Outcome of planned pregnancies in systemic lupus erythematosus: a prospective study on 62 pregnancies

Cross-sectional analysis of adverse outcomes in 1,029 pregnancies of Afro-Caribbean women in Trinidad with and without systemic lupus erythematosus

The objective of the study was to examine pregnancy outcomes in women with systemic lupus erythematosus (SLE) and population controls in Trinidad. We performed a cross-sectional analysis of adverse outcomes in pregnancies of Afro-Caribbean women with SLE and without SLE. One hundred and twenty-two female adult cases of SLE and 203 neighbourhood age-matched women without SLE were interviewed concerning details of their reproductive history, and the anticardiolipin antibody (ACL) status was established for women with SLE. A total of 1,029 pregnancies were reported (356 by women with SLE, 673 by women without SLE). In women with ≥ 1 pregnancy the total number of pregnancies was similar in women with a diagnosis of SLE and women without; however, a lower proportion of women with SLE had ever been pregnant compared with women without SLE (80% versus 91%, P = 0.002). In multivariate logistic regression analyses adjusted for maternal age, district of residence, pregnancy order and smoking, SLE pregnancies were more than twice as likely to end in foetal death than non-SLE pregnancies (odds ratio (OR), 2.4; 95% confidence interval (CI), 1.2–4.7). This effect was driven by a large increase in the odds of stillbirth (OR, 8.5; 95% CI, 2.5–28.8). The odds of early miscarriage (OR, 1.4; 95% CI, 0.6–3.1) and of mid-trimester miscarriage (OR, 1.9; 95% CI, 0.4–9.5) were higher, but were not statistically significantly different, in SLE pregnancies than in non-SLE pregnancies. The odds of ectopic pregnancy (OR, 7.5; 95% CI, 0.9–62.5) and of preterm birth (OR, 3.4; 95% CI, 1.2–10.0) were higher in SLE pregnancies conceived after diagnosis than in non-SLE pregnancies. There was no evidence of raised levels of IgG or IgM ACL among the majority (93/97 women, 96%) of SLE cases who reported sporadic mid-trimester miscarriage or stillbirth, although there was evidence of high levels of IgM and IgG ACL among women reporting three or more miscarriages and three consecutive miscarriages, and of raised IgG ACL among those experiencing ectopic pregnancy. In conclusion, we found evidence for a large increase in risk of stillbirth in the pregnancies of Afro-Caribbean Trinidadian women with SLE (not accounted for by high ACL status). There was some evidence of an increased risk of preterm delivery and ectopic pregnancy in pregnancies conceived after a diagnosis of maternal SLE.

Prevalence of undiagnosed autoimmune rheumatic diseases in the first trimester of pregnancy. Results of a two-steps strategy using a self-administered questionnaire and autoantibody testing

OBJECTIVE

To evaluate the prevalence of undiagnosed rheumatic diseases in the first trimester of pregnancy.

DESIGN

We screened for rheumatic diseases in 1210 consecutive pregnant women during the first trimester of pregnancy using a 10-item questionnaire.

SETTING

A university hospital in northern Italy.

POPULATION

One hundred and thirty-seven (11.3%) women who answered positively to at least one question constituted the cases and were compared with 107 negative controls.

METHODS

Cases and controls were tested for rheumatic autoantibodies (antinuclear antibody, anti-double-stranded DNA, anti-extractable nuclear antigen, anticardiolipin antibody, anti-beta2-glycoprotein I antibodies and lupus anticoagulant) and were evaluated by a rheumatologist for a definite diagnosis of rheumatic disease.

MAIN OUTCOME MEASURES

Prevalence of undiagnosed rheumatic disease in the first trimester of pregnancy.

