC, SMH; A. Thavaneswaran, MMath, BSc; A. Carty, BPH; N. Haroon, MD, PhD, DM; A. Anton, BSc; L. Passalent, BScPT, MHSc, TWH; K.A. Alnaqbi, MD, MSc, FRCPC, TWH, and Division of Rheumatology, Al Ain Hospital; L. Savage, MS; E. Aslanyan, BA, SAA; R.D. Inman, MD, FRCPC, TWH
| | - Laura Passalent
- From the Division of Rheumatology, University of Toronto, St. Michael's Hospital (SMH), and the Division of Rheumatology, University of Toronto, Toronto Western Hospital (TWH), Toronto, Ontario, Canada; the Division of Rheumatology, Al Ain Hospital, United Arab Emirates; and the Spondylitis Association of America (SAA), Van Nuys, California, USA.D. Mahendira, MD, MSc, FRCPC, SMH; A. Thavaneswaran, MMath, BSc; A. Carty, BPH; N. Haroon, MD, PhD, DM; A. Anton, BSc; L. Passalent, BScPT, MHSc, TWH; K.A. Alnaqbi, MD, MSc, FRCPC, TWH, and Division of Rheumatology, Al Ain Hospital; L. Savage, MS; E. Aslanyan, BA, SAA; R.D. Inman, MD, FRCPC, TWH
| | - Khalid A Alnaqbi
- From the Division of Rheumatology, University of Toronto, St. Michael's Hospital (SMH), and the Division of Rheumatology, University of Toronto, Toronto Western Hospital (TWH), Toronto, Ontario, Canada; the Division of Rheumatology, Al Ain Hospital, United Arab Emirates; and the Spondylitis Association of America (SAA), Van Nuys, California, USA.D. Mahendira, MD, MSc, FRCPC, SMH; A. Thavaneswaran, MMath, BSc; A. Carty, BPH; N. Haroon, MD, PhD, DM; A. Anton, BSc; L. Passalent, BScPT, MHSc, TWH; K.A. Alnaqbi, MD, MSc, FRCPC, TWH, and Division of Rheumatology, Al Ain Hospital; L. Savage, MS; E. Aslanyan, BA, SAA; R.D. Inman, MD, FRCPC, TWH
| | - Laurie Savage
- From the Division of Rheumatology, University of Toronto, St. Michael's Hospital (SMH), and the Division of Rheumatology, University of Toronto, Toronto Western Hospital (TWH), Toronto, Ontario, Canada; the Division of Rheumatology, Al Ain Hospital, United Arab Emirates; and the Spondylitis Association of America (SAA), Van Nuys, California, USA.D. Mahendira, MD, MSc, FRCPC, SMH; A. Thavaneswaran, MMath, BSc; A. Carty, BPH; N. Haroon, MD, PhD, DM; A. Anton, BSc; L. Passalent, BScPT, MHSc, TWH; K.A. Alnaqbi, MD, MSc, FRCPC, TWH, and Division of Rheumatology, Al Ain Hospital; L. Savage, MS; E. Aslanyan, BA, SAA; R.D. Inman, MD, FRCPC, TWH
| | - Elin Aslanyan
- From the Division of Rheumatology, University of Toronto, St. Michael's Hospital (SMH), and the Division of Rheumatology, University of Toronto, Toronto Western Hospital (TWH), Toronto, Ontario, Canada; the Division of Rheumatology, Al Ain Hospital, United Arab Emirates; and the Spondylitis Association of America (SAA), Van Nuys, California, USA.D. Mahendira, MD, MSc, FRCPC, SMH; A. Thavaneswaran, MMath, BSc; A. Carty, BPH; N. Haroon, MD, PhD, DM; A. Anton, BSc; L. Passalent, BScPT, MHSc, TWH; K.A. Alnaqbi, MD, MSc, FRCPC, TWH, and Division of Rheumatology, Al Ain Hospital; L. Savage, MS; E. Aslanyan, BA, SAA; R.D. Inman, MD, FRCPC, TWH
| | - Robert D Inman
- From the Division of Rheumatology, University of Toronto, St. Michael's Hospital (SMH), and the Division of Rheumatology, University of Toronto, Toronto Western Hospital (TWH), Toronto, Ontario, Canada; the Division of Rheumatology, Al Ain Hospital, United Arab Emirates; and the Spondylitis Association of America (SAA), Van Nuys, California, USA.D. Mahendira, MD, MSc, FRCPC, SMH; A. Thavaneswaran, MMath, BSc; A. Carty, BPH; N. Haroon, MD, PhD, DM; A. Anton, BSc; L. Passalent, BScPT, MHSc, TWH; K.A. Alnaqbi, MD, MSc, FRCPC, TWH, and Division of Rheumatology, Al Ain Hospital; L. Savage, MS; E. Aslanyan, BA, SAA; R.D. Inman, MD, FRCPC, TWH
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Ngo ST, Steyn FJ, McCombe PA. Gender differences in autoimmune disease. Front Neuroendocrinol 2014; 35:347-69. [PMID: 24793874 DOI: 10.1016/j.yfrne.2014.04.004] [Citation(s) in RCA: 600] [Impact Index Per Article: 60.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2014] [Revised: 04/20/2014] [Accepted: 04/22/2014] [Indexed: 12/21/2022]
