Pregnancy outcomes and contraceptive use in patients with systemic lupus Erythematosus, rheumatoid arthritis and women without a chronic illness: a comparative study

The impact of hormones in autoimmune cutaneous diseases

INTRODUCTION

Dermatomyositis, systemic and cutaneous lupus erythematosus have a significantly higher prevalence in women than men, emphasizing the relevance of exploring the relationship between sex hormones and autoimmune skin diseases. This review analyzes the interplay between sex hormones and these two skin diseases.

MATERIALS AND METHODS

We performed an extensive literature search using the PubMed database from July to August 2023. Search terms included 'contraceptives', 'pregnancy', 'hormone replacement', 'tamoxifen', and 'aromatase inhibitors'.

RESULTS AND DISCUSSION

This comprehensive literature review shows that there remains considerable debate regarding the use of hormonal contraceptives and hormonal replacement therapy in individuals with autoimmune skin conditions. Nonetheless, it is well established that their use is contraindicated in patients with antiphospholipid syndrome or when antiphospholipid antibodies are positive. Individuals experiencing disease flares and uncontrolled symptoms should also avoid these interventions. Pregnancy planning should be timed to coincide with well-managed disease states to minimize obstetric and neonatal complications. Hormonal breast cancer treatment requires close skin monitoring.

CONCLUSION

Pregnancy, menopause, contraceptive use, hormone replacement therapy, and breast cancer treatment drugs result in substantial shifts in hormone levels. Additionally, hormone levels are altered by aromatase inhibitors and anti-estrogen medications. These fluctuations can modulate mechanisms influencing autoimmune skin abnormalities.

Pre-pregnancy planning for female patients seen at a pregnancy and rheumatic diseases clinic: a retrospective analysis of patients with rheumatic diseases seeking pregnancy-related care

To assess the clinical utility of pre-pregnancy planning among female patients with rheumatic diseases attending a targeted pregnancy and rheumatic diseases clinic. We conducted a retrospective review using data collected via chart review of female patients with rheumatic diseases seen at the Pregnancy and Rheumatic Diseases Clinic at the Mary Pack Arthritis Centre in Vancouver, Canada, between January 2017 and July 2020. Patients were categorized according to an initial presentation at the clinic as (1) pregnant without pre-pregnancy planning; and (2) not pregnant with pre-pregnancy planning. The latter group was further categorized according to whether they had contraindications to pregnancy. Pregnancy outcomes were extracted from electronic medical records and analyzed using descriptive statistics. Our study included 230 female patients with rheumatic diseases. At the initial clinical presentation, 86 were pregnant and 144 were planning to become pregnant and presenting for pre-pregnancy planning. Compared to patients without pre-pregnancy planning, patients who received pregnancy planning experienced fewer prenatal disease flares (61.3% [38/62] vs. 22.6% [7/31]; p < 0.001), fewer medication changes during pregnancy (46.4% [39/84] vs. 18.9% [10/53]; p = 0.002), and improved disease control in the first trimester of pregnancy (p = 0.018). There were no statistically significant differences in the frequency of adverse pregnancy or fetal outcomes between patients with and without pre-pregnancy planning. Evaluation of patient outcomes suggests that pre-pregnancy planning may support early assessment of high-risk pregnancy status; therein, allowing healthcare providers to identify and manage risk factors for adverse pregnancy outcomes among patients living with rheumatic diseases.

Association between disease activity of rheumatoid arthritis and maternal and fetal outcomes in pregnant women: a systematic review and meta-analysis

BACKGROUND

A meta-analysis has compared the pregnancy outcomes between women with and without RA, while the effect of disease severity on pregnancy outcomes within women with RA has not been explored. Therefore, we performed a systematic review and meta-analysis to assess the association between disease activity of RA and pregnancy outcomes.

METHODS

Four English databases (Pubmed, Embase, Cochrane Library, and Web of Science) and three Chinese databases (China National Knowledge Infrastructure [CNKI], VIP, and Wan Fang) was searched for eligible studies up to August 13, 2023. Cochran's Q test and the I2 statistic were used to assess the heterogeneity of the included studies. The odds ratio (OR) (for counting data) and weighted mean difference (WMD) (for measurement data) were calculated with 95% confidence intervals (95%CIs) using random-effect model (I2 ≥ 50%) or fixed-effect model (I2 < 50%). Subgroup analysis based on study design and regions was used to explore the sources of heterogeneity. Sensitivity analysis was performed for all outcomes and the publication bias was assessed using Begg's test.