RESULTS

The overall rate of positivity to the antibodies tested was 43.1% (59/137) among cases and 9.3% (10/107) in the controls (P < 0.001). A definitive diagnosis of rheumatic disease was made in 35 cases (25.5%) and in none of the controls (P <0.001). In stepwise logistic regression analysis, photosensitivity (adjusted OR 5.72; 95% CI 2.38-13.8), erythema or malar rash (adjusted OR 3.91; 95% CI 1.53-10) and history of two or more miscarriages (adjusted OR 5.6; 95% CI 1.55-20.6) were independent predictors of a definitive diagnosis of rheumatic disease (area under receiving operator curve = 0.814; 95% CI 0.76-0.86). Birthweight was lower (3180 g +/- 475 compared with 3340 g +/- 452, P= 0.008), and overall serious pregnancy complications (miscarriage, fetal growth restriction, delivery before 34 weeks of pregnancy and severe pre-eclampsia) were higher among cases (12/137) than controls (2/107) (adjusted OR 5.60; 95% CI 1.29-24.3; P= 0.021).

CONCLUSIONS

A two-step screening process with a self-administered questionnaire proved to be a useful method to screen for undiagnosed rheumatic diseases during the first trimester of pregnancy.

Maternal and fetal outcomes of 72 pregnancies in Argentine patients with systemic lupus erythematosus (SLE)

The purpose of the following study was to analyze maternal and fetal outcomes in pregnant patients with systemic lupus erythematosus (SLE) and the influence of SLE exacerbations on those pregnancies. Seventy-two pregnancies in 61 SLE patients treated between January 1986 and February 2004 in Hospital de Clínicas "José de San Martin" were reviewed retrospectively. Patient age was 28.1 +/- 6.2 years (mean+/-standard deviation [SD]). Mean SLE duration was 4.5 +/- 3.2 years (range 6 months-10 years). No patient acquired the disorder during gestation. Four (5.5%) patients had signs of active disease at the beginning of her pregnancy. Sixteen patients, accounting for 20 pregnancies, had a history of lupus nephritis. Nine patients met secondary antiphospholipid syndrome criteria and had 13 pregnancies. There were 14 exacerbations of the disease during pregnancy (19.4%), with most flares being mild. The most common obstetric complications were gestational hypertension in 15 pregnancies (20.8%) and preeclampsia in 8 pregnancies (11%). Forty-six percent of pregnancies ended in preterm deliveries. There were 62 live births (1 twin birth; 85%), 6 stillbirths (8%), and 5 spontaneous abortions (7%). Thirty-nine percent of newborns had low birth weight. Adequate pregnancy follow-up and delivery care by an interdisciplinary team in Argentine SLE patients with no pre-gestational preparation resulted in maternal and fetal outcomes similar to those seen in world reference centers.

Outcome of pregnancy in patients with systemic lupus erythematosus

OBJECTIVE

To study the maternal and fetal outcomes in women with systemic lupus erythematosus (SLE).

MATERIALS AND METHODS

Over a period of 10 years, 24 pregnancies in 17 females with SLE in a single center were enrolled. Fetal and maternal outcomes were studied retrospectively.

RESULTS

The mean patient age was 27.7 years. Twenty-one of the 24 pregnancies occurred in the period of disease remission at the time of conception. Proteinuria presented in 12 pregnancies; however, no patient developed acute renal failure or deterioration of renal function. There were three cases of preeclampsia in this study. Two patients had their disease flare up and delivered stillborns. One woman with secondary antiphospholipid syndrome (APS) had a fetal loss. There was no maternal mortality. The mean gestation age was 34.3 weeks (range, 17-41 weeks), and the mean birth weight was 2,179 g. The mean APGAR scores were 8 and 9 at 1 and 5 minutes, respectively. One baby with congenital atrioventricular block was born to a mother with positive anti-SSA antibody. There were five cases (20.8%) of intrauterine growth retardation and 10 preterm deliveries (41.6%) in this study.

CONCLUSION

Pregnancy is relatively safe in women with SLE in remission but should be considered as a high-risk pregnancy. APS is associated with poor pregnancy outcome. The patient needs to cooperate with obstetricians and physicians for optimal disease control and detailed monitoring throughout the gestation.

