Management of pregnancy in autoimmune rheumatic diseases: maternal disease course, gestational and neonatal outcomes and use of medications in the prospectiveItalian P-RHEUM.it study

Abstract

Objectives: To investigate pregnancy outcomes in women with autoimmune rheumatic diseases (ARD) in the Italian prospective cohort study P-RHEUM.it.

Methods: Pregnant women with different ARD were enrolled for up to 20 gestational weeks in 29 Rheumatology Centres for 5 years (2018-2023). Maternal and infant information were collected in a web-based database.

Results: We analysed 866 pregnancies in 851 patients (systemic lupus erythematosus was the most represented disease, 19.6%). Maternal disease flares were observed in 135 (15.6%) pregnancies. 53 (6.1%) pregnancies were induced by assisted reproduction techniques, 61 (7%) ended in miscarriage and 11 (1.3%) underwent elective termination. Obstetrical complications occurred in 261 (30.1%) pregnancies, including 2.3% pre-eclampsia. Two cases of congenital heart block were observed out of 157 pregnancies (1.3%) with anti-Ro/SSA. Regarding treatments, 244 (28.2%) pregnancies were treated with glucocorticoids, 388 (44.8%) with hydroxychloroquine, 85 (9.8%) with conventional synthetic disease-modifying anti-rheumatic drugs and 122 (14.1%) with biological disease-modifying anti-rheumatic drugs. Live births were 794 (91.7%), mostly at term (84.9%); four perinatal deaths (0.5%) occurred. Among 790 newborns, 31 (3.9%) were small-for-gestational-age and 169 (21.4%) had perinatal complications. Exclusive maternal breast feeding was received by 404 (46.7%) neonates. The Edinburgh Postnatal Depression Scale was compiled by 414 women (52.4%); 89 (21.5%) scored positive for emotional distress.

Conclusions: Multiple factors including preconception counselling and treat-to-target with pregnancy-compatible medications may have contributed to mitigate disease-related risk factors, yielding limited disease flares, good pregnancy outcomes and frequency of complications which were similar to the Italian general obstetric population. Disease-specific issues need to be further addressed to plan preventative measures.

Keywords: antirheumatic agents; arthritis; autoimmune diseases; connective tissue diseases; systemic vasculitis.

Figure 1

Flowchart showing the selection of pregnancies included in the analysis.

Figure 2

Tree map reporting the number of patients included in the study according to their diagnosis of autoimmune rheumatic disease. Patients with RA, PsA, SpA, JIA, UA were labelled as IA group, while patients with SLE, PAPS/aPL carriers, UCTD, pSS, SSc, IIM as CTD group. The IIM group included 6 patients with poly-dermatomyositis and 14 with mixed connective tissue disease. The SV group comprised 23 patients with Behçet’s disease, 6 with Takayasu arteritis, 5 with ANCA-associated vasculitis and 3 with Cogan’s syndrome. anti-Ro/SSA, asymptomatic carriers of anti-Ro/SSA antibodies; CTD, connective tissue diseases; IA, inflammatory arthritis; IIM, idiopathic inflammatory myopathies; JIA, juvenile idiopathic arthritis; PAPS-aPL carriers, primary antiphospholipid syndrome and antiphospholipid antibody (aPL) carriers; PsA, psoriatic arthritis; pSS, primary Sjögren’s syndrome; RA, rheumatoid arthritis; SLE, systemic lupus erythematosus; SpA, spondyloarthritis; SSc, systemic sclerosis; SV, systemic vasculitis; UA, undifferentiated arthritis; UCTD, undifferentiated connective tissue disease.

Figure 3

Illustration of number of patients, pregnancies and neonates included in the analysis, presented on maternal diagnosis of autoimmune rheumatic disease. Non-viable pregnancies: A: pregnancy loss ≤10 GW; B: pregnancy loss 11–20 GW; C: pregnancy loss >20 GW; D: elective termination of pregnancy. anti-Ro/SSA, asymptomatic carriers of anti-Ro/SSA antibodies; GW, gestational week; IIM, idiopathic inflammatory myopathies; JIA, juvenile idiopathic arthritis; PAPS - aPL, primary antiphospholipid syndrome and antiphospholipid antibody carriers; PsA, psoriatic arthritis; pSS, primary Sjögren’s syndrome; RA, rheumatoid arthritis; SLE, systemic lupus erythematosus; SpA, spondyloarthritis; SSc, systemic sclerosis; SV, systemic vasculitis; UA, undifferentiated arthritis; UCTD, undifferentiated connective tissue disease.