Clinical predictors of fetal and maternal outcome in systemic lupus erythematosus: a prospective study of 103 pregnancies

The implications of autoimmunity and pregnancy

There are multiple epidemiological studies that document the potential adverse affects of autoimmunity on nearly every aspect of reproduction, even in the absence of clinically manifest autoimmune disease. Two decades ago, it was suggested that women with autoimmune diseases avoid pregnancy due to inordinate risks to the mother and the child. In contrast, newer epidemiological data demonstrated that advances in the treatment of autoimmune diseases and the management of pregnant women with these diseases have similarly improved the prognosis for mother and child. In particular, if pregnancy is planned during periods of inactive or stable disease, the result often is giving birth to healthy full-term babies without increased risks of pregnancy complications. Nonetheless, pregnancies in most autoimmune diseases are still classified as high risk because of the potential for major complications. These complications include disease exacerbations during gestation and increased perinatal mortality and morbidity in most autoimmune diseases, whereas fetal mortality is characteristic of the anti-phospholipid syndrome (APS). In this review, we will discuss these topics, including issues of hormones, along with potential long-term effects of the microchimerism phenomenon. With respect to pregnancy and autoimmune diseases, epidemiological studies have attempted to address the following questions: 1) Is it safe for the mother to become pregnant or are there acute or chronic effects of pregnancy on the course of the disease? 2) Does the disease alter the course and/or the outcome of a pregnancy and thereby represent an inordinate risk for the fetus and infant? And do new therapeutic and management approaches improve the pregnancy outcomes in women with autoimmune diseases? 3) Does passage of maternal autoantibodies represent a risk to the child? 4) Do pregnancy, parity, or other factors influencing hormonal status explain the female predominance of many autoimmune diseases, and is the pregnancy effect related to microchimerism? Answering these questions has taken on additional importance in recent decades as women in western countries now frequently choose to delay pregnancies and have some or all of their pregnancies after disease onset. In this paper, we primarily focus on APS, systemic lupus erythematosus (SLE), multiple sclerosis (MS), rheumatoid arthritis (RA), and type 1 diabetes (T1D).

A comparative study of pregnancy outcomes and menstrual irregularities in northern Indian patients with systemic lupus erythematosus and rheumatoid arthritis

Systemic lupus erythematosus (SLE) can affect the menstruation, fertility, and pregnancy outcomes of the affected subjects. There is very little data on this aspect of the disease in Indian patients. Our aim was to study the menstrual, fertility, and pregnancy outcomes in these patients in comparison with patients of rheumatoid arthritis (RA) and also to study the effect of cyclophosphamide therapy on menstrual cycles in patients with SLE. Four hundred and twenty patients of SLE (210) and RA (210) were interviewed using a standard questionnaire and available medical records used. After disease-onset, the chances of adverse pregnancy outcomes were significantly more in patients with SLE compared to RA [OR = 5.17 (2.13-12.52); p ≤ 0.001]. Compared to the National average in India, the average number of living children is lesser in patients with RA (2.39 ± 1.39, p = 0.002), but more so in patients with SLE (1.44 ± 1.35, p = 0.001). A younger age at diagnosis and cyclophosphamide therapy was found to be independently associated with menstrual irregularities after disease-onset. We conclude that pregnancy outcome in patients with SLE in India is worse in comparison to patients with RA. Average family size of patients with SLE and RA is less when compared to National average in India. Patients with SLE are more prone for menstrual irregularities, especially those who receive cyclophosphamide treatment.

[Hemophagocytic syndrome as primary manifestation in a patient with systemic lupus erythematosus after parturition]

A 33-year-old woman presented with fever, malar rash, lymphadenopathy and pancytopenia 3 weeks after parturition. Serum C3 level was decreased and antinuclear antibody, anti-dsDNA antibody and anti-SS-A antibody were positive. Serum ferritin level was elevated (3454 ng/ml), and bone marrow aspirate revealed hemophagocytosis. She was diagnosed having systemic lupus erythematosus (SLE) associated with hemophagocytic syndrome (HPS). Oral prednisolone (55 mg/day) was initiated. Clinical manifestations and pancytopenia were improved and serum ferritin level was decreased. However, elevated anti-dsDNA antibody titer and reduced C3 level continued for a month after steroid therapy. The additional therapy of tacrolimus (3 mg/day) improved clinical and laboratory findings. This is a rare SLE case associated with HPS as primary manifestation after parturition.

