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Bedei IA, Kniess D, Keil C, Wolter A, Schenk J, Sachs UJ, Axt-Fliedner R. Monitoring of Women with Anti-Ro/SSA and Anti-La/SSB Antibodies in Germany-Status Quo and Intensified Monitoring Concepts. J Clin Med 2024; 13:1142. [PMID: 38398455 PMCID: PMC10889801 DOI: 10.3390/jcm13041142] [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: 12/31/2023] [Revised: 02/10/2024] [Accepted: 02/14/2024] [Indexed: 02/25/2024] Open
Abstract
Background: The fetuses of pregnant women affected by anti-Ro/anti-La antibodies are at risk of developing complete atrioventricular heart block (CAVB) and other potentially life-threatening cardiac affections. CAVB can develop in less than 24 h. Treatment with anti-inflammatory drugs and immunoglobulins (IVIG) can restore the normal rhythm if applied in the transition period. Routine weekly echocardiography, as often recommended, will rarely detect emergent AVB. The surveillance of these pregnancies is controversial. Home-monitoring using a hand-held Doppler is a promising new approach. Methods: To obtain an overview of the current practice in Germany, we developed a web-based survey sent by the DEGUM (German Society of Ultrasound in Medicine) to ultrasound specialists. With the intention to evaluate practicability of home-monitoring, we instructed at-risk pregnant women to use a hand-held Doppler in the vulnerable period between 18 and 26 weeks at our university center. Results: There are trends but no clear consensus on surveillance, prophylaxis, and treatment of anti-Ro/La positive pregnant between specialists in Germany. Currently most experts do not offer home-monitoring but have a positive attitude towards its prospective use. Intensified fetal monitoring using a hand-held Doppler is feasible for pregnant women at risk and does not lead to frequent and unnecessary contact with the center. Conclusion: Evidence-based guidelines are needed to optimize the care of anti-Ro/La-positive pregnant women. Individual risk stratification could help pregnancy care of women at risk and is welcmed by most experts. Hand-held doppler monitoring is accepted by patients and prenatal medicine specialists as an option for intensified monitoring and can be included in an algorithm for surveillance.
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Affiliation(s)
- Ivonne Alexandra Bedei
- Department of Prenatal Diagnosis and Fetal Therapy, Justus-Liebig University Giessen, 35392 Giessen, Germany; (A.W.); (J.S.); (R.A.-F.)
| | - David Kniess
- Department of Prenatal Diagnosis and Fetal Therapy, Philipps-University Marburg, 35041 Marburg, Germany; (D.K.)
| | - Corinna Keil
- Department of Prenatal Diagnosis and Fetal Therapy, Philipps-University Marburg, 35041 Marburg, Germany; (D.K.)
| | - Aline Wolter
- Department of Prenatal Diagnosis and Fetal Therapy, Justus-Liebig University Giessen, 35392 Giessen, Germany; (A.W.); (J.S.); (R.A.-F.)
| | - Johanna Schenk
- Department of Prenatal Diagnosis and Fetal Therapy, Justus-Liebig University Giessen, 35392 Giessen, Germany; (A.W.); (J.S.); (R.A.-F.)
| | - Ulrich J. Sachs
- Institute for Clinical Immunology and Transfusion Medicine, Justus-Liebig University, 35392 Giessen, Germany;
- Center for Transfusion Medicine and Hemotherapy, University Hospital Giessen and Marburg, 35041 Marburg, Germany
- German Center for Fetomaternal Incompatibility (DZFI), University Hospital Giessen and Marburg, 35392 Giessen, Germany
| | - Roland Axt-Fliedner
- Department of Prenatal Diagnosis and Fetal Therapy, Justus-Liebig University Giessen, 35392 Giessen, Germany; (A.W.); (J.S.); (R.A.-F.)
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Sangah AB, Jabeen S, Hunde MZ, Devi S, Mumtaz H, Shaikh SS. Maternal and fetal outcomes of SLE in pregnancy: a literature review. J OBSTET GYNAECOL 2023; 43:2205513. [PMID: 37154805 DOI: 10.1080/01443615.2023.2205513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
Systemic Lupus Erythematosus (SLE) is an auto-immune disease in which the immune system assaults its tissues. We aimed to analyse the maternal and foetal outcomes during pregnancy in SLE mothers. A literature search was conducted by two investigators to assess SLE's outcomes on maternal and foetal during pregnancies. We searched PubMed/Medline, Embase, and Google scholar to collect evidence from different research studies, draw the conclusion, and report it. In our investigation, we found out that SLE could cause a spectrum of complications during pregnancy, not only for the mother but also for the foetus. It could affect fertility and cause difficult pregnancies for the couple as well which includes certain complications such as: preterm labour and delivery, high blood pressure (preeclampsia), placental insufficiency, miscarriage or stillbirth, whereas in the foetus SLE can cause mortality, preterm birth, and neonatal lupus (a temporary condition in the baby caused by SLE-related antibodies) and structural abnormalities. The literature suggests that SLE could prove fatal for the foetus and induce many complications in the mother. However, this could be avoided if pregnancy is planned right from the start and proper management is provided to the mother during pregnancy and delivery.p.
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Affiliation(s)
- Abdul Basit Sangah
- Liaquat National Hospital and Medical College Karachi, Karachi, Pakistan
| | - Sidra Jabeen
- Liaquat National Hospital and Medical College Karachi, Karachi, Pakistan
| | | | - Sunita Devi
- Liaquat National Hospital and Medical College Karachi, Karachi, Pakistan
| | - Hassan Mumtaz
- Senior Clinical Research Associate, Maroof International Hospital, Public Health Scholar, Health Services Academy, Islamabad, Pakistan
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3
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Saiki H, Saito K, Sato A. Reversible complete atrioventricular block in a neonate with maternal anti-Sjögren's syndrome-associated antibody: atypical phenotype of autoimmune congenital heart block. Cardiol Young 2023; 33:2430-2433. [PMID: 37466078 DOI: 10.1017/s1047951123002512] [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] [Indexed: 07/20/2023]
Abstract
The fetus of anti-Sjögren's syndrome-associated antibody-positive mother developed complete atrioventricular block at 39 weeks of gestation and required urgent ventricular pacing after birth. Unexpectedly, the patient recovered from the atrioventricular block within a few days. Fraction analysis of maternal anti-Sjögren's syndrome-associated antibody revealed positivity for isolated anti-Ro/SSA 60 kDa antibody, which is abnormal as most patients with complete atrioventricular block present with anti-Ro/SSA 52 kDa positivity, which may indicate a potentially atypical late and reversible manifestation of an autoimmune congenital atrioventricular block in this patient.
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Affiliation(s)
- Hirofumi Saiki
- Division of Pediatric Cardiology, Department of Pediatrics, Iwate Medical University, Yahaba, Japan
| | - Kanchi Saito
- Division of Pediatric Cardiology, Department of Pediatrics, Iwate Medical University, Yahaba, Japan
| | - Akira Sato
- Division of Pediatric Cardiology, Department of Pediatrics, Iwate Medical University, Yahaba, Japan
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Padovani P, Singh Y, Pass RH, Vasile CM, Nield LE, Baruteau AE. E-Health: A Game Changer in Fetal and Neonatal Cardiology? J Clin Med 2023; 12:6865. [PMID: 37959330 PMCID: PMC10650296 DOI: 10.3390/jcm12216865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 10/20/2023] [Accepted: 10/26/2023] [Indexed: 11/15/2023] Open
Abstract
Technological advancements have greatly impacted the healthcare industry, including the integration of e-health in pediatric cardiology. The use of telemedicine, mobile health applications, and electronic health records have demonstrated a significant potential to improve patient outcomes, reduce healthcare costs, and enhance the quality of care. Telemedicine provides a useful tool for remote clinics, follow-up visits, and monitoring for infants with congenital heart disease, while mobile health applications enhance patient and parents' education, medication compliance, and in some instances, remote monitoring of vital signs. Despite the benefits of e-health, there are potential limitations and challenges, such as issues related to availability, cost-effectiveness, data privacy and security, and the potential ethical, legal, and social implications of e-health interventions. In this review, we aim to highlight the current application and perspectives of e-health in the field of fetal and neonatal cardiology, including expert parents' opinions.
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Affiliation(s)
- Paul Padovani
- CHU Nantes, Department of Pediatric Cardiology and Pediatric Cardiac Surgery, FHU PRECICARE, Nantes Université, 44000 Nantes, France;
- CHU Nantes, INSERM, CIC FEA 1413, Nantes Université, 44000 Nantes, France
| | - Yogen Singh
- Division of Neonatology, Department of Pediatrics, Loma Linda University School of Medicine, Loma Linda, CA 92354, USA
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Robert H. Pass
- Department of Pediatric Cardiology, Mount Sinai Kravis Children’s Hospital, New York, NY 10029, USA;
| | - Corina Maria Vasile
- Department of Pediatric and Adult Congenital Cardiology, University Hospital of Bordeaux, 33600 Bordeaux, France;
| | - Lynne E. Nield
- Division of Cardiology, Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, ON M5S 1A1, Canada
- Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada
| | - Alban-Elouen Baruteau
- CHU Nantes, Department of Pediatric Cardiology and Pediatric Cardiac Surgery, FHU PRECICARE, Nantes Université, 44000 Nantes, France;
- CHU Nantes, INSERM, CIC FEA 1413, Nantes Université, 44000 Nantes, France
- CHU Nantes, CNRS, INSERM, L’Institut du Thorax, Nantes Université, 44000 Nantes, France
- INRAE, UMR 1280, PhAN, Nantes Université, 44000 Nantes, France
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5
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Jaeggi E, Kulasingam V, Chen J, Fan CPS, Laskin C, Hamilton RM, Hiraki LT, Silverman ED, Sepiashvili L. Maternal Anti-Ro Antibody Titers Obtained With Commercially Available Immunoassays Are Strongly Associated With Immune-Mediated Fetal Heart Disease. Arthritis Rheumatol 2023; 75:1556-1565. [PMID: 36996277 DOI: 10.1002/art.42513] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 03/04/2023] [Accepted: 03/10/2023] [Indexed: 04/01/2023]
Abstract
OBJECTIVE Anti-Ro antibody-positive mothers are frequently referred for serial echocardiography due to the fetal risk of developing heart block and endocardial fibroelastosis. Little is known why only some and not all offspring develop these cardiac manifestations of neonatal lupus (CNL). This prospective study examined associations between anti-Ro antibody titers and fetal CNL. METHODS Antibody-positive mothers referred since 2018 for fetal echocardiography at risk of CNL (group 1; n = 240) or with CNL (group 2; n = 18) were included. Maternal antibody titers were measured with a chemiluminescent immunoassay (CIA). Additional testing on diluted serum samples was used to quantify anti-Ro 60 antibody titers above the analytical measuring range (AMR) of the standard CIA (≥1,375 chemiluminescent units [CU]). RESULTS Among 27 total mothers with a fetal diagnosis of CNL, all displayed anti-Ro 60 antibody titers that exceeded the AMR of the CIA at least 10-fold. Of 122 mothers in group 1 who underwent additional anti-Ro 60 antibody testing, event rates of CNL (n = 9) were 0% (0 of 45) among mothers with anti-Ro 60 antibody titers from 1,375-10,000 CU, 5% (3 of 56) among mothers with titers from 10,000-50,000 CU, but 29% (6 of 21) among mothers with titers >50,000 CU (odds ratio 13.1, P = 0.0008). Of mothers in group 2 with a primary diagnosis of CNL, 0% (0 of 18 mothers) had anti-Ro 60 antibody titers <10,000 CU, 44% (8 of 18 mothers) had titers from 10,000-50,000 CU, and 56% (10 of 18 mothers) had titers >50,000 CU. CONCLUSION CNL is associated with substantially higher anti-Ro antibody titers than are obtained using a standard CIA. Enhancing the assay measuring range allows an improved specificity of identifying pregnancies at risk of CNL.
