Preterm birth phenotypes in women with autoimmune rheumatic diseases: a population-based cohort study

Considering pregnancies as repeated versus independent events: An empirical comparison of common approaches across selected perinatal outcomes

BACKGROUND

In population-based research, pregnancy may be a repeated event. Despite published guidance on how to address repeated pregnancies to the same individual, a variety of approaches are observed in perinatal epidemiological studies. While some of these approaches are supported by the chosen research question, others are consequences of constraints inherent to a given dataset (e.g., missing parity information). These decisions determine how appropriately a given research question can be answered and overall generalizability.

OBJECTIVE

To compare common cohort selection and analytic approaches used for perinatal epidemiological research by assessing the prevalence of two perinatal outcomes and their association with a clinical and a social independent variable STUDY DESIGN: Using vital records linked to maternal hospital discharge records for singleton births, we created four cohorts: (1) all-births (2) randomly selected one birth per individual (3) first observed birth per individual (4) primiparous-births (parity 1). Sampling of births was not conditional on cluster (i.e., we did not sample all births by a given mother, but rather sampled individual births). Study outcomes were severe maternal morbidity and preeclampsia/eclampsia, and the independent variables were self-reported race/ethnicity (as a social factor) and systemic lupus erythematosus. Comparing the four cohorts, we assessed the distribution of maternal characteristics, the prevalence of outcomes, overall and stratified by parity, and risk ratios for the associations of outcomes with independent variables. Among all-births, we then compared risk ratios from three analytic strategies: with standard inference that assumes independently sampled births to the same mother in the model, with cluster-robust inference, and adjusting for parity.

RESULTS

We observed minor differences in the population characteristics between the all-birth (N=2,736,693), random-selection, and first-observed birth cohorts (both N=2,284,660), with more substantial differences between these cohorts and the primiparous-births cohort (N=1,054,684). Outcome prevalence was consistently lowest among all-births and highest among primiparous-births (e.g., severe maternal morbidity 18.9 per 1,000 births among primiparous-births vs. 16.6 per 1,000 births among all-births). When stratified by parity, outcome prevalence was always the lowest in births of parity 2 and highest among births of parity 1 for both outcomes. Risk ratios differed for study outcomes across all four cohorts, with the most pronounced differences between the primiparous-birth cohort and other cohorts. Among all-births, robust inference minimally impacted the confidence bounds of estimates, compared to the standard inference, i.e., crude estimates (e.g., lupus-severe maternal morbidity association: 4.01, 95% CI 3.54-4.55 vs. 4.01, 95% CI 3.53-4.56 for crude estimate), while adjusting for parity slightly shifted estimates, towards the null for severe maternal morbidity and away from the null for preeclampsia/eclampsia.

CONCLUSION

Researchers should consider the alignment between the methods they use, their sampling strategy, and their research question. This could include refining the research question to better match inference possible for available data, considering alternative data sources, and appropriately noting data limitations and resulting bias, as well as the generalizability of findings. If parity is an established effect modifier, stratified results should be presented.

Reproductive health in female patients with systemic sclerosis: a cross-sectional study

OBJECTIVES

To explore the status of reproductive health and related factors in female patients with systemic sclerosis (SSc).

METHODS

A cross-sectional study was conducted among female patients from the Chinese Organization for Scleroderma through a questionnaire. Data on the status of reproductive health including fertility condition and menstrual status were obtained. The clinical and laboratory data of SSc were collected. For patients with pregnancies after disease onset, each pregnancy was matched with a healthy control. Associations between clinical characteristics and the status of reproductive health were analysed.

RESULTS

A total of 342 female patients with SSc were included, and 31.8% (108/342, 95% CI 26.9%-36.7%) of them presented problems with reproductive health. Compared with the national data, the menopausal age of patients with disease onset before menopause was earlier (45.2 ± 6.1 vs 48.2 ± 4.4, P < 0.001). Age of disease onset (P = 0.018) and digital ulcer (P = 0.020) had statistically significant effects on menopausal age. Although the infertility rate of patients was not increased, the rate of spontaneous abortions was higher compared with the national data (9/74, 12.2% vs 4.3%, P < 0.001). Compared with the healthy control group, the rate of premature infants (12/55, 21.8% vs 7/110, 6.4%, P = 0.003), low birth weight infants (15/55, 27.3% vs 6/110, 5.5%, P < 0.001), and cesarean section (27/55, 49.1% vs 21/110, 19.1%, P < 0.001) increased significantly.

CONCLUSION

The impairment of reproductive health is common and in many quarters in patients with SSc. Further action should be taken to improve reproductive health in patients with SSc, especially in maternal care.

Systemic lupus erythematosus is associated with an increased frequency of spontaneous preterm births: systematic review and meta-analysis

OBJECTIVE

Preterm birth is one of the most frequent complications of pregnancy in women with systemic lupus erythematosus. The high indicated preterm birth proportion due to hypertensive disorders of pregnancy and/or fetal growth restriction is well known, and preventive measures and screening for early detection are performed. The risk of spontaneous preterm birth is less well recognized. This study aimed to determine the proportions of spontaneous and indicated preterm birth in pregnancies of women with systemic lupus erythematosus.

DATA SOURCES

A systematic literature search using Pubmed, Embase, Web of Science, and Google Scholar was performed in June 2021.

STUDY ELIGIBILITY CRITERIA

Studies in pregnant women with systemic lupus erythematosus reporting spontaneous and indicated preterm birth rates were selected. Original research articles published from 1995 to June 2021 were included.

METHODS

Quality and risk of bias of the included studies were assessed using the Newcastle-Ottawa quality assessment scale. To estimate the pooled event rates and 95% confidence intervals, meta-analysis of single proportions with a random-effects model was performed.