Imitators of severe pre-eclampsia

There are many obstetric, medial, and surgical disorders that share many of the clinical and laboratory findings of patients with severe pre-eclampsia-eclampsia. Imitators of severe pre-eclampsia-eclampsia are life-threatening emergencies that can develop during pregnancy or in the postpartum period. These conditions are associated with high maternal and perinatal mortalities and morbidities, and survivors may face long-term sequelae. The pathophysiologic abnormalities in many of these disorders include vasospasm, platelet activation or destruction, microvascular thrombosis, endothelial cell dysfunction, and reduced tissue perfusion. Some of these disorders include acute fatty liver of pregnancy, thrombotic thrombocytopenic purpura, hemolytic uremic syndrome, acute exacerbation of systemic lupus erythematosus, and disseminated herpes simplex and sepsis syndromes. Differential diagnosis may be difficult due to the overlap of several clinical and laboratory findings of these syndrome. It is important that the clinician make the accurate diagnosis when possible because the management and complications from these syndromes may be different. Because of the rarity of these conditions during pregnancy and postpartum, the available literature includes only case reports and case series describing these syndromes. This review focuses on diagnosis, management, and counseling of women who develop these syndromes based on results of recent studies and my own clinical experience.

Pregnancy outcome in systemic lupus erythematosus (SLE) is improving: Results from a case control study and literature review

OBJECTIVES

For women who suffer from systemic lupus erythematosus (SLE), pregnancy can be a concern, placing the mother and fetus at risk. Our objectives were to assess the risk of adverse pregnancy outcome, disease flares, fertility rate, and co-morbidities in SLE women compared to healthy controls. We also systematically reviewed the literature available on pregnancy outcome in SLE to compare our results to other published data. Our hypothesis was that pregnancy outcome in SLE is improving over time.

METHODS

A case-control study comparing self-report of the above-mentioned parameters in SLE (N=108) vs healthy controls or patients with non-inflammatory musculoskeletal (MSK) disorders (N=134) was performed. Data were collected using a self-administered questionnaire. Proportions, means and odds ratios were calculated. We searched and quantified the literature on pregnancy outcome, lupus reactivation and fertility rate. Data were summarized and presented in mean % ± SEM and median % with interquartile range (IQR).

RESULTS

Gynecological history, fertility rate and age at first pregnancy in SLE patients were comparable to controls. Eighteen percent of SLE patients reported a flare and 18% reported an improvement of symptoms during pregnancy. Twenty-four percent of lupus patients had at least one preterm delivery vs 5% in controls (OR =8.32, p = 0.0008), however other pregnancy outcomes (miscarriage, therapeutic abortion, stillbirth and neonatal death rate) did not differ between the groups. Thyroid problems were reported to be more likely in SLE patients (p = 0.02), but the prevalence of other co-morbidities was similar to controls. A literature review demonstrated that fertility was not affected in SLE patients. Lupus reactivations are common during pregnancy (36.5% ± SEM 3.3%). Most agreed that SLE pregnancies had more fetal loss (19.5% ± SEM 1.6%) and preterm births (25.5% ± SEM 2.2%) when compared to the general population. Over time, the rate of SLE peripartum flares has improved (p = 0.002) and the proportion of pregnancies resulting in live birth has increased (p = 0.024). The frequency of fetal death has not significantly changed. Our findings from the case-control study were, in general, consistent with the literature including the frequency of fetal death, neonatal death, live births and pregnancy rate.

CONCLUSION

Prematurity (25.5% ± SEM 2.2%) and fetal death (19.5% ± SEM 1.6%) in SLE pregnancy are still a concern. However, new strategies with respect to pregnancy timing and multidisciplinary care have improved maternal and fetal outcome in SLE.

Pregnancy outcome in systemic lupus erythematosus complicated by anti-phospholipid antibodies

OBJECTIVE

Pregnant women affected by SLE are at high risk of gestational hypertension and pre-eclampsia (32-50%). This risk is particularly elevated if aPLs are dosable. The present study was planned to evaluate maternal-fetal outcomes of different groups of SLE pregnant patients characterized by diverse risk factors: patients affected by APS treated with a combination of low-dose aspirin (LDA) and low-molecular weight heparin (LMWH), nulliparous patients with dosable aPL treated by LMWH and SLE patients with no aPL administered no treatment during pregnancy.

METHODS

A retrospective description of maternal and fetal outcomes was made in a total of 62 pregnancies presenting APS in 8 cases (12.9%), aPL in 20 (32.2%) and no aPL in 34 (54.8%).