[Systematic lupus erythematosus and antiphospholipid syndrome during pregnancy]

Women with systemic lupus erythematosus (SLE) and antiphospholipid syndrome (APS) are subject to several complications during pregnancy, including reactivation of SLE, thrombosis, miscarriage, neonatal lupus, pregnancy-induced hypertension, pulmonary hypertension and drug toxicity. Correct management of these patients requires combined medical-obstetric care, close surveillance of baby's growth and well-being, control of SLE activity and correct thromboprophylaxis. With good care, most pregnancies in women with SLE and APS end successfully.

Etiology and prevention of stillbirth

OBJECTIVE

This is a systematic review of the literature on the causes of stillbirth and clinical opinion regarding strategies for its prevention.

STUDY DESIGN

We reviewed the causes of stillbirth by performing a Medline search limited to articles in English published in core clinical journals from January 1, 1995, to January 1, 2005. Articles before this date were included if they added historical information relevant to the topic. A total of 1445 articles obtained, 113 were the basis of this review and chosen based on the criterion that stillbirth or fetal death was central to the article.

RESULTS

Fifteen risk factors for stillbirths were identified and the prevalence of these conditions and associated risks are presented The most prevalent risk factors for stillbirth are prepregnancy obesity, socioeconomic factors, and advanced maternal age. Biologic markers associated with increased stillbirth risk are also reviewed, and strategies for its prevention identified.

CONCLUSION

Identification of risk factors for stillbirth assists the clinician in performing a risk assessment for each patient. Unexplained stillbirths and stillbirths related to growth restriction are the 2 categories of death that contribute the most to late fetal losses. Late pregnancy is associated with an increasing risk of stillbirth, and clinicians should have a low threshold to evaluate fetal growth. The value of antepartum testing is related to the underlying risk of stillbirth and, although the strategy of antepartum testing in patients with increased risk will decrease the risk of late fetal loss, it is of necessity associated with higher intervention rates.

The second trimester Doppler ultrasound examination is the best predictor of late pregnancy outcome in systemic lupus erythematosus and/or the antiphospholipid syndrome

OBJECTIVE

To examine the predictive value of clinical examination, laboratory tests and Doppler ultrasound examination in systemic lupus erythematosus (SLE) and/or antiphospholipid syndrome (APS) pregnancies.

METHODS

A prospective study of 116 pregnancies followed in a single tertiary referral centre. Outcomes analysed were fetal/neonatal death and adverse pregnancy outcome. Univariate analysis was performed for: (i) medical and obstetric history; (ii) medical and obstetric clinical examination; (iii) biological data; (iv) Doppler ultrasound examination. Variables significantly associated with the outcomes in the univariate analysis were entered into a logistic regression model.

RESULTS

Sixteen out of 116 pregnancies ended in 12 fetal deaths and 4 embryonic losses. Hence, data for 100 pregnancies were analysed. Seven fetal deaths and one neonatal death occurred, associated with abnormal end-diastolic umbilical artery Doppler flow at the second trimester (P < 0.006), a history of thrombophlebitis (P < 0.001) or notched uterine artery and growth restriction at the second trimester (P < 0.002). Multivariate analysis retained abnormal end-diastolic umbilical artery Doppler flow (P = 0.047) and history of thrombophlebitis (P = 0.018) as significant predictors. Thirty-one adverse pregnancy outcomes occurred, associated with notched uterine artery (P < 0.00003), abnormal end-diastolic umbilical artery Doppler flow (P < 0.0006) and fetal growth restriction at the second trimester (P < 0.008), growth restriction (P < 0.00001) and notched uterine artery at the third trimester (P < 0.0008), use of heparin (P < 0.05) and history of thrombophlebitis (P < 0.04). Notched uterine artery at the second trimester remained the only predictor in multivariate analysis (P = 0.001).

CONCLUSIONS

Results of the second trimester Doppler ultrasound examination are the best predictors for late pregnancy outcome in SLE and/or APS.

Pregnancy outcomes before and after a diagnosis of systemic lupus erythematosus

OBJECTIVE

The purpose of this study was to evaluate pregnancy outcomes before and after diagnosis of lupus.

