OP0125 THE MANAGEMENT OF PREGNANCY IN AUTOIMMUNE RHEUMATIC DISEASES: ANALYSIS OF 758 PREGNANCIES FROM THE PROSPECTIVE NATIONWIDE P-RHEUM.IT STUDY (THE ITALIAN REGISTRY OF PREGNANCY IN THE RHEUMATIC DISEASES)

Background

Pregnancy is a topic of fundamental importance for women living with autoimmune rheumatic diseases (ARD). Efforts at national and international levels have been put in the collection and harmonization of data in order to implement an evidence-based management of pregnant patients.

Objectives

The P-RHEUM.it study was designed as a nationwide, web-based longitudinal observational cohort study to collect data about pregnancy in ARD in 26 centers in Italy. The study started in May 2018 and has been supported by the Italian Society for Rheumatology.

Methods

Pregnant patients with a definite rheumatic disease according international criteria were enrolled up to gestational week (GW) 20. The course of maternal disease activity, the use of medications, fetal and maternal complications, and the quality of life (EuroQoL questionnaire) were collected for each trimester, as well as pregnancy outcome, mode of delivery, neonatal complications, and maternal and children’s follow-up to 6 months after delivery, including the screening for post-partum depression by means of EPDS (Edinburgh Postnatal Depression Scale).

Results

As of December 2021, 758 pregnancies had been enrolled, 205 (27%) ongoing and 553 (73%) with outcome. Pregnancy loss occurred in 54 (9.8%) cases (40 spontaneous miscarriages; 6 voluntary terminations). Live births were 495 (89.5%), perinatal death occurred in 4 (0.7%) cases. Table 1 reports on the group of 495 live births, along with subgroups of Rheumatoid Arthritis (RA) and Systemic Lupus Erythematosus (SLE), the two most represented diseases. Regarding treatments, 166 (30%) pregnancies were exposed to corticosteroids, 239 (43%) to hydroxychloroquine, 59 (10.7%) to csDMARDs, 84 (15.2%) to TNF inhibitors, 1 (0.2%) to non-TNFi bDMARDs, 299 (54%) to low dose acetylsalicylic acid, and 126 (22.8%) to heparin.

Table 1.PREGNANCIES WITH LIVE BIRTHS, EXCLUDING PERINATAL DEATHSTotal pregnancies (n=495)RA pregnancies (n=69)SLE pregnancies (n=93)Age at conception (years)34 (31 - 37)34.5 (32 - 38)34 (31 - 36)Disease duration (years)6.1 (2.2 - 11.1)7.1 (4.3 - 11.6)9.3 (5.9 - 15.9)Caucasian431 (87.8%)53 (79.1%)75 (80.6%)Never smokers358 (73.8%)53 (80.3%)66 (71.7%)Body Mass Index >3045 (9.5%)7 (10.3%)5 (5.6%)Arterial Hypertension6 (1.2%)0 (0%)2 (2.2%)Time to pregnancy (months)3 (1 - 6)3 (1 - 6)3 (0 - 10)Physician-reported flares in the 12 months prior to conception107 (23%)22 (34.4%)13 (14.8%)Physician global assessment at enrolment (VAS 0-100)5 (0 - 17)5 (0 - 20)4 (0 - 10)Patient global health at enrolment (VAS 0-100)18 (7 - 30)10 (5 - 29)10 (5 - 25)EuroQoL at enrolment (-1.6 – 1)1 (0.8 - 1)1 (0.8 - 1)1 (0.8 - 1)Flares during pregnancy35 (7.1%)6 (8.7%)7 (7.5%)Hypertensive disturbances*8 (1.7%)1 (1.6%)6 (6.6%)Delivery at term (≥37 GW)410 (85.1%)53 (77.9%)74 (80.4%)Spontaneous vaginal delivery173 (35.9%)23 (33.8%)23 (25.3%)Congenital malformations11 (2.4%)2 (3.1%)1 (1.1%)Small for gestational age (SGA) neonate24 (4.9%)1 (1.4%)9 (9.9%)Breastfeeding in the first 4 weeks after delivery341 (79.7%)45 (77.6%)59 (76.6%)EPDS score at risk for post-partum depression22 (14.1%)0 (0%)3 (10.3%)

Continuous variables are expressed as median (interquartile range); *gestational hypertension/preeclampsia/HELLP syndrome/eclampsia.

Conclusion

Multiple factors may have contributed to the high rate of live births, including good disease control before and during pregnancy thanks to the use of anti-rheumatic drugs and low frequency of general risk factors. SLE pregnancy was affected by a higher frequency of complications (hypertensive disturbances, SGA babies) as compared to RA pregnancy. Nearly 80% of patients breastfed in the first month after delivery. For the first time, data about the screening questionnaire for post-partum depression were collected, showing at least 1 out 10 patients can be at risk.

References

[1]Meissner Y et al. Arthritis Res Ther;21(1):241; Ann Rheum Dis. 2021;80(1):49-56.

Acknowledgements

P-RHEUM.it study is supported by the Italian Society for Rheumatology (SIR). All the Investigators are acknowledged for their contribution.

Disclosure of Interests

None declared

POS0476 CAN LOW-DOSE ASPIRIN DURING PREGNANCY PREVENT THE DEVELOPMENT OF ADVERSE PREGNANCY OUTCOMES IN WOMEN WITH ARTHRITIS? DATA FROM THE P-RHEUM.it STUDY

Background:

In rheumatic diseases, specifically in chronic inflammatory arthritis (IA), there are no data about the effectiveness of LDA in preventing pregnancy complications.

