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Rosta K, Heinzl F, Kuczwara V, Schindler S, Falcone V, Catic A, Riedmann M, Leitner H, Simader E, Ritschl V, Stamm T, Szlatinay A, Mandl P, Mazzucato-Puchner A. Pregnancy outcomes in patients with systemic lupus erythematosus compared to a high-risk tertiary cohort and to standard population from the Austrian birth registry. Acta Obstet Gynecol Scand 2024; 103:1820-1828. [PMID: 38943224 PMCID: PMC11324932 DOI: 10.1111/aogs.14880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Revised: 04/24/2024] [Accepted: 05/06/2024] [Indexed: 07/01/2024]
Abstract
INTRODUCTION Women with systemic lupus erythematosus (SLE) have a higher risk for fetal and maternal complications. We aimed to investigate maternal and fetal complications in pregnant women with SLE compared to a high-risk pregnancy cohort (HR) from a tertiary university center and a standard-risk general population (SR) from the Austrian Birth Registry. MATERIAL AND METHODS In this retrospective data analysis, we compared the incidence of fetal/neonatal and maternal complications of pregnancies and deliveries of women with SLE to age, body mass index and delivery date-matched high-risk pregnancies from the same department, a progressive tertiary obstetric center and to a group of women, who represent pregnancies with standard obstetric risk from the Austrian Birth Registry. RESULTS One hundred women with SLE were compared to 300 women with high-risk pregnancies and 207 039 women with standard-risk pregnancies. The incidence of composite maternal complications (preeclampsia, Hemolysis, Elevated Liver enzymes and Low Platelets [HELLP] syndrome, pregnancy-related hypertension, gestational diabetes mellitus, maternal death, thromboembolic events) was significantly higher in the SLE as compared to the SR group (28% vs. 6.28% SLE vs. SR, p = 0.001). There was no difference between the SLE and the HR groups (28% vs. 29.6% SLE vs. HR group, p = 0.80). The incidence of composite fetal complications (preterm birth before 37 weeks of gestation, stillbirths, birthweight less than 2500 g, fetal growth restriction, large for gestational age, admission to neonatal intensive care unit, 5-min Apgar <7) was also higher in the SLE than in the SR group (55% vs. 25.54% SLE vs. SR p < 0.001) while the higher incidence of adverse fetal outcome was detected in the HR than in the SLE group (55% vs. 75% SLE vs. HR group, p = 0.0005). CONCLUSIONS Although composite fetal risk is higher in the SLE group than in the general population, it is still significantly lower as compared to high-risk pregnant women at a tertiary obstetric center. Prepregnancy counseling of women with SLE should put fetal and maternal risk in perspective, not only in relation to healthy, low risk cohorts, but also compared to mixed HR populations.
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Affiliation(s)
- Klara Rosta
- Department of Obstetrics and Gynecology, Clinical Division of Gynecological Endocrinology and Reproductive Medicine, Medical University of Vienna, Vienna, Austria
| | - Florian Heinzl
- Department of Obstetrics and Gynecology, Clinical Division of Gynecological Endocrinology and Reproductive Medicine, Medical University of Vienna, Vienna, Austria
| | - Valerie Kuczwara
- Department of Obstetrics and Gynecology, Clinical Division of Gynecological Endocrinology and Reproductive Medicine, Medical University of Vienna, Vienna, Austria
| | - Stefanie Schindler
- Department of Obstetrics and Gynecology, Clinical Division of Gynecological Endocrinology and Reproductive Medicine, Medical University of Vienna, Vienna, Austria
| | - Veronica Falcone
- Department of Obstetrics and Gynecology, Clinical Division of Gynecological Endocrinology and Reproductive Medicine, Medical University of Vienna, Vienna, Austria
| | - Anja Catic
- Department of Obstetrics and Gynecology, Clinical Division of Gynecological Endocrinology and Reproductive Medicine, Medical University of Vienna, Vienna, Austria
| | - Marina Riedmann
- Department of Clinical Epidemiology, Tyrolean Federal Institute for Integrated Care, Tirol Kliniken GmbH, Innsbruck, Austria
| | - Hermann Leitner
- Department of Clinical Epidemiology, Tyrolean Federal Institute for Integrated Care, Tirol Kliniken GmbH, Innsbruck, Austria
| | - Elisabeth Simader
- Department of Internal Medicine III, Division of Rheumatology, Medical University of Vienna, Vienna, Austria
| | - Valentin Ritschl
- Center for Medical Data Science, Institute for Outcomes Research, Medical University of Vienna, Vienna, Austria
- Ludwig Boltzmann Institute for Arthritis and Rehabilitation, Vienna, Austria
| | - Tanja Stamm
- Center for Medical Data Science, Institute for Outcomes Research, Medical University of Vienna, Vienna, Austria
- Ludwig Boltzmann Institute for Arthritis and Rehabilitation, Vienna, Austria
| | - Alexandra Szlatinay
- Department of Internal Medicine III, Division of Rheumatology, Medical University of Vienna, Vienna, Austria
| | - Peter Mandl
- Department of Internal Medicine III, Division of Rheumatology, Medical University of Vienna, Vienna, Austria
| | - Antonia Mazzucato-Puchner
- Department of Internal Medicine III, Division of Rheumatology, Medical University of Vienna, Vienna, Austria
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Ravindran V, Bhadran S, Divakaran M, Reshma VM. Lupus pregnancy outcomes in women with previous adverse outcomes: a prospective cohort study. Clin Rheumatol 2024; 43:2911-2917. [PMID: 39017917 DOI: 10.1007/s10067-024-07069-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2024] [Revised: 07/09/2024] [Accepted: 07/11/2024] [Indexed: 07/18/2024]
Abstract
OBJECTIVES The primary objective of this prospective cohort study was to assess the usefulness of a predefined multidisciplinary care pathway-based management on pregnancy outcome(s) in women with SLE who already had at least one adverse obstetric outcome(s). METHODS Between March 2010 and March 2023, all consecutive, consenting women with SLE who already had at least one previous adverse obstetric outcome (preterm labour, pre-eclampsia, termination of pregnancy, miscarriage, intrauterine growth retardation (IUGR), preterm birth, low birth weight (LBW), intrauterine death (IUD) or stillbirth] were prospectively screened and counselled. The protocol comprised preconception and post-natal drug and disease status review, periodic ante-natal visits for the monitoring of pregnancy and drug and disease status review and post-natal drug and disease status review and contraception advice. Therapeutic changes were made as necessary at each visit. RESULTS A total of 213 women were screened and 197 women (age, 28 ± 6.34 years) were enrolled who had 226 pregnancies. Previous poor obstetric outcomes were miscarriage(s), 186; termination of pregnancy, 4; preterm labour, 51; IUGR, 36; IUD or stillbirth, 16; low birth weight (LBW), 44 and pre-eclampsia, 4. Seventy-seven (39%) women had secondary APS and 37 (19%) had a history of lupus nephritis. There were 194/226 (86%) live births [40 LBW (18%); caesarean section in 101 (45%)]. Thirty pregnancies culminated in miscarriages and 2 in IUDs (14%). Sixty-eight patients (30%) experienced lupus flare during pregnancy (36 mild, 20 moderate and 8 severe). CONCLUSION Our experience underscores the usefulness of a predefined multidisciplinary care pathway-based management for improving pregnancy outcomes in women with SLE who had previous adverse outcomes. Key Points • In women with SLE who had previous adverse obstetric outcome(s) a risk of poor outcome in subsequent pregnancy remains. • Good pregnancy outcomes in these women could be achieved by predefined multidisciplinary care pathways focussed on addressing all relevant issues. • Improved access to rheumatology services and collaboration between rheumatologists and obstetricians is key to improving outcomes in SLE pregnancies.
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Affiliation(s)
- Vinod Ravindran
- Centre for Rheumatology, Calicut, Kerala, India.
- Department of Medicine, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India.
| | - S Bhadran
- Department of Obstetrics, National Hospital, Calicut, Kerala, India
| | - Mini Divakaran
- Department of Obstetrics, PVS Hospital, Calicut, Kerala, India
| | - V M Reshma
- Department of Obstetrics, Indira Gandhi Hospital, Thalassery, Kerala, India
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Tang WZ, Tang Y, Lan X. The enigma of lupus pregnancy: a study of unresolved issues in women with prior adverse events. Clin Rheumatol 2024:10.1007/s10067-024-07104-1. [PMID: 39212795 DOI: 10.1007/s10067-024-07104-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2024] [Revised: 07/24/2024] [Accepted: 08/07/2024] [Indexed: 09/04/2024]
Affiliation(s)
- Wei-Zhen Tang
- Department of Obstetrics and Gynecology, Women and Children's Hospital of Chongqing Medical University, No. 120 Longshan Rd, Yubei District, Chongqing, 401147, China.
| | - Yue Tang
- Department of Obstetrics and Gynecology, Women and Children's Hospital of Chongqing Medical University, No. 120 Longshan Rd, Yubei District, Chongqing, 401147, China
| | - Xia Lan
- Department of Obstetrics and Gynecology, Women and Children's Hospital of Chongqing Medical University, No. 120 Longshan Rd, Yubei District, Chongqing, 401147, China.
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Singh M, Fayaz FFA, Wang J, Wambua S, Subramanian A, Reynolds JA, Nirantharakumar K, Crowe F. Pregnancy complications and autoimmune diseases in women: systematic review and meta-analysis. BMC Med 2024; 22:339. [PMID: 39183290 PMCID: PMC11346028 DOI: 10.1186/s12916-024-03550-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Accepted: 07/29/2024] [Indexed: 08/27/2024] Open
Abstract
BACKGROUND Pregnancy complications might lead to the development of autoimmune diseases in women. This review aims to summarise studies evaluating the association between pregnancy complications and the development of autoimmune diseases in women. METHODS Medline, CINAHL, and Cochrane databases were searched up to January 2024. Nineteen pregnancy complications and 15 autoimmune conditions were included. Title, abstract, full-text screening, data extraction, and quality assessment were performed by two reviewers independently. Data were synthesised using narrative and quantitative methods. Results were presented using odds ratios (OR), relative risks (RR), incidence rate ratios (IRR), and 95% confidence intervals (CI). RESULTS Thirty studies were included. One study reported composite exposure to pregnancy complications had a risk of any autoimmune disease RR 3.20 (2.90-3.51) compared to women without pregnancy complications. Women with hyperemesis gravidarum had a higher risk of developing coeliac disease (n = 1) IRR 1.98 (1.27-2.94), Crohn's disease (n = 1) IRR 1.61 (1.25-2.04), psoriasis (n = 1) IRR 1.33 (1.01-1.71), and rheumatoid arthritis (n = 2) IRR 1.35 (1.09-1.64). Miscarriage associated with subsequent diagnosis of Sjogren syndrome (n = 2) IRR 1.33 (1.06-2.81) and rheumatoid arthritis (n = 4) OR 1.11 (1.04-1.20). Gestational hypertension/preeclampsia was linked with the development of systemic sclerosis (n = 2) IRR 2.60 (1.10-4.60) and T1DM (n = 2) IRR 2.37 (2.09-2.68). Stillbirth associated with composite autoimmune conditions (n = 2) RR 5.82 (95% CI 4.87-6.81) and aIRR 1.25 (1.12-1.40). Postpartum psychosis was associated with autoimmune thyroid disease (n = 1) aIRR2.26 (1.61-2.90). CONCLUSIONS Women with pregnancy complications subsequently had a higher risk of being diagnosed with autoimmune conditions. Whether this is due to pre-existing undiagnosed health conditions or being causally linked to pregnancy complications is not known.
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Affiliation(s)
- Megha Singh
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | | | - Jingya Wang
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Steven Wambua
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | | | - John A Reynolds
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | | | - Francesca Crowe
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
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Wind M, Fierro JJ, Bloemenkamp KWM, de Leeuw K, Lely AT, Limper M, Sueters M, Teng YKO, Walter IJ, Kooiman J. Pregnancy outcome predictors in systemic lupus erythematosus: a systematic review and meta-analysis. THE LANCET. RHEUMATOLOGY 2024:S2665-9913(24)00160-7. [PMID: 39153486 DOI: 10.1016/s2665-9913(24)00160-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Revised: 06/04/2024] [Accepted: 06/04/2024] [Indexed: 08/19/2024]
Abstract
BACKGROUND To enhance patient-tailored preconception risk assessment for women with systemic lupus erythematosus (SLE), knowledge on risk factors associated with adverse pregnancy outcomes is required. Therefore, we did a systematic review and meta-analysis to identify and provide unambiguous effect sizes of preconception predictors of pregnancy outcomes in women with SLE. METHODS In this systematic review and meta-analysis, we searched PubMed and Embase for studies reporting preconception predictors of pregnancy outcomes in women with SLE, from database inception to Aug 22, 2023. Studies were included if they presented original, quantitative data on pregnant women with SLE and reported on preconception risk factors on at least one of the outcomes as defined in the protocol. Studies were excluded if they had a sample size of less than 20 patients, were restricted to multiple pregnancies, had unclear timing of prognostication, or exclusively reported a composite outcome. Literature screening, data extraction, and risk-of-bias assessment (quality in prognostic studies tool) were done by two reviewers independently, in a blinded, standardised manner. The reported outcomes included livebirth, pre-eclampsia, small for gestational age, preterm birth, pregnancy loss before and after 20 weeks of gestation, and SLE flares. We computed pooled univariate odds ratios (ORs) and 95% CIs using a random effects model. We assessed heterogeneity using the I2 statistic and prediction intervals. This study is registered with PROSPERO, CRD42022344732. FINDINGS Of the 6705 unique articles identified, 72 (1·1%) were included in the meta-analysis, comprising 10 355 pregnancies in 8065 women with SLE. One potentially eligible study was retracted and therefore removed from our analysis. Previous lupus nephritis was associated with decreased livebirth probability (OR 0·62 [95% CI 0·47-0·81]; I2=0%), increased risk of preterm birth (2·00 [1·55-2·57]; I2=17%), and increased risk of pre-eclampsia (3·11 [2·35-4·12]; I2=0%). Chronic hypertension was associated with increased risk of disease flare (2·50 [1·74-3·58]; I2=0%), preterm birth (2·65 [1·87-3·77]; I2=0%), and pre-eclampsia (5·86 [3·41-10·06]; I2=33%). SLE disease activity at conception or preconception was associated with increased risk of preterm birth (2·91 [1·96-4·33]; I2=21%) and pre-eclampsia (2·32 [1·40-3·83]; I2=0%). Secondary antiphospholipid syndrome was associated with decreased livebirth probability (0·40 [0·27-0·58]; I2=0%), increased risk of pregnancy loss after 20 weeks of gestation (2·77 [1·44-5·31]; I2=0%), and increased risk of preterm birth (1·65 [1·29-2·11]; I2=0%). Across studies, risk-of-bias assessment suggested considerable bias in study attrition and confounding. INTERPRETATION We identified previous lupus nephritis, chronic hypertension, SLE disease activity before and at conception, and secondary antiphospholipid syndrome as predictors of adverse pregnancy outcomes in women with SLE. These findings contribute to an optimal patient-tailored risk assessment in preconception counselling. FUNDING None.
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Affiliation(s)
- Merlijn Wind
- Department of Obstetrics, Leiden, Netherlands; Leiden University Medical Centre, Leiden, Netherlands; Department of Obstetrics, Haaglanden Medical Centre, The Hague, Netherlands.
| | - Juan J Fierro
- Department of Rheumatology and Clinical Immunology, University Medical Centre Groningen, Groningen, Netherlands; Grupo Reproducción, Departamento de Microbiología y Parasitología, Universidad de Antioquia UdeA, Medellín, Colombia
| | | | - Karina de Leeuw
- Department of Rheumatology and Clinical Immunology, University Medical Centre Groningen, Groningen, Netherlands
| | - A Titia Lely
- Department of Obstetrics, Utrecht, the Netherlands
| | - Maarten Limper
- Department of Rheumatology and Clinical Immunology, Utrecht, the Netherlands
| | | | | | | | - Judith Kooiman
- Department of Obstetrics, Utrecht, the Netherlands; University Medical Centre Utrecht, Utrecht, the Netherlands; Department of Obstetrics, Erasmus Medical Center, Rotterdam, Netherlands
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Potiris A, Fotiou A, Drakaki E, Potetsianaki A, Zikopoulos A, Moustakli E, Karampitsakos T, Topis S, Machairoudias P, Ouzouni S, Gerede A, Christopoulos P, Skentou C, Domali E, Drakakis P, Stavros S. Bridging the Gap between Galectin-3 Expression and Hypertensive Pregnancy Disorders: A Narrative Review. J Clin Med 2024; 13:4636. [PMID: 39200778 PMCID: PMC11354766 DOI: 10.3390/jcm13164636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2024] [Revised: 07/28/2024] [Accepted: 08/06/2024] [Indexed: 09/02/2024] Open
Abstract
Galectin-3 belongs to a family of soluble glycan-binding proteins, which are increasingly recognized as modulators of pregnancy-associated processes, including proper placental development. Gestational hypertension and preeclampsia are significant complications of pregnancy, affecting millions of women annually. Despite their prevalence, the underlying pathophysiological mechanisms remain poorly understood. Several theories have been proposed, including inflammation, placental insufficiency, disturbed placental invasion, and angiogenesis. The Scopus and PubMed/MEDLINE databases were utilized until the end of May 2024. In total, 11 articles with 1011 patients, with 558 in the control group and 453 in the preeclampsia group, were included. Seven articles investigated the expression of galectin-3 (Gal-3) in placental tissue samples, eight studies calculated the serum levels of Gal-3 in maternal blood samples, while one study referred to the possible correlation of galectin-3 levels in umbilical cord blood. The results were inconsistent in both the placental tissue and maternal serum; Gal-3 placental expression was found to be statistically increased in five studies compared to that in women without gestational hypertensive disorders, while two studies either mentioned decreased expression or no difference. Similarly, the Gal-3 maternal serum levels, compared to those in women without gestational hypertensive disorders, were found to be statistically increased in five studies, while three studies did not find any statistical difference. Gal-3 can play a crucial role in the pathogenesis of preeclampsia, and its expression is influenced by gestational age and placental insufficiency. A further investigation ought to be conducted to enlighten the correlation of Gal-3 with gestational hypertension and preeclampsia development.
