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Duhig K, Hyrich KL. Annals of the Rheumatic Diseases collection on pregnancy 2018-2023: observational data-driven knowledge. Ann Rheum Dis 2024; 83:965-970. [PMID: 38331590 DOI: 10.1136/ard-2023-224861] [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: 11/23/2023] [Accepted: 01/30/2024] [Indexed: 02/10/2024]
Abstract
Pregnancy can be an exciting time but for those living with rheumatic musculoskeletal diseases (RMDs), it can also be a time fraught with concern, including what effect pregnancy will have on the underlying RMD and what effect the RMD may have on the pregnancy and the baby, including the effects of medications. Generating an evidence base in pregnancy is challenging. Few interventional trials of medications in RMD pregnancies have ever been conducted, often for concerns of safety for both the mother and the child. Therefore, observational research remains important for informing clinical practice and helping women with RMDs make decisions regarding their health preconception and during pregnancy. The Annals of the Rheumatic Diseases (ARD) continues to publish important research on pregnancy in RMDs to increase the evidence base on this subject. Here we present an overview of papers published on this topic between January 2018 and December 2023. Our focus includes papers on pregnancy and RMD outcome, the effects of drug exposure, fetal outcomes as well as fertility.
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Affiliation(s)
- Kate Duhig
- Maternal and Fetal Health Research Centre, The University of Manchester, Manchester, UK
| | - Kimme L Hyrich
- Centre for Musculoskeletal Research, The University of Manchester, Manchester, UK
- NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester, UK
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2
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Rosta K, Binder J, Kuczwara V, Horvath M, Heinzl F, Hörhager C, Mayrhofer D, Mandl P, Fritsch-Stork R, Ott J, Mazzucato-Puchner A. Periconceptional Counselling in Women with Autoimmune Inflammatory Rheumatic Diseases. J Clin Med 2024; 13:2483. [PMID: 38731018 PMCID: PMC11084745 DOI: 10.3390/jcm13092483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Revised: 04/12/2024] [Accepted: 04/17/2024] [Indexed: 05/13/2024] Open
Abstract
Systemic autoimmune rheumatic diseases (SARDs) in pregnancy represent a complex challenge for both patients and healthcare providers. Timely preparation for pregnancy enables adequate disease control, thereby reducing the risk of disease flare and pregnancy complications. Interdisciplinary care starting from the pre-pregnancy period throughout pregnancy and during breastfeeding ensures better fetal and maternal outcomes. This review provides a comprehensive guide to pre-pregnancy counselling in SARDs, an overview of medication management strategies tailored to pregnancy, disease activity and pregnancy monitoring in patients, and the promotion of shared decision making between healthcare providers and patients. Guidelines from international organizations were selected to provide a basis for this review and guidance through the quintessential discussion points of care.
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Affiliation(s)
- Klara Rosta
- Division of Gynecological Endocrinology and Reproductive Medicine, Department of Obstetrics and Gynecology, Medical University of Vienna, 1090 Vienna, Austria
| | - Julia Binder
- Division of Obstetrics and Fetomaternal Medicine, Department of Obstetrics and Gynecology, Medical University of Vienna, 1090 Vienna, Austria
| | - Valerie Kuczwara
- Division of Gynecological Endocrinology and Reproductive Medicine, Department of Obstetrics and Gynecology, Medical University of Vienna, 1090 Vienna, Austria
| | - Mira Horvath
- Division of Gynecological Endocrinology and Reproductive Medicine, Department of Obstetrics and Gynecology, Medical University of Vienna, 1090 Vienna, Austria
| | - Florian Heinzl
- Division of Obstetrics and Fetomaternal Medicine, Department of Obstetrics and Gynecology, Medical University of Vienna, 1090 Vienna, Austria
| | - Christina Hörhager
- Division of Gynecological Endocrinology and Reproductive Medicine, Department of Obstetrics and Gynecology, Medical University of Vienna, 1090 Vienna, Austria
| | - Daniel Mayrhofer
- Division of Gynecological Endocrinology and Reproductive Medicine, Department of Obstetrics and Gynecology, Medical University of Vienna, 1090 Vienna, Austria