Objectives:

To assess the potential benefit of LDA administration during pregnancy to prevent adverse pregnancy outcomes (APO) in IA.

To compare pregnancy outcomes in IA pregnancies treated during pregnancy with LDA with those untreated.

Methods:

Italian P-RHEUM.it register is designed as a nationwide, web-based longitudinal observational cohort study collecting data on pregnancies in inflammatory rheumatic diseases. At baseline, socio-demographic parameters, obstetric history, comorbidities and clinical/laboratoristic characteristics are registered. During pregnancy, the course of maternal disease, medications, development of fetus and complications are collected for each trimester.

Results:

From May 2018 to May 2020, 349 patients were enrolled. Forty-five patients with IA had completed their pregnancy with known outcome (20 Rheumatoid Arthritis, 10 Psoriatic Arthritis, 6 Ankylosing spondylitis, 5 Juvenile Idiopathic Arthritis, 4 Undifferentiated Arthritis): 13 (28.89%) treated with LDA during pregnancy and 32 (71.11%) without LDA prophylaxis. LDA was used with a higher frequency in women with previous APO, anti-phospholipid positivity and on biological DMARDs even if it’s not statistically significant (Table 1). All the LDA-treated women had a live-birth rate of 100%, whereas among women not treated with LDA the live birth rate was of 84.4% with 27 live-birth pregnancies, 3 early miscarriages, 1 fetal loss and 1 stillbirth observed. There were no significant differences between the LDA and the not LDA groups regarding pregnancy/peripartum obstetric complications (p=0.14), although less adverse pregnancy/peripartum outcomes were registered in LDA patients’ group (Table 1).

Conclusion:

The preliminary data of this prospective cohort study show that LDA improve pregnancy outcome in IA even if women treated with LDA had more risk factors for APO. The extension of this cohort will allow us to further investigate these important results.

References:

[1]Roberge S, et al. AmJObstetGynecol.2017;216:110-120.e6.

[2]Andreoli L et al. Annals of the Rheumatic Diseases 2017;76: 476–85.

[3]Sammaritano L et al. Arthritis & Rheumatology 2020; 72: 529–56.

Table 1.

Comparison between inflammatory arthritis pregnancies treated with low-dose aspirin and those untreated.

LDA (n 19)Not LDA (n 39)pMaternal age at conception, median (IQR)33 (30.5 - 36.5)33 (28.2 - 35)BMI, median (IQR)25.4 (22.9 - 28.5)22.5 (20.4 - 24.5)Smoking, n (%)3 (15.8%)4/36 (11.1%)0.68Previous APO, n (%)7/11 (63.7%)7/13 (56.1%)0.34aPL+, n (%)3 (15.8%)1/36 (2.8%)0.1CRP+, n (%)5/15 (33.3%)11/27 (40.7%)0.75GC at baseline, n (%)9 (47.4%)15/34 (44.1%)0.82cDMARDs at baseline, n (%)1 (5.3%)3/34 (8.8%)1bDMARDs at baseline, n (%)6 (31.6%)11 (28.2%)0.79Live-birth pregnancy, n (%)18 (94.7%)32 (82.1%)0.25Pregnancy loss, n (%)1 (5.3%)7 (17,9%)0.25Hypertensive disorders, n (%)2/18 (11.1%)6/38 (15,8%)1HELLP syndrome, n (%)0 (0%)0 (0%)1PROM, n (%)0 (0%)3/38 (7.9%)0.54Preterm delivery, 34-37 GW, n (%)2 (10.5%)2 (5.2%)0.59Preterm delivery, <34 GW, n (%)1 (5.3%)1 (2.6%)1IUGR, n (%)0 (0%)3 (7.8%)0.54SGA, n (%)0 (0%)0 (0%)1Pregnancy/Peripartum complications, n (%)3 (15.8%)11 (28.9%)0.35

Legend: aPL, Antiphospholipid syndrome; bDMARDs, biological disease-modifying antirheumatic drugs; BMI, Body mass index; cDMARDs, Conventional disease-modifying antirheumatic drugs; CRP, C-reactive protein; GC, Glucocorticoids; GW, gestational week; HELLP, haemolysis, elevated liver enzymes, and low platelets; Hypertensive disorder defined as gestational hypertension, preeclampsia and eclampsia; IQR, Interquartile range; IUGR, intrauterine growth restriction; LDA, Low-dose Aspirin; Pregnancy loss defined as early fetal-loss, miscarriage and still-birth; PROM, Premature rupture of membranes; SGA, Small for gestational age.

Acknowledgements:

I would like to acknowledge the Epidemiology Unit of the Italian Society for Rheumatology and the Investigators of the Italian Registry.

Disclosure of Interests:

None declared

POS0760 MONITORING C3 AND C4 VARIATIONS IN SYSTEMIC LUPUS ERYTHEMATOSUS PREGNANCIES IS USEFUL TO RECOGNIZE COMPLICATIONS. DATA FROM 2 ITALIAN CENTERS

Background:

In SLE pregnancies adverse pregnancy outcomes (APO) are more frequent than in general obstetric population (GOP). In clinical practice, low C3 and C4 levels are associated with active disease and, during pregnancy, complement activation products are shown to be associated with APO.

Objectives:

To analyse complement variations during SLE pregnancies, focusing on disease flares and APO.

Methods:

Data on SLE pregnancies prospectively-followed by multidisciplinary team in 2 Italian Centers from 1987 to 2018 were retrospectively analysed. C3 and C4 normal levels were calculated in general obstetric population (GOP) as previously described1, and related to maternal and fetal outcome. Non categorical variables were compared using Mann-Whitney test or Wilcoxon test when appropriate.