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Affiliation(s)
- Anastasios Potiris
- Third Department of Obstetrics and Gynecology, University General Hospital “ATTIKON”, Medical School, National and Kapodistrian University of Athens, 12462 Athens, Greece; (A.F.); (A.Z.); (T.K.); (S.T.); (P.M.); (S.O.); (P.D.); (S.S.)
| | - Alexandros Fotiou
- Third Department of Obstetrics and Gynecology, University General Hospital “ATTIKON”, Medical School, National and Kapodistrian University of Athens, 12462 Athens, Greece; (A.F.); (A.Z.); (T.K.); (S.T.); (P.M.); (S.O.); (P.D.); (S.S.)
| | - Eirini Drakaki
- First Department of Obstetrics and Gynecology, Alexandra Hospital, Medical School, National and Kapodistrian University of Athens, 11528 Athens, Greece; (E.D.); (E.D.)
| | - Angeliki Potetsianaki
- School of Education and Social Sciences, Frederick University, 1036 Nicosia, Cyprus;
| | - Athanasios Zikopoulos
- Third Department of Obstetrics and Gynecology, University General Hospital “ATTIKON”, Medical School, National and Kapodistrian University of Athens, 12462 Athens, Greece; (A.F.); (A.Z.); (T.K.); (S.T.); (P.M.); (S.O.); (P.D.); (S.S.)
| | - Efthalia Moustakli
- Laboratory of Medical Genetics, Medical School, University of Ioannina, University of Ioannina, 45110 Ioannina, Greece;
| | - Theodoros Karampitsakos
- Third Department of Obstetrics and Gynecology, University General Hospital “ATTIKON”, Medical School, National and Kapodistrian University of Athens, 12462 Athens, Greece; (A.F.); (A.Z.); (T.K.); (S.T.); (P.M.); (S.O.); (P.D.); (S.S.)
| | - Spyridon Topis
- Third Department of Obstetrics and Gynecology, University General Hospital “ATTIKON”, Medical School, National and Kapodistrian University of Athens, 12462 Athens, Greece; (A.F.); (A.Z.); (T.K.); (S.T.); (P.M.); (S.O.); (P.D.); (S.S.)
| | - Pavlos Machairoudias
- Third Department of Obstetrics and Gynecology, University General Hospital “ATTIKON”, Medical School, National and Kapodistrian University of Athens, 12462 Athens, Greece; (A.F.); (A.Z.); (T.K.); (S.T.); (P.M.); (S.O.); (P.D.); (S.S.)
| | - Stamatoula Ouzouni
- Third Department of Obstetrics and Gynecology, University General Hospital “ATTIKON”, Medical School, National and Kapodistrian University of Athens, 12462 Athens, Greece; (A.F.); (A.Z.); (T.K.); (S.T.); (P.M.); (S.O.); (P.D.); (S.S.)
| | - Angeliki Gerede
- Department of Obstetrics and Gynecology, Democritus University of Thrace, 69100 Campus, Greece;
| | - Panagiotis Christopoulos
- Second Department of Obstetrics and Gynecology, Aretaieion University Hospital, Medical School, National and Kapodistrian University of Athens, 11528 Athens, Greece;
| | - Charikleia Skentou
- Department of Obstetrics and Gynecology, Medical School, University of Ioannina, 45110 Ioannina, Greece;
| | - Ekaterini Domali
- First Department of Obstetrics and Gynecology, Alexandra Hospital, Medical School, National and Kapodistrian University of Athens, 11528 Athens, Greece; (E.D.); (E.D.)
| | - Peter Drakakis
- Third Department of Obstetrics and Gynecology, University General Hospital “ATTIKON”, Medical School, National and Kapodistrian University of Athens, 12462 Athens, Greece; (A.F.); (A.Z.); (T.K.); (S.T.); (P.M.); (S.O.); (P.D.); (S.S.)
| | - Sofoklis Stavros
- Third Department of Obstetrics and Gynecology, University General Hospital “ATTIKON”, Medical School, National and Kapodistrian University of Athens, 12462 Athens, Greece; (A.F.); (A.Z.); (T.K.); (S.T.); (P.M.); (S.O.); (P.D.); (S.S.)
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Reynolds ML, Gibson KL, Manuck TA, Poulton CJ, Blazek L, Stuebe AM, Hogan SL, Falk RJ, Derebail VK. Lupus nephritis kidney biopsy characteristics and preterm birth. FRONTIERS IN NEPHROLOGY 2024; 4:1402597. [PMID: 39139800 PMCID: PMC11319279 DOI: 10.3389/fneph.2024.1402597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2024] [Accepted: 07/09/2024] [Indexed: 08/15/2024]
Abstract
Individuals with lupus nephritis (LN) are at high risk of adverse maternal and fetal outcomes in pregnancy. Outside of pregnancy, proliferative lesions on kidney biopsies are associated with disease progression, but these have not been consistently associated with increased risk in pregnancy. This retrospective, single-center study examines how histologic findings, the timing from kidney biopsy to pregnancy, and the clinical features in the first trimester are associated with preterm birth among individuals with LN. Among 35 deliveries in 31 women, the mean gestational age at delivery was 33.8 weeks. The presence of a urine protein-to-creatinine ratio >0.5 g/g in the first trimester was associated with preterm delivery (81% vs. 36%, p = 0.04). Preterm birth was more common in individuals with glomerular crescents on biopsy (89% in those with >20% crescents vs. 50% in those with <20%, p = 0.06). A pregnancy occurring within 2 years after a kidney biopsy was more likely to result in preterm birth than if the biopsy was performed more than 2 years prior to conception (82% vs. 23%, p = 0.01). The time from diagnostic biopsy may be a surrogate for disease activity, and a 2-year delay from biopsy might allow sufficient time to achieve disease remission. Overall, these data could aid family planning discussions and promote preconception disease optimization for patients and their providers.
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Affiliation(s)
- Monica L. Reynolds
- University of North Carolina (UNC) Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Keisha L. Gibson
- University of North Carolina (UNC) Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Tracy A. Manuck
- University of North Carolina (UNC) Maternal and Fetal Medicine, Division of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Caroline J. Poulton
- University of North Carolina (UNC) Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Lauren Blazek
- University of North Carolina (UNC) Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Alison M. Stuebe
- University of North Carolina (UNC) Maternal and Fetal Medicine, Division of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Susan L. Hogan
- University of North Carolina (UNC) Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Ronald J. Falk
- University of North Carolina (UNC) Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Vimal K. Derebail
- University of North Carolina (UNC) Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
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Huang J, Zhu Q, Wang B, Wang H, Xie Z, Zhu X, Zhao T, Yang Z. Antiphospholipid antibodies and the risk of adverse pregnancy outcomes in patients with systemic lupus erythematosus: a systematic review and meta-analysis. Expert Rev Clin Immunol 2024; 20:793-801. [PMID: 38445835 DOI: 10.1080/1744666x.2024.2324005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 02/12/2024] [Indexed: 03/07/2024]
Abstract
OBJECTIVE This article aims to evaluate the magnitude of adverse pregnancy outcomes (APOs) risks associated with different antiphospholipid antibody (aPL) profiles in women with systemic lupus erythematosus (SLE). METHODS Multiple databases were investigated to identify articles that explored the relationship between aPLs and APOs in SLE patients. A random effects model was used for calculating pooled odds ratios (OR). Stata version 15.0 was utilized to conduct the meta-analysis. RESULTS There were 5234 patients involved in 30 studies. Overall aPL was linked to an increased incidence of any kind of APOs, fetal loss, and preterm birth. Any kind of APOs and preterm delivery were more common in patients with lupus anticoagulant (LA) positive. Anticardiolipin antibody (aCL) was associated with an increased risk of any kind of APOs and fetal loss. The association between aCL-IgM and fetal loss was also significant. Patients with anti-beta2-glycoprotein1 antibody (antiβ2GP1) positivity had an increased risk of fetal loss. CONCLUSIONS Both LA and aCL were risk factors of APOs in patients with SLE. Not only ACL, particularly aCL-IgM, but antiβ2GP1 were associated with an increased risk of fetal loss, while LA appeared to indicate the risk of preterm birth.PROSPERO (CRD42023388122).
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Affiliation(s)
- Jinge Huang
- The First School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, China
| | - Qingmiao Zhu
- School of Basic Medical Sciences, Zhejiang Chinese Medical University, Hangzhou, China
| | - Baizhou Wang
- The First School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, China
| | - Hanzheng Wang
- The First School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, China
| | - Zhijun Xie
- School of Basic Medical Sciences, Zhejiang Chinese Medical University, Hangzhou, China
| | - Xingyu Zhu
- Department of Nephrology, Hangzhou TCM Hospital Affiliated to Zhejiang Chinese Medical University, Hangzhou, China
| | - Ting Zhao
- School of Basic Medical Sciences, Zhejiang Chinese Medical University, Hangzhou, China
| | - Zi Yang
- The Third School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, China
- Teaching Faculty, New Zealand College of Chinese Medicine, Greenlane, New Zealand
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Gamba A, Zen M, Depascale R, Calligaro A, Gatto M, Iaccarino L, Doria A. Modern Management of Pregnancy in Systemic Lupus Erythematosus: From Prenatal Counseling to Postpartum Support. J Clin Med 2024; 13:3454. [PMID: 38929983 PMCID: PMC11204490 DOI: 10.3390/jcm13123454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2024] [Revised: 06/05/2024] [Accepted: 06/12/2024] [Indexed: 06/28/2024] Open
Abstract
Systemic lupus erythematosus (SLE) is a chronic autoimmune disease that predominantly affects women of childbearing age. Pregnancy in SLE patients poses unique challenges due to the potential impact on maternal and fetal outcomes. We provide an overview of the management of SLE during pregnancy, including preconception risk stratification and counseling, treatment, and disease activity monitoring. These assessments are critical to minimize maternal and fetal adverse events in pregnant patients with SLE. Disease flares, preeclampsia, antiphospholipid syndrome complications, and maternal mortality are the major risks for a woman with SLE during gestation. Timely treatment of SLE relapse, differentiation of preeclampsia from lupus nephritis, and tailored management for antiphospholipid syndrome are essential for a successful pregnancy. Fetal outcomes include neonatal lupus (NL), preterm birth, cesarean delivery, fetal growth restriction (FGR), and small-for-gestational-age (SGA) infants. We focused on NL, linked to maternal anti-Ro/SS-A and anti-La/SS-B antibodies, which can lead to various manifestations, particularly cardiac abnormalities, in newborns. While there is a common consensus regarding the preventive effect of hydroxychloroquine, the role of echocardiographic monitoring and fluorinated steroid treatment is still debated. Finally, close postpartum monitoring and counseling for subsequent pregnancies are crucial aspects of care.
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Affiliation(s)
- Anna Gamba
- Rheumatology Unit, Department of Medicine-DIMED, University of Padova, 35128 Padova, Italy
| | - Margherita Zen
- Rheumatology Unit, Department of Medicine-DIMED, University of Padova, 35128 Padova, Italy
| | - Roberto Depascale
- Rheumatology Unit, Department of Medicine-DIMED, University of Padova, 35128 Padova, Italy
| | - Antonia Calligaro
- Rheumatology Unit, Department of Medicine-DIMED, University of Padova, 35128 Padova, Italy
| | - Mariele Gatto
- Academic Rheumatology Centre, Department of Clinical and Biological Sciences, University of Turin, AO Mauriziano di Torino, 10128 Turin, Italy
| | - Luca Iaccarino
- Rheumatology Unit, Department of Medicine-DIMED, University of Padova, 35128 Padova, Italy
| | - Andrea Doria
- Rheumatology Unit, Department of Medicine-DIMED, University of Padova, 35128 Padova, Italy
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Elahi T, Ahmed S, Mubarak M, Ahmed E. Maternal and fetal outcomes in pregnancy complicated by pre-existing lupus nephritis: Insights from a developing country Pakistan. Lupus 2024; 33:728-736. [PMID: 38594605 DOI: 10.1177/09612033241246642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2024]
Abstract
BACKGROUND Pregnancy in women with systemic lupus erythematosus (SLE) has remained a great challenge for clinicians in terms of maternal and fetal outcomes. The outcomes in women with pre-existing lupus nephritis (LN) are variable. The impact of different classes of LN on maternal and fetal outcomes during pregnancy is not well defined, as data is very scarce, especially from the developing countries. METHODS A retrospective analysis was conducted on 52 women with 89 pregnancies. All had biopsy-proven LN. Those women who conceived at least 6 months after the diagnosis were included. The analysis was conducted between July 1998 and June 2018 at Sindh Institute of Urology and Transplantation (SIUT), evaluating the outcomes for both the mother and the fetus with a minimum follow-up of 12 months after child birth. RESULTS The mean maternal age at SLE diagnosis was 21.45 ± 6 years and at first pregnancy was 26.49 ± 5.63 years. The mean disease duration was 14.02 ± 19.8 months. At conception, 47 (52.8%) women were hypertensive, 9 (10%) had active disease while 38 (42.7%) and 42 (47.2%) were in complete and partial remission, respectively. A total of 17 (19.1%) were on mycophenolate mofetil (MMF), which was switched to azathioprine (AZA). Out of 89 pregnancies, 56 (62.9%) were successful, while 33 (37.07%) had fetal complications like spontaneous abortion, stillbirth, perinatal death, and intrauterine growth retardation (IUGR). There were more vaginal deliveries (33 [58.92%]) than caesarean sections (23 [41.07%]). Renal flare was observed in 33 (37.1%) women while 15 (16.9%) developed pre-eclampsia. Proliferative LN was found in 56 (62.9%) cases, but no significant differences were found in maternal and fetal outcomes in relation to LN classes (p = .58). However, disease outcomes at 12 months were significantly poor in those with active disease at the time of conception (p < .05). There was only one maternal death. A total of 10 (11.2%) women showed deterioration in renal function and 5 (5.6%) were dialysis-dependent at 12 months. CONCLUSION The maternal and fetal outcomes in pre-existing LN depend on the disease activity at the time of conception. No correlation was found between International Society of Nephrology/Renal Pathology Society (ISN/RPS) classes of LN and adverse disease and pregnancy outcomes.
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Affiliation(s)
- Tabassum Elahi
- Department of Nephrology, Sindh Institute of Urology and Transplantation, Karachi, Pakistan
| | - Saima Ahmed
- Department of Nephrology, Sindh Institute of Urology and Transplantation, Karachi, Pakistan
| | - Muhammed Mubarak
- Department of Histopathology, Sindh Institute of Urology and Transplantation, Karachi, Pakistan
| | - Ejaz Ahmed
- Department of Nephrology, Sindh Institute of Urology and Transplantation, Karachi, Pakistan
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Muñoz Muñoz C, Farinha F, McDonnell T, J'bari H, Nguyen H, Isenberg D, Rahman A, Williams D, Alijotas-Reig J, Giles I. Comparing pregnancy outcomes in patients with Systemic Lupus Erythematosus (SLE) and Undifferentiated Connective Tissue Disease (UCTD): a descriptive cohort study. Rev Clin Esp 2024; 224:357-365. [PMID: 38670225 DOI: 10.1016/j.rceng.2024.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Accepted: 04/13/2024] [Indexed: 04/28/2024]
Abstract
BACKGROUND Females diagnosed with systemic lupus erythematosus (SLE) face an elevated risk of adverse pregnancy outcomes (APOs). However, the evidence regarding whether a similar association exists in patients with undifferentiated connective tissue disease (UCTD) is inconclusive. METHODS We conducted a retrospective review (2006-2019) of pregnancy outcomes among patients with SLE (n = 51) and UCTD (n = 20) within our institution. We examined the occurrence of various APOs, encompassing miscarriage, stillbirth, termination, preterm birth, pre-eclampsia, eclampsia, HELLP syndrome, intrauterine growth restriction, abruption placentae, congenital heart block, or other cardiac abnormalities. RESULTS The mean age at pregnancy was 35 ± 7.0 years for patients with SLE and 35 ± 6.8 years for those with UCTD (p = 0.349). The proportion of Caucasian women was 47% in SLE and 80% in UCTD. Pregnancies in both groups were planned (81% in SLE and 77% in UCTD), and patients presented with inactive disease at conception (96% in SLE and 89% in UCTD). Hydroxychloroquine at conception was utilized by 86% of women with SLE, in contrast to 36% in the UCTD group. Both, SLE and UCTD cohorts exhibited low rates of disease flares during pregnancy and/or puerperium (14% vs. 10%). The incidence of APOs was 15.6% in SLE patients compared to 5% in those with UCTD (Risk difference 19.5%; 95% confidence interval: -3.9 to 43.1; p = 0.4237). CONCLUSION Our study underscores the importance of strategic pregnancy planning and the maintenance of appropriate treatment throughout pregnancy to ensure optimal disease management and minimize adverse outcomes in both SLE and UCTD pregnancies.