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Affiliation(s)
- Edgar Jaeggi
- Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Vathany Kulasingam
- Division of Clinical Biochemistry, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Jack Chen
- Department of Laboratory Medicine & Pathobiology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Chun-Po Steve Fan
- Rogers Computational Program, Ted Rogers Centre for Heart Research, University Health Network, Toronto, Ontario, Canada
| | - Carl Laskin
- Department of Medicine, Mount Sinai Hospital, New York, New York
| | - Robert M Hamilton
- Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Linda T Hiraki
- Division of Rheumatology, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Earl D Silverman
- Division of Rheumatology, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Lusia Sepiashvili
- Department of Laboratory Medicine & Pathobiology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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6
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Abstract
Congenital complete heart block (CCHB) defines atrioventricular conduction abnormalities diagnosed in utero or within the first 27 days of life. Maternal autoimmune disease and congenital heart defects are most commonly responsible. Recent genetic discoveries have highlighted our understanding of the underlying mechanism. Hydroxychloroquine shows promise in preventing autoimmune CCHB. Patients may develop symptomatic bradycardia and cardiomyopathy. The presence of these and other specific findings warrants placement of a permanent pacemaker to relieve symptoms and prevent catastrophic events. The mechanisms, natural history, evaluation, and treatment of patients with or at risk for CCHB are reviewed.
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Affiliation(s)
- Leonard Steinberg
- Pediatric Cardiology, Children's Heart Center, Ascension St. Vincent, 8333 Naab Rd, Ste 320, Indianapolis, IN 46260, USA.
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7
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Khayata M, Wang TKM, Chan N, Alkharabsheh S, Verma BR, Oliveira GH, Klein AL, Littlejohn E, Xu B. Multimodality Cardiac Imaging in Patients with Systemic Lupus Erythematosus. Curr Probl Cardiol 2023; 48:101048. [PMID: 34774920 DOI: 10.1016/j.cpcardiol.2021.101048] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Accepted: 11/05/2021] [Indexed: 02/01/2023]
Abstract
Systemic lupus erythematous (SLE) is an autoimmune disease with a wide range of cardiovascular complications. The main manifestations include diseases of the coronary arteries, valves, pericardium, and myocardium. Multimodality cardiovascular imaging techniques are critical for evaluating the extent of cardiac manifestations in SLE patients, which can provide valuable prognostic information. However, their utility has previously not been well defined. This review provides a state-of-the-art update on the cardiovascular manifestations of lupus, as well as the role of multimodality cardiac imaging in guiding management of patients with SLE.
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Affiliation(s)
- Mohamed Khayata
- Department of Cardiovascular Sciences, University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - Tom Kai Ming Wang
- Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Section of Cardiovascular Imaging, Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Nicholas Chan
- Department of Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Saqer Alkharabsheh
- Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Beni R Verma
- Department of Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Guilherme H Oliveira
- Department of Cardiovascular Sciences, University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - Allan L Klein
- Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Section of Cardiovascular Imaging, Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Emily Littlejohn
- Department of Rheumatologic and Immunologic Disease, Cleveland Clinic, Ohio, USA
| | - Bo Xu
- Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Section of Cardiovascular Imaging, Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA.
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8
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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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Matsubara Y, Fujita D, Inamura N, Fujita T. Measurement of fetal atrioventricular intervals in pregnant women with anti-SSA/Ro antibodies. J Med Ultrason (2001) 2022; 49:451-461. [PMID: 35653003 DOI: 10.1007/s10396-022-01226-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Accepted: 04/27/2022] [Indexed: 11/24/2022]
Abstract
PURPOSE The objective of our study was to compare and consider reference values of fetal atrioventricular (AV) intervals as measured by four different pulsed Doppler wave techniques (left ventricular inflow/outflow [LV in/out], pulmonary vein/pulmonary artery [PV/PA], innominate vein/ascending aorta [InnV/AA], and supra vena cava/ascending aorta [SVC/AA]) in pregnant women with anti-SSA/Ro antibodies. METHODS Between March 2014 and September 2020, 52 pregnant women with anti-SSA antibodies were enrolled. No bradyarrhythmia was observed in the group. A pulsed Doppler examination of the fetal heart was performed to obtain measurements of the mechanical Doppler AV interval. Doppler measurements were performed using four methods: LV in/out, PV/PA, InnV/AA, and SVC/AA. A statistical analysis was performed to examine the mean, standard deviation, significant difference, and correlation of the four methods. The detection rate of each method was also calculated. RESULTS There was no significant difference in the AV intervals between any of the four methods. There was also a positive correlation in the AV intervals of each of the four methods. The fetal heart rate and AV interval showed no correlation. The gestational age and AV interval also showed no correlation. The detection rate was highest for LV in/out (62.6%, 95% confidence interval: 56.5-68.4). CONCLUSION All four pulsed Doppler methods are useful for measuring AV intervals. The most practical method is LV in/out.
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Affiliation(s)
- Yayoi Matsubara
- Fujita Clinic, Shimanouchi Building 2F, 2-11-20 Shimanouchi, Chuo-ku, Osaka-shi, Osaka, 542-0082, Japan.
| | - Daisuke Fujita
- Department of Obstetrics and Gynecology, Osaka Medical and Pharmaceutical University, 2-7 Daigakucho, Takatsuki, Osaka, 569-8686, Japan
| | - Noboru Inamura
- Department of Pediatrics, Faculty of Medicine, Kindai University, 377-2 Ohno-Higashi, Osaka-Sayama, Osaka, 589-8511, Japan
| | - Tomio Fujita
- Fujita Clinic, Shimanouchi Building 2F, 2-11-20 Shimanouchi, Chuo-ku, Osaka-shi, Osaka, 542-0082, Japan
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Kaplinski M, Cuneo BF. Novel approaches to the surveillance and management of fetuses at risk for anti-Ro/SSA mediated atrioventricular block. Semin Perinatol 2022; 46:151585. [PMID: 35410713 DOI: 10.1016/j.semperi.2022.151585] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Approximately one percent of pregnant women will produce anti-Sjogren's syndrome-related antigen A (anti-Ro/SSA) antibodies. Of these pregnancies, one to three percent will have a fetus that develops atrioventricular (AV) block. Earlier stages of AV block (1° or 2°) may respond to anti-inflammatory treatment, but complete (3°) AV block, which can occur within 24 hours of a normal fetal rhythm, is likely irreversible and carries substantial risk for significant morbidity and for mortality. Emerging data has shown that ambulatory fetal heart rhythm monitoring can detect the transition period from normal rhythm to 2° AV block, the time during which treatment with IVIG and dexamethasone can potentially restore normal sinus rhythm. Weekly or biweekly fetal echocardiograms occur too infrequently to detect this transition period but may still be useful in diagnosing extranodal anti-Ro antibody mediated cardiac disease. In this review, we evaluate the most innovative methods for surveillance and treatment of this disease.
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Affiliation(s)
- Michelle Kaplinski
- Division of Cardiology, Department of Pediatrics, Stanford University School of Medicine, Lucile Packard Children's Hospital, Palo Alto, CA, USA.
| | - Bettina F Cuneo
- Division of Cardiology, Departments of Pediatrics and Obstetrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO, USA
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11
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Congenital atrioventricular heart block: From diagnosis to treatment. Rev Port Cardiol 2022; 41:231-240. [DOI: 10.1016/j.repc.2019.09.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 09/23/2019] [Indexed: 11/22/2022] Open
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12
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Sunderji S, Peyvandi S, Jaeggi E, Szwast A, Ryan G, Tessier F, Siddiqui S, Cuneo B, Sheth S, Treadwell M, Frommelt M, Turan S, Copel J, Emery S, Rand L, Moon-Grady AJ. NAFTNet retrospective report on the treatment of anti-Ro/SSA mediated fetal heart block with dexamethasone. J Matern Fetal Neonatal Med 2022; 35:9263-9270. [PMID: 35014577 DOI: 10.1080/14767058.2022.2025536] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
BACKGROUND Complete atrioventricular block (CAVB) is a complication of maternal antibody positivity and treatment of fetal disease is controversial in terms of efficacy and safety. We hypothesized that dexamethasone treatment for fetal anti-Ro/SSA antibody-mediated cardiac disease leads to better pregnancy outcomes than expectant management. METHODS A retrospective multi-center cohort study of anti-Ro/SSA antibody positive pregnancies with fetal conduction disease reported by participating North American Fetal Therapy Network (NAFTNet) centers between January 2010 and December 2018. The primary outcomes included: fetal death, oligohydramnios, growth restriction, preterm delivery, and new maternal comorbidities. Secondary outcomes included: pacemaker prior to 28 days, transplantation, and neonatal death in maternal/fetal dyads treated with dexamethasone versus not. RESULTS In 127 anti-Ro/SSA positive pregnancies, 98 were treated with dexamethasone and 29 were not. Of those treated, 61/96 (63.5%) met the primary outcome including 45/91 (49.4%) premature deliveries; 20 mothers developed comorbidities during treatment (fetal death 5, 10 growth restriction, 14 oligohydramnios, two new/worsening gestational diabetes). In the untreated group, 15/25 (60%) met the primary outcome including 11/22 (50%) premature deliveries and four mothers developing comorbidities during their pregnancy (fetal death 3, one growth restriction, one new onset maternal hypertension). Regarding secondary outcomes, 37/96 (43%) treated fetuses required a pacemaker or died by 28 days, while untreated 13/25 (52%) required pacemaker placement, died prior to 28 days or required listing for transplantation. Excluding terminations, survival without transplant was 17 (68%) in untreated and 85 (89%) in treated patients (p<.01). CONCLUSIONS While the use of dexamethasone in anti-Ro/SSA positive pregnancies is associated with a high rate of poor pregnancy outcomes, there was an unexpected similarly high rate in untreated positive pregnancies. This suggests that the maternal disease itself is influencing pregnancy complications independent of dexamethasone. Our data, which show that treatment decreases neonatal morbidity and overall mortality without increasing overall pregnancy complications, warrant further study.