| | - Peter Mandl
- Division of Rheumatology, Department of Internal Medicine III, Medical University of Vienna, 1090 Vienna, Austria
| | - Ruth Fritsch-Stork
- Health Care Centre Mariahilf, ÖGK and Rheumatology Department, Sigmund Freud Private University, 1060 Vienna, Austria
| | - Johannes Ott
- Division of Gynecological Endocrinology and Reproductive Medicine, Department of Obstetrics and Gynecology, Medical University of Vienna, 1090 Vienna, Austria
| | - Antonia Mazzucato-Puchner
- Division of Rheumatology, Department of Internal Medicine III, Medical University of Vienna, 1090 Vienna, Austria
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3
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Andreoli L, Guadagni I, Picarelli G, Principi M. Comprehensive reproductive healthcare for women with immune-mediated inflammatory diseases: Addressing rheumatoid arthritis, spondyloarthritis and inflammatory bowel disease through life's stages. Autoimmun Rev 2024; 23:103507. [PMID: 38142899 DOI: 10.1016/j.autrev.2023.103507] [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: 11/30/2023] [Accepted: 12/19/2023] [Indexed: 12/26/2023]
Abstract
Immuno-mediated inflammatory diseases (IMIDs) such as rheumatoid arthritis, spondyloarthritis, and inflammatory bowel disease are characterised by pathophysiological mechanisms wherein the immune system erroneously targets the body's own tissues. This review explores the heightened vulnerability of women with IMIDs, influenced by hormonal modulators like estrogen and progesterone. The challenges this poses are multifaceted, encompassing the impact of active disease and medical treatments throughout life stages, including family planning, fertility, and menopause. From the perspectives of rheumatologists and gastroenterologists, we review current management strategies and underscore the need for a multidisciplinary and life-cycle approach to healthcare for women with IMIDs.
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Affiliation(s)
- Laura Andreoli
- Unit of Rheumatology and Clinical Immunology, ASST Spedali Civili; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy.
| | | | | | - Mariabeatrice Principi
- Emergency and Organ Transplantation Department, Section of Gastroenterology, AOU Policlinico, Bari, Italy
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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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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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Chighizola CB, Clowse M, Meroni PL, Andreoli L, Tincani A, Wallenius M, Nelson-Piercy C. The SPROUT study: A survey on current management practice of reproductive aspects in women of childbearing age with systemic autoimmune rheumatic diseases. Autoimmun Rev 2023:103376. [PMID: 37301275 DOI: 10.1016/j.autrev.2023.103376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 06/05/2023] [Indexed: 06/12/2023]
Abstract
The SPROUT (Survey on reproduction in RheUmaTology) study explored current practice in women of childbearing age with systemic autoimmune rheumatic diseases, investigating the counselling on contraception, the prescription of low dose acetylsalicylic acid (LDASA) to pregnant patients and the management of disease activity in the post-partum period. The SPROUT questionnaire was designed ad hoc and promoted in the three months before the "11th International Conference on Reproduction, Pregnancy and Rheumatic Disease". Between June and August 2021, 121 physicians responded to the survey. Even though 66.8% of the participants declared themselves to be confident in counselling surrounding birth control, only 62.8% of physicians always discuss contraception and family planning with women of childbearing age. Approximately 20% of respondents do not prescribe LDASA to pregnant women with rheumatic diseases, and wide heterogeneity exists in the dose and timing of LDASA prescription. Most respondents (43.8%) restart treatment with biological agents soon after delivery to prevent disease flares, opting for a drug compatible with breastfeeding while 41.3% of physicians continue biologics throughout pregnancy and post-partum. The SPROUT study highlighted the necessity to further foster physicians' education and identified the management of disease activity after delivery as a matter for discussion between all the clinicians involved in the care of pregnant women with rheumatic conditions.