RESULTS

No statistically significant difference was found comparing fetal and maternal outcomes of the three groups despite differences in SLE activity: SLE aPL-positive pregnancies were associated with a higher incidence of nephritis and chronic hypertension than pregnancies treated for APS or not presenting with the added risk factor. The incidence of pre-eclampsia is 15% in aPL positive, 12.5% in APS and 14.7% in no aPL pregnancies, respectively.

CONCLUSIONS

LMWH is rather a possible option of prophylaxis for SLE aPL-positive pregnancies with potential maternal-fetal outcomes similar to aPL-negative patients or to standard treated APS.

Prognosis of neonates in pregnant women with systemic lupus erythematosus

PURPOSE

The effects of maternal systemic lupus erythematosus (SLE) on neonatal prognosis were examined by comparing clinical features of full-term babies born to lupus mothers and age- and parity-matched controls.

PATIENTS AND METHODS

From January 2000 to December 2005, 39 singletons were born to 37 SLE women. Excluding 11 cases of prematurity and preeclampsia, 28 full-term neonates formed the lupus group. The control group included 66 full-term babies. The retrospective study examined medical records and compared gestational age, birth weight, days of hospital stay, small for gestational age (SGA) frequency, Apgar scores < 7, and parity. Lupus neonates were tested for anti-nuclear antibody (ANA) and platelet count, and electrocardiogram was performed.

RESULTS

Average gestational age (38 vs. 39 weeks, p < 0.05) and birth weight (2,775 vs. 3,263g, p < 0.05) were significantly different between the SLE and control groups. SGA frequency was higher in the SLE group (25% vs. 4.5%, p < 0.05). No significant difference was observed in Apgar score, birth weight, gestational age, SGA frequency, and platelet count between lupus subgroups formed based on anti-dsDNA antibody levels and antiphospholipid antibody status.

CONCLUSION

The association of maternal ANAs, antiphospholipid antibodies, and drug history with neonatal prognosis could not be elucidated. However, even in uncomplicated pregnancies, maternal lupus is disadvantageous for gestational age, birth weight, and SGA frequency.

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

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

Pregnancy in systemic lupus erythematosus: a retrospective study from a developing community

Little data exists from the developing world on pregnancy in systemic lupus erythematosus (SLE). A 10-year review of pregnancies in lupus patients was conducted at a tertiary hospital in a developing country. Forty-seven pregnancies in 31 patients were identified. Eleven (23%) booked after 20 weeks gestation. There were no maternal deaths; six (13%) mothers experienced flares-all mild. Twelve women developed preeclampsia of which one experienced an intrauterine death. One patient was diagnosed with lupus and nephritis during pregnancy. She required an abortion to control the disease. Another with active nephritis delivered a normal but premature infant despite cyclophosphamide therapy. There was only minor deterioration in renal function. There were 36 (77%) live births, 8 first trimester abortions, 2 elective abortions and 1 still birth. Fourteen (39%) of live births were premature, and five (14%) experienced intrauterine growth retardation (IUGR). Two live-born babies experienced neonatal heartblock, and one, a neonatal lupus rash. We discuss these finding in relation to risk factors and to results from the developed world.

Anti-prolactin autoantibodies in pregnant women with systemic lupus erythematosus: maternal and fetal outcome

The aim of this study was to determine in pregnant women with systemic lupus erythematosus (SLE) the frequency of anti-prolactin autoantibodies and to compare the outcome of pregnancy in SLE women with and without anti-prolactin autoantibodies. Ninety-nine consecutive SLE pregnant women and 151 healthy pregnant women were studied prospectively. Patients with or without anti-prolactin autoantibodies were identified by gel filtration chromatography and affinity chromatography for IgG. Serum total and free prolactin (PRL) levels and molecular heterogeneity of PRL at each trimester of pregnancy were determined. The frequency of anti-PRL autoantibodies in SLE pregnant women was 13.1%. Serum total PRL levels were significantly higher in women with anti-PRL autoantibodies compared with SLE women without anti-PRL autoantibodies and in healthy pregnant women; and serum free PRL levels were lower in the third trimester in women with anti-PRL autoantibodies than in healthy pregnant women. In contrast, serum total and free PRL levels were significantly lower in the second and third trimester in SLE pregnant women without anti-PRL autoantibodies compared with healthy pregnant women. All adverse outcomes of pregnancy studied were more frequent in SLE women without anti-PRL autoantibodies than anti-PRL autoantibody-positive SLE women. Moreover, both maternal and fetal main complications were significantly higher in SLE women without anti-PRL autoantibodies than anti-PRL autoantibody-positive SLE women (P </=0.03). We conclude that the frequency of anti-PRL autoantibodies in lupus pregnancy was 13.1%. SLE pregnant women with anti-PRL autoantibodies had fewer adverse outcomes of pregnancy. The presence of anti-PRL autoantibodies could be of potential use as a prognostic marker for outcomes of pregnancy in SLE.

