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Silver R, Craigo S, Porter F, Osmundson SS, Kuller JA, Norton ME. Society for Maternal-Fetal Medicine Consult Series #64: Systemic lupus erythematosus in pregnancy. Am J Obstet Gynecol 2023; 228:B41-B60. [PMID: 36084704 DOI: 10.1016/j.ajog.2022.09.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Systemic lupus erythematosus (SLE) is a chronic, multisystem, inflammatory autoimmune disease characterized by relapses (commonly called "flares") and remission. Many organs may be involved, and although the manifestations are highly variable, the kidneys, joints, and skin are commonly affected. Immunologic abnormalities, including the production of antinuclear antibodies, are also characteristic of the disease. Maternal morbidity and mortality are substantially increased in patients with systemic lupus erythematosus, and an initial diagnosis of systemic lupus erythematosus during pregnancy is associated with increased morbidity. Common complications of systemic lupus erythematosus include nephritis, hematologic complications such as thrombocytopenia, and a variety of neurologic abnormalities. The purpose of this document is to examine potential pregnancy complications and to provide recommendations on treatment and management of systemic lupus erythematosus during pregnancy. The following are the Society for Maternal-Fetal Medicine recommendations: (1) we recommend low-dose aspirin beginning at 12 weeks of gestation until delivery in patients with systemic lupus erythematosus to decrease the occurrence of preeclampsia (GRADE 1B); (2) we recommend that all patients with systemic lupus erythematosus, other than those with quiescent disease, either continue or initiate hydroxychloroquine (HCQ) in pregnancy (GRADE 1B); (3) we suggest that for all other patients with quiescent disease activity who are not taking HCQ or other medications, it is reasonable to engage in shared decision-making regarding whether to initiate new therapy with this medication in consultation with the patient's rheumatologist (GRADE 2B); (4) we recommend that prolonged use (>48 hours) of nonsteroidal antiinflammatory drugs (NSAIDs) generally be avoided during pregnancy (GRADE 1A); (5) we recommend that COX-2 inhibitors and full-dose aspirin be avoided during pregnancy (GRADE 1B); (6) we recommend discontinuing methotrexate 1-3 months and mycophenolate mofetil/mycophenolic acid at least 6 weeks before attempting pregnancy (GRADE 1A); (7) we suggest the decision to initiate, continue, or discontinue biologics in pregnancy be made in collaboration with a rheumatologist and be individualized to the patient (GRADE 2C); (8) we suggest treatment with a combination of prophylactic unfractionated or low-molecular-weight heparin and low-dose aspirin for patients without a previous thrombotic event who meet obstetrical criteria for antiphospholipid syndrome (APS) (GRADE 2B); (9) we recommend therapeutic unfractionated or low-molecular-weight heparin for patients with a history of thrombosis and antiphospholipid (aPL) antibodies (GRADE 1B); (10) we suggest treatment with low-dose aspirin alone in patients with systemic lupus erythematosus and antiphospholipid antibodies without clinical events meeting criteria for antiphospholipid syndrome (GRADE 2C); (11) we recommend that steroids not be routinely used for the treatment of fetal heart block due to anti-Sjögren's-syndrome-related antigen A or B (anti-SSA/SSB) antibodies given their unproven benefit and the known risks for both the pregnant patient and fetus (GRADE 1C); (12) we recommend that serial fetal echocardiograms for assessment of the PR interval not be routinely performed in patients with anti-SSA/SSB antibodies outside of a clinical trial setting (GRADE 1B); (13) we recommend that patients with systemic lupus erythematosus undergo prepregnancy counseling with both maternal-fetal medicine and rheumatology specialists that includes a discussion regarding maternal and fetal risks (GRADE 1C); (14) we recommend that pregnancy be generally discouraged in patients with severe maternal risk, including patients with active nephritis; severe pulmonary, cardiac, renal, or neurologic disease; recent stroke; or pulmonary hypertension (GRADE 1C); (15) we recommend antenatal testing and serial growth scans in pregnant patients with systemic lupus erythematosus because of the increased risk of fetal growth restriction (FGR) and stillbirth (GRADE 1B); and (16) we recommend adherence to the Centers for Disease Control and Prevention medical eligibility criteria for contraceptive use in patients with systemic lupus erythematosus (GRADE 1B).
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Moroni G, Calatroni M, Donato B, Ponticelli C. Kidney Biopsy in Pregnant Women with Glomerular Diseases: Focus on Lupus Nephritis. J Clin Med 2023; 12:jcm12051834. [PMID: 36902621 PMCID: PMC10003332 DOI: 10.3390/jcm12051834] [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: 12/31/2022] [Revised: 02/14/2023] [Accepted: 02/22/2023] [Indexed: 03/02/2023] Open
Abstract
Despite significant improvements of renal and obstetrical management, pregnancies in women with glomerular diseases and with lupus nephritis continue to be associated with increased complications both for the mother and the fetus as compared to those of pregnancies in healthy women. To reduce the risk of these complications, planning pregnancy in a phase of stable remission of the underlining disease is necessary. A kidney biopsy is an important event in any phase of pregnancy. A kidney biopsy can be of help during counselling before pregnancy in cases of incomplete remission of the renal manifestations. In these situations, histological data may differentiate active lesions that require the reinforcement of therapy from chronic irreversible lesions that may increase the risk of complications. In pregnant women, a kidney biopsy can identify new-onset systemic lupus erythematous (SLE) and necrotizing or primitive glomerular diseases and distinguish them from other, more common complications. Increasing proteinuria, hypertension, and the deterioration of kidney function during pregnancy may be either due to a reactivation of the underlying disease or to pre-eclampsia. The results of the kidney biopsy suggest the need to initiate an appropriate treatment, allowing the progression of the pregnancy and the fetal viability or the anticipation of delivery. Data from the literature suggest avoiding a kidney biopsy beyond 28 weeks of gestation to minimize the risks associated with the procedure vs. the risk of preterm delivery. In case of the persistence of renal manifestations after delivery in women with a diagnosis of pre-eclampsia, a renal kidney assessment allows the final diagnosis and guides the therapy.
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Affiliation(s)
- Gabriella Moroni
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy
- Nephrology and Dialysis Division, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy
- Correspondence: ; Tel.: +39-345-872-1910
| | - Marta Calatroni
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy
- Nephrology and Dialysis Division, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy
| | - Beatriz Donato
- Nephrology Department, Hospital Beatriz Ângelo, 2674-514 Loures, Portugal
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Nana M, Stannard MT, Nelson-Piercy C, Williamson C. The impact of preconception counselling on maternal and fetal outcomes in women with chronic medical conditions: A systematic review. Eur J Intern Med 2023; 108:52-59. [PMID: 36435697 DOI: 10.1016/j.ejim.2022.11.003] [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: 08/28/2022] [Revised: 10/29/2022] [Accepted: 11/01/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Beyond diabetes mellitus little data reports outcomes of women with chronic medical conditions who have received pre-conception counselling (PCC). This study aimed to perform a systematic review of the literature to evaluate evidence regarding the impact of PCC on maternal and fetal outcomes in women with chronic medical conditions aside from diabetes mellitus. METHODS A systematic review was conducted in accordance with PRISMA. PubMed, Cochrane, Ovid Medline and Web of Science were searched. Two reviewers screened abstracts and full texts. Inclusion criteria included studies relating to chronic medical disorders of interest published between database inception and 21st May 2022, reporting outcomes relating to disease activity and perinatal outcomes. RESULTS The search yielded 11,814 results of which six met criteria for inclusion. Two papers describe the demographics of women more likely to receive PCC which included younger age, shorter disease duration, nulliparity, IVF pregnancy and higher education/job security. Two reported the effects of PCC on women's behaviour with improvements demonstrated in correct medication adherence, folic acid intake and smoking cessation. Five studies reported outcomes related to disease activity; those receiving PCC were more likely to have quiescent disease during pregnancy. Improvements in pregnancy outcomes were described including reduced rates of small for gestational age, low birth weight, preterm birth, congenital abnormality and obstetric complications. DISCUSSION A paucity of data exists relating to pregnancy outcomes in women with chronic medical conditions receiving PCC. Reported outcomes are favorable, supporting the routine inclusion of PCC in preparation for pregnancy in such patients.
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Affiliation(s)
- Melanie Nana
- Department of Women's Health, King's College London, London, England
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Mehta B, Jannat-Khah D, Glaser KK, Luo Y, Sammaritano LR, Branch DW, Goodman SM, Lockshin M, Wang F, Ibrahim S, Salmon JE. Fetal and maternal morbidity in pregnant patients with Lupus: a 10-year US nationwide analysis. RMD Open 2023; 9:e002752. [PMID: 37185223 PMCID: PMC10255159 DOI: 10.1136/rmdopen-2022-002752] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 12/12/2022] [Indexed: 05/17/2023] Open
Abstract
OBJECTIVE To evaluate and quantify the indicators of fetal and maternal morbidity in deliveries for patients with systemic lupus erythematosus (SLE) compared with deliveries in patients without SLE. METHODS We used retrospective data from the National Inpatient Sample (NIS) to identify all delivery related hospital admissions of patients with and without SLE from 2008 to 2017 using ICD-9/10 codes. Fetal morbidity indicators included pre-term delivery and intrauterine growth restriction (IUGR). 21 indicators of severe maternal morbidity were identified using standard Centers for Disease Control and Prevention (CDC) definitions. Descriptive statistics, including 95% confidence intervals, were calculated using sample weights from the NIS dataset. RESULTS Among the 40 million delivery-related admissions, 51 161 patients were reported to have SLE. Patients with SLE had a higher risk of fetal morbidity, including IUGR (8.0% vs 2.7%) and pre-term delivery (14.5% vs 7.3%), than patients without SLE. During delivery, mothers with SLE were nearly four times as likely to require a blood transfusion or develop a cerebrovascular disorder, and 15 times as likely to develop acute renal failure than those without SLE. CONCLUSION Our study demonstrates that fetal morbidity and severe maternal morbidity occur at a higher rate in patients with SLE compared with those without. This quantitative work can help inform and counsel patients with SLE during pregnancy and planning.
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Affiliation(s)
- Bella Mehta
- Hospital for Special Surgery, New York, New York, USA
- Weill Cornell Medicine, New York, New York, USA
| | - Deanna Jannat-Khah
- Hospital for Special Surgery, New York, New York, USA
- Weill Cornell Medicine, New York, New York, USA
| | | | - Yiming Luo
- Columbia University Irving Medical Center, New York, New York, USA
| | - Lisa R Sammaritano
- Hospital for Special Surgery, New York, New York, USA
- Weill Cornell Medicine, New York, New York, USA
| | - D Ware Branch
- University of Utah Health, Salt Lake City, Utah, USA
| | - Susan M Goodman
- Hospital for Special Surgery, New York, New York, USA
- Weill Cornell Medicine, New York, New York, USA
| | - Michael Lockshin
- Hospital for Special Surgery, New York, New York, USA
- Weill Cornell Medicine, New York, New York, USA
| | - Fei Wang
- Weill Cornell Medicine, New York, New York, USA
| | | | - Jane E Salmon
- Hospital for Special Surgery, New York, New York, USA
- Weill Cornell Medicine, New York, New York, USA
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Fakhouri F, Schwotzer N, Cabiddu G, Barratt J, Legardeur H, Garovic V, Orozco-Guillen A, Wetzels J, Daugas E, Moroni G, Noris M, Audard V, Praga M, Llurba E, Wuerzner G, Attini R, Desseauve D, Zakharova E, Luders C, Wiles K, Leone F, Jesudason S, Costedoat-Chalumeau N, Kattah A, Soto-Abraham V, Karras A, Prakash J, Lightstone L, Ronco P, Ponticelli C, Appel G, Remuzzi G, Tsatsaris V, Piccoli GB. Glomerular diseases in pregnancy: pragmatic recommendations for clinical management. Kidney Int 2023; 103:264-281. [PMID: 36481180 DOI: 10.1016/j.kint.2022.10.029] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 10/10/2022] [Accepted: 10/18/2022] [Indexed: 12/12/2022]
Abstract
Our understanding of the various aspects of pregnancy in women with kidney diseases has significantly improved in the last decades. Nevertheless, little is known about specific kidney diseases. Glomerular diseases are not only a frequent cause of chronic kidney disease in young women, but combine many challenges in pregnancy: immunologic diseases, hypertension, proteinuria, and kidney tissue damage. An international working group undertook the review of available current literature and elicited expert opinions on glomerular diseases in pregnancy with the aim to provide pragmatic information for nephrologists according to the present state-of-the-art knowledge. This work also highlights areas of clinical uncertainty and emphasizes the need for further collaborative studies to improve maternal and fetal health.
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Affiliation(s)
- Fadi Fakhouri
- Service de Néphrologie et d'Hypertension, Département de Médecine, Centre Hospitalier Universitaire Vaudois, and Université de Lausanne, Lausanne, Switzerland.
