PV186 / #574 Poster Topic:AS21 - Pregnancy and Reproductive Health In the last decades, Systemic Lupus Erythematosus (SLE) pregnancies outcome has greatly improved thanks to pregnancy planning, preconception counseling, multidisciplinary follow-up and availability of compatible drugs. However, patients are burdened by an increased risk of disease flares and adverse maternal-fetal outcomes. The aim of this study was to assess how SLE pregnancies management has changed over time and how this has affected the maternal-fetal outcome. Retrospective data of SLE pregnancies prospectively followed in a pregnancy clinic were collected from preconception counseling throughout the 3 trimesters. Twin pregnancies were excluded. Pregnancies from 2 different time intervals were compared: Group 1 (1988 – 2012) and Group 2 (2013-2022). Statistical analysis was performed using Mann-Whitney, Fisher or chi-square test when appropriate. p<0.05 was considered significant. 204 pregnancies in 141 SLE patients were included. Compared to Group 1 (n=103), Group 2 (n=101) showed higher age at conception (30vs33 years; p = 0.013), lower frequency of Caucasian patients and lower rate of performed preconception counseling (90%vs63%, p < 0.0001) (Table 1). Moreover, pregnancies in Group 2 showed: lower median disease activity (SLEPDAI) and higher median C4 levels in each trimester (Table 1); higher rate of hydroxychloroquine usage (66%vs92%; p < 0.0001); lower rate of glucocorticoids usage (84%vs67%; p = 0.011) with lower median weekly dose (50 mgvs25 mg; p<0.00001). No statistically significant differences were observed in disease history, pattern of organ involvement, immunosuppressive treatment and maternal - fetal outcome between the 2 groups (Table 1). Table 1 Our data show how the approach to SLE pregnancies management has changed over time thanks to increasing knowledge and awareness in this field, as highlighted by recent recommendations. Despite the decreased use of corticosteroids, the increased use of hydroxychloroquine, and the lower disease activity observed in more recent pregnancies, pregnancy outcome was not improved. This can be related to a lower rate of preconception counseling (probably due to the increasing number of patients referred to our pregnancy clinic when already pregnant) in this group but also to the higher age at conception, the higher disease duration, and the high number of non-Caucasian patients, that are known to have a more difficult-to-treat disease because of their ethnicity and social status.

In the field of obstetric antiphospholipid syndrome (APS), studies in mouse models and case reports support the potential benefit of tumor necrosis factor-α inhibitors (TNF-α-i ) in preventing pregnancy loss associated with APS. We present the case of a 36-year-old woman with a diagnosis of Takayasu arteritis who suffered from antiphospholipid antibody (aPL)-related thrombotic microangiopathy/probable catastrophic APS during her first pregnancy and who had a subsequent successful pregnancy while on treatment with certolizumab pegol (CZP), heparin, and low-dose aspirin. The report is followed by the literature review of published cases of APS or aPL-positive pregnancies treated with CZP or other TNF-α-i . A total of 20 pregnancies, including the one here presented, were reported in high-risk APS patients exposed to TNF-α-i , showing a favorable outcome in most pregnancies (80% live births, 69% absence of adverse pregnancy outcomes). Despite the limited available evidence, TNF-α-i could represent a promising option for high-risk patients in obstetric APS.

