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Al Emadi S, Hadwan NN, Saleh R, Satti E, Singh R. Impact of Spondyloarthritis on Pregnancy Outcome: A Descriptive Analysis from a Specialized Center in Qatar. Open Access Rheumatol 2024; 16:21-29. [PMID: 38283655 PMCID: PMC10812142 DOI: 10.2147/oarrr.s449343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Accepted: 01/18/2024] [Indexed: 01/30/2024] Open
Abstract
Introduction Spondyloarthritis (SpA) most commonly presents at childbearing age; thus, pregnancy is of concern. However, data on pregnancy outcomes in these patients are limited. Purpose This study aimed to retrospectively describe pregnancy outcomes in patients with SpA from the Middle East. Patients and Methods We reviewed the electronic health records of all pregnant women attending a specialized pregnancy and rheumatic disease clinic between 2016 and 2022. All pregnant patients diagnosed with axial spondyloarthritis (axSpA) and peripheral SpA were included. Data on adverse maternal and fetal outcomes were collected. Results Fifty-seven eligible pregnancies were identified from hospital records: 10 pregnancies ended in early miscarriage. Forty-seven pregnancies resulted in live singleton births, 25 in patients with peripheral SpA and 22 with axSpA. Human leukocyte antigen B27 was positive in 7 (15%) patients and only in women with axSpA. Twenty-nine (64%) patients received treatment throughout pregnancy. Consistent biologic disease-modifying antirheumatic drug (bDMARD) use was high, in eight (32%) patients with peripheral SpA and in nine (41%) with axSpA. A conventional synthetic disease-modifying anti-rheumatic drug (csDMARD) was used as treatment in 11 (50%) patients with peripheral SpA and two (8%) with axSpA. Twenty-two (53%) neonates were delivered by cesarean section, 19 (40%) by normal vaginal delivery and three (6%) by assisted delivery. Additionally, 44 (94%) deliveries were at term, and 42 (91%) neonates had a normal birth weight. Exploration of a subgroup showed no difference in reported outcomes between patients treated with bDMARD and those treated with csDMARD. Conclusion This descriptive study reports a high rate of favorable pregnancy outcomes in patients with SpA. There was no evidence to suggest a difference in pregnancy outcomes between women with axSpA and those with peripheral SpA. This study was one of the first reports from the Middle East. Further studies with larger sample size are warranted.
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Affiliation(s)
- Samar Al Emadi
- Department of Rheumatology, Hamad Medical Corporation, Doha, Qatar
| | | | - Rawan Saleh
- Department of Rheumatology, Hamad Medical Corporation, Doha, Qatar
| | - Eman Satti
- Department of Rheumatology, Hamad Medical Corporation, Doha, Qatar
| | - Rajvir Singh
- Medical Research Center, Statistics, Hamad Medical Corporation, Doha, Qatar
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Yildirim M, Oluklu D, Menekse Beser D, Uyan Hendem D, Kara O, Tanacan A, Sahin D. Assessment of fetal thymus size in pregnant women with rheumatic diseases: A case-control study. JOURNAL OF CLINICAL ULTRASOUND : JCU 2023; 51:1342-1347. [PMID: 37537797 DOI: 10.1002/jcu.23532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Revised: 07/18/2023] [Accepted: 07/21/2023] [Indexed: 08/05/2023]
Abstract
PURPOSE To investigate the fetal thymic-thoracic ratio (TT-ratio) in pregnancies diagnosed with rheumatoid arthritis (RA) and ankylosing spondylitis (AS). METHODS Thirty-two pregnant women with rheumatic disease and 96 low-risk pregnant women between 20 and 37 weeks were included in the study. Three control patients were randomly selected for each study patient. TT-ratio was calculated by measuring the anterior-posterior diameter of the thymus and the intrathoracic mediastinal diameter. Data were compared between the study group, including RA and AS, and the control group. RESULTS Thirty-two pregnant women with arthritis, 19 diagnosed with RA and 13 with AS, were evaluated. The mean value of the study group TT-ratio was 0.33; control group, 0.36; a statistically significant difference was found (p < 0.001). Perinatal outcomes were not different when compared with control patients. There was a negative correlation between disease duration, maternal C-reactive protein, erythrocyte sedimentation rate, and TT-ratio. CONCLUSION This is the first study to prospectively evaluate the fetal TT-ratio in patients with RA and AS. Systemic inflammation appears to affect fetal thymus size. Appropriate management of maternal rheumatic diseases is essential for developing the thymus, a vital immune system component.
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Affiliation(s)
- Muradiye Yildirim
- 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
| | - Dilek Menekse Beser
- 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
| | - Ozgur Kara
- University of Health Sciences, Department of Obstetrics and Gynecology, Division of Perinatology, Turkish Ministry of Health Ankara City Hospital, Ankara, Turkey
| | - Atakan Tanacan
- University of Health Sciences, Department of Obstetrics and Gynecology, Division of Perinatology, Turkish Ministry of Health Ankara City Hospital, Ankara, Turkey
| | - Dilek Sahin
- University of Health Sciences, Department of Obstetrics and Gynecology, Division of Perinatology, Turkish Ministry of Health Ankara City Hospital, Ankara, Turkey
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Maguire S, Molto A. Pregnancy & neonatal outcomes in spondyloarthritis. Best Pract Res Clin Rheumatol 2023; 37:101868. [PMID: 37652852 DOI: 10.1016/j.berh.2023.101868] [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: 07/06/2023] [Accepted: 08/13/2023] [Indexed: 09/02/2023]
Abstract
Limited research has been conducted on the impact of spondylitis (SpA) on fertility, but some studies suggest a higher risk of subfertility in women with SpA compared to the general population. Factors associated with impaired fertility in SpA include pain, fatigue, stiffness, functional disorders, depression, anxiety, negative body image, and the use of nonsteroidal anti-inflammatory drugs (NSAIDs) preconceptionally, while TNF alpha inhibitors may play a role in improving fertility in certain cases. There has been a recent increase in clinical research focused on pregnancy outcomes in SpA. However, clear trends in terms of risk of pregnancy and fetal complications have been slow to emerge and many questions remain for women with SpA planning a pregnancy. This article discusses the current evidence for risk of specific pregnancy and fetal complications in women with axial and psoriatic SpA.
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Affiliation(s)
- Sinead Maguire
- Department of Rheumatology, Toronto Western Hospital, University Health Network, Toronto, Canada; School of Medicine, University of Toronto, Toronto, Canada
| | - Anna Molto
- Rheumatology Department, Cochin Hospital, Assistance Publique Hôpitaux de Paris, Paris, France; INSERM U-1153, Centre de Recherche en Epidémiologie et Sciences Statistiques (CRESS), Université Paris-Cité, Paris, France.
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Falcon RMG, Alcazar RMU, Mondragon AV, Penserga EG, Tantengco OAG. Rheumatoid arthritis and the risk of preterm birth. Am J Reprod Immunol 2023; 89:e13661. [PMID: 36450344 DOI: 10.1111/aji.13661] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 09/25/2022] [Accepted: 11/21/2022] [Indexed: 12/02/2022] Open
Abstract
During pregnancy, many diseases are correlated with different adverse outcomes. In turn, pregnancy affects the body, leading to increased disease susceptibility. This interplay between diseased states and pregnancy outcomes is illustrated in the effect of the chronic autoimmune disorder, rheumatoid arthritis (RA), and the adverse outcome, preterm birth (PTB). RA is a systemic disorder characterized by inflammation of the joints and other body organs. Joint pain and swelling are the most prominent manifestations of RA during pregnancy. However, the exact role of RA on PTB among pregnant women has yet to be established. This review highlighted the immunologic mechanisms involved in PTB in pregnant patients with RA. The immune cell population in pregnant women with RA exhibited higher activity of macrophages, dendritic cells, neutrophils, helper T (Th) 1 cells, and Vδ1 cells, but lower activity of CD4 + CD25high T regulatory (CD24 + CD25high Treg ), Th2, and Vδ2 cells. Increased pro-inflammatory cytokines IL-6, TNF-α, and IFN-γ and decreased anti-inflammatory cytokines IL-12 and IL-10 are also exhibited by pregnant patients with RA. This review also discussed factors that may predict the risk of PTB in RA. These include disease activity and severity of RA, laboratory parameters (cytokines and immune cell population), and sociodemographic factors such as ethnicity, smoking, alcohol intake, and the level of education. Current findings on the underlying immunological mechanisms of RA can help identify possible strategies to prevent PTB.
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Affiliation(s)
| | | | - Alric V Mondragon
- Division of Allergy and Immunology, Department of Medicine, University of the Philippines-Philippine General Hospital, Manila, Philippines
| | - Ester G Penserga
- Division of Rheumatology, Department of Medicine, University of the Philippines-Philippine General Hospital, Manila, Philippines
| | - Ourlad Alzeus G Tantengco
- Career Incentive Program, Department of Science and Technology - Science Education Institute, Taguig, Philippines
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Girbash EF, Abdelwahab SM, Atef RM, Sherif HE, Abdeldayem HM, Atta DS, Radwan AM. Maternal Interleukin-17 and disease activity influence pregnancy outcomes in women with psoriatic arthritis and ankylosing spondylitis. BMC Pregnancy Childbirth 2023; 23:35. [PMID: 36650451 PMCID: PMC9847183 DOI: 10.1186/s12884-023-05364-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 01/09/2023] [Indexed: 01/18/2023] Open
Abstract
OBJECTIVE We aimed in this study to evaluate the impact of maternal interleukin -17A and the activity of the illness on pregnancy outcomes in Psoriatic arthritis (PsA) and ankylosing spondylitis (AS) patients. METHODS This prospective cohort research was carried out on 48 Psoriatic arthritis and ankylosing spondylitis pregnant women attending the inpatient and outpatient clinics of the Rheumatology & Rehabilitation and Obstetrics & Gynecology Departments, Faculty of Medicine, Zagazig University Hospitals in Egypt and 30 apparently healthy age- and sex-matched pregnant women between January 1,2018, and December 31, 2019. RESULTS The study group patients had a higher risk of preterm labour (32-36 weeks gestation) (aRR 1.80, 95% CI 0.79-4.17), oligohydramnios (aRR 3.15, 95% CI 1.26-8.42), Caesarean delivery (aRR 1.57, 95% CI 1.41-2.68), and delivering infants small for gestational age (aRR 7.04, 95% CI 2.36-12.42). There was significant difference between the control group and the study groups regarding the level of IL-17A. CONCLUSION Many females with PsA and AS have uninhibited pregnancy with regard to adverse events, but in comparison with normal pregnancies particularly with high IL-17A during the third trimester we noticed a growing risk of preterm labour, oligohydramnios and cesarean section. Further studies are needed to evaluate high maternal IL-17A levels and fetal outcomes.
