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.

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.

Uterine artery Doppler for the prediction of outcome in pregnancies complicated by hypertensive disorders of pregnancy.

OBJECTIVES: To evaluate, in pregnancies complicated by hypertensive disorders of pregnancy (HDP), the predictive role of uterine artery (UtA) Doppler for pregnancy outcome compared to the definition of preeclampsia (PE) established by ISSHP recommendations. STUDY DESIGN: Retrospective cohort study including singleton pregnancies diagnosed with HDP, who underwent UtA Doppler assessment at admission in 2011-2017. The study population was classified considering the presence or absence of PE and according to the presence or absence of abnormal UtA Doppler (mean pulsatility index > 95th percentile). MAIN OUTCOME MEASURES: Pregnancy outcome, maternal and fetal complications, evaluated as composite outcomes (CO), and duration of pregnancy (from admission to delivery). RESULTS: A total of 311 mother-infant couples was included.The diagnostic ability of the two classifications was analysed comparing the relative likelihood ratio in the Biggerstaff graph. ISSHP definition turned out to be more efficient in detecting maternal adverse CO in comparison to UtA Doppler, relative positive likelihood ratio 1.50 (1.35-1.66) and 1.31 (1.07-1.60). UtA Doppler classification resulted more efficient in predicting adverse neonatal CO than PE definition, relative positive likelihood ratio 2.21 (1.77-2.75) and 1.61 (1.37-1.90). UtA Doppler was significantly associated with delivery at earlier gestational ages both for patients affected by PE and for women affected by HDP without superimposed PE (respectively p = 0.009 and p = 0.037). CONCLUSIONS: UtA Doppler at HDP diagnosis is a useful bedside marker of fetal/neonatal complications, and is associated with pregnancy duration.

Maternal functional hemodynamics in uncomplicated twin pregnancies: A longitudinal study using impedance cardiography.

INTRODUCTION: Longitudinal studies of maternal hemodynamics in twin pregnancy are scarce and preload reserve in twin pregnancies has not been studied. Thus, we aimed to investigate serial changes in maternal systemic hemodynamics from the first to third trimester, and cardiovascular response to passive leg raising to evaluate preload reserve using impedance cardiography in a cohort of uncomplicated twin pregnancies. MATERIAL AND METHODS: This was a prospective longitudinal study of 50 twin pregnancies. Maternal hemodynamics was assessed at baseline and 120 seconds after passive leg raising using impedance cardiography, at five time points during gestation. Women were excluded from the analysis if there were pregnancy complications or fewer than three of five planned assessments were available. RESULTS: Data from 37 uncomplicated twin pregnancies were available for analysis. Mean arterial pressure slightly decreased until 17 weeks' gestation, then increased. Systemic vascular resistance was constant in the first half of pregnancy before rising steadily thereafter, whereas the cardiac output increased from the first trimester, peaked by the end of the second trimester and then decreased in the third trimester. The change in stroke volume and cardiac output following passive leg raising during pregnancy ranged from -2.2% to 1.6% and from -3.7% to 3.2%, respectively. Although passive leg raising caused no significant changes in systemic vascular resistance, cardiac output or heart rate, mean arterial pressure decreased in the first and second trimesters. CONCLUSIONS: In uncomplicated twin pregnancies, maternal cardiovascular adaptation is evident from the first trimester. Twin pregnancies show a reduced preload reserve in the second half of gestation.

Placental morphology in pregnancies associated with pregravid obesity.

OBJECTIVE: Pre-gravid obesity is associated with increased morbidity and mortality for both mother and offspring. We aimed to investigate the changes in placental structure and to characterize the placental inflammatory status in obese women. METHODS: Placentas from 10 women with pregravid body mass index ≥ 30 kg/m(2) were analyzed histopathologically and compared with those from 10 normal weight women. The effect of pregravid obesity on placental structure was investigated by examining placental maturity, angiogenesis, inflammatory response, and vascular abnormalities. Hematoxylin and eosin stain, immunohistochemical analysis, and morphometric analysis were performed. RESULTS: Immaturity of the villous tree was demonstrated more often in the pregravid obesity group (p = 0.005). The villous tree was mainly represented by villi of larger diameter (p = 0.001) and lower number (p = 0.023) compared with controls. By contrast, the number of capillaries per villus was increased in the obese group (p = 0.001), while the global number of capillaries per surface unit did not differ in the studied groups (p = 1). There was no difference between the pre-gravid obese group and controls in inflammatory status and vascular pathology. CONCLUSIONS: Pregravid obesity is associated with focal immaturity of the villous tree and angiogenetic abnormalities of the placenta.