Background/Objectives: Evans’ syndrome (ES) is a rare autoimmune disorder characterized by the simultaneous or sequential onset of immune thrombocytopenia (ITP) and autoimmune hemolytic anemia (AIHA). Given its rarity, available data concerning the clinical course and optimal management in pregnancy are limited. Methods: We present the case of a 32-year-old woman who experienced ES during her first pregnancy. She had been previously diagnosed with childhood-onset SLE at the age of 14 but had been in treatment-free remission since the age of 24. The treatment of both AIHA and ITP included intravenous immunoglobulins, cyclosporine-A, high dosage oral corticosteroids, and, in the second trimester, rituximab. The delivery was planned at 34 + 6 weeks of gestation (GW); no immunological alterations or infectious complications were detected in the newborn. The post-delivery period was uncomplicated, and the mother was discharged with a normal blood count. A narrative review of available ES cases during pregnancy is also presented. Results: A total of 16 patients with ES in pregnancy were reported, including the one we described. None of them developed major bleedings during gestation, while a case of abruptio placentae with delayed postpartum hemorrhage occurred. ITP was difficult to treat in 4/16 women after delivery; 4/16 patients also developed gestational hypertensive disorders. Perinatal outcomes include 13/17 healthy newborns and 4/17 stillbirths (2 of them were twins), of which 1 was due to fetal AIHA. Gestational age at birth was before 37 GW in 8/17. In 15/16 women, ES resolved after delivery. Conclusions: The occurrence of ES during pregnancy has been rarely reported; it constitutes a clinical challenge due to the need for multiple treatments, including conventional immunosuppressants and/or biologic drugs as steroid-sparing agents. After delivery, ES appeared to be less resistant to treatment than it was during pregnancy.

OBJECTIVES:The aim of this study was to investigate the role of low molecular weight heparin in the prevention of preeclampsia and/or fetal growth restriction in pregnant women with chronic hypertension. METHODS:Women diagnosed with chronic hypertension were retrospectively selected from our electronic database from January 2019 to January 2024. The primary endpoint was the occurrence of adverse pregnancy outcomes described as the onset of preeclampsia and/or fetal growth restriction. RESULTS:A total of 219 pregnant women with chronic hypertension were included. BMI before pregnancy was 27.8 ± 6.4 kg/m 2 and age 36.1 ± 5.4 years. Preeclampsia and fetal growth restriction occurred in 22.9 and 9.6% of patients, respectively. As concerns prophylaxis in the first trimester, 80.1% of patients were administered low-dose aspirin (100 mg), while 16.7% low molecular weight heparin (at prophylactic doses according to BMI), of which 86.1% aspirin + heparin. The rate of preeclampsia was similar in patients taking aspirin or not (21.3 vs. 25%), while it significantly differed in those administered with heparin as thromboprophylaxis (8.8 vs. 25%, P  = 0.04). Fetal growth restriction occurrence did not differ according to the use of prophylaxis. High resistance at uterine arteries Doppler velocimetry at 24-25 weeks of gestation was confirmed to be associated with the onset of preeclampsia (51 vs. 11.9%; P  < 0.001) and fetal growth restriction (18.2 vs. 6.9%; P  = 0.04). CONCLUSION:Thromboprophylaxis with low molecular weight heparin reduces the onset of superimposed preeclampsia, independently from aspirin intake.

Abstract Women with systemic chronic inflammatory disease, such as those with scleroderma, systemic vasculitis, and Sjögren syndrome, need preconception evaluation by a multidisciplinary team. Counseling and pregnancy management should be tailored to patients' needs, considering specific disease features, organ involvement, treatment options, and risk factors to minimize risks of maternal-fetal complications during pregnancy. Additionally, considerations regarding fertility, assisted reproductive techniques, and contraception also need to be addressed for these women. In this narrative review, we integrate the current published literature with our expert opinion to address the issues faced by patients with the aforementioned inflammatory conditions.

Objective The Italian Association of Preeclampsia (AIPE) and the Italian Society of Perinatal Medicine (SIMP) developed clinical questions on maternal hemodynamics state of the art. Study Design AIPE and SIMP experts were divided in small groups and were invited to propose an overview of the existing literature on specific topics related to the clinical questions proposed, developing, wherever possible, clinical and/or research recommendations based on available evidence, expert opinion, and clinical importance. Draft recommendations with a clinical rationale were submitted to 8th AIPE and SIMP Consensus Expert Panel for consideration and approval, with at least 75% agreement required for individual recommendations to be included in the final version. Results More and more evidence in literature underlines the relationship between maternal and fetal hemodynamics, as well as the relationship between maternal cardiovascular profile and fetal-maternal adverse outcomes such as fetal growth restriction and hypertensive disorders of pregnancy. Experts agreed on proposing a classification of pregnancy hypertension, complications, and cardiovascular states based on three different hemodynamic profiles depending on total peripheral vascular resistance values: hypodynamic (>1,300 dynes·s·cm−5), normo-dynamic, and hyperdynamic (<800 dynes·s·cm−5) circulation. This differentiation implies different therapeutical strategies, based drugs' characteristics, and maternal cardiovascular profile. Finally, the cardiovascular characteristics of the women may be useful for a rational approach to an appropriate follow-up, due to the increased cardiovascular risk later in life. Conclusion Although the evidence might not be conclusive, given the lack of large randomized trials, maternal hemodynamics might have great importance in helping clinicians in understanding the pathophysiology and chose a rational treatment of patients with or at risk for pregnancy complications. Key Points