| | - Nora Schwotzer
- Service de Néphrologie et d'Hypertension, Département de Médecine, Centre Hospitalier Universitaire Vaudois, and Université de Lausanne, Lausanne, Switzerland
| | - Gianfranca Cabiddu
- Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy; Department of Nephrology, San Michele Hospital, ARNAS G. Brotzu, Cagliari, Italy
| | - Jonathan Barratt
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Hélène Legardeur
- Gynaecology, Woman Mother Child Department of the Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Vesna Garovic
- Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA; Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Alejandra Orozco-Guillen
- National Institute of Perinatology Isidro Espinosa de los Reyes (INPER), Department of Nephrology, Ciudad de Mexico, Mexico
| | - Jack Wetzels
- Department of Nephrology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Eric Daugas
- Service de Néphrologie, Hôpital Bichat and Université Paris Cité, Paris, France; Institut national de la santé et de la recherche médicale Inserm U1149, Paris, France
| | - Gabriella Moroni
- Department of Biomedical Sciences, Humanitas University, Milan, Italy; Nephrology and Dialysis Division, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Humanitas Research Hospital, Milan, Italy
| | - Marina Noris
- Istituto di Ricerche Farmacologiche Mario Negri, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Laboratory of Immunology and Genetics of Rare Diseases, Bergamo, Italy
| | - Vincent Audard
- Université Paris Est Créteil, Institut National de la Santé et de la Recherche Médicale (INSERM), Institut Mondor de Recherche Biomédicale (IMRB), Créteil, France; Assistance Publique des Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, Service de Néphrologie et Transplantation, Fédération Hospitalo-Universitaire « Innovative therapy for immune disorders », Créteil, France
| | - Manuel Praga
- Department of Nephrology, Hospital Universitario 12 de Octubre, Complutense University Madrid, Madrid, Spain
| | - Elisa Llurba
- Department of Obstetrics and Gynaecology, Institut d'Investigació Biomèdica Sant Pau - IIB Sant Pau, Hospital de la Santa Creu i Sant Pau, Madrid, Spain; Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Developmental Origin Network (RICORS), Instituto de Salud Carlos III, Madrid, Spain
| | - Grégoire Wuerzner
- Service de Néphrologie et d'Hypertension, Département de Médecine, Centre Hospitalier Universitaire Vaudois, and Université de Lausanne, Lausanne, Switzerland
| | - Rossella Attini
- Department of Obstetrics and Gynecology, University of Turin, Città della Salute e della Scienza, Sant'Anna Hospital, Turin, Italy
| | - David Desseauve
- Gynaecology, Woman Mother Child Department of the Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Elena Zakharova
- Nephrology, Moscow City Hospital n.a. Sergey Petrovich Botkin, Moscow, Russian Federation; Moscow State University of Medicine and Dentistry, Moscow, Russian Federation
| | - Claudio Luders
- Centro de Nefrologia e Dialise, Hospital Sirio-Libanes, São Paulo, Brazil
| | - Kate Wiles
- Department of Women's Health, Barts Health NHS Trust, London, UK
| | - Filomena Leone
- Clinical Nutrition Unit, S. Anna Hospital, Città della Salute e della Scienza, Turin, Italy
| | - Shilpanjali Jesudason
- Central Northern Adelaide Renal and Transplantation Service (CNARTS), Royal Adelaide Hospital, Adelaide, South Australia, Australia; Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Nathalie Costedoat-Chalumeau
- Centre de Référence Maladies Auto-Immunes et Systémiques Rares de l'île de France, Cochin Hospital, Université Paris Cité, Paris, France; Unité de l'Institut national de la santé et de la recherche médicale (INSERM) Unité 1153, Center for Epidemiology and Statistics (CRESS), Paris, France
| | - Andrea Kattah
- Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Virgilia Soto-Abraham
- Pathology Department, Hospital General de México Dr Eduardo Liceaga, México City, México
| | - Alexandre Karras
- Paris University, Paris, France; Renal Division, Georges Pompidou European Hospital, Paris, France
| | - Jai Prakash
- Department of Nephrology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Liz Lightstone
- Imperial Lupus Centre, Department of Medicine, Imperial College London, London, UK; Section of Renal Medicine and Vascular Inflammation, Department of Medicine, Imperial College London, London, UK
| | - Pierre Ronco
- Sorbonne Université, and Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche S1155, Paris, France; Department of Nephrology, Centre Hospitalier du Mans, Le Mans, France
| | | | - Gerald Appel
- Division of Nephrology, Columbia University Medical Center and the New York Presbyterian Hospital, New York, New York, USA
| | - Giuseppe Remuzzi
- Istituto di Ricerche Farmacologiche Mario Negri, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Laboratory of Immunology and Genetics of Rare Diseases, Bergamo, Italy
| | - Vassilis Tsatsaris
- Maternité Port-Royal, Fédération Hospitalo-Universitaire Prématurité (FHU PREMA), Assistance Publique des Hôpitaux de Paris AP-HP, Hôpital Cochin, AP-HP, Paris, France; Centre-Université de Paris, Université de Paris, Paris, France
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Dines V, Suvakov S, Kattah A, Vermunt J, Narang K, Jayachandran M, Abou Hassan C, Norby AM, Garovic VD. Preeclampsia and the Kidney: Pathophysiology and Clinical Implications. Compr Physiol 2023; 13:4231-4267. [PMID: 36715282 DOI: 10.1002/cphy.c210051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Preeclampsia and other hypertensive disorders of pregnancy are major contributors to maternal morbidity and mortality worldwide. This group of disorders includes chronic hypertension, gestational hypertension, preeclampsia, preeclampsia superimposed on chronic hypertension, and eclampsia. The body undergoes important physiological changes during pregnancy to allow for normal placental and fetal development. Several mechanisms have been proposed that may lead to preeclampsia, including abnormal placentation and placental hypoxia, impaired angiogenesis, excessive pro-inflammatory response, immune system imbalance, abnormalities of cellular senescence, alterations in regulation and activity of angiotensin II, and oxidative stress, ultimately resulting in upregulation of multiple mediators of endothelial cell dysfunction leading to maternal disease. The clinical implications of preeclampsia are significant as there are important short-term and long-term health consequences for those affected. Preeclampsia leads to increased risk of preterm delivery and increased morbidity and mortality of both the developing fetus and mother. Preeclampsia also commonly leads to acute kidney injury, and women who experience preeclampsia or another hypertensive disorder of pregnancy are at increased lifetime risk of chronic kidney disease and cardiovascular disease. An understanding of normal pregnancy physiology and the pathophysiology of preeclampsia is essential to develop novel treatment approaches and manage patients with preeclampsia and hypertensive disorders of pregnancy. © 2023 American Physiological Society. Compr Physiol 13:4231-4267, 2023.
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Affiliation(s)
- Virginia Dines
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Sonja Suvakov
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Andrea Kattah
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Jane Vermunt
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Kavita Narang
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Coline Abou Hassan
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Alexander M Norby
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Vesna D Garovic
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA.,Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, USA
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Wang S, Rexrode KM, Florio AA, Rich-Edwards JW, Chavarro JE. Maternal Mortality in the United States: Trends and Opportunities for Prevention. Annu Rev Med 2023; 74:199-216. [PMID: 36706746 DOI: 10.1146/annurev-med-042921-123851] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Maternal mortality is unusually high in the United States compared to other wealthy nations and is characterized by major disparities in race/ethnicity, geography, and socioeconomic factors. Similar to other developed nations, the United States has seen a shift in the underlying causes of pregnancy-related death, with a relative increase in mortality resulting from diseases of the cardiovascular system and preexisting medical conditions. Improved continuity of care aimed at identifying reproductive-age women with preexisting conditions that may heighten the risk of maternal death, preconception management of risk factors for major adverse pregnancy outcomes, and primary care visits within the first year after delivery may offer opportunities to address gaps in medical care contributing to the unacceptable rates of maternal mortality in the United States.
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Affiliation(s)
- Siwen Wang
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts, USA;
| | - Kathryn M Rexrode
- Division of Women's Health, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Andrea A Florio
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts, USA;
| | - Janet W Rich-Edwards
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts, USA.,Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Jorge E Chavarro
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts, USA; .,Department of Epidemiology, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts, USA.,Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
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Hu Z, Gao R, Huang W, Wang H, Qin L. Effect of Hydroxychloroquine on Lupus Activity, Preeclampsia and Intrauterine Growth Restriction in Pregnant Women with Systemic Lupus Erythematosus and/or Antiphospholipid Syndrome: A Systematic Review and Meta-Analysis. J Clin Med 2023; 12:jcm12020485. [PMID: 36675415 PMCID: PMC9866542 DOI: 10.3390/jcm12020485] [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: 11/19/2022] [Revised: 12/31/2022] [Accepted: 01/05/2023] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Hydroxychloroquine (HCQ) has been used in the treatment of systematic lupus erythematosus (SLE) and antiphospholipid syndrome (APS), but its effect on lupus activity during pregnancy, preeclampsia and intrauterine growth restriction (IUGR) remains unclear. METHODS PubMed, Embase and Cochrane databases were searched before 11 September 2022 for randomized clinical trials (RCT) or observational studies involving additional HCQ treatment and pregnant women diagnosed as having SLE and/or APS/positive antiphospholipid antibodies (aPLs). Risks of high lupus activity, preeclampsia and IUGR were explored. RESULTS One RCT and 13 cohort studies were included. A total of 1764 pregnancies were included in the pooled meta-analysis (709 in the HCQ group vs. 1055 in the control group). After the additional use of HCQ, the risk of high lupus activity decreased (RR: 0.74, 95% CI: 0.57-0.97, p = 0.03). For preeclampsia, the total incidence decreased (RR: 0.54, 95% CI: 0.37-0.78, p = 0.001). The subgroup analysis showed statistical significance in the SLE subgroup (RR: 0.51, 95% CI: 0.34-0.78, p = 0.002) but not in the APS/aPLs subgroup (RR: 0.66, 95% CI: 0.29-1.54, p = 0.34). For IUGR, the decrease in incidence was not statistically significant (RR: 0.80, 95% CI: 0.47-1.35, p = 0.46), neither in the SLE subgroup (RR: 0.74, 95% CI: 0.40-1.36, p = 0.33) nor in the APS/aPLs subgroup (RR: 1.26, 95% CI: 0.34-4.61, p = 0.73). CONCLUSION The additional use of HCQ may decrease the risk of high lupus activity during pregnancy and the incidence of preeclampsia for SLE patients, but the results do not support that using HCQ decreases the incidence of preeclampsia for APS/aPLs patients or reduces IUGR risk for SLE and/or APS/aPLs patients.
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Affiliation(s)
- Zhengyan Hu
- The Reproductive Medical Center, Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu 610041, China
- Key Laboratory of Birth Defects and Related of Women and Children of Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu 610041, China
- West China School of Medicine, Sichuan University, Chengdu 610041, China
| | - Rui Gao
- The Reproductive Medical Center, Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu 610041, China
- Key Laboratory of Birth Defects and Related of Women and Children of Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu 610041, China
- West China School of Medicine, Sichuan University, Chengdu 610041, China
| | - Wanrong Huang
- Department of Dermatology, The First Hospital of China Medical University, Shenyang 110001, China
| | - Huiqing Wang
- Key Laboratory of Birth Defects and Related of Women and Children of Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu 610041, China
- Medical Simulation Centre, West China Second University Hospital, Sichuan University, Chengdu 610041, China
- Correspondence: (H.W.); (L.Q.)
| | - Lang Qin
- The Reproductive Medical Center, Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu 610041, China
- Key Laboratory of Birth Defects and Related of Women and Children of Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu 610041, China
- Correspondence: (H.W.); (L.Q.)
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Mao R, Wang X, Long R, Wang M, Jin L, Zhu L. A new insight into the impact of systemic lupus erythematosus on oocyte and embryo development as well as female fertility. Front Immunol 2023; 14:1132045. [PMID: 37033965 PMCID: PMC10076658 DOI: 10.3389/fimmu.2023.1132045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Accepted: 03/14/2023] [Indexed: 04/11/2023] Open
Abstract
Background Systemic lupus erythematosus (SLE) is often associated with adverse reproductive outcomes. But it's currently unclear regarding the role of SLE in oocyte and embryonic development. Also, it's controversial whether SLE has an adverse effect on fertility. There is a lack of comprehensive understanding and assessment of fertility in patients with SLE. Objective This study was aim to investigate oocyte and embryonic development as well as ovarian reserve, and clinical outcomes in SLE patients during in vitro fertilization (IVF) treatment. By combining data on embryonic and gamete development in SLE patients, we hope to provide new insights into a comprehensive assessment of fertility in SLE patients. Methods In this study, we collected data from 34 SLE patients who were previously diagnosed and in remission for a total of 44 IVF cycles and matched 102 infertile women with a total of 148 IVF cycles by Propensity Score Matching (PSM) of 1:3 ratio. We then evaluated baseline characteristics, ovarian reserve, IVF laboratory outcomes, and clinical outcomes between the two groups. Results After PSM matching, baseline characteristics including age, infertility types, and duration, as well as infertility causes overall coincided between the two groups. Anti-müllerian hormone (AMH) was significantly lower in the SLE group vs comparison (1.9 vs. 3.3 ng/mL, P=0.001). The SLE group performed a significant reduction in available embryo rate (76.6% vs. 86.0%, P=0.001), good-quality blastocyst formation rate (35.1% vs. 47.0%, P=0.003), and blastocyst formation rate (51.0% vs. 67.7%, P=0.001) compared to the comparison. As for clinical outcomes, the implantation rate in the SLE group was notably lower (37.9% vs. 54.9%, P=0.022). The CLBR following every embryo-transfer procedure was distinctly lower (41.2% vs 64.7%, P=0.016) in the SLE group vs comparison. Also, the conservative and optimal CLBRs following every complete cycle procedure were significantly reduced in the SLE group vs the comparison (P=0.001, both). Conclusion Patients with SLE present worse outcomes in oocyte and embryonic development, thus yielding compromised female fertility and clinical pregnancy. Individualized fertility assessment and early fertility guidance are necessary for these special groups.
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Affiliation(s)
| | | | | | | | - Lei Jin
- *Correspondence: Lixia Zhu, ; Lei Jin,
| | - Lixia Zhu
- *Correspondence: Lixia Zhu, ; Lei Jin,
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Smith-Jackson K, Harrison RA. Alternative pathway activation in pregnancy, a measured amount "complements" a successful pregnancy, too much results in adverse events. Immunol Rev 2023; 313:298-319. [PMID: 36377667 PMCID: PMC10100418 DOI: 10.1111/imr.13169] [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: 11/16/2022]
Abstract
During pregnancy, the maternal host must adapt in order to enable growth of the fetus. These changes affect all organ systems and are designed both to protect the fetus and to minimize risk to the mother. One of the most prominent adaptations involves the immune system. The semi-allogenic fetoplacental unit has non-self components and must be protected against attack from the host. This requires both attenuation of adaptive immunity and protection from innate immune defense mechanisms. One of the key innate immune players is complement, and it is important that the fetoplacental unit is not identified as non-self and subjected to complement attack. Adaptation of the complement response must, however, be managed in such a way that maternal protection against infection is not compromised. As the complement system also plays a significant facilitating role in many of the stages of a normal pregnancy, it is also important that any necessary adaptation to accommodate the semi-allogenic aspects of the fetoplacental unit does not compromise this. In this review, both the physiological role of the alternative pathway of complement in facilitating a normal pregnancy, and its detrimental participation in pregnancy-specific disorders, are discussed.
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Affiliation(s)
- Kate Smith-Jackson
- Complement Therapeutics Research Group, Translational and Clinical Research Institute, Faculty of Medical Science, Newcastle University, Newcastle-upon-Tyne, UK.,The National Renal Complement Therapeutics Centre (NRCTC), Newcastle-upon-Tyne Hospitals NHS Foundation Trust, Newcastle-upon-Tyne, UK
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Silva ACBD, Sun SY, Campanharo FF, Morooka LT, Cecatti JG, Mattar R. Maternal Near Miss in Patients with Systemic Lupus Erythematosus. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRÍCIA 2023; 45:11-20. [PMID: 36878248 PMCID: PMC10098454 DOI: 10.1055/s-0042-1759633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2023] Open
Abstract
OBJECTIVE Systemic lupus erythematosus (SLE) may cause irreversible organ damage. Pregnancy with SLE may have severe life-threatening risks. The present study aimed to determine the prevalence of severe maternal morbidity (SMM) in patients with SLE and analyze the parameters that contributed to cases of greater severity. METHODS This is a cross-sectional retrospective study from analysis of data retrieved from medical records of pregnant women with SLE treated at a University Hospital in Brazil. The pregnant women were divided in a control group without complications, a group with potentially life-threatening conditions (PLTC), and a group with maternal near miss (MNM). RESULTS The maternal near miss rate was 112.9 per 1,000 live births. The majority of PLTC (83.9%) and MNM (92.9%) cases had preterm deliveries with statistically significant increased risk compared with the control group (p = 0.0042; odds ratio [OR]: 12.05; 95% confidence interval [CI]: 1.5-96.6 for the MNM group and p = 0.0001; OR: 4.84; 95%CI: 2.2-10.8 for the PLTC group). Severe maternal morbidity increases the risk of longer hospitalization (p < 0.0001; OR: 18.8; 95%CI: 7.0-50.6 and p < 0.0001; OR: 158.17; 95%CI: 17.6-1424,2 for the PLTC and MNM groups, respectively), newborns with low birthweight (p = 0.0006; OR: 3.67; 95%CI: 1.7-7.9 and p = 0.0009; OR: 17.68; 95%CI: 2-153.6) for the PLTC and MNM groups, respectively] as well as renal diseases (PLTC [8.9%; 33/56; p = 0.0069] and MNM [78.6%; 11/14; p = 0.0026]). Maternal near miss cases presented increased risk for neonatal death (p = 0.0128; OR: 38.4; 95%CI: 3.3-440.3]), and stillbirth and miscarriage (p = 0.0011; OR: 7.68; 95%CI: 2.2-26.3]). CONCLUSION Systemic lupus erythematosus was significantly associated with severe maternal morbidity, longer hospitalizations, and increased risk of poor obstetric and neonatal outcomes.