Abstract
Autoimmune diseases are a range of diseases in which the immune response to self-antigens results in damage or dysfunction of tissues. Autoimmune diseases can be systemic or can affect specific organs or body systems. For most autoimmune diseases there is a clear sex difference in prevalence, whereby females are generally more frequently affected than males. In this review, we consider gender differences in systemic and organ-specific autoimmune diseases, and we summarize human data that outlines the prevalence of common autoimmune diseases specific to adult males and females in countries commonly surveyed. We discuss possible mechanisms for sex specific differences including gender differences in immune response and organ vulnerability, reproductive capacity including pregnancy, sex hormones, genetic predisposition, parental inheritance, and epigenetics. Evidence demonstrates that gender has a significant influence on the development of autoimmune disease. Thus, considerations of gender should be at the forefront of all studies that attempt to define mechanisms that underpin autoimmune disease.
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Affiliation(s)
- S T Ngo
- School of Biomedical Sciences, University of Queensland, St Lucia, Queensland, Australia; University of Queensland Centre for Clinical Research, University of Queensland, Herston, Queensland, Australia
| | - F J Steyn
- School of Biomedical Sciences, University of Queensland, St Lucia, Queensland, Australia
| | - P A McCombe
- University of Queensland Centre for Clinical Research, University of Queensland, Herston, Queensland, Australia; Department of Neurology, Royal Brisbane & Women's Hospital, Herston, Queensland, Australia.
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Soh MC, Nelson-Piercy C. Update of the management of rheumatoid arthritis in pregnancy. ACTA ACUST UNITED AC 2014. [DOI: 10.1586/eog.11.77] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Friis CM, Paasche Roland MC, Godang K, Ueland T, Tanbo T, Bollerslev J, Henriksen T. Adiposity-related inflammation: effects of pregnancy. Obesity (Silver Spring) 2013; 21:E124-30. [PMID: 23505192 DOI: 10.1002/oby.20120] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2012] [Accepted: 09/04/2012] [Indexed: 11/05/2022]
Abstract
UNLABELLED In the nonpregnant population, there is extensive evidence of a systemic low-grade inflammatory status in relation to excess adipose tissue. Less is known about the relation during pregnancy. OBJECTIVE Our main objective was therefore to explore the effect of pregnancy on adiposity-related systemic inflammation. DESIGN AND METHODS This study is a longitudinal cohort study of 240 pregnant women of Scandinavian heritage at Oslo University hospital-Rikshospitalet, Norway from 2002 to 2005. The inflammatory markers (C-reactive protein [CRP], Interleukin-6 [IL-6], monocyte chemoattractant protein 1 [MCP-1], IL1-Ra, tumor necrosis factor receptor II, and IL-10) were measured at four timepoints during pregnancy and analyzed by enzyme immuno-assay. The women were categorized based on BMI at inclusion (BMI <25, 25-30, and >30 kg/m(2)). Data were analyzed by Friedman-test, Wilcoxon signed rank test, or Kruskal-Wallis test as appropriate. RESULTS Maternal adiposity was associated with significantly higher circulatory levels of several inflammatory markers (CRP, MCP-1, IL-6, and IL-1Ra). However, this proinflammatory upregulation was not evident toward the end of pregnancy, as levels of CRP, MCP-1, and IL-6 were not any longer significantly different between the BMI categories. CONCLUSIONS Although normal pregnancy exhibits proinflammatory features, this does not seem to have additive or synergistic effects on the inflammation associated with adiposity. On the contrary, we found that the BMI-dependent increase in proinflammatory markers was not evident at the end of pregnancy.