RESULTS

We included 21 articles, containing data of 8157 pregnancies in women with systemic lupus erythematosus. On average, 31% (95% prediction interval, 0.14-0.50) of the pregnancies resulted in preterm birth, including 14% (95% prediction interval, 0.04-0.27) spontaneous and 16% (95% prediction interval, 0.03-0.35) indicated preterm birth.

CONCLUSION

In pregnant women with systemic lupus erythematosus, spontaneous and indicated preterm birth proportions are high. This information should be applied in (prepregnancy) counseling and management in pregnancy. The knowledge obtained by this meta-analysis paves the way for further research of associated risk factors and development of interventions to reduce spontaneous preterm birth in systemic lupus erythematosus pregnancies.

Detection of potential safety signals related to the use of remdesivir and tocilizumab in the COVID era during pregnancy, resorting to open data from the FDA adverse event reporting system (FAERS)

Background: The in-hospital treatment for COVID-19 may include medicines from various therapeutic classes, such as antiviral remdesivir and immunosuppressant tocilizumab. Safety data for these medicines are based on controlled clinical trials and case reports, limiting the knowledge about less frequent, rare or unique population adverse events excluded from clinical trials. Objective: This study aims at analyzing the reports of Adverse Drug Events (ADEs) related to these two medicines, focusing on events in pregnant women and foetuses. Methods: Data from the open-access FDA Adverse Event Reporting System (FAERS) from 2020 to 2022 were used to create a dashboard on the Grafana platform to ease querying and analyzing report events. Potential safety signals were generated using the ROR disproportionality measure. Results: Remdesivir was notified as the primary suspect in 7,147 reports and tocilizumab in 19,602. Three hundred and three potential safety signals were identified for remdesivir, of which six were related to pregnant women and foetuses (including abortion and foetal deaths). Tocilizumab accumulated 578 potential safety signals, and three of them were associated with this population (including neonatal death). Discussion: None of the possible signals generated for this population were found in the product labels. According to the NIH and the WHO protocols, both medicines are recommended for pregnant women hospitalized with COVID-19. Conclusion: Despite the known limitations of working with open data from spontaneous reporting systems (e.g., absence of certain clinical data, underreporting, a tendency to report severe events and recent medicines) and disproportionality analysis, the findings suggest concerning associations that need to be confirmed or rejected in subsequent clinical studies.

Maternal risk factors for preterm birth in Taiwan, a nationwide population-based cohort study

BACKGROUND

The rate of preterm birth is increasing globally. It causes significant short-term and long-term health care burdens. A comprehensive recognition of the risk factors related to preterm births is important in the prevention of preterm birth. Our study is to investigate the incidence and maternal risk factors of preterm birth from a nationwide population-based perspective.

METHODS

This is a retrospective cohort study. All live births from 2004 to 2014 in Taiwan enrolled. The main data source was Taiwan's Birth Certificate Application (BCA) database. The BCA database was linked with the National Health Insurance Research Database (NHIRD) to establish any links between information on newborns and maternal underlying disease.

RESULTS

A total of 1,385,979 births were included in the analysis. The incidence of preterm birth increased gradually in Taiwan from 8.85% in 2004 to 10.73% in 2014. Maternal age, socioeconomic status, maternal allergy and autoimmune diseases, gynecological diseases, and pregnancy-related complications were significant risk factors for preterm birth.

CONCLUSION

The overall incidence of preterm births has gradually increased in Taiwan. Maternal age, socioeconomic status, certain underlying diseases, and pregnancy-related complications were risk factors for preterm birth.

Pregnancy and Inflammatory Rheumatological Diseases: A Single-Center Retrospective Cohort Study

Background Rheumatic diseases pose risks to pregnant women, leading to complications like preterm birth, congenital heart block, and pregnancy loss. These diseases are expected to deteriorate during pregnancy and further in the postpartum period. The impact of these diseases on the pregnancy will add further burden on the patient, fetus, physician, and healthcare system. Advances in diagnosis and treatment have improved outcomes making them similar to that of healthy women, but close follow-up in a multidisciplinary clinic is essential. The objective of this study is to study the outcome of pregnancy in women with rheumatological disease and the behavior of the disease during pregnancy. Methods A retrospective cohort study was conducted in King Abdulaziz Medical City (KAMC) in Riyadh, Saudi Arabia, to compare the outcomes of pregnancy across three rheumatological diseases: Sjogren syndrome (SS), systemic lupus erythematosus (SLE), and rheumatoid arthritis (RA) from 2016 to 2021. A total of 128 pregnancies in 107 women with rheumatological diseases were included in this study. Pregnancy measures and outcomes were investigated by assessing maternal health, fetal health, and pregnancy complications, specifically maternal disease activity, medications to control the disease, infection, preterm birth, birth weight, abortions/stillbirths, mode of delivery, bleeding, preeclampsia, congenital heart block, and neonatal lupus. Results There were 55 patients with RA (63 RA pregnancies), 44 with SLE (54 SLE pregnancies), and eight with primary SS (11 SS pregnancies). In most of the pregnancies (n= 108; 95.58%), the patients were in clinical remission before pregnancy. Lupus nephritis, which was in remission before pregnancy, has been reported in nine (16.67%) out of 54 SLE pregnancies. Vaginal delivery was the most common mode of delivery (n=87; 67.97%). On the other hand, there were 38 cesarean sections (29.69%). Rheumatological disease flares occurred in 10 pregnancies (7.87%). One hundred and twenty-two live births were delivered. Preterm infants were born in 25 pregnancies (20.16%), and 16 (13.22%) of the newborns needed neonatal intensive care unit (NICU) care. Interestingly, congenital heart block (CHB) was found in five (12.2%) neonates out of 41 anti-SS-related antigen A (anti-SSA) positive mothers; one of those five died from heart block. Eleven neonates were delivered with positive serology, and five were diagnosed with neonatal lupus. Conclusion The outcome of pregnancy in patients with rheumatological disease is favorable. A multidisciplinary team approach and close clinical follow-up are the cornerstone for such success. A small dose of prednisolone (5 mg or less) is safe and will not have a negative impact on maternal or fetal health. CHB is a concern for pregnant women with positive anti-SSA.