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Affiliation(s)
- Sherzana Sunderji
- Department of Pediatrics, University of California, Davis, Sacramento, CA, USA
| | - Shabnam Peyvandi
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA, USA
| | | | - Anita Szwast
- The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Greg Ryan
- Mount Sinai Hospital, Toronto, Canada
| | - Francine Tessier
- Children's & Women's Health Centre of British Columbia, Vancouver, Canada
| | | | | | | | - Marjorie Treadwell
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
| | | | - Shifa Turan
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
| | | | - Stephen Emery
- Department of Obstetrics, Gynecology, & Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Larry Rand
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA, USA
| | - Anita J Moon-Grady
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA, USA
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Mawad W, Hornberger L, Cuneo B, Raboisson MJ, Moon-Grady AJ, Lougheed J, Diab K, Parkman J, Silverman E, Jaeggi E. Outcome of Antibody-Mediated Fetal Heart Disease With Standardized Anti-Inflammatory Transplacental Treatment. J Am Heart Assoc 2022; 11:e023000. [PMID: 35001672 PMCID: PMC9238501 DOI: 10.1161/jaha.121.023000] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Background Transplacental fetal treatment of immune-mediated fetal heart disease, including third-degree atrioventricular block (AVB III) and endocardial fibroelastosis, is controversial. Methods and Results To study the impact of routine transplacental fetal treatment, we reviewed 130 consecutive cases, including 108 with AVB III and 22 with other diagnoses (first-degree/second-degree atrioventricular block [n=10]; isolated endocardial fibroelastosis [n=9]; atrial bradycardia [n=3]). Dexamethasone was started at a median of 22.4 gestational weeks. Additional treatment for AVB III included the use of a β-agonist (n=47) and intravenous immune globulin (n=34). Fetal, neonatal, and 1-year survival rates with AVB III were 95%, 93%, and 89%, respectively. Variables present at diagnosis that were associated with perinatal death included an atrial rate <90 beats per minute (odds ratio [OR], 258.4; 95% CI, 11.5-5798.9; P<0.001), endocardial fibroelastosis (OR, 28.9; 95% CI, 1.6-521.7; P<0.001), fetal hydrops (OR, 25.5; 95% CI, 4.4-145.3; P<0.001), ventricular dysfunction (OR, 7.6; 95% CI, 1.5-39.4; P=0.03), and a ventricular rate <45 beats per minute (OR, 12.9; 95% CI, 1.75-95.8; P=0.034). At a median follow-up of 5.9 years, 85 of 100 neonatal survivors were paced, and 1 required a heart transplant for dilated cardiomyopathy. Cotreatment with intravenous immune globulin was used in 16 of 22 fetuses with diagnoses other than AVB III. Neonatal and 1-year survival rates of this cohort were 100% and 95%, respectively. At a median age of 3.1 years, 5 of 21 children were paced, and all had normal ventricular function. Conclusions Our findings reveal a low risk of perinatal mortality and postnatal cardiomyopathy in fetuses that received transplacental dexamethasone±other treatment from the time of a new diagnosis of immune-mediated heart disease.
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Affiliation(s)
- Wadi Mawad
- The Hospital for Sick Children Toronto Ontario Canada
| | - Lisa Hornberger
- Stollery Children's Hospital University of Alberta Edmonton Alberta Canada
| | | | | | | | - Jane Lougheed
- Children's Hospital of Eastern Ontario Ottawa Ontario Canada
| | - Karim Diab
- Rush University Medical Center Chicago IL
| | - Julia Parkman
- Stollery Children's Hospital University of Alberta Edmonton Alberta Canada
| | | | - Edgar Jaeggi
- The Hospital for Sick Children Toronto Ontario Canada
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14
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Abstract
Congenital complete heart block (CCHB) defines atrioventricular conduction abnormalities diagnosed in utero or within the first 27 days of life. Maternal autoimmune disease and congenital heart defects are most commonly responsible. Recent genetic discoveries have highlighted our understanding of the underlying mechanism. Hydroxychloroquine shows promise in preventing autoimmune CCHB. Patients may develop symptomatic bradycardia and cardiomyopathy. The presence of these and other specific findings warrants placement of a permanent pacemaker to relieve symptoms and prevent catastrophic events. The mechanisms, natural history, evaluation, and treatment of patients with or at risk for CCHB are reviewed.
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15
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Oliveira FR, Valim V, Pasoto SG, Fernandes MLMS, Lopes MLL, de Magalhães Souza Fialho SC, Pinheiro AC, Dos Santos LC, Appenzeller S, Fidelix T, Ribeiro SLE, de Brito DCSE, Libório T, Santos MCLFS, Tanure L, Gennari JDA, Civile VT, Pinto ACPN, Rocha-Filho CR, Miyamoto ST, Guedes LKN, Pugliesi A, Trevisani VFM. 2021 recommendations of the Brazilian Society of Rheumatology for the gynecological and obstetric care of patients with Sjogren's syndrome. Adv Rheumatol 2021; 61:54. [PMID: 34479630 DOI: 10.1186/s42358-021-00208-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 08/03/2021] [Indexed: 12/29/2022] Open
Abstract
Sjogren's syndrome (SS) is an autoimmune disease characterized by lymphocytic infiltration of the exocrine glands and other organs. Women with SS often experience gynecological symptoms due to the disease and need extra care regarding their sexual activity, reproductive health and during pregnancy, conditions that are not properly conducted in the clinical practice. To cover this gap, a panel of experts from the Brazilian Society of Rheumatology conducted a systematic review and meta-analysis on the identification of symptoms, diagnosis, monitoring, prognosis, and treatment of these manifestations. A Focus Group meeting was held and included experts in the field and methodologists, based on a previously developed script, with themes related to the objective of the study. The most important topics were summarized and 11 recommendations were provided.
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Affiliation(s)
- Fabiola Reis Oliveira
- Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto (HCFMRP-USP), Av. Bandeirantes, 3900, Vila Monte Alegre, Ribeirão Preto, SP, CEP: 14049-900, Brazil
| | - Valeria Valim
- Serviço de Reumatologia, Hospital Universitário Cassiano Antônio de Moraes, Universidade Federal do Espírito Santo, Av. Marechal Campos, 1468, Maruípe, Vitória, ES, CEP: 29075-910, Brazil
| | - Sandra Gofinet Pasoto
- Disciplina de Reumatologia, Laboratório de Autoimunidade (DLC + LIM17), Hospital das Clínicas da Faculdade de Medicina da USP (HCFMUSP), R. Dr. Ovídio Pires de Campos, 225 - Cerqueira César, São Paulo, SP, CEP: 05403-010, Brazil
| | | | - Maria Lucia Lemos Lopes
- Disciplina de Reumatologia Departamento de Clínica Médica, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA),, R. Sarmento Leite, 245 - Centro Histórico de Porto Alegre, Porto Alegre, RS, CEP: 90050-170, Brazil
| | | | - Aysa César Pinheiro
- Disciplina de Reumatologia, Departamento de Clínica Médica, Universidade Federal de Pernambuco, Av. Prof. Moraes Rego, 1235, Cidade Universitária, Recife, PE, CEP: 50670-901, Brazil
| | - Laura Caldas Dos Santos
- Departamento de Oftalmologia, Escola Paulista de Medicina-Universidade Federal de São Paulo (EPM-UNIFESP), Rua Botucatu, 820, Vila Clementino, Sao Paulo, SP, CEP: 04023-062, Brazil
| | - Simone Appenzeller
- Departamento de Ortopedia, Reumatologia e Traumatologia da Faculdade de Ciências Médicas da Universidade Estadual de Campinas (UNICAMP), R. Tessália Vieira de Camargo, 126 - Cidade Universitária, Campinas, SP, CEP: 13083-887, Brazil
| | - Tania Fidelix
- Departamento de Oftalmologia, Escola Paulista de Medicina-Universidade Federal de São Paulo (EPM-UNIFESP), Rua Botucatu, 820, Vila Clementino, Sao Paulo, SP, CEP: 04023-062, Brazil
| | - Sandra Lucia Euzébio Ribeiro
- Disciplina de Reumatologia, Universidade Federal do Amazonas, Rua Afonso Pena, 1053, Manaus, AM, CEP: 69020-160, Brazil
| | - Danielle Christinne Soares Egypto de Brito
- Disciplina de Reumatologia, Departamento de Medicina Interna, Centro de Ciências Médicas, Universidade Federal de Paraíba (UFPB), Campus I - Lot. Cidade Universitária, Paraíba, PB, CEP: 58051-900, Brazil
| | - Tatiana Libório
- Disciplina de Reumatologia, Universidade Federal do Amazonas, Rua Afonso Pena, 1053, Manaus, AM, CEP: 69020-160, Brazil
| | - Maria Carmen Lopes Ferreira Silva Santos
- Departamento de Patologia, Hospital Universitário Cassiano Antônio de Moraes, Universidade Federal do Espírito Santo, Av. Marechal Campos, 1468, Maruípe, Vitória, ES, CEP: 29075-910, Brazil
| | - Leandro Tanure
- Disciplina de Reumatologia, Universidade Federal de Minas Gerais, Av. Pres. Antônio Carlos, 6627, Pampulha, Belo Horizonte, MG, CEP: 31270-901, Brazil
| | - Juliana DAgostino Gennari
- Serviço de Reumatologia da Santa Casa de São Paulo, R. Dr. Cesário Mota Júnior, 112, Vila Buarque, São Paulo, SP, CEP: 01221-020, Brazil
| | - Vinicius Tassoni Civile
- Disciplina de Medicina de Urgência e Medicina Baseada em Evidências, Escola Paulista de Medicina-Universidade Federal de São Paulo (EPM-UNIFESP), Rua Botucatu 740 Vila Clementino, São Paulo, SP, CEP: 04023-062, Brazil
| | - Ana Carolina Pereira Nunes Pinto
- Disciplina de Medicina de Urgência e Medicina Baseada em Evidências, Escola Paulista de Medicina-Universidade Federal de São Paulo (EPM-UNIFESP), Rua Botucatu 740 Vila Clementino, São Paulo, SP, CEP: 04023-062, Brazil
| | - César Ramos Rocha-Filho
- Disciplina de Medicina de Urgência e Medicina Baseada em Evidências, Escola Paulista de Medicina-Universidade Federal de São Paulo (EPM-UNIFESP), Rua Botucatu 740 Vila Clementino, São Paulo, SP, CEP: 04023-062, Brazil
| | - Samira Tatiyama Miyamoto
- Departamento de Educação Integrada em Saúde, Universidade Federal do Espírito Santo (UFES), Av. Marechal Campos, 1468, Maruípe, Vitória, ES, CEP: 29040-090, Brazil
| | - Lissiane Karine Noronha Guedes
- Disciplina de Reumatologia, Laboratório de Autoimunidade (DLC + LIM17), Hospital das Clínicas da Faculdade de Medicina da USP (HCFMUSP), R. Dr. Ovídio Pires de Campos, 225 - Cerqueira César, São Paulo, SP, CEP: 05403-010, Brazil
| | - Alisson Pugliesi
- Departamento de Ortopedia, Reumatologia e Traumatologia da Faculdade de Ciências Médicas da Universidade Estadual de Campinas (UNICAMP), R. Tessália Vieira de Camargo, 126 - Cidade Universitária, Campinas, SP, CEP: 13083-887, Brazil.