Lupus activity in pregnancy

Pregnancy in a woman with systemic lupus erythematosus (SLE) can be complicated by both lupus activity and pregnancy mishaps. The majority of recent studies found an increase in lupus activity during pregnancy, perhaps exacerbated by hormonal shifts required to maintain pregnancy. Increased lupus activity, in turn, prompts an elevated risk for poor pregnancy outcomes, including stillbirth, preterm birth, low birth weight, and preeclamspsia. Fortunately, the majority of pregnancies in women with SLE are successful. However, the interaction between pregnancy and SLE activity can lead to complications for both mother and baby.

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

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

Imitators of Severe Preeclampsia

There are several obstetric, medical, and surgical disorders that share many of the clinical and laboratory findings of patients with severe preeclampsia-hemolysis, elevated liver enzymes, and low platelets syndrome. Imitators of severe preeclampsia-hemolysis, elevated liver enzymes, and low platelets syndrome are life-threatening emergencies that can develop during pregnancy or in the postpartum period. These conditions are associated with high maternal mortality, and survivors may face long-term sequelae. Perinatal mortality and morbidity also remain high in many of these conditions. The pathophysiologic abnormalities in many of these disorders include thrombotic microangiopathy, thrombocytopenia, and hemolytic anemia. Some of these disorders include acute fatty liver of pregnancy, thrombotic thrombocytopenic purpura, hemolytic uremic syndrome, and acute exacerbation of systemic lupus erythematosus. Because of the rarity of these conditions during pregnancy and postpartum, the available literature includes only case reports and case series describing these syndromes. Consequently, there are no systematic reviews or randomized trials on these subjects. Differential diagnosis may be difficult due to the overlap of several clinical and laboratory findings of these syndromes. It is important that the clinician make the accurate diagnosis when possible because the management and complications from these syndromes may be different. For example, severe preeclampsia and acute fatty liver of pregnancy are treated by delivery, whereas it is possible to continue pregnancy in those with thrombotic thrombocytopenic purpura-hemolytic uremic syndrome and exacerbation of systemic lupus erythematosus. This review focuses on diagnosis, management, and counseling of women who develop these syndromes based on results of recent studies.

Lupus and pregnancy: complex yet manageable

Systemic lupus erythematosus is a chronic multi-system autoimmune disease that occurs predominantly in women of childbearing age. The risk of complications and adverse fetal outcomes in pregnant women with lupus is high. Moreover, pregnancy can cause flares of lupus disease activity necessitating maternal immunosuppressive intervention. Interestingly, many potential complications of pregnancy present as symptoms of lupus making diagnosis and treatment a challenge. Advancing technology and better understanding of the maternal-fetal dyad in lupus have improved outcomes in lupus pregnancies over the last 40 years. This article will briefly review the important issues in pregnancies complicated by lupus and provide a general guideline to physicians for monitoring and treatment.

Conséquences périnatales des connectivites maternelles : étude prospective de 73 cas

AIM

To describe a group of newborns born from mothers with connective tissue diseases, to determine their perinatal characteristics and the neonatal morbidity, and to assess the possible role of drugs received by mothers on the obstetrical and neonatal morbidity.

PATIENTS AND METHODS

During a 34-month period, newborns born from mothers with connective tissue diseases and followed in a single center were prospectively included in the study. In all cases, maternal treatments (i.e. hydroxychloroquine and/or prednisone) were continued during pregnancy.

RESULTS

Among the 73 included infants, 18 (25%) were born before 37 weeks of gestation and 3 (4%) were small for gestational age. A neonatal lupus syndrome with facial rash and thrombopenia was observed in 1 case. No neonatal congenital heart block was observed and maternal treatment did not significantly influence the mean PR or QT intervals. Four infants had minor congenital abnormalities and 3 had feto-maternal infection.

CONCLUSION

These data show that perinatal morbidity is lower than that previously published. We postulate that a strict follow-up during pregnancy may have played a significant positive role in these results.

Predictors of post-partum damage accrual in systemic lupus erythematosus: data from LUMINA, a multiethnic US cohort (XXXVIII)

OBJECTIVE

To determine the impact of pregnancy on systemic lupus erythematosus (SLE) outcome.