Impact of maternal psoriasis on adverse maternal and neonatal outcomes: a systematic review and meta-analysis

BACKGROUND

There is a dearth of robust evidence regarding the correlation between psoriasis with maternal and neonatal outcomes, making it challenging to establish definitive recommendations for the management of these patients. This systematic review and meta-analysis aimed to review the evidence with regard to the impact of maternal psoriasis on maternal and neonatal outcomes.

METHODS

Following the PRISMA guideline, a systematic search of English articles using PubMed, Embase, Scopus, ScienceDirect, Web of Science, Google Scholar, and the Cochrane Library was conducted. The search was performed from inception to 22nd of May 2022.

RESULT

A significant association was observed between psoriasis and maternal outcomes, including cesarean delivery [OR = 1.25 (95% CI: 1.13-1.30, p-value = 0.001)], (pre)eclampsia [OR = 1.29 (95% CI: 1.15-1.44, p-value = 0.0001)], gestational diabetes [Odds Ratio (OR) = 1.23 (95% Confidence Intervals (CI): 1.15-1.30, p-value = 0.001)], gestational hypertension [OR = 1.31 (95% CI: 1.18-1.45, p-value = 0.001)] and preterm birth [OR = 1.22 (95% CI: 1.10-1.35, p-value = 0.001)]. Also, there was a significant association between psoriasis and neonatal outcomes, including small for gestational age [OR = 1.07 (95% CI: 1.02-1.11, p-value = 0.053)], low birth weight [OR = 1.19 (95% CI: 1.02-1.38, p-value = 0.001)] and stillbirth [OR = 1.27 (95% CI: 1.04-1.55, p-value = 0.023)].

CONCLUSION

Maternal psoriasis could negatively impact maternal and neonatal outcomes. Our results strengthen the importance of close monitoring of the mothers' psoriasis status before and during pregnancy.

Immunology of pregnancy and reproductive health in autoimmune rheumatic diseases. Update from the 11th International Conference on Reproduction, Pregnancy and Rheumatic Diseases

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.

Benefits and risks of low molecular weight heparin use on reproductive outcomes: A retrospective cohort study

OBJECTIVE

Low molecular weight heparin (LMWH) has been given to reproductive-age women with various indications. This study aims to assess the benefits and risks of such use.

MATERIALS AND METHODS

We retrospectively reviewed data (n = 204) between Jan 2016 and May 2019. Logistic regression analysis was conducted to evaluate the correlation between indications and reproductive outcomes.

RESULTS

LMWH use had higher odds of live birth in women less than 30 years of age (OR: 4.98; 95% CI = 1.13-21.98; p = 0.034) and with protein S deficiency (OR: 3.90; 95% CI = 1.77-8.59; p = 0.001). For the subgroup of recurrent pregnant loss, LMWH use was only advantageous to women with protein S deficiency (OR: 2.45; 95%:1.01-5.97; p = 0.048). Risks such as preterm delivery, small-for-gestational-age, placental abruption, antepartum/postpartum hemorrhage were not significantly increased among subgroups. Women treated with LMWH and who had successful live births (n = 171) had a slightly increased risk of postpartum hemorrhage compared to controls (n = 8058) during this period in our institution (2.9% vs 1.2%, p < 0.001).

CONCLUSION

LMWH administration produces a higher chance of live-birth to women younger than 30 years of age or with protein S deficiency. However, risk of postpartum hemorrhage is increased.

Maternal leucocyte trajectory across pregnancy associated with offspring's growth

BACKGROUND

Leucocytes for individuals during pregnancy may form into different trajectory patterns. Since no studies have been conducted, we aim to examine the associations between leucocyte trajectory across pregnancy and offspring's birth outcomes and growth during the first 2 years.

METHODS

We conducted a retrospective study enrolled 1070 singleton pregnancies aged 21-46 years old between 2014 and 2018 in Huazhong University of Science and Technology Union Shenzhen Hospital, China. Leucocyte trajectories were modelled using growth mixture modelling and four trajectories were identified: moderate-increasing (n = 41), low-stable (n = 828), high-decreasing (n = 145) and low-increasing (n = 56).

RESULTS

Relative to the low-stable group, logistic regression analysis after adjusting for covariates indicated that the odds ratios of preterm were 3.06 (95% confidence interval (CI): 1.43-6.23) for moderate-increasing, 0.78 (95% CI: 0.38-1.47) for high-decreasing and 0.68 (95% CI: 0.23-1.61) for the low-increasing group, respectively. By using generalized estimating equation analysis, we observed that infants in the moderate-increasing and low-increasing group had -0.35 and -0.21 (P &lt; 0.01) lower head circumference z-score compared with the low-stable group, respectively. No significant association of leucocyte trajectory with other birth weight measures or anthropometric measure z-scores was found.

CONCLUSIONS

Changes in leucocytes across pregnancy affected the occurrence of preterm and offspring's head circumference during the first 2 years of life.