| | - Virginia Fernandes Moça Trevisani
- Disciplina de Medicina de Urgência e Medicina Baseada em Evidências, Escola Paulista de Medicina-Universidade Federal de São Paulo (EPM-UNIFESP), Rua Botucatu 740 Vila Clementino, São Paulo, SP, CEP: 04023-062, Brazil.,Disciplina de Reumatologia, Universidade de Santo Amaro, Rua Enéas Siqueira Neto, Jardim das Imbuias, São Paulo, SP, CEP: 04829-300, Brazil
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16
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Singampalli KL, Jui E, Shani K, Ning Y, Connell JP, Birla RK, Bollyky PL, Caldarone CA, Keswani SG, Grande-Allen KJ. Congenital Heart Disease: An Immunological Perspective. Front Cardiovasc Med 2021; 8:701375. [PMID: 34434978 PMCID: PMC8380780 DOI: 10.3389/fcvm.2021.701375] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 07/13/2021] [Indexed: 12/28/2022] Open
Abstract
Congenital heart disease (CHD) poses a significant global health and economic burden-despite advances in treating CHD reducing the mortality risk, globally CHD accounts for approximately 300,000 deaths yearly. Children with CHD experience both acute and chronic cardiac complications, and though treatment options have improved, some remain extremely invasive. A challenge in addressing these morbidity and mortality risks is that little is known regarding the cause of many CHDs and current evidence suggests a multifactorial etiology. Some studies implicate an immune contribution to CHD development; however, the role of the immune system is not well-understood. Defining the role of the immune and inflammatory responses in CHD therefore holds promise in elucidating mechanisms underlying these disorders and improving upon current diagnostic and treatment options. In this review, we address the current knowledge coinciding CHDs with immune and inflammatory associations, emphasizing conditions where this understanding would provide clinical benefit, and challenges in studying these mechanisms.
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Affiliation(s)
- Kavya L. Singampalli
- Department of Bioengineering, Rice University, Houston, TX, United States
- Medical Scientist Training Program, Baylor College of Medicine, Houston, TX, United States
- Laboratory for Regenerative Tissue Repair, Division of Pediatric Surgery, Department of Surgery, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, United States
| | - Elysa Jui
- Department of Bioengineering, Rice University, Houston, TX, United States
| | - Kevin Shani
- John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, MA, United States
| | - Yao Ning
- Laboratory for Regenerative Tissue Repair, Division of Pediatric Surgery, Department of Surgery, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, United States
| | | | - Ravi K. Birla
- Laboratory for Regenerative Tissue Repair, Division of Pediatric Surgery, Department of Surgery, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, United States
- Division of Congenital Heart Surgery, Departments of Surgery and Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, United States
| | - Paul L. Bollyky
- Division of Infectious Diseases, Department of Medicine, Stanford University School of Medicine, Stanford, CA, United States
| | - Christopher A. Caldarone
- Division of Congenital Heart Surgery, Departments of Surgery and Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, United States
| | - Sundeep G. Keswani
- Laboratory for Regenerative Tissue Repair, Division of Pediatric Surgery, Department of Surgery, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, United States
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17
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Milazzo R, Ligato E, Laoreti A, Ferri G, Basili L, Serati L, Brucato A, Cetin I. Home fetal heart rate monitoring in anti Ro/SSA positive pregnancies: Literature review and case report. Eur J Obstet Gynecol Reprod Biol 2021; 259:1-6. [PMID: 33556767 DOI: 10.1016/j.ejogrb.2021.01.031] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 01/18/2021] [Indexed: 10/22/2022]
Abstract
Anti-Ro/SSA antibodies are associated with a risk of 1-2 % to develop complete atrioventricular block (AVB) in fetuses of positive mothers. Complete AVB is irreversible, but studies suggest that anti-inflammatory treatment during the transition period from a normal fetal heart rate (FHR) to an AVB might stop this progression and restore sinus rhythm. The most efficient method for diagnostic evaluation of this arrhythmia is the pulsed-Doppler fetal echocardiography. However, weekly or bi-weekly recommended fetal echocardiographic surveillance can rarely identify an AVB in time for treatment success, also because the transition from a normal rhythm to a third degree AVB is very fast. Daily FHR monitoring in a medical facility could increase the chances of identifying the AVB onset but is difficult to realize. For this reason, an alternative method of FHR monitoring, performed directly by mothers in their home context, has been recently proposed. We present a case report utilizing this approach and review the current evidence about this condition.
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Affiliation(s)
- Roberta Milazzo
- Department of Woman, Mother and Neonate, "V. Buzzi" Children Hospital, ASST Fatebenefratelli Sacco, Milan, Italy.
| | - Elisa Ligato
- Department of Woman, Mother and Neonate, "V. Buzzi" Children Hospital, ASST Fatebenefratelli Sacco, Milan, Italy
| | - Arianna Laoreti
- Department of Woman, Mother and Neonate, "V. Buzzi" Children Hospital, ASST Fatebenefratelli Sacco, Milan, Italy
| | - Giulia Ferri
- Department of Woman, Mother and Neonate, "V. Buzzi" Children Hospital, ASST Fatebenefratelli Sacco, Milan, Italy
| | - Ludovica Basili
- Department of Woman, Mother and Neonate, "V. Buzzi" Children Hospital, ASST Fatebenefratelli Sacco, Milan, Italy
| | - Lisa Serati
- Internal Medicine, Fatebenefratelli Hospital, Milan, Italy
| | | | - Irene Cetin
- Department of Woman, Mother and Neonate, "V. Buzzi" Children Hospital, ASST Fatebenefratelli Sacco, Milan, Italy; Department of Biomedical and Clinical Sciences "Luigi Sacco", University of Milan, Milan, Italy
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18
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Butt S, Kiran S, Qadir N, Menghani D, Tanzeem H. Cardiac Conduction Defects in Systemic Lupus Erythematosus. Cureus 2020; 12:e10882. [PMID: 33178534 PMCID: PMC7652344 DOI: 10.7759/cureus.10882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Systemic autoimmune conditions may cause morbidity and mortality. Systemic lupus erythematosus (SLE) is a prominent example of such diseases. It can result in conduction abnormalities due to accelerated atherosclerosis, vasculitis, or autoantibodies-induced myocarditis. Cardiac conduction abnormalities may produce sinus tachycardia, sinus bradycardia, prolonged QT intervals, atrial fibrillation, or atrioventricular (AV) nodal blocks. Neonatal lupus is sometimes associated with anti-Ro/SSA and anti-La/SSB antibodies, but their role remains a matter of controversy in adults.
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Affiliation(s)
- Shayan Butt
- Internal Medicine, Baptist Memorial Hospital, Oxford, USA
| | - Simra Kiran
- Pulmonology and Critical Care, University of Cincinnati Medical Center, Cincinnati, USA
| | - Nida Qadir
- Infectious Diseases, University of Louisville, Louisville, USA
| | - Divya Menghani
- Infectious Diseases, University of Louisville, Louisville, USA
| | - Hammad Tanzeem
- Medicine, Dow Medical College/Civil Hospital, Karachi, PAK
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19
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Hansahiranwadee W. Diagnosis and Management of Fetal Autoimmune Atrioventricular Block. Int J Womens Health 2020; 12:633-639. [PMID: 32884363 PMCID: PMC7434531 DOI: 10.2147/ijwh.s257407] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 07/17/2020] [Indexed: 11/23/2022] Open
Abstract
Autoimmune congenital atrioventricular block (CAVB) has been extensively studied in recent decades. The American Heart Association published guidelines for monitoring pregnant women with anti-Ro/Sjögren’s syndrome antigen A (SSA) or anti-La/Sjögren’s syndrome antigen B (SSB) autoantibodies, which are considered to increase the risk of CAVB. Information about the natural history of the disease in utero has contributed to the detection of fetuses with CAVB in the treatable stage. Hydroxychloroquine (HCQ) may be used to prevent CAVB. The lack of large randomized control trials is a major drawback to fully confirm the benefits of fluorinated steroids such as dexamethasone. Although, when combined with a β-sympathomimetic agent, the outcome of administering a fluorinated steroid in complete CAVB is still controversial. Novel treatments targeting the immunological process might prevent the recurrence of CAVB in pregnant women with previously affected children.
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Affiliation(s)
- Wirada Hansahiranwadee
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynaecology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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20
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Padmanabhan A, Connelly-Smith L, Aqui N, Balogun RA, Klingel R, Meyer E, Pham HP, Schneiderman J, Witt V, Wu Y, Zantek ND, Dunbar NM, Schwartz GEJ. Guidelines on the Use of Therapeutic Apheresis in Clinical Practice - Evidence-Based Approach from the Writing Committee of the American Society for Apheresis: The Eighth Special Issue. J Clin Apher 2019; 34:171-354. [PMID: 31180581 DOI: 10.1002/jca.21705] [Citation(s) in RCA: 775] [Impact Index Per Article: 155.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The American Society for Apheresis (ASFA) Journal of Clinical Apheresis (JCA) Special Issue Writing Committee is charged with reviewing, updating and categorizing indications for the evidence-based use of therapeutic apheresis (TA) in human disease. Since the 2007 JCA Special Issue (Fourth Edition), the committee has incorporated systematic review and evidence-based approaches in the grading and categorization of apheresis indications. This Eighth Edition of the JCA Special Issue continues to maintain this methodology and rigor in order to make recommendations on the use of apheresis in a wide variety of diseases/conditions. The JCA Eighth Edition, like its predecessor, continues to apply the category and grading system definitions in fact sheets. The general layout and concept of a fact sheet that was introduced in the Fourth Edition, has largely been maintained in this edition. Each fact sheet succinctly summarizes the evidence for the use of TA in a specific disease entity or medical condition. The Eighth Edition comprises 84 fact sheets for relevant diseases and medical conditions, with 157 graded and categorized indications and/or TA modalities. The Eighth Edition of the JCA Special Issue seeks to continue to serve as a key resource that guides the utilization of TA in the treatment of human disease.
