Disease activity during and after pregnancy in women with axial spondyloarthritis: a prospective multicentre study.

Objective: The aim was to study disease activity in women with axial spondyloarthritis (axSpA) during and after pregnancy. Methods: The study included 179 pregnancies in 166 women with axSpA from a Norwegian nationwide register. Disease activity was assessed at seven time points before, throughout and after pregnancy with the DAS BASDAI. Scores assessed at each time point were analysed in a linear mixed model. The same statistical method was used to study self-reported physical functioning, pain and mental health. Results: Altogether, disease activity was stable throughout the study period. We found the highest disease activity and worst self-reported pain in the second trimester, when 45% of the women had active disease. At this time point, disease activity was significantly higher than 6 weeks postpartum (mean BASDAI 3.97 vs 3.46, P = 0.005). Self-reported mental health was also stable, but significantly better 6 weeks postpartum than in the first trimester (mean RAND-36 mental health 79.3 vs 73.2, P < 0.001). Physical functioning was significantly worse in third trimester than postpartum (mean BASFI 3.6 vs 2.6, P < 0.001). Conclusion: Studying women with axSpA, we found that disease activity was highest in the second trimester, but altogether low and stable in the period from planning pregnancy to 1 year after delivery.

Women with systemic lupus erythematosus get pregnant more easily than women with rheumatoid arthritis.

Objectives: To examine possible differences in the ability to get pregnant and time to pregnancy (TTP) in women with SLE and RA, and to study possible influencing factors. Methods: Data from RevNatus, a Norwegian nationwide prospective observational register including women with inflammatory rheumatic diseases when planning pregnancy or after conception, was used. We compared rate of achieved pregnancy, the pregnancy outcomes live birth or pregnancy loss, and TTP between women with SLE (n = 53) and women with RA (n = 180). TTP was compared between the groups using Kaplan-Meier plots, and Cox proportional hazard regression was performed adjusting for maternal age, parity and medication use. RAND-36 was used to assess health-related quality of life (HRQoL) in women achieving and not achieving pregnancy. Results: Women with SLE had a pregnancy ratio of 1.91 (95% CI: 1.27, 2.88, P = 0.002) compared with women with RA, and a substantially shorter median TTP (3.0 vs 7.0 months, P = 0.001). Higher maternal age, medication use and low HRQoL in the physical domains may influence the ability to achieve pregnancy and prolong TTP in women with RA. Women with SLE not achieving pregnancy had lower HRQoL scores than SLE-women achieving pregnancy, while women with RA had generally low scores in physical domains whether or not achieving pregnancy, indicating poor HRQoL. Conclusions: In the studied cohort, women with SLE got pregnant more easily than women with RA.

Influence of disease activity and medications on offspring birth weight, pre-eclampsia and preterm birth in systemic lupus erythematosus: a population-based study.

OBJECTIVES: Exploring the associations between disease activity and medications with offspring birth weight, pre-eclampsia and preterm birth in systemic lupus erythematosus (SLE). METHODS: Data from the Medical Birth Registry of Norway (MBRN) were linked with data from RevNatus, a nationwide observational register recruiting women with inflammatory rheumatic diseases. Singleton births in women with SLE included in RevNatus 2006-2015 were cases (n=180). All other singleton births registered in MBRN during this time (n=498 849) served as population controls. Z-score for birth weight adjusted for gestational age and gender was calculated. Disease activity was assessed using Lupus Activity Index in Pregnancy. We compared z-scores for birth weight, pre-eclampsia and preterm birth in cases with inactive disease, cases with active disease and population controls. RESULTS: Z-scores for birth weight in offspring were lower in inactive (-0.64) and active (-0.53) diseases than population controls (-0.11). Inactive disease did not predict pre-eclampsia while active disease yielded OR 5.33 and OR 3.38 compared with population controls and inactive disease, respectively. Preterm birth occurred more often in inactive (OR 2.57) and active (OR 8.66) diseases compared with population controls, and in active compared with inactive disease (OR 3.36). CONCLUSIONS: SLE has an increased odds for low birth weight and preterm birth, amplified by active disease. The odds for pre-eclampsia is elevated in active, but not inactive disease. This calls for tight follow-up targeting inactive disease before and throughout pregnancy.

Disease Activity During Pregnancy and the First Year Postpartum in Women With Systemic Lupus Erythematosus.