RESULTS

A total of 41 eligible articles were finally included. RA women had higher odds to suffer from preeclampsia, gestational diabetes, spontaneous abortion, and cesarean delivery (all P < 0.05). The infants born from RA mother showed the higher risk of stillbirth, SGA, LBW, congenital abnormalities, diabetes type 1, and asthma (all P < 0.05). The high disease activity of RA was significantly associated with the higher risk of cesarean delivery (OR: 2.29, 95%CI: 1.02-5.15) and premature delivery (OR: 5.61, 95%CI: 2.20-14.30).

CONCLUSIONS

High disease activity of RA was associated with the high risk of adverse pregnancy outcomes, suggesting that it was important to control disease for RA women with high disease activity who prepared for pregnancy.

Pregnancy Outcumes and Contraceptive Use in Women with Rheumatoid Arthritis: A Comparative Study

Background. Rheumatoid arthritis (RA) is a common chronic autoimmune disorder that has a female predominance and commonly affects women of childbearing age. It is shown to remit during pregnancy in most studies and improve in about half of the patients when assessed with objective disease activity measures.

Objective — to assess the pregnancy outcomes in women with RA prior and after the diagnosis and compare them with those in women with no chronic illness, to evaluate contraceptive practices and contraceptive method efficacy with the use of concomitant rheumatic medications (methotrexate, leflunomide).

Patients and Methods. Female patients diagnosed with RA according to ACR/EULAR 2010 classification criteria were compared with apparently healthy female controls matching in age in this case-control study. Data were collected by questionnaires and interviews. The questionnaires included demographic data and pregnancy outcomes, mode of delivery, contraceptive methods used by patients against the background of methotrexate and leflunomide therapy.

Results and discussion. One hundred patients with RA were included. The mean age of the patients and controls was 38.4±5.1 and 36.7±4.5 years, respectively. The live births significantly decreased in female patients with RA compared to the controls and the period before the diagnosis (p=0.01, p=0.002, respectively). Caesarean section frequency was higher in the control group compared to patients with RA (p=0.001). But in patients with RA, frequency of caesarean section increased after the diagnosis (p=0.021). Frequency of unplanned pregnancy significantly decreased after the diagnosis of RA compared to the period before the diagnosis (p<0.001). About 75.4% of patients had the desired number of children in their family before the diagnosis, and 24.6% feared the effect of RA on themselves and their children. 81% of 100 women with RA used methotrexate, 43.2% of them received rheumatological consultation regarding the contraceptive methods, and 56.8% did not. 30.86% of patients treated with methotrexate used ineffective contraceptive methods, 27.16% — long-acting reversible methods, 14.81% — effective contraceptive methods, and 24.69% did not use any contraceptive methods. 19% of RA patients used leflunomide, and 73.7% of them received rheumatological consultation regarding the type of contraceptive methods, 36.84% used effective methods of contraception, 31.58% — long-acting reversible methods, 15.79% — ineffective contraceptive methods and 15.79% did not use any contraceptive methods.

Conclusion. There is a decrease in live births and an increase in preterm birth frequency as well as caesarean sections in Iraqi female patients with RA. There is lack of knowledge about the importance of contraceptive methods efficacy in relation to teratogenic medications (methotrexate, and leflunomide).

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.

Combined oral contraceptive use in rheumatoid arthritis for the purpose of pregnancy prevention and additional benefits: A narrative review

Combined oral contraceptives are a common method of contraception and many females prefer them regardless of their medical history. The use in patients with rheumatoid and autoimmune disorders has not been extensively studied with previous reviews focusing on the safety component. This review seeks to address the effectiveness and benefits of utilizing combined oral contraceptives in females with rheumatoid arthritis (RA). Current literature regarding combined oral contraceptives was surveyed for its use in RA and two PubMed searches were conducted, yielding 202 and 142 results, respectively. Results were screened and analyzed for relevance to this review topic. Eighteen results, consisting of clinical trials, observational studies, patient cases, and meta-analyses were used in this narrative review. Historically, it was thought that females with an autoimmune disorder such as RA need to be on contraception due to the teratogenicity potential with disease-modifying therapy but no evidence exists about which type of contraception is the most effective and least interacting. Current evidence available shows no preference for types of contraception in this population, but it has been demonstrated that combination oral contraceptives may provide contraceptive benefits and have a potential for other benefits such as less disability and the prevention of disease progression. Although current evidence provides reasoning to believe combination oral contraceptives are safe and efficacious in patients with RA and may even offer additional benefits, further studies and clinical trials are needed to completely understand the role combination oral contraceptives play in this patient population.