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Affiliation(s)
- Ehab F. Girbash
- grid.31451.320000 0001 2158 2757Obstetrics and Gynecology department, Faculty of Medicine, Zagazig University, Zagazig City, Egypt
| | - Shaimaa M. Abdelwahab
- grid.31451.320000 0001 2158 2757Obstetrics and Gynecology department, Faculty of Medicine, Zagazig University, Zagazig City, Egypt ,grid.31451.320000 0001 2158 2757Rheumatology and Rehabilitation department, Faculty of Medicine, Zagazig University, Zagazig City, Egypt
| | - Rehab M. Atef
- grid.31451.320000 0001 2158 2757 Clinical and Chemical Pathology department, Faculty of Medicine, Zagazig University, Zagazig City, Egypt
| | - Hala E. Sherif
- grid.31451.320000 0001 2158 2757Obstetrics and Gynecology department, Faculty of Medicine, Zagazig University, Zagazig City, Egypt
| | - Hussein M. Abdeldayem
- grid.31451.320000 0001 2158 2757Obstetrics and Gynecology department, Faculty of Medicine, Zagazig University, Zagazig City, Egypt
| | - Doaa S. Atta
- grid.31451.320000 0001 2158 2757Rheumatology and Rehabilitation department, Faculty of Medicine, Zagazig University, Zagazig City, Egypt
| | - Ahmed M. Radwan
- grid.31451.320000 0001 2158 2757Obstetrics and Gynecology department, Faculty of Medicine, Zagazig University, Zagazig City, Egypt
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Gerardi MC, Crisafulli F, García-Fernandez A, Lini D, Bazzani C, Cavazzana I, Filippini M, Fredi M, Gorla R, Lazzaroni MG, Nalli C, Taglietti M, Lojacono A, Ramazzotto F, Zanardini C, Zatti S, Franceschini F, Tincani A, Andreoli L. Stopping bDMARDs at the beginning of pregnancy is associated with disease flares and preterm delivery in women with rheumatoid arthritis. Front Pharmacol 2022; 13:887462. [PMID: 35991899 PMCID: PMC9384697 DOI: 10.3389/fphar.2022.887462] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 06/29/2022] [Indexed: 11/13/2022] Open
Abstract
Objectives: Women with Rheumatoid Arthritis (RA) can experience flares during pregnancy that might influence pregnancy outcomes. We aimed at assessing the disease course during pregnancy and identifying risk factors for flares. Methods: Data about prospectively-followed pregnancies in RA were retrospectively collected before conception, during each trimester and in the post-partum period. Clinical characteristics, disease activity (DAS28-CRP3), medication use, and pregnancy outcomes were analysed with regard to disease flares. Results: Among 73 women who had a live birth, 64 (88%) were in remission/low disease activity before conception. During pregnancy, a flare occurred in 27 (37%) patients, mainly during first and second trimester. Flares during pregnancy were associated with the discontinuation of bDMARDs at positive pregnancy test (55% of patients with flare vs. 30% of patients with no flare, p 0.034, OR 2.857, 95% CI 1.112–8.323) and a previous use of >1 bDMARDs (33% of patients with flare vs. 10% of patients with no flare, p 0.019, OR 4.1, 95%CI 1.204–13.966). Preterm pregnancies were characterised by higher values of CRP [10 mg/L (5–11) vs. 3 mg/L (2.5–5), p 0.01] and DAS28-CRP3 [4.2 (1.9–4.5) vs. 1.9 (1.7–2.6), p 0.01] during the first trimester as compared with pregnancies at term. Preterm delivery was associated with the occurrence of flare during pregnancy (flare 27% vs. no-flare 7%, p 0.034, OR 4.625, 95%CI 1.027–20.829). Conclusion: Preterm delivery in RA patients was associated with flares during pregnancy. Flares occurred more frequently after the discontinuation of bDMARDs at positive pregnancy test. Women with aggressive RA on treatment with bDMARDs should be considered as candidates for continuing bDMARDs during pregnancy in order to reduce the risk of flare and adverse pregnancy outcomes.
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Affiliation(s)
- Maria Chiara Gerardi
- Rheumatology and Clinical Immunology, ASST Spedali Civili; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Francesca Crisafulli
- Rheumatology and Clinical Immunology, ASST Spedali Civili; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | | | - Daniele Lini
- Rheumatology and Clinical Immunology, ASST Spedali Civili; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Chiara Bazzani
- Rheumatology and Clinical Immunology, ASST Spedali Civili; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Ilaria Cavazzana
- Rheumatology and Clinical Immunology, ASST Spedali Civili; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Matteo Filippini
- Rheumatology and Clinical Immunology, ASST Spedali Civili; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Micaela Fredi
- Rheumatology and Clinical Immunology, ASST Spedali Civili; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Roberto Gorla
- Rheumatology and Clinical Immunology, ASST Spedali Civili; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Maria Grazia Lazzaroni
- Rheumatology and Clinical Immunology, ASST Spedali Civili; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Cecilia Nalli
- Rheumatology and Clinical Immunology, ASST Spedali Civili; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Marco Taglietti
- Rheumatology and Clinical Immunology, ASST Spedali Civili; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Andrea Lojacono
- Obstetrics and Gynaecology Unit, ASST Garda Ospedale of Desenzano, Desenzano del Garda, Italy
| | | | | | - Sonia Zatti
- Obstetrics and Gynaecology, ASST Spedali Civili, Brescia, Italy
| | - Franco Franceschini
- Rheumatology and Clinical Immunology, ASST Spedali Civili; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Angela Tincani
- Rheumatology and Clinical Immunology, ASST Spedali Civili; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Laura Andreoli
- Rheumatology and Clinical Immunology, ASST Spedali Civili; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
- *Correspondence: Laura Andreoli,
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Hamroun S, Hamroun A, Bigna JJ, Allado E, Förger F, Molto A. Fertility and pregnancy outcomes in women with spondyloarthritis: a systematic review and meta-analysis. Rheumatology (Oxford) 2021; 61:1314-1327. [PMID: 34297033 DOI: 10.1093/rheumatology/keab589] [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: 03/18/2021] [Revised: 07/19/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To determine the impact of spondyloarthritis (SpA) and its treatments on fertility and pregnancy outcomes, as well as the impact of pregnancy on disease activity. METHODS A systematic review and meta-analyses were performed, including studies in women with SpA (axial (axSpA) and peripheral SpA, including psoriatic arthritis (PsA)). The heterogeneity between studies was quantified (I2), and in case of substantial heterogeneity, the results were reported in a narrative review. RESULTS Within 4397 eligible studies, 21 articles were included, assessing overall 3566 patients and 3718 pregnancies compared to 42264 controls. Fertility suffers from a lack of data in the literature. We found an increased risk of preterm birth (pooled OR 1,64 [1,15-2,33], I2 =24% in axSpA and 1,62 [1,23-2,15], I2 =0,0% in PsA), small for gestational age (pooled OR 2,05, [1,09-3,89], I2 =5,8% in axSpA), preeclampsia (pooled OR 1,59, [1,11-2,27], I2 =0% in axSpA) and caesarean section (pooled OR 1,70 [1,44-2,00], I2 =19,9% in axSpA and 1,71 [1,14-2,55], I2 =74,3% in PsA), without any other unfavourable pregnancy outcome. Further analysis showed a significant higher risk for elective caesarean (pooled OR 2,64, [1,92-3,62], I2 =0,0% in axSpA and 1,47, [1,15-1,88], I2 =0,0% in PsA), without increased risk for emergency caesarean in PsA. During pregnancy, there appears to be a tendency for unchanged or worsened disease activity in axSpA and unchanged or improved disease activity in PsA. Both conditions tend to flare in postpartum period. CONCLUSION SpA seems to be associated with an increased risk of preterm birth, small for gestational age, preeclampsia, and caesarean section.