OBJECTIVE: Disease activity measured by validated methods has been sparsely examined during and after pregnancy in women with systemic lupus erythematosus (SLE). The aim of this study was to describe the longitudinal course of disease activity during pregnancy and the first year postpartum using the Lupus Activity Index in Pregnancy (LAI-P). METHODS: RevNatus is a nationwide Norwegian prospective observational register including women diagnosed with inflammatory rheumatic diseases. LAI-P is a modified version of the LAI, with a good ability to assess disease activity in pregnant women with SLE. These indexes were used to assess disease activity at 6 visits (in trimesters 1, 2, and 3, and at 6 weeks, 6 months, and 12 months postpartum). The longitudinal course of disease activity was analyzed using an ordinal logistic mixed model. RESULTS: A total of 757 visits (145 pregnancies) in women with SLE were included in the analysis. More than half (51.6%) of the disease activity scores indicated remission, and only 6.3% indicated moderate disease activity. The model showed a statistically significant and clinically relevant change in disease activity over time, and a higher disease activity 6 and 12 months postpartum compared to the third trimester and 6 weeks postpartum. CONCLUSION: The majority of women had low or no disease activity at conception and during pregnancy, with higher disease activity at 6 and 12 months after delivery. This points to the importance of tight disease control not only before and during pregnancy but also in the first year postpartum.

[Chronic inflammatory arthritis and pregnancy]. / Kronisk inflammatorisk artritt og svangerskap.

BACKGROUND: Chronic inflammatory arthritis often appears first in women of fertile age. Their pregnancies are considered to be of low risk compared with pregnancies in women with systemic inflammatory connective tissue disease. METHOD: The article is based on literature searches in PubMed for studies of the pregnancy outcomes of women with chronic inflammatory arthritis. Studies without a reference group or studies based on analyses of mixed populations of inflammatory arthritis and connective tissue disease patients were excluded. RESULTS: Recurrent findings in the published literature were: low mean birth weight, a higher proportion of children with a birth weight of less than 2500 grams, children born small for gestational age, preterm births and a higher proportion of Caesarean sections. A high level of disease activity is associated with the risk of low birth weight and preterm birth. However, serious complications are not frequently reported. Glucocorticosteroids and disease-modifying medicines such as sulphasalazine and hydroxychloroquine may be used during pregnancy. Non-steroidal anti-inflammatory drugs such as ibuprofen and naproxen may be used until gestational week 32. Methotrexate is contraindicated and must be terminated three months before conception. The TNF inhibitors adalimumab, etanercept and infliximab may be used until conception. INTERPRETATION: Pregnancy is seldom absolutely contraindicated for women with inflammatory arthritis. Pregnancy should be planned carefully and preferably be confined to periods with a low level of disease activity. First pregnancies require special attention. Interdisciplinary collaboration between rheumatologists and gynaecologists is recommended for monitoring patients with active arthritis.

A 50-year-old man with eosinophilia and cardiomyopathy: need for endomyocardial biopsy?

A 50-year-old man was admitted with a suspected acute coronary syndrome. The coronary angiogram, however, was normal. He was found to have a cardiomyopathy and eosinophilia. The diagnosis was established as a perimyocarditis secondary to the Churg-Strauss syndrome. An important question is whether an endomyocardial biopsy should have been performed.

Performance in leisure-time physical activities and self-efficacy in females with rheumatoid arthritis.

The purpose of this study was to examine leisure-time physical activities (LTPAs) and their association with self-efficacy in females with rheumatoid arthritis (RA) (n = 238). Their self-reported performance in LTPAs was measured by the Interest Checklist and efficacy beliefs by using the Arthritis Self-Efficacy Scales (ASES). LTPAs were classified as active or less active according to how many LTPAs they performed. The participants had reduced their participation in LTPAs by almost one-third during the last year. Active individuals performed the vigorous activities more often, they had a higher level of education, were working to a significantly greater extent, and reported better function, higher scores on the self-efficacy scales, and lower joint pain and fatigue. Multivariate analyses demonstrated that a high level of LTPAs was independently related to less fatigue (OR 0.98, p = 0.004), positive self-efficacy in coping with RA functions (OR 1.03, p = 0.015), and higher employment level (OR 0.42, p = 0.039). Only a quarter of the responders were physically active in their leisure time in the present study. Less active individuals reduced their performance in LTPAs to a much higher degree than active individuals during the last year. Partaking in a high amount of LTPAs was related to less fatigue and higher efficacy beliefs.

[Systemic lupus erythematosus and pregnancy]. / Systemisk lupus erythematosus og svangerskap.

