The Influence of Treatment of Inflammatory Arthritis During Pregnancy on the Long-Term Children's Outcome

Axial spondyloarthritis and breastfeeding: a prospective study

BACKGROUND

There is sparse literature on the topic of breastfeeding in women with axial spondyloarthritis (axSpA). Our aim was to obtain more knowledge about variables affecting breastfeeding for women with axSpA.

METHODS

This prospective study used data from the nationwide quality register RevNatus, which collects pregnancy-related data in women with inflammatory rheumatic diseases from Norwegian outpatient clinics in rheumatology. Data were collected during January 2016 to August 2023, reporting on 436 pregnancies in 363 patients with axSpA. The study eventually included 417 births in 350 women. Breastfeeding and non-breastfeeding women were compared at six weeks, six and twelve months postpartum. We compared the groups regarding demographic and obstetric data, neonatal outcome, disease characteristics, medical treatment and self-reported data on pain, fatigue and disease burden. Information on breastfeeding was registered at least once during the follow-up postpartum. Disease activity was measured by Ankylosing Spondyloarthritis Disease Activity Index-CRP (ASDAS-CRP) and Bath Ankylosing Disease Activity Index (BASDAI).

RESULTS

The proportion of patients breastfeeding at the postpartum follow ups was 86% (347 women) at six weeks, 70% (221 women) at six months, and 38% (104 women) at twelve months, respectively. A larger proportion of the non-breastfeeding group had delivered with caesarean section (C-section), 24 of 59 (41%) non-breastfeeding vs 70 of 347 (20%) breastfeeding women. ASDAS-CRP was higher for the non-breastfeeding group at six weeks (2.6 vs 2.2) and at six months (2.6 vs 2.1), and BASDAI was higher for the same group at six months (4.1 vs 3.2). CRP (mg/L) was significantly higher among the non-breastfeeding at six months (5.3 vs 3.3). VAS pain scores were higher for the non-breastfeeding group at six weeks (41.0 vs 31.6) and six months (43.9 vs 31.0). VAS fatigue was higher for the same group at six months (46.8 vs 37.8).

CONCLUSION

Our results suggest that particular attention should be given regarding breastfeeding to women with active inflammatory disease and those who have undergone C-section.

Pre-Pregnancy Counselling for Women with Rheumatoid Arthritis: A Guide on Risks, Evaluations, and Multidisciplinary Approaches

This paper explores the essential role of pre-pregnancy counselling for women with rheumatoid arthritis (RA), focusing on minimising risks and optimising pregnancy outcomes. RA, a prevalent inflammatory arthritis with onset during childbearing years, necessitates targeted preconception counselling to manage disease activity and comorbidities effectively. The counselling ensures medication compatibility and planning around disease flares, and it involves a multidisciplinary team comprising rheumatologists, obstetricians, and other specialists to develop individualised care plans. This literature review highlights the challenges women with RA face, including prolonged time to pregnancy, increased risks during pregnancy, such as hypertension and preeclampsia, and potential fertility issues related to medication and disease activity. Emphasis is placed on the importance of assessing autoantibody presence and managing specific joint involvements that may affect anaesthetic procedures during pregnancy. This paper underscores the importance of timing conception during periods of low disease activity and adopting a "Treat-to-Target" approach using acceptable medications to maintain disease remission. This study calls for routine family planning discussions and preconception evaluations to address reproductive health and treatment plans, thereby supporting women with RA in achieving favourable pregnancy outcomes comparable to the general population. The multidisciplinary approach and regular counselling are critical to navigating the complexities of RA and pregnancy successfully.

Association between maternal multimorbidity and neurodevelopment of offspring: a prospective birth cohort study from the Japan Environment and Children's Study

OBJECTIVES

To investigate the association between multimorbidity during pregnancy and neurodevelopmental delay in offspring using data from a Japanese nationwide birth cohort study.

DESIGN

This study was a prospective birth cohort study.

SETTING

This study population included 104 059 fetal records who participated in The Japan Environment and Children's Study from 2011 to 2014.

PARTICIPANTS

Pregnant women whose children had undergone developmental testing were included in this analysis.

