Lisa Sammaritano and Eliza Chakravarty have put together a remarkable issue summarizing state-of-the-art knowledge of diagnosis, pathogenesis, management, and prevention in the important world of reproductive health. Both editors have assembled an impressive array of talent to take us through an in-depth approach. Lisa herself has addressed the complex area of contraception in our patients with rheumatic diseases, emphasizing the need for a proper balance between the high risk (to both mother and child) of pregnancy and the risk of methods to prevent it. Bonnie Bermas follows this article, addressing the common theme of medication implementation to avoid disease flare and possible risk to the newborn contrasted with the clear benefits of breastfeeding for both mother and child. Monica Ostensen discusses the overall important concept of medication risk worries and the benefits of optimal disease control. She addresses the ideal situation where preconception counseling should be shared with all doctors and health professionals involved in the care of a pregnant patient. De Jong and Dolhain get right to the point through their emphasis on optimal control of disease activity in order to counter the data that rheumatoid arthritis pregnancy outcomes are less favorable compared with the general population; they postulate that this is most likely related to incomplete control of disease activity. These authors discuss emerging evidence on the safety of TNF inhibitors in the pregnant RA patient. Megan Clowse, a senior authority in this complex area, discusses the interplay between vasculitis disease activity management with potentially teratogenic medications and pregnancy outcome. She emphasizes that commonly employed medications used to treat various forms of vasculitis (methotrexate, cyclophosphamide, and mycophenolate) are teratogenic and should be replaced in the pregnant patient with lower-risk alternatives.
Vinet and Bernatsky provide a thoughtful epidemiologic approach to the widely disparate data on pregnancy outcomes and address the small but significant risk to optimal pregnancy outcomes in our RA and SLE patients. They point out that the absolute risk is small and by itself should not be an automatic discouragement to having children. Somers and Marder tackle the ever-present problem of fertility in the face of the disease itself as well as medications used to control the disease and their effect on preservation of ovarian function. Significant advances have been made in this area. Soh and Nelson-Piercy discuss the emerging role of biomarkers to assign risk for preeclampsia or accelerated cardiovascular risk in young women with rheumatic diseases; they caution about overinterpretation of rapidly accumulating data and oversimplification of a complex clinical problem. Lateef and Petri, with a wealth of SLE experience, recommend specific monitoring protocols and very closely tailored multidisciplinary care to avoid unwanted outcomes to mother and child. Heinlin and Chakravarty thoughtfully review the risks and development of comorbid conditions, including cancer in women with systemic autoimmune diseases, and Talsania and Scofield discuss the complex interplay between physiologic menopause and both susceptibility and severity of several rheumatic diseases.
It is hoped this issue will stimulate others to move the field forward by pointing out the advantages of a comprehensive approach to the clinical care of these patients as well as the need to stimulate investigators to provide much needed insights where there are gaps in our knowledge. These editors deserve congratulations on a job well done.