METHODS

SLE patients, age >or=16 yrs, disease duration <or=5 yrs at enrolment in LUMINA, a multiethnic cohort (Hispanics, African-Americans and Caucasians), were studied. The first pregnancy after SLE diagnosis was examined. A good pregnancy outcome was a full-term delivery; an adverse outcome was a miscarriage, abortion, premature birth or stillbirth. Dependent variables were disease activity (Systemic Lupus Activity Measure-Revised, SLAM-R) and damage accrual [Systemic Lupus International Collaborating Clinics (SLICC) Damage Index, SDI]. Differences in these variables between the visit immediately prior to, and the first visit after, pregnancy and their relationship with pregnancy outcome were examined. Damage accrual due to pregnancy exposure was examined by a case-crossover design.

RESULTS

Sixty-three SLE women from all ethnic groups were included. The mean (S.D.) age and disease duration at pregnancy outcome were 27.6 (6.5) yrs and 18.3 (22.5) months, respectively. Adverse pregnancy outcomes occurred in 76.2% women. The SLAM-R and SDI scores were statistically different after pregnancy (P = 0.050 and P < 0.001, respectively); the SDI score was independent of pregnancy outcome but strongly associated with pregnancy duration (P = 0.006), disease activity (P = 0.001), damage prior to pregnancy (P < 0.001) and total disease duration (P = 0.039) by multivariable analyses. Exposure to pregnancy itself did not impact on damage accrual in the case-crossover analyses of 142 patients (17 pregnancy exposures) (OR = 1.25; 95% CI 0.336-4.655; P = 0.480).

CONCLUSIONS

Pregnancy duration, total disease duration, disease activity and damage immediately prior to pregnancy decisively impact on damage accrual after pregnancy in patients with SLE.

Shared and disparate components of the pathophysiologies of fetal growth restriction and preeclampsia

Intrauterine growth restriction (IUGR) and preeclampsia differ in their association with maternal disease but share a similar placental pathology. Moreover, mothers who have had pregnancies complicated by preeclampsia or IUGR are at elevated later-life cardiovascular risk. Why, then, do some women develop IUGR and others develop preeclampsia? In this clinical opinion, based on a review of the literature, we hypothesize that both women experiencing preeclampsia and IUGR enter pregnancy with some degree of endothelial dysfunction, a lesion that predisposes to shallow placentation. In our opinion, preeclampsia develops when abnormal placentation, through the mediator of elevated circulating cytokines, interacts with maternal metabolic syndrome, comprised of adiposity, insulin resistance/hyperglycemia, hyperlipidemia, and coagulopathy. IUGR develops in the absence of antenatal metabolic syndrome. Among these women, the baby is affected by shallow placentation but the mother does not develop clinically apparent disease. This conceptualization provides a testable framework for future etiologic studies of preeclampsia and IUGR.

Th2 immune deviation induced by pregnancy: the two faces of autoimmune rheumatic diseases

One of the most important immunological modifications during pregnancy is the Th1/Th2 shift, due to the progressive increase of progesterone and estrogens during pregnancy, which reach their peak-level in the third trimester of gestation. At high levels, estrogens seem mainly to suppress Th1 cytokines and stimulate Th2-mediated immunological responses as well as antibody production. For this reason Th1-mediated diseases, like rheumatoid arthritis (RA), tend to improve and Th2-mediated disease, like systemic lupus erythematosus (SLE), tend to worsen during pregnancy. SLE is the autoimmune rheumatic disease in which pregnancy most frequently occurs because it predominantly affects young females in their childbearing age. Other autoimmune rheumatic diseases, including RA, are less frequently observed during pregnancy due to their low female-to-male ratio and peak onset after the age of 40. This review is focused on the disease course, gestational outcome and management of patients with SLE and RA during pregnancy.

Early risk factors for pregnancy loss in lupus

OBJECTIVE

To identify early risk factors for pregnancy loss in lupus pregnancies.

METHODS

We conducted a cohort study of all pregnancies seen in the first trimester in lupus patients followed from 1987 to 2002 at the Hopkins Lupus Center. At each visit, vital signs, a complete blood count, a urinalysis, and a 24-hour urine collection for total protein, if the dipstick revealed proteinuria, were obtained. Proteinuria was defined as protein greater than 500 mg in a 24-hour urine collection. Secondary antiphospholipid syndrome was diagnosed by using the Sapporo criteria. Thrombocytopenia was defined as platelets under 150,000. Hypertension was defined as blood pressure over 140/90 mm Hg during the first trimester. Pregnancies electively terminated were excluded from this study.