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Affiliation(s)
- Cecilia Beatrice Chighizola
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy; Unit of Pediatric Rheumatology, ASST Pini - CTO, Milan, Italy
| | - Megan Clowse
- Division of Rheumatology & Immunology, Duke University School of Medicine, Durham, NC, USA
| | - Pier Luigi Meroni
- Experimental laboratory of ImmunoRheumatological Researches, IRCCS Istituto Auxologico Italiano, Cusano Milanino, Milan, Italy
| | - Laura Andreoli
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy; Rheumatology and Clinical Immunology Unit, ASST Spedali Civili, Brescia, Italy
| | - Angela Tincani
- Rheumatology and Clinical Immunology Unit, ASST Spedali Civili, Brescia, Italy
| | - Marianne Wallenius
- National Advisory Unit on Pregnancy and Rheumatic Diseases, St Olavs Hospital, Trondheim, Norway; University Hospital and Institute of Neuromedicine and Movement Science, NTNU, Norwegian University of Science and Technology, Trondheim, Norway
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7
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Andreoli L, Chighizola CB, Iaccarino L, Botta A, Gerosa M, Ramoni V, Tani C, Bermas B, Brucato A, Buyon J, Cetin I, Chambers CD, Clowse MEB, Costedoat-Chalumeau N, Cutolo M, De Carolis S, Dolhain R, Fazzi EM, Förger F, Giles I, Haase I, Khamashta M, Levy RA, Meroni PL, Mosca M, Nelson-Piercy C, Raio L, Salmon J, Villiger P, Wahren-Herlenius M, Wallenius M, Zanardini C, Shoenfeld Y, Tincani A. Immunology of pregnancy and reproductive health in autoimmune rheumatic diseases. Update from the 11 th International Conference on Reproduction, Pregnancy and Rheumatic Diseases. Autoimmun Rev 2023; 22:103259. [PMID: 36549355 DOI: 10.1016/j.autrev.2022.103259] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 12/18/2022] [Indexed: 12/24/2022]
Abstract
Autoimmune rheumatic diseases (ARD) can affect women and men during fertile age, therefore reproductive health is a priority issue in rheumatology. Many topics need to be considered during preconception counselling: fertility, the impact of disease-related factors on pregnancy outcomes, the influence of pregnancy on disease activity, the compatibility of medications with pregnancy and breastfeeding. Risk stratification and individualized treatment approach elaborated by a multidisciplinary team minimize the risk of adverse pregnancy outcomes (APO). Research has been focused on identifying biomarkers that can be predictive of APO. Specifically, preeclampsia and hypertensive disorders of pregnancy tend to develop more frequently in women with ARD. Placental insufficiency can lead to intrauterine growth restriction and small-for-gestational age newborns. Such APO have been shown to be associated with maternal disease activity in different ARD. Therefore, a key message to be addressed to the woman wishing for a pregnancy and to her family is that treatment with compatible drugs is the best way to ensure maternal and fetal wellbeing. An increasing number of medications have entered the management of ARD, but data about their use in pregnancy and lactation are scarce. More information is needed for most biologic drugs and their biosimilars, and for the so-called small molecules, while there is sufficient evidence to recommend the use of TNF inhibitors if needed for keeping maternal disease under control. Other issues related to the reproductive journey have emerged as "unmet needs", such as sexual dysfunction, contraception, medically assisted reproduction techniques, long-term outcome of children, and they will be addressed in this review paper. Collaborative research has been instrumental to reach current knowledge and the future will bring novel insights thanks to pregnancy registries and prospective studies that have been established in several Countries and to their joint efforts in merging data.
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Affiliation(s)
- Laura Andreoli
- Rheumatology and Clinical Immunology Unit, ASST Spedali Civili, Brescia, Italy; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Cecilia B Chighizola
- Paediatric Rheumatology Unit, ASST G. Pini & CTO, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Luca Iaccarino
- Rheumatology Unit, Department of Medicine-DIMED, University of Padova, Padova, Italy
| | - Angela Botta
- Department of Obstetrics, Gynaecology and Pediatrics, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Maria Gerosa
- Division of Clinical Rheumatology, ASST Gaetano Pini-CTO, Research Center for Adult and Pediatric Rheumatic Diseases, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Véronique Ramoni
- Medicina Generale Lodi, ASST Lodi-Ospedale Maggiore, Lodi, Italy
| | - Chiara Tani
- Rheumatology Unit, Azienda Ospedaliero Universitaria Pisana and Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | | | - Antonio Brucato
- Internal Medicine, Fatebenefratelli Hospital, Milan, Italy; Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
| | - Jill Buyon
- Division of Rheumatology, New York University Grossman School of Medicine, New York, NY, USA
| | - Irene Cetin
- Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy; Department of Woman, Mother and Child, Luigi Sacco and Vittore Buzzi Children Hospitals, ASST Fatebenefratelli-Sacco, Milan, Italy
| | - Christina D Chambers
- Department of Pediatrics, University of California, Herbert Wertheim School of Public Health and Longevity Science, University of California, San Diego, La Jolla, CA, USA
| | - Megan E B Clowse
- Division of Rheumatology & Immunology, Duke University School of Medicine, Durham, NC, USA
| | - Nathalie Costedoat-Chalumeau
- Internal Medicine Department, Cochin Hospital, Referral center for rare autoimmune and systemic diseases, Université de Paris, CRESS, INSERM, INRA, Paris, France