STUDY DESIGN

Successive selection criterion applied to 148 lupus and 78,905 non-lupus pregnancies, generated 3 groups: lupus group, 84 pregnancies (not-yet-diagnosed group, 15 women; already-diagnosed group, 69 women), and control group, 51,000 pregnancies. Three-way analysis of variance and the chi-squared test were used for analyses.

RESULTS

Stillbirth outcome was increased in the lupus group compared with the control group (odds ratio, 4.84 [95% CI, 1.72,11.08]); the not-yet-diagnosed group (odds ratio, 9.89 [95% CI, 1.09,42.63]), and the already-diagnosed group (odds ratio, 3.85 [95% CI, 1.02,10.31]). Considering >1 pregnancy per patient would have overestimated the stillbirth rate. Stillbirth risk was increased significantly in severe maternal disease that was marked by central nervous system involvement. The already-diagnosed group had more hypertensive complications (P = .001 and .0001). Both lupus groups showed a significantly greater proportion of preterm births (P = .03), growth restriction (P = .019), and infants in the very low birth weight category (P = .021) compared with the control group.

CONCLUSION

Poor fetal outcomes are seen in pregnancies that are complicated by lupus, even before clinical appearance of disease, which supports a predisease state.

Antiphospholipid syndrome in systemic lupus erythematosus: is the whole greater than the sum of its parts?

This article compares the manifestations of systemic lupus erythematosus (SLE) in the presence and absence of antiphospholipid antibodies (aPLs), the hallmark autoantibodies of antiphospholipid syndrome (APS). The combination of SLE and APS appears to be of greater concern than either entity alone. APS complicates SLE by adding a vaso-occlusive factor to the inflammatory component that adversely affects the prognosis of those who have lupus and aPLs. The increase in both morbidity and mortality when both are present has significant therapeutic implications. Anticoagulation may be a safer and more appropriate therapeutic option than instituting a regimen of corticosteroids and immunosuppressive agents with all their attendant adverse effects. It falls upon the physician to clearly define the disease entity and fully evaluate the disease process.

Factors that predict prematurity and preeclampsia in pregnancies that are complicated by systemic lupus erythematosus

OBJECTIVE

The purpose of this study was to describe the outcomes of a 10-year cohort of pregnancies in patients with systemic lupus erythematosus and to evaluate clinical and laboratory markers for adverse outcomes.

STUDY DESIGN

We reviewed all pregnancies in patients with systemic lupus erythematosus who were seen at Stanford University from 1991 to 2001. Univariate analyses were performed to identify potential risk factors for adverse outcomes.

RESULTS

Sixty-three pregnancies in 48 women were identified. Approximately 35% of the pregnancies occurred in women with previous renal disease and 10% in women with previous central nervous system disease. Flares occurred in 68% of the pregnancies, the majority of which were mild to moderate. Preeclampsia complicated 12 pregnancies. Factors that were associated with premature delivery included prednisone use at conception (relative risk, 1.8), the use of antihypertensive medications (relative risk, 1.8), and a severe flare during pregnancy (relative risk, 2.0). Thrombocytopenia was associated with an increased risk of preeclampsia (relative risk, 3.2).

CONCLUSION

Flares, most of which were mild to moderate, occurred most of the pregnancies in our cohort of patients with systemic lupus erythematosus. Thrombocytopenia, hypertension, and prednisone use may be predictive factors for particular adverse outcomes.

Evaluation of systemic lupus erythematosus activity during pregnancy

Due to our increasing knowledge on the pathophysiological basis of autoimmunity and the development of combined medical-obstetric clinics, pregnancy is becoming common among women with systemic lupus erythematosus (SLE). However, whether lupus worsens during pregnancy continues to be a controversial issue. SLE assessment during pregnancy is sometimes difficult due to physiological changes during this period, and common tools for measuring lupus activity during pregnancy were not available until recently. Several lupus activity scales in common use have been adapted for pregnancy [systemic lupus erythematosus in pregnancy activity index (SLEPDAI), modified lupus activity measurement (m-SLAM) and lupus activity index in pregnancy (LAI-P)]. All of them take into account the influence of pregnancy on clinical manifestation and common biochemical tests. LAI-P also accounts for specific manifestations of antiphospholipid syndrome in order not to score them as due to SLE activity. LAI-P has recently been validated for use in SLE pregnancy and could be used in future studies. However, daily assessment and management of individual pregnant women with lupus still relies on the clinical skills of attending physicians.