Results:

Two hundred forty-six pregnancies in 172 SLE patients were analysed (mean age at conception 31.3 ±4.9 years; mean disease duration 8.3 ±7.1). Anti-Ro antibodies were positive in 64 patients (37%) and anti-phospholipid antibodies (aPL) were positive in 84 (48%), with single positivity in 54%, double in 24% and triple in 21%; 9 patients (5%) had also a diagnosis of obstetric-antiphospholipid syndrome (APS) and 8 (4%) had thrombotic-APS. Seventy-one patients (41%) had history of Lupus Nephritis.

Thirty-five flares were recorded in 30 pregnancies (12%). APO occurred in 47 pregnancies (19%) and were: 27 fetal loss (20 early miscarriage <10th week and 7 intrauterine fetal death), 11 severe preterm birth (<34th week) and 15 hypertensive disorder (11 pre-eclampsia and 5 pre-eclampsia+HELLP syndrome).

In GOP, C3 progressively increased throughout pregnancy and C4 increase from the 1st trimester to the 2nd trimester, as well as in SLE pregnancies without flares and without APO, from preconception (Fig 1). In the other SLE groups, C3 and C4 showed a different trend: in pregnancies with flares, they did not increase from preconception to the 1st trimester; in fetal losses and severe pre-term births, they remained stable throughout pregnancy; in hypertensive disorders they increased only between preconception and the 1st trimester.

C3 and C4 levels were higher in GOP than in all SLE pregnancies groups (including those without flares and without APO) in each trimester. SLE pregnancies without flares showed higher C3 and C4 levels than pregnancies with flares, at preconception and in each trimester. SLE pregnancies without APO had higher C3 and C4 levels than pregnancies with fetal death at 2nd trimester, higher C3 levels than severe pre-term births in each trimester and higher C4 at 3rd trimester (Fig.1).

At preconception, pregnancies with flares showed a higher frequency of low C3 and of low C4 than in pregnancies without flares (76% vs 42%, p=0.01; 76% vs 26%, p<0.001, respectively). Using the normality range previously calculated in GOP, SLE pregnancies with flares had higher frequency of low C4 in every trimester as compared with pregnancies without flares (1st: 82% vs 48%, p=0.003; 2nd: 82% vs 64%, p=0.01; 3rd: 64% vs 30%, p=0.002). At multivariate analysis, low C4 at preconception was associated with flare (OR [95% CI]: 10.34 [2.52-42.39]; p=0.001).

Figure 1.

Variations of C3 and C4 median levels (mg/dL) throughout pregnancy in GOP1 and in SLE pregnancies without and with flare (a) and without and with APO (b).

* p <0.05

^as compared with SLE groups: p<0.05; § as compared with SLE pregnancies without flare: p<0.05; + as compared with SLE pregnancies without APO: p<0.05

Conclusion:

In SLE pregnancies, monitoring of C3 and C4 is important: its failure to increase can be useful to recognize potential risk situations which deserve particular monitoring.

References:

[1]Reggia R. et al. Rheumatology 2012;51:2186-2190.

Disclosure of Interests:

None declared

AB0822 BREASTFEEDING AMONG WOMEN WITH RHEUMATIC DISEASES: ANALYSIS OF DATA FROM THE P-RHEUM.IT STUDY

Background:

The World Health Organization recommends that infants should be exclusively breastfed until the age of 6 months. The aim of this study was to assess the ratio of breastfeeding patients with Rheumatic Diseases (RD) and to identify possible causes of its discontinuation.

Objectives:

The aim of this study was to assess the ratio of breastfeeding patients with Rheumatic Diseases (RD) and to identify possible causes of its discontinuation.

Methods:

This study was embedded in the P-RHEUM.it register, as a nationwide prospective cohort study collecting data of pregnancies in inflammatory RD. Pregnancies, enrolled until the 20th week of pregnancy, are followed from pregnancy until 6 months postpartum. At baseline, sociodemographic parameters, obstetric history, comorbidities are reported. During pregnancy, the course of maternal disease, development of foetus and complications are reported. After delivery, the pregnancy outcome, data on lactation and child development are collected.

Results:

From May 2018 to May 2020 data of 349 patients were available. Data on lactation were available in 44 pregnancies. Two months after delivery 37 were continuing breastfeeding (n=26) or mixed feeding (n=11), while 7 were using formula feeding. Among patients using formula feeding 2 had a diagnosis of rheumatoid arthritis (RA), 1 of juvenile idiopathic arthritis, 1 of undifferentiated arthritis (UA), 1 of anti-phospholipid syndrome (APS), 1 of vasculitis and 1 of systemic lupus erythematosus. The reasons of formula feeding were the following: 2 for agalactia, 2 for personal preferences, 3 for drug-related concerns (1 for physician’s decision in a patient with APS; 2 for maternal concerns about drugs in patients with RA and UA treated respectively with Adalimumab and Tocilizumab). At 6 months 30 continued breastfeeding (n=23) or mixed feeding (n=7) and 14 formula feeding. The reasons of formula feeding were available in 9 patients: 3 for agalactia, 2 for personal preferences, 2 for physician’s decision in a patient with APS and in a patient positive for anti-phospholipid antibodies; 2 for maternal concerns about drugs.

Conclusion:

Preliminary data of this prospective study demonstrate a high percentage of breastfeeding/mixed feeding after delivery and after 6 months among women with RD. Drug related concerns are the main reason of discontinuation of breastfeeding, although medication results compatible with lactation. Using our results, strategies supporting patients with RD whishing to breastfeed may be developed.