| | - Maurizio Cutolo
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal M edicine, University of Genoa, IRCSS San Martino Polyclinic, Genoa, Italy
| | - Sara De Carolis
- Department of Obstetrics, Gynaecology and Pediatrics, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Radboud Dolhain
- Department of Rheumatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Elisa M Fazzi
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy; Child Neurology and Psychiatry Unit, ASST Spedali Civili, Brescia, Italy
| | - Frauke Förger
- Department of Rheumatology and Immunology, University Hospital (Inselspitaland University of Bern, Bern, Switzerland
| | - Ian Giles
- Centre for Rheumatology, Department of Inflammation, Division of Medicine, University College London, Department of rheumatology, University College London Hospital, London, UK
| | - Isabell Haase
- Department for Rheumatology and Hiller Research Institute, Heinrich-Heine-University, Düsseldorf, Germany
| | - Munther Khamashta
- Women & Children's Health, King's College, London, UK; GlaxoSmithKline Global Medical Expert, Dubai, United Arab Emirates
| | - Roger A Levy
- Universidade do Estado de Rio de Janeiro, Rio de Janeiro, Brazil; GlaxoSmithKline Global Medical Expert, Collegeville, PA, USA
| | - Pier Luigi Meroni
- IRCCS Istituto Auxologico Italiano, Immunorheumatology Research Laboratory, Milan, Italy
| | - Marta Mosca
- Rheumatology Unit, Azienda Ospedaliero Universitaria Pisana and Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | | | - Luigi Raio
- Department of Obstetrics and Gynaecology, University Hospital (Inselspitaland University of Bern, Bern, Switzerland
| | - Jane Salmon
- Division of Rheumatology, Department of Medicine, Hospital for Special Surgery and Weill Cornell Medicine, New York, NY, USA
| | - Peter Villiger
- Rheumatology and Clinical Immunology, Medical Center Monbijou, Bern, Switzerland
| | - Marie Wahren-Herlenius
- Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Marianne Wallenius
- National Advisory Unit on Pregnancy and Rheumatic Diseases, St Olavs Hospital, Trondheim, University Hospital and Institute of Neuromedicine and Movement Science, NTNU, Norwegian University of Science and Technology, Trondheim, Norway
| | - Cristina Zanardini
- Department of Obstetrics and Gynecology, ASST Spedali Civili, Brescia, Italy
| | - Yehuda Shoenfeld
- Sackler Faculty of Medicine, Ariel University, Ariel, Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel
| | - Angela Tincani
- Rheumatology and Clinical Immunology Unit, ASST Spedali Civili, Brescia, Italy; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy.
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Morin M, Frisell T, Stephansson O, Hellgren K. Temporal trends in adverse pregnancy outcomes in axial spondyloarthritis in Sweden: a cohort study. THE LANCET. RHEUMATOLOGY 2023; 5:e121-e129. [PMID: 38251608 DOI: 10.1016/s2665-9913(23)00001-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 12/13/2022] [Accepted: 12/19/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Evidence on the risks associated with pregnancy and childbirth in women with axial spondyloarthritis is scarce and conflicting, with more research needed to guide policy and clinical practice. We aimed to assess the risks of adverse pregnancy outcomes in a large cohort of women with axial spondyloarthritis, and to investigate how outcomes varied over time and in relation to anti-rheumatic treatment. METHODS In this register-based cohort study, we included births in Sweden between April 1, 2007, and Dec 31, 2020, to women with axial spondyloarthritis and general population comparators, matched 1:10 on year of delivery, maternal age, and parity. Our main data source was the Medical Birth Register (MBR), which includes over 98% of births in Sweden and prospectively collects data on antenatal care, delivery, and foetal outcomes. The information in MBR was linked to other registers, including the National Patient Register, the Prescribed Drug Register, and registers with demographic data. Our main outcomes were the relative risks of adverse pregnancy outcomes, analysed using modified Poisson regression. We also studied how the frequency of certain adverse outcomes, as well as disease-modifying antirheumatic drug (DMARD) and non-steroidal anti-inflammatory drug treatments, changed over the study period by linear regression and loess plots. FINDINGS Between April 1, 2007, and Dec 31, 2020, 1580 births in women with axial spondyloarthritis recorded in MBR fulfilled the inclusion criteria and were matched with 15 792 comparator births. Among the 1580 births in women with axial spondyloarthritis, we found increased risks of preterm birth (risk ratio 1·43, 95% CI 1·13-1·80), pre-eclampsia (1·44, 1·08-1·92), elective caesarean delivery (1·59, 1·37-1·84), and serious infant infection (1·29, 1·05-1·59) compared with births in general population comparators. The risks of preterm birth, infant infection, and caesarean delivery decreased by around 0·5 percentage points annually during the study period, while the use of tumour necrosis factor inhibitors during pregnancy increased. INTERPRETATION In view of remaining concerns regarding safety of the use of biological DMARDs during pregnancy, we saw a reassuring trend in which pregnancy outcomes improved over time in the axial spondyloarthritis group, concurrent with increased use of biological DMARDs. If the current rate of improvement is maintained, women with axial spondyloarthritis treated in accordance with clinical guidelines might eventually not be at an increased risk of adverse pregnancy outcomes. FUNDING Swedish Research Council and The Swedish Rheumatism Association.