RESULTS

One hundred sixty-six pregnancies in 125 women were followed in the Hopkins Lupus Cohort from the first trimester onward. Twenty-seven pregnancies (16%) ended with a loss. Pregnancy loss was increased 2.6 times in women with first-trimester proteinuria (P = .04). A diagnosis of secondary antiphospholipid syndrome led to a 3.1-fold increase in pregnancy loss, predominantly after 20 weeks of gestation (P = .004). Thrombocytopenia in the first trimester led to an increase in pregnancy loss by 3.3 fold (P < or = .001). First-trimester hypertension led to a 2.4-fold increase in pregnancy loss (P = .027). Each risk factor was independent in raising pregnancy loss risk.

CONCLUSION

The acronym PATH can help remind clinicians to monitor for Proteinuria, Antiphospholipid syndrome, Thrombocytopenia, and Hypertension early in pregnancy. Close observation, with frequent laboratory analysis and appropriate therapy, is important to pregnancy success in women with lupus.

LEVEL OF EVIDENCE

II-2.

Systemic lupus erythematosus in pregnancy--case report

Systemic lupus erythematosus (SLE) is a chronic inflammatory connective tissue disease commonly diagnosed after the age of 20, mostly around the age of 30 years. It is more common in women than in men, especially during the fertile period. Women with SLE are at higher risk for spontaneous abortions, intrauterine fetal death, preeclampsia and eclampsia, preterm delivery and intrauterine growth retardation. This paper is a case report of a pregnant woman with SLE complicated with preeclampsia, but it also discusses follow-up of such pregnancies.

Laparoscopic splenectomy for the treatment of refractory immune thrombocytopenia in pregnancy

BACKGROUND

Immune thrombocytopenic purpura (ITP) is a condition with potential hazard during pregnancy for both mother and fetus if platelet concentrations fall below a critical level. This report describes the use of laparoscopic splenectomy following unsuccessful medical management.

CASE

A 35-year-old primigravid woman with systemic lupus erythematosis (SLE) developed ITP several years before becoming pregnant. She was treated early in pregnancy with high-dose oral prednisone and weekly intravenous immunoglobulin (IVIG) alternating with anti-D immune globulin, but laparoscopic splenectomy was indicated at 20 weeks' gestation because of thrombocytopenia. Following surgery, she continued prednisone and intermittent IVIG therapy until spontaneous delivery at 34 weeks' gestation. A small accessory spleen was identified postpartum by nuclear medicine scan. Satisfactory platelet concentrations were maintained postpartum using danazol and prednisone.

CONCLUSION

Laparoscopic splenectomy is a therapeutic option for women with ITP during pregnancy that fails to respond to medical management.

Pregnancy outcomes before and after a diagnosis of systemic lupus erythematosus

OBJECTIVE

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

STUDY DESIGN

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

RESULTS

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

CONCLUSION

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

Pregnancy outcome in women with pre-existing lupus nephritis

The aim of the present study was to assess the fetal and maternal outcome in a cohort of patients with lupus nephritis. Twenty-four pregnancies in 22 women with lupus nephritis occurring between 1991 and 2000 were analysed retrospectively. Lupus nephritis was biopsy proven before pregnancy in all cases. Women were followed from the beginning of pregnancy up to 6 months postpartum. Close fetal-maternal monitoring and frequent laboratory investigations were applied routinely to all patients. All women were prescribed steroid therapy from the beginning of the pregnancy. There were 18 live births, four spontaneous abortions and two stillbirths. Of the 18 live births, 14 were premature and four were term deliveries, representing a 25% fetal loss rate and 58% prematurity rate. There were two fetuses with congenital heart block. We recorded hypertension in 42%, proteinuria in 50% and pre-eclampsia in 25% of our patients. Proteinuria was irreversible in four cases. No maternal deaths or postpartum exacerbation of the disease were recorded in the study period. All renal flares were reversed postpartum. Patients positive for antiphospholipid antibodies had a worse perinatal outcome. Hypertension, proteinuria and antiphospholipid antibodies appear to be associated with adverse perinatal outcome and pregnancy complications. Pregnancy is not contraindicated in women with lupus nephritis, but is associated with significant fetal and maternal risks.