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Affiliation(s)
- Candido Muñoz Muñoz
- Centre for Rheumatology, Division of Medicine, University College London, London, UK; Systemic Autoimmune Disease Unit, Department of Medicine, Vall d'Hebron University Hospital, Barcelona, Spain.
| | - Filipa Farinha
- Centre for Rheumatology, Division of Medicine, University College London, London, UK; Rheumatology, Hospital Distrital de Santarém, Santarém, Portugal
| | - Thomas McDonnell
- Department of Biochemical Engineering, University College London, London, UK
| | - Hajar J'bari
- Centre for Rheumatology, Division of Medicine, University College London, London, UK
| | - Hanh Nguyen
- Centre for Rheumatology, Division of Medicine, University College London, London, UK
| | - David Isenberg
- Centre for Rheumatology, Division of Medicine, University College London, London, UK
| | - Anisur Rahman
- Centre for Rheumatology, Division of Medicine, University College London, London, UK
| | - David Williams
- Women's Health, University College London Hospital NHS Foundation Trust, London, UK
| | - Jaume Alijotas-Reig
- Systemic Autoimmune Disease Unit, Department of Medicine, Vall d'Hebron University Hospital, Barcelona, Spain.
| | - Ian Giles
- Centre for Rheumatology, Division of Medicine, University College London, London, UK
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Zhu S, Ren J, Feng L, Jiang Y. Systemic Lupus Erythematosus and Pregnancy Complications and Outcomes: A Mendelian Randomization Study and Retrospective Validation. Int J Womens Health 2024; 16:891-902. [PMID: 38779383 PMCID: PMC11110830 DOI: 10.2147/ijwh.s461640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 05/11/2024] [Indexed: 05/25/2024] Open
Abstract
Introduction Previous studies have shown that pregnant women with systemic lupus erythematosus (SLE) tend to have a higher risk of adverse pregnancy outcomes, but the potential causal role remained unclear. In this study, we aimed to investigate the causal relationship between SLE and some common pregnancy complications and outcomes using two-sample Mendelian randomization (MR). Methods The genetic tools were derived from genome-wide association studies of SLE and pregnancy complications and outcomes. MR analysis was performed using inverse variance weighting as primary method. Sensitivity analyses were performed to evaluate the robustness of the results. A retrospective analysis was conducted on 200 pregnant women with SLE and a control group of pregnant women delivering at Tongji Hospital. Results In the results, we found that genetic susceptibility to SLE was associated with a higher risk of gestational diabetes mellitus (OR = 1.028, 95% CI: 1.006-1.050), premature delivery (OR = 1.039, 95% CI: 1.013-1.066), polyhydramnios (OR = 1.075, 95% CI: 1.004-1.151) and premature rupture of membranes (OR = 1.030, 95% CI: 1.001-1.060). Some of the retrospective analysis results align with the findings from the MR analysis, indicating that pregnant women with SLE have a higher risk of developing gestational diabetes mellitus and preterm birth. Additionally, although MR analysis did not reveal a causal relationship between SLE and preeclampsia/eclampsia, retrospective analysis discovered that SLE pregnant women are more susceptible to developing preeclampsia/eclampsia (OR = 2.935, 95% CI: 1.118-7.620). Conclusion Our study findings suggest a potential causal relationship between SLE and increased risks of gestational diabetes and preterm delivery. Clinical data indicate that pregnant women with SLE are more prone to developing preeclampsia/eclampsia. Clinicians need to be vigilant about the occurrence of these conditions when managing pregnant women with SLE.
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Affiliation(s)
- Shenglan Zhu
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430030, People’s Republic of China
| | - Junlin Ren
- Department of Computer Science, Huazhong University of Science and Technology, Wuhan, 430074, People’s Republic of China
| | - Ling Feng
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430030, People’s Republic of China
| | - Yi Jiang
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430030, People’s Republic of China
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Dai Q, Li M, Tian X, Song Y, Zhao J. Predictive Factors for the Common Adverse Maternal and Fetal Outcomes in Pregnancies Complicated by Systemic Lupus Erythematosus. WOMEN'S HEALTH REPORTS (NEW ROCHELLE, N.Y.) 2024; 5:434-443. [PMID: 39035137 PMCID: PMC11257104 DOI: 10.1089/whr.2023.0180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/03/2024] [Indexed: 07/23/2024]
Abstract
Objectives This study aimed to evaluate the outcomes of pregnancy in patients with systemic lupus erythematosus (SLE). It focused on identifying clinical and laboratory markers that could predict the common adverse pregnancy outcomes (APOs) after 20 weeks of gestation, namely preeclampsia (PE) and preterm birth (PTB) in them. Methods Pregnant SLE women who delivered at the study center from 2010 to 2023 were retrospectively analyzed. Categorical variables were evaluated using the chi-square test or Fisher's exact test, while continuous variables underwent Mann-Whitney U testing. Stepwise regression was used to assess the predictors of pregnancy outcomes. Results The study enrolled 445 pregnancies in 408 women diagnosed with SLE. Of these, 202 pregnancies (45.4%) resulted in at least one APO. Disease flare-ups, hypertension, and proteinuria during the first trimester were primary predictors of at least one APO and PTB. The most frequently recorded maternal adverse outcome was PE (14.6%), while PTB accounted for 32.6% of fetal adverse outcomes. Multivariate regression analysis identified hypertension, history of PE, associated antiphospholipid syndrome (APS), proteinuria, and low serum C4 in the first trimester as independent risk factors for PE. Regular follow-ups at our center correlated with lower risks of APOs, PE, and PTB. APS also emerged as a risk factor for PTB, whereas the use of hydroxychloroquine (HCQ) during pregnancy seemed to protect against PTB. Conclusion For pregnancies complicated by SLE, we recommend early pregnancy screening for proteinuria-even in the absence of lupus nephritis-as well as continued use of HCQ and routine prenatal care throughout pregnancy.
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Affiliation(s)
- Qianwen Dai
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Beijing, China
| | - Mengtao Li
- Dept of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Xinping Tian
- Dept of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Yijun Song
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Beijing, China
| | - Jiuliang Zhao
- Dept of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
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Saavedra MÁ, Gracia-Aréchiga TS, Miranda-Hernández D, Sánchez A, Arrucha-Cozaya M, Cruz-Domínguez MDP. Active but not quiescent lupus nephritis during pregnancy is associated with a higher rate of adverse obstetric outcomes: Analysis of a prospective cohort. Int J Gynaecol Obstet 2024. [PMID: 38736284 DOI: 10.1002/ijgo.15601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Revised: 04/08/2024] [Accepted: 04/28/2024] [Indexed: 05/14/2024]
Abstract
OBJECTIVE To compare the maternal-fetal/neonatal outcome in patients with systemic lupus erythematosus (SLE) with and without lupus nephritis (LN) in remission or with active disease. METHODS A prospective cohort of pregnant patients with SLE (ACR 1997 criteria) was studied from January 2009 to December 2021. Demographic, clinical, biochemical, and immunological variables as well as the usual maternal-fetal/neonatal complications were recorded. We compared four groups according to the status of SLE during pregnancy: patients with quiescent SLE without lupus nephritis, patients with active SLE without lupus nephritis, patients with quiescent lupus nephritis, and patients with active lupus nephritis. Statistical analysis included descriptive statistics, bivariate analysis, and Cox regression analysis. RESULTS A total of 439 pregnancies were studied, with a median age of 28 ± 6, SLE duration of 60 months (interquartile range 36-120). A higher frequency of maternal and fetal/neonatal complications was observed in patients with active SLE with or without lupus nephritis. Multivariate analysis showed that active LN was a risk factor for gestational hypertension (hazard ratios [HR] 1.95; 95% confidence intervals [CI]: 1.01-6.39), premature rupture of membranes (HR 3.56; 95% CI: 1.79-16.05) and more frequent cesarean section (HR 1.82; 95% CI: 1.13-2.94). CONCLUSION LN is associated with a higher frequency of maternal complications, especially in those patients with active disease during pregnancy, and those maternal complications had an impact on poor fetal/neonatal outcomes. Strict control and timely care of LN could improve the obstetric prognosis.
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Affiliation(s)
- Miguel Ángel Saavedra
- División de Investigación en Salud, Hospital de Especialidades Dr. Antonio Fraga Mouret, Centro Médico Nacional La Raza, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - Tayde Sarahí Gracia-Aréchiga
- Departamento de Reumatología, Hospital de Especialidades Dr. Antonio Fraga Mouret, Centro Médico Nacional La Raza, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - Dafhne Miranda-Hernández
- Departamento de Reumatología, Hospital de Especialidades Dr. Antonio Fraga Mouret, Centro Médico Nacional La Raza, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - Antonio Sánchez
- Departamento de Reumatología, Hospital de Especialidades Dr. Antonio Fraga Mouret, Centro Médico Nacional La Raza, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | | | - María Del Pilar Cruz-Domínguez
- Dirección de Educación e Investigación en Salud, Hospital de Especialidades Dr. Antonio Fraga Mouret, Centro Médico Nacional La Raza, México City, Mexico
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Di Ludovico A, Rinaldi M, Mainieri F, Di Michele S, Girlando V, Ciarelli F, La Bella S, Chiarelli F, Attanasi M, Mauro A, Bizzi E, Brucato A, Breda L. Molecular Mechanisms of Fetal and Neonatal Lupus: A Narrative Review of an Autoimmune Disease Transferal across the Placenta. Int J Mol Sci 2024; 25:5224. [PMID: 38791261 PMCID: PMC11120786 DOI: 10.3390/ijms25105224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Revised: 05/01/2024] [Accepted: 05/08/2024] [Indexed: 05/26/2024] Open
Abstract
This study, conducted by searching keywords such as "maternal lupus", "neonatal lupus", and "congenital heart block" in databases including PubMed and Scopus, provides a detailed narrative review on fetal and neonatal lupus. Autoantibodies like anti-Ro/SSA and anti-La/SSB may cross the placenta and cause complications in neonates, such as congenital heart block (CHB). Management options involve hydroxychloroquine, which is able to counteract some of the adverse events, although the drug needs to be used carefully because of its impact on the QTc interval. Advanced pacing strategies for neonates with CHB, especially in severe forms like hydrops, are also assessed. This review emphasizes the need for interdisciplinary care by rheumatologists, obstetricians, and pediatricians in order to achieve the best maternal and neonatal health in lupus pregnancies. This multidisciplinary approach seeks to improve the outcomes and management of the disease, decreasing the burden on mothers and their infants.
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Affiliation(s)
- Armando Di Ludovico
- Paediatric Department, University of Chieti “G. D’Annunzio”, 66100 Chieti, Italy; (A.D.L.); (F.M.); (V.G.); (F.C.); (S.L.B.); (F.C.); (M.A.)
| | - Marta Rinaldi
- Paediatric Department, Buckinghamshire Healthcare NHS Trust, Aylesbury-Thames Valley Deanery, Aylesbury HP21 8AL, UK;
| | - Francesca Mainieri
- Paediatric Department, University of Chieti “G. D’Annunzio”, 66100 Chieti, Italy; (A.D.L.); (F.M.); (V.G.); (F.C.); (S.L.B.); (F.C.); (M.A.)
| | - Stefano Di Michele
- Department of Surgical Science, Division of Obstetrics and Gynecology, University of Cagliari, Cittadella Universitaria Blocco I, Asse didattico Medicina P2, Monserrato, 09042 Cagliari, Italy;
| | - Virginia Girlando
- Paediatric Department, University of Chieti “G. D’Annunzio”, 66100 Chieti, Italy; (A.D.L.); (F.M.); (V.G.); (F.C.); (S.L.B.); (F.C.); (M.A.)
| | - Francesca Ciarelli
- Paediatric Department, University of Chieti “G. D’Annunzio”, 66100 Chieti, Italy; (A.D.L.); (F.M.); (V.G.); (F.C.); (S.L.B.); (F.C.); (M.A.)
| | - Saverio La Bella
- Paediatric Department, University of Chieti “G. D’Annunzio”, 66100 Chieti, Italy; (A.D.L.); (F.M.); (V.G.); (F.C.); (S.L.B.); (F.C.); (M.A.)
| | - Francesco Chiarelli
- Paediatric Department, University of Chieti “G. D’Annunzio”, 66100 Chieti, Italy; (A.D.L.); (F.M.); (V.G.); (F.C.); (S.L.B.); (F.C.); (M.A.)
| | - Marina Attanasi
- Paediatric Department, University of Chieti “G. D’Annunzio”, 66100 Chieti, Italy; (A.D.L.); (F.M.); (V.G.); (F.C.); (S.L.B.); (F.C.); (M.A.)
| | - Angela Mauro
- Pediatric Rheumatology Unit, Department of Childhood and Developmental Medicine, Fatebenefratelli—Sacco Hospital, Piazzale Principessa Clotilde, 20121 Milan, Italy
| | - Emanuele Bizzi
- Division of Internal Medicine, ASST Fatebenefratelli Sacco, Fatebenefratelli Hospital, University of Milan, 20121 Milan, Italy; (E.B.); (A.B.)
| | - Antonio Brucato
- Division of Internal Medicine, ASST Fatebenefratelli Sacco, Fatebenefratelli Hospital, University of Milan, 20121 Milan, Italy; (E.B.); (A.B.)
- Department of Biomedical and Clinical Sciences “Sacco”, University of Milano, Ospedale Fatebenefratelli, 20121 Milan, Italy
| | - Luciana Breda
- Paediatric Department, University of Chieti “G. D’Annunzio”, 66100 Chieti, Italy; (A.D.L.); (F.M.); (V.G.); (F.C.); (S.L.B.); (F.C.); (M.A.)
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Cozzi GD, Battarbee AN, Sanjanwala AR, Casey BM, Subramaniam A. Association of Maternal Medical Comorbidities with Duration of Expectant Management in Patients with Severe Preeclampsia. Am J Perinatol 2024; 41:e1521-e1530. [PMID: 37072011 PMCID: PMC10582202 DOI: 10.1055/s-0043-1768232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/20/2023]
Abstract
OBJECTIVE This study aimed to estimate the association between number of maternal comorbidities and duration of expectant management and perinatal outcomes in patients with preeclampsia with severe features. STUDY DESIGN Retrospective cohort of patients with preeclampsia with severe features delivering live, nonanomalous singletons at 23 to 342/7 weeks' gestation at a single center from 2016 to 2018. Patients delivered for an indication other than severe preeclampsia were excluded. Patients were categorized based on the number (0, 1, or ≥2) of comorbidities present: chronic hypertension, pregestational diabetes, chronic kidney disease, and systemic lupus erythematosus. The primary outcome was proportion of potential expectant management time achieved, that is, days of expectant management achieved divided by total potential expectant management time (days from severe preeclampsia diagnosis to 340/7 weeks). Secondary outcomes included delivery gestational age, days of expectant management, and perinatal outcomes. Outcomes were compared in bivariable and multivariable analyses. RESULTS Of 337 patients included, 167 (50%) had 0, 151 (45%) had 1, and 19 (5%) had ≥2 comorbidities. Groups differed with respect to age, body mass index, race/ethnicity, insurance, and parity. The median proportion of potential expectant management achieved in this cohort was 1.8% (interquartile range: 0-15.4), and did not differ by number of comorbidities (adjusted β: 5.3 [95% confidence interval [CI]: -2.1 to 12.9] for 1 comorbidity vs. 0 and adjusted β: -2.9 [95% CI: -18.0 to 12.2] for ≥2 comorbidities vs. 0). There was no difference in delivery gestational age or duration of expectant management in days. Patients with ≥2 (vs. 0) comorbidities had higher odds of composite maternal morbidity (adjusted odds ratio: 3.0 [95% CI: 1.1-8.2]). There was no association between number of comorbidities and composite neonatal morbidity. CONCLUSION Among patients with preeclampsia with severe features, the number of comorbidities was not associated with duration of expectant management; however, patients with ≥2 comorbidities had higher odds of adverse maternal outcomes. KEY POINTS · Greater number of medical comorbidities were not associated with expectant management duration.. · Two or more medical comorbidities were associated with higher odds of adverse maternal outcomes.. · Expectant management should be undertaken cautiously in medically complicated patients..
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Affiliation(s)
- Gabriella D. Cozzi
- Division of Maternal Fetal Medicine Center for Women’s Reproductive Health, University of Alabama at Birmingham, Alabama
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Alabama
| | - Ashley N. Battarbee
- Division of Maternal Fetal Medicine Center for Women’s Reproductive Health, University of Alabama at Birmingham, Alabama
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Alabama
| | - Aalok R. Sanjanwala
- Division of Maternal Fetal Medicine Center for Women’s Reproductive Health, University of Alabama at Birmingham, Alabama
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Alabama
| | - Brian M. Casey
- Division of Maternal Fetal Medicine Center for Women’s Reproductive Health, University of Alabama at Birmingham, Alabama
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Alabama
| | - Akila Subramaniam
- Division of Maternal Fetal Medicine Center for Women’s Reproductive Health, University of Alabama at Birmingham, Alabama
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Alabama
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Wu Y, Yu X, Li M, Zhu J, Yue J, Wang Y, Man Y, Zhou C, Tong R, Wu X. Risk prediction model based on machine learning for predicting miscarriage among pregnant patients with immune abnormalities. Front Pharmacol 2024; 15:1366529. [PMID: 38711993 PMCID: PMC11070771 DOI: 10.3389/fphar.2024.1366529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Accepted: 04/03/2024] [Indexed: 05/08/2024] Open
Abstract
Introduction: It is known that patients with immune-abnormal co-pregnancies are at a higher risk of adverse pregnancy outcomes. Traditional pregnancy risk management systems have poor prediction abilities for adverse pregnancy outcomes in such patients, with many limitations in clinical application. In this study, we will use machine learning to screen high-risk factors for miscarriage and develop a miscarriage risk prediction model for patients with immune-abnormal pregnancies. This model aims to provide an adjunctive tool for the clinical identification of patients at high risk of miscarriage and to allow for active intervention to reduce adverse pregnancy outcomes. Methods: Patients with immune-abnormal pregnancies attending Sichuan Provincial People's Hospital were collected through electronic medical records (EMR). The data were divided into a training set and a test set in an 8:2 ratio. Comparisons were made to evaluate the performance of traditional pregnancy risk assessment tools for clinical applications. This analysis involved assessing the cost-benefit of clinical treatment, evaluating the model's performance, and determining its economic value. Data sampling methods, feature screening, and machine learning algorithms were utilized to develop predictive models. These models were internally validated using 10-fold cross-validation for the training set and externally validated using bootstrapping for the test set. Model performance was assessed by the area under the characteristic curve (AUC). Based on the best parameters, a predictive model for miscarriage risk was developed, and the SHapley additive expansion (SHAP) method was used to assess the best model feature contribution. Results: A total of 565 patients were included in this study on machine learning-based models for predicting the risk of miscarriage in patients with immune-abnormal pregnancies. Twenty-eight risk warning models were developed, and the predictive model constructed using XGBoost demonstrated the best performance with an AUC of 0.9209. The SHAP analysis of the best model highlighted the total number of medications, as well as the use of aspirin and low molecular weight heparin, as significant influencing factors. The implementation of the pregnancy risk scoring rules resulted in accuracy, precision, and F1 scores of 0.3009, 0.1663, and 0.2852, respectively. The economic evaluation showed a saving of ¥7,485,865.7 due to the model. Conclusion: The predictive model developed in this study performed well in estimating the risk of miscarriage in patients with immune-abnormal pregnancies. The findings of the model interpretation identified the total number of medications and the use of other medications during pregnancy as key factors in the early warning model for miscarriage risk. This provides an important basis for early risk assessment and intervention in immune-abnormal pregnancies. The predictive model developed in this study demonstrated better risk prediction performance than the Pregnancy Risk Management System (PRMS) and also demonstrated economic value. Therefore, miscarriage risk prediction in patients with immune-abnormal pregnancies may be the most cost-effective management method.