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Affiliation(s)
- Matilda Morin
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden.
| | - Thomas Frisell
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Olof Stephansson
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden; Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Karin Hellgren
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
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Moltó A. TNF inhibitor use during pregnancy in axial spondyloarthritis: are we asking the right questions? THE LANCET. RHEUMATOLOGY 2023; 5:e112-e113. [PMID: 38251605 DOI: 10.1016/s2665-9913(23)00036-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 02/01/2023] [Indexed: 02/22/2023]
Affiliation(s)
- Anna Moltó
- Rheumatology Department, Cochin Hospital, Paris 75014, France.
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10
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Meissner Y, Strangfeld A, Molto A, Forger F, Wallenius M, Costedoat-Chalumeau N, Bjørngaard H, Couderc M, Flipo RM, Guettrot-Imbert G, Haase I, Jakobsen B, Koksvik HSS, Richez C, Sellam J, Weiß A, Zbinden A, Fischer-Betz R. Pregnancy and neonatal outcomes in women with axial spondyloarthritis: pooled data analysis from the European Network of Pregnancy Registries in Rheumatology (EuNeP). Ann Rheum Dis 2022; 81:1524-1533. [PMID: 35961759 DOI: 10.1136/ard-2022-222641] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 07/13/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To investigate outcome and course of pregnancies in women with axial spondyloarthritis (axSpA) in a pooled data analysis of pregnancy registries in rheumatology. METHODS Prospectively followed women with axSpA, fulfilling ASAS classification criteria and for whom a pregnancy outcome was reported, were eligible for the analysis. Anonymised data of four registries was pooled. Rates of adverse pregnancy outcomes were calculated. Systemic inflammation, disease activity and treatment patterns with tumour necrosis factor inhibitor (TNFi) before, during and after pregnancy were analysed. RESULTS In a total of 332 pregnancies from 304 axSpA women, 98.8% of the pregnancies resulted in live birth. Mean maternal age was 31 years and disease duration 5 years. Most of these patients received pre-conception counselling (78.4%). Before pregnancy, 53% received TNFi treatment, 27.5% in first and 21.4% in third trimester. Pregnancy and neonatal outcomes were favourable with rates of 2.2% for pre-eclampsia, 4.9% for preterm birth, 3.1% for low birth weight and 9.5% for small for gestational age. Neonates were delivered by caesarean section in 27.7% of pregnancies, of which 47.4% were emergencies. Pooled mean CRP was 4 mg/L before conception peaking in the second trimester at 9.4 mg/L. Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) was below 4 at all time-points. CONCLUSIONS Pooled rates of most outcomes were better than what had been reported in the literature and within expected rates of those reported for the general population. Pre-conception counselling, planned pregnancies and a tight management in expert centres applying a tailored treatment approach may have contributed to the favourable pregnancy outcomes.