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Affiliation(s)
| | - Sue Yazaki Sun
- Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | | | - Letícia Tiemi Morooka
- Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | | | - Rosiane Mattar
- Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil
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Alanazi AS, Victor F, Rehman K, Khan YH, Yunusa I, Alzarea AI, Akash MSH, Mallhi TH. Pre-Existing Diabetes Mellitus, Hypertension and KidneyDisease as Risk Factors of Pre-Eclampsia: A Disease of Theories and Its Association with Genetic Polymorphism. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:16690. [PMID: 36554576 PMCID: PMC9778778 DOI: 10.3390/ijerph192416690] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Revised: 11/25/2022] [Accepted: 12/03/2022] [Indexed: 06/17/2023]
Abstract
Pre-existing diabetes, hypertension and kidney disorders are prominent risk factors of pre-eclampsia (PE). It is a multifactorial pregnancy disorder associated with high blood pressure, proteinuria, and multiorgan failure, which develops after the 20th week of pregnancy. It is one of the most feared pregnancy disorders, as it consumes thousands of fetomaternal lives per annum. According to clinical and pathological studies, the placenta appears to be a key player in the pathogenesis of PE; however, the exact origin of this disorder is still under debate. Defective placentation and angiogenesis are the hallmarks of PE progression. This angiogenic imbalance, together with maternal susceptibility, might determine the severity and clinical presentation of PE. This article comprehensively examines the mechanisms of pathogenesis of PE and current evidence of the factors involved in its progression. Finally, this article will explore the genetic association of PE, various candidate genes, their proposed mechanisms and variants involved in its pathogenesis.
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Affiliation(s)
- Abdullah Salah Alanazi
- Department of Clinical Pharmacy, College of Pharmacy, Jouf University, Sakaka 72388, Saudi Arabia
| | - Francis Victor
- Department of Pharmacy, University of Chenab, Gujrat 50700, Pakistan
| | - Kanwal Rehman
- Department of Pharmacy, The Women University, Multan 66000, Pakistan
| | - Yusra Habib Khan
- Department of Clinical Pharmacy, College of Pharmacy, Jouf University, Sakaka 72388, Saudi Arabia
| | - Ismaeel Yunusa
- College of Pharmacy, University of South Carolina, Columbia, SC 29208, USA
| | | | | | - Tauqeer Hussain Mallhi
- Department of Clinical Pharmacy, College of Pharmacy, Jouf University, Sakaka 72388, Saudi Arabia
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White AA, Lin A, Bickendorf X, Cavve BS, Moore JK, Siafarikas A, Strickland DH, Leffler J. Potential immunological effects of gender-affirming hormone therapy in transgender people - an unexplored area of research. Ther Adv Endocrinol Metab 2022; 13:20420188221139612. [PMID: 36533187 PMCID: PMC9747891 DOI: 10.1177/20420188221139612] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 10/31/2022] [Indexed: 12/14/2022] Open
Abstract
There are well-described sex-based differences in how the immune system operates. In particular, cisgender (cis) females have a more easily activated immune system; associated with an increased prevalence of autoimmune diseases and adverse events following vaccinations. Conversely, cis males have a higher threshold for immune activation, and are more prone to certain infectious diseases, such as coronavirus disease (COVID-19). Oestrogen and testosterone have immune-modulatory properties, and it is likely that these contribute to the sexual dimorphism of the immune system. There are also important immune-related genes located on the X chromosome, such as toll-like receptor (TLR) 7/8; and the mosaic bi-allelic expression of such genes may contribute to the state of immune hyperactivation in cis females. The scientific literature strongly suggests that sex-based differences in the functioning of the immune system are related to both X-linked genes and immune modulation by sex hormones. However, it is currently not clear how this impacts transgender (trans) people receiving gender-affirming hormonal therapy. Moreover, it is estimated that in Australia, at least 2.3% of adolescents identify as trans and/or gender diverse, and referrals to specialist gender-affirming care are increasing each year. Despite the improving social awareness of trans people, they remain chronically underrepresented in the scientific literature. In addition, a small number of case studies describe new onset autoimmune disorders in adult trans females following oestrogen use. However, there is currently minimal long-term research with an immunological focus on trans people. Therefore, to ensure the positive health outcomes of trans people, it is crucial that the role of sex hormones in immune modulation is investigated further.
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Affiliation(s)
- Alice A. White
- Telethon Kids Institute, University of Western Australia, Nedlands, WA, Australia
| | - Ashleigh Lin
- Telethon Kids Institute, University of Western Australia, Nedlands, WA, Australia
| | - Xander Bickendorf
- Telethon Kids Institute, University of Western Australia, WA, Australia
- Gender Diversity Service, Child and Adolescent Health Service, Nedlands, WA, Australia
| | - Blake S. Cavve
- Gender Diversity Service, Child and Adolescent Health Service, Nedlands, WA, Australia
| | - Julia K. Moore
- Gender Diversity Service, Child and Adolescent Health Service, Nedlands, WA, Australia
- School of Psychiatry and Clinical Neurosciences, University of Western Australia, Nedlands, WA, Australia
| | - Aris Siafarikas
- Telethon Kids Institute, University of Western Australia, Nedlands, WA, Australia
- Gender Diversity Service, Child and Adolescent Health Service, Nedlands, WA, Australia
- Paediatrics, Medical School, The University of Western Australia, Nedlands, WA, Australia
| | | | - Jonatan Leffler
- Telethon Kids Institute, University of Western Australia, Perth Children’s Hospital, 15 Hospital Ave., Nedlands, WA 6009, Australia
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Kidney biopsy during pregnancy: a difficult decision. A case series reporting on 20 patients from Mexico. J Nephrol 2022; 35:2293-2300. [PMID: 35994230 DOI: 10.1007/s40620-022-01366-1] [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: 01/13/2022] [Accepted: 05/23/2022] [Indexed: 10/15/2022]
Abstract
BACKGROUND Kidney biopsy is a routine procedure in the diagnosis of kidney disease, but during pregnancy it carries potential adverse effects for both mother and child, aside from the challenges of obtaining adequate tissue samples. Nevertheless, a precise diagnosis is necessary when specific and potentially toxic treatments are to be used during pregnancy. The present report presents our experience with regard to the usefulness and safety of kidney biopsies during pregnancy. METHODS Retrospective analysis of clinical indications, complications, histopathological diagnoses, and treatment of patients who had kidney biopsies done at a single academic center during gestation weeks 11-30 between January 2015 and January 2019. RESULTS Kidney biopsies were carried out in 20 pregnant patients with nephrotic proteinuria. Biopsy was adequate in all patients. The histological diagnoses included focal segmental glomerulosclerosis (collapsing, tip and perihiliar varieties), membranous lupus nephropathy, diabetic nephropathy, and IgA nephropathy. Treatment was associated with reduction of proteinuria in 17 patients and reduction of serum creatinine in 9 out of 11 patients who had serum creatinine ≥ 1 mg/dl at the time of biopsy. There was one major bleeding complication that required transfusion of one unit of blood. There was a high incidence of preeclampsia, preterm delivery, and low birth weight despite appropriate kidney disease therapy. CONCLUSIONS Kidney biopsy may be done during pregnancy when therapeutic decisions depend on a precise pathologic diagnosis.
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Mohammed RHA, Mumtaz H, Sangah AB, Shaikh SS, Nasir N, Jabeen S. Pregnancy in lupus: an updated consensus to guide best practice strategies. EGYPTIAN RHEUMATOLOGY AND REHABILITATION 2022. [DOI: 10.1186/s43166-022-00167-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Abstract
Background
Systemic lupus erythematosus is a multifaceted chronic relapsing autoimmune disease of unknown etiology. The disease has always been a serious diagnosis in women being a multisystem pathology that is classically encountered during the childbearing age posing serious systemic comorbidities with a potential impact on the functional performance, psychosocial status, and survival. In this article, we review critical issues related to the decision to conceive in female with lupus highlighting the impact of the diagnosis and disease activity status on the mother and the fetus, attempting to suggest a consensus to guide safe decision making for pregnancy with SLE.
Main body
The pleomorphic dysregulated immune nature of lupus in the presence of uncontrolled disease carries a higher risk of complicated pregnancy. Therefore, SLE pregnancies should be well planned and are usually encouraged if the disease is inactive (at least 6 months prior to conception) to ensure immune quiescence towards a safer outcome.
Conclusion
With the proper implementation of preconception counseling strategy, choice of the correct timing of conception, close monitoring of SLE flares with tight control, and the appreciation of the value of multidisciplinary management to best practice most young women with SLE can carry on successful pregnancies with favorable outcome.
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El Miedany Y, Kamel NS, Abu-Zaid MH, El Hadidi K, Mahmoud GA, El Gaafary M, Sarhan E, Abdel-Nasser A, Abualfadl EM, Azim AA, Fathi NA, Mokbel A, Hassan W, Eissa M, Tabra SAA, Mortada M, Fouad NA, Elnemr R, Mansour AE, Elaraby I, Medhat BM, Mohamed SS, Abdelradi ER, Ibrahim RA, Saber S. Egyptian recommendations for treating to target of lupus nephritis: an evidence-based consensus on clinical practice recommendations for the management of lupus nephritis and pregnancy. EGYPTIAN RHEUMATOLOGY AND REHABILITATION 2022. [DOI: 10.1186/s43166-022-00142-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Nephritis is known to be one of the most serious complications of lupus and a strong predictor of poor outcome. This study was carried out aiming at setting up an up-to-date recommendation for the management of women living with lupus nephritis and planning for a family throughout conception, pregnancy, and the postpartum period.
Ten key clinical questions were identified by the scientific committee according to the Patient/Population, Intervention, Comparison, Outcomes and Timing (PICOT) approach. The literature review team performed a systematic review to summarise evidence advocating the benefits and harms of available pharmacologic and nonpharmacologic therapies for women living with lupus nephritis (LN) and planning for a family. Subsequently, recommendations were formulated. The level of evidence was determined for each section using the Oxford Centre for Evidence-Based Medicine (CEBM) system. A 2-round Delphi process was conducted with 24 experts. All rounds were conducted online. A consensus was achieved on the direction and the strength of the recommendations.
Results
An online questionnaire was sent to an expert panel who participated in the two rounds (response rate 100%). At the end of round 2, a total of 20 recommendation items, categorised into 10 domains to address the main LN with pregnancy categories, were obtained. The percentage of those who agreed with the recommendations (rank 7–9) ranged from 88.5 to 100%. On the phrasing of all the clinical standards defined by the scientific committee, a consensus was reached (i.e., 75% of respondents strongly agreed or agreed). An algorithm for the management of LN with pregnancy has been suggested.
Conclusion
These recommendations provide an updated consensus on the pharmacological treatment of LN with pregnancy and strategies to reach optimal outcomes for both the mother and newborn in common clinical scenarios, based on a combination of evidence and expert opinion. Best treatment decisions should be tailored to each individual patient’s situation.
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Dodd KC, Menon M. Sex bias in lymphocytes: Implications for autoimmune diseases. Front Immunol 2022; 13:945762. [PMID: 36505451 PMCID: PMC9730535 DOI: 10.3389/fimmu.2022.945762] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 11/03/2022] [Indexed: 11/25/2022] Open
Abstract
Autoimmune diseases are characterized by a significant sex dimorphism, with women showing increased susceptibility to disease. This is, at least in part, due to sex-dependent differences in the immune system that are influenced by the complex interplay between sex hormones and sex chromosomes, with contribution from sociological factors, diet and gut microbiota. Sex differences are evident in the number and function of lymphocyte populations. Women mount a stronger pro-inflammatory response than males, with increased lymphocyte proliferation, activation and pro-inflammatory cytokine production, whereas men display expanded regulatory cell subsets. Ageing alters the immune landscape of men and women in differing ways, resulting in changes in autoimmune disease susceptibility. Here we review the current literature on sex differences in lymphocyte function, the factors that influence this, and the implications for autoimmune disease. We propose that improved understanding of sex bias in lymphocyte function can provide sex-specific tailoring of treatment strategies for better management of autoimmune diseases.
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Affiliation(s)
- Katherine C. Dodd
- Lydia Becker Institute of Immunology and Inflammation, Division of Immunology, Immunity to Infection and Respiratory Medicine, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom,Manchester Centre for Clinical Neurosciences, Salford Royal Hospital, Salford, United Kingdom
| | - Madhvi Menon
- Lydia Becker Institute of Immunology and Inflammation, Division of Immunology, Immunity to Infection and Respiratory Medicine, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom,*Correspondence: Madhvi Menon,
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Fernández-Buhigas I. Obstetric management of the most common autoimmune diseases: A narrative review. Front Glob Womens Health 2022; 3:1031190. [PMID: 36505012 PMCID: PMC9728613 DOI: 10.3389/fgwh.2022.1031190] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 10/10/2022] [Indexed: 11/24/2022] Open
Abstract
Historically, women with an autoimmune disease (AD) could not get pregnant due to infertility frequently linked to the medical condition or because the pregnancy was contraindicated, as it could harm the mother and the future child. Sometimes, pregnancy was contraindicated because the medication needed to control the AD could not be given during pregnancy. All these items are no longer true nowadays. Fertility treatments have advanced, obstetric care is better, and the medical treatments of autoimmune diseases have progressed, so women with any kind of AD are encouraged to get pregnant, and their presence in obstetric clinics is arising. This is challenging for the obstetricians, as to be sure that these pregnancies are safe for the mother and the future child, the obstetricians need to know the natural evolution of these conditions, the impact of pregnancy and postpartum on the illness, and the impact of the AD in the pregnancy. In this narrative review, we aim to make a brief resume of the obstetric management of the most common diseases (Systemic lupus erythematosus, antiphospholipid syndrome, the Anti-Ro/SSA and Anti-La/SSB antigen-antibody systems, rheumatoid arthritis, Sjögren's syndrome and Undifferentiated systemic rheumatic disease and overlap syndromes).
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Affiliation(s)
- Irene Fernández-Buhigas
- Obstetrics and Gynecology Department, Hospital Universitario de Torrejón, Madrid, Spain,School of Medicine, Universidad Francisco de Vitoria, Pozuelo de Alarcón, Madrid, Spain,Correspondence: Irene Fernández-Buhigas
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Baños N, Castellanos AS, Barilaro G, Figueras F, Lledó GM, Santana M, Espinosa G. Early Prediction of Adverse Pregnancy Outcome in Women with Systemic Lupus Erythematosus, Antiphospholipid Syndrome, or Non-Criteria Obstetric Antiphospholipid Syndrome. J Clin Med 2022; 11:jcm11226822. [PMID: 36431299 PMCID: PMC9696942 DOI: 10.3390/jcm11226822] [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: 10/23/2022] [Revised: 11/14/2022] [Accepted: 11/15/2022] [Indexed: 11/19/2022] Open
Abstract
A prospectively study of pregnant women with systemic lupus erythematosus (SLE), antiphospholipid syndrome, or non-criteria obstetric antiphospholipid syndrome was conducted to describe the characteristics of women followed in a referral unit and to derive a predictive tool for adverse pregnancy outcome (APO). Demographic characteristics, treatments, SLE activity, and flares were recorded. Laboratory data included a complete blood cell count, protein-to-creatinine urinary ratio (Pr/Cr ratio), complement, anti dsDNA, anti-SSA/Ro, anti-SSB/La, and antiphospholipid antibodies status. A stepwise regression was used to identify baseline characteristics available before pregnancy and during the 1st trimester that were most predictive of APO and to create the predictive model. A total of 217 pregnancies were included. One or more APO occurred in 45 (20.7%) women. A baseline model including non-Caucasian ethnicity (OR 2.78; 95% CI [1.16-6.62]), smoking (OR 4.43; 95% CI [1.74-11.29]), pregestational hypertension (OR 16.13; 95% CI [4.06-64.02]), and pregestational corticosteroids treatment OR 2.98; 95% CI [1.30-6.87]) yielded an AUC of 0.78 (95% CI, [0.70-0.86]). Among first-trimester parameters, only Pr/Cr ratio improved the model fit, but the predictive performance was not significantly improved (AUC of 0.78 vs. 0.81; p = 0.16). Better biomarkers need to be developed to efficiently stratify pregnant women with the most common autoimmune diseases.