References:

[1]Carina Gotestam Sporken et al. The EULAR points to consider for use of antirheumatic drugs before pregnancy, and during pregnancy and lactation. Ann Rheum Dis 2016.

[2]Sammaritano et al. 2020 American College of Rheumatology Guideline for the management of reproductive health in rheumatic and muscoloskeletal diseases, Arthritis Rheumatol. 2020.

Acknowledgements:

Authors would like to thank SIR study center and all patients who accepted to partecipate to our study

Disclosure of Interests:

None declared

SAT0202 C4 LEVELS AS PREDICTOR OF DISEASE FLARES AND ADVERSE PREGNANCY OUTCOMES IN SYSTEMIC LUPUS ERYTHEMATOSUS PREGNANCIES

Background:

SLE pregnancies have an increased risk of Adverse Pregnancy Outcomes (APO). In clinical practice, low C3 and C4 levels are associated with active disease and, during pregnancy, complement activation products are shown to be associated with APO.

Objectives:

To analyse potential association between C3 and C4 variations and disease flares and APO during SLE pregnancies.

Methods:

Demographic, clinical and laboratory data on SLE pregnancies prospectively-followed by a multidisciplinary team in a pregnancy clinic from 1987 to 2015 were retrospectively analysed at preconception and at each trimester. Hypocomplementemia was defined according to the normality range calculated in healthy pregnancies by Reggia et al1. APO were defined as: early miscarriage (<10thweek), intrauterine fetal death (>10thweek), perinatal death (<30thday of life), pre-eclampsia (PE), severe preterm birth (<34thweek).

Results:

134 pregnancies in 98 SLE patients were analysed. APO occurred in 22 (16%) pregnancies: 9 early miscarriages, 4 intrauterine fetal deaths, 3 severe preterm births, 6 PE (hesitated in 1 intrauterine fetal death, 1 perinatal death; 2 preterm birth between 34thand 37thweeks and 2 term births). 13 flares (2 renal, 4 articular, 6 cutaneous and 1 neurological) were recorded in 11 (8%) pregnancies.

The mean C3 and C4 levels at each trimester are shown in table 1.

Table 1.

C3 and C4 mean levels (mg/dL) at pre-conceptional visit (T0), 1sttrimester (T1), 2ndtrimester (T2) and 3rdtrimester (T3).

C3 T0C3 T1C3 T2C3 T3p T0-T1p T1-T2p T2-T3Pregnancies with flares73.282.283.897.50.040.020.06Pregnancies without flares85.391.8104.4114.7<0.001<0.001<0.001Pregnancies with APO*84.791.598.5106.30.030.030.89Pregnancies without APO*84.590.9102.8112.8<0.001<0.001<0.001C4 T0C4 T1C4 T2C4 T3p T0-T1p T1-T2p T2-T3Pregnancies with flares8.611.810.911.40.010.430.27Pregnancies without flares13.214.716.316.6<0.001<0.0010.98Pregnancies with APO**13.116.115.914.70.010.30.13Pregnancies without APO**12.914.215.816.1<0.001<0.0010.42

Comparison of C3 and C4 mean levels between pregnancies with APO vs without APO:

* T0, T1, T2, T3: ns; ** T0, T1, T2, T3: ns

Both in pregnancies with flares and with APO, there was no increase of C3 between the 2ndand the 3rdtrimester and of C4 between the 1stand the 2ndtrimester.

At preconception, mean levels of C4 were lower in pregnancies with flares compared to those without flares (images 1 and 2); during the 2ndand the 3rdtrimesters the mean levels of both C3 and C4 were lower in pregnancies with flares.

In pregnancies with APO, the variation of C4 levels between the 2ndand the 3rdtrimester was lower than in pregnancies without APO (-3.18 vs 0.27; p=0.01).

A higher frequency of low C4 was observed at pre-conceptional visit, 1sttrimester and 3rdtrimester (6/7 vs 25/103 p=0.002; 8/9vs56/106 p=0.04; 9/11 vs 33/96 p=0.003) in pregnancies with flare as compared with pregnancies without flares.

Figure 1.

Image 1: comparison of C3 mean levels between pregnancies with faresvswithout flares

Figure 2.

Image 2: comparison of C4 mean levels between pregnancies with faresvswithout flares

Conclusion:

In our cohort of prospectively-followed SLE pregnancies, low C4 levels at preconception seems to predict flares during pregnancy. Low increase of C4 levels between the 2ndand the 3rdtrimester could predict an APO.

References:

[1]Reggia R. et al. Rheumatology 2012;51:2186-90

Disclosure of Interests:

None declared

AB0678 RISK FACTORS FOR ADVERSE PREGNANCY OUTCOMES IN SPONDYLOARTHRITIS: DISEASE PHENOTYPE AND DISEASE ACTIVITY MAY PLAY A ROLE

Background:

Pregnant patients (pts) with spondyloarthritis (SpA) seem at increased risk for adverse pregnancy outcomes (APO), however limited and conflicting data have been published so far and risk factors for APO in these pts remain poorly understood.

Objectives:

To assess APO and identify possible risk factors for those in a cohort of SpA pregnant pts.

Methods:

Data on SpA pts prospectively-followed in a pregnancy clinic from 2010 to 2019 were retrospectively analysed before conception and during each trimester. Pregnancies complicated by APO were compared with those that were uneventful for demographic and clinical variables. Active disease was defined as a DAS-28-CRP>3.2 or an ASDAS-CRP ≥ 2.1 according to peripheral or axial dominant disease respectively.