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Affiliation(s)
- Anand Padmanabhan
- Medical Sciences Institute & Blood Research Institute, Versiti & Department of Pathology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Laura Connelly-Smith
- Department of Medicine, Seattle Cancer Care Alliance & University of Washington, Seattle, Washington
| | - Nicole Aqui
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rasheed A Balogun
- Department of Medicine, University of Virginia, Charlottesville, Virginia
| | - Reinhard Klingel
- Apheresis Research Institute, Cologne, Germany & First Department of Internal Medicine, University of Mainz, Mainz, Germany
| | - Erin Meyer
- Department of Hematology/Oncology/BMT/Pathology, Nationwide Children's Hospital, Columbus, Ohio
| | - Huy P Pham
- Department of Pathology, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Jennifer Schneiderman
- Department of Pediatric Hematology/Oncology/Neuro-oncology/Stem Cell Transplant, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University, Chicago, Illinois
| | - Volker Witt
- Department for Pediatrics, St. Anna Kinderspital, Medical University of Vienna, Vienna, Austria
| | - Yanyun Wu
- Bloodworks NW & Department of Laboratory Medicine, University of Washington, Seattle, Washington, Yale University School of Medicine, New Haven, Connecticut
| | - Nicole D Zantek
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, Minnesota
| | - Nancy M Dunbar
- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
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21
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Costedoat-Chalumeau N, Morel N, Fischer-Betz R, Levesque K, Maltret A, Khamashta M, Brucato A. Routine repeated echocardiographic monitoring of fetuses exposed to maternal anti-SSA antibodies: time to question the dogma. THE LANCET. RHEUMATOLOGY 2019; 1:e187-e193. [PMID: 38229394 DOI: 10.1016/s2665-9913(19)30069-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 09/06/2019] [Accepted: 09/09/2019] [Indexed: 11/21/2022]
Abstract
In around 1% of exposed pregnancies, anti-Ro/SSA and anti-La/SSB antibodies lead to congenital heart block, the main feature of neonatal lupus syndrome. As such, echocardiographic screening to detect congenital heart block, done every other week from 16 weeks to at least 24 weeks gestation, is widely recommended for anti-SSA-positive pregnant women. Such screening is now routinely done in many centres worldwide. In this Viewpoint, we call this dogma into question for several reasons. Even if congenital heart block is discovered (which is rare), the usefulness of treatment with fluorinated steroids has not been shown, whereas the associated side-effects are well known. The discovery of congenital heart block very early in the pregnancy does not modify obstetric management, and at least 500 ultrasounds are needed to find one case of congenital heart block, which would ultimately be found by other means. Finally, this screening strategy misses most cases of congenital heart block because most affected women are not known to have anti-SSA antibodies, and thus are not screened. Accordingly, except in the context of research protocols, which are certainly needed and are outside the scope of this Viewpoint, overturning the dogma of routine repeated screenings for congenital heart block could save money and health-care staff time and prevent maternal stress without substantial clinical consequences.
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Affiliation(s)
- Nathalie Costedoat-Chalumeau
- Assistance Publique - Hôpitaux de Paris, Cochin Hospital, Internal Medicine Department, Referral Center for Rare Autoimmune and Systemic Diseases, Paris, France; Centre of Research in Epidemiology and Statistics, Institut National de la Santé et de la Recherche Médicale, Institut National de la Recherche Agronomique, Université de Paris, Paris, France.
| | - Nathalie Morel
- Assistance Publique - Hôpitaux de Paris, Cochin Hospital, Internal Medicine Department, Referral Center for Rare Autoimmune and Systemic Diseases, Paris, France
| | - Rebecca Fischer-Betz
- Policlinic of Rheumatology and Hiller Research Unit Rheumatology, Medical Faculty, Heinrich-Heine-University, Dusseldorf, Germany
| | - Kateri Levesque
- Service Médecine Interne Gynéco-obstétricale, Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Canada
| | - Alice Maltret
- Assistance Publique - Hôpitaux de Paris, Service de Cardiologie, Hôpital Necker, Paris, France
| | - Munther Khamashta
- Lupus Clinic Rheumatology Department, Dubai Hospital, Dubai, United Arab Emirates
| | - Antonio Brucato
- Dipartimento di Scienze Biomediche e Cliniche, Università degli Studi di Milano, Ospedale Fatebenefratelli, Milano, Italy
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22
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Michael A, Radwan AA, Ali AK, Abd-Elkariem AY, Shazly SA. Use of antenatal fluorinated corticosteroids in management of congenital heart block: Systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol X 2019; 4:100072. [PMID: 31517303 PMCID: PMC6728741 DOI: 10.1016/j.eurox.2019.100072] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 06/11/2019] [Accepted: 06/12/2019] [Indexed: 01/18/2023] Open
Abstract
Objective To evaluate outcomes of fluorinated corticosteroids, with or without other medications, for treatment of congenital heart block in-utero. Study design A search was conducted through MEDLINE, EMBASE, WEB OF SCIENCE and SCOPUS from inception to October 2017. Only comparative studies are considered eligible. Outcomes include fetal death, downgrade of heart block, neonatal death, need for neonatal pacing, fetal and maternal complications. Random effects model was used. Results Out of 923 articles, 12 studies were eligible. Compared to no treatment, there was no significant difference in incidence of fetal death (OR 1.10, 95%CI 0.65–1.84), neonatal death (OR 0.98, 95%CI 0.41–2.33), or need for pacing (OR 1.46, 95%CI 0.78–2.74). Heart block downgrade was significantly higher in treatment group (9.48%vs.1.76%, OR 3.27, 95%CI 1.23–8.71). Conclusion antenatal fluorinated corticosteroids do not improve fetal/neonatal morbidity or mortality of congenital heart block and are associated with higher incidence of fetal and maternal complications.
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23
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Fredi M, Andreoli L, Bacco B, Bertero T, Bortoluzzi A, Breda S, Cappa V, Ceccarelli F, Cimaz R, De Vita S, Di Poi E, Elefante E, Franceschini F, Gerosa M, Govoni M, Hoxha A, Lojacono A, Marozio L, Mathieu A, Meroni PL, Minniti A, Mosca M, Muscarà M, Padovan M, Piga M, Priori R, Ramoni V, Ruffatti A, Tani C, Tonello M, Trespidi L, Zatti S, Calza S, Tincani A, Brucato A. First Report of the Italian Registry on Immune-Mediated Congenital Heart Block (Lu.Ne Registry). Front Cardiovasc Med 2019; 6:11. [PMID: 30873413 PMCID: PMC6404544 DOI: 10.3389/fcvm.2019.00011] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 01/31/2019] [Indexed: 12/12/2022] Open
Abstract
Objective: Neonatal Lupus (NL) is a rare syndrome caused by placental transfer of maternal anti-SSA/Ro and anti-La/SSB autoantibodies to the fetus. The rarity of this condition requires the establishment of multidisciplinary registries in order to improve our knowledge. Method: Inclusion criteria in this retrospective study were the maternal confirmed positivity for anti-SSA/Ro and/or anti-SSB/La antibodies, and the presence of II or III degree congenital heart block (CHB) in utero or neonatal period (up to 27 days after birth). Result: Eighty-nine cases of CHB were observed in 85 women with 88 pregnancies that occurred between 1969 and 2017. CHB was mostly detected in utero (84 cases, 94.2%), while five cases were observed in the neonatal period. A permanent pacemaker was implanted in 51 of 73 children born alive (69.8), whereas global mortality rate was 25.8% (23 cases): 16 in utero, five perinatal, and two during childhood. By univariate analysis, factors associated with fetal death were pleural effusion (p = 0.005, OR > 100; CI 95% 2.88->100 and hydrops (p = 0.003, OR = 14.09; CI 95% 2.01–122). Fluorinated steroids (FS) were administered in 71.4% pregnancies, and its use was not associated with better survival. Some centers treated all cases with fluorinated steroids and some centers did not treat any case. CHB was initially incomplete in 24 fetuses, and of them five cases of II degree block reverted to a lower degree block after treatments. Recurrence rate in subsequent pregnancies was 17.6% (3 out of 17). A prophylactic treatment was introduced in 10 of these 16 subsequent (58.8%) pregnancies, mostly with FS or high dose intravenous immunoglobulins. Conclusion: This is the first report from the Italian Registry of neonatal lupus/CHB. The live birth rate was nearly 80%, with nearly two thirds of the children requiring the implantation of a pacemaker. The management of fetuses diagnosed with CHB was heterogeneous across Italian Centers. The registry at present is mainly rheumatological, but involvement of pediatric cardiologists and gynecologists is planned.