Racial Differences in Contraception Encounters and Dispensing Among Female Medicaid Beneficiaries With Systemic Lupus Erythematosus

OBJECTIVE

African American and Hispanic women with systemic lupus erythematosus (SLE) have the highest rates of potentially avoidable pregnancy complications, yet racial disparities in family planning among reproductive-age women with SLE have not been well-studied. Our objective was to examine whether there are racial differences in contraception encounters and dispensing among US Medicaid-insured women with SLE.

METHODS

Using Medicaid claims data from 2000-2010, we identified women ages 18-50 years with SLE. We examined contraception encounters and uptake over 24 months. We used multivariable logistic regression to estimate the odds ratio and 95% confidence interval by race/ethnicity of contraception encounters, any contraception dispensing, and highly effective contraception (HEC) use, adjusted for age, region, year, SLE severity, and contraindication to estrogen. We also compared contraception encounters and dispensing among women with SLE to the general population and women with diabetes mellitus.

RESULTS

We identified 24,693 reproductive-age women with SLE; 43% were African American, 35% White, 15% Hispanic, 4% Asian, 2% other race, and 1% American Indian/Alaska Native. Nine percent had a contraceptive visit, 10% received any contraception, and 2% received HEC. Compared to White women, African American and Asian women had lower odds of contraception dispensing, and African American women had lower odds of HEC use. Women with SLE were more likely to receive HEC than the general population and women with diabetes mellitus.

CONCLUSION

In this study of reproductive-age women with SLE, African American and Asian women had lower odds of contraception dispensing and African American women had lower odds of HEC use. Further study is needed to understand the factors driving these racial disparities among this population.

Contraceptive Prevalence and Consulting Service in Women with Systemic Lupus Erythematosus: A Cross-Sectional Study

Background

Systemic lupus erythematosus (SLE), often affects women of childbearing age. Family planning consultation is a major aspect of medical care in these patients because of the risk of disease activation and poor pregnancy and fetal outcomes. The aim of the present study was to evaluate contraceptive prevalence and consulting service in women with SLE.

Methods

In a cross-sectional study, a total of 144 female patients with SLE, ages 15–50, who were presented to rheumatology clinics in Sari, north of Iran, were evaluated. The study was conducted between March 2019 and May 2020. Patients' clinico-demographic profile and fertility information were obtained. Disease activity and damage were assessed by the systemic lupus erythematosus disease activity (SLEDAI) and Systemic Lupus International Collaborating Clinics/American College of Rheumatology (SLICC/ACR) Damage Index (SDI).

Results

One hundred and forty-four SLE patients of childbearing age participated in this study. From 102 patients with the possibility of pregnancy, 36(35.2%) received contraceptive consultations in last year. Withdrawal was the most prevalent contraceptive method (41.7%), followed by permanent (11.8%), and barrier methods (9%). There were no significant differences in age, disease duration, marriage duration, SDI or SLEDAI scores between the women who received or not received contraceptive counseling (P>0.05).

Conclusion

Many SLE patients did not receive adequate information about contraception, and it may be associated with many adverse effects on disease activity and pregnancy outcomes. Therefore, contraceptive consultation as an important aspect of patient's management is strongly suggested.