PRIMARY AND SECONDARY OUTCOME MEASURES

Neurodevelopment of offspring was assessed using the Japanese version of the Ages and Stages Questionnaire, third edition, comprising five developmental domains. The number of comorbidities among the pregnant women was categorised as zero, single disease or multimorbidity (two or more diseases). Maternal chronic conditions included in multimorbidity were defined as conditions with high prevalence among women of reproductive age. A multivariate logistic regression analysis was conducted to examine the association between multimorbidity in pregnant women and offspring development.

RESULTS

Pregnant women with multimorbidity, single disease and no disease accounted for 3.6%, 30.6% and 65.8%, respectively. The ORs for neurodevelopmental impairment during the follow-up period were similar for infants of mothers with no disease comorbidity and those with a single disease comorbidity. However, the ORs for neurodevelopmental impairment were significantly higher for children born to mothers with multimorbidity compared with those born to healthy mothers.

CONCLUSION

An association was observed between the number of comorbidities in pregnant women and developmental delay in offspring. Multimorbidity in pregnant women may be associated with neurodevelopmental delay in their offspring. Further research is required in this regard in many other regions of the world.

The outcomes of children born to mothers with autoimmune rheumatic diseases

Maternal autoimmune rheumatic diseases can influence the outcomes of children through several life stages. During pregnancy, maternal inflammation and autoantibodies can hinder fetal development and lead to growth restriction, preterm birth, and low birth weight; prematurity, especially at extreme gestational ages, can in turn impair future child health. Treatment with compatible immunomodulatory drugs and preventive medications aims to keep maternal disease under control and minimise the risk of adverse pregnancy outcomes. However, concerns have been raised about the effects of immunomodulatory drugs on neonatal conditions (ie, the risk of serious infections, inadequate responses to vaccinations, and organ toxicity) and long-term outcomes (metabolic and cardiovascular problems and neurodevelopmental disorders). Among the unmet needs of parents with autoimmune rheumatic diseases, there is the estimation of risk for the children to develop autoimmune disorders and the need for reassurance about parenting capacity while living with a chronic condition. This Series paper provides a comprehensive overview of the literature and guidance on discussing these topics with patients.

The time of equipoise on the use of biological DMARDs in for inflammatory arthritis during pregnancy is finally over: a reappraisal of evidence to optimise pregnancy management

Active inflammatory arthritis in pregnancy is associated with an increased risk of adverse pregnancy outcomes. Treatment of active inflammation and maintenance of low disease activity with medication reduces these risks. Therapeutic decisions on disease-modifying antirheumatic drugs (DMARDs) in pregnancy are complicated by safety concerns, which have led to inappropriate withdrawal of treatment and consequential harm to mother and fetus. Studies of inflammatory arthritis in pregnancy have consistently shown minimal safety concerns with the use of biological DMARDs and an increased risk of disease flare with discontinuation of biological DMARDs. It is our opinion that during pregnancy, the benefits of disease control with biological DMARDs, when required in addition to conventional synthetic DMARDs, outweigh the risks. In this Series paper, we review the reasons for reconsideration of equipoise and propose an agenda for future research to optimise the use of biological DMARDs in inflammatory arthritis during pregnancy.

Neurodevelopmental profile in children born to mothers affected by systemic sclerosis

BACKGROUND

Systemic sclerosis (SSc) is a chronic immune-mediated connective tissue disease that can affect women of childbearing age. The long-term outcomes of their offspring remain poorly explored. Aim of this study was to detail the neurodevelopmental profile of children born to SSc mothers.

METHODS

Twenty children (mean age: 96 ± 4.32 months; 10 males) born to SSc mothers were enrolled. We collected data on clinical history, neurological examination, cognitive profile and adaptive behavior in all subjects. According to the chronological age, we also investigated quality of life, behavioral characteristics, psychological functioning and self-image.