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Affiliation(s)
- Camilla M Friis
- Division of Obstetrics and Gynaecology, Oslo University Hospital Rikshospitalet, Oslo, Norway.
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de Steenwinkel FDO, Hokken-Koelega ACS, de Man YA, de Rijke YB, de Ridder MAJ, Hazes JMW, Dolhain RJEM. Circulating maternal cytokines influence fetal growth in pregnant women with rheumatoid arthritis. Ann Rheum Dis 2012; 72:1995-2001. [DOI: 10.1136/annrheumdis-2012-202539] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BackgroundHigh rheumatoid arthritis (RA) disease activity during pregnancy is associated with a lower birth weight. Active RA is characterised by high circulating levels of cytokines, which can mediate placental growth and remodelling.ObjectivesTo assess the influence of maternal serum cytokine levels on birth weight in RA pregnancy.MethodsThis study is embedded in the PARA Study, a prospective study on RA and pregnancy. In the present study, 161 pregnant women with RA and 32 healthy pregnant women were studied. The main outcome measures were birth weight SD score (birth weight SDS) in relation to maternal serum levels of interleukin-10 (IL-10), interleukin-6 (IL-6) and tumour necrosis factor-α (TNFα) at three different time points: preconception and during the first and third trimester. Single-nucleotide polymorphisms (SNPs) in the corresponding cytokine genes were also studied.ResultsDuring the first trimester, IL-10 was detectable in 16% of patients with RA, IL-6 in 71%, and TNFα in all patients with RA. Mean birth weight SDS of children born to mothers with RA was higher when IL-10 level was high compared with low (difference=0.75; p=0.04), and lower when IL-6 was high compared with low (difference=0.50; p<0.01) in the first trimester. No correlation was seen at the other time points studied or with TNFα. Cytokine levels were not related to their corresponding SNPs.ConclusionsMaternal IL-10 and IL-6 levels are associated with fetal growth in RA. In the first trimester, high IL-10 levels are associated with higher birth weight SDS, and high IL-6 levels are associated with lower birth weight SDS, even after correction for disease activity.
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Weix J, Förger F, Häupl T, Surbek D, Østensen M, Villiger PM. Influence of pregnancy on the adipocytokine and peroxisome proliferator-activated receptor pathways in peripheral blood mononuclear cells from healthy donors and rheumatoid arthritis patients. ACTA ACUST UNITED AC 2012; 64:2095-103. [PMID: 22231457 DOI: 10.1002/art.34375] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
OBJECTIVE To identify candidate genes that are regulated by human pregnancy and have the potential to modulate rheumatoid arthritis (RA) disease activity. METHODS Peripheral blood mononuclear cells (PBMCs) from healthy pregnant volunteers were analyzed using Affymetrix GeneChips at 4 time points (during the first, second, and third trimesters and 6 weeks postpartum). Based on the GeneChip data, target genes were further analyzed via real-time quantitative polymerase chain reaction (qPCR) using PBMCs from healthy controls and RA patients. In order to determine the cellular source of the candidate gene messenger RNA (mRNA), monocytes and lymphocytes from healthy controls and RA patients were positively selected using magnetic beads, and their mRNA was analyzed by qPCR. RESULTS One-way analysis of variance identified 1,286 mRNAs that were differentially expressed with regard to the 4 time points. The changes became more pronounced as pregnancy progressed, and they were reversed postpartum. A subsequent pathway analysis suggested a regulatory role of pregnancy on the adipocytokine pathway as well as on the peroxisome proliferator-activated receptor (PPAR) signaling pathway. Of 19 preselected candidate genes, AKT3, SOCS3, FADS2, STAT1, and CD36 proved to be differentially regulated by pregnancy. In samples from RA patients, the differences were concordant with those in healthy controls but more pronounced. Both T lymphocytes and monocytes contributed to the regulated expression of these genes. CONCLUSION Our findings indicate that normal human pregnancy leads to changes in the expression of several molecular pathways in PBMCs, which are reversed postpartum. Changes in RA patients, although concordant, exceed the levels observed in healthy controls. Genes of the adipocytokine and PPAR signaling pathways qualify as candidates for the modulation of RA disease activity during pregnancy.