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Affiliation(s)
- Núria Baños
- BCNatal-Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Déu), Sabino de Arana, 1, 08028 Barcelona, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer, Universitat de Barcelona, Carrer del Rosselló, 149, 08036 Barcelona, Spain
- Correspondence:
| | - Aleida Susana Castellanos
- BCNatal-Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Déu), Sabino de Arana, 1, 08028 Barcelona, Spain
| | - Giuseppe Barilaro
- Department of Autoimmune Diseases, Hospital Clínic. Carrer de Villarroel, 08036 Barcelona, Spain
| | - Francesc Figueras
- BCNatal-Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Déu), Sabino de Arana, 1, 08028 Barcelona, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer, Universitat de Barcelona, Carrer del Rosselló, 149, 08036 Barcelona, Spain
| | - Gema María Lledó
- Department of Autoimmune Diseases, Hospital Clínic. Carrer de Villarroel, 08036 Barcelona, Spain
| | - Marta Santana
- BCNatal-Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Déu), Sabino de Arana, 1, 08028 Barcelona, Spain
| | - Gerard Espinosa
- Institut d’Investigacions Biomèdiques August Pi i Sunyer, Universitat de Barcelona, Carrer del Rosselló, 149, 08036 Barcelona, Spain
- Department of Autoimmune Diseases, Hospital Clínic. Carrer de Villarroel, 08036 Barcelona, Spain
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Zahid S, Mohamed MS, Wassif H, Nazir NT, Khan SS, Michos ED. Analysis of Cardiovascular Complications During Delivery Admissions Among Patients With Systemic Lupus Erythematosus, 2004-2019. JAMA Netw Open 2022; 5:e2243388. [PMID: 36445710 PMCID: PMC9709646 DOI: 10.1001/jamanetworkopen.2022.43388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 09/18/2022] [Indexed: 11/30/2022] Open
Abstract
Importance Individuals with systemic lupus erythematosus (SLE) have an increased risk of pregnancy-related complications. However, data on acute cardiovascular complications during delivery admissions remain limited. Objective To investigate whether SLE is associated with an increased risk of acute peripartum cardiovascular complications during delivery hospitalization among individuals giving birth. Design, Setting, and Participants This population-based cross-sectional study was conducted with data from the National Inpatient Sample (2004-2019) by using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) or International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Clinical Modification (ICD-10-CM) codes to identify delivery hospitalizations among birthing individuals with a diagnosis of SLE. A multivariable logistic regression model was developed to report an adjusted odds ratio (OR) for the association between SLE and acute peripartum cardiovascular complications. Data were analyzed from May 1 through September 1, 2022. Exposure Diagnosed SLE. Main Outcomes and Measures Primary study end points were preeclampsia, peripartum cardiomyopathy, and heart failure. Secondary end points included ischemic and hemorrhagic stroke, pulmonary edema, cardiac arrhythmias, acute kidney injury (AKI), venous thromboembolism (VTE), length of stay, and cost of hospitalization. Results A total of 63 115 002 weighted delivery hospitalizations (median [IQR] age, 28 [24-32] years; all were female patients) were identified, of which 77 560 hospitalizations (0.1%) were among individuals with SLE and 63 037 442 hospitalizations (99.9%) were among those without SLE. After adjustment for age, race and ethnicity, comorbidities, insurance, and income level, SLE remained an independent risk factor associated with peripartum cardiovascular complications, including preeclampsia (adjusted OR [aOR], 2.12; 95% CI, 2.07-2.17), peripartum cardiomyopathy (aOR, 4.42; 95% CI, 3.79-5.13), heart failure (aOR, 4.06; 95% CI, 3.61-4.57), cardiac arrhythmias (aOR, 2.06; 95% CI, 1.94-2.21), AKI (aOR, 7.66; 95% CI, 7.06-8.32), stroke (aOR, 4.83; 95% CI, 4.18-5.57), and VTE (aOR, 6.90; 95% CI, 6.11-7.80). For resource use, median (IQR) length of stay (3 [2-4] days vs 2 [2-3] days; P < .001) and cost of hospitalization ($4953 [$3305-$7517] vs $3722 [$2606-$5400]; P < .001) were higher for deliveries among individuals with SLE. Conclusions and Relevance This study found that SLE was associated with increased risk of complications, including preeclampsia, peripartum cardiomyopathy, heart failure, arrhythmias, AKI, stroke, and VTE during delivery hospitalization and an increased length and cost of hospitalization.
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Affiliation(s)
- Salman Zahid
- Department of Medicine, Sands-Constellation Heart Institute, Rochester General Hospital, Rochester, New York
| | - Mohamed S. Mohamed
- Department of Medicine, Sands-Constellation Heart Institute, Rochester General Hospital, Rochester, New York
| | - Heba Wassif
- Division of Cardiology, Cleveland Clinic, Cleveland, Ohio
| | - Noreen T. Nazir
- Division of Cardiology, University of Illinois at Chicago, Chicago, Illinois
| | - Sadiya S. Khan
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Erin D. Michos
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Du Q, Shi Z, Chen H, Zhang Y, Qiu Y, Lang Y, Kong L, Zhou H. Effects of pregnancy on neuromyelitis optica spectrum disorder and predictors of related attacks. Ann Clin Transl Neurol 2022; 9:1918-1925. [PMID: 36314431 PMCID: PMC9735372 DOI: 10.1002/acn3.51683] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Revised: 09/11/2022] [Accepted: 10/07/2022] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE Our study aimed to investigate the influence of pregnancy on the course of neuromyelitis optica spectrum disorders (NMOSD) and to explore the independent predictors of pregnancy-related attacks. METHODS We performed a retrospective study of patients with NMOSD based on the Wingerchuk 2006 or the revised Wingerchuk 2015 criteria. Demographic, clinical, and pregnancy data were recorded. We compared the annualized relapse rate (ARR) before, during, and after pregnancy. The Expanded Disability Status Scale (EDSS) score was used to assess the degree of disability. Multivariate Cox proportional hazards models were used to identify the independent risk factors that predict pregnancy-related attacks. RESULTS There were 202 informative pregnancies following symptom onset in 112 women with NMOSD. The ARR in the first-trimester postpartum period (1.44 ± 2.04) was higher than that before pregnancy (0.23 ± 0.48; p < 0.001) and during pregnancy. The EDSS score increased from 1.40 ± 1.38 before pregnancy to 1.99 ± 1.78 postpartum (p = 0.004). Multivariate Cox proportional hazards models indicated that increased disease activity 1 year before conception (HR = 1.79, 95% CI 1.09-2.92, p = 0.021) and lack of immunotherapy during pregnancy and the postpartum period (HR = 5.25, 95% CI 1.91-14.42, p = 0.001) were independent risk factors that predicted pregnancy-related attacks. INTERPRETATION The postpartum period is a particularly high-risk time for the onset and relapse of NMOSD. Pregnancy exerted detrimental effects on the disease courses of NMOSD. Immunotherapy during pregnancy and the postpartum period might be recommended to decrease the risk of pregnancy-related attacks. Larger-scale prospective studies are warranted to confirm our findings.
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Affiliation(s)
- Qin Du
- Department of Neurology, West China HospitalSichuan UniversityGuo Xuexiang #37Chengdu610041China
| | - Ziyan Shi
- Department of Neurology, West China HospitalSichuan UniversityGuo Xuexiang #37Chengdu610041China
| | - Hongxi Chen
- Department of Neurology, West China HospitalSichuan UniversityGuo Xuexiang #37Chengdu610041China
| | - Ying Zhang
- Department of Neurology, West China HospitalSichuan UniversityGuo Xuexiang #37Chengdu610041China
| | - Yuhan Qiu
- Department of Neurology, West China HospitalSichuan UniversityGuo Xuexiang #37Chengdu610041China
| | - Yanlin Lang
- Department of Neurology, West China HospitalSichuan UniversityGuo Xuexiang #37Chengdu610041China
| | - Lingyao Kong
- Department of Neurology, West China HospitalSichuan UniversityGuo Xuexiang #37Chengdu610041China
| | - Hongyu Zhou
- Department of Neurology, West China HospitalSichuan UniversityGuo Xuexiang #37Chengdu610041China
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72
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Low Prognostic Nutritional Index Contributes to High Adverse Events in Preeclampsia. DISEASE MARKERS 2022; 2022:1187742. [PMID: 36267459 PMCID: PMC9578871 DOI: 10.1155/2022/1187742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 09/27/2022] [Indexed: 01/12/2023]
Abstract
Background Preeclampsia (PE) is a common obstetric complication that has caused significant harm to pregnant mothers. The clinical significance of poor nutritional status in PE patients is unclear. The aim of our study was to evaluate the nutritional status as measured by the prognostic nutritional index (PNI) score at admission, and its ability to predict in-hospitalization adverse events in patients with PE. Methods We enrolled patients diagnosed with PE in the Third Affiliated Hospital of Guangzhou Medical University from January 2019 to December 2021. Patients were divided into low and high nutritional status group according to the cut-off value of PNI score at admission using the receiver operating characteristic (ROC) curve. PNI score were used to explore the relationship between PNI score and in-hospitalization adverse events presented with hazard ratio (HR) and 95% confidence intervals (CI). Results A total of 733 patients were included in the study. The proportion of adverse events and admission to intensive care unit (ICU) was higher in the low nutritional status group than in the high nutritional status group (P < 0.05). ROC curve analysis revealed an area under curve (AUC) of 0.628 for PNI score and the cut-off value of PNI was 37. The free-event rates determined by KM analysis were significantly lower in the low nutritional status compared to the high nutritional status (P < 0.05). Adjusted multivariate analysis showed that PNI score was independently associated with favorable outcomes (HR: 2.66; 95% CI: 1.724-4.050, P < 0.001). Conclusion High PNI score at admission was associated with reduced in-hospitalization risk of adverse events in patients with PE. Additional enhancing nutritional status during hospitalization may help to prevent unfavorable prognosis in clinical practices.
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73
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Kaufman KP, Eudy AM, Harris N, Neil L, Clowse MEB. Pregnancy Outcomes in Undifferentiated Connective Tissue Disease Compared to Systemic Lupus Erythematosus: A Single Academic Center's Experience. Arthritis Care Res (Hoboken) 2022; 74:1631-1639. [PMID: 33973409 PMCID: PMC8578567 DOI: 10.1002/acr.24644] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 04/07/2021] [Accepted: 05/04/2021] [Indexed: 11/12/2022]
Abstract
OBJECTIVE Systemic lupus erythematosus (SLE) patients have more pregnancy complications than healthy patients. Data regarding pregnancy outcomes in women with undifferentiated connective tissue disease (UCTD) are more limited, and existing studies are concentrated in Italy and predominantly in patients with a new diagnosis. Our objective was to compare pregnancy outcomes for UCTD and SLE patients with established disease. METHODS Between 2008 and 2017, patients with UCTD and SLE at an academic medical center were recruited to a prospective pregnancy registry. UCTD was defined as a positive autoantibody plus connective tissue disease symptoms not meeting criteria for another rheumatic diagnosis. SLE was defined by American College of Rheumatology or Systemic Lupus International Collaborating Clinics classification criteria or by physician diagnosis. Data were collected throughout pregnancy and postpartum. Comparator groups included UCTD, low-activity SLE, and high-activity SLE. RESULTS A total of 150 SLE and 51 UCTD pregnancies were analyzed. Disease activity was low in most patients, although more patients with SLE had severe activity during pregnancy (12% versus 2%; P = 0.05). The frequencies of prematurity and preeclampsia were significantly lower in UCTD than in high-activity SLE patients (preterm 17% versus 45% [P = 0.004] and preeclampsia 6% versus 34% [P = 0.0008]), although similar to low-activity SLE patients. More infants who were small for gestational age were born to SLE than UCTD patients (33% versus 7% [P = 0.0005]), regardless of disease activity level. CONCLUSION Pregnancies in women with UCTD managed by a rheumatologist have a high rate of pregnancy success and fewer risks than those in women with active SLE.
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Affiliation(s)
| | - Amanda M Eudy
- Duke University Medical Center, Durham, United States
| | | | - Laura Neil
- Duke University Medical Center, Durham, United States
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74
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Lucas A, Eudy AM, Gladman D, Petri M, Urowitz M, Wyatt CM, Clowse ME. The association of lupus nephritis with adverse pregnancy outcomes among women with lupus in North America. Lupus 2022; 31:1401-1407. [PMID: 36017607 PMCID: PMC9880879 DOI: 10.1177/09612033221123251] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVES We evaluated the association of lupus nephritis (LN) and adverse pregnancy outcomes in prospective cohorts of pregnant women with SLE (systemic lupus erythematosus). METHODS We conducted a patient-level pooled analysis of data from three cohorts of pregnant women with SLE. Pooled logistic regression models were used to evaluate the association of LN and adverse pregnancy outcomes. Odds ratios and 95% confidence intervals were calculated using a fixed effect model by enrolling cohort. RESULTS The pooled cohort included 393 women who received care at clinics in the United States and Canada from 1995 to 2015. There were 144 (37%) women with a history of LN. Compared to women without LN, those with LN had higher odds of fetal loss (OR: 1.90; 95% CI: 1.01, 3.56) and preeclampsia (OR: 2.04; 95% CI: 1.01, 4.13). Among the 31 women with active nephritis (defined as urine protein ≥ 0.5 g/24 h) there was a higher odds of poor pregnancy outcome (OR: 3.08; 95% CI: 1.31, 7.23) and fetal loss (OR: 6.29; 95% CI: 2.52, 15.70) compared to women without LN. CONCLUSIONS In this pooled cohort of women with SLE, a history of LN was associated with fetal loss and preeclampsia. Active nephritis was associated with poor pregnancy outcome and fetal loss.
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Affiliation(s)
- Anika Lucas
- 12277Duke University School of Medicine, Durham, NC, USA
| | - Amanda M Eudy
- 12277Duke University School of Medicine, Durham, NC, USA
| | | | - Michelle Petri
- School of Medicine, 1466Johns Hopkins University, Baltimore, MD, USA
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Preparing for Pregnancy in Women with Systemic Lupus Erythematosus—A Multidisciplinary Approach. Medicina (B Aires) 2022; 58:medicina58101371. [DOI: 10.3390/medicina58101371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 09/22/2022] [Accepted: 09/23/2022] [Indexed: 11/17/2022] Open
Abstract
Pregnancy is one of the most challenging processes the human body is exposed to: the healthy mother can carry to term a genetically different new-born, while her immune system adapts to tolerate this new status and avoids rejection. In autoimmune disorders, motherhood is even more challenging, with additional medical counselling, mother care, and foetus development checks being necessary. While the aspects of supplementary mother care and pregnancy progress tracking are associated with well-established medical procedures and protocols, counselling, be it pre- or post-conception, is still underestimated and scarcely applied. Indeed, over the past decades, medical counselling for this particular population has changed significantly, but from a healthcare’s provider point of view, more is required to ensure a smooth, controllable pregnancy evolution. One of the most frequent autoimmune diseases affecting young females during their fertile years is Systemic Lupus Erythematosus (SLE). Like other heterogenous diseases, it exposes the mother to severe, organ-threatening complications and unpredictable evolution. Both the disease and its treatment can significantly affect the mother’s willingness to engage in a potentially risky pregnancy, as well as the likeliness to carry it to term without any impairments. A good collaboration between the patient’s rheumatologist and obstetrician is therefore mandatory in order to: (a) allow the mother to make an informed decision on pursuing with the pregnancy; (b) ensure a perfect synchronization between pregnancy terms and treatment; and (c) avoid or minimize potential complications. The best approach to achieve these outcomes is pregnancy planning. Moreover, knowing one desired prerequisite for a successful pregnancy evolution in SLE mothers is a stable, inactive, quiescent disease for at least six months prior to conception, planning becomes more than a recommended procedure. One particular aspect that requires attention before conception is the treatment scheme applied before delivery as autoantibodies can influence significantly the course of pregnancy. In this view, future SLE mothers should ideally benefit from preconception counselling within their agreed care pathway. A multidisciplinary team including at least the rheumatologist and obstetrician should be employed throughout the pregnancy, to decide on the appropriate timing of conception and compatible medication with respect to disease activity, as well as to monitor organ involvement and foetus development progress.