Pregnancy outcome in women with different rheumatic diseases: a retrospective analysis

Objective: Pregnancy may influence the course of inflammatory rheumatic diseases and, conversely, rheumatic and musculoskeletal diseases (RMDs) can affect the outcome of pregnancy. This study aimed to retrospectively analyse the outcome of pregnancy and disease in women with RMDs.Method: Subjects were patients with high-risk pregnancy and connective tissue diseases (CTDs) or inflammatory joint diseases (IJDs) managed at a specialized rheumatology outpatient clinic from 2007 to 2014. Data from conception to 6 months postpartum were collected from medical records and a questionnaire, and analysed regarding clinical symptoms, medications, pregnancy complications, birth outcomes, and infant development. Generalized estimating equations were used to compare the groups (CTD vs IJD).Results: The eligible 66 pregnancies in 57 RMD patients were divided into two groups by RMD type: CTD (n = 48) or IJD (n = 18). The live birth rate was 97% overall. Pregnancy complications (excluding two twin pregnancies) were incurred in 39.1%: miscarriage (n = 2), premature delivery (n = 12), small-for-gestational-age infants (n = 5), and/or pregnancy-related diseases (n = 14). Three children born to women with CTDs had affected development (autism spectrum disorder, congenital heart disease, bronchopulmonary dysplasia). CTD infants had a significantly lower mean gestational age (in weeks) (p = 0.042), weight (p = 0.009), and length (p = 0.016) at birth than IJD infants.Conclusion: Although the live birth rate was high, complications occurred in 39.1% of pregnancies in this cohort. Therefore, interdisciplinary management of pregnant women with RMDs at specialized clinics is strongly recommended.

Risk of adverse pregnancy outcomes in Japanese systemic lupus erythematosus patients with prior severe organ manifestations: A single-center retrospective analysis

BACKGROUND

Systemic lupus erythematosus (SLE) increases the incidence of adverse pregnancy outcomes (APOs). Nevertheless, most of the data on SLE pregnancies were derived from database studies in which details of the pregnancies were unavailable, and no consensus exists on the risk of APO in patients with prior severe organ manifestations.

METHODS

SLE patients followed by rheumatologists and gynecologists throughout pregnancy at our institute were retrospectively identified, and their data between April 2003 and December 2020 were reviewed from electronic records. We assigned patients based on the presence of prior severe organ manifestation (renal/neurological manifestation, prior treatment with methylprednisolone pulse therapy/prednisolone 1 mg/kg/day/biological or cytotoxic therapy) and compared the incidence of overall and serious APO (maternal death, pregnancy loss, preterm birth <32 weeks, birthweight <1500 g, Apgar score <7 at 5 min and birth defect).

RESULTS

This study included 34 pregnancies in 32 patients; 23 pregnancies in 22 patients were classified as SLE with prior severe organ manifestation. There was no statistical difference in the incidence of overall APO between the two groups (52.2% vs 45.5%, P = 1). Among patients with prior severe organ manifestation, 17.4% had serious APO. A detailed electronic health record search revealed specific causes of APO in all pregnancies with serious APO, except the presence of prior severe organ manifestation.

CONCLUSION

The incidence of overall APO in SLE patients was not affected by prior severe organ manifestation. Although the incidence of serious APOs increased in patients with previous severe organ manifestation, there were other risk factors for poor pregnancy outcomes besides prior lupus severity. Therefore, proper management by rheumatologists and gynecologists may enable patients with prior severe organ manifestation to safely deliver healthy babies.

A questionnaire-based study on contraceptive practice in patients with rheumatic disease found no significant difference in age-matched healthy controls

OBJECTIVE

Birth control is crucial in preventing unplanned pregnancy. The study analyzed contraceptive practice in women and men with rheumatic disease.

METHODS

A questionnaire-based study investigated the actual contraceptive practices in patients of reproductive age from three European countries and compared them to age-matched healthy women and men. Associations between patient characteristics and contraception behavior were analyzed by association analysis.

RESULTS

No significant difference in the frequency of contraception use was found in 133 rheumatic patients compared to 122 healthy controls. The main reason for not using contraception was lack of partner or the wish to become pregnant, whereas the current use of contraception was predominantly to limit family size in general or at this stage of life. Both patients and controls preferred barrier methods (48% and 45%, respectively) followed by hormonal contraceptives (31% and 38%, respectively). Characteristics associated with less use of contraception in patients were living single, having no children, and for being religious, whereas gender and education had no influence. Treatment with teratogenic drugs was no major patient concern, and 13 of 30 female patients using methotrexate, mycophenolate mofetil, or leflunomide did not practice birth control.

CONCLUSION

Patients used contraception less frequently than healthy individuals, and the main reason for use was to limit family size. Contraception should be an integral part of counseling patients of fertile age, since the patient-preferred methods in case of active disease or therapy with teratogenic drugs were unreliable for the prevention of pregnancy.

