• Insomnia
• Mental Health
• Pregnancy
• Sleep
• Systemic Autoimmune Disease

Introduction: This study explores the complex interrelationships among pregnancy, systemic autoimmune diseases (SADs), and mental health, with a particular focus on sleep disturbances, mood disorders, and anxiety. The research addresses a significant gap in understanding these aspects, especially during pregnancy, where the interplay of SADs and mental health issues is not well understood.
Objectives: The objectives of the present study are to compare mental health variables (insomnia, anxiety, mood, and emotion regulation) among pregnant (P), non-pregnant (NP), and postpartum (PP) patients with SAD (objective 1); to compare these variables between patients diagnosed with SAD and controls (patients with positive autoantibodies) during pregnancy (objective 2); and to evaluate pregnant patients with SAD during the first, second, and third trimesters (objective 3). Additionally, we aimed to characterize pregnancy outcomes in patients with SAD.
Methods: This longitudinal, prospective, monocentric study conducted in two phases at the University Hospital of Pisa's pregnancy clinic, the study initially assessed 54 patients between 2019 and 2020 and then included an additional 126 patients from July 2023 to April 2024. included women diagnosed with SADs and those who tested positive for autoantibodies (Control), aged over 18. Patients were evaluated across different stages of pregnancy and compared with pre-pregnancy and postpartum periods. Mental health was assessed using the Insomnia Severity Index, STAI-Y for anxiety, Mood Disorder Questionnaire, and the Postpartum Depression Predictors Inventory-Revised (PDPI-R).
Results: Considering patients with SAD diagnosis, a total of 152 evaluations were performed, at least once during pregnancy (P) in n=92 patients, during postpartum (PP) in n=27 patients, and in non-pregnant patients (NP) n=33. Additionally, n=46 patients with positive antibodies but without SAD diagnosis (Control-Group) were evaluated, n=27 during pregnancy(P), n=3 during postpartum (PP), and n=16 non-pregnant (NP).
First Objective: Among pregnant patients with SAD, 53.3% reported insomnia symptoms, 55.6% reported state anxiety, and 48.9% reported trait anxiety. Mood disorders were noted in 45.7% of patients, with significant emotional regulation difficulties. Moreover, significant differences were found in insomnia symptoms, with non-pregnant patients reporting lower scores compared to pregnant and postpartum patients (p = 0.001).
Second Objective: Comparing patients with SAD to controls, significant differences were observed in treatment with HCQ and GC, and in mood symptom scores, with higher scores in the SAD group (p = 0.044).
Third Objective: Longitudinal evaluations during pregnancy were performed in n=62 patients (first trimester n=51, second trimester n=58, and third trimester n=45). No significant differences across trimesters emerged for any mental health scale.
Fourth Objective: Comparison of corticosteroid treatment showed no significant differences. However, HCQ-treated patients had lower anxiety and postpartum depression scores. No significant differences were found in patients treated with immunosuppressors, immunomodulators, biologics, anticoagulants, or antiplatelets.
Pregnancy Outcomes: Among 54 participants, congenital anomalies were rare (1.9%), with low incidences of gestational diabetes (3.8%) and preeclampsia, while preterm delivery and cesarean delivery were observed in 8.3% and 33.3% of cases, respectively. Overall, effective pregnancy management was indicated, although there were higher rates of preterm births and cesarean sections compared to controls.
Conclusion: This study highlights the significant impact of SAD on mental health during pregnancy, with increased symptoms of insomnia, anxiety, and mood disorders. Notably, over half of the pregnant patients reported symptoms of insomnia, surpassing rates observed in the general population and aligning with those in patients with systemic autoimmune diseases. Additionally, significant mood disturbances were observed in patients with SAD compared to controls, warranting attention to the mental well-being of this vulnerable group. Despite these challenges, our study revealed effective management of pregnancy in patients with SAD, as evidenced by favorable obstetric outcomes, albeit with a slightly high rate of preterm births and cesarean interventions. The findings of the present study emphasize the importance of targeted mental health support and effective pregnancy management for patients with SAD to improve both mental health outcomes and pregnancy outcomes