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Affiliation(s)
- Yue Wu
- Department of Pharmacy, Personalised Drug Therapy Key Laboratory of Sichuan Province, Sichuan Academy of Medical Sciences and Sichuan Provincial People’s Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Xixuan Yu
- School of Pharmacy, Chengdu Medical College, Chengdu, China
| | - Mengting Li
- Department of Pharmacy, Personalised Drug Therapy Key Laboratory of Sichuan Province, Sichuan Academy of Medical Sciences and Sichuan Provincial People’s Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Jing Zhu
- Department of Rheumatology and Immunology, Sichuan Provincial People’s Hospital, Chengdu, China
| | - Jun Yue
- Department of Gynaecology and Obstetrics, Sichuan Provincial People’s Hospital, Chengdu, China
| | - Yan Wang
- Department of Gynaecology and Obstetrics, Sichuan Provincial People’s Hospital, Chengdu, China
| | - Yicun Man
- Department of Gynaecology and Obstetrics, Sichuan Provincial People’s Hospital, Chengdu, China
| | - Chao Zhou
- Department of Gastroenterology, Sichuan Provincial People’s Hospital, Chengdu, China
| | - Rongsheng Tong
- Department of Pharmacy, Personalised Drug Therapy Key Laboratory of Sichuan Province, Sichuan Academy of Medical Sciences and Sichuan Provincial People’s Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Xingwei Wu
- Department of Pharmacy, Personalised Drug Therapy Key Laboratory of Sichuan Province, Sichuan Academy of Medical Sciences and Sichuan Provincial People’s Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
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18
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Bafor EE, Erwin-Cohen RA, Martin T, Baker C, Kimmel AE, Duverger O, Fenimore JM, Ramba M, Spindel T, Hess MM, Sanford M, Lazarevic V, Benayoun BA, Young HA, Valencia JC. Aberrant CD8 +T cells drive reproductive dysfunction in female mice with elevated IFN-γ levels. Front Immunol 2024; 15:1368572. [PMID: 38698852 PMCID: PMC11064017 DOI: 10.3389/fimmu.2024.1368572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 03/22/2024] [Indexed: 05/05/2024] Open
Abstract
Introduction Interferon-gamma (IFN-γ) is pivotal in orchestrating immune responses during healthy pregnancy. However, its dysregulation, often due to autoimmunity, infections, or chronic inflammatory conditions, is implicated in adverse reproductive outcomes such as pregnancy failure or infertility. Additionally, the underlying immunological mechanisms remain elusive. Methods Here, we explore the impact of systemic IFN-γ elevation on cytotoxic T cell responses in female reproduction utilizing a systemic lupus-prone mouse model with impaired IFN-γ degradation. Results Our findings reveal that heightened IFN-γ levels triggered the infiltration of CD8+T cells in the pituitary gland and female reproductive tract (FRT), resulting in prolactin deficiency and subsequent infertility. Furthermore, we demonstrate that chronic IFN-γ elevation increases effector memory CD8+T cells in the murine ovary and uterus. Discussion These insights broaden our understanding of the role of elevated IFN-γ in female reproductive dysfunction and suggest CD8+T cells as potential immunotherapeutic targets in female reproductive disorders associated with chronic systemic IFN-γ elevation.
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Affiliation(s)
- Enitome E. Bafor
- Cancer Innovation Laboratory, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Frederick, MD, United States
| | - Rebecca A. Erwin-Cohen
- Cancer Innovation Laboratory, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Frederick, MD, United States
| | - Toni Martin
- Cancer Innovation Laboratory, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Frederick, MD, United States
| | - Clayton Baker
- Leonard Davis School of Gerontology, University of Southern California, Los Angeles, CA, United States
- Molecular and Computational Biology Department, University of Southern California, Dornsife College of Letters, Arts and Sciences, Los Angeles, CA, United States
| | - Adrienne E. Kimmel
- Cancer Innovation Laboratory, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Frederick, MD, United States
| | - Olivier Duverger
- Craniofacial Anomalies and Regeneration Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, United States
| | - John M. Fenimore
- Cancer Innovation Laboratory, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Frederick, MD, United States
| | - Meredith Ramba
- Cancer Innovation Laboratory, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Frederick, MD, United States
| | - Thea Spindel
- Cancer Innovation Laboratory, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Frederick, MD, United States
| | - Megan M. Hess
- Cancer Innovation Laboratory, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Frederick, MD, United States
| | - Michael Sanford
- Cancer Innovation Laboratory, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Frederick, MD, United States
| | - Vanja Lazarevic
- Experimental Immunology Branch, Center for Cancer Research, National Cancer Institute, Bethesda, MD, United States
| | - Bérénice A. Benayoun
- Leonard Davis School of Gerontology, University of Southern California, Los Angeles, CA, United States
- Molecular and Computational Biology Department, University of Southern California, Dornsife College of Letters, Arts and Sciences, Los Angeles, CA, United States
| | - Howard A. Young
- Cancer Innovation Laboratory, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Frederick, MD, United States
| | - Julio C. Valencia
- Cancer Innovation Laboratory, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Frederick, MD, United States
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19
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Isojima S, Yajima N, Yanai R, Miura Y, Fukuma S, Kaneko K, Fujio K, Oku K, Matsushita M, Miyamae T, Wada T, Tanaka Y, Kaneko Y, Nakajima A, Murashima A. Physician approval for pregnancy in patients with systemic lupus erythematosus showing only serological activity: A vignette survey study. Mod Rheumatol 2024; 34:509-514. [PMID: 37243689 DOI: 10.1093/mr/road049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 03/03/2023] [Accepted: 05/24/2023] [Indexed: 05/29/2023]
Abstract
OBJECTIVE The European League Against Rheumatism recommends that the disease activity of systemic lupus erythematosus should be stable before pregnancy because complications and disease flares increase if pregnancy occurs while disease activity is high. However, some patients have ongoing serological activity even after treatment. Herein, we investigated how physicians decide on the acceptability of pregnancy in patients showing only serological activity. METHODS A questionnaire was administered from December 2020 to January 2021. It included the characteristics of physicians, facilities, and the allowance for pregnancies of patients using vignette scenarios. RESULTS The questionnaire was distributed to 4946 physicians, and 9.4% responded. The median age of respondents was 46 years, and 85% were rheumatologists. Pregnancy allowance was significantly affected by the duration of the stable period and status of serological activity [duration: proportion difference 11.8 percentage points (p.p.), P < .001; mild activity: proportion difference -25.8 p.p., P < .001; high activity: proportion difference -65.6 p.p., P < .001]. For patients with high-level serological activity, 20.5% of physicians allowed pregnancy if there were no clinical symptoms for 6 months. CONCLUSIONS Serological activity had a significant effect on the acceptability of pregnancy. However, some physicians allowed patients with serological activity alone to become pregnant. Further observational studies are required to clarify such prognoses.
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Affiliation(s)
- Sakiko Isojima
- Division of Rheumatology, Department of Internal Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Nobuyuki Yajima
- Division of Rheumatology, Department of Internal Medicine, Showa University School of Medicine, Tokyo, Japan
- Department of Healthcare Epidemiology, Kyoto University Graduate School of Medicine and Public Health, Kyoto, Japan
- Center for Innovative Research for Communities and Clinical Excellence, Fukushima Medical University, Fukushima, Japan
| | - Ryo Yanai
- Division of Rheumatology, Department of Internal Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Yoko Miura
- Division of Rheumatology, Department of Internal Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Shingo Fukuma
- Human Health Sciences, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Kayoko Kaneko
- Division of Maternal Medicine, Center of Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Keishi Fujio
- Department of Allergy and Rheumatology, Graduate School of Medicine and Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kenji Oku
- Department of Rheumatology and Infectious Diseases, Kitasato University School of Medicine, Kanagawa, Japan
| | - Masakazu Matsushita
- Department of Internal Medicine and Rheumatology, Juntendo University School of Medicine, Tokyo, Japan
| | - Takako Miyamae
- Department of Pediatric Rheumatology, Institute of Rheumatology, Tokyo Women's Medical University Hospital, Tokyo, Japan
- Division of Rheumatology, Department of Internal Medicine, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Takashi Wada
- Department of Nephrology and Laboratory Medicine, Kanazawa University, Ishikawa, Japan
| | - Yoshiya Tanaka
- The First Department of Internal Medicine, University of Occupational and Environmental Health, Fukuoka, Japan
| | - Yuko Kaneko
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Ayako Nakajima
- Center for Rheumatic Diseases, Mie University Hospital, Tsu, Japan
| | - Atsuko Murashima
- Division of Maternal Medicine, Center of Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
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20
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Abheiden CNH, Blomjous BS, Slaager C, Landman AJEMC, Ket JCF, Salmon JE, Buyon JP, Heymans MW, de Vries JIP, Bultink IEM, de Boer MA. Systemic lupus erythematosus is associated with an increased frequency of spontaneous preterm births: systematic review and meta-analysis. Am J Obstet Gynecol 2024:S0002-9378(24)00439-3. [PMID: 38492714 DOI: 10.1016/j.ajog.2024.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 03/06/2024] [Accepted: 03/06/2024] [Indexed: 03/18/2024]
Abstract
OBJECTIVE Preterm birth is one of the most frequent complications of pregnancy in women with systemic lupus erythematosus. The high indicated preterm birth proportion due to hypertensive disorders of pregnancy and/or fetal growth restriction is well known, and preventive measures and screening for early detection are performed. The risk of spontaneous preterm birth is less well recognized. This study aimed to determine the proportions of spontaneous and indicated preterm birth in pregnancies of women with systemic lupus erythematosus. DATA SOURCES A systematic literature search using Pubmed, Embase, Web of Science, and Google Scholar was performed in June 2021. STUDY ELIGIBILITY CRITERIA Studies in pregnant women with systemic lupus erythematosus reporting spontaneous and indicated preterm birth rates were selected. Original research articles published from 1995 to June 2021 were included. METHODS Quality and risk of bias of the included studies were assessed using the Newcastle-Ottawa quality assessment scale. To estimate the pooled event rates and 95% confidence intervals, meta-analysis of single proportions with a random-effects model was performed. RESULTS We included 21 articles, containing data of 8157 pregnancies in women with systemic lupus erythematosus. On average, 31% (95% prediction interval, 0.14-0.50) of the pregnancies resulted in preterm birth, including 14% (95% prediction interval, 0.04-0.27) spontaneous and 16% (95% prediction interval, 0.03-0.35) indicated preterm birth. CONCLUSION In pregnant women with systemic lupus erythematosus, spontaneous and indicated preterm birth proportions are high. This information should be applied in (prepregnancy) counseling and management in pregnancy. The knowledge obtained by this meta-analysis paves the way for further research of associated risk factors and development of interventions to reduce spontaneous preterm birth in systemic lupus erythematosus pregnancies.
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Affiliation(s)
- Carolien N H Abheiden
- Department of Obstetrics and Gynaecology, Amsterdam University Medical Center, Amsterdam, the Netherlands; Amsterdam Reproduction and Development Research Institute, Amsterdam, the Netherlands.
| | - Birgit S Blomjous
- Department of Rheumatology and Clinical Immunology, Amsterdam Rheumatology and Immunology Center, Amsterdam University Medical Center, Amsterdam, the Netherlands; Amsterdam institute for Immunology and Infectious Diseases, Amsterdam, the Netherlands
| | - Ciska Slaager
- Department of Gynecology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Anadeijda J E M C Landman
- Department of Obstetrics and Gynaecology, Amsterdam University Medical Center, Amsterdam, the Netherlands; Amsterdam Reproduction and Development Research Institute, Amsterdam, the Netherlands
| | - Johannes C F Ket
- Medical Library, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Jane E Salmon
- Hospital for Special Surgery, Weill Cornell Medical College, New York, NY
| | - Jill P Buyon
- NYU Grossman School of Medicine, New York University, New York, NY
| | - Martijn W Heymans
- Department of Epidemiology and Data Science, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Johanna I P de Vries
- Department of Obstetrics and Gynaecology, Amsterdam University Medical Center, Amsterdam, the Netherlands; Amsterdam Reproduction and Development Research Institute, Amsterdam, the Netherlands
| | - Irene E M Bultink
- Department of Rheumatology and Clinical Immunology, Amsterdam Rheumatology and Immunology Center, Amsterdam University Medical Center, Amsterdam, the Netherlands; Amsterdam institute for Immunology and Infectious Diseases, Amsterdam, the Netherlands
| | - Marjon A de Boer
- Department of Obstetrics and Gynaecology, Amsterdam University Medical Center, Amsterdam, the Netherlands; Amsterdam Reproduction and Development Research Institute, Amsterdam, the Netherlands
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21
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Singh M, Wambua S, Lee SI, Okoth K, Wang Z, Fayaz FFA, Eastwood KA, Nelson-Piercy C, Reynolds JA, Nirantharakumar K, Crowe F. Autoimmune diseases and adverse pregnancy outcomes: an umbrella review. BMC Med 2024; 22:94. [PMID: 38438886 PMCID: PMC10913233 DOI: 10.1186/s12916-024-03309-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Accepted: 02/19/2024] [Indexed: 03/06/2024] Open
Abstract
BACKGROUND There is a high prevalence of autoimmune conditions in women specially in the reproductive years; thus, the association with adverse pregnancy outcomes has been widely studied. However, few autoimmune conditions/adverse outcomes have been studied more than others, and this umbrella review aims to consolidate existing knowledge in this area with the aim to provide new knowledge and also identify gaps in this research area. METHODS Medline, Embase, and Cochrane databases were searched from inception to December 2023. Screening, data extraction, and quality appraisal (AMSTAR 2) were done by two independent reviewers. Data were synthesised narratively and quantitatively. Relative risks (RR)/odds ratio (OR) with 95% confidence intervals were reported. RESULTS Thirty-two reviews were included consisting of 709 primary studies. The review reported the association between 12 autoimmune conditions and 16 adverse pregnancy outcomes. Higher risk of miscarriage is reported in women with Sjögren's syndrome RR 8.85 (95% CI 3.10-25.26) and systemic lupus erythematosus (SLE) OR 4.90 (3.10-7.69). Pre-eclampsia was reported higher in women with type 1 diabetes mellitus (T1DM) OR 4.19 (3.08-5.71) and SLE OR 3.20 (2.54-4.20). Women reported higher risk of diabetes during pregnancy with inflammatory bowel disease (IBD) OR 2.96 (1.47-5.98). There was an increased risk of intrauterine growth restriction in women with systemic sclerosis OR 3.20 (2.21-4.53) and coeliac disease OR 1.71 (1.36-2.14). Preterm birth was associated with T1DM OR 4.36 (3.72-5.12) and SLE OR 2.79 (2.07-3.77). Low birth weight babies were reported in women with women with SLE or systemic sclerosis OR 5.95 (4.54-7.80) and OR 3.80 (2.16-6.56), respectively. There was a higher risk of stillbirth in women with T1DM OR 3.97 (3.44-4.58), IBD OR 1.57 (1.03-2.38), and coeliac disease OR 1.57 (1.17-2.10). T1DM in women was associated with 32% lower odds of small for gestational age baby OR 0.68 (0.56-0.83). CONCLUSIONS Pregnant women with autoimmune conditions are at a greater risk of developing adverse pregnancy outcomes. Further research is required to develop better preconception to postnatal care for women with autoimmune conditions.
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Affiliation(s)
- Megha Singh
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Steven Wambua
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Siang Ing Lee
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Kelvin Okoth
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Zhaonan Wang
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | | | - Kelly-Ann Eastwood
- Centre for Public Health, University of Belfast, Belfast, Queen, BT7 1NN, UK
- Michael's Hospital, University Hospitals Bristol NHS Foundation Trust, Bristol, BS2 8EG, UK
| | | | - John A Reynolds
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | | | - Francesca Crowe
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
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22
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Kim YM, Sung JH, Cha HH, Oh SY. Hydroxychloroquine in obstetrics: potential implications of the prophylactic use of hydroxychloroquine for placental insufficiency during pregnancy. Obstet Gynecol Sci 2024; 67:143-152. [PMID: 38246692 PMCID: PMC10948207 DOI: 10.5468/ogs.23252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 11/20/2023] [Accepted: 11/22/2023] [Indexed: 01/23/2024] Open
Abstract
Proper placentation during early pregnancy is a key factor for maintaining a healthy pregnancy. Placental insufficiency leads to critical complications such as preeclampsia, fetal growth restriction, and fetal demise. These complications are often associated with pathological findings of restricted remodeling and obstructive lesions of the myometrial spiral arteries, which have high recurrence rates during subsequent pregnancies. Currently, there are no pharmacological interventions other than aspirin for the prevention of preeclampsia. Hydroxychloroquine (HCQ), a well-known antimalarial drug, reduces inflammatory and thrombotic changes in vessels. For decades, the use of HCQ for autoimmune diseases has resulted in the successful prevention of both arterial and venous thrombotic events and has been extended to the treatment of lupus and antiphospholipid antibody syndrome during pregnancy. HCQ reduces the risk of preeclampsia with lupus by up to 90%. Several recent studies have investigated whether HCQ improves pregnancy outcomes in women with a history of poor outcomes. In addition, in vitro and animal studies have demonstrated the beneficial effects of HCQ in improving endothelial dysfunction and alleviating hypertension and proteinuria. Therefore, we hypothesized that HCQ has the potential to attenuate the vascular inflammatory and thrombogenic pathways associated with placental insufficiency and conducted a multicenter clinical trial on the efficacy of combining aspirin with HCQ for pregnancies at high risk for preeclampsia in Korea. This study summarizes the potential effects of HCQ on pregnancies with placental insufficiency and the implications of HCQ treatment in the field of obstetrics.