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Affiliation(s)
- Yvette Meissner
- Programmbereich Epidemiologie und Versorgungsforschung, Deutsches Rheuma-Forschungszentrum Berlin, Berlin, Germany
| | - Anja Strangfeld
- Programmbereich Epidemiologie und Versorgungsforschung, Deutsches Rheuma-Forschungszentrum Berlin, Berlin, Germany.,Department of Rheumatology and Clinical Immunology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Anna Molto
- Rheumatology Department, Hospital Cochin, Paris, France.,Clinical Epidemiology and Biostatistics, Université de Paris, INSERM U1153, Paris, France
| | - Frauke Forger
- Department of Rheumatology and Immunology, University Hospital (Inselspital) and University of Bern, Bern, Switzerland
| | - Marianne Wallenius
- Institute of Neuromedicine and Movement Science, Faculty of Medicine and Health Sciences, NTNU, Norwegian University of Science and Technology, Trondheim, Norway.,Norwegian National Advisory Unit on Pregnancy and Rheumatic Diseases, Department of Rheumatology, St Olavs Hospital Trondheim University Hospital, Trondheim, Norway
| | - Nathalie Costedoat-Chalumeau
- Internal Medicine Department, Referral Center for Rare Autoimmune and Systemic Diseases, Hopital Cochin, Paris, France.,CRESS, INSERM, INRA, Université de Paris, Paris, France
| | - Hilde Bjørngaard
- Norwegian National Advisory Unit on Pregnancy and Rheumatic Diseases, Department of Rheumatology, St Olavs Hospital Trondheim University Hospital, Trondheim, Norway
| | - Marion Couderc
- Rheumatology Department, University Hospital Centre Clermont-Ferrand, Clermont-Ferrand, France.,Inserm/ Imost UMR1240, Clermont Auvergne University, Clermont-Ferrand, France
| | - René-Marc Flipo
- Service de Rhumatologie, CHU Roger Salengro, Université de Lille, Lille, France
| | - Gaëlle Guettrot-Imbert
- Internal Medicine Department, Referral Center for Rare Autoimmune and Systemic Diseases, Hopital Cochin, Paris, France
| | - Isabell Haase
- Policlinic for Rheumatology and Hiller Research Institute, Heinrich-Heine-Universitat Dusseldorf, Dusseldorf, Germany
| | - Bente Jakobsen
- Norwegian National Advisory Unit on Pregnancy and Rheumatic Diseases, Department of Rheumatology, St Olavs Hospital Trondheim University Hospital, Trondheim, Norway
| | - Hege Suorza Svean Koksvik
- Norwegian National Advisory Unit on Pregnancy and Rheumatic Diseases, Department of Rheumatology, St Olavs Hospital Trondheim University Hospital, Trondheim, Norway
| | - Christophe Richez
- Service de Rhumatologie, Referral Center for Rare Autoimmune and Systemic Diseases RESO, Centre Hospitalier Universitaire de Bordeaux Groupe hospitalier Pellegrin, Bordeaux, France.,UMR CNRS 5164, Université de Bordeaux Collège Sciences de la Santé, Bordeaux, France
| | - Jérémie Sellam
- INSERM UMRS_938, Sorbonne Universite, Paris, France.,Department of Rheumatology, Hospital Saint-Antoine, Paris, France
| | - Anja Weiß
- Programmbereich Epidemiologie und Versorgungsforschung, Deutsches Rheuma-Forschungszentrum Berlin, Berlin, Germany
| | - Astrid Zbinden
- Department of Rheumatology and Immunology, University Hospital (Inselspital) and University of Bern, Bern, Switzerland
| | - Rebecca Fischer-Betz
- Department for Rheumatology and Hiller Research Institute, Heinrich-Heine-Universitat Dusseldorf, Dusseldorf, Germany
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11
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Redeker I, Strangfeld A, Callhoff J, Marschall U, Zink A, Baraliakos X. Maternal and infant outcomes in pregnancies of women with axial spondyloarthritis compared with matched controls: results from nationwide health insurance data. RMD Open 2022; 8:rmdopen-2021-002146. [PMID: 35840311 PMCID: PMC9295643 DOI: 10.1136/rmdopen-2021-002146] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 05/04/2022] [Indexed: 12/03/2022] Open
Abstract
Objectives To investigate pregnancy outcomes in women with axial spondyloarthritis (axSpA) under different pharmacological treatments in comparison with matched controls. Methods Using health insurance data from 2006 to 2019, pregnancy outcomes of women with axSpA were compared with those of age-matched and calendar year-matched controls without axSpA. Women with axSpA were further stratified by treatment prior to delivery and pregnancy outcomes compared. Adjusted ORs (aORs) with 95% CIs were calculated using generalised estimating equation analyses. Results A total of 1021 pregnancy outcomes in patients with axSpA were identified (928 deliveries, 80 abortions, 13 ectopic pregnancies) and compared with 10 210 pregnancy outcomes in controls (9488 deliveries, 615 abortions, 147 ectopic pregnancies). Compared with controls, women with axSpA showed higher odds of elective caesarean section (aOR 1.52; 1.25 to 1.85). Among women with axSpA, the risk of preterm birth was higher under non-steroidal anti-inflammatory drugs (NSAIDs) treatment (aOR 2.22; 1.09 to 4.52) than without any anti-inflammatory treatment. The risks of preterm birth (aOR 4.01; 1.93 to 8.34) and small-for-gestational-age (aOR 3.22; 1.34 to 7.73) were increased under NSAIDs treatment in combination with conventional synthetic disease-modifying anti-rheumatic drugs (DMARDs), steroids or analgesics. Non-significant increased risks of small-for-gestational-age (aOR 1.68; 0.43 to 6.57) and preterm birth (aOR 1.56; 0.51 to 4.83) were found under biological DMARDs. Conclusions Women with axSpA have significantly increased odds of caesarean section compared with matched controls. Risks of preterm birth and small-for-gestational-age vary by type of anti-inflammatory treatment.