IMPACT

Previous researches on the association of leucocytes with pregnancy outcomes mainly focused on leucocytes in a specific trimester. No studies until now have been conducted to assess the influences of the leucocyte trajectories on the growth and development of infants. Changes in leucocytes across pregnancy affected the occurrence of preterm and offspring's head circumference during the first 2 years of life. Our study will positively contribute to the dialogue regarding the treatment of pregnancies with different levels of inflammation in each trimester to minimize adverse pregnancy outcomes and optimize brain growth.

Pregnancy in adult-onset dermatomyositis/polymyositis: a systematic review

Idiopathic inflammatory myopathy in pregnancy is uncommon but may result in complications for both mother and the fetus. In this systematic review, we summarized the current literature investigating outcomes of pregnancy related to the dermatomyositis/polymyositis (DM/PM) process. We searched PubMed, Embase, Cochrane Library, and Web of Science databases and included 61 studies reporting the disease course, pregnancy outcomes, and management of both pregnancy and DM/PM in the final analysis. The specific information of 221 pregnancies was extracted and these pregnancies were divided into three distinct forms: pregnancies after disease onset (n = 159), pregnancies with new disease onset (n = 37), and pregnancies followed by postpartum onset (n = 25). In most cases, DM/PM disease activity remained stable or improved throughout pregnancy (80.2%) and the postpartum period (83.9%). Active DM/PM during pregnancy significantly increased the risk of stillbirth or neonatal death (12% vs. 1%, P = 0.005) and preterm birth (34.7% vs. 11%, P<0.001). The rates of other poor outcomes (total fetal loss, low birth weight, and intrauterine growth retardation) were also increased in pregnancies with active disease. Mainstay treatments for active DM/PM during pregnancy are glucocorticoids and intravenous immunoglobins. The present results underline the importance of good control of myopathy in optimizing the pregnancy outcomes of women with DM/PM. This article is protected by copyright. All rights reserved.

Diagnostic value of Serum Amyloid A, Interleukin-6 in gravidas with spontaneous preterm birth

PURPOSE

Spontaneous preterm birth (SPB) can't be predicted accurately nowadays. We aim to investigate the value of serum amyloid A(SAA) and interleukin-6(IL-6) for forecasting the risk of SPB.

METHODS

A total of 302 pregnant women who completed delivery in our hospital from January 2019 to December 2021 were included. According to gestational days, they were divided into the case group (28-33⁺⁶ weeks, 41 cases; 34-36⁺⁶ weeks, 96 cases) and the control group (37-42 weeks, 165 cases). The general data of the two groups were analyzed and the values of SAA and IL-6 in speculating the risk of SPB were studied in this study.

RESULTS

The levels of SAA and IL-6 in the case group were higher than those in the control group(P < 0.05), and the most practical value of SAA and IL-6 access SPB risk were 17.35 mg/L, 112.41 pg/mL respectively. The area under the ROC curve of diagnosis to predict SPB were 0.8849, 0.8664.

CONCLUSIONS

The assessment of SPB risk by SAA and IL-6 bearscertain clinical value, which could assist clinicians in recognizing and evaluating the potential dangers of SPB.

Maternal and neonatal outcomes among pregnant women with inflammatory myopathies

OBJECTIVES

Pregnancy outcomes in women with inflammatory myopathies (IM) are not well studied. The purpose of this study is to evaluate the effects of IM on maternal and neonatal outcomes.

METHODS

We conducted a retrospective cohort study using data from the Healthcare Cost and Utilization Project - Nationwide Inpatient Sample (HCUP-NIS) from 1999 to 2015. Among all pregnant women who delivered during this period, those with a diagnosis of IM were identified using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) coding, which included all patients with dermatomyositis and polymyositis. Maternal and neonatal outcomes were compared in pregnant women with and without IM. Multivariate logistic regression analysis was used to estimate the adjusted effects of IM on these outcomes.

RESULTS

A total of 13,792,544 pregnant women delivered between 1999 and 2015, of which 308 had a diagnosis of IM, for an overall prevalence of 2 per 100,000 pregnant women, with rates increasing over the study period. Pregnant women with IM were more likely to be older, African American and suffer from other autoimmune connective tissue diseases. IM in pregnancy was associated with greater risk of preeclampsia, caesarean delivery, major postpartum infections, urinary tract infections and longer hospital stay. Neonates born to mothers with IM had greater risk of prematurity, small for gestational age and intrauterine fetal demise.

CONCLUSIONS

Pregnant women with IM are at higher risk of adverse maternal and neonatal outcomes and should be closely followed in specialized centers with collaboration between maternal-fetal medicine and rheumatology.

Pregnancy in juvenile idiopathic arthritis: maternal and foetal outcome, and impact on disease activity

Objective:

This retrospective cohort study describes the modulation of disease activity during gestation and in the year following delivery as well as maternal and neonatal outcomes in a monocentric cohort of women with juvenile idiopathic arthritis (JIA).

Methods:

Disease activity was assessed using DAS28-CRP before conception and every 3 months during pregnancy and in the first year postpartum. The risk of complicated pregnancies was measured applying a generalized estimating equation model. Changes in disease activity during gestation and in the first year postpartum were assessed in a linear mixed model for repeated measures.