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Affiliation(s)
- Yoo-Min Kim
- Department of Obstetrics and Gynecology, Chung-Ang University Gwangmyeong Hospital, Chung-Ang University School of Medicine, Seoul,
Korea
| | - Ji-Hee Sung
- Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul,
Korea
| | - Hyun-Hwa Cha
- Department of Obstetrics and Gynecology, Kyungpook National University Chilgok Hospital, Kyungpook National University School of Medicine, Daegu,
Korea
| | - Soo-Young Oh
- Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul,
Korea
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23
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Bränn E, Chen Y, Song H, László KD, D'Onofrio BM, Hysaj E, Almqvist C, Larsson H, Lichtenstein P, Valdimarsdottir UA, Lu D. Bidirectional association between autoimmune disease and perinatal depression: a nationwide study with sibling comparison. Mol Psychiatry 2024; 29:602-610. [PMID: 38191927 PMCID: PMC11153129 DOI: 10.1038/s41380-023-02351-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 11/22/2023] [Accepted: 11/27/2023] [Indexed: 01/10/2024]
Abstract
Although major depression, characterized by a pro-inflammatory profile, genetically overlap with autoimmune disease (AD) and the perinatal period involve immune system adaptations and AD symptom alterations, the bidirectional link between perinatal depression (PND) and AD is largely unexplored. Hence, the objective of this study was to investigate the bidirectional association between PND and AD. Using nationwide Swedish population and health registers, we conducted a nested case-control study and a matched cohort study. From 1,347,901 pregnancies during 2001-2013, we included 55,299 incident PND, their unaffected full sisters, and 10 unaffected matched women per PND case. We identified 41 subtypes of AD diagnoses recorded in the registers and compared PND with unaffected population-matched women and full sisters, using multivariable regressions. Women with an AD had a 30% higher risk of subsequent PND (95% CI 1.2-1.5) and women exposed to PND had a 30% higher risk of a subsequent AD (95% CI 1.3-1.4). Comparable associations were found when comparing exposed women with their unaffected sisters (nested case-control OR: 1.3, 95% CI 1.2-1.5, matched cohort HR: 1.3, 95% CI 1.1-1.6), and when studying antepartum and postpartum depression. The bidirectional association was more pronounced among women without psychiatric comorbidities (nested case-control OR: 1.5, 95% CI 1.4-1.6, matched cohort HR: 1.4, 95% CI 1.4-1.5) and strongest for multiple sclerosis (nested case-control OR: 2.0, 95% CI 1.6-2.3, matched cohort HR: 1.8, 95% CI 1.0-3.1). These findings demonstrate a bidirectional association between AD and PND independent of psychiatric comorbidities, suggesting possibly shared biological mechanisms. If future translational science confirms the underlying mechanisms, healthcare providers need to be aware of the increased risk of PND among women with ADs and vice versa.
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Affiliation(s)
- Emma Bränn
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.
| | - Yufeng Chen
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Huan Song
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- West China Biomedical Big Data Center, West China Hospital, Sichuan University, Chengdu, China
| | - Krisztina D László
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden
| | - Brian M D'Onofrio
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Department of Psychological and Brain Sciences, Indiana University, Bloomington, IN, USA
| | - Elgeta Hysaj
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Catarina Almqvist
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Henrik Larsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Paul Lichtenstein
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Unnur A Valdimarsdottir
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
- Center of Public Health Sciences, Faculty of Medicine, University of Iceland, Reykjavík, Iceland
| | - Donghao Lu
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
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24
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Lopez A, Wen T, Patel N, Booker WA, D'Alton ME, Friedman AM. Trends in and outcomes of delivery hospitalizations with lupus and antiphospholipid syndrome. Int J Gynaecol Obstet 2024; 164:1001-1009. [PMID: 37789684 DOI: 10.1002/ijgo.15171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 09/14/2023] [Accepted: 09/18/2023] [Indexed: 10/05/2023]
Abstract
OBJECTIVE To assess trends and outcomes associated with systemic lupus erythematosus (SLE) and antiphospholipid syndrome (APS) during US delivery hospitalizations. STUDY DESIGN The National Inpatient Sample from 2000 to 2019 was used for this repeated cross-sectional analysis. We identified delivery hospitalizations with and without SLE. Temporal trends in SLE during delivery hospitalizations were determined using joinpoint regression. Adjusted logistic regression models accounting for demographic, clinical, and hospital factors were used to determine adjusted odds ratios (aORs) for adverse outcomes based on the presence or absence of SLE. RESULTS Of an estimated 76 698 775 delivery hospitalizations identified in the NIS, 79386 (0.10%) had an associated diagnosis of SLE. Over the study period, SLE increased from 6.7 to 14.6 cases per 10 000 delivery hospitalizations (average annual percent change 4.5%, 95% CI 4.0-5.1). Deliveries with SLE had greater odds of non-transfusion severe morbidity (aOR 2.21, 95% CI 2.00, 2.44) and underwent a larger absolute increase in morbidity risk over the study period. SLE was associated with a range of other adverse outcomes including preterm delivery, eclampsia, cesarean delivery, and blood transfusion. CONCLUSION The proportion of deliveries to women with SLE has increased over time in the US, and SLE and APS are associated with a broad range of adverse outcomes.
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Affiliation(s)
- Ashley Lopez
- Department of Obstetrics and Gynecology, Columbia University, New York, New York, USA
| | - Timothy Wen
- Department of Obstetrics and Gynecology, University of California-San Francisco, San Francisco, California, USA
| | - Naomi Patel
- Division of Rheumatology, Allergy and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Whitney A Booker
- Department of Obstetrics and Gynecology, Columbia University, New York, New York, USA
| | - Mary E D'Alton
- Department of Obstetrics and Gynecology, Columbia University, New York, New York, USA
| | - Alexander M Friedman
- Department of Obstetrics and Gynecology, Columbia University, New York, New York, USA
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Jiang Y, Tao M, Chen J, Luo L, You Q, Wu H, Zhang N. Calcineurin inhibitors in the treatment of systemic lupus erythematosus during pregnancy: A narrative review with emphasis on efficacy and safety. Eur J Obstet Gynecol Reprod Biol 2024; 294:148-155. [PMID: 38245953 DOI: 10.1016/j.ejogrb.2023.12.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Revised: 11/21/2023] [Accepted: 12/31/2023] [Indexed: 01/23/2024]
Abstract
Systemic lupus erythematosus (SLE) predominantly affects child-bearing women, leading to an elevated risk of maternal and fetal complications and adverse pregnancy outcomes. Since some medications can cross the placental barrier that persist a threat to both mother and fetus, the risk-benefit ratio of SLE medications should be taken into consideration during pregnancy. Calcineurin inhibitor (CNI), mainly including cyclosporin A, tacrolimus, and voclosporin, is a category of immunosuppressive agents that inhibit calcium/calmodulin-dependent phosphatase calcineurin to block T cell activation. Based on the current clinical evidence, CNI is an alternative in pregnant SLE patients with persistent disease activity (especially lupus nephritis patients) and non-responders to azathioprine. However, there is no comprehensive review that summarizes the efficacy and safety profile of CNI for SLE management during pregnancy. This review presents a summary on the utilization of CNI for SLE management during pregnancy, including the mechanism of action, gestational amelioration of lupus flare, and the balance of maternal benefit-fetal risk, which may provide more references for the management of SLE pregnancies.
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Affiliation(s)
- Yi Jiang
- Department of Rheumatology and Immunology, The First Hospital Affiliated to Army Medical University, Chongqing 400038, China
| | - Min Tao
- Department of Pediatrics, The First Hospital Affiliated to Army Medical University, Chongqing 400038, China
| | - Jingjing Chen
- Department of Rheumatology and Immunology, The First Hospital Affiliated to Army Medical University, Chongqing 400038, China
| | - Lihua Luo
- Department of Rheumatology and Immunology, The First Hospital Affiliated to Army Medical University, Chongqing 400038, China
| | - Qingxia You
- Department of Rheumatology and Immunology, The First Hospital Affiliated to Army Medical University, Chongqing 400038, China
| | - Hong Wu
- Department of Rheumatology and Immunology, The First Hospital Affiliated to Army Medical University, Chongqing 400038, China
| | - Nian Zhang
- Department of Traditional Chinese Medicine, The Second Hospital Affiliated to Army Medical University, Chongqing 400037, China.
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Siriratnam P, Huda S, Butzkueven H, van der Walt A, Jokubaitis V, Monif M. Risks and outcomes of pregnancy in neuromyelitis optica spectrum disorder: A comprehensive review. Autoimmun Rev 2024; 23:103499. [PMID: 38061621 DOI: 10.1016/j.autrev.2023.103499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 11/30/2023] [Indexed: 04/30/2024]
Abstract
Neuromyelitis optica spectrum disorder (NMOSD) is a rare central nervous system autoimmune disease. Aquaporin-4 antibody (AQP4-IgG) is present in over 75% of cases and criteria also exist for the diagnosis of seronegative NMOSD. AQP4-IgG NMOSD has a strong female predominance (9:1 ratio), with a median onset age of 40 years. Pregnancy in those with NMOSD is therefore an important topic. Fecundity in NMOSD is likely impaired, and for females who conceive, obstetric complications including miscarriages and pre-eclampsia are significantly higher in NMOSD compared to the general population and in related conditions such as multiple sclerosis (MS). In contrast to MS, NMOSD disease activity does not subside during pregnancy. Also, relapse risk substantially rises above pre-pregnancy rates in the early postpartum period. In view of the evolving landscape of NMOSD, we provide a contemporary update of the impacts of pregnancy in NMOSD.
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Affiliation(s)
- Pakeeran Siriratnam
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia; Department of Neurology, Alfred Health, Melbourne, Victoria, Australia
| | - Saif Huda
- Department of Neurology, Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Helmut Butzkueven
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia; Department of Neurology, Alfred Health, Melbourne, Victoria, Australia
| | - Anneke van der Walt
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia; Department of Neurology, Alfred Health, Melbourne, Victoria, Australia
| | - Vilija Jokubaitis
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia; Department of Neurology, Alfred Health, Melbourne, Victoria, Australia
| | - Mastura Monif
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia; Department of Neurology, Alfred Health, Melbourne, Victoria, Australia; Department of Neurology, The Royal Melbourne Hospital, Parkville, VIC, Australia.
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Tai YY, Lee CN, Juan HC, Lin MW, Liao JC, Li HY, Lin SY, Poon LC. Prediction by uterine artery Doppler screening of small-for-gestational-age neonates at 19-24 weeks' gestation. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2024; 63:222-229. [PMID: 37519188 DOI: 10.1002/uog.27444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 07/12/2023] [Accepted: 07/21/2023] [Indexed: 08/01/2023]
Abstract
OBJECTIVE Small-for-gestational-age (SGA) neonates are at increased risk of perinatal mortality and morbidity. We aimed to investigate the performance of uterine artery pulsatility index (UtA-PI) at 19-24 weeks' gestation to predict the delivery of a SGA neonate in a Chinese population. METHODS This was a retrospective cohort study using data obtained between January 2010 and June 2018. Doppler ultrasonography was performed at 19-24 weeks' gestation. SGA was defined as birth weight below the 10th centile according to the INTERGROWTH-21st fetal growth standards. The performance of UtA-PI to predict the delivery of a SGA neonate was assessed using receiver-operating-characteristics (ROC)-curve analysis. RESULTS We included 6964 singleton pregnancies, of which 748 (11%) delivered a SGA neonate, including 115 (15%) women with preterm delivery. Increased UtA-PI was associated with an elevated risk of SGA, both in neonates delivered at or after 37 weeks' gestation (term SGA) and those delivered before 37 weeks (preterm SGA). The areas under the ROC curve (AUCs) for UtA-PI were 64.4% (95% CI, 61.5-67.3%) and 75.8% (95% CI, 69.3-82.3%) for term and preterm SGA, respectively. The performance of combined screening by maternal demographic/clinical characteristics and estimated fetal weight in the detection of term and preterm SGA was improved significantly by the addition of UtA-PI, although the increase in AUC was modest (2.4% for term SGA and 4.9% for preterm SGA). CONCLUSIONS This is the first Chinese study to evaluate the role of UtA-PI at 19-24 weeks' gestation in the prediction of the delivery of a neonate with SGA. The addition of UtA-PI to traditional risk factors improved the screening performance for SGA, and this improvement was greater in predicting preterm SGA compared with term SGA. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- Y-Y Tai
- Department of Medical Genetics, National Taiwan University Hospital, Taipei, Taiwan
| | - C-N Lee
- Department of Obstetrics and Gynecology, National Taiwan University Hospital, Taipei, Taiwan
| | - H-C Juan
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - M-W Lin
- Department of Obstetrics and Gynecology, National Taiwan University Hospital, Taipei, Taiwan
| | - J-C Liao
- Department of Obstetrics and Gynecology, National Taiwan University Hospital, Taipei, Taiwan
| | - H-Y Li
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - S-Y Lin
- Department of Obstetrics and Gynecology, National Taiwan University Hospital, Taipei, Taiwan
| | - L C Poon
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Hong Kong SAR
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Al Rayes H, AlOudah N, Alsolaimani R, Alharthi A, Attar M, Daghasi H, Albeity A, Afifi AM, AlQahtani A, Alkaff A, Alkhamesi SM, Elnady B. Adverse Impact of Systemic Lupus Erythematosus on Pregnancy Outcomes: A Saudi Arabia Retrospective Multi-Center Study. Open Access Rheumatol 2024; 16:31-41. [PMID: 38322608 PMCID: PMC10844007 DOI: 10.2147/oarrr.s448186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Accepted: 01/26/2024] [Indexed: 02/08/2024] Open
Abstract
Objective The current study aimed to determine the pregnancy outcomes complications in patients with SLE and its association with clinical, laboratory variables, disease activity, and medication use in the Saudi population, as well as pregnancy effect on disease activity. Methods A multicenter study included pregnant female patients with Systemic Lupus Erythematosus (SLE) from three tertiary centers in Saudi Arabia. The demographics, clinical, and laboratory variables, SLE disease activity index (SLEDAI), medication before, during, and after pregnancy, planned pregnancy, pregnancy-related outcomes, and complications in comparison to age-matched healthy female controls were noted. Results A total of 66 pregnant patients with SLE and 93 healthy age-matched pregnant controls were included in the study. A total of 77.3% had SLEDAI-2K ≤ 4 before conception, and 84.85% of pregnancies were planned. Age of conception, cesarean section, miscarriage, and low birth weight were statistically significant (p <0.05) higher in SLE patients than in healthy controls. Among all clinical and laboratory variables, SLEDAI-2K > 4 and active lupus nephritis during pregnancy were statistically associated with adverse outcomes (p <0.05), history of lupus nephritis was not associated with statistically adverse pregnancy outcomes. Higher SLEDAI-2K > 4 was an independent risk at least 4.87 times higher association with adverse pregnancy outcomes. (p <0.05). Conclusion SLE is intricately connected with unfavorable pregnancy outcomes. The preconception of high disease activity stands as a pivotal risk factor for adverse outcomes. Despite the disease remission and meticulous planning, SLE patients frequently grapple with disease exacerbations during pregnancy, culminating in unexpected and unfavorable pregnancy-related outcomes. This underscores the intricate and multifaceted nature of managing SLE during gestation.
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Affiliation(s)
- Hanan Al Rayes
- Department of Rheumatology, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Norah AlOudah
- Department of Rheumatology, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Roaa Alsolaimani
- Department of Medicine, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
- Department of Medicine, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | | | - Mohammed Attar
- Department of Rheumatology, Al Hada Armed Forces Hospital, Taif, Saudi Arabia
| | - Hassan Daghasi
- Department of Rheumatology, Al Hada Armed Forces Hospital, Taif, Saudi Arabia
| | - Abdurahman Albeity
- Department of Medicine, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
| | - Afnan M Afifi
- Department of Medicine, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
| | - Abdulelah AlQahtani
- Department of Rheumatology, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Alya Alkaff
- Obstetrics and Gynecology Department, King Faisal Specialist Hospital, and Research Center, Jeddah, Saudi Arabia
| | - Sultan M Alkhamesi
- Department of Medicine, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Basant Elnady
- Department of Rheumatology, Al Hada Armed Forces Hospital, Taif, Saudi Arabia
- Rheumatology and Rehabilitation Department, Faculty of Medicine, Benha University, Benha, Egypt
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Yan P, Yao J, Ke B, Fang X. Mendelian randomization reveals systemic lupus erythematosus and rheumatoid arthritis and risk of adverse pregnancy outcomes. Eur J Obstet Gynecol Reprod Biol 2024; 293:78-83. [PMID: 38128388 DOI: 10.1016/j.ejogrb.2023.12.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 11/16/2023] [Accepted: 12/13/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND The effect of systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA) on adverse pregnancy outcomes is a controversial topic. This study aimed to use Mendelian randomization (MR) analysis to assess the causal relationship between SLE, RA and adverse pregnancy outcomes. METHODS Genetic variants for SLE and RA, as well as adverse pregnancy outcomes, were derived from pooled statistics from large public genome-wide association studies. Several methods, such as inverse variance weighting (IVW), MR-Egger, weighted median and MR-Pleiotropic Residuals Sum and Outliers, were employed to estimate two-sample causality. RESULTS Genetic prediction of SLE was associated with higher odds of preterm labour [odds ratio (OR) 1.03, 95 % confidence interval (CI) 1.01-1.05; p = 0.008]. RA was associated with higher odds of preterm labour (OR 1.03, 95 % CI 1.01-1.06; p = 0.009), pre-eclampsia or eclampsia (OR 1.04, 95 % CI 1.01-1.07; p = 0.005), and poor fetal growth (OR 1.08, 95 % CI 1.04-1.12; p = 2.91 × 10-5). The results of bidirectional MR analysis did not indicate that SLE was associated with spontaneous abortion, pre-eclampsia or eclampsia, preterm rupture of membranes, or poor fetal growth (p-value for IVW 0.13-0.97). CONCLUSIONS This study found a genetic association between SLE and the risk of preterm labour, and highlights the importance of perinatal care and monitoring for patients with SLE. Furthermore, RA was found to be associated with a wide range of adverse outcomes, including preterm labour, pre-eclampsia or eclampsia, and poor fetal growth; as such, there is a need for more intensive therapeutic interventions and prenatal monitoring.
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Affiliation(s)
- Peng Yan
- Department of Nephrology, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nangchang 330000, China
| | - Jiahuizi Yao
- Department of Nephrology, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nangchang 330000, China
| | - Ben Ke
- Department of Nephrology, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nangchang 330000, China.
| | - Xiangdong Fang
- Department of Nephrology, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nangchang 330000, China.