Active disease during pregnancy is associated with poor foetal outcome in Indian patients with systemic lupus erythematosus

There is a paucity of data regarding the outcome of pregnancy from the Indian subcontinent. Therefore, we decided to analyse the outcome of pregnancy in our cohort of mothers with systemic lupus erythematosus (SLE). Data regarding pregnancies after onset of disease in patients with SLE was analysed in terms of number of pregnancies, effect of pregnancy on disease activity and effect of disease such as organ involvement, presence of anticardiolipin and anti-Ro antibodies, on the outcome of pregnancy. Fifty-two pregnancies occurred in 31 patients. Thirty-one and 21 pregnancies occurred when the disease was inactive and active, respectively. Excluding the 11 induced abortions, the live birth rate was 82.6% in the inactive group and 27.7% in the active group. Foetal loss was mainly due to 12 spontaneous abortions. There were three stillbirths and two neonatal deaths. Disease flare occurred only in the active group, one during pregnancy and two post-partum, one of which resulted in the death of the patient. The presence of antibodies to cardiolipin and to Ro/La was not associated with adverse outcome. Thus, the live birth rate in developing countries in SLE mothers is worse compared with developed countries. Active disease during pregnancy is significantly associated with increased foetal loss.

Making pregnancy safer for patients with lupus

Systemic lupus erythematosus is a hormone-dependent disorder predominantly affecting young women in whom changes in hormonal activity affect the course of the disease. More specifically, pregnancy is associated in 50 to 60% of cases with a clinical flare manifesting as renal or hematological symptoms, usually during the second or third trimester but occasionally in the postpartal period. Patients should be strongly advised to start a pregnancy only if their disease has been stable for at least 6 months, and they should be informed of the few contraindications. Severe flares are uncommon (10%) and the risk of maternal death is now 2 to 3%. The risk of the fetus remains high, however. Thus, fetal loss is common, particularly in patients with a lupus anticoagulant, renal failure, or arterial hypertension. Preterm birth occurs in 25% to 50% of cases and intrauterine growth retardation in 30%. Neonatal lupus with or without congenital heart block is exceedingly rare, being seen in the 1% of SLE women who have anti-SSA (Ro) and/or SSB (La) antibodies. To ensure a favorable outcome for both the mother and the child, the pregnancy should be planned, started during a period of disease stability, monitored closely (physical examination, laboratory tests, and Doppler ultrasound), and treated as needed (with antimalarial therapy throughout the pregnancy). Even with these precautions, however, preterm birth remains common.

Measuring systemic lupus erythematosus activity during pregnancy: validation of the lupus activity index in pregnancy scale

OBJECTIVE

To validate the Lupus Activity Index in Pregnancy (LAI-P) scale as a diagnostic tool for lupus flares during pregnancy and the puerperium.

METHODS

The LAI-P is a modified activity scale specific for pregnancy. Thirty-eight pregnant women with systemic lupus erythematosus (SLE) were prospectively followed in 3 clinics specific for lupus in pregnancy. On each visit, LAI-P was calculated. A modified physician global assessment (m-PGA) scale was used as gold standard (0 = no activity, 1 = mild-moderate activity, 2 = severe activity). A change > or = 0.25 in LAI-P was predefined as a flare according to previous studies in nonpregnant patients. For the purposes of the study, each visit was considered as an independent case.