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Affiliation(s)
- Imke Redeker
- Epidemiology and Health Services Research, German Rheumatism Research Centre, Berlin, Berlin, Germany
| | - Anja Strangfeld
- Epidemiology and Health Services Research, German Rheumatism Research Centre, Berlin, Berlin, Germany
| | - Johanna Callhoff
- Epidemiology and Health Services Research, German Rheumatism Research Centre, Berlin, Berlin, Germany
| | - Ursula Marschall
- BARMER Institute for Health Systems Research, BARMER Statutory Health Insurance, Wuppertal, Germany
| | - Angela Zink
- Epidemiology and Health Services Research, German Rheumatism Research Centre, Berlin, Berlin, Germany
| | - Xenofon Baraliakos
- Internal Medicine and Rheumatology, Ruhr University Bochum, Bochum, Germany
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12
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Maguire S, Wilson F, Gallagher P, Mohamed MMS, Maher S, O'Shea F. What to Expect when Women with Axial Spondyloarthritis are Expecting: Prevalence of Complications of Pregnancies in Women with Axial Spondyloarthritis. Semin Arthritis Rheum 2022; 54:151993. [DOI: 10.1016/j.semarthrit.2022.151993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 03/03/2022] [Accepted: 03/08/2022] [Indexed: 11/29/2022]
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13
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Psoriatic Arthritis: The Influence of Co-morbidities on Drug Choice. Rheumatol Ther 2021; 9:49-71. [PMID: 34797530 PMCID: PMC8814223 DOI: 10.1007/s40744-021-00397-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 09/28/2021] [Indexed: 12/20/2022] Open
Abstract
Psoriatic arthritis (PsA) is associated with a higher burden of co-morbidities such as obesity, cardiovascular disease, non-alcoholic fatty liver disease, inflammatory eye disease, inflammatory bowel disease, skin cancer and depression compared to the general population. In the last 20 years, the therapeutic options for PsA have increased exponentially with the availability of tumor necrosis factor-alpha (TNF) inhibitors, interleukin (IL)-17 inhibitors, IL-12/23 inhibitors and Janus kinases/signal transducer and activator of transcription proteins (JAK/STAT) inhibitors. The articular and extra-articular manifestations of PsA usually dictate the treatment choice but important consideration must be given to the corresponding co-morbidities while deciding the drug therapy due to associated safety profile, effect on disease activity, etc. This review provides a comprehensive review of common co-morbidities in PsA and how they can influence treatment choices.
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14
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Crisafulli F, Tincani A, Franceschini F, Andreoli L. Women of childbearing age living with spondyloarthritis: time for improving knowledge and counselling about reproductive issues. Rheumatology (Oxford) 2021; 61:1307-1309. [PMID: 34791099 DOI: 10.1093/rheumatology/keab857] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 10/26/2021] [Accepted: 11/11/2021] [Indexed: 12/31/2022] Open
Affiliation(s)
- Francesca Crisafulli
- Unit of Rheumatology and Clinical Immunology, ASST Spedali Civili, Brescia; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Angela Tincani
- Unit of Rheumatology and Clinical Immunology, ASST Spedali Civili, Brescia; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Franco Franceschini
- Unit of Rheumatology and Clinical Immunology, ASST Spedali Civili, Brescia; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Laura Andreoli
- Unit of Rheumatology and Clinical Immunology, ASST Spedali Civili, Brescia; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
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