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Keum H, Bermas B, Patel S, Jacobe HT, Chong BF. Patients with autoimmune skin diseases are at increased risk of adverse pregnancy outcomes. Am J Obstet Gynecol MFM 2024; 6:101226. [PMID: 37972926 DOI: 10.1016/j.ajogmf.2023.101226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 11/06/2023] [Accepted: 11/10/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND Increased rates of adverse pregnancy outcomes have been reported in association with rheumatologic diseases such as systemic lupus erythematosus, rheumatoid arthritis, dermatomyositis. However, little is known about pregnancy outcomes in patients with autoimmune skin diseases. OBJECTIVE This study aimed to determine the frequency of adverse pregnancy outcomes in patients with autoimmune skin diseases. We hypothesized that similar to rheumatic diseases, the rate of adverse pregnancy outcomes in patients with autoimmune skin diseases would be higher than the general population. STUDY DESIGN This is a case control study using the TriNetX US Collaborative Network, which is a database of electronic medical records of >95 million patients seen at 57 healthcare organizations in the United States. All pregnant women between the ages of 15 and 44 years who were seen at a healthcare organization between January 1, 2016 and December 31, 2021 were included. Participants with autoimmune skin disease were matched to healthy controls and controls with systemic rheumatologic conditions (systemic lupus erythematosus or rheumatoid arthritis). For both the autoimmune skin disease and healthy control groups, those with systemic rheumatologic condition or hidradenitis suppurativa were excluded. The primary outcomes were adverse pregnancy outcomes defined as spontaneous abortion, gestational hypertension, preeclampsia or eclampsia, gestational diabetes mellitus, intrauterine growth restriction, preterm premature rupture of membranes, preterm birth, and stillbirth. Patients with autoimmune skin diseases and controls were 1:1 propensity score-matched by age, race, ethnicity, comorbidities, obesity, and substance use. For each outcome, odds ratio with a 95% confidence interval was calculated. RESULTS A total of 2788 patients with autoimmune skin diseases were matched to 2788 healthy controls. Patients with autoimmune skin diseases were at a higher risk of spontaneous abortions than controls (odds ratio, 1.54; 95% confidence interval, 1.36-1.75; P<.001). Compared with patients with systemic lupus erythematosus, patients with autoimmune skin diseases were at lower risk of having infants with intrauterine growth restriction (odds ratio, 0.59; 95% confidence interval, 0.4-0.87; P=.01), preterm birth (odds ratio, 0.68; 95% confidence interval, 0.47-0.98; P=.04), and stillbirth (odds ratio, 0.50; 95% confidence interval, 0.25-0.97; P=.04). The differences in adverse pregnancy outcomes between patients with autoimmune skin diseases and those with rheumatoid arthritis were not statistically significant. CONCLUSION Patients with autoimmune skin diseases are at a higher risk of spontaneous abortions than patients without autoimmune skin diseases. When analyzed by each autoimmune skin disease, patients with cutaneous lupus erythematosus or vitiligo remained at increased risk of spontaneous abortions compared with patients without autoimmune skin diseases. Patients with autoimmune skin diseases have similar risks of adverse pregnancy outcomes as patients with rheumatoid arthritis, but lower risks than patients with systemic lupus erythematosus.
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Affiliation(s)
- Heejo Keum
- Department of Dermatology, The University of Texas Southwestern Medical Center, Dallas, TX (Ms Keum, Drs Jacobe and Chong)
| | - Bonnie Bermas
- Division of Rheumatology, Department of Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, TX (Dr Bermas)
| | - Shivani Patel
- Department of Obstetrics and Gynecology, The University of Texas Southwestern Medical Center, Dallas, TX (Dr Patel)
| | - Heidi T Jacobe
- Department of Dermatology, The University of Texas Southwestern Medical Center, Dallas, TX (Ms Keum, Drs Jacobe and Chong)
| | - Benjamin F Chong
- Department of Dermatology, The University of Texas Southwestern Medical Center, Dallas, TX (Ms Keum, Drs Jacobe and Chong).
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Zucchi D, Fischer-Betz R, Tani C. Pregnancy in systemic lupus erythematosus. Best Pract Res Clin Rheumatol 2023; 37:101860. [PMID: 37596173 DOI: 10.1016/j.berh.2023.101860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 07/25/2023] [Indexed: 08/20/2023]
Abstract
Systemic lupus erythematosus (SLE) is a chronic autoimmune disease which frequently affects women of childbearing age. Nowadays, pregnancy is not contraindicated in cases of well-controlled disease activity, but pregnancies are still at higher risk of maternal and fetal complications compared to the general population. During pregnancy and puerperium patients are at risk of disease flare, and obstetric complications are more frequent in cases of active disease at conception/beginning of pregnancy, a history of lupus nephritis, and concomitant presence of antiphospholipid syndrome. To improve pregnancy outcomes in SLE patients, appropriate preconception counseling with changes in medication, if necessary, and close rheumatological and obstetrical monitoring are fundamental. This review aims to summarize the risk factors for adverse pregnancy outcomes and provide an update on developments in medical care for pregnancy in SLE patients.
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Affiliation(s)
- Dina Zucchi
- Rheumatology Unit, Azienda Ospedaliero Universitaria Pisana and Department of Clinical and Experimental Medicine, University of Pisa, Italy; Department of Medical Biotechnologies, University of Siena, Italy
| | - Rebecca Fischer-Betz
- Medical Faculty, Department Rheumatology & Hiller-Research Unit Rheumatology, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Chiara Tani
- Rheumatology Unit, Azienda Ospedaliero Universitaria Pisana and Department of Clinical and Experimental Medicine, University of Pisa, Italy.
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Liang Q, Wang X, He Q, Ni X, Zhao R, Ji J, Dong C, Gu Z. Factors associated with fertility intention among women with systemic lupus erythematosus in China: A cross-sectional study. Int J Rheum Dis 2023; 26:2419-2429. [PMID: 37849430 DOI: 10.1111/1756-185x.14927] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 09/06/2023] [Accepted: 09/11/2023] [Indexed: 10/19/2023]
Abstract
OBJECTIVE This study aims to explore the status and influencing factors of fertility intention in women of childbearing age with systemic lupus erythematosus (SLE). METHODS A total of 158 SLE patients admitted to the Affiliated Hospital of Nantong University from February 2021 to February 2022 were selected for a cross-sectional study. The dependent variable in this study was the fertility intention of lupus women of childbearing age, so the questionnaire was selected: "In view of your disease, do you plan to have children? Yes/no" as the measurement statement. Lupus patients were divided into fertility intention groups and non-fertility intention groups. The questionnaire survey comprises following scales: Hospital Anxiety and Depression Scale (HADS), Multidimensional Fatigue Inventory (MFI-20), Female Sexual Distress Scale-Revised (FSDS-R), and others. Independent t-test, one-way ANOVA, Mann-Whitney U test, and binary logistic regression were used for analysis. RESULTS The results showed that 20.9% of lupus patients in this study had a fertility intention. The fertility intention was associated with age, reproductive history, reproductive concerns, sexual distress, fatigue, family function, social support, depression, and sleep. Binary logistic regression showed that physical fatigue (OR 3.56, 95% CI 1.048-12.07) and personal health (OR 2.50, 95% CI 1.065-5.853) had significant predictors of fertility intention. CONCLUSION Our study identified a lower fertility intention in SLE patients who had reproductive concerns, sexual distress, family dysfunction, and fatigue. We encourage healthcare institutions to provide counseling services to all the SLE patients who have fertility intention and focus more on those who have requirements for fertility.
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Affiliation(s)
- Qian Liang
- Department of Rheumatology, Affiliated Hospital of Nantong University, Nantong University, Nantong, China
- Research Center of Clinical Medicine, Affiliated Hospital of Nantong University, Nantong, China
| | - Xingxin Wang
- Department of Pulmonary and Critical care Medicine, Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Qian He
- Department of Rheumatology, Affiliated Hospital of Nantong University, Nantong University, Nantong, China
| | - Xiaowei Ni
- Department of Rheumatology, Affiliated Hospital of Nantong University, Nantong University, Nantong, China
| | - Rui Zhao
- Department of Rheumatology, Affiliated Hospital of Nantong University, Nantong University, Nantong, China
- Research Center of Clinical Medicine, Affiliated Hospital of Nantong University, Nantong, China
| | - Juan Ji
- Department of Rheumatology, Affiliated Hospital of Nantong University, Nantong University, Nantong, China
| | - Chen Dong
- Department of Rheumatology, Affiliated Hospital of Nantong University, Nantong University, Nantong, China
| | - Zhifeng Gu
- Department of Rheumatology, Affiliated Hospital of Nantong University, Nantong University, Nantong, China
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Sangah AB, Jabeen S, Hunde MZ, Devi S, Mumtaz H, Shaikh SS. Maternal and fetal outcomes of SLE in pregnancy: a literature review. J OBSTET GYNAECOL 2023; 43:2205513. [PMID: 37154805 DOI: 10.1080/01443615.2023.2205513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
Systemic Lupus Erythematosus (SLE) is an auto-immune disease in which the immune system assaults its tissues. We aimed to analyse the maternal and foetal outcomes during pregnancy in SLE mothers. A literature search was conducted by two investigators to assess SLE's outcomes on maternal and foetal during pregnancies. We searched PubMed/Medline, Embase, and Google scholar to collect evidence from different research studies, draw the conclusion, and report it. In our investigation, we found out that SLE could cause a spectrum of complications during pregnancy, not only for the mother but also for the foetus. It could affect fertility and cause difficult pregnancies for the couple as well which includes certain complications such as: preterm labour and delivery, high blood pressure (preeclampsia), placental insufficiency, miscarriage or stillbirth, whereas in the foetus SLE can cause mortality, preterm birth, and neonatal lupus (a temporary condition in the baby caused by SLE-related antibodies) and structural abnormalities. The literature suggests that SLE could prove fatal for the foetus and induce many complications in the mother. However, this could be avoided if pregnancy is planned right from the start and proper management is provided to the mother during pregnancy and delivery.p.
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Affiliation(s)
- Abdul Basit Sangah
- Liaquat National Hospital and Medical College Karachi, Karachi, Pakistan
| | - Sidra Jabeen
- Liaquat National Hospital and Medical College Karachi, Karachi, Pakistan
| | | | - Sunita Devi
- Liaquat National Hospital and Medical College Karachi, Karachi, Pakistan
| | - Hassan Mumtaz
- Senior Clinical Research Associate, Maroof International Hospital, Public Health Scholar, Health Services Academy, Islamabad, Pakistan
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Tan B, So PN, Krishnan A, Carriazo S, Bahamonde JR, Lamech TM, Hassanein M, Lerma E, Wiegley N. Approach to Pregnancy in Patients With Lupus Nephritis. Kidney Med 2023; 5:100724. [PMID: 37915962 PMCID: PMC10616386 DOI: 10.1016/j.xkme.2023.100724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2023] Open
Abstract
Active lupus nephritis (LN) in pregnancy is strongly associated with poor maternal and fetal outcomes and, therefore, has implications on the planning, timing, and management. Prepregnancy evaluation is essential for all LN patients with childbearing potential to ensure pregnancies proceed in a safe and timely manner. Both maternal and fetal risks are communicated to patient during the evaluation. Stratification into different risk profile groups is then made based on disease activity and organ impairment severity. Patients with LN are generally divided into 3 main groups. Patients with LN who become pregnant receive treatments that are nonteratogenic and optimal for fetal and maternal outcomes. Throughout the pregnancy period, these patients are monitored closely under surveillance by a multidisciplinary team of clinicians. The management of patients with LN in pregnancy can be challenging both diagnostically (distinguishing LN from pre-eclampsia and determining the role and timing of kidney biopsy) and therapeutically (LN flares during pregnancy and managing a newly diagnosed LN during pregnancy).
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Affiliation(s)
- Benjamin Tan
- Nephrology Unit, Queen Elizabeth Hospital, Kota Kinabalu, Malaysia
| | | | | | - Sol Carriazo
- Department of Nephrology and Hypertension Department, Fundacion Jimenez Diaz Hospital, Madrid, Spain
| | | | | | - Mohamed Hassanein
- Division of Nephrology and Hypertension, University of Mississippi Medical Center, Jackson, MI
| | - Edgar Lerma
- Section of Nephrology, University of Illinois at Chicago, Chicago, IL
| | - Nasim Wiegley
- Division of Nephrology, University of California Davis School of Medicine, Sacramento, CA
| | - GlomCon Editorial Team
- Nephrology Unit, Queen Elizabeth Hospital, Kota Kinabalu, Malaysia
- Private Practice, Manila, Philippines
- Royal Perth Hospital, Perth, Australia
- Department of Nephrology and Hypertension Department, Fundacion Jimenez Diaz Hospital, Madrid, Spain
- Department of Nephrology, St Luke’s University Health Network, PA
- Institute of Nephrology, Madras Medical College, India
- Division of Nephrology and Hypertension, University of Mississippi Medical Center, Jackson, MI
- Section of Nephrology, University of Illinois at Chicago, Chicago, IL
- Division of Nephrology, University of California Davis School of Medicine, Sacramento, CA
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Çetin Ç, Saraç-Sivrikoz T, Ateş-Tıkız M, Zaralı S, Ersoy A, Yalçınkaya Y, Gül A, İnanç M, Has R, Kalelioğlu İ, Artım Esen B. The correlation between pregnancy, disease activity and adverse pregnancy outcomes in patients with systemic lupus erythematosus. Lupus 2023; 32:1509-1517. [PMID: 37855206 DOI: 10.1177/09612033231208844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2023]
Abstract
OBJECTIVE In this study, our pregnant systemic lupus erythematosus (SLE) cohort, which was under medical surveillance of both our Rheumatology and Obstetrics departments, was analyzed. We intended to determine the effects of pregnancy on disease activity and the correlation between disease flares and adverse pregnancy outcomes. METHODS One hundred sixty eight pregnancy data involving 136 patients with SLE were examined. Cumulative clinical, laboratory, and serological parameters were described. Disease activity and flares were calculated using the systemic lupus erythematosus disease activity index 2000 (SLEDAI-2K) in the pre/postpartum periods and the SLEPDAI in the three trimesters of pregnancy. Patients with a SLEDAI-2K or SLEPDAI ≥ 4 were classified as "active." Patients with lupus low disease activity state (LLDAS) during each of these periods were identified.Fetal/neonatal death, premature birth due to pre-eclampsia, eclampsia or hemolysis, elevated Liver enzymes (HELLP) syndrome, and neonates small for gestational age were determined as adverse pregnancy outcomes (APO). RESULTS Out of 168 pregnancies, there were 60 (35.7%) pregnancies with flares covering the pregnancy and 6 months of postpartum period. The mean SLEDAI in the 6 months postpartum period was significantly higher compared to mean disease activity during pregnancy (p < .05). Of all pregnancies, 132 (78.6%) were in LLDAS during pregnancy. Comparison of the frequency of severe postpartum flares in patients who were in LLDAS during pregnancy revealed a lower percentage of flares compared to those who were not in the LLDAS group (11 vs 29%, p < .05). APO was observed in 33.9% of 168 pregnancies. The mean SLEPDAI score was significantly higher in APO+ pregnancies than in APO- pregnancies (4.9 ± 6.1 vs 2.8 ± 4.9, p = .002). Comparison of SLICC damage score between APO - and + pregnancies revealed a significantly higher score in APO+ pregnancies (1.8 ± 2.1 vs 0.8 ± 1.3, p = .001). CONCLUSION Postpartum six-month period appears to have the highest risk for disease flares during SLE pregnancies. Disease activity during pregnancy increases the risk of APO. In order to achieve a positive pregnancy outcome and lower maternal morbidity, regular follow-up of patients is necessary.
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Affiliation(s)
- Çiğdem Çetin
- Division of Rheumatology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Tuğba Saraç-Sivrikoz
- Division of Perinatology, Department of Obstetrics and Gynecology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Müge Ateş-Tıkız
- Division of Perinatology, Department of Obstetrics and Gynecology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Sibel Zaralı
- Division of Rheumatology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Ayşenur Ersoy
- Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Yasemin Yalçınkaya
- Division of Rheumatology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Ahmet Gül
- Division of Rheumatology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Murat İnanç
- Division of Rheumatology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Recep Has
- Division of Perinatology, Department of Obstetrics and Gynecology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - İbrahim Kalelioğlu
- Division of Perinatology, Department of Obstetrics and Gynecology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Bahar Artım Esen
- Division of Rheumatology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
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Khogali HI, Al-Bluwi GSM, Guy Pedo V, Al Dhanhani AM. Maternal and fetal health outcomes in systemic lupus erythematosus pregnancies in the Emirati population: A comparative study. Lupus 2023; 32:1453-1461. [PMID: 37786253 DOI: 10.1177/09612033231204650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
OBJECTIVES To evaluate adverse pregnancy outcomes in patients with systemic lupus erythematosus (SLE), compare their maternal and fetal outcomes with those of age-matched pregnant women without SLE, and identify factors linked to increased risks of adverse outcomes. METHODS Medical records from Tawam Hospital were reviewed retrospectively to identify patients with SLE and a history of pregnancy. Demographics, clinical variables, and maternal and fetal outcomes were obtained. A one-to-one age-matched healthy control group was randomly selected. The outcomes and odd ratios of women with and without SLE were compared, and factors associated with adverse pregnancy outcomes were examined. RESULTS The outcomes of 78 SLE pregnancies in 39 women were analyzed. Adverse maternal outcomes, such as gestational diabetes mellitus (GDM), occurred in 32% of pregnancies, whereas adverse fetal outcomes, such as low-birth weight and preterm deliveries, occurred in 51% of pregnancies. Pregnant women with SLE had a 5-fold higher risk of GDM, had higher odds of maternal hypertension, and were more likely to deliver through cesarean section than those without SLE. Preterm deliveries and low-birth weight were also more common in SLE pregnancies. Steroid use during pregnancy was significantly associated with an increased risk of GDM development. Lupus nephritis, maternal hypertension, pre-eclampsia, and GDM were linked to preterm deliveries. CONCLUSION Pregnant women with SLE were at a higher risk for adverse maternal and fetal outcomes than age-matched pregnant women without SLE. These findings can guide clinical management and emphasize the need for close monitoring of SLE pregnancies.