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76
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Sagar PS, Fischer E, Gangadharan Komala M, Bose B. A case of minimal change disease during pregnancy - benefits of early diagnosis and use of corticosteroids. Obstet Med 2022; 15:198-200. [PMID: 36262820 PMCID: PMC9574446 DOI: 10.1177/1753495x21990214] [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: 06/24/2020] [Revised: 12/27/2020] [Accepted: 01/02/2021] [Indexed: 09/03/2023] Open
Abstract
Nephrotic syndrome presenting in pregnancy is rare and poses a diagnostic and therapeutic challenge. Timing of renal biopsy is important given the increased risk of bleeding and miscarriage, and the choice of immunosuppression is limited due to the teratogenicity profiles of standard drugs. We report and discuss a case of minimal change disease diagnosed by renal biopsy during early pregnancy and treated with corticosteroids throughout the pregnancy. Prompt diagnosis and treatment of glomerular disease in pregnancy are vital to prevent poor maternal and fetal outcomes.
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Affiliation(s)
- Priyanka S Sagar
- Department of Renal Medicine, Nepean
Hospital, Penrith, NSW, Australia
| | - Eddy Fischer
- Department of Renal Medicine, Nepean
Hospital, Penrith, NSW, Australia
| | | | - Bhadran Bose
- Department of Renal Medicine, Nepean
Hospital, Penrith, NSW, Australia
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Castellanos Gutierrez AS, Figueras F, Morales-Prieto DM, Schleußner E, Espinosa G, Baños N. Placental damage in pregnancies with systemic lupus erythematosus: A narrative review. Front Immunol 2022; 13:941586. [PMID: 36059466 PMCID: PMC9428442 DOI: 10.3389/fimmu.2022.941586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 07/12/2022] [Indexed: 11/17/2022] Open
Abstract
Systemic lupus erythematosus (SLE) is a chronic inflammatory autoimmune disease of unknown cause, which mainly affects women of childbearing age, especially between 15 and 55 years of age. During pregnancy, SLE is associated with a high risk of perinatal morbidity and mortality. Among the most frequent complications are spontaneous abortion, fetal death, prematurity, intrauterine Fetal growth restriction (FGR), and preeclampsia (PE). The pathophysiology underlying obstetric mortality and morbidity in SLE is still under investigation, but several studies in recent years have suggested that placental dysfunction may play a crucial role. Understanding this association will contribute to developing therapeutic options and improving patient management thus reducing the occurrence of adverse pregnancy outcomes in this group of women. In this review, we will focus on the relationship between SLE and placental insufficiency leading to adverse pregnancy outcomes.
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Affiliation(s)
- Aleida Susana Castellanos Gutierrez
- BCNatal, Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Déu), Institut Clínic de Ginecologia, Obstetrícia i Neonatologia Fetal i+D Fetal Medicine Research Center, Barcelona, Spain
- Placenta Lab, Department of Obstetrics, Jena University Hospital, Jena, Germany
| | - Francesc Figueras
- BCNatal, Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Déu), Institut Clínic de Ginecologia, Obstetrícia i Neonatologia Fetal i+D Fetal Medicine Research Center, Barcelona, Spain
- Institut d’Investigacions Biomèdiques Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Diana M. Morales-Prieto
- Placenta Lab, Department of Obstetrics, Jena University Hospital, Jena, Germany
- *Correspondence: Núria Baños, ; Diana M. Morales-Prieto,
| | - Ekkehard Schleußner
- Placenta Lab, Department of Obstetrics, Jena University Hospital, Jena, Germany
| | - Gerard Espinosa
- Institut d’Investigacions Biomèdiques Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Department of Autoimmune Diseases, Hospital Clinic, Barcelona, Spain
| | - Núria Baños
- BCNatal, Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Déu), Institut Clínic de Ginecologia, Obstetrícia i Neonatologia Fetal i+D Fetal Medicine Research Center, Barcelona, Spain
- *Correspondence: Núria Baños, ; Diana M. Morales-Prieto,
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Tsakiridis I, Giouleka S, Mamopoulos A, Athanasiadis A, Dagklis T. Investigation and management of stillbirth: a descriptive review of major guidelines. J Perinat Med 2022; 50:796-813. [PMID: 35213798 DOI: 10.1515/jpm-2021-0403] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 02/01/2022] [Indexed: 11/15/2022]
Abstract
Stillbirth is a common and devastating pregnancy complication. The aim of this study was to review and compare the recommendations of the most recently published guidelines on the investigation and management of this adverse outcome. A descriptive review of guidelines from the American College of Obstetricians and Gynecologists (ACOG), the Royal College of Obstetricians and Gynecologists (RCOG), the Perinatal Society of Australia and New Zealand (PSANZ), the Society of Obstetricians and Gynecologists of Canada (SOGC) on stillbirth was carried out. Regarding investigation, there is consensus that medical history and postmortem examination are crucial and that determining the etiology may improve care in a subsequent pregnancy. All guidelines recommend histopathological examination of the placenta, genetic analysis and microbiology of fetal and placental tissues, offering less invasive techniques when autopsy is declined and a Kleihauer test to detect large feto-maternal hemorrhage, whereas they discourage routine screening for inherited thrombophilias. RCOG and SOGC also recommend a complete blood count, coagulopathies' testing, anti-Ro and anti-La antibodies' measurement in cases of hydrops and parental karyotyping. Discrepancies exist among the reviewed guidelines on the definition of stillbirth and the usefulness of thyroid function tests and maternal viral screening. Moreover, only ACOG and RCOG discuss the management of stillbirth. They agree that, in the absence of coagulopathies, expectant management should be considered and encourage vaginal birth, but they suggest different labor induction protocols and different management in subsequent pregnancies. It is important to develop consistent international practice protocols, in order to allow effective determination of the underlying causes and optimal management of stillbirths, while identifying the gaps in the current literature may highlight the need for future research.
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Affiliation(s)
- Ioannis Tsakiridis
- Third Department of Obstetrics and Gynaecology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Sonia Giouleka
- Third Department of Obstetrics and Gynaecology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Apostolos Mamopoulos
- Third Department of Obstetrics and Gynaecology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Apostolos Athanasiadis
- Third Department of Obstetrics and Gynaecology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Themistoklis Dagklis
- Third Department of Obstetrics and Gynaecology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Li HH, Sai LT, Liu Y, Freel CI, Wang K, Zhou C, Zheng J, Shu Q, Zhao YJ. Systemic lupus erythematosus dysregulates the expression of long noncoding RNAs in placentas. Arthritis Res Ther 2022; 24:142. [PMID: 35701843 PMCID: PMC9195362 DOI: 10.1186/s13075-022-02825-7] [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] [Received: 06/24/2021] [Accepted: 05/21/2022] [Indexed: 11/15/2022] Open
Abstract
Background Systemic lupus erythematosus (SLE) can cause placental dysfunctions, which may result in pregnancy complications. Long noncoding RNAs (lncRNAs) are actively involved in the regulation of immune responses during pregnancy. The present study aimed to determine the lncRNA expression profiles in placentas from women with SLE to gain new insights into the underlying molecular mechanisms in SLE pregnancies. Methods RNA sequencing (RNA-seq) analysis was performed to identify SLE-dysregulated lncRNAs and mRNAs in placentas from women with SLE and normal full-term (NT) pregnancies. Bioinformatics analysis was conducted to predict the biological functions of these SLE-dysregulated lncRNAs and mRNAs. Results RNA-seq analysis identified 52 dysregulated lncRNAs in SLE placentas, including 37 that were upregulated and 15 downregulated. Additional 130 SLE-dysregulated mRNAs were discovered, including 122 upregulated and 8 downregulated. Bioinformatics analysis revealed that SLE-dysregulated genes were associated with biological functions and gene networks, such as regulation of type I interferon-mediated signaling pathway, response to hypoxia, regulation of MAPK (mitogen-activated protein kinase) cascade, response to steroid hormone, complement and coagulation cascades, and Th1 and Th2 cell differentiation. Conclusions This is the first report of the lncRNA profiles in placentas from SLE pregnancies. These results suggest that the aberrant expression and the potential regulatory function of lncRNAs in placentas may play comprehensive roles in the pathogenesis of SLE pregnancies. SLE-dysregulated lncRNAs may potentially serve as biomarkers for SLE. Supplementary Information The online version contains supplementary material available at 10.1186/s13075-022-02825-7.
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Affiliation(s)
- Hui-Hui Li
- Department of Obstetrics and Gynecology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250012, Shandong, China.,Department of Obstetrics and Gynecology, University of Wisconsin-Madison, Madison, WI, 53715, USA
| | - Lin-Tao Sai
- Department of Infectious Diseases, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250012, Shandong, China
| | - Yuan Liu
- Department of Obstetrics and Gynecology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250012, Shandong, China
| | - Colman I Freel
- Department of Obstetrics and Gynecology, University of Wisconsin-Madison, Madison, WI, 53715, USA.,Scholars Program, University of Nebraska Medical Center, Omaha, NE, 68198, USA
| | - Kai Wang
- Clinical and Translational Research Center, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, China
| | - Chi Zhou
- School of Animal and Comparative Biomedical Sciences, University of Arizona, Tucson, AZ, 85719, USA
| | - Jing Zheng
- Department of Obstetrics and Gynecology, University of Wisconsin-Madison, Madison, WI, 53715, USA
| | - Qiang Shu
- Department of Rheumatology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250012, Shandong, China. .,Shandong Provincial Clinical Research Center for Immune Diseases and Gout, Jinan, 250012, Shandong, China.
| | - Ying-Jie Zhao
- Department of Obstetrics and Gynecology, University of Wisconsin-Madison, Madison, WI, 53715, USA. .,Department of Rheumatology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250012, Shandong, China. .,Shandong Provincial Clinical Research Center for Immune Diseases and Gout, Jinan, 250012, Shandong, China.
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Gohr M, Jakobsen IM, Helmig RB, Stengaard-Pedersen K, Laurberg TB, Troldborg A. Improved pregnancy outcomes in systemic lupus erythematosus: A retrospective study of pregnancies from a single centre in Denmark from 2010-2020 compared with the period 1990-2010. Lupus 2022; 31:1202-1210. [PMID: 35676102 DOI: 10.1177/09612033221107538] [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: 11/15/2022]
Abstract
OBJECTIVES Over the past decades new international guidelines recommend that pregnant Systemic lupus erythematosus (SLE) patients are monitored closely in a multi-professional team throughout pregnancy. The importance of low disease activity before pregnancy and continued treatment during pregnancy has been established. However, there is still a high risk of adverse pregnancy outcome (APO).The APO in a Danish SLE cohort was evaluated and compared with the results in a previous study cohort from the same centre and referral area. METHODS This retrospective cohort study used the local patient registry to identify pregnancies in SLE patients followed at the Department of Rheumatology, Aarhus University Hospital, Denmark, from January 2010 to October 2020. In total, 66 pregnancies were registered in 41 women. Data were compared with a previous retrospective study (1990-2010) from the same hospital. RESULTS Adverse pregnancy outcome occurred in 65% of pregnancies. Forty-seven pregnancies resulted in a live birth, while 15 ended in miscarriages. Compared to the 1990-2010 cohort, a numerical reduction in preterm deliveries (7.58% vs. 17.9%) and emergent caesarean (6.1% vs. 15.5%) was observed, although not reaching statistical significance (p = .07 in both cases). Further, a higher average birth weight (3045 g vs. 2870 g) as well as a higher number of pregnancies and live births per year were observed. Gestational hypertension was significantly reduced from 23.8% to 13.6% (p = .05). Significantly more patients were treated with prednisolone (66.7% vs 35.7%, p = .0002), hydroxychloroquine (6% vs. 73.4%, p < .0001) and acetylsalicylic acid (39.3% vs. 73.1%, p = .0001) in 2010-2020 compared to the 1990-2010. CONCLUSION We observed significant improvements in the frequency of some APOs in the recent 2010-2020 cohort compared with the previous cohort followed from 1990 to 2010. However, even though a specialized multi-professional team closely follows SLE patients through their pregnancies, pregnancy in SLE still carries a high risk of APO.
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Affiliation(s)
- Mette Gohr
- Department of Rheumatology, 11297Aarhus University Hospital, Aarhus, Denmark
| | - Iris Marie Jakobsen
- Department of Rheumatology, 53141Aalborg University Hospital, Aalborg, Denmark
| | - Rikke Bek Helmig
- Department of Gynecology and Obstetrics, 11297Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, 1006Aarhus University, Aarhus, Denmark
| | | | - Trine Bay Laurberg
- Department of Rheumatology, 11297Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, 1006Aarhus University, Aarhus, Denmark
| | - Anne Troldborg
- Department of Rheumatology, 11297Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, 1006Aarhus University, Aarhus, Denmark.,Department of Biomedicine, 1006Aarhus University, Aarhus, Denmark
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81
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Tani C, Zucchi D, Haase I, Gerosa M, Larosa M, Cavagna L, Bortoluzzi A, Crisafulli F, Mucke J, Strigini FAL, Baglietto L, Fornili M, Monacci F, Elefante E, Erra R, Bellis E, Padovan M, Andreoli L, Coletto LA, Zanframundo G, Govoni M, Iaccarino L, Tincani A, Doria A, Fischer-Betz R, Mosca M. Impact of low-dose acetylsalicylic acid on pregnancy outcome in systemic lupus erythematosus: results from a multicentre study. Lupus Sci Med 2022; 9:e000714. [PMID: 35701044 PMCID: PMC9198794 DOI: 10.1136/lupus-2022-000714] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 06/02/2022] [Indexed: 11/10/2022]
Abstract
OBJECTIVE It is still a matter of debate whether low-dose acetylsalicylic acid (LDASA) should be prescribed to all patients with SLE during pregnancy. This study aimed at investigating the impact of LDASA on pregnancy outcomes in patients with SLE without history of renal involvement and without antiphospholipid antibodies (aPL). METHODS This is a retrospective analysis of prospectively monitored pregnancies at seven rheumatology centres. Previous/current renal involvement and aPL positivity were the exclusion criteria. Adverse pregnancy outcome (APO) is the composite outcome of the study and included proteinuric pre-eclampsia, preterm delivery <37 weeks, small-for-gestational age infant, low birth weight <2500 g, intrauterine growth restriction and intrauterine fetal death after 12 weeks of gestation of a morphologically normal fetus. RESULTS 216 pregnancies in 187 patients were included; 82 pregnancies (38.0%) were exposed to LDASA treatment. No differences in terms of age at conception, disease duration, clinical manifestations, comorbidities and disease flare during pregnancy were observed between patients taking LDASA and those who did not take LDASA during pregnancy. APO was observed in 65 cases (30.1%), including 13 cases (6.1%) of pre-eclampsia. The incidence of all complications was similar in the two groups. However, it is interesting to note that pre-eclampsia had lower frequency in patients taking LDASA versus those not taking LDASA (2.4% vs 8.3%, p=0.14). CONCLUSIONS In pregnant patients with SLE without renal involvement and were aPL-negative, there is a low risk of severe obstetric complications, such as early pre-eclampsia. LDASA treatment does not provide a statistically significant advantage over these complications. However, a careful individual risk-benefit balance is warranted.