Pregnancy after lupus nephritis

Systemic lupus erythematosus (SLE) is an autoimmune disease that affects primarily women, commonly in their reproductive years but does not influence fertility. For these reasons, the clinician has often to face the many problems of pregnancy in patients with SLE including the influence of SLE on fetal outcome and that of pregnancy on SLE. As there is increasing evidence of an important role of sex hormones in immunity, the influence of pregnancy on SLE is probably due to the changes in sex hormone levels during pregnancy that are more important than in any other period of life. Early reports emphasized a high fetal and maternal risk in particular in patients with lupus nephritis. However in the same period the prognosis of lupus nephritis was poor, so it was difficult to know whether pregnancy actually influenced the prognosis of the disease. More recent prospective studies indicate that pregnancy is safe for the majority of mothers if it is planned when SLE is quiescent. Instead, although fetal risk has been progressively reduced in the last 40 years, it continues to be higher than that occurring in pregnancies of healthy women. In particular the presence of antiphospholipid antibodies considerably worsen the fetal outcome.

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

OBJECTIVE

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

STUDY DESIGN

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

RESULTS

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

CONCLUSION

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

Hypocomplementemia in systemic lupus erythematosus and primary antiphospholipid syndrome: prevalence and clinical significance in 667 patients

The objective of the study was to analyse the prevalence and clinical significance of hypocomplementemia in a large series of patients diagnosed either with systemic lupus erythematosus (SLE) or with primary antiphospholipid syndrome (APS) and its association with the main clinical, hematological and immunological features of these diseases. Between 1992 and 2003, complement determinations (C3 and C4 levels, CH50 activity) were performed in 597 consecutive patients diagnosed with SLE (530 women and 67 men, mean age 32.6 years) and 70 with primary APS (57 women and 13 men, mean age 38.7) visited in our department. Complement determinations are routinely made at the first visit of patients and yearly during the follow-up. SLE and primary APS were diagnosed according to current classification criteria. Hypocomplementemia was detected in 371 (62%) of SLE patients. Compared with patients with normal complement values, those with hypocomplementemia showed a higher prevalence of female gender (P < 0.001), fever (P = 0.021), nephropathy (P < 0.001), cutaneous vasculitis (P = 0.023), positive anti-dsDNA antibodies (P = 0.012) and cryoglobulinemia (P < 0.001). In addition, patients with hypocomplementemia showed a higher prevalence of APS-related features such as hemolytic anemia (P = 0.001) and antiphospholipid antibodies (P < 0.001). Hypocomplementemia was prospectively related to accumulated hospitalization in SLE patients but not with the accumulated number of lupus flares or with the survival after follow-up of five years. In contrast, 33 (47%) patients with primary APS presented low complement values, which were associated with a higher prevalence of livedo reticularis (P = 0.022), thrombocytopenia (P = 0.004), lupus anticoagulant (P = 0.013), positive IgM-aCL (P = 0.039), positive ANA (P = 0.002) and anti-dsDNA (P = 0.046). The diagnostic value of hypocomplementemia in patients with SLE is based on the association with disease activity, immune-complex mediated manifestations (glomerulonephritis, cryoglobulinemia) and APS-related features (livedo reticularis, hemolytic anemia and aPL). Hypocomplementemia was found in nearly half of patients with primary APS, and was associated with some APS features (livedo reticularis, thrombocytopenia, aPL) but also with SLE-related immunological markers (ANA and anti-dsDNA), identifying a subset of patients with primary APS with a higher risk of evolving to SLE. These results clearly support the routine determination of complement factors in the clinical follow-up of patients with SLE and primary APS.

Prevalence and Clinical Correlation of Anti-Phospholipid–Binding Protein Antibodies in Anticardiolipin-Negative Patients With Systemic Lupus Erythematosus and Women With Unexplained Recurrent Miscarriages

Context.—Anti-phospholipid antibodies (aPL) are a heterogeneous group of autoantibodies, the presence of which is associated with thrombotic events and miscarriage.

Objective.—To establish whether antibodies directed against phospholipid-binding plasma proteins such as β2-glycoprotein I (β2GPI), prothrombin (PT), and annexin V (Anx V) constitute a risk factor for thromboembolism in patients with systemic lupus erythematosus (SLE) and for miscarriage in women with recurrent pregnancy loss (RPL), independently of the presence of the classic anticardiolipin (aCL) antibodies, and whether their determination together with that of aCL would help to increase the diagnostic sensitivity of aPL tests.

Design.—The prevalence of various antibodies directed toward phospholipids (CL and other anionic phospholipids [APL]) and phospholipid-binding proteins (β2GPI, PT, and Anx V) was determined by immunoenzymatic methods in 311 serum samples.