Results:

56 pregnancies (mean age 34±5 years; median disease duration 60 months, IQR 24-123) in 47 pts were analysed: 37 psoriatic arthritis, 7 axial SpA, 6 undifferentiated SpA, 3 enteropathic SpA, 2 reactive arthritis and 1 enthesitis-related juvenile idiopathic arthritis. APO were recorded in 23/56 (41%) pregnancies: 5 (9%) early miscarriages, 1 (2%) medical abortion (central nervous system malformation), 3 (5%) preterm births (≥34 gestational week, all for preterm premature rupture of membranes - PROM); 2 (4%) PROM; 7 (13%) small for gestational age newborns (SGA); 3 gestational diabetes and 2 cholestasis of pregnancy. Table 1 displays the comparison between pregnancies with and without APO. A higher number of pts with active disease were detected during the 2ndtrimester in both groups, however differences between those were only significant at the 3rdtrimester (p=0.03). History of inflammatory bowel symptoms (IBS) was also associated with an increased risk for APO (p=0.02). Although not reaching statistical significance, APO occurred more frequently in pts with a previous use of > 1 conventional synthetic (cs) or biological (b) disease-modifying antirheumatic drug (DMARD) (p=0.05), suggesting a more difficult to treat phenotype. Likewise, pts with APO were less often treated with low dose aspirin (LDA) during pregnancy.

Conclusion:

SGA was the main APO recorded. History of IBS, a more difficult to treat phenotype and the presence of active disease during pregnancy influenced APO in this cohort, reinforcing the need for tight disease control before and during pregnancy. Larger and prospective data are warranted to confirm these results and to assess the potential protective role of LDA.

References:

[1]Molto 2018; Zbinden 2018.

Table 1.

Differences between patients with and without APO

Pregnancieswith APOPregnancies without APOpN, %23, 41.133, 58.9Maternal age at conception,mean±SD (years)33.8±533.8±4.9NSHx previous APO– N, %4,17.43, 9.1NSDisease duration,median (IQR), (months)96 (36-132)48 (24-96)NSAxial dominant disease– N, %6, 26.16, 18.2NSPeripheral dominant disease –N, %11, 47.820, 60.6NSHx enthesitis– N, %9, 39.113, 39.4NSHx dactylitis– N, %5, 21.711, 33.3NSHx psoriasis– N, %10, 43.518, 54.5NSHx uveitis–N, %1, 4.34, 12.1NSHx inflammatory bowel symptoms– N, %4, 17.40, 00.02HLA-B27– N, %8, 34.87, 21.2NS>1 cs or bDMARDs before conception –N, %13, 56.510, 30.30.05LDA during pregnancy– N, %7, 30.417, 51.5NSActive disease before conception- N, %5, 21.72, 6.1NSActive disease 1sttrimester- N, %1, 4.34, 12.1NSActive disease 2ndtrimester- N, %6, 26.15, 15.2NSActive disease 3rdtrimester- N, %3, 130, 00.03

Legend: Hx – history of; NS – non significant.

Disclosure of Interests:

None declared

SAT0368 PREGNANCY IN WOMEN WITH SPONDYLOARTHRITIS: WHO ARE THE PATIENTS AT RISK OF DISEASE FLARE?

Background:

Patients with Spondyloarthritis (SpA) can experience flares during pregnancy and postpartum even though the available data are limited and not conclusive.

Objectives:

To assess disease activity and treatment modification during pregnancy and postpartum in patients with SpA and to identify risk factors for disease flare.

Methods:

Data on SpA pregnancies prospectively-followed in a pregnancy clinic from 2010 to 2019 were retrospectively analysed. Disease activity was assessed during each trimester and postpartum using ASDAS-CRP or DAS28-CRP. Flare was defined as an increase of disease activity leading to treatment modification (introduction or increase ≥5mg/day of prednisone, introduction of cDMARD or bDMARD)1.

Results:

Data on 50 pregnancies in 46 patients were collected (mean age at conception 33±4.7 years; median disease duration: 60 months (IQR 24-132); 33 psoriatic arthritis, 6 axialSpA, 2 reactive arthritis, 2 IBD-related SpA; 6 undifferentiated SpA, 1 juvenile idiopathic arthritis). Six pregnancies ended in miscarriage, so they weren’t considered for the analysis of flares during pregnancy (table 1). Fifteen out of 44 (34%) pregnancies had at least one flare during pregnancy (6, 7 and 4 during 1st, 2ndand 3rdtrimester respectively; 2 pregnancies had multiple flares). A higher rate of flare was observed in pregnancies of patients with axial involvement (p=0.01), on treatment with bDMARDs at preconceptional visit (p=0.03) and who stopped TNFi at positive pregnancy test (p=0.03). Peripheral involvement was associated with a lower rate of flares (p=0.02). Medications resumed during pregnancy were steroids (in 6 pregnancies), cDMARDs (2 sulfasalazine, 1 cyclosporine) and bDMARDs (4 certolizumab, 4 etanercept). During postpartum period flares were recorded in 46% of patients.