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Affiliation(s)
- Janine Weix
- University Hospital and University of Bern, Bern, Switzerland
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Pregnancy-associated inflammatory markers are elevated in pregnant women with systemic lupus erythematosus. Cytokine 2012; 59:392-9. [PMID: 22633082 DOI: 10.1016/j.cyto.2012.04.046] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2011] [Revised: 04/19/2012] [Accepted: 04/25/2012] [Indexed: 11/23/2022]
Abstract
During normal pregnancy a dampening in T cell-mediated immunity is compensated by an increased pro-inflammatory activity. Likewise, the autoimmune disease systemic lupus erythematosus (SLE) is associated with inflammatory activity and pregnancy complications occur frequently in women with SLE. The aim of this study was to elucidate how SLE influences the chemokine and cytokine balance during and after pregnancy. Blood samples were taken from pregnant women with or without SLE at second and third trimester and 8-12 weeks after pregnancy. Cytokines (interleukin (IL)-1β, IL-2, IL-4, IL-6, IL-10, IL-12p70, IL-17A, TNF, IFN-γ and IFN-α), chemokines (CXCL8/IL-8, CXCL9/MIG, CXCL10/IP-10, CCL2/MCP-1, CCL5/RANTES and CCL17/TARC), soluble IL-6 receptor (sIL-6R) and soluble glycoprotein 130 (gp130) were measured in serum using cytometric bead array (CBA) or enzyme-linked immunosorbent assay (ELISA). Women with SLE had increased serum concentrations of CXCL8/IL-8, CXCL9/MIG, CXCL10/IP-10 and IL-10 compared to controls both during and after pregnancy. Further, when dividing the patients based on disease activity, the women with active disease had the highest levels. Importantly, women with SLE seemed to respond to pregnancy in a similar way as controls, since the changes of cytokines and chemokines over the course of pregnancy were similar but with overall higher levels in the patient group. In conclusion, changes in pro- and anti-inflammatory serum components during pregnancy in women with SLE, occurring on top of already more pro-inflammatory levels, might increase their risk for pregnancy complications and flares. How their children are affected by this heightened inflammatory milieu during pregnancy needs further investigation.
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Wakefield D, El-Asrar AA, McCluskey P. Treatment of Severe Inflammatory Eye Disease in Patients of Reproductive Age and during Pregnancy. Ocul Immunol Inflamm 2012; 20:277-87. [DOI: 10.3109/09273948.2012.684736] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Mackensen F, Max R. [Management of patients with ocular diseases during pregnancy. Diabetes, glaucoma and uveitis]. Ophthalmologe 2012; 109:235-41. [PMID: 22447420 DOI: 10.1007/s00347-011-2461-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Many ocular diseases require treatment even during pregnancy. Some conditions, such as diabetic retinopathy tend to worsen during pregnancy but others, such as uveitis may benefit from the physiological changes occurring during pregnancy. But generally even a favorable development is not sufficient to obtain a steady state without treatment. Each medication applied during pregnancy should only be given after thorough consideration of the pros and cons and discussion of these with the patient. There are sufficient medications for ocular diseases that can be given when indicated following published guidelines and experiences. This review focuses on the course and therapy of glaucoma, diabetic retinopathy and uveitis during pregnancy.