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Affiliation(s)
- Sabrina Hamroun
- Rheumatology Department, Cochin Hospital (AP-HP), rue du Faubourg Saint-Jacques, F-75014 Paris, France
| | - Aghilès Hamroun
- Lille University, University Hospital Center of Lille, rue Michel Polonovski, F-59037 Lille, France
| | - Jean-Joël Bigna
- School of Public Health, University Hospital of Le Kremlin-Bicêtre, rue du Général Leclerc, F-94270 Le Kremlin-Bicêtre, France
| | - Edem Allado
- Rheumatology Department, University Hospital of Nancy, Rue du Morvan, F-54500 Vandœuvre-lès-Nancy, France
| | - Frauke Förger
- University Hospital and University of Bern, Hochschulstrasse 6, 3012 Bern, Switzerland
| | - Anna Molto
- INSERM (U-1153), Clinical Epidemiology and Biostatistics, PRES Sorbonne Paris-City, rue du Faubourg Saint-Antoine, F-75014 Paris, France
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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: 15] [Impact Index Per Article: 5.0] [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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Maguire S, O'Dwyer T, Mockler D, O'Shea F, Wilson F. Pregnancy in axial spondyloarthropathy: A systematic review & meta-analysis. Semin Arthritis Rheum 2020; 50:1269-1279. [PMID: 33065422 DOI: 10.1016/j.semarthrit.2020.08.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 08/18/2020] [Accepted: 08/24/2020] [Indexed: 02/09/2023]
Abstract
BACKGROUND Axial spondyloarthropathy (axSpA) is an inflammatory arthritis which affects the sacroiliac joints and the spine. Many females affected are of childbearing age. Studies on effects of pregnancy on axSpA disease activity and medication use have been limited, with divergent conclusions. OBJECTIVE To review literature on axSpA in pregnancy to determine the effect of disease on pregnancy outcomes. METHODS A systematic review of case-control trials, observational studies, cross sectional studies and case series (n>5) on axSpA in pregnancy. EMBASE, Medline (OVID), CINAHL, Maternity and Infant Care (MIDIRS online), and Web of Science were searched for keywords. Two reviewers reviewed articles to determine suitability for inclusion. The Newcastle Ottawa Scale was used to assess risk of bias. Data extraction was performed using a standardized template to streamline data to allow comparison and meta-analysis. RESULTS Search strategy returned 884 records, 130 full text articles were assessed for eligibility. Eighteen studies with a total of 3,166 axSpA participants were eligible for inclusion. There was an increased prevalence of pre-eclampsia (OR 1.3, 95% CI 0.92-1.82) and IUGR (OR 1.17, 95% CI 0.26-5.17) and a statistically significant increase in cesarean sections (OR 1.85, 95% CI 1.46-2.30) in axSpA females, with an especially high prevalence of elective cesarean sections (OR 2.26, 95% CI 1.74, 2.93). There was a trend towards increased prevalence of fetal complications in axSpA pregnancies (LBW OR 1.47, 95% CI 0.98-2.21; SGA OR1.66, 95% CI 0.93-2.95; congenital abnormalities OR 1.34, 95% CI0.63-1.24; NICU admissions OR 1.55, 95% CI 0.96-2.51) which did not reach significance. CONCLUSION AxSpA females have an increased prevalence of cesarean sections compared to the general population. There is a trend towards increased prevalence of pre-eclampsia, IUGR and certain fetal complications. Ongoing development of national registries could help to better understand axSpA in pregnancy.
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Affiliation(s)
- Sinead Maguire
- Department of Rheumatology, St James' Hospital, James' Street, Dublin, Ireland.
| | | | - David Mockler
- John Stearne Medical Library, Trinity College Dublin, Dublin, Ireland
| | - Finbar O'Shea
- Department of Rheumatology, St James' Hospital, James' Street, Dublin, Ireland
| | - Fiona Wilson
- Discipline of Physiotherapy, Trinity College, Dublin, Ireland
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10
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Smith CJF, Bandoli G, Kavanaugh A, Chambers CD. Birth Outcomes and Disease Activity During Pregnancy in a Prospective Cohort of Women With Psoriatic Arthritis and Ankylosing Spondylitis. Arthritis Care Res (Hoboken) 2020; 72:1029-1037. [PMID: 31074583 PMCID: PMC6842404 DOI: 10.1002/acr.23924] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Accepted: 05/07/2019] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To add to data on adverse birth outcomes accounting for disease activity in women with psoriatic arthritis (PsA) and ankylosing spondylitis (AS). METHODS Data were analyzed from women enrolled in the Organization of Teratology Information Specialists Autoimmune Disease Project from 2004 to 2018. Disease activity was measured according to the Health Assessment Questionnaire (HAQ) or Routine Assessment of Patient Index Data 3 (RAPID3) scores. Poisson regression was used to estimate adjusted risk ratios (ARRs) with 95% confidence intervals (95% CIs) for selected adverse pregnancy outcomes. RESULTS Compared to healthy controls (n = 717), women with PsA (n = 117) were at increased risk for moderate preterm delivery (32-36 weeks' gestation) (ARR 1.81, 95% CI 1.01-3.26), oligohydramnios (ARR 3.79, 95% CI 1.34-10.74), and cesarean delivery (ARR 1.63, 95% CI 1.26-2.12). Women with AS (n = 129) had an increased risk of delivering infants requiring intensive care (ARR 1.67, 95% CI 1.05-2.67). A high HAQ score at 32 weeks was associated with preterm delivery in women with PsA (ARR 3.82, 95% CI 1.51-9.67). In women with AS, a high RAPID3 score was associated with cesarean delivery (ARR 5.82, 95% 1.06-31.78), and second trimester glucocorticoid use was associated with preterm delivery (ARR 4.41, 95% CI 1.57-12.41). CONCLUSION Women with PsA and AS have increased risk for selected adverse pregnancy outcomes. Active disease and use of glucocorticoids may increase the risk for some adverse pregnancy outcomes in women with these conditions.
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Affiliation(s)
- Chelsey J. F. Smith
- Division of Rheumatology, Allergy, and Immunology.
University of California San Diego. 9500 Gilman Drive, La Jolla, CA 92093
- Division of Rheumatology. Cedars-Sinai Medical Center.
8700 Beverly Blvd, Los Angeles, CA 90048
| | - Gretchen Bandoli
- Departments of Pediatrics and Family Medicine and Public
Health, University of California San Diego. 9500 Gilman Drive, La Jolla, CA
92093
| | - Arthur Kavanaugh
- Division of Rheumatology, Allergy and Immunology,
University of California San Diego. 9500 Gilman Drive, La Jolla, CA 92093
| | - Christina D. Chambers
- Departments of Pediatrics and Family Medicine and Public
Health, University of California San Diego. 9500 Gilman Drive, La Jolla, CA
92093
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11
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Lee JS, Oh JS, Kim YJ, Hong S, Lee CK, Yoo B, Kim YG. Reasons for the High Cesarean Delivery Rate among Women with Ankylosing Spondylitis: Using the Korean National Health Insurance Database. J Rheumatol 2020; 47:668-673. [PMID: 31615913 DOI: 10.3899/jrheum.190754] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2019] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Women with ankylosing spondylitis (AS) have reported a higher rate of cesarean births than healthy controls. This study aimed to identify factors associated with cesarean births in women with AS. METHODS Based on the Korean Health Insurance Review and Assessment Service claims database, the subjects comprised female patients aged 20-49 years old with AS. In total, 1293 deliveries after AS diagnosis were included. A logistic regression analysis was performed to identify factors associated with cesarean births. RESULTS Among the 1293 deliveries in women with AS, 657 were cesarean and 636 were vaginal deliveries. Compared to vaginal delivery, the women who had cesarean deliveries were older, had a longer disease duration, and had a higher portion of primipara and dispensation of drugs. These factors were associated with a higher risk of cesarean delivery: maternal age (OR 1.08, 95% CI 1.04-1.12), disease duration (OR 1.09, 95% CI 1.03-1.14), and preeclampsia (OR 3.94, 95% CI 1.17-13.32). Further, compared to no drug dispensation, these drugs showed higher risks of cesarean delivery: nonsteroidal antiinflammatory drugs (NSAID; OR 1.64, 95% CI 1.31-2.37), tumor necrosis factor inhibitor (TNFi), disease-modifying antirheumatic drugs (DMARD), or corticosteroids (OR 2.01, 95% CI 1.57-2.58). In the subgroup analysis in primiparas, maternal age, or dispensation of NSAID alone, or TNFi, DMARD, or corticosteroids was associated with a higher risk of cesarean delivery. CONCLUSION Women with AS showed a higher cesarean delivery rate, influenced by both maternal age and disease-related factors.