BACKGROUND:Iron deficiency and iron deficiency anemia represent global health issues, particularly during pregnancy and the postpartum. The present paper aims to summarize the appropriate management of these conditions in order to try to improve how clinicians perceive, diagnose and treat iron deficiency and iron deficiency anemia. METHODS:An expert panel of Italian obstetricians of Lazio region was convened to evaluate the available literature on iron deficiency and iron deficiency anemia during pregnancy and the post-partum in order to try to define a flow chart on the appropriate management of such conditions; aspects related to the patient blood management have also been investigated. RESULTS:According to both hemoglobin level and ferritin values, five the flow charts on the appropriate management of iron deficiency and iron deficiency anemia have been drawn. CONCLUSIONS:It is desired to define appropriate flow charts to treat iron deficiency and iron deficiency anemia, which are too often not promptly diagnosed and managed, in order to try to improve antenatal care.

OBJECTIVES:To compare characteristics of labor, cardiotocography traces, and maternal and neonatal outcomes, in a cohort of pregnancies at term complicated by maternal intrapartum pyrexia, with or without a histologic diagnosis of chorioamnionitis. METHODS:This is a retrospective case-control study including pregnancies at term with detection of maternal intrapartum pyrexia, delivered between January 2020 and June 2021. Cardiotocography traces were entirely evaluated, since admission till delivery, and classified according to the International Federation of Obstetrics and Gynecology (FIGO) guideline. Maternal and neonatal outcomes were also recorded as secondary outcomes. Placentas have been studied according to the Amniotic Fluid Infection Nosology Committee. RESULTS:Forty four patients met the inclusion criteria and were included in the study cohort. There was a significant association between the use of oxytocin augmentation in labor and the histologic diagnosis of chorioamnionitis. A significative recurrence of loss and/or absence of accelerations at the point of pyrexia was also documented in women with histological chorioamnionitis compared to the others. CONCLUSIONS:Chorioamnionitis appears to be associated with myometrial disfunction, as suggested by the increased use of oxytocin augmentation during active labor of women at term with intrapartum pyrexia and histologic diagnosis of chorioamnionitis.

Objective. This review aims to summarize the most recent and updated data on pregnancy in patients with axial spondyloarthritis (axSpA), focusing on the recurrence of pregnancy-related complications, the disease activity throughout gestation and the postpartum, and the latest indications for the treatments of future mothers. Methods. We have conducted a narrative review with an online literature search on Medline and PubMed. We selected only studies written in English published until January 2024, including observational and retrospective studies, meta-analyses, and systematic reviews. Results. Proper preconception counseling and maternal-fetal monitoring are necessary to ensure the best outcome for both the mother and her baby. Despite the limited and conflicting evidence about the prevalence of adverse pregnancy outcomes in women with axSpA compared to healthy controls, primary findings demonstrate an increased risk of preterm delivery (PTD), low birth weight (LBW), and elective cesarean section (CS). Concerning disease activity, data suggests that 25-80% of women with ankylosing spondylitis experience disease flares during pregnancy, particularly around 20 weeks of gestation. On the contrary, the data on the postpartum disease flare are heterogeneous. The use of biological drugs in pregnancy is safe and effective in controlling disease activity. Conclusions. Data on pregnancy outcomes in patients with axSpA are scarce and discordant. Probably the difference in maternal disease classification, the evolution of treatment indications, and the differences emerging from study designs can account for these discrepancies. The main evidence shows an increased risk of PTD, LBW, and elective CS (although the latter may reflect cultural influences rather than medical needs due to axSpA itself). The majority of drugs used to treat axSpA, including TNFi, are safe in pregnancy without harming mothers or fetuses. Further data is needed to clarify many controversial aspects in this area.