RESULTS

During the study period, 158 visits took place for a total 621 patient-weeks. Sensitivity to change was high (standardized response mean for LAI-P = 1.6). We found a significant association between LAI-P and m-PGA (P < 0.002 in all regression models performed). Sensitivity, specificity, and positive and negative predictive values were 0.93, 0.98, 0.88, and 0.99. Positive and negative likelihood ratios were 49 and 0.07, respectively.

CONCLUSIONS

LAI-P has a high sensitivity to changes in lupus activity, a significant correlation with m-PGA, and high sensitivity, specificity, predictive values, and likelihood ratios for diagnosing SLE flares during pregnancy and the puerperium.

Lupus et autres connectivites et vie hormonale

Among connective tissue diseases, systemic lupus erythematosus is the illness that is most concerned by hormonal life events. The sex ratio is 9/1, and symptoms begin mostly during the third decade, sometimes during birth pill contraception or during pregnancy. As soon as systemic lupus is under control of an efficient treatment, pregnancy is no longer contra-indicated. A medical multidisciplinary surveillance is required. Complicated pregnancy concerns mother and baby. Lupus flares are more frequent during the second and third trimesters as well as during the post-partum period. Usually the intensity is moderate. Severe flares concern patients with renal involvement, hypertension and renal insufficiency and are mostly seen in patients with unplanified pregnancy and yet with still active lupus. Foetal death occurs in 10-30% of the cases, depending on the lupus activity and severity (renal lupus). Prematurity remains an important cause of morbidity (30% of live births). Foetal deaths and prematurity are even more frequent if the patient has an antiphospholipid syndrome. Neonatal cutaneous lupus and auriculo-ventricular congenital heart block is infrequent (1% of SLE patients with anti-Ro/SSA antibodies). Among other connective tissue diseases, polymyositis has a very severe obstetrical prognosis for both mother and foetus. Among primary vasculitis, polyarteritis nodosa, as found during pregnancy, can herald a very bad prognosis.

Pregnancy outcomes in female renal recipients: a comparison of systemic lupus erythematosus with other diagnoses

This study compares pregnancy outcomes in systemic lupus erythematosus (SLE) patients post renal transplant with recipients with other primary diagnoses, utilizing data from the National Transplantation Pregnancy Registry, Philadelphia, PA. Recipients were referred from transplant centers nationwide. A retrospective analysis was performed using data from questionnaires, hospital records and telephone interviews. Outcomes of pregnancies post renal transplant secondary to lupus nephritis (SLE: n = 38; 60 pregnancies) were compared with the pregnancy outcomes of renal recipients with other diagnoses (non-SLE: n = 247; 374 pregnancies). Drug-treated hypertension during pregnancy was less common in the SLE group than in the non-SLE group (45.0% vs. 62.5%, p = 0.015). There were fewer cesarean sections in the SLE group (30.2 vs. 53.2%, p = 0.008). There was no primary or gestational diabetes in the SLE group. There were no other statistical differences in maternal conditions or pregnancy outcomes between the SLE and non-SLE groups, or in the incidence of post pregnancy graft loss. Female recipients transplanted for renal failure secondary to lupus nephritis can successfully maintain pregnancy. Outcomes are comparable to renal recipients with other diagnoses. Newborns in both groups were often premature and had low birthweight. Overall childhood health was reported to be good; there were no apparent predominant structural malformations among the children.

Importance of planning ovulation induction therapy in systemic lupus erythematosus and antiphospholipid syndrome: a single center retrospective study of 21 cases and 114 cycles

OBJECTIVE

To analyze the results and complications of ovulation induction therapy (OIT) in women with systemic lupus erythematosus (SLE) and/or the antiphospholipid syndrome (APS).

METHODS

A retrospective study of 21 women followed in a single tertiary-referral French center who underwent 114 OIT cycles with or without in vitro fertilization and embryo transfer (IVFET).