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Affiliation(s)
- Jung Sun Lee
- From the Division of Rheumatology, Department of Internal Medicine, University of Ulsan College of Medicine, and the Department of Biomedical Informatics, and the Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, Seoul, Korea.,J.S. Lee, MD, Department of Rheumatology, Asan Medical Center; J.S. Oh, MD, PhD, Department of Biomedical Informatics, Asan Medical Center; Y.J. Kim, PhD, Department of Clinical Epidemiology and Biostatistics, Asan Medical Center; S. Hong, MD, PhD, Department of Rheumatology, Asan Medical Center; C.K. Lee, MD, PhD, Department of Rheumatology, Asan Medical Center; B. Yoo, MD, PhD, Department of Rheumatology, Asan Medical Center; Y.G. Kim, MD, PhD, Department of Rheumatology, Asan Medical Center
| | - Ji Seon Oh
- From the Division of Rheumatology, Department of Internal Medicine, University of Ulsan College of Medicine, and the Department of Biomedical Informatics, and the Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, Seoul, Korea.,J.S. Lee, MD, Department of Rheumatology, Asan Medical Center; J.S. Oh, MD, PhD, Department of Biomedical Informatics, Asan Medical Center; Y.J. Kim, PhD, Department of Clinical Epidemiology and Biostatistics, Asan Medical Center; S. Hong, MD, PhD, Department of Rheumatology, Asan Medical Center; C.K. Lee, MD, PhD, Department of Rheumatology, Asan Medical Center; B. Yoo, MD, PhD, Department of Rheumatology, Asan Medical Center; Y.G. Kim, MD, PhD, Department of Rheumatology, Asan Medical Center
| | - Ye-Jee Kim
- From the Division of Rheumatology, Department of Internal Medicine, University of Ulsan College of Medicine, and the Department of Biomedical Informatics, and the Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, Seoul, Korea.,J.S. Lee, MD, Department of Rheumatology, Asan Medical Center; J.S. Oh, MD, PhD, Department of Biomedical Informatics, Asan Medical Center; Y.J. Kim, PhD, Department of Clinical Epidemiology and Biostatistics, Asan Medical Center; S. Hong, MD, PhD, Department of Rheumatology, Asan Medical Center; C.K. Lee, MD, PhD, Department of Rheumatology, Asan Medical Center; B. Yoo, MD, PhD, Department of Rheumatology, Asan Medical Center; Y.G. Kim, MD, PhD, Department of Rheumatology, Asan Medical Center
| | - Seokchan Hong
- From the Division of Rheumatology, Department of Internal Medicine, University of Ulsan College of Medicine, and the Department of Biomedical Informatics, and the Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, Seoul, Korea.,J.S. Lee, MD, Department of Rheumatology, Asan Medical Center; J.S. Oh, MD, PhD, Department of Biomedical Informatics, Asan Medical Center; Y.J. Kim, PhD, Department of Clinical Epidemiology and Biostatistics, Asan Medical Center; S. Hong, MD, PhD, Department of Rheumatology, Asan Medical Center; C.K. Lee, MD, PhD, Department of Rheumatology, Asan Medical Center; B. Yoo, MD, PhD, Department of Rheumatology, Asan Medical Center; Y.G. Kim, MD, PhD, Department of Rheumatology, Asan Medical Center
| | - Chang-Keun Lee
- From the Division of Rheumatology, Department of Internal Medicine, University of Ulsan College of Medicine, and the Department of Biomedical Informatics, and the Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, Seoul, Korea.,J.S. Lee, MD, Department of Rheumatology, Asan Medical Center; J.S. Oh, MD, PhD, Department of Biomedical Informatics, Asan Medical Center; Y.J. Kim, PhD, Department of Clinical Epidemiology and Biostatistics, Asan Medical Center; S. Hong, MD, PhD, Department of Rheumatology, Asan Medical Center; C.K. Lee, MD, PhD, Department of Rheumatology, Asan Medical Center; B. Yoo, MD, PhD, Department of Rheumatology, Asan Medical Center; Y.G. Kim, MD, PhD, Department of Rheumatology, Asan Medical Center
| | - Bin Yoo
- From the Division of Rheumatology, Department of Internal Medicine, University of Ulsan College of Medicine, and the Department of Biomedical Informatics, and the Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, Seoul, Korea.,J.S. Lee, MD, Department of Rheumatology, Asan Medical Center; J.S. Oh, MD, PhD, Department of Biomedical Informatics, Asan Medical Center; Y.J. Kim, PhD, Department of Clinical Epidemiology and Biostatistics, Asan Medical Center; S. Hong, MD, PhD, Department of Rheumatology, Asan Medical Center; C.K. Lee, MD, PhD, Department of Rheumatology, Asan Medical Center; B. Yoo, MD, PhD, Department of Rheumatology, Asan Medical Center; Y.G. Kim, MD, PhD, Department of Rheumatology, Asan Medical Center
| | - Yong-Gil Kim
- From the Division of Rheumatology, Department of Internal Medicine, University of Ulsan College of Medicine, and the Department of Biomedical Informatics, and the Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, Seoul, Korea. .,J.S. Lee, MD, Department of Rheumatology, Asan Medical Center; J.S. Oh, MD, PhD, Department of Biomedical Informatics, Asan Medical Center; Y.J. Kim, PhD, Department of Clinical Epidemiology and Biostatistics, Asan Medical Center; S. Hong, MD, PhD, Department of Rheumatology, Asan Medical Center; C.K. Lee, MD, PhD, Department of Rheumatology, Asan Medical Center; B. Yoo, MD, PhD, Department of Rheumatology, Asan Medical Center; Y.G. Kim, MD, PhD, Department of Rheumatology, Asan Medical Center.
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Saito J, Yakuwa N, Takai C, Kaneko K, Goto M, Nakajima K, Yamatani A, Murashima A. Abatacept concentrations in maternal serum and breast milk during breastfeeding and an infant safety assessment: a case study. Rheumatology (Oxford) 2020; 58:1692-1694. [PMID: 31323087 DOI: 10.1093/rheumatology/kez135] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2019] [Indexed: 12/25/2022] Open
Affiliation(s)
- Jumpei Saito
- Department of Pharmaceuticals, National Center for Child Health and Development
| | - Naho Yakuwa
- Japan Drug Information Institute in Pregnancy, National Center for Child Health and Development
| | - Chinatsu Takai
- Japan Drug Information Institute in Pregnancy, National Center for Child Health and Development
| | - Kayoko Kaneko
- Division of Maternal Medicine, Center of Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Mikako Goto
- Division of Maternal Medicine, Center of Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Ken Nakajima
- Japan Drug Information Institute in Pregnancy, National Center for Child Health and Development
| | - Akimasa Yamatani
- Department of Pharmaceuticals, National Center for Child Health and Development
| | - Atsuko Murashima
- Japan Drug Information Institute in Pregnancy, National Center for Child Health and Development
- Division of Maternal Medicine, Center of Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
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13
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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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14
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Lee JS, Oh JS, Kim YJ, Hong S, Lee CK, Yoo B, Kim YG. Effects of Pregnancy and Delivery Methods on Change in Ankylosing Spondylitis Treatment Using the Korean Health Insurance Review and Assessment Service Claims Database. J Korean Med Sci 2019; 34:e238. [PMID: 31559710 PMCID: PMC6763397 DOI: 10.3346/jkms.2019.34.e238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 08/12/2019] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Women with ankylosing spondylitis (AS) show a higher rate of cesarean section (CS) compared with healthy women. In this study, we determined the effects of pregnancy and delivery methods on AS worsening by analyzing prescription patterns. METHODS The subjects were women with AS aged 20-49 years listed in the Korean Health Insurance Review and Assessment Service claims database. Change in treatment was defined as change in prescriptions 1-2 years before delivery or 1 year after delivery. We compared change in prescriptions between AS women with delivery or without delivery (1:1 matched). Moreover, we evaluated change in prescriptions according to delivery method among AS women with delivery. RESULTS A total of 6,821 women with AS were included. Women in the delivery group (n = 996) were younger and showed less drug use and lower comorbidity rates than those in the no delivery group. Change in prescriptions did not differ between the delivery and no delivery groups (odds ratio [OR], 0.76; 95% confidence interval [CI], 0.56-1.05). Furthermore, the overall change in prescriptions did not significantly differ between vaginal delivery (VD) and CS (OR, 0.72; 95% CI, 0.45-1.14). CONCLUSION The rate of change in prescriptions was comparable between AS patients with and without delivery. There was no association between the method of delivery and change in prescription. Therefore, pregnancy and VD may not be the factors associated with AS worsening.
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Affiliation(s)
- Jung Sun Lee
- Division of Rheumatology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ji Seon Oh
- Department of Biomedical Informatics, Asan Medical Center, Seoul, Korea
| | - Ye Jee Kim
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, Seoul, Korea
| | - Seokchan Hong
- Division of Rheumatology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chang Keun Lee
- Division of Rheumatology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Bin Yoo
- Division of Rheumatology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yong Gil Kim
- Division of Rheumatology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
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15
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Tsuda S, Sameshima A, Sekine M, Kawaguchi H, Fujita D, Makino S, Morinobu A, Murakawa Y, Matsui K, Sugiyama T, Watanabe M, Suzuki Y, Nagahori M, Murashima A, Atsumi T, Oku K, Mitsuda N, Takei S, Miyamae T, Takahashi N, Nakajima K, Saito S. Pre-conception status, obstetric outcome and use of medications during pregnancy of systemic lupus erythematosus (SLE), rheumatoid arthritis (RA) and inflammatory bowel disease (IBD) in Japan: Multi-center retrospective descriptive study. Mod Rheumatol 2019; 30:852-861. [DOI: 10.1080/14397595.2019.1661592] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Affiliation(s)
- Sayaka Tsuda
- Department of Obstetrics and Gynecology, University of Toyama, Toyama, Japan
| | - Azusa Sameshima
- Department of Obstetrics and Gynecology, University of Toyama, Toyama, Japan
| | - Michikazu Sekine
- Department of Epidemiology and Health Policy, Graduate School of Medicine and Pharmaceutical Sciences University of Toyama, Toyama, Japan
| | - Haruna Kawaguchi
- Department of Maternal Fetal Medicine, Osaka Women’s and Children’s Hospita, Osaka, Japan
| | - Daisuke Fujita
- Department of Obstetrics and Gynecology, Osaka Medical College, Osaka, Japan
| | - Shintaro Makino
- Department of Obstetrics and Gynecology, Faculty of Medicine, Juntendo University, Tokyo, Japan
| | - Akio Morinobu
- Department of Internal Medicine, Division of Rheumatology and Clinical Immunology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yohko Murakawa
- Department of Rheumatology, Faculty of Medicine, Shimane University, Shimane, Japan
| | - Kiyoshi Matsui
- Department of Internal Medicine, Division of Rheumatology, Hyogo College of Medicine, Hyogo, Japan
| | - Takao Sugiyama
- Department of Rheumatology, National Hospital Organization Shimoshizu National Hospital, Yotuskaido City, Japan
| | - Mamoru Watanabe
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yasuo Suzuki
- Inflammatory Bowel Disease Center, Sakura Medical Center, Toho University, Chiba, Japan
| | - Masakazu Nagahori
- Clinical Research Center, Tokyo Medical and Dental University Hospital of Medicine, Tokyo, Japan
| | - Atsuko Murashima
- Center for Maternal-Fetal-Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Tatsuya Atsumi
- Department of Rheumatology, Endocrinology and Nephrology, Graduate School of Medicine and Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - Kenji Oku
- Department of Rheumatology, Endocrinology and Nephrology, Graduate School of Medicine and Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - Nobuaki Mitsuda
- Department of Maternal Fetal Medicine, Osaka Women’s and Children’s Hospita, Osaka, Japan
| | - Syuji Takei
- Department of Pediatrics, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Takako Miyamae
- Department of Pediatric Rheumatology, Institute of Rheumatology, Tokyo Women's Medical University, Tokyo, Japan
| | - Naoto Takahashi
- Department of Pediatric and Neonatal Intensive Care, The University of Tokyo Hospital, Tokyo, Japan
| | - Ken Nakajima
- Department of Pharmacy, National hospital organization Sagamihara National Hospital, Kanagawa, Japan
| | - Shigeru Saito
- Department of Obstetrics and Gynecology, University of Toyama, Toyama, Japan
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16
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Stratifying management of rheumatic disease for pregnancy and breastfeeding. Nat Rev Rheumatol 2019; 15:391-402. [DOI: 10.1038/s41584-019-0240-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/14/2019] [Indexed: 12/16/2022]
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17
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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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Sammaritano LR, Bermas BL. Management of pregnancy and lactation. Best Pract Res Clin Rheumatol 2018; 32:750-766. [DOI: 10.1016/j.berh.2019.03.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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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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Zbinden A, van den Brandt S, Østensen M, Villiger PM, Förger F. Risk for adverse pregnancy outcome in axial spondyloarthritis and rheumatoid arthritis: disease activity matters. Rheumatology (Oxford) 2018; 57:1235-1242. [PMID: 29617883 DOI: 10.1093/rheumatology/key053] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Revised: 02/06/2018] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE To analyse pregnancy outcome and delivery mode in patients with RA and axial spondyloarthritis (axSpA) in relation to disease activity and anti-rheumatic drugs. METHODS Patients with RA and axSpA were compared with age-matched healthy controls (HCs) with respect to pregnancy outcome and delivery mode. Disease activity (DAS28, ASDAS, CRP) and medication use of patients was assessed once at each trimester. ORs with 95% CI were calculated with univariate and multivariate regression models. RESULTS We analysed 244 pregnancies, of which 96 occurred in patients with RA, 78 in patients with axSpA and 70 in HCs. The adjusted analysis showed that pregnant women with RA and axSpA had a higher risk of pregnancy complications (gestational diabetes, preeclampsia, infection, preterm premature rupture of membranes), small for gestational age infants and preterm deliveries (all P < 0.05). Active disease was a predictor for preterm delivery in both RA [odds ratio (OR) = 3.9, 95% CI: 1.25, 12.15] and axSpA (OR = 13.8, 95% CI: 1.33, 143.94). Regarding delivery mode, most patients had vaginal deliveries. However, women with RA revealed an increased risk of caesarean section compared with HC (P < 0.05), which was not seen in patients with axSpA. CONCLUSION Our findings show that disease activity of RA and axSpA during pregnancy influences pregnancy outcome. To allow for successful pregnancy a treatment strategy that targets inactive disease beyond conception should be followed.