Results:

Thirty-one women (49 pregnancies) with persisting JIA and at least one conception were enrolled. Adjusted DAS28-CRP levels remained stable from preconception through the first trimester, but increased significantly in the second and decreased not significantly in the third. In the postpartum, adjusted disease activity peaked at 3 months after delivery, stabilized at 6 months to decrease at 1 year, although not significantly. Preconceptional DAS28-CRP and number of biological drugs predicted disease activity fluctuation during gestation. The number of biological drugs and the length of gestational exposure to biologics significantly predicted pregnancy morbidity. In particular, JIA women had a higher probability of preterm delivery compared with healthy and disease controls. Adjusted for breastfeeding and DAS28-CRP score in the third trimester, postconceptional exposure to biologics was inversely related with disease activity in the postpartum: the longer the patient continued treatment, the lower the probability of experiencing an adverse pregnancy outcome.

Conclusion:

These data offer novel insights on how treatment affects disease activity during pregnancy and postpartum as well as obstetric outcomes in women with JIA.

Reproductive Issues and Pregnancy Implications in Systemic Sclerosis

Systemic sclerosis (SSc) is a rare systemic autoimmune disease that can influence reproductive health. SSc has a strong female predominance, and the disease onset can occur during fertility age in almost 50% of patients. Preconception counseling, adjustment of treatment, and close surveillance during pregnancy by a multidisciplinary team, are key points to minimize fetal and maternal risks and favor successful pregnancy outcomes. The rates of spontaneous pregnancy losses are comparable to those of the general obstetric population, except for patients with diffuse cutaneous SSc and severe internal organ involvement who may carry a higher risk of abortion. Preterm birth can frequently occur in women with SSc, as it happens in other rheumatic diseases. Overall disease activity generally remains stable during pregnancy, but particular attention should be paid to women with major organ disease, such as renal and cardiopulmonary involvement. Women with such severe involvement should be thoroughly informed about the risks during pregnancy and possibly discouraged from getting pregnant. A high frequency of sexual dysfunction has been described among SSc patients, both in females and in males, and pathogenic mechanisms of SSc may play a fundamental role in determining this impairment. Fertility is overall normal in SSc women, while no studies in the literature have investigated fertility in SSc male patients. Nevertheless, some considerations regarding the impact of some immunosuppressive drugs should be done with male patients, referring to the knowledge gained in other rheumatic diseases.

Adverse Perinatal Outcomes Before and After Diagnosis with Systemic Lupus Erythematosus Among African American Women

OBJECTIVE

Women with systemic lupus erythematosus (SLE) may experience adverse perinatal outcomes in the years before an SLE diagnosis. Overall, there is limited research on perinatal outcomes among African American women with SLE.

METHODS

Women with SLE identified from the Georgia Lupus Registry and the Georgians Organized Against Lupus Cohort were linked with birth certificates by the Georgia Department of Public Health. Births were categorized into occurring more than 3 years before SLE diagnosis, 0-3 years before SLE diagnosis, 0-3 years after SLE diagnosis or more than 3 years after SLE diagnosis. Comparison births certificates to African American women in the same geographic area were obtained from the National Center for Health Statistics. We used log-risk models to compare the risk of preterm birth or small-for-gestational age among SLE births in each diagnosis timing category to the general population, adjusting for maternal age and education and parity.

RESULTS

Births to women with SLE were more likely to occur preterm 0-3 years before SLE diagnosis (risk ratio [RR]: 1.71, 95% confidence interval [CI]: 1.24, 2.35), 0-3 years after SLE diagnosis (RR: 2.29, 95% CI: 1.70, 3.09) and 3 or more years after diagnosis (RR: 2.83, 95% CI: 2.36, 3.38), but not 3 or more years before SLE diagnosis compared to the general population (RR: 1.03, 95% CI: 0.77, 1.38). Similar results were observed for small-for-gestational age births.

CONCLUSION

Our analysis, conducted among African American women, demonstrates an increased risk of adverse perinatal outcomes even before a clinical diagnosis of SLE.

Pregnancy outcomes in relation to disease activity and anti-rheumatic treatment strategies in women with rheumatoid arthritis

OBJECTIVES

To explore the association of maternal rheumatoid arthritis (RA) to pregnancy outcomes, especially preterm birth (PTB) and small for gestational age (SGA), in relation to disease activity and anti-rheumatic treatment before and during pregnancy.

METHODS

By linking prospective clinical rheumatology registers (CRR) in Sweden (SRQ) and Denmark (DANBIO) with medical birth registers, we identified 1,739 RA-pregnancies and 17 390 control-pregnancies (matched 1:10 on maternal age, birth year, parity) with delivery 2006-2018. Disease activity (DAS28, CRP, HAQ-score) and anti-rheumatic treatment nine months before and during pregnancy were identified through CRR and prescribed drug registers. Using logistic regression, we estimated adjusted odds ratios (aOR) with 95% confidence intervals (CI) for PTB and SGA overall and stratified by disease activity and anti-rheumatic treatment before and during pregnancy, adjusting for maternal characteristics.

RESULTS

We found increased aOR of PTB (1.92, 1.56-2.35) and SGA (1.93, 1.45-2.57) in RA-pregnancies vs control-pregnancies. For RA-pregnancies with DAS28-CRP ≥ 4.1 vs < 3.2 during pregnancy, aOR was 3.38 (1.52-7.55) for PTB and 3.90 (1.46-10.4) for SGA. Use of oral corticosteroids (yes/no) during pregnancy resulted in an aOR of 2.11 (0.94-4.74) for PTB. Corresponding figure for biologics was 1.38 (0.66-2.89). Combination therapy, including biologics before pregnancy, was a marker of increased risk of both PTB and SGA.

CONCLUSION

During pregnancy, disease activity rather than treatment seems to be the most important risk factor for PTB and SGA in RA. Women with RA should be carefully monitored during pregnancy, especially if they have moderate to high disease activity or/and are treated with extensive anti-rheumatic treatment.