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Affiliation(s)
- Chiara Tani
- Rheumatology Unit, Azienda Ospedaliero Universitaria Pisana and Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Dina Zucchi
- Rheumatology Unit, Azienda Ospedaliero Universitaria Pisana and Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
- Department of Medical Biotechnologies, University of Siena, Siena, Italy
| | - Isabell Haase
- Policlinic and Hiller Research Unit for Rheumatology, Heinrich Heine University Duesseldorf, Duesseldorf, Germany
| | - Maria Gerosa
- Division of Clinical Rheumatology, ASST Pini-CTO, Research Centre for Adult and Pediatric Rheumatic Diseases, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Maddalena Larosa
- Rheumatology Unit, Department of Medicine (DIMED), University of Padova, Padova, Italy
| | - Lorenzo Cavagna
- Rheumatology Unit, University and IRCCS Policlinico S Matteo Foundation, Pavia, Italy
| | - Alessandra Bortoluzzi
- Section of Rheumatology, Department of Medical Sciences, University of Ferrara and Azienda Ospedaliera-Universitaria di Ferrara, Ferrara, Italy
| | - Francesca Crisafulli
- Unit of Rheumatology and Clinical Immunology, ASST Spedali Civili, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Johanna Mucke
- Policlinic and Hiller Research Unit for Rheumatology, Heinrich Heine University Duesseldorf, Duesseldorf, Germany
| | - Francesca A L Strigini
- Department of Clinical and Experimental Medicine, Division of Obstetrics and Gynecology, University of Pisa, Pisa, Italy
| | - Laura Baglietto
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Marco Fornili
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Francesca Monacci
- Department of Clinical and Experimental Medicine, Division of Obstetrics and Gynecology, University of Pisa, Pisa, Italy
| | - Elena Elefante
- Rheumatology Unit, Azienda Ospedaliero Universitaria Pisana and Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Roberta Erra
- Obstetrics Unit, Department of Woman Child and Newborn, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Elisa Bellis
- Rheumatology Unit, University and IRCCS Policlinico S Matteo Foundation, Pavia, Italy
| | - Melissa Padovan
- Section of Rheumatology, Department of Medical Sciences, University of Ferrara and Azienda Ospedaliera-Universitaria di Ferrara, Ferrara, Italy
| | - Laura Andreoli
- Unit of Rheumatology and Clinical Immunology, ASST Spedali Civili, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Lavinia Agra Coletto
- Division of Clinical Rheumatology, ASST Pini-CTO, Research Centre for Adult and Pediatric Rheumatic Diseases, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Giovanni Zanframundo
- Rheumatology Unit, University and IRCCS Policlinico S Matteo Foundation, Pavia, Italy
| | - Marcello Govoni
- Section of Rheumatology, Department of Medical Sciences, University of Ferrara and Azienda Ospedaliera-Universitaria di Ferrara, Ferrara, Italy
| | - Luca Iaccarino
- Rheumatology Unit, Department of Medicine (DIMED), University of Padova, Padova, Italy
| | - Angela Tincani
- Unit of Rheumatology and Clinical Immunology, ASST Spedali Civili, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Andrea Doria
- Rheumatology Unit, Department of Medicine (DIMED), University of Padova, Padova, Italy
| | - Rebecca Fischer-Betz
- Policlinic and Hiller Research Unit for Rheumatology, Heinrich Heine University Duesseldorf, Duesseldorf, Germany
| | - Marta Mosca
- Rheumatology Unit, Azienda Ospedaliero Universitaria Pisana and Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
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Pryor KP, Albert B, Desai S, Ritter SY, Tarter L, Coblyn J, Bermas BL, Santacroce LM, Dutton C, Braaten KP, Pace LE, Rexrode K, Janiak E, Feldman CH. Pregnancy Intention Screening in Patients With Systemic Rheumatic Diseases: Pilot Testing a Standardized Assessment Tool. ACR Open Rheumatol 2022; 4:682-688. [PMID: 35639495 PMCID: PMC9374050 DOI: 10.1002/acr2.11449] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 04/26/2022] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVE Systemic rheumatic conditions affect reproductive-aged patients and often require potentially teratogenic medications. We assessed the feasibility and impact of a standardized pregnancy intention screening question (One Key Question [OKQ]) in a large academic rheumatology practice. METHODS This 6-month pilot quality improvement initiative prompted rheumatologists to ask female patients aged 18 to 49 years about their pregnancy intentions using OKQ. We administered surveys to assess rheumatologists' barriers to and comfort with reproductive health issues. We performed chart reviews to assess uptake and impact on documentation, comparing charts with OKQ documented with 100 randomly selected charts eligible for pregnancy intention screening but without OKQ documented. RESULTS When we compared 32 of 43 preimplementation responses with 29 of 41 postimplementation responses, the proportion of rheumatologists who reported they were very comfortable with assessing their patients' reproductive goals increased (31%-38%) and the proportion reporting obstetrics and gynecology (OB/GYN) referral challenges as barriers to discussing reproductive goals decreased (41%-21%). During the implementation period, 83 of 957 (9%) eligible patients had OKQ documented in their chart. Female providers were more likely to screen than male providers (odds ratio 2.42, 95% confidence interval 1.21-4.85). Screened patients were more likely to have their contraceptive method documented (P < 0.001) and more likely to have been referred to OB/GYN for follow-up (P = 0.003) compared with patients who were not screened with OKQ. CONCLUSION Although uptake was low, this tool improved provider comfort with assessing reproductive goals, the quality of documentation, and the likelihood of OB/GYN referral. Future studies should examine whether automated medical record alerts to prompt screening increase uptake.
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Affiliation(s)
- Katherine P Pryor
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Bill Albert
- Power to Decide, Washington, District of Columbia
| | - Sonali Desai
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Susan Y Ritter
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Laura Tarter
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Jonathan Coblyn
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | | | - Leah M Santacroce
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Caryn Dutton
- Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Kari P Braaten
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Lydia E Pace
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Kathryn Rexrode
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Elizabeth Janiak
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Candace H Feldman
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
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He H, Luo M, Xiong JH. Efficacy of bortezomib in reduction of systemic lupus erythematosus disease activity index score: A meta-analysis. EUR J INFLAMM 2022. [DOI: 10.1177/1721727x221105152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: Systemic lupus erythematosus (SLE) is a chronic autoimmune disease characterised by the production of auto-antibodies against nuclear and cytoplasmic antigens, which can affect multiple organs. To date, no meta-analysis has reported the efficacy of bortezomib in SLE. We performed a meta-analysis to investigate the efficacy of bortezomib in patients with SLE. Methods: We searched the PubMed, Embase, Cochrane Library, China National Knowledge Infrastructure, and Chinese BioMedical databases for articles published before 18 August 2021 to identify all studies relevant to SLE. The following were our inclusion criteria: (1) written in all languages, (2) bortezomib administration in patients with SLE and, (3) a clear description of SLE Disease Activity Index (SLEDAI) scores. Following were the exclusion criteria: (1) duplicate publications (the most recent article was included for analysis)and, (2) animal experiments, case reports, meeting reports, and reviews. The pooled data were analysed using a fixed- or random-effects model, depending on heterogeneity (determined using the I2 index). Results: Three articles that described 29 patients were included in this study. The forest plot showed a positive association between bortezomib therapy and SLE based on analysis of SLEDAI scores, with an odds ratio of 11.30 (95% confidence interval 7.03–15.56, p < .00001). Conclusion: Bortezomib treatment can reduce the SLEDAI scores in patients with SLE, which suggests the usefulness of this therapeutic approach for SLE.
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Affiliation(s)
- Huan He
- Department of Rheumatology and Immunology, Suining Central Hospital, Suining, China
| | - Man Luo
- Department of Rheumatology and Immunology, Suining Central Hospital, Suining, China
| | - Jin-He Xiong
- Department of Rheumatology and Immunology, Suining Central Hospital, Suining, China
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Pimenta JM, Painter JL, Gemzoe K, Levy RA, Powell M, Meizlik P, Powell G. Identifying Barriers to Enrollment in Patient Pregnancy Registries: Building Evidence Through Crowdsourcing. JMIR Form Res 2022; 6:e30573. [PMID: 35612888 PMCID: PMC9178445 DOI: 10.2196/30573] [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] [Received: 05/21/2021] [Revised: 03/04/2022] [Accepted: 03/15/2022] [Indexed: 11/15/2022] Open
Abstract
Background Enrollment in pregnancy registries is challenging despite substantial awareness-raising activities, generally resulting in low recruitment owing to limited safety data. Understanding patient and physician awareness of and attitudes toward pregnancy registries is needed to facilitate enrollment. Crowdsourcing, in which services, ideas, or content are obtained by soliciting contributions from a large group of people using web-based platforms, has shown promise for improving patient engagement and obtaining patient insights. Objective This study aimed to use web-based crowdsourcing platforms to evaluate Belimumab Pregnancy Registry (BPR) awareness among patients and physicians and to identify potential barriers to pregnancy registry enrollment with the BPR as a case study. Methods We conducted 2 surveys using separate web-based crowdsourcing platforms: Amazon Mechanical Turk (a 14-question patient survey) and Sermo RealTime (a 11-question rheumatologist survey). Eligible patients were women, aged 18-55 years; diagnosed with systemic lupus erythematosus (SLE); and pregnant, recently pregnant (within 2 years), or planning pregnancy. Eligible rheumatologists had prescribed belimumab and treated pregnant women. Responses were descriptively analyzed. Results Of 151 patient respondents over a 3-month period (n=88, 58.3% aged 26-35 years; n=149, 98.7% with mild or moderate SLE; and n=148, 98% from the United States), 51% (77/151) were currently or recently pregnant. Overall, 169 rheumatologists completed the survey within 48 hours, and 59.2% (100/169) were based in the United States. Belimumab exposure was reported by 41.7% (63/151) patients, whereas 51.7% (75/145) rheumatologists had prescribed belimumab to <5 patients, 25.5% (37/145) had prescribed to 5-10 patients, and 22.8% (33/145) had prescribed to >10 patients who were pregnant or trying to conceive. Of the patients exposed to belimumab, 51% (32/63) were BPR-aware, and 45.5% (77/169) of the rheumatologists were BPR-aware. Overall, 60% (38/63) of patients reported belimumab discontinuation because of pregnancy or planned pregnancy. Among the 77 BPR-aware rheumatologists, 70 (91%) referred patients to the registry. Concerns among rheumatologists who did not prescribe belimumab during pregnancy included unknown pregnancy safety profile (119/169, 70.4%), and 61.5% (104/169) reported their patients’ concerns about the unknown pregnancy safety profile. Belimumab exposure during or recently after pregnancy or while trying to conceive was reported in patients with mild (6/64, 9%), moderate (22/85, 26%), or severe (1/2, 50%) SLE. Rheumatologists more commonly recommended belimumab for moderate (84/169, 49.7%) and severe (123/169, 72.8%) SLE than for mild SLE (36/169, 21.3%) for patients trying to conceive recently or currently pregnant. Overall, 81.6% (138/169) of the rheumatologists suggested a belimumab washout period before pregnancy of 0-30 days (44/138, 31.9%), 30-60 days (64/138, 46.4%), or >60 days (30/138, 21.7%). Conclusions In this case, crowdsourcing efficiently obtained patient and rheumatologist input, with some patients with SLE continuing to use belimumab during or while planning a pregnancy. There was moderate awareness of the BPR among patients and physicians.
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Affiliation(s)
| | - Jeffery L Painter
- Safety Innovation and Analytics, GlaxoSmithKline, Durham, NC, United States
| | - Kim Gemzoe
- GlaxoSmithKline, Stevenage, United Kingdom
| | | | - Marcy Powell
- Safety Innovation and Analytics, GlaxoSmithKline, Durham, NC, United States
| | | | - Gregory Powell
- Safety Innovation and Analytics, GlaxoSmithKline, Durham, NC, United States
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85
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Sakowska J, Arcimowicz Ł, Jankowiak M, Papak I, Markiewicz A, Dziubek K, Kurkowiak M, Kote S, Kaźmierczak-Siedlecka K, Połom K, Marek-Trzonkowska N, Trzonkowski P. Autoimmunity and Cancer-Two Sides of the Same Coin. Front Immunol 2022; 13:793234. [PMID: 35634292 PMCID: PMC9140757 DOI: 10.3389/fimmu.2022.793234] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 04/12/2022] [Indexed: 02/06/2023] Open
Abstract
Autoimmune disease results from the immune response against self-antigens, while cancer develops when the immune system does not respond to malignant cells. Thus, for years, autoimmunity and cancer have been considered as two separate fields of research that do not have a lot in common. However, the discovery of immune checkpoints and the development of anti-cancer drugs targeting PD-1 (programmed cell death receptor 1) and CTLA-4 (cytotoxic T lymphocyte antigen 4) pathways proved that studying autoimmune diseases can be extremely helpful in the development of novel anti-cancer drugs. Therefore, autoimmunity and cancer seem to be just two sides of the same coin. In the current review, we broadly discuss how various regulatory cell populations, effector molecules, genetic predisposition, and environmental factors contribute to the loss of self-tolerance in autoimmunity or tolerance induction to cancer. With the current paper, we also aim to convince the readers that the pathways involved in cancer and autoimmune disease development consist of similar molecular players working in opposite directions. Therefore, a deep understanding of the two sides of immune tolerance is crucial for the proper designing of novel and selective immunotherapies.
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Affiliation(s)
- Justyna Sakowska
- Department of Medical Immunology, Medical University of Gdańsk, Gdańsk, Poland
| | - Łukasz Arcimowicz
- International Centre for Cancer Vaccine Science, University of Gdańsk, Gdańsk, Poland
| | - Martyna Jankowiak
- Department of Medical Immunology, Medical University of Gdańsk, Gdańsk, Poland
| | - Ines Papak
- International Centre for Cancer Vaccine Science, University of Gdańsk, Gdańsk, Poland
| | - Aleksandra Markiewicz
- Laboratory of Translational Oncology, Intercollegiate Faculty of Biotechnology, University of Gdańsk and Medical University of Gdańsk, Gdańsk, Poland
| | - Katarzyna Dziubek
- International Centre for Cancer Vaccine Science, University of Gdańsk, Gdańsk, Poland
| | - Małgorzata Kurkowiak
- International Centre for Cancer Vaccine Science, University of Gdańsk, Gdańsk, Poland
| | - Sachin Kote
- International Centre for Cancer Vaccine Science, University of Gdańsk, Gdańsk, Poland
| | | | - Karol Połom
- Department of Surgical Oncology, Medical University of Gdańsk, Gdańsk, Poland
| | - Natalia Marek-Trzonkowska
- International Centre for Cancer Vaccine Science, University of Gdańsk, Gdańsk, Poland
- Laboratory of Immunoregulation and Cellular Therapies, Department of Family Medicine, Medical University of Gdańsk, Gdańsk, Poland
| | - Piotr Trzonkowski
- Department of Medical Immunology, Medical University of Gdańsk, Gdańsk, Poland
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Moroni G, Calatroni M, Ponticelli C. The Impact of Preeclampsia in Lupus Nephritis. Expert Rev Clin Immunol 2022; 18:1-13. [PMID: 35510378 DOI: 10.1080/1744666x.2022.2074399] [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: 01/20/2022] [Accepted: 05/03/2022] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Women with systemic lupus erythematosus (SLE), particularly those with lupus nephritis (LN), remain at high risk for adverse pregnancy outcome. Although in the last decades maternal and fetal outcomes have improved dramatically, preeclampsia remains a major cause of maternal and perinatal morbidity and mortality. AREAS COVERED A narrative review of literature was conducted, underlying the importance of pre-conception counseling, and focusing on the correlation between preeclampsia and LN. The clinical characteristics of preeclampsia were described, with emphasis on risk factors in LN and the differential diagnosis between preeclampsia and lupus flares. Additionally, the prevention and treatment of preeclampsia were discussed, as well as the management of short-term and long-term consequences of preeclampsia. We highlight the importance of a pre-pregnancy counseling from a multidisciplinary team to plan pregnancy during inactive SLE and LN. EXPERT OPINION Further studies are needed to evaluate the long-term consequences of pregnancy in LN. Considering that preeclamptic patients can be at high risk for long-term renal failure, we suggest renal checkup for at least 6-12 months after delivery in all patients.