Routine ultrasound before operative vaginal delivery does not improve the accuracy of instrument placement.

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.

ObjectiveThe study aims to assess how oral misoprostol for cervical ripening affects the time of cesarean delivery (CD) for fetal heart rate (FHR) abnormalities in pre-eclampsia patients. Secondary goals include determining the role of uterine hyperstimulation, comparing misoprostol with Foley catheter, and identifying risk factors for FHR abnormalities associated with CD.MethodsA previously published randomized clinical trial was subjected to a secondary analysis (NCT01801410). We conducted a time-dependent analysis, stratifying the population based on the final mode of induction used (low-dose oral misoprostol vs Foley catheter).ResultsThere was no CD for FHR abnormalities within 2 h of starting misoprostol. At 5 h, the cumulative incidence of CD for FHR abnormalities in the misoprostol group was 2.10%, while it was 1.00% in the Foley group (P = 0.565). After 25 h, the CD risk for FHR abnormalities remained constant in both groups at 21.00% (95% confidence interval [CI] 15.00%-28.00%). Within 5 h of misoprostol induction, the risk of uterine hyperstimulation was similar in both groups (0.33% in misoprostol vs 0.34% in Foley group, P = 0.161). The risk of CD for FHR abnormalities was unaffected by newborn weight centiles.ConclusionThere was no significant difference in CD risk for FHR abnormalities between misoprostol and Foley catheter induction. Nonetheless, the cumulative incidence of CD for FHR abnormalities increased faster in the misoprostol group, indicating that FHR monitoring timing should be tailored to the induction method. The incidence of cesarean delivery for fetal heart anomalies increased faster in the misoprostol group than in Foley group, and for that reason tailoring fetal monitoring timing to induction method is critical.

Pulmonary sequestration is an uncommon congenital malformation of the lung, generally diagnosed in childhood or adolescence, corresponding to dysplastic lung tissue not communicating with the rest of vascular or bronchial lung system but receiving an arterial blood supply from systemic arteries. Currently, surgical resection is usually indicated in order to prevent or treat related symptoms or complications, although controversy exists regarding its use in asymptomatic patients and adults. We present the case of a 32-year-old pregnant woman with acute chest pain and vomiting diagnosed with intralobar sequestration at 32+2 weeks of gestation and treated with pulmonary lobectomy after giving birth by cesarean section at 33+0 weeks of gestation.

Synopsis An optimal materno‐neonatal outcome was obtained in a pregnancy with inherited episodic ataxia through a multidisciplinary team handling timing and mode of delivery.

OBJECTIVE:To investigate pathological associations between sleep-disordered breathing (SDB) and pregnancy outcomes.METHODS:From May 2016 to September 2019, obese women during their uncomplicated singleton pregnancies underwent screening sleep questionnaires, oxygen saturation monitoring, and, in proper cases, complete overnight polysomnography. Their medical records were also recorded.RESULTS:In all, 112 pregnant women were included in the study cohort; 44 showed an oxygen desaturation index ≥10, and their newborns had a significantly higher rate of congenital abnormalities and respiratory distress syndrome compared with the women with normal pulse oximetry. Stepwise multivariate regression analysis showed that basal oxygen saturation was independently associated with the occurrence of fetal growth restriction.CONCLUSION:Among obese pregnant women, the rate of congenital abnormalities is higher in the ones with altered pulse oximetry. Maternal basal oxygen saturation in the first trimester of pregnancy predicts fetal growth restriction independently of maternal age, ethnicity, body mass index, gravidity, and hypertensive disorders of pregnancy.

EDITORIAL article Front. Cardiovasc. Med., 03 April 2023Sec. Heart Failure and Transplantation Volume 10 - 2023 | https://doi.org/10.3389/fcvm.2023.1179616