BACKGROUND: Systemic lupus erythematosus (SLE) often starts in women of fertile age. Due to the unpredictable nature of the disease and the increased risk of the disease flaring up during pregnancy, women with SLE have previously often been advised to avoid pregnancy. This summary reviews current insights in pregnancy management of women with SLE. METHOD: Search in the Medline database (period 1980-2005) using keywords: SLE, lupus nephritis, antiphospholipid antibody, neonatal lupus and pregnancy. RESULTS: Previous studies of pregnant women with SLE have had different designs, sample sizes, selections of patients, definitions and measures of outcome. Women with previous pregnancy losses, an ongoing active disease with nephritis or hypertension and positive antiphospholipid antibodies, have an increased risk of pregnancy loss. The most favourable pregnancy outcomes are achieved when conception takes place during a remission of the disease. INTERPRETATION: There are few absolute contraindications for pregnancies in women with SLE. Women with SLE may experience uncomplicated pregnancies, but they need to plan their pregnancies as the risk for complications is increased. Best results are achieved through the cooperation of rheumatologists, gynaecologists and nephrologists. Glucocorticosteroids, hydroxychlorocine, azathioprine and anticoagulation may be used during pregnancy.

Pregnancy outcome in patients with primary Sjögren's syndrome. a case-control study.

OBJECTIVE: To study the outcome of pregnancy in patients with primary Sjögren's syndrome (pSS). METHODS: A questionnaire covering demographic data and the outcome of pregnancies was answered by 58 patients with pSS and 157 controls. For 36 patients and 93 controls, we analyzed detailed data about pregnancy, birth, and status of the newborn from the Medical Birth Registry of Norway (MFR) for birth order one, 2, and 3. Thirty-two of 36 patients registered in MFR were diagnosed with pSS after the last birth. RESULTS: Pregnancy outcomes were not different in patients compared to controls. Two patients (3.4%) reported giving birth to a child with congenital heart block. CONCLUSION: PSS had no impact on pregnancy outcome before disease onset. The most important condition associated with pSS in anti-SSA positive mothers was congenital heart block in the offspring.

[Clinical experience with TNF-alpha inhibitors in rheumatoid arthritis]. / Klinisk erfaring med TNF-alpha-hemmere ved revmatoid artritt.

BACKGROUND: Infliximab and etanercept, both tumour necrosis factor-alpha inhibitors, are proven to be effective in patients with rheumatoid arthritis in randomised controlled trials. MATERIAL AND METHODS: Patients with active rheumatoid arthritis were treated with infliximab (n = 29) or etanercept (n = 24) in clinical hospital practice. They were examined before and during treatment. All patients had tried at least one DMARD before. Details of disease activity were monitored by measuring tender and swollen joints, global and pain patient visual analogue scales, Disease Activity Index Score (DAS 28), the Modified Health Assessment Questionnaire, blood and urine samples, and adverse effects. The patients were monitored regularly for two years or until they stopped treatment. RESULTS: In the infliximab group we observed statistically significantly better values for all the registered variables after 6 weeks. At the other times of registration the variables were varying a lot; however, DAS 28 scores after baseline were all within the limits of moderate effect. In the etanercept group we observed statistically significantly better values for all the variables except for erythrocyte sedimentation rate after 6 weeks. At the other times of registration all the variables had significantly better values. Adverse effects were reported in 9 patients in the infliximab group and in 5 in the etanercept group, but no serious adverse effects were reported. 18 patients in the infliximab group (61%) and 10 in the etanercept group (42%) had stopped treatment within two years, either because of adverse effects or lack of effect. CONCLUSION: In this open study of patients with active rheumatoid arthritis, most experienced a rapid effect of infliximab, but a varying effect later on. In the etanercept group the patients experienced both a rapid and sustained effect among those who tolerated the medication. Compared to what several others have reported, a large number of patients stopped treatment; this may reflect limited experience.

[Reversible infertility from nonsteroidal anti-inflammatory drugs]. / Reversibel infertilitet ved ikke-steroide antiinflammatoriske midler.

BACKGROUND: Nonsteroidal anti-inflammatory drugs (NSAIDs) and selective cyclooxygenase-2 inhibitors may interfere with ovulation and the rupture of the follicle, causing reversible infertility. METHOD: Literature review. RESULTS: Reversible infertility is shown both in animal and human studies of these drugs. As determined by ultrasound, the drugs may delay or inhibit ovulation. These findings are also confirmed by a few randomized controlled studies showing an increase in time from the luteinizing hormone surge to rupture of the follicle and an increased size of the unruptured follicle. Most of the hormone analyses show values in accordance with the ovulation/menstrual cycle. Also, two epidemiological studies have shown an association between NSAID use and spontaneous abortion. These studies have methodological weaknesses and their findings have to be elucidated in future studies. INTERPRETATION: Women with fertility problems should avoid not only the selective cyclooxygenase-2 inhibitors, but also the traditional NSAIDs. However, women with rheumatic disease responding well to therapy should consult their physicians before stopping treatment. Reduced dose of a NSAID and temporary stop of drug treatment early in the menstrual cycle, or alternative drug treatment, may be a solution. NSAIDs should not be used in the last eight weeks of pregnancy.