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Affiliation(s)
- F Mackensen
- Interdisziplinäres Uveitiszentrum Universität Heidelberg, INF 400, 69120 Heidelberg.
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Østensen M, Villiger PM, Förger F. Interaction of pregnancy and autoimmune rheumatic disease. Autoimmun Rev 2011; 11:A437-46. [PMID: 22154710 DOI: 10.1016/j.autrev.2011.11.013] [Citation(s) in RCA: 87] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
During pregnancy, the fetus represents a natural allograft that is not normally rejected. While the maternal immune system retains the ability to respond to foreign antigens, tolerance mechanisms are up-regulated to protect the fetus from immunologic attacks by the mother. The profound immunologic adaptations during and after pregnancy do influence maternal autoimmune rheumatic diseases in several ways. One is triggering the onset of a rheumatic disease in the post partum period, the other influencing disease activity of established rheumatic disease. The review will discuss the mechanisms of increased susceptibility of rheumatoid arthritis (RA) in the first year post partum with a specific emphasis on the role of fetal cells or antigens persisting in the maternal circulation (so called microchimerism). Furthermore, the different influences of pregnancy on established rheumatic diseases will be highlighted. A marked beneficial effect of pregnancy is observed on RA whereas several other rheumatic diseases as ankylosing spondylitis (AS) and systemic lupus erythematosus (SLE) show either no particular effect or an aggravation of symptoms during pregnancy. Differences emerging in regard to modulation of disease symptoms during pregnancy seem related to response to hormones, the type of cytokine profile and immune response prevailing as well as further downstream interactions of molecular pathways that are important in disease pathogenesis.
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Affiliation(s)
- Monika Østensen
- Department of Rheumatology and Clinical Immunology and Allergology, University Hospital, Bern, Switzerland.
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Abstract
Antigen-presenting molecules vary between individuals of the same species, making it more difficult for pathogens to evade immune recognition and spread through the whole population. As a result of this genetic diversity, transplants between individuals are recognized as foreign and are rejected. This alloreactivity turns placental viviparity into a major immunological challenge. The maternal immune system has to balance the opposing needs of maintaining robust immune reactivity to protect both mother and fetus from invading pathogens, while at the same time tolerating highly immunogenic paternal alloantigens in order to sustain fetal integrity. Regulatory T cells are responsible for the establishment of tolerance by modulating the immune response, and uterine natural killer cells direct placentation by controlling trophoblast invasion. A variety of other cell types, including decidual stromal cells, dendritic cells, and immunomodulatory multipotent mesenchymal stromal cells, are found at the fetal-maternal interface. These cells conspire to establish a suitable environment for fetal development without compromising systemic immunity. Defects in any of these components can lead to gestational failure despite successful fertilization.
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Affiliation(s)
- Alba Munoz-Suano
- Laboratory of Molecular Biology, Medical Research Council, Cambridge, UK
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Meriño-Ibarra E, Delgado Beltrán C. [Rheumatoid arthritis: how to use drugs during pregnancy and lactation?]. REUMATOLOGIA CLINICA 2011; 7:262-266. [PMID: 21794829 DOI: 10.1016/j.reuma.2010.11.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2010] [Revised: 11/17/2010] [Accepted: 11/21/2010] [Indexed: 05/31/2023]
Abstract
Rheumatoid arthritis is a disease that is highly prevalent in women of childbearing age. A review is done about the characteristics of the placental barrier, the passage of drugs through it and the use of drugs during pregnancy: those which are potentially safe drugs, those drugs that can only be used if there is a life threatening condition for the mother, drugs that are contraindicated and those with insufficient data on safety and therefore should be avoided, the latter group comprises biological drugs. Also a review is done about the use of drugs during lactation, a period that a flare of rheumatoid arthritis can occur.