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Affiliation(s)
| | - Ghada S M Al-Bluwi
- Internal Medicine Department, College of Medicine & Health Sciences, UAE University, Al Ain, UAE
| | - Virgie Guy Pedo
- Internal Medicine Department, College of Medicine & Health Sciences, UAE University, Al Ain, UAE
| | - Ali M Al Dhanhani
- Internal Medicine Department, College of Medicine & Health Sciences, UAE University, Al Ain, UAE
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Donohue S, Gomez S, Singh T, Garg S. Triphasic: Preeclampsia, Systemic Lupus Erythematosus, and Severe Neutropenia With Use of Granulocyte Colony Stimulating Factor in the Partum and Postpartum Period. Arthritis Care Res (Hoboken) 2023; 75:2036-2043. [PMID: 37093032 DOI: 10.1002/acr.25138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 03/28/2023] [Accepted: 04/18/2023] [Indexed: 04/25/2023]
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Tian X, Zhao J, Song Y, Wang Q, Li M, Liu J, Zeng X. 2022 Chinese guideline for the management of pregnancy and reproduction in systemic lupus erythematosus. RHEUMATOLOGY AND IMMUNOLOGY RESEARCH 2023; 4:115-138. [PMID: 37781682 PMCID: PMC10538620 DOI: 10.2478/rir-2023-0019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 08/19/2023] [Indexed: 10/03/2023]
Abstract
Systemic lupus erythematosus (SLE), a prevalent autoimmune disease predominantly affecting women of childbearing age, presents ongoing challenges despite notable advances in diagnosis and treatment. Although survival rates for SLE patients have significantly improved, pregnancy continues to pose a considerable obstacle. Addressing this critical need for enhanced reproductive and prenatal care, there is a pressing imperative to establish standardized protocols for peri-gestational monitoring and treatment in SLE patients. This guideline is jointly sponsored by the National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), the Chinese Systemic Lupus Erythematosus Treatment and Research Group (CSTAR), and the Chinese Research Committee of Pregnancy and Reproduction in Autoimmune Rheumatic Diseases (CHOPARD). Thirteen pertinent clinical questions have been generated through several rounds of rigorous clinical and methodological expert discussions and selections for a comprehensive understanding of key aspects in this domain. Guided by thorough examination of research evidence and expert perspectives, the formulated recommendations aim to optimize pregnancy success rates, reduce maternal and infant mortality rates, and ultimately enhance the overall well-being of SLE patients.
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Affiliation(s)
- Xinping Tian
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences& Peking Union Medical College; National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science& Technology; State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College; Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing100730, China
| | - Jiuliang Zhao
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences& Peking Union Medical College; National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science& Technology; State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College; Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing100730, China
| | - Yijun Song
- Department of Obstetrics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing100730, China
| | - Qian Wang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences& Peking Union Medical College; National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science& Technology; State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College; Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing100730, China
| | - Mengtao Li
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences& Peking Union Medical College; National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science& Technology; State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College; Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing100730, China
| | - Juntao Liu
- Department of Obstetrics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing100730, China
| | - Xiaofeng Zeng
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences& Peking Union Medical College; National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science& Technology; State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College; Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing100730, China
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Nie X, Dong X, Hu Y, Xu F, Hu C, Shu C. Coenzyme Q10 Stimulate Reproductive Vatality. Drug Des Devel Ther 2023; 17:2623-2637. [PMID: 37667786 PMCID: PMC10475284 DOI: 10.2147/dddt.s386974] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 08/15/2023] [Indexed: 09/06/2023] Open
Abstract
Female infertility and pregnancy maintenance are associate with various factors, including quantity and quality of oocytes, genital inflammation, endometriosis, and other diseases. Women are even diagnosed as unexplained infertility or unexplained recurrent spontaneous abortion when failed to achieve pregnancy with current treatment, which are urgent clinical issues need to be addressed. Coenzyme Q10 (CoQ10) is a lipid-soluble electron carrier in the mitochondrial electron transport chain. It is not only essential for the mitochondria to produce energy, but also function as an antioxidant to maintain redox homeostasis in the body. Recently, the capacity of CoQ10 to reduce oxidative stress (OS), enhance mitochondrial activity, regulate gene expression and inhibit inflammatory responses, has been discovered as a novel adjuvant in male reproductive performance enhancing in both animal and human studies. Furthermore, CoQ10 is also proved to regulate immune balance, antioxidant, promote glucose and lipid metabolism. These properties will bring highlight for ovarian dysfunction reversing, ovulation ameliorating, oocyte maturation/fertilization promoting, and embryonic development optimizing. In this review, we systematically discuss the pleiotropic effects of CoQ10 in female reproductive disorders to investigate the mechanism and therapeutic potential to provide a reference in subsequent studies.
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Affiliation(s)
- Xinyu Nie
- Obstetrics and Gynecology Center, First Hospital of Jilin University, Changchun, Jilin, People’s Republic of China
- Reproductive Medicine Center, Prenatal Diagnosis Center, First Hospital of Jilin University, Changchun, Jilin, People’s Republic of China
| | - Xinru Dong
- Obstetrics and Gynecology Center, First Hospital of Jilin University, Changchun, Jilin, People’s Republic of China
- Reproductive Medicine Center, Prenatal Diagnosis Center, First Hospital of Jilin University, Changchun, Jilin, People’s Republic of China
| | - Yuge Hu
- Obstetrics and Gynecology Center, First Hospital of Jilin University, Changchun, Jilin, People’s Republic of China
- Reproductive Medicine Center, Prenatal Diagnosis Center, First Hospital of Jilin University, Changchun, Jilin, People’s Republic of China
| | - Fangjun Xu
- Obstetrics and Gynecology Center, First Hospital of Jilin University, Changchun, Jilin, People’s Republic of China
| | - Cong Hu
- Reproductive Medicine Center, Prenatal Diagnosis Center, First Hospital of Jilin University, Changchun, Jilin, People’s Republic of China
| | - Chang Shu
- Obstetrics and Gynecology Center, First Hospital of Jilin University, Changchun, Jilin, People’s Republic of China
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Suzuki K, Uno S, Wakasugi N. Tacrolimus use and renal function in pregnancy with lupus nephritis: Analysis of post-marketing surveillance data in Japan. Mod Rheumatol 2023; 33:944-952. [PMID: 35982545 DOI: 10.1093/mr/roac094] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 07/18/2022] [Accepted: 08/09/2022] [Indexed: 11/14/2022]
Abstract
OBJECTIVES Tacrolimus may be administered to pregnant women with lupus nephritis in Japan if considered therapeutically beneficial, but supporting data are limited. We assessed the safety and effectiveness of tacrolimus before, during, and after pregnancy in women with lupus nephritis receiving tacrolimus. METHODS This was an ad hoc analysis of data from a post-marketing surveillance study of tacrolimus in patients with lupus nephritis in Japan. Pregnancy outcomes, nephritis status, and adverse events were assessed for up to 2 years postpartum. RESULTS Data were available for 23 births in 21 patients (two patients had two births each). Tacrolimus for lupus nephritis was continued during 11 births in nine patients (during and after pregnancy) and discontinued in 12 patients (when pregnancy was known or when approaching delivery). Renal function was generally maintained in patients who gave birth while receiving tacrolimus; however, there were cases of increased urine protein and decreased renal function over 2 years. There were no unexpected adverse events/safety concerns. CONCLUSIONS These data from clinical practice suggest that tacrolimus is a valid treatment option for lupus nephritis in fertile women in Japan and, with careful monitoring, pregnant women with lupus nephritis may continue their tacrolimus treatment.
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Tanaka K, Asano T, Watanabe E, Matsumoto K, Kashima H, Koito Y, Miura T, Takahashi Y, Tsuboi R, Ishii T, Otake H, Yoshikawa S, Uehara T, Sekine M, Matsumoto S, Asabe S, Miyatani H, Mashima H. Adult-onset Still's Disease Diagnosed during Puerperium with Liver Dysfunction in Pregnancy and Liver Failure of the Infant. Intern Med 2023; 62:2349-2354. [PMID: 37587054 PMCID: PMC10484755 DOI: 10.2169/internalmedicine.1038-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Accepted: 10/31/2022] [Indexed: 08/18/2023] Open
Abstract
Most cases of liver dysfunction in pregnancy are pregnancy-related, but the onset of systemic autoimmune diseases is also differentiated. A 24-year-old woman presented with liver dysfunction at 28 weeks' gestation with suspected autoimmune hepatitis and started taking ursodeoxycholic acid. She gave birth prematurely at 35 weeks' gestation, and the infant presented with pancytopenia and liver failure but survived because of liver transplantation. Since the patient had major symptoms during the puerperium, she was diagnosed with adult-onset Still's disease. When encountering a patient with liver dysfunction during pregnancy, we should also consider the onset of autoimmune diseases.
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Affiliation(s)
- Kenjo Tanaka
- Department of Gastroenterology, Saitama Medical Center, Jichi Medical University, Japan
| | - Takeharu Asano
- Department of Gastroenterology, Saitama Medical Center, Jichi Medical University, Japan
| | - Eri Watanabe
- Department of Rheumatology, Saitama Medical Center, Jichi Medical University, Japan
| | - Keita Matsumoto
- Department of Gastroenterology, Saitama Medical Center, Jichi Medical University, Japan
| | - Hitomi Kashima
- Department of Gastroenterology, Saitama Medical Center, Jichi Medical University, Japan
| | - Yudai Koito
- Department of Gastroenterology, Saitama Medical Center, Jichi Medical University, Japan
| | - Takaya Miura
- Department of Gastroenterology, Saitama Medical Center, Jichi Medical University, Japan
| | - Yuko Takahashi
- Department of Gastroenterology, Saitama Medical Center, Jichi Medical University, Japan
| | - Rumiko Tsuboi
- Department of Gastroenterology, Saitama Medical Center, Jichi Medical University, Japan
| | - Takehiro Ishii
- Department of Gastroenterology, Saitama Medical Center, Jichi Medical University, Japan
| | - Haruka Otake
- Department of Gastroenterology, Saitama Medical Center, Jichi Medical University, Japan
| | - Shuhei Yoshikawa
- Department of Gastroenterology, Saitama Medical Center, Jichi Medical University, Japan
| | - Takeshi Uehara
- Department of Gastroenterology, Saitama Medical Center, Jichi Medical University, Japan
| | - Masanari Sekine
- Department of Gastroenterology, Saitama Medical Center, Jichi Medical University, Japan
| | - Satohiro Matsumoto
- Department of Gastroenterology, Saitama Medical Center, Jichi Medical University, Japan
| | - Shinichi Asabe
- Department of Gastroenterology, Saitama Medical Center, Jichi Medical University, Japan
| | - Hiroyuki Miyatani
- Department of Gastroenterology, Saitama Medical Center, Jichi Medical University, Japan
| | - Hirosato Mashima
- Department of Gastroenterology, Saitama Medical Center, Jichi Medical University, Japan
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Laíño-Piñeiro MC, Rúa-Figueroa I, Jiménez N, Lozano MJC, Martínez-Barrio J, Serrano B, Galindo-Izquierdo M, Nack A, Loricera J, Tomero-Muriel E, Ibáñez-Barceló M, Vázquez NM, Manrique-Arija S, Lorenzo NA, Narváez J, Rosas J, Menor-Almagro R, Martínez-Taboada VM, Aurrecoechea-Aguinaga E, Horcada L, Ruiz-Lucea E, Raya E, Toyos FJ, Expósito L, Vela P, Freire-González M, Moriano-Morales C, Bonilla-Hernán G, Ibáñez TC, Lozano-Rivas N, Moreno M, Andreu JL, Ubiaga CLI, Torrente-Segarra V, Valls E, Velloso-Feijoo ML, Alcázar JL, Pego-Reigosa JM. Pregnancy outcomes in 1869 pregnancies in a large cohort from the Spanish Society of Rheumatology Lupus Register (RELESSER). Semin Arthritis Rheum 2023; 61:152232. [PMID: 37348350 DOI: 10.1016/j.semarthrit.2023.152232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 05/15/2023] [Accepted: 06/11/2023] [Indexed: 06/24/2023]
Abstract
INTRODUCTION Obstetric complications are more common in women with systemic lupus erythematosus (SLE) than in the general population. OBJECTIVE To assess pregnancy outcomes in women with SLE from the RELESSER cohort after 12 years of follow-up. METHODS A multicentre retrospective observational study was conducted. In addition to data from the RELESSER register, data were collected on obstetric/gynaecological variables and treatments received. The number of term pregnancies was compared between women with pregnancies before and after the diagnosis of SLE. Further, clinical and laboratory characteristics were compared between women with pregnancies before and after the diagnosis, on the one hand, and with and without complications during pregnancy, on the other. Bivariate and multivariate analyses were carried out to identify factors potentially associated with complications during pregnancy. RESULTS A total of 809 women were included, with 1869 pregnancies, of which 1395 reached term. Women with pregnancies before the diagnosis of SLE had more pregnancies (2.37 vs 1.87) and a higher rate of term pregnancies (76.8% vs 69.8%, p < 0.001) compared to those with pregnancies after the diagnosis. Women with pregnancies before the diagnosis were diagnosed at an older age (43.4 vs 34.1 years) and had more comorbidities. No differences were observed between the groups with pregnancies before and after diagnosis in antibody profile, including anti-dsDNA, anti-Sm, anti-Ro, anti-La, lupus anticoagulant, anticardiolipin or anti-beta-2-glycoprotein. Overall, 114 out of the 809 women included in the study experienced complications during pregnancy, including miscarriage, preeclampsia/eclampsia, foetal death, and/or preterm birth. Women with complications had higher rates of antiphospholipid syndrome (40.5% vs 9.9%, p < 0.001) and higher rates of positivity for IgG anticardiolipin (33.9% vs 21.3%, p = 0.005), IgG anti-beta 2 glycoprotein (26.1% vs 14%, p = 0.007), and IgM anti-beta 2 glycoprotein (26.1% vs 16%, p = 0.032) antibodies, although no differences were found regarding lupus anticoagulant. Among the treatments received, only heparin was more commonly used by women with pregnancy complications. We did not find differences in corticosteroid or hydroxychloroquine use. CONCLUSIONS The likelihood of term pregnancy is higher before the diagnosis of SLE. In our cohort, positivity for anticardiolipin IgG and anti-beta-2- glycoprotein IgG/IgM, but not lupus anticoagulant, was associated with a higher risk of poorer pregnancy outcomes.
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Affiliation(s)
| | - Iñigo Rúa-Figueroa
- Department of Rheumatology, Hospital Universitario Doctor Negrín, Las Palmas de Gran Canaria, Spain
| | - Norman Jiménez
- IRIDIS Group (Investigation in Rheumatology and Immune-Diseases), Galicia Sur Health Research Institute (IISGS), Vigo, Spain
| | | | | | - Belén Serrano
- Department of Rheumatology, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | | | - Annika Nack
- Department of Rheumatology, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Javier Loricera
- Department of Rheumatology, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Eva Tomero-Muriel
- Department of Rheumatology, Hospital Universitario La Princesa, Madrid, Spain
| | | | - Natalia Mena Vázquez
- Department of Rheumatology, Hospital Regional Universitario de Málaga, Málaga, Spain
| | - Sara Manrique-Arija
- Department of Rheumatology, Hospital Regional Universitario de Málaga, Málaga, Spain
| | - Nerea Alcorta Lorenzo
- Department of Rheumatology, Hospital Universitario de Donostia, San Sebastián, Spain
| | - Javier Narváez
- Department of Rheumatology, Hospital Universitario de Bellvitge, L'Hospitalet de Llobregat, Spain
| | - José Rosas
- Department of Rheumatology, Hospital Marina Baixa, Alicante, Spain
| | - Raúl Menor-Almagro
- Department of Rheumatology, Hospital Jerez de la Frontera, Jerez de la Frontera, Spain
| | | | | | - Loreto Horcada
- Department of Rheumatology, Hospital Universitario de Navarra, Pamplona, Spain
| | | | - Enrique Raya
- Department of Rheumatology, Hospital Universitario Clínico San Cecilio, Granada, Spain
| | - F Javier Toyos
- Department of Rheumatology, Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - Lorena Expósito
- Department of Rheumatology, Hospital Universitario de Canarias, Tenerife, Spain
| | - Paloma Vela
- Department of Rheumatology, Hospital General Universitario de Alicante, Alicante, Spain
| | | | | | | | - Tatiana Cobo Ibáñez
- Department of Rheumatology, Hospital Universitario Infanta Sofía, Madrid, Spain
| | - Nuria Lozano-Rivas
- Department of Rheumatology, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Mireia Moreno
- Department of Rheumatology, Hospital Universitario Parc Taulí, Sabadell, Spain
| | - José Luis Andreu
- Department of Rheumatology, Hospital Puerta de Hierro-Majadahonda, Madrid, Spain
| | | | - Vicenç Torrente-Segarra
- Department of Rheumatology, Hospital Comarcal Alt Penedès-Garraf, Vilafranca del Penedès, Spain
| | - Elia Valls
- Department of Rheumatology, Hospital Dr. Peset, Valencia, Spain
| | - M L Velloso-Feijoo
- Department of Rheumatology, Hospital Universitario de Valme, Sevilla, Spain
| | - Juan Luis Alcázar
- Department of Obstetrics and Gynecology, Clínica Universidad de Navarra, Pamplona, Spain
| | - José M Pego-Reigosa
- IRIDIS Group (Investigation in Rheumatology and Immune-Diseases), Galicia Sur Health Research Institute (IISGS), Vigo, Spain; Department of Rheumatology, Complejo Hospitalario Universitario de Vigo, Vigo, Spain
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Dar S, Koirala S, Khan A, Bellary MD, Patel AV, Mathew B, Singh R, Baigam N, Razzaq W, Abdin ZU, Khawaja UA. A Comprehensive Literature Review on Managing Systemic Lupus Erythematosus: Addressing Cardiovascular Disease Risk in Females and Its Autoimmune Disease Associations. Cureus 2023; 15:e43725. [PMID: 37727166 PMCID: PMC10505685 DOI: 10.7759/cureus.43725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 08/18/2023] [Indexed: 09/21/2023] Open
Abstract
This review aimed to evaluate the mechanism of premature cardiovascular disease (CVD) in systemic lupus erythematosus (SLE) patients, particularly in the female population, and emphasize the need for early management interventions; explore the association between SLE and two autoimmune diseases, myasthenia gravis (MG) and antiphospholipid antibody syndrome (APS), and their management strategies; and evaluate the effectiveness of pharmacological and non-pharmacological interventions in managing SLE, focusing on premenopausal females, females of childbearing age, and pregnant patients. We conducted a comprehensive literature review to achieve these objectives using various databases, including PubMed, Google Scholar, and Cochrane. The collected data were analyzed and synthesized to provide an evidence-based overview of SLE, its management strategies as an independent disease, and some disease associations. The treatment should be focused on remission, preventing organ damage, and improving the overall quality of life (QOL). Extensive emphasis should also be focused on diagnosing SLE and concurrent underlying secondary diseases timely and managing them appropriately.