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Affiliation(s)
- Micaela Fredi
- Rheumatology and Clinical Immunology Unit, Department of Clinical and Experimental Science, ASST Spedali Civili, University of Brescia, Brescia, Italy
| | - Laura Andreoli
- Rheumatology and Clinical Immunology Unit, Department of Clinical and Experimental Science, ASST Spedali Civili, University of Brescia, Brescia, Italy
| | - Beatrice Bacco
- S.S.d.D.U. Immunologia, Allergologia, A.O. Ordine Maurziano di Torino, Torino, Italy
| | - Tiziana Bertero
- S.S.d.D.U. Immunologia, Allergologia, A.O. Ordine Maurziano di Torino, Torino, Italy
| | - Alessandra Bortoluzzi
- UO e Sezione di Reumatologia, Dipartimento di Scienze Mediche, Universita' degli Studi di Ferrara, Cona, Italy
| | - Silvia Breda
- Struttura Complessa Medicina Interna, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Veronica Cappa
- Unit of Biostatistics, Biomathematics, and Bioinformatics, Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | - Fulvia Ceccarelli
- UO Complessa Reumatologia, Policlinico Umberto I- University La Sapienza, Rome, Italy
| | - Rolando Cimaz
- Anna Meyer Children's Hospital, University of Firenze, Firenze, Italy
| | - Salvatore De Vita
- Clinica di Reumatologia, Azienda Sanitaria Universitaria Integrata di Udine, Udine, Italy
| | - Emma Di Poi
- Clinica di Reumatologia, Azienda Sanitaria Universitaria Integrata di Udine, Udine, Italy
| | - Elena Elefante
- UO Reumatologia, Dipartimento di Medicina Clinica e Sperimentale, Universita' di Pisa, Pisa, Italy
| | - Franco Franceschini
- Rheumatology and Clinical Immunology Unit, Department of Clinical and Experimental Science, ASST Spedali Civili, University of Brescia, Brescia, Italy
| | - Maria Gerosa
- Istituto Ortopedico Gaetano Pini, University of Milan, Milan, Italy
| | - Marcello Govoni
- UO e Sezione di Reumatologia, Dipartimento di Scienze Mediche, Universita' degli Studi di Ferrara, Cona, Italy
| | - Ariela Hoxha
- Unità di Reumatologia, Dipartimento di Medicina, Università di Padova, Padova, Italy
| | - Andrea Lojacono
- Department of Obstetrics and Gynecology, ASST Spedali Civili and University, Brescia, Italy
| | - Luca Marozio
- Ginecologia e Ostetricia 1, Dipartimento di Scienze Chirurgiche, Università di Torino, Turin, Italy
| | - Alessandro Mathieu
- Cattedra e Struttura Complessa di Reumatologia, Universita' degli Studi e AOU di Cagliari, Cagliari, Italy
| | - Pier Luigi Meroni
- Immunorheumatology Research Laboratory, Istituto Auxologico Italiano, Milan, Italy
| | - Antonina Minniti
- UO Complessa Reumatologia, Policlinico Umberto I- University La Sapienza, Rome, Italy
| | - Marta Mosca
- UO Reumatologia, Dipartimento di Medicina Clinica e Sperimentale, Universita' di Pisa, Pisa, Italy
| | | | - Melissa Padovan
- UO e Sezione di Reumatologia, Dipartimento di Scienze Mediche, Universita' degli Studi di Ferrara, Cona, Italy
| | - Matteo Piga
- Cattedra e Struttura Complessa di Reumatologia, Universita' degli Studi e AOU di Cagliari, Cagliari, Italy
| | - Roberta Priori
- UO Complessa Reumatologia, Policlinico Umberto I- University La Sapienza, Rome, Italy
| | - Véronique Ramoni
- Rheumatology, IRCCS Policlinico San Matteo Foundation, University of Pavia, Padova, Italy
| | - Amelia Ruffatti
- Unità di Reumatologia, Dipartimento di Medicina, Università di Padova, Padova, Italy
| | - Chiara Tani
- UO Reumatologia, Dipartimento di Medicina Clinica e Sperimentale, Universita' di Pisa, Pisa, Italy
| | - Marta Tonello
- Unità di Reumatologia, Dipartimento di Medicina, Università di Padova, Padova, Italy
| | - Laura Trespidi
- Dipartimento per la Salute della Donna, Bambino e Neonato, Fondazione Ospedale Maggiore, Milan, Italy
| | - Sonia Zatti
- Department of Obstetrics and Gynecology, ASST Spedali Civili and University, Brescia, Italy
| | - Stefano Calza
- Unit of Biostatistics, Biomathematics, and Bioinformatics, Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | - Angela Tincani
- Rheumatology and Clinical Immunology Unit, Department of Clinical and Experimental Science, ASST Spedali Civili, University of Brescia, Brescia, Italy
| | - Antonio Brucato
- Struttura Complessa Medicina Interna, ASST Papa Giovanni XXIII, Bergamo, Italy.,Dipartimento di Scienze Biomediche e Cliniche "Sacco", Università degli Studi di Milano, Milan, Italy
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Batra AS, Balaji S. Fetal arrhythmias: Diagnosis and management. Indian Pacing Electrophysiol J 2019; 19:104-109. [PMID: 30817991 PMCID: PMC6531664 DOI: 10.1016/j.ipej.2019.02.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 02/20/2019] [Accepted: 02/22/2019] [Indexed: 11/23/2022] Open
Abstract
This article reviews important features for improving the diagnosis and management of fetal arrhythmias. The normal fetal heart rate ranges between 110 and 160 beats per minute. A fetal heart rate is considered abnormal if the heart rate is beyond the normal ranges or the rhythm is irregular. The rate, duration, and origin of the rhythm and degree of irregularity usually determine the potential for hemodynamic consequences. Most of the fetal rhythm disturbances are the result of premature atrial contractions (PACs) and are of little clinical significance. Other arrhythmias include tachyarrhythmias (heart rate in excess of 160 beats/min) such as atrioventricular (AV) reentry tachycardia, atrial flutter, and ventricular tachycardia, and bradyarrhythmias (heart rate <110 beats/min) such as sinus node dysfunction, complete heart block (CHB) and long QT syndrome (which is associated with sinus bradycardia and pseudo-heart block).
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Affiliation(s)
- Anjan S Batra
- Department of Pediatrics, University of California, Irvine, CA, USA.
| | - Seshadri Balaji
- Department of Pediatrics, Oregon Health & Science University, Portland, OR, USA
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Arese V, Murabito P, Ribero S, Panzone M, Tonella L, Fierro MT, Papini M, Quaglino P. Autoimmune connective tissue diseases and pregnancy. GIORN ITAL DERMAT V 2019; 154:263-276. [PMID: 30650958 DOI: 10.23736/s0392-0488.18.06252-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Autoimmune connective tissue-diseases are more frequent in women and deserve a multidisciplinary approach in which the dermatologist play a major role together with other physicians. Pregnancy in these patients has to be considered a high-risk situation, because of possible worsening of the mother's disease and increased morbility and mortality for the fetus; also, therapies have to be chosen carefully because some drugs cannot be used during pregnancy. For all these reasons, the decision to become pregnant needs to consider the type of disease, stage of disease, age and clinical condition, and requires a multidisciplinary approach. A correct counselling, a close monitoring, a specific approach based on the risks involved and the use of appropriate therapies are the keys to obtain optimal pregnancy outcomes.
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Affiliation(s)
- Veronica Arese
- Department of Medical Sciences, Dermatologic Clinic, University of Turin, Turin, Italy
| | - Pierangela Murabito
- Department of Medical Sciences, Dermatologic Clinic, University of Turin, Turin, Italy
| | - Simone Ribero
- Department of Medical Sciences, Dermatologic Clinic, University of Turin, Turin, Italy
| | - Michele Panzone
- Department of Medical Sciences, Dermatologic Clinic, University of Turin, Turin, Italy
| | - Luca Tonella
- Department of Medical Sciences, Dermatologic Clinic, University of Turin, Turin, Italy
| | - Maria T Fierro
- Department of Medical Sciences, Dermatologic Clinic, University of Turin, Turin, Italy
| | - Manuela Papini
- Department of Surgical and Biomedical Sciences, Dermatologic Clinic of Terni, University of Perugia, Perugia, Italy
| | - Pietro Quaglino
- Department of Medical Sciences, Dermatologic Clinic, University of Turin, Turin, Italy -
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Michau A, Gitz L, Proulx F, Besse M, Tezenas du Montcel S, Leclère B, Dommergues M, Benachi A. Pulsed Doppler fetal atrioventricular interval measurement: Assessment of a new image scoring method. J Gynecol Obstet Hum Reprod 2018; 48:121-127. [PMID: 30415076 DOI: 10.1016/j.jogoh.2018.10.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 10/28/2018] [Accepted: 10/31/2018] [Indexed: 10/27/2022]
Abstract
OBJECTIVES We propose an image scoring method to improve the quality and the reproducibility of measurement of the AV interval before establishing reference tables of the measurements and studies on the prevention and treatment of first-degree AV block especially if the first child has been diagnosed AV block. METHOD Prospective study from May 2015 to June 2016. Sonographers were asked to measure AV interval with pulsed Doppler in a five-chamber view in standard second-trimester screening before and after having received our image scoring method. Images were scored by 2 blinded reviewers. RESULTS The intra-class correlation coefficient (ICC) between the two reviewers for the overall score was 0.91. On average, the measurement quality increased by 2.5 points/10 (95% CI 1.0-4.0). In the second set of images, after the scoring method was given, the score stared at 6.50 for the first image, with a significant improvement of 0.18 (p = 0.016) per subsequent image comparing to a non significant improvement for the first set of image. There was a significant improvement in intra-observer reliability, ICC: 0.680 [95% CI 0.606-0.854] versus 0.458 [95% CI 0.140-0.651]. CONCLUSION The use of this scoring method is simple, reproducible and improves image quality and reproducibility of AV interval measurement in a five-chamber view.
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Affiliation(s)
- Adélie Michau
- Departement of Obstetrics and Gynaecology, Hôpital Bicêtre, AP-HP, University Paris Sud, Kremlin Bicêtre, France; Department of Obstetrics and Gynaecology, Hôpital Antoine Béclère, APHP, University Paris Sud, Clamart, France.
| | - Laurence Gitz
- Departement of Obstetrics and Gynaecology, Hôpital Bicêtre, AP-HP, University Paris Sud, Kremlin Bicêtre, France.
| | - Francine Proulx
- Department of Obstetrics and Gynaecology, Hôpital Antoine Béclère, APHP, University Paris Sud, Clamart, France.
| | - Marion Besse
- Department of Obstetrics and Gynaecology, Hôpital Antoine Béclère, APHP, University Paris Sud, Clamart, France.
| | - Sophie Tezenas du Montcel
- Sorbonne Universités, Université Pierre et Marie Curie (UPMC) Univ Paris 06, UMR S 1136, INSERM U 1136, Institut Pierre Louis d'Epidémiologie et de Santé Publique, F-75013, Paris, France; Biostatistics Unit, Groupe Hospitalier Pitié-Salpêtrière, AP-HP, Paris, France.
| | - Brice Leclère
- Research Unit, Medical Evaluation and Epidemiology Department, PHU11, Saint-Jacques University Hospital, Nantes, France.
| | - Marc Dommergues
- Department of Obstetrics and Gynaecology, Groupe hospitalier Pitié-Salpêtrière, APHP, Paris, France.
| | - Alexandra Benachi
- Department of Obstetrics and Gynaecology, Hôpital Antoine Béclère, APHP, University Paris Sud, Clamart, France.
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Cuneo BF, Sonesson SE, Levasseur S, Moon-Grady AJ, Krishnan A, Donofrio MT, Raboisson MJ, Hornberger LK, Van Eerden P, Sinkovskaya E, Abuhamad A, Arya B, Szwast A, Gardiner H, Jacobs K, Freire G, Howley L, Lam A, Kaizer AM, Benson DW, Jaeggi E. Home Monitoring for Fetal Heart Rhythm During Anti-Ro Pregnancies. J Am Coll Cardiol 2018; 72:1940-1951. [DOI: 10.1016/j.jacc.2018.07.076] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Revised: 07/06/2018] [Accepted: 07/09/2018] [Indexed: 10/28/2022]
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Progress in the pathogenesis and treatment of cardiac manifestations of neonatal lupus. Curr Opin Rheumatol 2018; 29:467-472. [PMID: 28520682 DOI: 10.1097/bor.0000000000000414] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
PURPOSE OF REVIEW To provide new insights into pathogenesis, prevention and management of cardiac manifestations of neonatal lupus (cardiac neonatal lupus) and issues pertinent to all anti-SSA/Ro positive individuals of childbearing age. RECENT FINDINGS Antibody specificity with high risk for cardiac neonatal lupus remains elusive, but high titers of Ro60, Ro52 or Ro52p200 antibodies appear to be required. Varying antibody specificities to the p200 region of Ro52 can induce first-degree block in a rodent model. In consideration of the contribution of macrophages to inflammation and fibrosis in cardiac neonatal lupus, hydroxychloroquine (HCQ) is being considered as preventive therapy. Cord blood biomarkers support the association of fetal reactive inflammatory and fibrotic components with the development and morbidity of cardiac neonatal lupus. Data from U.S. and French registries do not provide evidence that the prompt use of fluorinated steroids in cases of isolated block significantly alters fetal/neonatal morbidity or mortality. SUMMARY The search for a high-risk cardiac neonatal lupus antibody profile remains, but high-titer antibodies to Ro60 and R052 are a consistent finding, and this may guide the need for fetal echocardiographic surveillance. The uniform use of fluorinated steroids to prevent progression of cardiac neonatal lupus or reduce mortality does not appear justified. HCQ, based on diminishing an inflammatory component of cardiac neonatal lupus, is under consideration as a potential preventive approach.