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Abstract
Over the past years, biological therapies, especially anti-TNF-α antibody therapy has emerged as a treatment approach in patients who have failed to achieve or maintain remission with tradional DMARDs. Women suffering from inflammatory arthritis may need to continue therapy throughout pregnancy and/or in the lactation period, hence the increased concern over the safety of antirheumatic drugs during pregnancy. Anti-TNF agents fall within the US FDA category B concerning fetal risk, indicating that no adequate and well-controlled studies have been conducted in pregnant or lactating women. However, in the last decade, numerous case series and registry data of pregnancies exposed to anti-TNF therapy have accumulated in the literature. According to these data, TNF inhibitor therapies appear to be safe in pregnancy, since no increased risk of malformations has been demonstrated. Ceasing therapy after conception should be considered, but treatment may be continued during pregnancy when indicated.The use of these agents is likely compatible with breast-feeding. The extent of fetal risk is not clarified for exposure to other biologics, such as Rituximab.
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Affiliation(s)
- R E Fischer-Betz
- Klinik für Endokrinolologie, Diabetologie und Rheumatologie, Rheumazentrum Rhein-Ruhr, Moorenstr. 5, 40225, Düsseldorf.
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McConico A, Butters K, Lien K, Knudsen B, Wu X, Platt JL, Ogle BM. In utero cell transfer between porcine littermates. Reprod Fertil Dev 2011; 23:297-302. [PMID: 21211462 DOI: 10.1071/rd10165] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2010] [Accepted: 07/05/2010] [Indexed: 12/18/2022] Open
Abstract
Trafficking of cells between mother and fetus during the course of normal pregnancy is well documented. Similarly, cells are known to travel between twins that share either a placenta (i.e. monozygotic) or associated chorion (i.e. monochorionic). Transferred cells are thought to be channelled via the vessels of the placenta or vascular connections established via the chorion and the long-term presence of these cells (i.e. microchimerism) can have important consequences for immune system function and reparative capacity of the host. Whether cells can be transferred between twins with separate placentas and separate chorions (i.e. no vascular connections between placentas) has not been investigated nor have the biological consequences of such a transfer. In the present study, we tested the possibility of this type of cell transfer by injecting human cord blood-derived cells into a portion of the littermates of swine and probing for human cells in the blood and tissues of unmanipulated littermates. Human cells were detected in the blood of 78% of unmanipulated littermates. Human cells were also detected in various tissues of the unmanipulated littermates, including kidney (56%), spleen (33%), thymus (11%) and heart (22%). Human cells were maintained in the blood until the piglets were sacrificed (8 months after birth), suggesting the establishment of long-term microchimerism. Our findings show that the transfer of cells between fetuses with separate placentas and separate chorions is significant and thus such twins may be subject to the same consequences of microchimerism as monozygotic or monochorionic counterparts.
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Affiliation(s)
- Andrea McConico
- Department of Surgery, Mayo Clinic College of Medicine, Rochester, MN 55901, USA
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Abstract
PURPOSE OF REVIEW This review discusses how inflammatory rheumatic diseases [rheumatoid arthritis, ankylosing spondylitis, systemic lupus erythematosus (SLE)] of the mother can influence the course of pregnancy and the development of the fetus. Antirheumatic drug therapy of the mother and strategies to prevent fetal complications namely in SLE must be considered with care. RECENT FINDINGS The current literature is presented discussing hypotheses about the immunologic mechanisms leading to amelioration or exacerbation of the rheumatic symptoms in rheumatoid arthritis and ankylosing spondylitis during pregnancy. In SLE, several recent studies have been published concerning fetal complications in the antiphospholipid syndrome and in Ro/SSA-positive and La/SSB-positive mothers and how to diagnose, treat, or prevent these. SUMMARY Today, women with inflammatory rheumatic diseases are normally fertile and can be encouraged to become pregnant, when there is a stable and quiescent phase of the disease. This is in particular important for patients with SLE, although pregnancy outcome in SLE has improved over the last decades. Pregnancy in SLE is still a high-risk period during the disease course with the highest risk in women with active lupus nephritis. In contrast, women with rheumatoid arthritis develop amelioration of the rheumatic symptoms during the course of pregnancy in most cases; female ankylosing spondylitis patients are likely to show unaltered or aggravated symptoms of back pain and impaired function.