Pregnancy outcomes in women with psoriatic arthritis with respect to presence and timing of antirheumatic treatment

OBJECTIVE

To evaluate pregnancy outcomes in relation to antirheumatic treatment before and during pregnancy as a proxy of disease severity in PsA-pregnancies as compared to non-PsA-pregnancies.

METHODS

Swedish nationwide register-based cohort study of 921 PsA- pregnancies and 9210 non-PSA-pregnancies (matched 1:10 on maternal age, year, and parity) 2007-2017. We estimated adjusted odds ratios (aOR) overall and stratified by presence, timing, and type of antirheumatic treatment. Adjustments were made for BMI, smoking, educational level and country of birth. The outcome preterm birth was also stratified by parity.

RESULTS

Women with PsA vs. non-PsA-pregnancies were more obese, more often smokers and had a diagnosis of pre-gestational hypertension and diabetes more often. Increased risks in PsA vs. non-PsA-pregnancies were foremost preterm birth (aOR 1.69, 95% CI 1.27-2.24) and cesarean delivery, (aOR 1.77, 95% CI 1.43-2.20 for elective and aOR 1.42, 95% CI 1.10-1.84 for emergency cesarean delivery). The risks differed with presence, timing, and type of antirheumatic treatment with the most increased risks in PsA-pregnancies (vs. non-PsA) with antirheumatic treatment during pregnancy, aOR preterm birth; 2.30, 95% CI 1.49-3.56. Corresponding aOR for biologics exposed PsA-pregnancies was 4.49, 95% CI 2.60-7.79. Risk of preterm birth was primarily increased in first pregnancies.

CONCLUSION

In comparison with non-PsA-pregnancies risks of preterm birth and cesarean delivery were mostly increased in those exposed to antirheumatic treatment during pregnancy, especially biologics. As parity influences the risk of preterm birth in PsA pregnancies special attention to first pregnancies is warranted. Women with PsA, should receive individualized monitoring during pregnancy.

Evolutionary transcriptomics implicates new genes and pathways in human pregnancy and adverse pregnancy outcomes

Evolutionary changes in the anatomy and physiology of the female reproductive system underlie the origins and diversification of pregnancy in Eutherian ('placental') mammals. This developmental and evolutionary history constrains normal physiological functions and biases the ways in which dysfunction contributes to reproductive trait diseases and adverse pregnancy outcomes. Here, we show that gene expression changes in the human endometrium during pregnancy are associated with the evolution of human-specific traits and pathologies of pregnancy. We found that hundreds of genes gained or lost endometrial expression in the human lineage. Among these are genes that may contribute to human-specific maternal-fetal communication (HTR2B) and maternal-fetal immunotolerance (PDCD1LG2) systems, as well as vascular remodeling and deep placental invasion (CORIN). These data suggest that explicit evolutionary studies of anatomical systems complement traditional methods for characterizing the genetic architecture of disease. We also anticipate our results will advance the emerging synthesis of evolution and medicine ('evolutionary medicine') and be a starting point for more sophisticated studies of the maternal-fetal interface. Furthermore, the gene expression changes we identified may contribute to the development of diagnostics and interventions for adverse pregnancy outcomes.

Inflammatory factors, genetic variants, and predisposition for preterm birth

Preterm birth is a major clinical and public health challenge, with a prevalence of 11% worldwide. It is the leading cause of death in children younger than 5 years old and represents 70% of neonatal deaths and 75% of neonatal morbidity. Despite the clinical and public health significance, this condition's etiology is still unclear, and most of the cases are spontaneous. There are several known preterm birth risk factors, including inflammatory diseases and the genetic background, although the underlying molecular mechanisms are far from understood. The present review highlights the research advances on the association between inflammatory-related genes and the increased risk for preterm delivery. The most associated genetic variants are the TNFα rs1800629, the IL1α rs17561, and the IL1RN rs2234663. Moreover, many of the genes discussed in this review are also implicated in pathologies involving inflammatory or autoimmune systems, such as periodontal disease, bowel inflammatory disease, and autoimmune rheumatic diseases. This review presents evidence suggesting a common genetic background to preterm birth, autoimmune and inflammatory diseases susceptibility.

Maternal and Neonatal Outcomes in Pregnant Women with Psoriasis and Psoriatic Arthritis: A Systematic Review and Meta-Analysis

OBJECTIVE

Psoriasis and psoriatic arthritis (PsA) are inflammatory diseases that affect women in their reproductive years. We aimed to investigate whether maternal psoriasis and PsA are associated with adverse pregnancy outcomes.

METHODS

We searched multiple electronic databases from inception to 3 August 2020, and reference lists of selected articles. Observational studies reporting at least one pregnancy outcomes in women with psoriasis or PsA with a comparator of general population or healthy subjects were included. Data were pooled by random-effects models and expressed as odds ratio (OR) and 95% confidence interval (CI).

RESULTS

Overall, 16 studies were included in the meta-analysis. The pooled analyses showed pregnant women with psoriatic diseases have significantly higher risk of adverse maternal outcomes compared with general population (caesarean delivery: 1.33 (1.17-1.52); preterm birth: 1.32 (1.15-1.52); (pre)eclampsia: 1.28 (1.14-1.43); gestational diabetes: 1.19 (1.10-1.30); gestational hypertension: 1.30 (1.18-1.44). However, no statistically increased risks of fetal complications were observed in women with psoriatic diseases (small for gestational age: 1.02 (0.93-1.11); low birth weight: 1.15 (0.93-1.42); congenital malformations: 1.03 (0.93-1.14); Apgar score <7: 1.07 (0.81-1.39); neonatal mortality: 1.13 (0.90-1.43); stillbirth: 1.19 (0.95-1.50)). Subgroup analysis found similar results in women with either psoriasis or PsA regarding maternal outcomes and the magnitude of risk estimates seems to be greater in PsA though without statistical difference.