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Affiliation(s)
- Gabriella Moroni
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Nephrology and Dialysis Division, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Marta Calatroni
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Nephrology and Dialysis Division, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Claudio Ponticelli
- Independent Researcher, Past Director Nephrology Policlinico, Milan, Italy
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Deseive S, Scheiermann P, Starrach T, Hasbargen U, Peterß S. Perikarderguss bei systemischem Lupus erythematodes in der Spätschwangerschaft. Geburtshilfe Frauenheilkd 2022. [DOI: 10.1055/a-1448-6992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Affiliation(s)
| | | | - Teresa Starrach
- Klinik und Poliklinik für Frauenheilkunde und Geburtshilfe, Klinikum der Ludwig-Maximilians-Universität München – Campus Großhadern, München, Deutschland
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Murata T, Kyozuka H, Fukuda T, Toba N, Kanno A, Yasuda S, Yamaguchi A, Nomura Y, Kanno T, Migita K, Fujimori K. Maternal disease activity and serological activity as predictors of adverse pregnancy outcomes in women with systemic lupus erythematosus: a retrospective chart review. Arch Gynecol Obstet 2022; 305:1177-1183. [PMID: 34535802 DOI: 10.1007/s00404-021-06148-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 06/23/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE To evaluate the association between disease activity, serological activity, and adverse pregnancy outcomes (APOs) in women with systemic lupus erythematosus (SLE) and determine the cut-off values of complements to predict APOs in live birth cases. METHODS This retrospective chart review included pregnant women with SLE who had singleton live births after 22 weeks between 2006 and 2020. First trimester maternal disease activity was assessed for SLE onset during pregnancy, antiphospholipid syndrome, SLE pregnancy disease activity index (SLEPDAI), disease flare-ups, lupus nephritis, pancytopenia, and daily prednisolone dosage. Serological activity was assessed for autoantibodies and complements. APOs included preterm birth (PTB), low birth weight infants, small-for-gestational age infants, preterm premature rupture of membranes, and preeclampsia (PE). Chi-square and Fisher's exact tests were used to compare categorical variables; a receiver-operating characteristic analysis was performed to calculate the cut-off values of complements to predict APOs. RESULTS Fifty-two participants met the inclusion criteria. The incidence of PTB and PE was associated with a high SLEPDAI (p < 0.001, p = 0.001), disease flare-ups (p = 0.007, p < 0.001), lupus nephritis (p = 0.020, p = 0.012), anti-dsDNA antibodies (p = 0.047, p = 0.016), anti-SSA antibodies (p = 0.003, p = 0.004), low CH 50 (p < 0.001, p < 0.001), low C3 (p < 0.001, p < 0.001), and low C4 (p < 0.001, p = 0.001), respectively. The cut-off values of C4 to predict PTB and PE were 13.0 mg/dL (higher than the normal lowest limit). CONCLUSION High maternal disease activity and high serological activity in the first trimester in women with SLE are significantly associated with APOs. Proper disease control and close management for hypocomplementemia are required for better perinatal outcomes.
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Affiliation(s)
- Tsuyoshi Murata
- Department of Obstetrics and Gynecology, Fukushima Medical University School of Medicine, 1 Hikarigaoka, Fukushima, 960-1295, Japan.
| | - Hyo Kyozuka
- Department of Obstetrics and Gynecology, Fukushima Medical University School of Medicine, 1 Hikarigaoka, Fukushima, 960-1295, Japan
| | - Toma Fukuda
- Department of Obstetrics and Gynecology, Fukushima Medical University School of Medicine, 1 Hikarigaoka, Fukushima, 960-1295, Japan
| | - Naoya Toba
- Department of Obstetrics and Gynecology, Ohta-Nishinouchi Hospital, Fukushima, Japan
| | - Aya Kanno
- Department of Obstetrics and Gynecology, Fukushima Medical University School of Medicine, 1 Hikarigaoka, Fukushima, 960-1295, Japan
| | - Shun Yasuda
- Department of Obstetrics and Gynecology, Fukushima Medical University School of Medicine, 1 Hikarigaoka, Fukushima, 960-1295, Japan
| | - Akiko Yamaguchi
- Department of Obstetrics and Gynecology, Fukushima Medical University School of Medicine, 1 Hikarigaoka, Fukushima, 960-1295, Japan
| | - Yasuhisa Nomura
- Department of Obstetrics and Gynecology, Ohta-Nishinouchi Hospital, Fukushima, Japan
| | - Takashi Kanno
- Department of Rheumatology, Ohta-Nishinouchi Hospital, Fukushima, Japan
| | - Kiyoshi Migita
- Department of Rheumatology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Keiya Fujimori
- Department of Obstetrics and Gynecology, Fukushima Medical University School of Medicine, 1 Hikarigaoka, Fukushima, 960-1295, Japan
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Waites BT, Walker AR, Caughey AB. Delivery timing in dichorionic diamniotic twin pregnancies complicated by preeclampsia: a decision analysis. J Matern Fetal Neonatal Med 2022; 35:9780-9785. [PMID: 35437110 DOI: 10.1080/14767058.2022.2053103] [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: 10/18/2022]
Abstract
OBJECTIVE To determine the optimal timing of delivery in Dichorionic-diamniotic (DCDA) pregnancies complicated by preeclampsia without severe features. METHODS A decision-analytic model was created to compare outcomes of expectant management vs. delivery from 34 to 37w0d. Outcomes included quality-adjusted life years (QALYs), development of severe preeclampsia, maternal mortality, maternal stroke, small for gestational age (SGA) due to fetal growth restriction (FGR) detected antenatally, stillbirth, cerebral palsy (CP), and neonatal mortality. Probabilities, utilities, and life expectancies were derived from the literature. Univariate analysis was used to evaluate the impact of delivery at various gestational ages. Maternal and neonatal outcomes were calculated for a theoretical cohort of 10,000 DCDA pregnancies with preeclampsia. RESULTS The optimal gestational age for delivery was 36w0d when the total QALYs (868,112) were highest. Delivery at 34w0d resulted in the fewest cases of severe preeclampsia, maternal mortality, and maternal stroke (0, 4, and 15 cases per 10,000, respectively). The incidence of each of these adverse outcomes increased with gestational age, with the greatest number of adverse outcomes at 37w0d (2452 cases of severe preeclampsia, eight maternal deaths, and 31 cases of maternal stroke per 10,000). Delivery at 34w0d resulted in the fewest cases of severe preeclampsia (0), maternal stroke (15), maternal mortality (4), stillbirth (0), and SGA (1183). However, this strategy was also associated with most cases of neonatal CP (91) and neonatal mortality (87). CONCLUSION DCDA twin pregnancies complicated by preeclampsia without severe features appear to have the best outcomes when delivered at 36w0d. Specifically, when compared to delivery at 37w0d, this strategy reduced maternal and neonatal morbidity and mortality.
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Affiliation(s)
- Bethany T Waites
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, OR, USA
| | - Allison R Walker
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, OR, USA
| | - Aaron B Caughey
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, OR, USA
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Li HH, Sai LT, Tian S, Liu Y, Freel CI, Wang K, Zhou C, Zheng J, Shu Q, Zhao YJ. Sexual Dimorphisms of Protein-Coding Gene Profiles in Placentas From Women With Systemic Lupus Erythematosus. Front Med (Lausanne) 2022; 9:798907. [PMID: 35372436 PMCID: PMC8965019 DOI: 10.3389/fmed.2022.798907] [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] [Received: 10/20/2021] [Accepted: 02/09/2022] [Indexed: 11/15/2022] Open
Abstract
Background Systemic lupus erythematosus (SLE) may cause pathogenic changes in the placentas during human pregnancy, such as decreased placental weight, intraplacental hematoma, ischemic hypoxic change, placental infarction, and decidual vasculopathy, which contribute to high maternal and fetal mortality and morbidity. Sex-specific adaptations of the fetus are associated with SLE pregnancies. The present study aimed to determine the transcriptomic profiles of female and male placentas from women with SLE. Methods RNA sequencing (RNA-seq) was performed to identify differentially expressed protein-coding genes (DEGs) in placentas from women with SLE vs. normal term (NT) pregnancies with female and male fetuses (n = 3-5/sex/group). Real-time-quantitative PCR was performed (n = 4 /sex/group) to validate the RNA-seq results. Bioinformatics functional analysis was performed to predict the biological functions and pathways of SLE-dysregulated protein-coding genes. Results Compared with NT-female (NT-F) placentas, 119 DEGs were identified in SLE-female (SLE-F) placentas. Among these 119 DEGs, five and zero are located on X- and Y-chromosomes, respectively, and four are located on the mitochondrial genome. Compared with NT-male (NT-M) placentas, 458 DEGs were identified in SLE-male (SLE-M) placentas, among which 16 are located on the X-chromosome and zero on the Y-chromosome and mitochondrial genome. Twenty-four DEGs were commonly dysregulated in SLE-F and -M placentas. Functional analysis showed that SLE-dysregulated protein-coding genes were associated with diverse biological functions and pathways, including angiogenesis, cellular response to growth factor stimulus, heparin-binding, HIF (hypoxia-inducible factor)-1 signaling pathway, and Interleukin-17 (IL-17) signaling pathway in both SLE-F and -M placentas. Biological regulations were differentially enriched between SLE-F and -M placentas. Regulation of blood circulation, response to glucocorticoid, and rhythmic process were all enriched in SLE-F, but not SLE-M placentas. In contrast, tumor necrosis factor production, Th17 cell differentiation, and MDA (melanoma differentiation-associated gene)-5 signaling pathway were enriched in SLE-M but not SLE-F placentas. Conclusion This report investigated the protein-coding gene profiles of placenta tissues from SLE patients using RNA-seq. The results suggest that the SLE-dysregulated protein-coding genes in placentas may contribute to the pathophysiological progress of SLE pregnancies in a fetal sex-specific manner, leading to adverse pregnancy outcomes.
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Affiliation(s)
- Hui-Hui Li
- Department of Obstetrics and Gynecology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China.,Department of Obstetrics and Gynecology, University of Wisconsin-Madison, Madison, WI, United States
| | - Lin-Tao Sai
- Department of Infectious Diseases, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Shan Tian
- Center for Reproductive Medicine, Jinan Central Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Yuan Liu
- Department of Obstetrics and Gynecology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Colman I Freel
- Department of Obstetrics and Gynecology, University of Wisconsin-Madison, Madison, WI, United States
| | - Kai Wang
- Clinical and Translational Research Center, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, China
| | - Chi Zhou
- School of Animal and Comparative Biomedical Sciences, University of Arizona, Tucson, AZ, United States
| | - Jing Zheng
- Department of Obstetrics and Gynecology, University of Wisconsin-Madison, Madison, WI, United States
| | - Qiang Shu
- Department of Rheumatology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China.,Shandong Provincial Clinical Research Center for Immune Diseases and Gout, Jinan, China
| | - Ying-Jie Zhao
- Department of Rheumatology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China.,Shandong Provincial Clinical Research Center for Immune Diseases and Gout, Jinan, China
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91
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Predictors Associated with Adverse Pregnancy Outcomes in a Cohort of Women with Systematic Lupus Erythematosus from Romania-An Observational Study (Stage 2). J Clin Med 2022; 11:jcm11071964. [PMID: 35407573 PMCID: PMC9000014 DOI: 10.3390/jcm11071964] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 03/16/2022] [Accepted: 03/30/2022] [Indexed: 12/16/2022] Open
Abstract
Background: Pregnancy in women with systemic lupus erythematosus (SLE) is accompanied by adverse pregnancy outcomes (APOs). We aimed to investigate the association between clinical, sonographic, and laboratory parameters and APOs (preeclampsia, intrauterine growth restriction, premature birth, and maternal mortality). Methods: This observational retrospective study included all pregnancies in women with SLE who attended two tertiary maternity hospitals from Romania between January 2013 and December 2020. Clinical, sonographic, and laboratory variables were examined. Bivariate associations of APO status and each predictor variable were evaluated, and significant predictors were further included in a classification model based on discriminant analysis. Results: Predictors of APOs included BMI > 25 kg/m2, personal history of lupus nephritis or chronic hypertension, proteinuria, low C3, SLE Disease Activity Index 2000 (SLEDAI-2k score ≥ 4 and physician’s global-assessment (PGA) score ≥ 1 throughout pregnancy, increased mean uterine arteries pulsatility index in the first and second trimesters, cerebroplacental ratio < 1 in the second and third trimesters, and small fetal abdominal circumference in the third trimester. Glucocorticoids, methyldopa, and aspirin use appeared to be protective against APOs. Conclusions: This study provides a comprehensive analysis of the most important predictors for APOs in pregnant patients with SLE, which could constitute a basis for further research.
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92
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Maguire S, Wilson F, Gallagher P, Mohamed MMS, Maher S, O'Shea F. What to Expect when Women with Axial Spondyloarthritis are Expecting: Prevalence of Complications of Pregnancies in Women with Axial Spondyloarthritis. Semin Arthritis Rheum 2022; 54:151993. [DOI: 10.1016/j.semarthrit.2022.151993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 03/03/2022] [Accepted: 03/08/2022] [Indexed: 11/29/2022]
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93
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Dao KH, Bermas BL. Systemic Lupus Erythematosus Management in Pregnancy. Int J Womens Health 2022; 14:199-211. [PMID: 35210867 PMCID: PMC8859727 DOI: 10.2147/ijwh.s282604] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 01/19/2022] [Indexed: 01/08/2023] Open
Abstract
Systemic lupus erythematosus (SLE) affects reproductive aged women. Issues regarding family planning are an important part of SLE patient care. Women with SLE can flare during pregnancy, in particular those who have active disease at conception or prior history of renal disease. These flares can lead to increased adverse pregnancy outcomes including fetal loss, pre-eclampsia, preterm birth and small for gestational aged infants. In addition, women with antiphospholipid antibodies can have thrombosis during pregnancy or higher rates of fetal loss. Women who have anti-Ro/SSA and anti-La/SSB antibodies need special monitoring as their offspring are at risk for congenital complete heart block and neonatal lupus. Ideally, SLE patients should have their disease under good control on medications compatible with pregnancy prior to conception. All patients with SLE should remain on hydroxychloroquine unless contraindicated. We recommend the addition of 81mg/d of aspirin at the end of the first trimester to reduce the risk of pre-eclampsia. The immunosuppressive azathioprine, tacrolimus and cyclosporine are compatible with pregnancy and lactation, mycophenolate mofetil (MMF)/mycophenolic acid are not. Providers should use glucocorticoids at the lowest possible dose. Methotrexate, leflunomide and cyclophosphamide are contraindicated in pregnancy and lactation. SLE patients on the biologics rituximab, belimumab and abatacept can continue these medications until conception and resume during lactation.
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Affiliation(s)
- Kathryn H Dao
- Division of Rheumatic Diseases, UTSouthwestern Medical Center, Dallas, TX, USA
| | - Bonnie L Bermas
- Division of Rheumatic Diseases, UTSouthwestern Medical Center, Dallas, TX, USA
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94
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Marinaki S, Tsiakas S, Skalioti C, Kapsia E, Lionaki S, Vallianou K, Boletis J. Pregnancy in Women With Preexisting Glomerular Diseases: A Single-Center Experience. Front Med (Lausanne) 2022; 9:801144. [PMID: 35237623 PMCID: PMC8882916 DOI: 10.3389/fmed.2022.801144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Accepted: 01/10/2022] [Indexed: 11/13/2022] Open
Abstract
AimWomen with glomerular diseases are often of childbearing age. Besides lupus nephritis, data regarding pregnancy in patients with glomerular diseases are limited, posing a challenging task to attending nephrologists. This study aimed to investigate the pregnancy outcomes and the impact on the underlying glomerular disease among women followed in our institution.MethodsA single-center retrospective cohort study of women with biopsy-proven glomerular diseases who experienced pregnancy between 2010 and 2020. We analyzed data before, during, and after gestation.ResultsA total of 22 women, 13 women with primary and 9 women with secondary glomerular diseases, were included in this study. Most patients (82%) had received immunosuppressive treatment at various times before pregnancy. All the women were in remission, either complete (62%) or partial (38%), with well-preserved renal function (82%) before conception. A total of 30 live births and 1 stillbirth were recorded; the rate of preterm delivery was 23%. Renal function and proteinuria remained stable during pregnancy. Preeclampsia was observed in 6.7% of patients and disease relapse in 6.9% of the pregnancies.ConclusionPregnancy was associated with a low frequency of adverse events in women with underlying glomerular diseases, provided they have quiescent disease and preserved renal function.