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Affiliation(s)
- Saleha Dar
- Department of Adult Medicine, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Sabina Koirala
- Department of Medicine, Gandaki Medical College, Pokhara, NPL
| | - Arooba Khan
- Department of Internal Medicine, Khyber Medical College, Peshawar, PAK
| | | | - Arya V Patel
- Department of Internal Medicine, Smt. Nathiba Hargovandas Lakhmichand (NHL) Municipal Medical College, Ahmedabad, IND
| | - Bejoi Mathew
- Department of Internal Medicine, Sri Devaraj Urs Medical College, Kolar, IND
| | - Rahul Singh
- Department of Medicine, Armed Forces Medical College, Pune, IND
| | - Nahida Baigam
- Department of Medicine, Association of Physicians of Pakistani Descent of North America (APPNA), Westmont, USA
| | - Waleed Razzaq
- Department of Internal Medicine, Services Hospital Lahore, Lahore, PAK
| | - Zain U Abdin
- Department of Medicine, District Head Quarter Hospital, Faisalabad, PAK
| | - Uzzam Ahmed Khawaja
- Department of Pulmonary and Critical Care Medicine, Jinnah Medical and Dental College, Karachi, PAK
- Department of Clinical and Translational Research, Dr. Ferrer BioPharma, South Miami, USA
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Ullrich FTH, Skapenko A, Schulze‐Koops H. Spontaneous abortion as differential diagnosis of intermittent glomerular proteinuria in inactive systemic lupus erythematosus. Clin Case Rep 2023; 11:e7686. [PMID: 37484753 PMCID: PMC10359442 DOI: 10.1002/ccr3.7686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 06/07/2023] [Accepted: 06/14/2023] [Indexed: 07/25/2023] Open
Abstract
In women of childbearing age, severe proteinuria in systemic lupus erythematosus raises concern for renal involvement and pregnancy complications. While persisting renal loss of protein is known to culminate in extensive interventions, intermittent proteinuria in inactive disease requires an adjusted approach. Contextual awareness of this urinary finding is thus essential.
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Affiliation(s)
- Fabian T. H. Ullrich
- Division of Rheumatology and Clinical Immunology, Department of Medicine IV, LMU University HospitalLMU MunichMunichGermany
| | - Alla Skapenko
- Division of Rheumatology and Clinical Immunology, Department of Medicine IV, LMU University HospitalLMU MunichMunichGermany
| | - Hendrik Schulze‐Koops
- Division of Rheumatology and Clinical Immunology, Department of Medicine IV, LMU University HospitalLMU MunichMunichGermany
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Rao AG, M N, Ch S, Jhawar J. Bullous systemic lupus erythematosus in a pregnant woman with anaemia coexisting with asymptomatic hepatic haemangioma. Indian J Dermatol Venereol Leprol 2023; 89:585-588. [PMID: 37067137 DOI: 10.25259/ijdvl_1299_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 11/01/2022] [Indexed: 02/05/2023]
Affiliation(s)
| | - Naresh M
- Department of Dermatology, SVS Medical College, Mahbubnagar, Telangana, India
| | - Sruthi Ch
- Department of Dermatology, SVS Medical College, Mahbubnagar, Telangana, India
| | - Jayshree Jhawar
- Department of Dermatology, SVS Medical College, Mahbubnagar, Telangana, India
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Sokou R, Parastatidou S, Iliodromiti Z, Lampropoulou K, Vrachnis D, Boutsikou T, Konstantinidi A, Iacovidou N. Knowledge Gaps and Current Evidence Regarding Breastfeeding Issues in Mothers with Chronic Diseases. Nutrients 2023; 15:2822. [PMID: 37447149 DOI: 10.3390/nu15132822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 06/16/2023] [Accepted: 06/19/2023] [Indexed: 07/15/2023] Open
Abstract
The prevalence of chronic maternal disease is rising in the last decades in the developed world. Recent evidence indicated that the incidence of chronic maternal disease ranges from 10 to 30% of pregnancies worldwide. Several epidemiological studies in mothers with chronic diseases have mainly focused on the risk for adverse obstetric outcomes. Evidence from these studies supports a correlation between maternal chronic conditions and adverse perinatal outcomes, including increased risk for preeclampsia, cesarean section, preterm birth, and admission in the Neonatal Intensive Care Unit (NICU). However, there is a knowledge gap pertaining to the management of these women during lactation. This review aimed at summarizing the available research literature regarding breastfeeding in mothers with chronic diseases. Adjusted and evidence-based support may be required to promote breastfeeding in women with chronic diseases; however, our comprehension of breastfeeding in this subpopulation is still unclear. The literature related to breastfeeding extends in various scientific areas and multidisciplinary effort is necessary to compile an overview of current evidence and knowledge regarding breastfeeding issues in mothers with chronic diseases.
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Affiliation(s)
- Rozeta Sokou
- Neonatal Intensive Care Unit, "Agios Panteleimon" General Hospital of Nikea, 3 D.Mantouvalou Str., Nikea, 18454 Piraeus, Greece
- Neonatal Department, School of Medicine, National and Kapodistrian University of Athens, Aretaieio Hospital, 11528 Athens, Greece
| | - Stavroula Parastatidou
- Neonatal Intensive Care Unit, "Elena Venizelou" Maternity Hospital, 11521 Athens, Greece
| | - Zoi Iliodromiti
- Neonatal Department, School of Medicine, National and Kapodistrian University of Athens, Aretaieio Hospital, 11528 Athens, Greece
| | - Katerina Lampropoulou
- Neonatal Intensive Care Unit, School of Medicine, University of Ioannina, 45110 Ioannina, Greece
| | - Dionysios Vrachnis
- Endocrinology Unit, 2nd Department of Obstetrics and Gynecology, School of Medicine, National and Kapodistrian University of Athens, Aretaieio Hospital, 11528 Athens, Greece
| | - Theodora Boutsikou
- Neonatal Department, School of Medicine, National and Kapodistrian University of Athens, Aretaieio Hospital, 11528 Athens, Greece
| | - Aikaterini Konstantinidi
- Neonatal Intensive Care Unit, "Agios Panteleimon" General Hospital of Nikea, 3 D.Mantouvalou Str., Nikea, 18454 Piraeus, Greece
| | - Nicoletta Iacovidou
- Neonatal Department, School of Medicine, National and Kapodistrian University of Athens, Aretaieio Hospital, 11528 Athens, Greece
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Chighizola CB, Clowse M, Meroni PL, Andreoli L, Tincani A, Wallenius M, Nelson-Piercy C. The SPROUT study: A survey on current management practice of reproductive aspects in women of childbearing age with systemic autoimmune rheumatic diseases. Autoimmun Rev 2023:103376. [PMID: 37301275 DOI: 10.1016/j.autrev.2023.103376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 06/05/2023] [Indexed: 06/12/2023]
Abstract
The SPROUT (Survey on reproduction in RheUmaTology) study explored current practice in women of childbearing age with systemic autoimmune rheumatic diseases, investigating the counselling on contraception, the prescription of low dose acetylsalicylic acid (LDASA) to pregnant patients and the management of disease activity in the post-partum period. The SPROUT questionnaire was designed ad hoc and promoted in the three months before the "11th International Conference on Reproduction, Pregnancy and Rheumatic Disease". Between June and August 2021, 121 physicians responded to the survey. Even though 66.8% of the participants declared themselves to be confident in counselling surrounding birth control, only 62.8% of physicians always discuss contraception and family planning with women of childbearing age. Approximately 20% of respondents do not prescribe LDASA to pregnant women with rheumatic diseases, and wide heterogeneity exists in the dose and timing of LDASA prescription. Most respondents (43.8%) restart treatment with biological agents soon after delivery to prevent disease flares, opting for a drug compatible with breastfeeding while 41.3% of physicians continue biologics throughout pregnancy and post-partum. The SPROUT study highlighted the necessity to further foster physicians' education and identified the management of disease activity after delivery as a matter for discussion between all the clinicians involved in the care of pregnant women with rheumatic conditions.
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Affiliation(s)
- Cecilia Beatrice Chighizola
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy; Unit of Pediatric Rheumatology, ASST Pini - CTO, Milan, Italy
| | - Megan Clowse
- Division of Rheumatology & Immunology, Duke University School of Medicine, Durham, NC, USA
| | - Pier Luigi Meroni
- Experimental laboratory of ImmunoRheumatological Researches, IRCCS Istituto Auxologico Italiano, Cusano Milanino, Milan, Italy
| | - Laura Andreoli
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy; Rheumatology and Clinical Immunology Unit, ASST Spedali Civili, Brescia, Italy
| | - Angela Tincani
- Rheumatology and Clinical Immunology Unit, ASST Spedali Civili, Brescia, Italy
| | - Marianne Wallenius
- National Advisory Unit on Pregnancy and Rheumatic Diseases, St Olavs Hospital, Trondheim, Norway; University Hospital and Institute of Neuromedicine and Movement Science, NTNU, Norwegian University of Science and Technology, Trondheim, Norway
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48
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Attia DH, Mokbel A, Mohamed MF, Haggag HM. Long-term impact of pregnancy on renal function among Egyptian women with lupus nephritis: A case control study. Lupus 2023:9612033231174410. [PMID: 37161972 DOI: 10.1177/09612033231174410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
Few studies tackled the long-term effect of pregnancy on lupus nephritis (LNs); thus, the study aimed to explore the long-term impact of pregnancy on renal outcomes in Egyptian patients with LN. Group I patients included females who had their first pregnancy after LN onset with ≥5 years elapsing after delivery; group II patients included females who had never got pregnant for ≥7 years after LN onset. Data were retrospectively collected at baseline (T0) and the last visit (Tlast). The study included 43 patients in group I and 39 patients in group II. The comparisons between the two groups regarding the characteristics at Tlast showed no significant difference regarding the serum creatinine, estimated glomerular filtration rate (eGFR), renal component of SLICC/ACR Damage Index (SDI) as well as the rate of renal flares, new-onset chronic kidney disease (CKD), progressed CKD and end-stage renal disease. Multivariate regression analysis revealed that systemic hypertension and renal flares were predictors of new-onset/progressed CKD (p = 0.019, OR [95% CI] = 4 [1.3-13]; and 0.022, 13.8 [1.5-128.8], respectively) while pregnancy was not (p = 0.363). Paired comparisons between T0 and Tlast characteristics within each group revealed significant increment of serum creatinine, renal SDI and CKD prevalence; as well as decrement of eGFR in group I (p = 0.004, <0.001, 0.001 and <0.001, respectively) and group II (p = 0.006, <0.001, 0.004 and 0.002, respectively). In conclusion, pregnancy, per se, does not affect the long-term renal outcome in LN patients; however, it is rather dependent on the existence of baseline renal damage and the development of renal flares.
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Affiliation(s)
- Doaa Hs Attia
- Rheumatology and Rehabilitation Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Abir Mokbel
- Rheumatology and Rehabilitation Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Moataz Fatthy Mohamed
- Internal Medicine and Nephrology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Hisham Mamdouh Haggag
- Obstetrics and Gynecology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
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Cao Y, Zhao S, Bexelius TS, Söderling J, Shi M, Roelstraete B, Warner BB, Stephansson O, Ludvigsson JF. Pregnancy and neonatal outcomes among women with early-onset colorectal cancer: a nationwide case-control study. EClinicalMedicine 2023; 59:101963. [PMID: 37125404 PMCID: PMC10139893 DOI: 10.1016/j.eclinm.2023.101963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 03/23/2023] [Accepted: 03/27/2023] [Indexed: 05/02/2023] Open
Abstract
Background Early-onset colorectal cancer has risen worldwide, leaving more women with colorectal cancer at reproductive ages. We aimed to investigate the risk of adverse pregnancy and neonatal outcomes among women with early-onset colorectal cancer. Methods We conducted a nationwide, matched case-control study of maternal/pregnancy outcomes including pre-eclampsia and Cesarean delivery (C-section) as well as neonatal outcomes including preterm birth among 207 births in women with early-onset colorectal cancer (ages 18-49) and 1019 births in women without colorectal cancer in Sweden (1992-2019). Early-onset colorectal cancer cases were identified through the Cancer Register, and outcome data were retrieved through linkage to Medical Birth Register and National Patient Register. Using conditional logistic regression, we estimated multivariable-adjusted odds ratios (ORs) and 95% confidence intervals (CIs). Findings Between Jan 1, 1992, and Dec 31, 2019, women with early-onset colorectal cancer who gave birth had increased odds of pre-eclampsia (7.2% vs 3.2%; OR = 2.52, 95%CI = 1.25-5.08), any C-section (24.6% vs 19.4%; OR = 1.43, 95%CI = 1.00-2.06), particularly emergency C-section (17.4% vs 10.5%; OR = 1.79, 95%CI = 1.17-2.75), after adjustment for maternal education level, country of birth, body mass index and smoking in early pregnancy, and comorbidities. Maternal history of early-onset colorectal cancer was also associated with offspring preterm birth (12.1% vs 5.2%; OR = 2.31, 95%CI = 1.34-3.99), delineated as spontaneous (OR = 1.06, 95%CI = 0.47-2.39) or medically-indicated preterm birth (OR = 4.48, 95%CI = 2.05-9.79). There was no increased risk of congenital malformation or small for gestational age birth. Interpretation In this population-based study, maternal history of early-onset colorectal cancer was associated with risk of both adverse pregnancy (pre-eclampsia, C-section) and neonatal outcomes (preterm birth). Funding US National Institutes of Health, Swedish Society of Medicine, Swedish Cancer Foundation.
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Affiliation(s)
- Yin Cao
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
- Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, USA
- Division of Gastroenterology, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Stephanie Zhao
- School of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Tomas S. Bexelius
- Department of Women's and Children's Health, Childhood Cancer Research Unit and Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Department of Paediatric Oncology, Astrid Lindgren Children Hospital, Stockholm, Sweden
| | - Jonas Söderling
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Mengyao Shi
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Bjorn Roelstraete
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Barbara B. Warner
- Division of Newborn Medicine, Department of Pediatrics, Washington University in St Louis, St Louis, MO, USA
| | - Olof Stephansson
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
- Division of Women's Health, Department of Obstetrics, Karolinska University Hospital, Stockholm, Sweden
| | - Jonas F. Ludvigsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Department of Paediatrics, Örebro University Hospital, Örebro, Sweden
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, USA
- Corresponding author. Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, PO Box 281, SE-17177, Stockholm, Sweden.
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50
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Mokbel A, Attia DH, Zayed HS, Eesa Naeem N, Mahmoud G, Riad R, Abou Elewa S, Youssef M, Haggag H, Mohamed SS. Pregnancy outcomes among Egyptian women with systemic lupus erythematosus: A prospective cohort study. Lupus 2023; 32:521-530. [PMID: 36889920 DOI: 10.1177/09612033231159468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/10/2023]
Abstract
Pregnant patients with systemic lupus erythematosus (SLE) represent a high-risk group. The aim of this study is to describe the pregnancy outcomes among SLE patients who were followed prospectively at a conjoint high-risk pregnancy/rheumatology clinic from 2007 to 2021 and to identify predictors of adverse maternal and fetal outcomes. This study included 201 singleton pregnancies of 123 women with SLE. Their mean age was 27.16 ± 4.80 years, and their mean disease duration was 7.35 ± 5.46 years. Secondary antiphospholipid syndrome (APS) was diagnosed in 77 (38.3%) pregnancies. The pregnancy was planned in 104 (51.7%) pregnancies. Flares occurred in 83 (41.3%) and pre-eclampsia in 15 (7.5%) pregnancies. Full-term pregnancy occurred in 93 (46.3%), fetal loss (miscarriage and intra-uterine fetal death) in 41 (20.4%), and prematurity in 67 (33.3%) of the pregnancies, respectively. Seven neonates died from complications of prematurity, and another one died from cardiac congenital anomalies. In the multivariate analyses, unplanned pregnancy was associated with eight times higher risk of disease flare OR = 7.92 (p < 0.001), lupus nephritis flare during pregnancy increased the odds of pre-eclampsia occurrence four times OR = 3.98 (p = 0.02), while disease flares during pregnancy predicted prematurity OR = 2.49, p = 0.049. Patients with secondary APS had three times increased risk of fetal loss OR = 2.97, p = 0.049. To conclude, unplanned pregnancy, disease flares, and APS have been identified as predictors for adverse maternal and/or fetal outcomes. Pregnancy planning is necessary to reduce maternal and fetal complications.
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Affiliation(s)
- Abir Mokbel
- Department of Rheumatology and Rehabilitation, 63527Kasr-Alainy School of Medicine, Cairo University, Cairo, Egypt.,Department of Health Research Methods, McMaster University, Hamilton, Canada
| | - Doaa Hs Attia
- Department of Rheumatology and Rehabilitation, 63527Kasr-Alainy School of Medicine, Cairo University, Cairo, Egypt
| | - Hania S Zayed
- Department of Rheumatology and Rehabilitation, 63527Kasr-Alainy School of Medicine, Cairo University, Cairo, Egypt
| | - Nahlaa Eesa Naeem
- Department of Rheumatology and Rehabilitation, 63527Kasr-Alainy School of Medicine, Cairo University, Cairo, Egypt
| | - Geilan Mahmoud
- Department of Rheumatology and Rehabilitation, 63527Kasr-Alainy School of Medicine, Cairo University, Cairo, Egypt
| | - Rafat Riad
- Department of Obstetrics and Gynecology, 63527Kasr-Alainy School of Medicine, Cairo University, Cairo, Egypt
| | - Soumaya Abou Elewa
- Department of Obstetrics and Gynecology, 63527Kasr-Alainy School of Medicine, Cairo University, Cairo, Egypt
| | - Mohamed Youssef
- Department of Obstetrics and Gynecology, 63527Kasr-Alainy School of Medicine, Cairo University, Cairo, Egypt
| | - Hisham Haggag
- Department of Obstetrics and Gynecology, 63527Kasr-Alainy School of Medicine, Cairo University, Cairo, Egypt
| | - Sally S Mohamed
- Department of Rheumatology and Rehabilitation, 63527Kasr-Alainy School of Medicine, Cairo University, Cairo, Egypt
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