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Affiliation(s)
- Astrid Zbinden
- Department of Rheumatology, Immunology and Allergology, University Hospital and University of Bern, Bern, Switzerland
| | - Stephanie van den Brandt
- Department of Rheumatology, Immunology and Allergology, University Hospital and University of Bern, Bern, Switzerland
| | - Monika Østensen
- Department of Rheumatology, Immunology and Allergology, University Hospital and University of Bern, Bern, Switzerland
| | - Peter M Villiger
- Department of Rheumatology, Immunology and Allergology, University Hospital and University of Bern, Bern, Switzerland
| | - Frauke Förger
- Department of Rheumatology, Immunology and Allergology, University Hospital and University of Bern, Bern, Switzerland
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Clowse ME, Förger F, Hwang C, Thorp J, Dolhain RJ, van Tubergen A, Shaughnessy L, Simpson J, Teil M, Toublanc N, Wang M, Hale TW. Minimal to no transfer of certolizumab pegol into breast milk: results from CRADLE, a prospective, postmarketing, multicentre, pharmacokinetic study. Ann Rheum Dis 2017; 76:1890-1896. [PMID: 28814432 PMCID: PMC5705850 DOI: 10.1136/annrheumdis-2017-211384] [Citation(s) in RCA: 105] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2017] [Revised: 05/22/2017] [Accepted: 07/01/2017] [Indexed: 01/20/2023]
Abstract
Background Women with chronic inflammatory diseases face uncertainty regarding the safety of biologics during breast feeding. CRADLE was the first industry-sponsored study to evaluate certolizumab pegol (CZP) concentrations in human breast milk and estimate average daily infant dose (ADID) of maternal CZP. Methods CRADLE (NCT02154425) was a pharmacokinetic study of lactating mothers receiving CZP. After ≥3 CZP doses, breast milk samples were collected across one dosing period (14 days for 200 mg every 2 weeks [Q2W]; 28 days for 400 mg every 4 weeks [Q4W]). Optimal analytical methods were developed to determine CZP and polyethylene glycol (PEG) levels in breast milk. ADID and relative infant dose (RID) were estimated. Safety events in mothers and infants were assessed. Results 19 CZP-treated mothers were screened; 17 entered the sampling period: 16 on 200 mg Q2W, 1 on 400 mg Q4W. 77/137 (56%) breast milk samples had no measurable CZP. For 4/17 mothers, all samples were below the lower limit of quantification (LLOQ). Estimated ADID was 0–0.0104 mg/kg/day; median RID: 0.15%. PEG was undetectable in 134/137 samples (results could not be determined in three samples). Infants of CZP-exposed mothers had a safety profile consistent with that of unexposed similar-age infants. Conclusion When quantifiable, CZP concentrations were <3× LLOQ (<1% plasma concentration observed with therapeutic dose), indicating no/minimal CZP transfer from plasma to breast milk. RID was 0.15% of maternal dose; <10% is considered unlikely to be of clinical concern. No PEG transfer was observed. CZP absorption by infants via breast milk is unlikely due to its low oral bioavailability and Fc-free molecular structure. These findings are reassuring and support continuation of CZP treatment during breast feeding. Trial registration number NCT02154425; Results.
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Affiliation(s)
- Megan Eb Clowse
- Duke University School of Medicine, Durham, North Carolina, USA
| | - Frauke Förger
- Department of Rheumatology and Immunology and Allergology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | | | - John Thorp
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | | | | | | | | | | | | | | | - Thomas W Hale
- Texas Tech University School of Medicine, Amarillo, Texas, USA
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Ince-Askan H, Hazes JMW, Dolhain RJEM. Identifying Clinical Factors Associated With Low Disease Activity and Remission of Rheumatoid Arthritis During Pregnancy. Arthritis Care Res (Hoboken) 2017; 69:1297-1303. [PMID: 27813290 DOI: 10.1002/acr.23143] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Revised: 10/24/2016] [Accepted: 11/01/2016] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To identify a combination of clinical factors associated with low disease activity and remission in the third trimester during pregnancy in women with rheumatoid arthritis (RA). METHODS This study is embedded in the Pregnancy-Induced Amelioration of Rheumatoid Arthritis study, a prospective cohort study. There were data available on 190 pregnancies from first trimester until delivery. Multivariate regression analyses were performed on the disease activity (Disease Activity Score in 28 joints [DAS28] using the C-reactive protein [CRP] level) in the third trimester. Independent covariates were the DAS28-CRP-3 in first trimester, prednisone and sulfasalazine use in the first trimester, parity, methotrexate use in the past, autoantibody status, the presence of erosions, and RA disease duration. RESULTS In multivariate regression models, the DAS28-CRP-3, use of prednisone in the first trimester, and the presence of autoantibodies were negatively associated with low disease activity (DAS28-CRP-3 <3.2) in the third trimester (P < 0.05), and the DAS28-CRP-3 and presence of autoantibodies were also associated with remission (DAS28-CRP-3 <2.6) (P < 0.001). Subgroup analysis revealed that the associations of prednisone use and presence of autoantibodies were only present in patients with moderate-to-high disease activity (DAS28-CRP-3 ≥3.2) in the first trimester. CONCLUSION RA patients who have a low DAS28-CRP-3 in the first trimester (irrespective of autoantibody status or prednisone use) are likely to have low disease activity or remission in the third trimester. Also, women with higher disease activity who are not taking prednisone and who express no autoantibodies still have a fair chance of low disease activity in the last trimester.
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Desai RJ, Huybrechts KF, Bateman BT, Hernandez-Diaz S, Mogun H, Gopalakrishnan C, Patorno E, Kim SC. Brief Report: Patterns and Secular Trends in Use of Immunomodulatory Agents During Pregnancy in Women With Rheumatic Conditions. Arthritis Rheumatol 2017; 68:1183-9. [PMID: 26606742 DOI: 10.1002/art.39521] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Accepted: 11/17/2015] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To describe patterns and secular trends in the use of immunomodulatory agents in pregnant women with systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), psoriatic arthritis (PsA), or ankylosing spondylitis (AS). METHODS We identified a cohort of women with SLE, RA, PsA, or AS enrolled in public (Medicaid, 2001-2010) or private (Optum Clinformatics, 2004-2012) health insurance, and we included women filling prescriptions for immunomodulatory agents (including steroids, nonbiologic disease-modifying agents, and biologic agents) in the 3-month period immediately prior to their pregnancies. The proportion of women continuing or discontinuing individual agents during pregnancy was reported. Annual prescription fill rates, estimated after accounting for patient characteristics and random variability from year to year in mixed-effects regression models, were used to conduct time trends analysis. RESULTS We included 2,645 women being treated with immunomodulatory agents prior to pregnancy. More women with PsA or AS stopped filling prescriptions for immunomodulatory agents during pregnancy (61%) than women with SLE (26%) or women with RA (34.5%). From the first to the third trimester, the proportions of women filling prescriptions for immunomodulatory agents decreased across all indications. Overall, steroids and hydroxychloroquine were the most frequently used agents in pregnancy (48.4% and 27.1%, respectively). The rates (reported per 100 deliveries in our cohort) for steroid prescription fills during pregnancy decreased significantly from 54.4 in 2001 to 42.4 in 2012, while rates for biologic agents increased from 5.1 in 2001 to 16.6 in 2012 (P < 0.001 for both trends). CONCLUSION Steroids and hydroxychloroquine remain the most widely prescribed treatment options in pregnancy, but the use of biologic agents is becoming increasingly common.