Table 1.

clinical features, medication and disease activity in pregnancies with flare vs without flare

CLINICAL FEATURESFLARE (15)NO FLARE (29)pAxial involvement, n (%)11/15 (73)9/29 (31)0.01Peripheral arthritis, n (%)8/15 (53)26/29 (90)0.02Enthesitis, n (%)5/15 (33)14/29 (48)nsDactilitis, n (%)3/15 (20)8/29 (28)nsPsoriasis, n (%)6/15 (40)17/29 (59)nsIBD, n (%)2/15 (13)0nsUveitis, n(%)1/15 (7)3/29 (10)nsHLAB27 +7/11 (64)5/12 (42)nsMEDICATION HISTORYbDMARDs, n (%)11/15 (73)7/29 (24)0.003bDMARDs at preconception visit, n (%)8/15 (53)6/29 (21)0.04bDMARDs stopped at positive pregnancy test, n (%)7/15 (47)4/29 (14)0.03cDMARDs, n (%)12/15 (80)25/29 (86)nsDISEASE ACTIVITYACTIVE DISEASE* preconception visit, n(%)3/14 (21)4/23 (17)nsACTIVE DISEASE 1sttrimester, n(%)6/15 (40)1/29 (3)0.004ACTIVE DISEASE 2ndtrimester, n(%)8/15 (47)2/29 (7)0.001ACTIVE DISEASE 3rdtrimester, n(%)2/15 (13)1/29 (3)ns

*DAS28-CRP>3.2 or ASDAS-CRP≥2.1

Conclusion:

In our cohort of prospectively-followed SpA pregnancies, 34% experienced a flare during pregnancy and 46% during postpartum. Flares occurred especially in those patients who discontinued TNFi early in pregnancy and with axial involvement. When resumed during pregnancy, TNFi was able to control the disease. At preconception counselling, the continuation of TNFi during pregnancy should be considered to ensure a better control of disease.

References:

[1]Fischer-Betz R et al.Arthritis Rheumatol. 2015; 67.

Disclosure of Interests: :

None declared

Patients with longstanding primary antiphospholipid syndrome: retrospective analysis of organ damage and mortality

Objective

To assess the prevalence of disease- and therapy-related complications and of the organ damage after a follow-up of 15 years or more in patients with primary antiphospholipid syndrome (PAPS).

Methods

Medical records of patients prospectively followed in our centre for at least 15 years were retrospectively reviewed.

Results

Thirty-five Caucasian patients (33 female, two male) with diagnosis of PAPS followed from 1984 to 2013 with a mean age at onset of 32 years (SD 8.17) and a median follow-up of 20.5 years (range 15–30) were included. The occurrence of systemic autoimmune disease was observed in 14% of patients. Haemorrhagic, infective and neoplastic events were recorded in 34%, 6% and 9% respectively. Organ damage was present in 20% of patients at the end of the follow-up (17% neurological and 3% renal) and was significantly associated with the occurrence of thrombotic events ( p: 0.027), particularly arterial ( p < 0.001). A 48-year-old patient died from sepsis.

Conclusion

During long-term follow-up of PAPS systemic autoimmunity is not unexpected. Organ damage progresses in a significant proportion of patients especially if they have suffered previous arterial events. Our study clearly shows the possible evolution of the disease and of organ damage, suggesting that optimal therapy and optimal prophylaxis of each PAPS patient should be carefully identified and strictly applied.

Morbidity and mortality in the antiphospholipid syndrome during a 10-year period: a multicentre prospective study of 1000 patients

Objectives

To assess the prevalence of the main causes of morbi-mortality in the antiphospholipid syndrome (APS) during a 10-year-follow-up period and to compare the frequency of early manifestations with those that appeared later.

Methods

In 1999, we started an observational study of 1000 APS patients from 13 European countries. All had medical histories documented when entered into the study and were followed prospectively during the ensuing 10 years.

Results

53.1% of the patients had primary APS, 36.2% had APS associated with systemic lupus erythematosus and 10.7% APS associated with other diseases. Thrombotic events appeared in 166 (16.6%) patients during the first 5-year period and in 115 (14.4%) during the second 5-year period. The most common events were strokes, transient ischaemic attacks, deep vein thromboses and pulmonary embolism. 127 (15.5%) women became pregnant (188 pregnancies) and 72.9% of pregnancies succeeded in having one or more live births. The most common obstetric complication was early pregnancy loss (16.5% of the pregnancies). Intrauterine growth restriction (26.3% of the total live births) and prematurity (48.2%) were the most frequent fetal morbidities. 93 (9.3%) patients died and the most frequent causes of death were severe thrombosis (36.5%) and infections (26.9%). Nine (0.9%) cases of catastrophic APS occurred and 5 (55.6%) of them died. The survival probability at 10 years was 90.7%.

Conclusions

Patients with APS still develop significant morbidity and mortality despite current treatment. It is imperative to increase the efforts in determining optimal prognostic markers and therapeutic measures to prevent these complications.

Novel topical drug delivery systems and their potential use in acne vulgaris

A vast spectrum of topical anti-acne agents has emerged in response to new insights that have been gained through the understanding of disease pathophysiology and the need for clinicians to adopt an individualized therapeutic approach. Because topical agents are most commonly used for acne management, this article reviews some novel vehicle delivery advances that are poised to further enhance the efficacy of topical acne formulations, and/or offer the possibility of simplified dosing regimens that may improve treatment outcomes.

Heart involvement in systemic lupus erythematosus, anti-phospholipid syndrome and neonatal lupus

Cardiac involvement is one of the main complications substantially contributing to the morbidity and mortality of patients suffering from systemic autoimmune diseases. All the anatomical heart structures can be affected, and multiple pathogenic mechanisms have been reported. Non-organ-specific autoantibodies have been implicated in immune complex formation and deposition as the initial triggers for inflammatory processes responsible for Libman-Sacks verrucous endocarditis, myocarditis and pericarditis. Anti-phospholipid antibodies have been associated with thrombotic events in coronary arteries, heart valve involvement and intra-myocardial vasculopathy in the context of primary and secondary anti-phospholipid syndrome. Antibodies-SSA/Ro and anti-SSB/La antigens play a major pathogenic role in affecting the heart conduction tissue leading to the electrocardiographic abnormalities of the neonatal lupus syndrome and have been closely associated with endocardial fibroelastosis.