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Affiliation(s)
- Smaragdi Marinaki
- Department of Nephrology and Renal Transplantation, Medical School, National and Kapodistrian University of Athens, Laiko Hospital, Athens, Greece
| | - Stathis Tsiakas
- Department of Nephrology and Renal Transplantation, Medical School, National and Kapodistrian University of Athens, Laiko Hospital, Athens, Greece
- *Correspondence: Stathis Tsiakas
| | - Chrysanthi Skalioti
- Department of Nephrology and Renal Transplantation, Medical School, National and Kapodistrian University of Athens, Laiko Hospital, Athens, Greece
| | - Eleni Kapsia
- Department of Nephrology and Renal Transplantation, Medical School, National and Kapodistrian University of Athens, Laiko Hospital, Athens, Greece
| | - Sophia Lionaki
- Second Department of Internal Medicine, Faculty of Medicine, National and Kapodistrian University of Athens, Attikon Hospital, Athens, Greece
| | - Kalliopi Vallianou
- Department of Nephrology and Renal Transplantation, Medical School, National and Kapodistrian University of Athens, Laiko Hospital, Athens, Greece
| | - John Boletis
- Department of Nephrology and Renal Transplantation, Medical School, National and Kapodistrian University of Athens, Laiko Hospital, Athens, Greece
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Dima A, Jurcut C, Chasset F, Felten R, Arnaud L. Hydroxychloroquine in systemic lupus erythematosus: overview of current knowledge. Ther Adv Musculoskelet Dis 2022; 14:1759720X211073001. [PMID: 35186126 PMCID: PMC8848057 DOI: 10.1177/1759720x211073001] [Citation(s) in RCA: 54] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 12/17/2021] [Indexed: 12/22/2022] Open
Abstract
The antimalarial hydroxychloroquine (HCQ) has demonstrated several crucial properties for the treatment of systemic lupus erythematosus (SLE). Herein, we reviewed the main HCQ pharmacologic features, detailed its mechanism of action, and summarized the existing guidelines and recommendations for HCQ use in rheumatology with a systematic literature search for the randomized controlled trials focused on lupus. HCQ has been shown to decrease SLE activity, especially in mild and moderate disease, to prevent disease flare and to lower the long-term glucocorticoid need. The numerous benefits of HCQ are extended to pregnancy and breastfeeding period. Based on cohort studies, antithrombotic and metabolic HCQ’s effects were shown, including lipid-lowering properties, which might contribute to an improved cardiovascular risk. Moreover, early HCQ use in antinuclear antibodies positive individuals might delay the progression to SLE. Finally, HCQ has a significant favorable impact on long-term outcomes such as damage accrual and mortality in SLE. Based on these multiple benefits, HCQ is now the mainstay long-term treatment in SLE, recommended by current guidelines in all patients unless contraindications or side effects. The daily dose associated with the best compromise between efficacy and safety is matter of debate. The concern regarding retinal toxicity rather than proper efficacy data is the one that dictated the daily dosage of ⩽5 mg/kg/day actual body weight currently agreed upon.
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Affiliation(s)
- Alina Dima
- Department of Rheumatology, Colentina Clinical Hospital, Bucharest, Romania
| | - Ciprian Jurcut
- Department of Internal Medicine, Dr. Carol Davila Central Military Emergency University Hospital, Bucharest, Romania
| | - François Chasset
- Department of Dermatology and Allergology, Hôpital Tenon, Paris, France; Faculté de Médecine, Sorbonne Université, Paris, France
| | - Renaud Felten
- National Reference Center for Rare Auto-immune and Systemic Diseases Est Sud-Est (RESO), Strasbourg, France
- Department of Rheumatology, Les Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Laurent Arnaud
- National Reference Center for Rare Auto-immune and Systemic Diseases Est Sud-Est (RESO), Strasbourg, France
- Department of Rheumatology, Les Hôpitaux Universitaires de Strasbourg, Strasbourg, France
- Université de Strasbourg, Inserm UMR-S 1109, Strasbourg, France
- Service de Rhumatologie, Hôpital de Hautepierre, 1, avenue Molière BP 83049, 67098 Strasbourg Cedex, France
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96
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Park JS, Chung MK, Lim H, Lee J, Lee CH. Risk of Pregnancy Complications and Low Birth Weight Offsprings in Korean Women With Rheumatic Diseases: A Nationwide Population-Based Study. J Korean Med Sci 2022; 37:e18. [PMID: 35014229 PMCID: PMC8748664 DOI: 10.3346/jkms.2022.37.e18] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 11/18/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND To determine the risk of pregnancy complications and adverse offspring outcomes in Korean women with rheumatic diseases (RDs). METHODS Women aged 20-44 years with pregnancies ending in delivery were identified from the National Health Insurance Service-National Health Information Database (2009-2016). Women with RD including systemic lupus erythematosus (SLE), seropositive rheumatoid arthritis (SPRA), and ankylosing spondylitis (AS) (n = 4,284) were age-matched with controls (n = 26,023). Outcome variables included threatened abortion (TA), preterm birth (PB), preeclampsia/eclampsia (PE/E), intrauterine growth retardation (IGR), urinary tract infection, low birth weight (LBW) offsprings, and offspring death within 1 year of birth. RESULTS Women with RDs had increased risks for cesarean section delivery (odds ratio [OR], 1.5; 95% confidence interval [CI], 1.4-1.6), TA (OR, 1.4; 95% CI, 1.2-1.5), PB (OR, 2.4; 95% CI, 1.9-3.2), PE/E (OR, 4.4; 95% CI, 3.3-5.9), and IGR (OR, 2.4; 95% CI, 2.0-3.1) than the controls. The risk of pregnancy complications was increased in SLE and SPRA pregnancies but not in AS pregnancies. Offsprings of women with RDs had an increased risk of LBW (OR, 4.0; 95% CI, 3.2-4.9). The offspring mortality rate within 1 year of birth was higher in women with RDs (6.2/10,000 persons) than in the controls (4.9/10,000 persons). CONCLUSION Women with RDs are at a risk of developing pregnancy complications, and the risk of LBW offsprings and offspring death within 1 year of birth is increased in these women. Therefore, this population requires special attention during their childbearing years.
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Affiliation(s)
- Jin-Su Park
- Division of Rheumatology, Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Min Kyung Chung
- Division of Rheumatology, Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, Korea
| | - Hyunsun Lim
- Research and Analysis Team, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Jisoo Lee
- Division of Rheumatology, Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, Korea.
| | - Chan Hee Lee
- Division of Rheumatology, Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Korea.
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97
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Javinani A, Radmard F, Razavinia FS, Masoumi M. Preconception Obstetrics and Rheumatology Consultation: A Protective Factor Against Spontaneous Abortion in Women With Autoimmune Rheumatic Disorders. J Clin Rheumatol 2022; 28:e166-e170. [PMID: 33323753 DOI: 10.1097/rhu.0000000000001667] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Autoimmune rheumatic disorders are a group of illnesses that significantly affect pregnancy outcomes. AIM The aim of this study was to evaluate the incidence and risk factors of spontaneous abortion and its association with maternal medical care in women with autoimmune rheumatic diseases. METHODS In this medical record review study, we recruited patients who were referred to our clinic from September 2014 to September 2019. All confirmed pregnancies (based on a positive pregnancy test and sonogram) were included. Binary logistic regression was applied to construct the statistical model. FINDINGS The present study involved 97 women (215 total confirmed pregnancies) who were diagnosed with 7 different autoimmune rheumatic disorders. The rate of spontaneous abortion was 28.8%. In the univariate analysis, the preconception obstetrics and rheumatology consultation were negatively associated with spontaneous abortion (p < 0.001; odds ratio [OR], 0.255; 95% confidence interval [CI], 0.136-0.480; and p < 0.001; OR, 0.042; 95% CI, 0.015-0.122, respectively). Perinatal obstetric care had a significant protective effect (p < 0.001; OR, 0.260; 95% CI, 0.139-0.486). The multivariate analysis showed that the preconception rheumatology consultation (p = 0.003; OR, 0.062; 95% CI, 0.010-0.393) was negatively associated with spontaneous abortions. The presence of active diseases before pregnancy (p = 0.005; OR, 9.978; 95% CI, 2.023-49.223), anti-SSA/Ro (p < 0.001; OR, 22.927; 95% CI, 4.921-106.818), and anticardiolipin IgM (p = 0.004; OR, 298.207; 95% CI, 6.209-14,323.037) were associated with a heightened risk of spontaneous abortion. CONCLUSIONS A collaborative work carried out by maternal-fetal medicine specialists and rheumatologists could remarkably improve pregnancy outcomes.
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Affiliation(s)
- Ali Javinani
- From the Rheumatology Research Center, Tehran University of Medical Sciences, Tehran
| | | | | | - Maryam Masoumi
- Clinical Research Development Center, Shahid Beheshti Hospital, Qom University of Medical Sciences, Qom, Iran
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98
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LI J, LI Z, YU L, SU J. Maternal and neonatal outcomes of pregnancy complicated with Systemic Lupus Erythematosus. FOOD SCIENCE AND TECHNOLOGY 2022. [DOI: 10.1590/fst.56921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Jie LI
- Tianjin Medical University General Hospital, China
| | - Zengyan LI
- Tianjin Medical University General Hospital, China
| | - Limin YU
- Tianjin Medical University General Hospital, China
| | - Jing SU
- Tianjin Medical University General Hospital, China
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99
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Lian XJ, Fan L, Xia X, Huang XM, Ye HJ, Yu XQ, Chen HT, Chen W. Fetal and maternal outcome in patients with active lupus nephritis: comparison between new-onset and pre-existing lupus nephritis. BMC Nephrol 2021; 22:419. [PMID: 34933676 PMCID: PMC8691084 DOI: 10.1186/s12882-021-02633-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 12/09/2021] [Indexed: 12/24/2022] Open
Abstract
Background This study aimed to investigate fetal and maternal outcomes in women with active lupus nephritis (LN). Specifically, we compared women who had new-onset LN and those with pre-existing LN during pregnancy. Methods Patients with active LN during pregnancy were divided into the new-onset group (LN first occurred during pregnancy) and the pre-existing group (a history of LN) on the basis of the onset time of LN. Data on clinical features, laboratory findings, and pregnancy outcome were collected and analyzed between the two groups. Multivariate logistic regression analysis was used to compare the effects of active LN on adverse pregnancy outcomes. Results We studied 73 pregnancies in 69 women between 2010 and 2019. Of these, 38 pregnancies were in the pre-existing LN group and 35 were in the new-onset group. Patients with pre-existing LN had a higher risk of composite adverse fetal outcomes than those with new-onset LN [adjusted odds ratio (ORs), 44.59; 95% confidence interval (CI), 1.21–1664.82; P = 0.039]. However, the two groups had similar adverse maternal outcomes (ORs, 1.24; 95% CI, 0.36–4.29). Serum albumin and proteinuria significantly improved after pregnancy (P < 0.001). Kaplan–Meier analysis showed that the long-term renal outcome was similar between the two groups. Conclusions Pregnant patients with pre-existing LN were associated with a higher risk of composite adverse fetal outcomes than those with new-onset LN. However, these two groups of patients had similar adverse maternal outcomes. The long-term renal outcomes were not different after pregnancy between these two groups. Supplementary Information The online version contains supplementary material available at 10.1186/s12882-021-02633-2.
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Affiliation(s)
- Xing-Ji Lian
- Department of Nephrology, The First Affiliated Hospital, NHC Key Laboratory of Nephrology, Guangdong Provincial Key Laboratory of Nephrology, Sun Yat-sen University, No. 58 Zhongshan Er Lu, Guangzhou, 510080, China
| | - Li Fan
- Department of Nephrology, The First Affiliated Hospital, NHC Key Laboratory of Nephrology, Guangdong Provincial Key Laboratory of Nephrology, Sun Yat-sen University, No. 58 Zhongshan Er Lu, Guangzhou, 510080, China
| | - Xi Xia
- Department of Nephrology, The First Affiliated Hospital, NHC Key Laboratory of Nephrology, Guangdong Provincial Key Laboratory of Nephrology, Sun Yat-sen University, No. 58 Zhongshan Er Lu, Guangzhou, 510080, China
| | - Xia-Min Huang
- Department of Nephrology, The First Affiliated Hospital, NHC Key Laboratory of Nephrology, Guangdong Provincial Key Laboratory of Nephrology, Sun Yat-sen University, No. 58 Zhongshan Er Lu, Guangzhou, 510080, China
| | - Hong-Jian Ye
- Department of Nephrology, The First Affiliated Hospital, NHC Key Laboratory of Nephrology, Guangdong Provincial Key Laboratory of Nephrology, Sun Yat-sen University, No. 58 Zhongshan Er Lu, Guangzhou, 510080, China
| | - Xue-Qing Yu
- Department of Nephrology, The First Affiliated Hospital, NHC Key Laboratory of Nephrology, Guangdong Provincial Key Laboratory of Nephrology, Sun Yat-sen University, No. 58 Zhongshan Er Lu, Guangzhou, 510080, China.,Division of Nephrology, Guangdong Provincial People's Hospital and Guangdong Academy of Medical Sciences, Guangzhou, 510080, China
| | - Hai-Tian Chen
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Sun Yat-sen University, No. 58 Zhongshan Er Lu, Guangzhou, 510080, Guangdong, China.
| | - Wei Chen
- Department of Nephrology, The First Affiliated Hospital, NHC Key Laboratory of Nephrology, Guangdong Provincial Key Laboratory of Nephrology, Sun Yat-sen University, No. 58 Zhongshan Er Lu, Guangzhou, 510080, China.
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100
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Mo S, Malhamé I, Schneiderman M, Vinet É. Pregnancy termination in patients with rheumatic diseases. Arthritis Care Res (Hoboken) 2021; 74:1745-1750. [PMID: 34890122 DOI: 10.1002/acr.24835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 11/17/2021] [Accepted: 12/09/2021] [Indexed: 11/05/2022]
Abstract
Rheumatic diseases affect women during their reproductive years. Many women with rheumatic diseases become pregnant; some undergo pregnancy termination. However, there are no official guidelines on pregnancy termination in patients with rheumatic diseases. This paper provides an overview of considerations that healthcare professionals must take into account. We highlight areas that require further studies and the importance of pregnancy planning and contraception counseling. Patients with rheumatic diseases need to be informed of adverse maternal and fetal outcomes of pregnancy to make informed reproductive decisions and reduce the need for pregnancy terminations. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Sophy Mo
- Department of Medicine, Faculty of Medicine, McGill University, Montreal, Canada
| | - Isabelle Malhamé
- Department of Medicine, Faculty of Medicine, McGill University, Montreal, Canada.,Division of General Internal Medicine, McGill University Health Centre, Montreal, Canada.,Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre (RI-MUHC), Montreal, Canada
| | - Megan Schneiderman
- Department of Medicine, Faculty of Medicine, McGill University, Montreal, Canada.,Department of Obstetrics and Gynecology, St. Mary's Hospital, Montreal, Canada
| | - Évelyne Vinet
- Department of Medicine, Faculty of Medicine, McGill University, Montreal, Canada.,Division of Rheumatology, Division of Clinical Epidemiology, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada.,Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre (RI-MUHC), Montreal, Canada
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