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Kwan LY, Mahadevan U. Inflammatory bowel disease and pregnancy: an update. Expert Rev Clin Immunol 2010; 6:643-57. [PMID: 20594137 DOI: 10.1586/eci.10.35] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Women with inflammatory bowel disease have similar rates of conception to the general population unless they have had pelvic surgery. Once pregnant, regardless of disease activity, they have an increased risk of adverse pregnancy outcome and should be followed as high-risk obstetric patients. Most medications are compatible with pregnancy and lactation, as described in this article. Ideally, women should discuss their plans for pregnancy with their physician prior to conception so that risks and benefits can be reviewed, medications adjusted and healthcare maintenance updated. Once pregnant, a multidisciplinary team of gastroenterologists, obstetricians and pediatricians should help to ensure the best care for the mother and child.
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Affiliation(s)
- Lola Y Kwan
- University of Rochester Medical Center, Rochester, NY, USA
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Andreoli L, Bazzani C, Taraborelli M, Reggia R, Lojacono A, Brucato A, Meroni PL, Tincani A. Pregnancy in autoimmune rheumatic diseases: the importance of counselling for old and new challenges. Autoimmun Rev 2010; 10:51-4. [PMID: 20696283 DOI: 10.1016/j.autrev.2010.08.004] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2010] [Accepted: 08/03/2010] [Indexed: 12/16/2022]
Abstract
Rheumatic diseases can affect women during their childbearing age. Therefore, physicians should introduce a discussion with the patients about pregnancy and its problems. Lupus pregnancies can be successful, even in patients with renal disease, when planned in remission state; the use of low dose aspirin was shown to be an independent predictor of good outcome, so it can be suggested as a preventive measure. Pregnancies in women with Antiphospholipid Syndrome can fail even if properly treated, especially when associated with a systemic autoimmune disease, a history of both thrombosis and pregnancy morbidity, and a triple positivity of antiphospholipid antibody assays. Women with systemic sclerosis have generally a good obstetric outcome, except for an increase rate of preterm deliveries. Severe disease complications were sometimes reported, but their relationship with gestation is not clear yet. Although data on human pregnancy are still preliminary, anti-TNF agents are classified as non teratogens in contrast to methotrexate and leflunomide. So women affected by aggressive chronic arthritis may be treated with anti-TNF in the pre-conceptional period, discontinuing the drug as soon as pregnancy starts. In order to increase maternal compliance and cope with difficult cases, a multidisciplinary team (rheumatologists/internists, obstetricians and neonatologists) should take care of patients during pregnancy.
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Affiliation(s)
- Laura Andreoli
- Rheumatology and Clinical Immunology, Spedali Civili and University of Brescia, Brescia, Italy
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Abstract
Postpartum depression (PPD) is a serious mood disorder that may carry life-long consequences for a woman and her family. Multiple risk factors for PPD have been identified, including psychosocial, situational, and biological stimuli, several of which are experienced by most, if not all, postpartum women. Given the commonality of these risk factors, it is unclear why fewer than 20% of postpartum women actually develop PPD. In this review, we suggest that different susceptibility to PPD among postpartum women may be explained by the presence or absence of genetic variants that confer increased risk. We review three categories of genes known to code for proteins associated with depression in the general population or proteins known to be affected by childbirth for their possible association with PPD, including genes related to central nervous system monoamine availability, proinflammatory cytokines, and brain neuropeptides. Only two studies are available in the literature to date specifically looking at polymorphisms in postpartum women as related to PPD; both are concerned with monoamine availability. These are discussed in further depth. Conclusions regarding the contribution of genetic polymorphisms to the development of PPD are mixed. Ultimately, the complexity of the disorder and the interrelationships among different genes thought to contribute to depression suggest that much more research is required to understand the heritability of PPD. The complexity of the disorder also suggests that epigenetic influences must be considered as well when discussing susceptibility.
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Affiliation(s)
- Elizabeth J Corwin
- Division of Women, Children, and Family Health, The College of Nursing, The University of Colorado-Denver, Aurora, CO 80045, USA.
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