Anticardiolipin antibody assay: a methodological analysis for a better consensus in routine determinations--a cooperative project of the European Antiphospholipid Forum

Despite the widely recognized practical importance of anticardiolipin (aCL) ELISA, the reliability of this test has been recently discussed. In order to investigate this area on European scale, we sent to 30 experienced centers a questionnaire focusing on the diagnostic procedures applied to patients with antiphospholipid syndrome (APS) and on the detailed protocols used to perform aCL. Anticardiolipin ELISA was found to be the most frequently performed test in patients with suspected APS, but significant difference was shown among the various protocols. The cross-laboratory multiple examination of ten serum samples evaluated independently by the 24 centers pointed out the difficulty in getting comparable results. Therefore a "consensus" protocol was derived from the aCL methods giving the best performance. The materials and reagents necessary to perform the "consensus" method, including, as putative standards, one IgG and one IgM monoclonal antibody (HCAL and EY2C9) were distributed to 19 Centers. The results of one IgG and one IgM aCL high positive sera measured in serial dilutions were compared. A progressive decrease in the variability of the values obtained for a given sample appeared evident when all the laboratories used the same standard, in their own in-house ELISA and even more in the "consensus" ELISA. Our data show that aCL ELISA standardization is necessary in order to obtain comparable results in different laboratories.

CD3-CD4+ cells with a Th2-like pattern of cytokine production in the peripheral blood of a patient with cutaneous T cell lymphoma

A case of cutaneous T cell lymphoma associated with mild eosinophilia and rise of IgE levels is reported. A population of CD3-CD4+ cells was observed in the peripheral blood. After activation, these purified CD3-CD4+ cells showed a Th2 pattern of cytokine production, secreting higher levels of IL-5 and IL-4 and lower levels of IFN-gamma compared to the patient's and controls' CD3+CD4+ cells. Moreover, high levels of IL-5 and soluble CD30, a marker of Th2 cell activation, were detected in the patient's serum.

Brain enzyme adaptation to mild normobaric intermittent hypoxia

The adaptation to repeated periods of intermittent normobaric hypoxia (oxygen:nitrogen = 10:90, 12 hr daily for 5 days) of some specific enzymatic activities related to energy metabolism has been observed in different rat brain areas (cerebral cortex, hippocampus, corpus striatum, hypothalamus, cerebellum, and medulla oblongata). The evaluation of the maximum rate (Vmax) of the enzymes was carried out on: the homogenate "in toto," the nonsynaptic mitochondrial fraction, and the crude synaptosomal fraction. The adaptation to intermittent normobaric hypoxic exposure was characterized by significant modifications of some enzyme activities in the homogenate "in toto" (decrease of hexokinase activity in cerebellum), in the nonsynaptic mitochondrial fraction (increase of succinate dehydrogenase activity in corpus striatum and decrease of cytochrome oxidase activity in cerebral cortex), and, particularly, in the synaptosomal fraction (decrease of cytochrome oxidase activity in cerebral cortex, hippocampus, corpus striatum, and cerebellum, and decrease of malate dehydrogenase and lactate dehydrogenase activity in cerebellum). The adaptation to normobaric intermittent hypoxia differs according to the brain area, subcellular fraction, and enzyme activity tested.

Modification of the skeletal muscle energy metabolism induced by intermittent normobaric hypoxia and treatment with biological pyrimidines

Muscular glycolytic fuels, intermediates and end-products (glycogen, glucose, glucose-6-phosphate, pyruvate, lactate), Krebs cycle intermediates (citrate, alpha-ketoglutarate, succinate, malate), related free amino acids (glutamate, alanine), ammonia, energy store (creatine phosphate), energy mediators (ATP, ADP, AMP) and energy charge potential were evaluated. Furthermore the maximum rate (Vmax) of the following enzyme activities was evaluated in the crude extract and/or mitochondrial fraction: for the anaerobic glycolytic pathway: hexokinase, phosphofructokinase, pyruvate kinase, lactate dehydrogenase; for the tricarboxylic acid cycle: citrate synthase, malate dehydrogenase; for the electron transfer chain: total NADH cytochrome c reductase, cytochrome oxidase. The rat gastrocnemius muscles were analysed in normoxia and after normobaric intermittent hypoxia (12 hours continuously daily; for 5 days). Cytidine and/or uridine were administered daily at the dose of 120 mg/kg, i.p., 30 min before the beginning of the experimental hypoxia. The intermittent normobaric hypoxia induced a biochemical adaptation characterized by the decrease of the muscular contents of creatine phosphate, citrate, alpha-ketoglutarate and glutamate. This adaptation occurred in the absence of significant changes in the Vmax of the tested muscle enzymes. In gastrocnemius muscle from hypoxic rats, the two biological pyrimidines tested induced various discrete, but often related, modifications of the contents of some Krebs cycle intermediates (i.e., alpha-ketoglutarate, malate) and related free amino acids (i.e., glutamate, alanine). In any case, the treatment with cytidine and/or uridine did not modify the Vmax of marker enzymes related to energy transduction.