Contraception in chronic kidney disease: a best practice position statement by the Kidney and Pregnancy Group of the Italian Society of Nephrology

Even though fertility is reduced, conception and delivery are possible in all stages of CKD. While successful planned pregnancies are increasing, an unwanted pregnancy may have long-lasting deleterious effects, hence the importance of birth control, an issue often disregarded in clinical practice. The evidence summarized in this position statement is mainly derived from the overall population, or other patient categories, in the lack of guidelines specifically addressed to CKD. Oestroprogestagents can be used in early, non-proteinuric CKD, excluding SLE and immunologic disorders, at high risk of thromboembolism and hypertension. Conversely, progestin only is generally safe and its main side effect is intramestrual spotting. Non-medicated intrauterine devices are a good alternative; their use needs to be carefully evaluated in patients at a high risk of pelvic infection, even though the degree of risk remains controversial. Barrier methods, relatively efficacious when correctly used, have few risks, and condoms are the only contraceptives that protect against sexually transmitted diseases. Surgical sterilization is rarely used also because of the risks surgery involves; it is not definitely contraindicated, and may be considered in selected cases. Emergency contraception with high-dose progestins or intrauterine devices is not contraindicated but should be avoided whenever possible, even if far preferable to abortion. Surgical abortion is invasive, but experience with medical abortion in CKD is still limited, especially in the late stages of the disease. In summary, personalized contraception is feasible, safe and should be offered to all CKD women of childbearing age who do not want to get pregnant.

Risk of gestational diabetes mellitus in systemic lupus erythematosus pregnancy: a systematic review and meta-analysis

Background

It is well established that the risks of insulin resistance and diabetes mellitus are elevated in systemic lupus erythematosus (SLE) patients. However, the relationship between SLE pregnancy and gestational diabetes mellitus (GDM) is still obscure. We perform the present systematic review and meta-analysis to determine the relationship between GDM and SLE pregnancy.

Methods

According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, relevant studies were carefully retrieved through PubMed, Cochrane library and Web of Science, China National Knowledge Infrastructure, Wanfang database and China Biology Medicine database from inception till 30 August 2018. GDM risk ratio (RR) of pregnant SLE patients versus controls was calculated to evaluate the association between GDM and SLE. Pooled RRs and 95% confidence intervals (CIs) were calculated using random effects model by R software.

Results

The literature retrieval identified 339 potential studies in total, and five studies containing 3432 pregnant participants with 248 GDM events were included finally. Pooled analysis found that the risk of GDM were not significant increased in SLE patients compared to controls (RR = 1.08, 95% CI = 0.49 to 2.41, Z = 0.19 and P = 0.848). Nevertheless, meta-regression identified that glucocorticoids use and anti-double stranded DNA antibodies positive of SLE patients were positively associated with the risk of GDM.

Conclusions

Our meta-analysis demonstrated that SLE pregnancy may not increase the risk of GDM, but the steroid use during pregnancy was associated with increased risk of GDM. Further large prospective and basic immunologic studies should be implemented for exploring the mechanism underlying glucocorticoids use and GDM.

Electronic supplementary material

The online version of this article (10.1186/s12884-019-2329-0) contains supplementary material, which is available to authorized users.

Contraception in autoimmune diseases

Autoimmune diseases (AIDs) affect women and men with a 2:1 ratio, which suggests that hormonal contraceptives play a role in their clinical course. Combined oral contraceptives have complex, sometimes contradictory, effects on AIDs; they can worsen the situation in women with systemic lupus erythematosus and with anti-phospholipid syndrome, conditions in which they are contraindicated. Early studies indicated a positive effect on rheumatoid arthritis (RA), whereas more recent trials failed to do so, possibly because of the lowering of oestrogen content. Evidence of effects on multiple sclerosis (MS) is conflicting: risk may vary depending on the progestin used. Minor adverse effects may exist on inflammatory bowel diseases, and no significant effect was found on autoimmune thyroid diseases. Women can become sensitised to sex hormones. Progestin-only contraceptives may be used, although copper-releasing intra-uterine devices represent the best option. Finally, several organisations have issued guidelines for contraceptive use in women with AIDs.