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Affiliation(s)
- Rishi J Desai
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Krista F Huybrechts
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Brian T Bateman
- Brigham and Women's Hospital, Massachusetts General Hospital, and Harvard Medical School, Boston, Massachusetts
| | | | - Helen Mogun
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | | | - Elisabetta Patorno
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Seoyoung C Kim
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
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Abstract
Fertility is impaired in women with rheumatoid arthritis (RA), whereas less is known about male fertility problems. Pregnancy outcome in patients with RA is slightly less favorable compared with the general population, especially in patients with active disease. Disease activity usually improves during pregnancy, but less than previously thought. Although several antirheumatic drugs are contraindicated in pregnancy, more treatment options are available. There is evidence on the safety of TNF inhibitors in pregnancy. Given the impact of active disease on fertility and pregnancy outcome, a treat-to-target strategy is recommended for patients who are pregnant or have a wish to conceive.
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Polachek A, Li S, Polachek IS, Chandran V, Gladman D. Psoriatic arthritis disease activity during pregnancy and the first-year postpartum. Semin Arthritis Rheum 2017; 46:740-745. [PMID: 28196621 DOI: 10.1016/j.semarthrit.2017.01.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Revised: 12/20/2016] [Accepted: 01/09/2017] [Indexed: 11/20/2022]
Abstract
OBJECTIVES To evaluate disease activity in the joints and skin during pregnancy and the first-year postpartum in patients with psoriatic arthritis (PsA). METHODS Women with PsA who were pregnant between 1990 and 2015 with at least 1 clinic visit during pregnancy were identified from the Toronto PsA database. The course of joint and skin disease activity was defined by the following 5 states: improvement, worsening, stable low, stable high, or a mixed. As controls, 67 nonpregnant PsA women were identified and evaluated over a similar timeframe. RESULTS Altogether, 29 PsA women with 42 pregnancies were identified. Of the 42 pregnancies, 40 (95%) resulted in normal live birth. Arthritis improved or was stable low activity in 24 (58.5%) of pregnancies. During the postpartum period, 21 (52.5%) had either improvement or stable low PsA activity, whereas 16 (40%) had either worsening or stable high disease activity. The skin activity during pregnancy either improved or stayed in a stable low state in 30 (88.2%), and in the postpartum period there was worsening in 15 (42.9%). A logistic regression analysis revealed a favourable skin disease course during the pregnancy period in the pregnant group compared to the control group (OR = 6.8, p = 0.004), but not in joint disease. CONCLUSIONS The outcome of pregnancy among patients with PsA is excellent. Arthritis activity trends toward a favourable course while the skin disease shows a favorable course during pregnancy. When compared to controls, pregnancy period has significant beneficial influence only on the skin but not on the joints in PsA.
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Affiliation(s)
- Ari Polachek
- Centre for Prognosis Studies in the Rheumatic Diseases, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Suzanne Li
- Centre for Prognosis Studies in the Rheumatic Diseases, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Inbal Shlomi Polachek
- Reproductive Life Stages Program, Women׳s College Hospital, Toronto, Ontario, Canada
| | - Vinod Chandran
- Department of Medicine, Division of Rheumatology, University of Toronto, Toronto, Ontario, Canada; Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada; Krembil Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Dafna Gladman
- Department of Medicine, Division of Rheumatology, University of Toronto, Toronto, Ontario, Canada; Krembil Research Institute, University Health Network, Toronto, Ontario, Canada; Psoriatic Arthritis Program, Center for Prognostic Studies in the Rheumatic Diseases, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada.
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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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Förger F, Villiger PM. Treatment of rheumatoid arthritis during pregnancy: present and future. Expert Rev Clin Immunol 2016; 12:937-44. [DOI: 10.1080/1744666x.2016.1184973] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Förger F, Zbinden A, Villiger PM. Certolizumab treatment during late pregnancy in patients with rheumatic diseases: Low drug levels in cord blood but possible risk for maternal infections. A case series of 13 patients. Joint Bone Spine 2016; 83:341-3. [DOI: 10.1016/j.jbspin.2015.07.004] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Accepted: 07/08/2015] [Indexed: 01/11/2023]
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Ince-Askan H, Hazes JM, Dolhain RJ. Is Disease Activity in Rheumatoid Arthritis during Pregnancy and after Delivery Predictive for Disease Activity in a Subsequent Pregnancy? J Rheumatol 2015; 43:22-5. [DOI: 10.3899/jrheum.150565] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/30/2015] [Indexed: 11/22/2022]
Abstract
Objective.To determine whether disease activity in women with rheumatoid arthritis (RA) in 1 pregnancy is predictive for disease activity in a subsequent pregnancy.Methods.In the Pregnancy-induced Amelioration of Rheumatoid Arthritis study, there are prospective data on 27 patients who participated twice. Improvement and deterioration is determined by changes in the Disease Activity Score in 28 joints.Results.Only 4 patients (14.8%) had comparable disease courses in both pregnancies, whereas treatment remained mostly similar. In contrast, a flare postpartum after the first pregnancy was predictive for a flare after the second pregnancy (p = 0.003).Conclusion.RA disease course in following pregnancies cannot be predicted based upon previous pregnancies. However, a flare postpartum seems to predict subsequent flares.
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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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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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Noronha LE, Antczak DF. Modulation of T-cell reactivity during equine pregnancy is antigen independent. Am J Reprod Immunol 2012; 68:107-15. [PMID: 22587222 DOI: 10.1111/j.1600-0897.2012.01154.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2012] [Accepted: 04/14/2012] [Indexed: 12/12/2022] Open
Abstract
PROBLEM Pregnant mares demonstrate a reduction in cytotoxic T lymphocyte (CTL) reactivity against cells from the breeding stallion. We investigated whether this effect is limited to activity against paternal major histocompatibility complex (MHC) antigens, and whether it occurs during MHC-compatible pregnancy. METHOD OF STUDY Mares were mated to carry MHC-compatible or MHC-incompatible pregnancies. CTL activity of these mares when pregnant and non-pregnant was measured against cells from horses with MHC haplotypes unrelated to the mare or breeding stallion. RESULTS While carrying MHC-incompatible pregnancies, mares demonstrated reduced CTL activity against lymphocytes from third-party horses in addition to those from the breeding stallion. This effect was also observed in mares carrying MHC-compatible pregnancies. CONCLUSIONS The decrease in maternal T-cell reactivity characteristic of normal equine pregnancy is not restricted to paternal alloantigen, and occurs during MHC-matched matings. This suggests that antigen-independent mechanisms may be responsible for this reduction in cell-mediated immune activity.
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Affiliation(s)
- Leela E Noronha
- Baker Institute for Animal Health, College of Veterinary Medicine, Cornell University, Ithaca, NY 14853, USA
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Wallenius M, Skomsvoll JF, Salvesen KA. [Chronic inflammatory arthritis and pregnancy]. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2012; 132:658-62. [PMID: 22456146 DOI: 10.4045/tidsskr.11.0684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND Chronic inflammatory arthritis often appears first in women of fertile age. Their pregnancies are considered to be of low risk compared with pregnancies in women with systemic inflammatory connective tissue disease. METHOD The article is based on literature searches in PubMed for studies of the pregnancy outcomes of women with chronic inflammatory arthritis. Studies without a reference group or studies based on analyses of mixed populations of inflammatory arthritis and connective tissue disease patients were excluded. RESULTS Recurrent findings in the published literature were: low mean birth weight, a higher proportion of children with a birth weight of less than 2500 grams, children born small for gestational age, preterm births and a higher proportion of Caesarean sections. A high level of disease activity is associated with the risk of low birth weight and preterm birth. However, serious complications are not frequently reported. Glucocorticosteroids and disease-modifying medicines such as sulphasalazine and hydroxychloroquine may be used during pregnancy. Non-steroidal anti-inflammatory drugs such as ibuprofen and naproxen may be used until gestational week 32. Methotrexate is contraindicated and must be terminated three months before conception. The TNF inhibitors adalimumab, etanercept and infliximab may be used until conception. INTERPRETATION Pregnancy is seldom absolutely contraindicated for women with inflammatory arthritis. Pregnancy should be planned carefully and preferably be confined to periods with a low level of disease activity. First pregnancies require special attention. Interdisciplinary collaboration between rheumatologists and gynaecologists is recommended for monitoring patients with active arthritis.
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Affiliation(s)
- Marianne Wallenius
- Nasjonalt kompetansesenter for svangerskap og revmatisk sykdom Revmatologisk avdeling, Klinikk for ortopedi, revmatologi og hudsykdommer, St. Olavs hospital, Norway.
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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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Vinet E, Pineau C, Gordon C, Clarke AE, Bernatsky S. Anti-TNF therapy and pregnancy outcomes in women with inflammatory arthritis. Expert Rev Clin Immunol 2010; 5:27-34. [PMID: 20476897 DOI: 10.1586/1744666x.5.1.27] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Women suffering from inflammatory arthritis may experience a change in disease activity during and after pregnancy. Although the majority will improve, some women may need to continue therapy throughout pregnancy and/or in the lactation period. Since certain disease-modifying antirheumatic drugs have proven to be human teratogens, treatment is limited in these women. 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 case reports of pregnancies exposed to anti-TNF therapy have accumulated in the literature. Since these agents may constitute an important therapeutic alternative in pregnant women facing persistent or increased disease activity, we propose a review of the available information on the safety of anti-TNF agents in pregnancy and lactation.
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Affiliation(s)
- Evelyne Vinet
- Montreal General Hospital, McGill University Health Center, 1650 Cedar Avenue, Room A6 162.2, Montreal (PQ), H3G 1A4, Canada.