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Incidence, risk factors, and mortality of neonatal and late-onset dilated cardiomyopathy associated with cardiac neonatal lupus. Int J Cardiol 2017; 248:263-269. [DOI: 10.1016/j.ijcard.2017.07.100] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Revised: 07/19/2017] [Accepted: 07/26/2017] [Indexed: 01/12/2023]
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Murakami K, Yamamoto Y, Fukunaga H, Matsushita M, Hirai C, Makino S, Shimizu T, Itakura A, Takeda S. Predictive markers and prenatal management of isolated fetal complete atrioventricular block: A retrospective review at a single institution. J Obstet Gynaecol Res 2017; 44:228-233. [PMID: 29160028 DOI: 10.1111/jog.13511] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Accepted: 08/12/2017] [Indexed: 11/30/2022]
Abstract
AIM The study was conducted to determine an effective method for identifying patients at high risk of developing isolated complete atrioventricular block (CAVB) and to review the efficacy of prenatal anti-inflammatory treatment. METHODS Fourteen CAVB cases and 76 anti-Ro-positive cases without CAVB were included in the study. Anti-Ro/La titers by double immunodiffusion and the prevalence of anti-52 kDa/60 kDa-Ro/48 kDa-La by Western blotting were compared between anti-Ro-positive women with and without CAVB. Outcomes of anti-Ro-positive CAVB cases were compared based on active prenatal anti-inflammatory treatment (plasma exchange or transplacental betamethasone). We evaluated the outcomes of five pregnancies from three women who had an affected child and underwent prophylactic plasma exchange (PEX) during subsequent pregnancy. RESULTS Ten out of 14 patients with CAVB were positive for anti-Ro. Anti-Ro titers were significantly higher in patients with CAVB (CAVB median 64; without CAVB median 16; P < 0.01). All cases with CAVB showed high titers of anti-Ro (≥ 32×), whereas only 42% of cases without CAVB showed high titers (≥ 32×) (P < 0.001). The survival rate at one year was 80% in anti-Ro-positive CAVB cases with active prenatal anti-inflammatory treatment, but only 40% in cases that did not receive treatment. Recurrence was not observed in cases treated with prophylactic PEX. CONCLUSIONS An anti-Ro level of 32× could be the threshold value for CAVB development. Prenatal anti-inflammatory treatment in patients with CAVB and prophylactic PEX in patients who had an affected child may have the potential to improve pregnancy outcomes.
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Affiliation(s)
- Keisuke Murakami
- Department of Obstetrics and Gynecology, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Yuka Yamamoto
- Department of Obstetrics and Gynecology, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Hideo Fukunaga
- Department of Pediatrics, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Masakazu Matsushita
- Department of Internal Medicine and Rheumatology, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Chihiro Hirai
- Department of Obstetrics and Gynecology, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Shintaro Makino
- Department of Obstetrics and Gynecology, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Toshiaki Shimizu
- Department of Pediatrics, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Atsuo Itakura
- Department of Obstetrics and Gynecology, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Satoru Takeda
- Department of Obstetrics and Gynecology, Juntendo University Faculty of Medicine, Tokyo, Japan
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31
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Should we treat congenital heart block with fluorinated corticosteroids? Autoimmun Rev 2017; 16:1115-1118. [DOI: 10.1016/j.autrev.2017.09.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Accepted: 08/02/2017] [Indexed: 12/11/2022]
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Miyasato-Isoda M, Waguri M, Yamada Y, Miyano A, Wada Y. Anti-Ro52 antibody level is an important marker of fetal congenital heart block risk in anti-Ro/SSA antibody positive pregnancy. Mod Rheumatol 2017; 28:690-696. [DOI: 10.1080/14397595.2017.1374235] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Mai Miyasato-Isoda
- Department of Obstetric Medicine, Osaka Women’s and Children’s Hospital, Osaka, Japan
| | - Masako Waguri
- Department of Obstetric Medicine, Osaka Women’s and Children’s Hospital, Osaka, Japan
| | - Yuko Yamada
- Department of Obstetric Medicine, Osaka Women’s and Children’s Hospital, Osaka, Japan
| | - Akira Miyano
- Department of Laboratory Medicine, Osaka Women’s and Children’s Hospital, Osaka, Japan
| | - Yoshinao Wada
- Department of Obstetric Medicine, Osaka Women’s and Children’s Hospital, Osaka, Japan
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Heart sounds at home: feasibility of an ambulatory fetal heart rhythm surveillance program for anti-SSA-positive pregnancies. J Perinatol 2017; 37:226-230. [PMID: 27977016 DOI: 10.1038/jp.2016.220] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Revised: 10/12/2016] [Accepted: 10/14/2016] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Fetuses exposed to anti-SSA (Sjögren's) antibodies are at risk of developing irreversible complete atrioventricular block (CAVB), resulting in death or permanent cardiac pacing. Anti-inflammatory treatment during the transition period from normal heart rhythm (fetal heart rhythm (FHR)) to CAVB (emergent CAVB) can restore sinus rhythm, but detection of emergent CAVB is challenging, because it can develop in ⩽24 h. We tested the feasibility of a new technique that relies on home FHR monitoring by the mother, to surveil for emergent CAVB. STUDY DESIGN We recruited anti-SSA-positive mothers at 16 to 18 weeks gestation (baseline) from 8 centers and instructed them to monitor FHR two times a day until 26 weeks, using a Doppler device at home. FHR was also surveilled by weekly or every other week fetal echo. If FHR was irregular, the mother underwent additional fetal echo. We compared maternal stress/anxiety before and after monitoring. Postnatally, infants underwent a 12-lead electrocardiogram. RESULTS Among 133 recruited, 125 (94%) enrolled. Among those enrolled, 96% completed the study. Reasons for withdrawal (n=5) were as follows: termination of pregnancy, monitoring too time consuming or moved away. During home monitoring, 9 (7.5%) mothers detected irregular FHR diagnosed by fetal echo as normal (false positive, n=2) or benign atrial arrhythmia (n=7). No CAVB was undetected or developed after monitoring. Questionnaire analysis indicated mothers felt comforted by the experience and would monitor again in future pregnancies. CONCLUSION These data suggest ambulatory FHR surveillance of anti-SSA-positive pregnancies is feasible, has a low false positive rate and is empowering to mothers.
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Kan N, Silverman ED, Kingdom J, Dutil N, Laskin C, Jaeggi E. Serial echocardiography for immune-mediated heart disease in the fetus: results of a risk-based prospective surveillance strategy. Prenat Diagn 2017; 37:375-382. [DOI: 10.1002/pd.5021] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2016] [Revised: 01/28/2017] [Accepted: 02/03/2017] [Indexed: 11/08/2022]
Affiliation(s)
- Nobuhiko Kan
- Fetal Cardiac Program, Labatt Family Heart Centre, Hospital for Sick Children; University of Toronto; Toronto Canada
| | - Earl D. Silverman
- Department of Immunology; Hospital for Sick Children, University of Toronto; Toronto Canada
| | - John Kingdom
- Department of Obstetrics and Gynecology; Mount Sinai Hospital, University of Toronto; Toronto Canada
| | - Nathalie Dutil
- Fetal Cardiac Program, Labatt Family Heart Centre, Hospital for Sick Children; University of Toronto; Toronto Canada
| | - Carl Laskin
- Department of Medicine; Mount Sinai Hospital, University of Toronto; Toronto Canada
| | - Edgar Jaeggi
- Fetal Cardiac Program, Labatt Family Heart Centre, Hospital for Sick Children; University of Toronto; Toronto Canada
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35
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Van den Berg N, Slieker M, van Beynum I, Bilardo C, de Bruijn D, Clur S, Cornette J, Frohn-Mulder I, Haak M, van Loo-Maurus K, Manten G, Rackowitz A, Rammeloo L, Reimer A, Rijlaarsdam M, Freund M. Fluorinated steroids do not improve outcome of isolated atrioventricular block. Int J Cardiol 2016; 225:167-171. [DOI: 10.1016/j.ijcard.2016.09.119] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Revised: 09/25/2016] [Accepted: 09/29/2016] [Indexed: 10/20/2022]
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Abstract
OBJECTIVES Autoimmune diseases do not impair fertility, and women with autoimmune diseases who become pregnant are likely to experience more complicated pregnancies than are women without the disease. Pregnancies complicated by these disorders have a high clinical impact on both the pregnancy and the disease. The effect of autoimmune disease on pregnancy differs according to the type of maternal disease, disease activity, severity of organ damage, antibody profile, and drug treatment. Sjögren syndrome is an autoimmune disease with a high prevalence of anti-SS-A (anti-Ro) and anti-SS-B (anti-La) antibodies. Anti-SS-A antibodies are associated with congenital heart block. Data on pregnancy outcomes in primary Sjögren syndrome are scarce. METHODS We performed a review of the literature regarding pregnancy outcomes in women with Sjögren syndrome. RESULTS Women with Sjögren syndrome are likely to experience more complications during pregnancy than women without an autoimmune disease. Studies show a high incidence of poor fetal outcomes for these patients. CONCLUSION Women with Sjögren syndrome require prenatal counseling explaining the risks involved and the need to control the disease well before conception. High-risk pregnancies can be optimally managed by a multidisciplinary team.
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Affiliation(s)
- Suruchi Gupta
- Medical Officer in the Department of Obstetrics and Gynecology at the Vardhman Mahavir Medical College and Safdarjung Hospital in Delhi, New Delhi, India.
| | - Nikhil Gupta
- Fellow in Clinical Immunology & Rheumatology at the Christian Medical College in Vellore, India.