Patients.—Twenty-five patients with aCL-positive primary anti-phospholipid syndrome (pAPS); 89 patients with SLE, 23 of whom had thrombotic complications (SLE/APS) and 66 of whom had no thrombosis; and 77 women with unexplained recurrent pregnancy loss comprised our study group. One hundred twenty healthy subjects matched for age and sex were studied as the control group.

Results.—Immunoglobulin (Ig) G and/or IgM aAPL, anti-β2GPI, anti-PT, and IgG anti-Anx V antibodies were detected in 25 (100%), 20 (80%), 15 (60%), and 6 (24%), respectively, of the 25 aCL-positive pAPS patients; IgG and/or IgM aCL, aAPL, anti-β2GPI, anti-PT, and IgG anti-Anx V antibodies were detected in 33 (37%), 42 (47%), 31 (35%), 40 (45%), and 12 (13%) of the 89 SLE patients, respectively. Of the 56 SLE patients who proved to be aCL negative, anti-β2GPI was present in 3 patients (5%), anti-PT in 13 (23%) patients, and anti-Anx V in 5 (9%) patients. In the subset of 23 SLE/APS patients, IgG anti-PT prevalence was higher than that of the other autoantibodies (87% vs 70% aCL, 66% aAPL, 57% anti-β2GPI, and 4% anti-Anx V), and in 26% of cases, IgG anti-PT was the only antibody present. Anti-PT had a slightly lower specificity than aCL (46% vs 49%); however, the occurrence of both antibodies brought the specificity to 92.4%. The highest risk for thrombosis in SLE patients was associated with the presence of IgG anti-PT antibody (odds ratio [OR] 15.3, P &lt; .001, vs 6.5 aCL, 3.5 aAPL, 3.4 anti-β2GPI, 0.2 anti-Anx V). Fifty-one of the 77 women with recurrent pregnancy loss were negative for all antibodies investigated; the prevalence of IgG and/or IgM aCL, aAPL, anti-β2GPI, anti-PT, and IgG anti-Anx V antibodies was 6% (5), 12% (9), 6% (5), 16% (12), and 17% (13), respectively. Of the 67 aCL-negative women, none had anti-β2GPI antibodies, 7 (11%) were anti-PT positive, and 13 (19%) were anti-Anx V positive. In the subgroup of 26 recurrent pregnancy loss patients who had at least one antibody, anti-Anx V was present in 50% of cases (in 42% as the sole antibody) and was the only antibody significantly associated with miscarriage (P = .02).

Conclusions.—The results of this study indicate that it is useful to measure anti-PT antibodies in addition to the more widely used aCL and anti-β2GPI antibodies in the prognostic evaluation of SLE patients for the risk of thrombosis, and the results also confirm that anti-Anx V antibodies may play an important role in recurrent pregnancy loss.

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

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

Imitators of severe pre-eclampsia/eclampsia

Several microangiopathic disorders that are encountered during pregnancy provide physicians with a formidable diagnostic challenge. Severe pre-eclampsia with hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome and many other obstetric and medical or surgical conditions produce similar clinical presentations and laboratory study results to pre-eclampsia. Pre-eclampsia is frequently superimposed on one of the above disorders, further confounding an already difficult differential diagnosis. Because of the remarkably similar clinical and laboratory findings of these disease processes, even the most experienced physician will face a diagnostic challenge. An effort should be made to make an accurate diagnosis, given the fact that management strategies and outcome may differ among these conditions.

Normal human pregnancy is associated with an elevation in the immune suppressive CD25+ CD4+ regulatory T-cell subset

Summary CD4+ CD25+ T regulatory cells (TReg), suppress antigen-specific immune responses and are important for allograft tolerance. During pregnancy the mother tolerates an allograft expressing paternal antigens (the fetus) requiring substantial changes in immune regulation over a programmed period of time. We analysed whether immune-suppressive TReg cells were altered during pregnancy and therefore might play a part in this tolerant state. The presence of TReg cells was assessed in the blood of 25 non-pregnant, 63 pregnant and seven postnatal healthy women by flow cytometry. We observed an increase in circulating TReg cells during early pregnancy, peaking during the second trimester and then a decline postpartum. Isolated CD25+ CD4+ cells expressed FoxP3 messenger RNA, a marker of TReg cells, and suppressed proliferative responses of autologous CD4+ CD25- T cells to allogeneic dendritic cells. These data support the concept that normal pregnancy is associated with an elevation in the number of TReg cells which may be important in maintaining materno-fetal tolerance.