RESULTS

All the children had normal neurological examination, cognitive profile and adaptive functioning, except for one (5 %) who suffered from Autism Spectrum Disorder. An important discrepancy was observed between parental and child opinion regarding the perception of quality of life, more compromised in the latter. We documented a risk for internalizing behavioral problems in 2 cases (10 %), for externalizing problems in 3 (15 %), for both in 1 (5 %) and for social and out-of-school activities in 5 (25 %). As regards psychological functioning, evaluated in 11 children, three (28 %) were at risk for anxiety, 1 (9 %) for depressive disorders and other 4 (36 %) for somatic disturbances. Emotional fragility and poor competence in metabolizing one's emotional experiences were observed in 9 out of the 13 subjects assessed (70 %).

CONCLUSIONS

Children born to SSc women exhibit normal cognitive and adaptive abilities but an increased vulnerability to psychopathological problems and fragility in social functioning. These observations might reflect that children need to feel mature to accept maternal chronic disease that, in turn, may hinder support for offspring's social and emotional development.

Comprehensive reproductive healthcare for women with immune-mediated inflammatory diseases: Addressing rheumatoid arthritis, spondyloarthritis and inflammatory bowel disease through life's stages

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.

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.

The mosaic of autoimmunity - Finally discussing in person. The 13th international congress on autoimmunity 2022 (AUTO13) Athens

While autoimmunity is a branch of medicine linked to every single organ system via direct and indirect pathways, meeting in person to discuss autoimmunity during the 13^th international congress on autoimmunity (AUTO13) with participants from all over the world had a very good reason. The mechanisms involved in autoimmune diseases are of extreme importance and in fact critical in understanding the course of diseases as well as selecting proper therapies. COVID-19 has served as a great example of how autoimmunity is deeply involved in the disease and directly correlated to severity, morbidity, and mortality. For instance, initially the term cytokine storm dominated, then COVID-19 was addressed as the new member of the hyperferritinemic syndrome, and also the use of immunosuppressants in patients with COVID-19 throughout the pandemic, all shed light on the fundamental role of autoimmunity. Unsurprisingly, SARS-CoV-2 was called the “autoimmune virus” during AUTO13. Subsequently, the correlation between autoimmunity and COVID-19 vaccines and post-COVID, all were discussed from different autoimmune aspects during the congress. In addition, updates on the mechanisms of diseases, autoantibodies, novel diagnostics and therapies in regard to autoimmune diseases such as antiphospholipid syndrome, systemic lupus erythematosus, systemic sclerosis and others, were discussed in dedicated sessions. Due to the magnificence of the topics discussed, we aimed to bring in our article hereby, the pearls of AUTO13 in terms of updates, new aspects of autoimmunity, and interesting findings. While more than 500 abstract were presented, concluding all the topics was not in reach, hence major findings were summarized.

Active counselling and well-controlled disease result in a higher percentage of women with rheumatoid arthritis that breast feed: results from the PreCARA study

OBJECTIVES

Previous research has demonstrated that patients with rheumatoid arthritis (RA) are less likely to breast feed their offspring. Treatment options for RA during lactation have expanded and the importance of counselling is recognised. The aim of the current research was to study breast feeding among women with RA who benefit from these developments.

METHODS

Patients were derived from the Preconceptional Counselling in Active Rheumatoid Arthritis (PreCARA) cohort. Patients were treated according to a modified treat-to-target approach aimed at remission and received pregnancy counselling, including counselling on breast feeding. Postpartum visits were scheduled at 4-6, 12 and 26 weeks post partum. Prevalence of breast feeding at each postpartum visit was compared with a historical reference cohort (Pregnancy-induced Amelioration of Rheumatoid Arthritis cohort) and the general population.

RESULTS

Data on 171 pregnancies were available for the current analysis. 120 (70.2%) patients with RA initiated breast feeding. 103/171 (60.2%), 68/171 (39.8%) and 45/171 (26.3%) patients with RA breast fed their offspring at 4-6, 12 and 26 weeks post partum, respectively. These percentages were higher at all postpartum visits compared with the historical reference cohort (p<0.001). In comparison with the general population, the rates were similar at each time point.

CONCLUSION

Patients with RA in the PreCARA cohort were more likely to breast feed their offspring compared with patients with RA in the historical reference cohort. The breastfeeding rates observed were similar to breastfeeding rates among women in the general population. The increase in breast feeding among patients with RA may be due to the extension of lactation-compatible medication and pregnancy counselling.