CONCLUSIONS

Pregnant women with psoriasis and PsA have excess risk of adverse maternal events, but not adverse neonatal events. Close monitoring of the mothers' clinical status before and during pregnancy is decidedly required in daily practice.

A hierarchical procedure to select intrauterine and extrauterine factors for methodological validation of preterm birth risk estimation

Background

Etiopathogenesis of preterm birth (PTB) is multifactorial, with a universe of risk factors interplaying between the mother and the environment. It is of utmost importance to identify the most informative factors in order to estimate the degree of PTB risk and trace an individualized profile. The aims of the present study were: 1) to identify all acknowledged risk factors for PTB and to select the most informative ones for defining an accurate model of risk prediction; 2) to verify predictive accuracy of the model and 3) to identify group profiles according to the degree of PTB risk based on the most informative factors.

Methods

The Maternal Frailty Inventory (MaFra) was created based on a systematic review of the literature including 174 identified intrauterine (IU) and extrauterine (EU) factors. A sample of 111 pregnant women previously categorized in low or high risk for PTB below 37 weeks, according to ACOG guidelines, underwent the MaFra Inventory. First, univariate logistic regression enabled p-value ordering and the Akaike Information Criterion (AIC) selected the model including the most informative MaFra factors. Second, random forest classifier verified the overall predictive accuracy of the model. Third, fuzzy c-means clustering assigned group membership based on the most informative MaFra factors.

Results

The most informative and parsimonious model selected through AIC included Placenta Previa, Pregnancy Induced Hypertension, Antibiotics, Cervix Length, Physical Exercise, Fetal Growth, Maternal Anxiety, Preeclampsia, Antihypertensives. The random forest classifier including only the most informative IU and EU factors achieved an overall accuracy of 81.08% and an AUC of 0.8122. The cluster analysis identified three groups of typical pregnant women, profiled on the basis of the most informative IU and EU risk factors from a lower to a higher degree of PTB risk, which paralleled time of birth delivery.

Conclusions

This study establishes a generalized methodology for building-up an evidence-based holistic risk assessment for PTB to be used in clinical practice. Relevant and essential factors were selected and were able to provide an accurate estimation of degree of PTB risk based on the most informative constellation of IU and EU factors.

Supplementary Information

The online version contains supplementary material available at (10.1186/s12884-021-03654-3).

Pregnancy outcomes in women with vitiligo: A Taiwanese nationwide cohort study

Vitiligo is perceived as an autoimmune skin disease. Previous studies showed conflicting data about vitiligo and pregnancy outcomes. To delineate the associations between vitiligo and the pregnancy outcomes, we used the National Health Insurance Research Database of Taiwan to conduct a retrospective cohort study from January 1, 2000 to December 31, 2015. This study population was composed of 1,096 women with vitiligo and 4,384 women without vitiligo, who were all matched according to age, comorbidity, and index year. Compared with the non-vitiligo controls, women with vitiligo had a higher risk of abortion (aHR 1.158, 95% confidence interval (CI) 1.095–1.258, P < .001). Perinatal events, such as preterm delivery, pre-eclampsia/eclampsia, gestational diabetes mellitus, stillbirth, and intrauterine growth retardation, were not different between both groups (aHR 1.065, 95% CI 0.817–1.157, P = .413). To determine if systemic treatment before conception decreases the risk of abortion, we assessed the medical history of pregnant women with vitiligo 1 year before pregnancy. Patients who were treated with oral medications had a lower risk of abortion than those who were not (aHR: 0.675, 95% CI: 0.482–0.809, P < .001). Our study indicates that there is a higher risk of abortion in pregnant women with vitiligo and the control of disease activity with systemic treatment before conception could improve pregnancy outcomes.

Chronic histiocytic intervillositis: A breakdown in immune tolerance comparable to allograft rejection?

Chronic histiocytic intervillositis (CHI) is a pregnancy disorder characterized by infiltration of maternal macrophages into the intervillous space of the human placenta, often with accompanying perivillous fibrin deposition. CHI is associated strongly with foetal growth restriction and increased risk of miscarriage and stillbirth. Although rare, affecting 6 in every 10 000 pregnancies beyond 12 weeks' gestation, the rate of recurrence is high at 25%-100%. To date, diagnosis of CHI can only be made post-delivery upon examination of the placenta due to a lack of diagnostic biomarkers, and criteria vary across publications. No treatment options have shown proven efficacy, and CHI remains a serious obstetric conundrum. Although its underlying aetiology is unclear, due to the presence of maternal macrophages and the reported increased incidence in women with autoimmune disease, CHI is hypothesized to be an inappropriate immune response to the semi-allogeneic foetus. Given this lack of understanding, treatment approaches remain experimental with limited rationale. However, there is recent evidence that immunosuppression and antithrombotic therapies may be effective in preventing recurrence of associated adverse pregnancy outcomes. With similarities noted between the pathological features of CHI and acute rejection of solid organ transplants, further investigation of this hypothesis may provide a basis for tackling CHI and other immune-related placental conditions. This review will explore parallels between CHI and allograft rejection and identify areas requiring further confirmation and exploitation of this comparison.

Pregnancy outcomes in women with idiopathic inflammatory myopathy, before and after diagnosis-a population-based study

Objectives

To examine pregnancy outcomes among births to women with idiopathic inflammatory myopathy (IIM) in relation to time of IIM diagnosis using population-based data.