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Abstract
Systemic rheumatic diseases commonly affect women during the childbearing years. Many women with these diseases may be contemplating pregnancy or discover an inadvertent pregnancy, leading to concerns regarding medication use, changes in disease activity during pregnancy, safety of lactation, and future ability to care for a child given the presence of chronic illnesses. There are outstanding reviews that summarize the safety and use of immunosuppressive medications during pregnancy. However, in addition to medication use, providers need to be aware of the available data regarding fertility, pregnancy outcomes, delivery, and lactation issues that may be specific to individual diseases. Optimally, women should plan pregnancies to occur around times of disease quiescence, several months after potentially teratogenic medications have been discontinued. The course of the underlying rheumatic disease during pregnancy is variable, and there are no specific clinical or laboratory variables that consistently predict disease improvement or worsening during pregnancy. Recent data suggest that increased disease activity in women with most autoimmune diseases during pregnancy may lead to increased risk of premature delivery, low-birth-weight infants, and other adverse pregnancy outcomes. Arthritis involving the cervical spine and hips may impact delivery and must be considered by both obstetricians and obstetric anesthesiologists. Data are mixed regarding the impact of breastfeeding on underlying autoimmune diseases; the choice to continue breastfeeding is a personal decision.
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Affiliation(s)
- Amy B Elliott
- Division of Immunology and Rheumatology, Stanford University School of Medicine, Palo Alto, CA 94304, USA
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Abstract
Pregnancy can create a challenge for physicians caring for women with rheumatic diseases. For many women with rheumatoid arthritis (RA), pregnancy can provide a reprieve from long-term joint pain and inflammation, but others will not experience remission and will continue to need medication. Systemic lupus erythematosus (SLE) may remain quiet in some women, but in others may become more aggressive during pregnancy, putting both mother and foetus at risk. Women with limited scleroderma can do remarkably well, but scleroderma renal crises can be difficult to manage. A third of pregnancies in women with antiphospholipid syndrome (APS) may be refractory to our best therapy. In general, active inflammation from rheumatic diseases poses a stronger threat to the well-being of both mother and foetus than many immunosuppressant medications. Therefore, continued immunosuppression with the least risky medications will allow for the most optimal pregnancy outcomes.
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Affiliation(s)
- K Mitchell
- Division of Rheumatology and Immunology, Department of Medicine, Duke University Medical Center, Durham, NC 27710, USA
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de Man YA, Hazes JMW, van der Heide H, Willemsen SP, de Groot CJM, Steegers EAP, Dolhain RJEM. Association of higher rheumatoid arthritis disease activity during pregnancy with lower birth weight: results of a national prospective study. ACTA ACUST UNITED AC 2010; 60:3196-206. [PMID: 19877045 DOI: 10.1002/art.24914] [Citation(s) in RCA: 191] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To determine the outcome of pregnancy in women with rheumatoid arthritis (RA) in relation to disease activity and medication use during the pregnancy. METHODS In a prospective study, pregnant women with RA were evaluated before conception (when possible), during each trimester of the pregnancy, and postpartum. Clinical characteristics, disease activity, medication use, and pregnancy outcome were analyzed. To examine the independent influence of prednisone use and disease activity on birth weight, regression analyses were performed, with adjustments for gestational age of the child at delivery, the sex of the newborn, and the mother's smoking status, education level, parity, and use of an assisted reproduction technique. Kaplan-Meier curve analyses were performed to examine the association between medication use and gestational age at delivery. RESULTS Data from 152 Caucasian RA patients with singleton pregnancies were available. Both the mean +/- SD birth weight (3,379 +/- 564 gm) and the mean +/- SD birth weight standard deviation score (SDS; +0.1 +/- 1.1), which is the birth weight adjusted for the gestational age and sex of the newborn, were comparable with those in the general population. On multiple linear regression analyses of birth weight and birth weight SDS, both of which were adjusted for covariates, only disease activity was associated with lower birth weight (P = 0.025). The gestational age at delivery was significantly lower in women who were taking prednisone (38.8 versus 39.9 weeks; P = 0.001), and their delivery was more often premature (<37 weeks; P = 0.004). CONCLUSION Pregnancy outcome in women with well-controlled RA is comparable with that in the general population. The effect of prednisone on birth weight is mediated by a lower gestational age at delivery, whereas a higher level of disease activity independently influences birth weight negatively, suggesting an immune-mediated mechanism.
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Affiliation(s)
- Yaël A de Man
- Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.
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Kell DB. Iron behaving badly: inappropriate iron chelation as a major contributor to the aetiology of vascular and other progressive inflammatory and degenerative diseases. BMC Med Genomics 2009; 2:2. [PMID: 19133145 PMCID: PMC2672098 DOI: 10.1186/1755-8794-2-2] [Citation(s) in RCA: 369] [Impact Index Per Article: 24.6] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2008] [Accepted: 01/08/2009] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND The production of peroxide and superoxide is an inevitable consequence of aerobic metabolism, and while these particular 'reactive oxygen species' (ROSs) can exhibit a number of biological effects, they are not of themselves excessively reactive and thus they are not especially damaging at physiological concentrations. However, their reactions with poorly liganded iron species can lead to the catalytic production of the very reactive and dangerous hydroxyl radical, which is exceptionally damaging, and a major cause of chronic inflammation. REVIEW We review the considerable and wide-ranging evidence for the involvement of this combination of (su)peroxide and poorly liganded iron in a large number of physiological and indeed pathological processes and inflammatory disorders, especially those involving the progressive degradation of cellular and organismal performance. These diseases share a great many similarities and thus might be considered to have a common cause (i.e. iron-catalysed free radical and especially hydroxyl radical generation).The studies reviewed include those focused on a series of cardiovascular, metabolic and neurological diseases, where iron can be found at the sites of plaques and lesions, as well as studies showing the significance of iron to aging and longevity. The effective chelation of iron by natural or synthetic ligands is thus of major physiological (and potentially therapeutic) importance. As systems properties, we need to recognise that physiological observables have multiple molecular causes, and studying them in isolation leads to inconsistent patterns of apparent causality when it is the simultaneous combination of multiple factors that is responsible.This explains, for instance, the decidedly mixed effects of antioxidants that have been observed, since in some circumstances (especially the presence of poorly liganded iron) molecules that are nominally antioxidants can actually act as pro-oxidants. The reduction of redox stress thus requires suitable levels of both antioxidants and effective iron chelators. Some polyphenolic antioxidants may serve both roles.Understanding the exact speciation and liganding of iron in all its states is thus crucial to separating its various pro- and anti-inflammatory activities. Redox stress, innate immunity and pro- (and some anti-)inflammatory cytokines are linked in particular via signalling pathways involving NF-kappaB and p38, with the oxidative roles of iron here seemingly involved upstream of the IkappaB kinase (IKK) reaction. In a number of cases it is possible to identify mechanisms by which ROSs and poorly liganded iron act synergistically and autocatalytically, leading to 'runaway' reactions that are hard to control unless one tackles multiple sites of action simultaneously. Some molecules such as statins and erythropoietin, not traditionally associated with anti-inflammatory activity, do indeed have 'pleiotropic' anti-inflammatory effects that may be of benefit here. CONCLUSION Overall we argue, by synthesising a widely dispersed literature, that the role of poorly liganded iron has been rather underappreciated in the past, and that in combination with peroxide and superoxide its activity underpins the behaviour of a great many physiological processes that degrade over time. Understanding these requires an integrative, systems-level approach that may lead to novel therapeutic targets.
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Affiliation(s)
- Douglas B Kell
- School of Chemistry and Manchester Interdisciplinary Biocentre, The University of Manchester, 131 Princess St, Manchester, M1 7DN, UK.
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Dunlop AL, Jack BW, Bottalico JN, Lu MC, James A, Shellhaas CS, Hallstrom LHK, Solomon BD, Feero WG, Menard MK, Prasad MR. The clinical content of preconception care: women with chronic medical conditions. Am J Obstet Gynecol 2008; 199:S310-27. [PMID: 19081425 DOI: 10.1016/j.ajog.2008.08.031] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2008] [Accepted: 08/08/2008] [Indexed: 11/29/2022]
Abstract
This article reviews the medical conditions that are associated with adverse pregnancy outcomes for women and their offspring. We also present the degree to which specific preconception interventions and treatments can impact the effects of the condition on birth outcomes. Because avoiding, delaying, or achieving optimal timing of a pregnancy is often an important component of the preconception care of women with medical conditions, contraceptive considerations particular to the medical conditions are also presented.
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Affiliation(s)
- Anne L Dunlop
- Department of Family and Preventive Medicine, Emory University School of Medicine, Atlanta, GA 30322, USA.