Influence of intermittent hypoxia and pyrimidinic nucleosides on cerebral enzymatic activities related to energy transduction

The effect of intermittent normobaric hypoxia and of biological pyrimidines (uridine and cytidine) on the specific activities of some enzymes related to cerebral energy metabolism were studied. Measurement were carried out on the following: homogenate in toto; purified mitochondrial fraction; crude synaptosomal fraction, in different areas of rat brain: cerebral cortex, hippocampus, corpus striatum, hypothalamus, cerebellum, and medulla oblongata. Intermittent normobaric hypoxia (12 hours daily for 5 days) caused modifications of the enzyme activities in the homogenate in toto (decrease of hexokinase in cerebellum; increase of pyruvate kinase in medulla oblongata), in the purified mitochondrial fraction (increase of succinate dehydrogenase in the corpus striatum) and in the crude synaptosomal fraction (decrease of cytochrome oxidase activity in cerebral cortex, hippocampus, and cerebellum; decrease of malate dehydrogenase in hippocampus and cerebellum; decrease of lactate dehydrogenase in cerebellum). Daily treatment with cytidine or uridine altered some enzyme activities either affected or unaffected by intermittent hypoxia.

Recovery period after profound hypoglycemia. Influence of some metabolic modulators on the cerebral endogenous substrate utilization

The content of "energy-rich" phosphates was markedly decreased in rat cerebral cortex after 20 min of severe hypoglycemia, followed by partial restitution during the recovery period. The adenine nucleotide pool remained reduced even if the energy charge returned to normal. During hypoglycemia the non-glucose endogenous substrates were provided by glycolytic intermediates, by Krebs' cycle intermediates and by related amino acids. Other substrates for brain oxidation were provided by the breakdown of phospholipids and fatty acids. After a 20 min period of post-hypoglycemic recovery, partial restoration of carbohydrates and amino acids occurred, the amino acid pool size being still reduced. The alterations in phospholipids and fatty acids persisted, while there was a tendency towards normalization of the free fatty acid cerebral content. During the post-hypoglycemic recovery, treatment with some specific metabolic modulators (i.e., uridine, L-acetylcarnitine, hopantenate, 6-amino-nicotinamide) suggests the possibility of an alternative cerebral substrate utilization due to the modulation of the cerebral biochemical machinery. Thus, increased carbohydrate utilization by hopantenate was consistent with decreased lipid breakdown, while increased carbohydrate utilization by uridine was concomitant with decreased amino acid degradation. On the other hand, decreased cerebral carbohydrate utilization by 6-aminonicotinamide was concomitant with increased lipid and amino acid breakdown. Furthermore, the increased loss of cerebral phospholipids and fatty acids by L-acetylcarnitine occurred in the presence of a large glucose availability and was concomitant with an extensive reduction on cerebral glycolytic flux.

On the possible pharmacological role of UDP-glucose on some muscular metabolites

The effects of intraperitoneal administration of UDP-glucose were studied on male rat gastrocnemius muscle. Muscular glycolytic substrates and metabolites (glycogen, glucose, glucose-6-phosphate, pyruvate, lactate), Krebs' cycle intermediates (citrate, alpha-ketoglutarate, malate), related aminoacids (glutamate, alanine), ammonia, energy store and mediators (creatine phosphate, ATP, ADP, AMP) and the energy charge potential were evaluated. UDP-glucose was administered intraperitoneally at doses of 0.8, 2.0 and 5.0 mg/kg daily for 1, 2 and 4 weeks. The influence of the factors: "dose" of UDP-glucose and "time-course" of treatment was defined. After two weeks, the administration of the three doses tested of UDP-glucose changed the muscular concentration of few glycolytic metabolites, and of some Krebs' cycle intermediates, while after 1 or 4 weeks of treatment there was negligible response.

Action of testosterone on some biochemical parameters related to the energy metabolism of the skeletal muscle

The effect of intramuscular administration of testosterone propionate was studied on rat gastrocnemius muscle. Muscular glycolytic substrates and Krebs' cycle metabolites (glycogen, glucose, glucose-6-phosphate, pyruvate, lactate, citrate, alpha-ketoglutarate, succinate, malate), related aminoacids (glutamate, alanine, ammonia), energy store and mediators (creatine phosphate, ATP, ADP, AMP) and the energy charge potential were evaluated. The influence of the factors: testosterone dose, time course of treatment and sex of animals was investigated, no relevant changes being noticed.

Recovery after hypoglycemic brain injury. Action of some biological substances on the cerebral metabolism

In artificially ventilated beagle dogs a severe hypoglycemic condition was induced by insulin injection, while the posthypoglycemic recovery was induced by glucose treatment at the end of a 20-min period of spontaneous electroencephalographic silence. The motor area of the cerebral cortex was analyzed for glycolytic metabolites, related amino acids, energy mediators, fatty acids, phospholipids and free fatty acids. The effects on the posthypoglycemic recovery of a intracarotid infusion with some agents (i.e. uridine, cytidine, DL-carnitine, DL-acetylcarnitine, papaverine) were tested. Severe hypoglycemia induced an extensive derangement of the brain metabolism, with partial restitution during the posthypoglycemic recovery. During this condition, the intracarotid perfusion with some biological pyrimidines (uridine, cytidine) interfered with the glycolytic and amino acid metabolites, inducing a decrease in glucose, pyruvate and lactate contents, and an increase in succinate, alanine and glutamine cerebral concns. The lipid carriers (DL-carnitine, DL-acetylcarnitine) interfered with the fatty acid degradation inducing a magnification of the decrease in the individual (palmitic acid, oleic acid) and total fatty acids, the vasodilating agent (papaverine) being practically inactive.