Methods

This study used Swedish nationwide registers to identify all singleton births that occurred between 1973 and 2016 among women diagnosed with IIM between 1998 and 2016 and among women unexposed to IIM. We classified births according to the IIM status of the mother at time of delivery: post-IIM (n = 68), 1–3 years pre-IIM (n = 23), >3 years pre-IIM (n = 710) and unexposed to IIM (n = 4101). Multivariate regression models were used to estimate relative risks of adverse pregnancy outcomes in post-IIM births and pre-IIM births separately, in comparison with their non-IIM comparators.

Results

We found that post-IIM births had increased risks of caesarean section [adjusted relative risk (aRR) = 1.98; 95% CI: 1.08, 3.64], preterm birth (aRR = 3.35; 95% CI: 1.28, 8.73) and low birth weight (aRR = 5.69; 95% CI: 1.84, 17.55) compared with non-IIM comparators. We also noticed higher frequencies of caesarean section and instrumental delivery in 1–3 years pre-IIM births than in the non-IIM comparators.

Conclusion

Women who gave birth after IIM diagnosis had higher risks of caesarean section, preterm birth and low birth weight. These results further underline the importance of special care and close monitoring of women with IIM. Higher frequencies of caesarean section and instrumental delivery in pre-IIM births highlight the need for future research on the influence of subclinical features of IIM on pregnancy outcomes.

Simplified disease activity index and clinical disease activity index before and during pregnancy correlate with those at postpartum in patients with rheumatoid arthritis

OBJECTIVES

We explored rheumatoid arthritis (RA) disease activity before, during, and after pregnancy in patients treated with tight control and investigated the association between disease activity in the postpartum period and those before and during pregnancy.

METHODS

We retrospectively reviewed disease activity and medications of 27 patients before pregnancy, at every trimester, and in the postpartum period.

RESULTS

Prednisolone was administered to 33% of patients with a median dose of 0 (0-2.5) mg/day and biologic agents was 78% in the third trimester. The median remission rates during all periods were the Disease Activity Score-28-C-reactive Protein assessed with three variables (DAS28-CRP-3) 85%, Simplified Disease Activity Index (SDAI) 55%, and Clinical Disease Activity Index (CDAI) 54%. Although SDAI and CDAI decreased significantly from before pregnancy to the first trimester and increased from the third trimester to the postpartum period, DAS28-CRP-3 did not change during all periods. Although SDAI and CDAI before and during pregnancy were significantly correlated with those in the postpartum period, DAS28-CRP-3 was not.

CONCLUSIONS

Tight control before pregnancy suppressed RA disease activity during pregnancy and in the postpartum period. SDAI/CDAI before and during pregnancy were predictive for disease activity in the postpartum period.

Prevalence of autoimmune disease among pregnant women and women of reproductive age in New South Wales, Australia: a population-based study

BACKGROUND

Autoimmune diseases disproportionately affect women and have been linked to increased risk of maternal and perinatal mortality and morbidity. Our aim was to determine the prevalence of autoimmune disease among pregnant women and women of reproductive age (WRA), which is not well described.

MATERIALS AND METHODS

A population-based study was conducted using data from a survey of general practitioner (GP) encounters and state-wide hospital admissions in New South Wales (NSW). A list of 29 conditions and relevant diagnosis codes was used to identify autoimmune disease. Prevalence estimates and trends were calculated using population denominators for GP encounters for WRA in 2011-2015 and hospital admissions for WRA and pregnant women in 2013-2017.

RESULTS

A total 31,065 GP encounters for WRA were identified and 607 (2.0%) reported an autoimmune disease, equivalent to 1.1 GP encounters per 10 WRA each year when extrapolating to NSW population figures. For WRA admitted to hospital, 2.6% had an autoimmune diagnosis recorded each year equivalent to a population prevalence of 0.5%. A total 477,243 births were identified, of which 4230 mothers (0.9%) had at least one autoimmune disease recorded during a 1-year pregnancy lookback period. Autoimmune disease prevalence among both pregnant women and WRA either attending GP or hospital increased, on average, 2-4% per year over the study period.

CONCLUSIONS

A small, but potentially growing proportion of reproductive age and pregnant women have a diagnosed autoimmune disease, and this may impact their health outcomes.

Risk of adverse obstetric outcomes in Japanese women with systemic lupus erythematosus: The Japan Environment and Children's Study

Systemic lupus erythematosus, simply known as lupus, is associated with adverse obstetric outcomes. This study evaluated the incidence of preterm births (before 37 and 34 weeks), low birthweight infants (<2500 g and <1500 g), small-for-gestational age infants, preterm premature rupture of membranes, and gestational hypertension in mothers with lupus and compared them with those of the Japanese general population. Data from participants in the Japan Environment and Children’s Study who gave birth between 2011 and 2014 were collected. Only participants with singleton pregnancies were included. Adjusted odds ratios for the variables were calculated using a logistic regression model, with a general population as the reference. In total, 88,017 participants were included in the analysis, and 63 of them had lupus. The adjusted odds ratios of preterm births before 37 and 34 weeks, low birthweight infants <2500 g and <1500 g, small-for-gestational age infants, and preterm premature rupture of membranes in the systemic lupus erythematosus group were 8.1 (95% CI, 4.7–14.1), 5.2 (1.6–16.5), 6.5 (3.9–10.8), 5.4 (1.3–22.4), 2.9 (1.4–5.9), and 12.1 (5.7–25.5), respectively. The adjusted odds ratio of gestational hypertension was 1.4 (0.4–4.5). This study revealed increased risk of preterm births, low birthweight infants, small-for-gestational age infants, and preterm premature rupture of membranes in patients with lupus when compared with those in the general population.