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Cortés M, Canellada A, Miranda S, Dokmetjian J, Gentile T. Placental secreted factors: Their role in the regulation of anti-CII antibodies and amelioration of collagen induced arthritis in rats. Immunol Lett 2008; 119:42-8. [DOI: 10.1016/j.imlet.2008.04.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2007] [Revised: 04/01/2008] [Accepted: 04/08/2008] [Indexed: 10/22/2022]
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Lee W, Reveille JD, Weisman MH. Women with ankylosing spondylitis: a review. ACTA ACUST UNITED AC 2008; 59:449-54. [PMID: 18311755 DOI: 10.1002/art.23321] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Affiliation(s)
- Wonuk Lee
- Cedars-Sinai Medical Center, Los Angeles, California, USA
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44
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Auci D, Kaler L, Subramanian S, Huang Y, Frincke J, Reading C, Offner H. A New Orally Bioavailable Synthetic Androstene Inhibits Collagen-Induced Arthritis in the Mouse: Androstene Hormones as Regulators of Regulatory T Cells. Ann N Y Acad Sci 2007; 1110:630-40. [PMID: 17911478 DOI: 10.1196/annals.1423.066] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Dehydroepiandrosterone (DHEA) has attracted much interest because of its many antiaging, metabolic and immune-modulating effects in rodents. Synthetic derivatives, such as 5-androstene-16alpha-fluoro-17-one (HE2500) and certain natural metabolites also provide benefit in various animal models of autoimmune and metabolic diseases. But, like DHEA, low potency and low oral bioavailability suggested limited usefulness of these compounds in humans. We hypothesized that HE3286, a novel 17-ethynyl derivative would be orally bioavailable, more potent, and chemically more useful in man than its parent compound. We found that on a dose/mass basis, HE3286 demonstrated up to 25% oral bioavailability in mice. In the DBA mouse model of collagen-induced arthritis (CIA), animals receiving oral treatment with HE3286 (50 mg/kg), beginning at onset of disease, significantly decreased CIA peak scores and daily severity of arthritis scores. Benefit was associated with decreases in: (1) production of TNF-alpha, IL-6, and IL-17; and (2) decreases in joint inflammation, erosion, and synovial proliferation as judged by histological analysis. HE3286 was not found to be immune suppressive in any of the classical models tested, including mitogen-induced proliferation, delayed-type hypersensitivity, or mixed lymphocyte reaction. Instead, benefit was associated with increases in numbers and function of CD4+CD25+FOXp3+CD127- regulatory T cells (T reg). To our knowledge, this is probably the first study to report that an orally bioavailable synthetic analogue of DHEA can ameliorate ongoing disease in a CIA mouse model with relevance to rheumatoid arthritis (RA) and to correlate that finding with decreases in proinflammatory cytokines and increases in T reg cells. Hormones targeting T reg cells hold the intriguing potential to treat autoimmune, infectious, and neoplastic diseases.
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Affiliation(s)
- D Auci
- Hollis-Eden Pharmaceuticals, San Diego, California, USA.
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45
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Sammaritano LR. Therapy insight: guidelines for selection of contraception in women with rheumatic diseases. ACTA ACUST UNITED AC 2007; 3:273-81; quiz 305-6. [PMID: 17471246 DOI: 10.1038/ncprheum0484] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2006] [Accepted: 03/13/2007] [Indexed: 11/09/2022]
Abstract
Use of contraceptives by women with rheumatic diseases, especially those with systemic lupus erythematosus, has long been thought to carry risks, such as disease exacerbation, thrombosis and other adverse effects. The use of effective contraception has, therefore, been avoided, despite many affected women being of reproductive age. Knowledge of risks and benefits of contraceptive methods in the general population has improved, as have the safety and effectiveness of hormonal contraceptives. Methods of administration have evolved and now include transdermal and intravaginal routes, a progesterone-releasing intrauterine device, and an extended-cycle oral contraceptive. Birth control pills are not all alike; the risk of adverse effects varies depending on the amount of estrogen and type of progestin used. Data show that patients with stable systemic lupus erythematosus are not at increased risk of disease flare while taking standard oral contraceptives. Despite a lack of randomized studies, evidence strongly suggests that the elevated risk of thrombosis makes estrogen-containing contraceptives unsuitable for patients with antiphospholipid antibody. Other important issues include potential interactions between hormonal contraceptives and other medications and possible risk of infection if an intrauterine device is used. Rheumatologists are increasingly working with gynecologists and patients to make choices about which contraceptive methods to use. Decisions should be individualized according to the patient's medical status, personal preference, and stage of reproductive life.
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Affiliation(s)
- Lisa R Sammaritano
- Weill Medical College of Cornell University, Hospital for Special Surgery, Department of Medicine, New York, NY, USA.
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Abstract
Rheumatoid arthritis (RA) is an autoimmune disease that is favorably influenced by pregnancy but relapses after delivery. A variety of circulating factors has been considered as candidates for inducing gestational improvement of RA; however, the factors/pathways responsible remain still elusive. This review discusses recent research on the effect of pregnancy on RA with a focus on immunregulation, cytokine secretion, HLA antigens, microchimerism, and innate immunity. The complex hormonal and immunological alterations of pregnancy may temporarily correct the disturbed immunregulation of RA.
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Affiliation(s)
- Monika Ostensen
- Clinic for Rheumatology and Clinical Immunology, University Hospital of Berne, CH-3010 Bern, Switzerland.
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Skomsvoll JF, Wallenius M, Koksvik HS, Rødevand E, Salvesen KA, Spigset O, Kvien TK. Drug insight: Anti-tumor necrosis factor therapy for inflammatory arthropathies during reproduction, pregnancy and lactation. ACTA ACUST UNITED AC 2007; 3:156-64. [PMID: 17334338 DOI: 10.1038/ncprheum0426] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2006] [Accepted: 12/17/2006] [Indexed: 12/17/2022]
Abstract
Tumor necrosis factor (TNF) antagonists are widely used to reduce disease activity and joint damage, and to improve health-related quality of life in patients suffering from rheumatoid arthritis, ankylosing spondylitis, or psoriatic arthritis. To date, no increased risk of embryotoxicity or teratogenicity, or adverse pregnancy outcome (such as birth defects, premature birth, and low birth weight) has been reported in patients with inflammatory arthropathies treated with anti-TNF therapy, compared with the general population. However, the available data are limited, and methotrexate, which is commonly used in combination with anti-TNF drugs, is teratogenic. Until more data are available, no firm conclusions can be reached regarding the safety of anti-TNF therapy in pregnancy. Nevertheless, in selected cases where there is high disease activity, anti-TNF therapy might be recommended, depending on the results of individual risk-benefit analyses. Fully informed consent from the mother is needed in such cases. Anti-TNF agents are not usually used during lactation, although the risk of toxicity is probably negligible.
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Affiliation(s)
- Johan F Skomsvoll
- Department of Obstetrics, Trondheim University Hospital, Trondheim, Norway.
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Gromnica-Ihle E, Ostensen M. [Pregnancy in patients with rheumatoid arthritis and inflammatory spondylarthropathies]. Z Rheumatol 2007; 65:209-12, 214-6. [PMID: 16670812 DOI: 10.1007/s00393-006-0053-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
The activity of a rheumatic disease can be influenced by pregnancy and puerperium. Prospective studies have shown an improvement in joint involvement in rheumatoid arthritis in two thirds to three quarters of pregnancies. After birth, an exacerbation is common. In spondylarthropathies there is no relevant change in disease activity. The fetal outcome is not impaired in patients with rheumatoid arthritis and inflammatory spondylarthropathies. Every pregnancy in women with a rheumatic disease should be considered as high-risk, and such pregnancies require close collaboration between rheumatologists and obstetricians.
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Offner H, Polanczyk M. A potential role for estrogen in experimental autoimmune encephalomyelitis and multiple sclerosis. Ann N Y Acad Sci 2007; 1089:343-72. [PMID: 17261780 DOI: 10.1196/annals.1386.021] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The extensive literature and the work from our laboratory illustrate the large number of complex processes affected by estrogen that might contribute to the striking ability of 17-beta estradiol (E2) and its derivatives to inhibit clinical and histological signs of experimental autoimmune encephalomyelitis (EAE) in mice. These effects require sustained exposure to relatively low doses of exogenous hormone and offer better protection when initiated prior to induction of EAE. The E2 mediates inhibition of encephalitogenic T cells, inhibition of cell migration into central nervous system tissue, and neuroprotective effects that promote axon and myelin survival. E2 effects on EAE are mediated through Esr-1 (alpha receptor for E2) but not Esr-2 (beta receptor for E2), as are its anti-inflammatory and neuroprotective effects. A novel finding is that E2 upregulated the expression of FoxP3 that contributes to the activity of CD4 + CD25 + T regulatory cells (Treg). The protective effects of E2 in EAE suggest its use as a therapy for multiple sclerosis (MS). Possible risks may be minimized by using sub-pregnancy levels of exogenous E2 that produced synergistic effects when used in combination with another immunoregulatory therapy. Alternatively, one might envision using E2 derivatives alone or in combination therapies in both male and female MS patients.
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Affiliation(s)
- Halina Offner
- Neuroimmunology Research, Veterans Affairs Medical Center, 3710 SW U.S. Veterans Hospital Rd., Portland, OR 97239, USA.
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50
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de Man YA, Hazes JMW, van de Geijn FE, Krommenhoek C, Dolhain RJEM. Measuring disease activity and functionality during pregnancy in patients with rheumatoid arthritis. ACTA ACUST UNITED AC 2007; 57:716-22. [PMID: 17530669 DOI: 10.1002/art.22773] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
OBJECTIVE Pregnancy has a favorable effect on the course of rheumatoid arthritis (RA), although the magnitude of this effect is equivocal because RA assessment tools have never been validated in pregnancy. The goal of this study was to assess how pregnancy influences the scoring of the Disease Activity Score in 28 joints (DAS28) and the Health Assessment Questionnaire (HAQ), and how both scores perform in pregnant patients with RA. METHODS Thirty-two healthy women and 30 pregnant patients with RA were prospectively studied during pregnancy and at postpartum. At each trimester and postpartum the components of the DAS28 (global health [GH], erythrocyte sedimentation rate [ESR], and C-reactive protein level [CRP]) and HAQ scores were determined. Maximal influences of healthy pregnancy on each component of the DAS28 were calculated. The performances of different DAS28 scores and the HAQ were also determined in RA patients. Furthermore, variants of the HAQ were developed within the HAQ scoring rules. RESULTS The components of the DAS28 were influenced by healthy pregnancy, with average increases in DAS28 score of 0.22 (GH), 1.1 (ESR), and 0.25 (CRP). The DAS28 calculated with CRP (DAS28-CRP) and without GH performed the best in pregnant RA patients. In healthy pregnancy, the median HAQ increased to 0.50 in the third trimester and was reduced by the HAQ variants to 0.25. CONCLUSION Pregnancy considerably influences the scoring of the DAS28 and HAQ. RA disease activity in pregnant patients should preferably be calculated with DAS28-CRP without GH. Even with HAQ variants, influences of pregnancy on the assessment of functionality cannot be precluded.
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Affiliation(s)
- Yaël A de Man
- Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.
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