RESULTS

Before OIT, SLE was present in 6 women, APS in 3, SLE-related APS in 3, and discoid lupus in 1. Eight women had no identified disease and underwent 36 cycles of OIT. Diagnosis (SLE, n = 3; primary APS, n = 5) was made after OIT complication: spontaneous abortion (n = 5), SLE flare (n = 2), and thrombophlebitis (n = 1). Five women with known disease intentionally concealed their history from their gynecologists and underwent 34 cycles. Forty-four cycles were planned in 11 women, in 3 of them after complications of prior OIT performed without particular therapy and monitoring. Eighteen pregnancies occurred, which ended in 9 live births, 4 fetal deaths, and 5 embryonic losses. The pregnancy rate was higher with gonadotropin and/or gonadotropin-releasing hormone analog (GnRHa) (25% of cycles) than with clomiphene (4% of cycles, P <.0001). When the gynecologists did not know the underlying disease, three-quarters of pregnancies induced by OIT with IVFET ended in embryonic losses or fetal deaths. In contrast, 6 of 7 pregnancies induced by planned OIT with IVFET ended in live births (P <.0001). Phlebothromboses were observed only with gonadotropin treatment. The SLE flare rate was higher with gonadotropin and/or GnRHa (27% of cycle) than with clomiphene (6%, NS). It also was higher (30%) when the gynecologists did not know the underlying disease than in the planned procedures (10%, NS).

CONCLUSIONS

The OIT may precipitate SLE or APS. A careful review of the patient's history and appropriate laboratory tests should be undertaken before OIT. Clomiphene complications are rare. When gonadotropins are prescribed, preventive anti-inflammatory therapy should be considered in women with SLE, in addition to heparin and/or anti-aggregant therapy in patients with asymptomatic anti-phospholipid antibodies or prior thrombotic events.

Foetal loss, liver necrosis and acute lupus erythematosus in a patient with antiphospholipid antibody syndrome

The antiphospholipid antibody syndrome (APS) is characterized by arterial or venous thromboses and recurrent foetal loss. It occurs as primary disease, but also in the context of systemic lupus erythematosus (SLE). Whereas primary APS induces a thrombotic microangiopathy without significant inflammatory reaction, secondary APS in SLE is usually associated with vasculitis. Here we report a patient with APS who presented with acute diarrhoea and then developed a HELLP-like syndrome characterized by a spontaneous abortion, multifocal hepatic necroses and thrombocytopenia. Thereafter an acute flare of SLE with arthralgias, pleuritis, skin rash and glomerulitis occurred. Clinical amelioration was only achieved by combining curettage, anticoagulation and immunosuppression, a treatment taking into account the pathogenesis of HELLP-like disease, APS and SLE. To our knowledge this is the first reported case of APS associated with combined acute manifestations of these three syndromes triggered by a presumable intestinal infection.

Maternal medical disease: risk of antepartum fetal death

Although certain maternal medical conditions increase the risk of antepartum fetal death, improvements in medical and obstetric care have decreased the likelihood of stillbirth. This article examines the current stillbirth rates reported in pregnancies complicated by common medical diseases. The reported stillbirth rates are expressed as the number of stillbirths occurring at > or = 20 weeks of gestation per 1,000 births in patients with the condition. Overall, about 10% of all fetal deaths are related to maternal medical illnesses such as hypertension, diabetes, obesity, systemic lupus erythematosus, chronic renal disease, thyroid disorders, and cholestasis of pregnancy. The early recognition of maternal medical diseases provides an opportunity for increased surveillance and interventions that may lead to more favorable pregnancy outcomes.

Pregnancy in past or present lupus nephritis: a study of 32 pregnancies from a single centre

OBJECTIVE

To study maternal and fetal outcome in women with past or present histologically proven systemic lupus erythematosus (SLE) nephritis.

METHOD

Retrospective study of 32 pregnancies in 22 women with past or present histologically proven SLE nephritis in a single French centre.

RESULTS

Pregnancy (25 planned and 7 not planned) occurred in a mean (SD) of 8 (5) years after SLE diagnosis and 6 (4) years after renal disease onset. Seven occurred in women with antiphospholipid syndrome. At pregnancy onset, all but one woman had creatininaemia below 100 micromol/l, five had proteinuria >0.5 g/day, none had hypertension. Twelve pregnancies occurred in women previously treated with immunosuppressant drugs. Treatment comprised prednisone (n=31), hydroxychloroquine (n=11), aspirin (n=22), heparin (n=12), and azathioprine in one patient with steroid resistant nephrotic syndrome disclosing SLE. No therapeutic abortion was done. During pregnancy or the postpartum period, or both, proteinuria >0.5 g/day occurred in 10 women (five related to pre-eclampsia, four to renal flare, one to stable nephrotic syndrome). One flare consisted of mild arthralgias. Pregnancy outcome comprised one feto-maternal death in SLE disclosed by pregnancy, five embryonic losses, two fetal deaths, and 18 premature (one neonatal death) and six full term births. No criterion appeared to influence fetal survival significantly. At long term, one patient died during an SLE flare, three women had renal relapses. At the last visit, all had creatininaemia below 100 micromol/l except one woman with creatinine level 115 micromol/l, nine had proteinuria >0.5 g/day, and one was treated for hypertension.

CONCLUSION

Pregnancy need not be discouraged in women with a history of SLE nephritis with normal or mildly impaired renal function. Deterioration of renal function rarely occurs. However, these pregnancies are at high risk of pre-eclampsia and prematurity.

Hypocomplementemia correlates with intrauterine growth retardation in systemic lupus erythematosus

PROBLEM

The aim of this study was to elucidate fetomaternal risks in systemic lupus erythematosus (SLE)-complicated pregnancy.

METHOD OF STUDY

Pregnancy course, complications, and fetal outcome in 82 pregnancies of 55 patients with SLE were investigated.

RESULTS

These 82 pregnancies resulted in 14 fetal losses and 66 live births. Without clinical manifestation of SLE-flare, 4 of 8 patients who had low serum complement activity during the pregnancies delivered small-for-date neonates. The rate of the intrauterine growth retardation was significantly higher than that observed in pregnancies with normal complement activity. The frequency of premature deliveries (60%) in patients who received more than 15 mg/day of prednisolone was significantly high when compared with pregnancies maintained by 0-15 mg/day (13.1%).

CONCLUSIONS

These data demonstrate the preconceptional and perinatal management necessary in SLE and suggest that the pregnancy with hypocomplementemia, the disease activity, and/or a relatively high maintenance dose of corticosteroid should be carefully managed and monitored.

Hormonal regulation of tumor necrosis factor-alpha, interleukin-12 and interleukin-10 production by activated macrophages. A disease-modifying mechanism in rheumatoid arthritis and systemic lupus erythematosus?

Rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE) frequently develop and progress in settings in which sympathoadrenomedullary and gonadal hormone levels are changing, e.g., during pregnancy, postpartum period, menopause, estrogen administration. This paper addresses the view that adrenal and gonadal hormonal deficiency facilitates excessive macrophage production of TNF-alpha and IL-12 that characterizes RA, whereas excessive estrogen action is suggested to play an essential role in the production of IL-10 in patients with SLE. Disease activity in SLE, in contrast to RA, appears to be associated with high-level production of IL-10, relative to the proinflammatory cytokines, TNF-alpha and IL-12. Accumulating data suggest that novel therapeutic approaches may ultimately be developed from continued investigation of the role of the neuroendocrine factors in RA and SLE.

Can we advise ovulation induction in patients with SLE?

The prognosis of systemic lupus erythematosus (SLE) has greatly improved during the last two decades, now allowing most patients to have a very long survival including a satisfactory quality of life. Initially considered contraindicated in SLE due to its overwhelming risks, pregnancy is nowadays allowed in a majority of patients, and fair results are usually obtained under appropriate management (1-3). Consequently, patients thought to have infertility ask the question of a possible therapy, i.e. ovulation induction (OI) associated or not with in vitro fertilization (IVF). Considering the importance of estrogens in the pathogenesis of the disease, the use of such procedures raise several questions in SLE. Though data remain to date extremely scarce, the theoretical and practical aspects of OI in SLE will be briefly reviewed here.