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37
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Buyon JP, Rupel A, Clancy RM. Congenital heart block: do fetal factors fuel the fire from inflammation to fibrosis? Lupus 2016; 12:731-4. [PMID: 14596420 DOI: 10.1191/0961203303lu466ed] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Biggioggero M, Borghi MO, Gerosa M, Trespidi L, Cimaz R, Meroni PI. Immune function in children born to mothers with autoimmune diseases and exposed in utero to immunosuppressants. Lupus 2016; 16:651-6. [PMID: 17711903 DOI: 10.1177/0961203307079569] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The administration of immunosuppressive drugs during pregnancy is often necessary in women with autoimmune diseases. Teratogenicity of immunosuppressives during pregnancy has been evaluated, only few data exist about the effects on immune systems. We therefore performed a pilot study on the influence of foetal exposure to immunosuppressives on immune function of babies born to mothers with autoimmune disorders. We investigated serological and cellular parameters as indicators of immune system status. We included in the study 14 babies (mean age 11 months, range 1—24) born to mothers with autoimmune diseases and exposed in utero to different immunosuppressants and, as controls, 14 babies whose mothers had autoimmune manifestations but did not receive immunosuppressive therapy. We evaluated: (i) complete blood count, (ii) immunoglobulin levels and IgG subclasses, (iii) antibody response to hepatitis B vaccine, (iv) leukocyte subpopulations and (v) interleukin-2 and interferon γ in vitro production by resting or activated peripheral blood mononuclear cells. We did not find statistically significant differences between exposed and not exposed babies or among treatments for the tested parameters. Immunosuppressive regimens currently in use for controlling maternal autoimmune disorders do not significantly affect the immune status of the offspring. Lupus (2007) 16, 651—656.
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Affiliation(s)
- M Biggioggero
- Department of Internal Medicine, University of Milan, IRCCS Istituto Auxologico Italiano, Milan, Italy
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Abstract
The neonatal lupus syndromes (NLS), while quite rare, carry significant mortality and morbidity in cases of cardiac manifestations. Although anti-SSA/Ro-SSB/La antibodies are detected in .85% of mothers whose fetuses are identified with congenital heart block (CHB) in a structurally normal heart, when clinicians applied this testing to their pregnant patients, the risk for a woman with the candidate antibodies to have a child with CHB was at or below 1 in 50. While the precise pathogenic mechanism of antibody-mediated injury remains unknown, it is clear that the antibodies alone are insufficient to cause disease and fetal factors are likely contributory. In vivo and in vitro evidence supports a pathologic cascade involving apoptosis of cardiocytes, surface translocation of Ro and La antigens, binding of maternal autoantibodies, secretion of profibrosing factors (e.g., TGFb) from the scavenging macrophages and modulation of cardiac fibroblasts to a myofibroflast scarring phenotype. The spectrum of cardiac abnormalities continues to expand, with varying degrees of block identified in utero and reports of late onset cardiomyopathy (some of which display endocardial fibroelastosis). Moreover, there is now clear documentation that incomplete blocks (including those improving in utero with dexamethasone) can progress postnatally, despite the clearance of the maternal antibodies from the neonatal circulation. Better echocardiographic measurements which identify first degree block in utero may be the optimal means of approaching pregnant women at risk. Prophylactic therapies, including treatment with intravenous immunoglobulin, await larger trials. In order to achieve advances at both the bench and bedside, national research registries established in the US and Canada are critical.
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Affiliation(s)
- J P Buyon
- Department of Medicine, Division of Rheumatology, New York University School of Medicine, New York, NY, USA.
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Ductal constriction during dexamethasone treatment in an anti-SSA-antibody-exposed fetus with signs of myocardial inflammation. Cardiol Young 2016; 26:1021-4. [PMID: 27087593 DOI: 10.1017/s1047951116000378] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
This report describes the clinical course and multi-modality imaging findings in an anti-SSA-antibody-exposed fetus with suspected myocardial inflammation. Postnatal cardiac MRI - using fast acquisition, free-breathing with feed-and-swaddle technique - was used to evaluate for myocardial fibrosis/inflammation. This is the first published report, to our knowledge, of ductal constriction temporally associated with oral dexamethasone therapy in an anti-SSA-antibody-exposed fetus and of the use of this unique postnatal MRI protocol in this setting.
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Abstract
Congenital atrioventricular block (CAVB) affects approximately 2% of fetuses of mothers with anti-Ro or anti-La antibodies, regardless of maternal rheumatologic symptoms. Anti-Ro and anti-La antibodies are antinuclear antibodies commonly found in autoimmune diseases. Congenital atrioventricular block is associated with a relatively high fetal morbidity and mortality, particularly more advanced degrees of block. There is significant controversy surrounding surveillance of anti-Ro/La-positive pregnancies and treatment of fetuses diagnosed with CAVB. Studies of dexamethasone in the treatment of CAVB have yielded conflicting results, with most suggesting only a limited potential benefit in first- and seconddegree CAVB and in cases complicated by fetal hydrops. Larger prospective studies are needed to further evaluate the efficacy of intravenous immunoglobulin in the treatment of CAVB and of intravenous immunoglobulin and hydroxychloroquine in the prevention of CAVB in fetuses of at-risk mothers. Surveillance and treatment regimens should be determined on a case-by-case basis, taking into consideration the degree of CAVB, costs, and potential adverse effects of treatment.
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Abstract
Cardiac arrhythmias are an important aspect of fetal and neonatal medicine. Premature complexes of atrial or ventricular origin are the main cause of an irregular heart rhythm. The finding is typically unrelated to an identifiable cause and no treatment is required. Tachyarrhythmia most commonly relates to supraventricular reentrant tachycardia, atrial flutter, and sinus tachycardia. Several antiarrhythmic agents are available for the perinatal treatment of tachyarrhythmias. Enduring bradycardia may result from sinus node dysfunction, complete heart block and nonconducted atrial bigeminy as the main arrhythmia mechanisms. The management and outcome of bradycardia depend on the underlying mechanism.
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MESH Headings
- Anti-Arrhythmia Agents/therapeutic use
- Arrhythmias, Cardiac/diagnosis
- Arrhythmias, Cardiac/drug therapy
- Atrial Flutter/diagnosis
- Atrial Flutter/drug therapy
- Atrial Premature Complexes/diagnosis
- Atrial Premature Complexes/drug therapy
- Bradycardia/diagnosis
- Bradycardia/drug therapy
- Electrocardiography
- Fetal Diseases/diagnosis
- Fetal Diseases/drug therapy
- Heart Block/diagnosis
- Heart Block/drug therapy
- Humans
- Infant, Newborn
- Infant, Newborn, Diseases/diagnosis
- Infant, Newborn, Diseases/drug therapy
- Sick Sinus Syndrome/diagnosis
- Sick Sinus Syndrome/drug therapy
- Tachycardia, Sinus/diagnosis
- Tachycardia, Sinus/drug therapy
- Tachycardia, Supraventricular/diagnosis
- Tachycardia, Supraventricular/drug therapy
- Ventricular Premature Complexes/diagnosis
- Ventricular Premature Complexes/drug therapy
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Affiliation(s)
- Edgar Jaeggi
- Labatt Family Heart Centre, Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada.
| | - Annika Öhman
- Labatt Family Heart Centre, Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada
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Sonesson SE, Acharya G. Hemodynamics in fetal arrhythmia. Acta Obstet Gynecol Scand 2015; 95:697-709. [PMID: 26660845 DOI: 10.1111/aogs.12837] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Accepted: 12/03/2015] [Indexed: 10/22/2022]
Abstract
Fetal arrhythmias are among the few conditions that can be managed in utero. However, accurate diagnosis is essential for appropriate management. Ultrasound-based imaging methods can be used to study fetal heart structure and function noninvasively and help to understand fetal cardiovascular pathophysiology, and they remain the mainstay of evaluating fetuses with arrhythmias in clinical settings. Hemodynamic evaluation using Doppler echocardiography allows the elucidation of the electrophysiological mechanism and helps to make an accurate diagnosis. It can also be used as a tool to understand fetal cardiac pathophysiology, for assessing fetal condition and monitoring the effect of antiarrhythmic treatment. This narrative review describes Doppler techniques that are useful for evaluating fetal cardiac rhythms to refine diagnosis and provides an overview of hemodynamic changes observed in different types of fetal arrhythmia.
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Affiliation(s)
- Sven-Erik Sonesson
- Pediatric Cardiology Unit, Department of Women's and Children's Health, Karolinska Institute, Stockholm, Sweden
| | - Ganesh Acharya
- Women's Health and Perinatology Research Group, Department of Clinical Medicine, Faculty of Health Sciences, UiT - The Arctic University of Norway, Tromsø, Norway.,Department of Obstetrics and Gynecology, University Hospital of Northern Norway, Tromsø, Norway.,Department of Clinical Sciences, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
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Abadir S, Fournier A, Vobecky SJ, Rohlicek CV, Romeo P, Khairy P. Left Atrial Inexcitability in Children With Congenital Lupus-Induced Complete Atrioventricular Block. J Am Heart Assoc 2015; 4:JAHA.115.002676. [PMID: 26675254 PMCID: PMC4845288 DOI: 10.1161/jaha.115.002676] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Background Congenital atrioventricular block is a well‐established immunologic complication of maternal systemic lupus erythematosus. We sought to further characterize the electrophysiological manifestations of maternal systemic lupus erythematosus on neonatal atria. Methods and Results Cases of isolated congenital atrioventricular block treated at our center over the past 41 years were identified. Data were extracted from clinical charts, pacemaker interrogations, ECGs, echocardiograms, and histopathological reports, when available. Of 31 patients with isolated congenital atrioventricular block, 18 were negative for maternal antibodies and had normal epicardial atrial sensing and pacing thresholds. In contrast, 12 of 13 patients with positive maternal antibodies had epicardial pacemakers, 5 (42%) of whom had left atrial (LA) inexcitability and/or atrial conduction delay. In 3 patients, the LA could not be captured despite high‐output pacing. The fourth patient had acutely successful LA appendage and left ventricular lead placement. At early follow‐up, an increased delay between the surface P‐wave and intracardiac atrial depolarization was observed, indicative of atrial conduction delay. The fifth patient exhibited LA lead dysfunction, with atrial under‐sensing and an increased capture threshold, 2 weeks after implantation. Biopsies of LA appendages performed in 2 patients showed no evidence of atrial fibrosis or loss of atrial myocytes. Conclusions Herein, we report previously undescribed yet prevalent electrophysiological ramifications of maternal systemic lupus erythematosus, which extend beyond congenital atrioventricular block to encompass alterations in LA conduction, including LA inexcitability. These manifestations can complicate epicardial pacemaker implantation in newborns. In the absence of histological evidence of extensive atrial fibrosis, immune‐mediated functional impairment of electrical activity is suspected.
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Affiliation(s)
- Sylvia Abadir
- Divisions of Cardiology and Cardiac Surgery, CHU mère-enfant Sainte-Justine, Université de Montréal, Quebec, Canada (S.A., A.F., S.J.V., P.K.) Department of Cardiology, Montreal Children's Hospital, McGill University, Montreal, Quebec, Canada (S.A., C.V.R.)
| | - Anne Fournier
- Divisions of Cardiology and Cardiac Surgery, CHU mère-enfant Sainte-Justine, Université de Montréal, Quebec, Canada (S.A., A.F., S.J.V., P.K.)
| | - Suzanne J Vobecky
- Divisions of Cardiology and Cardiac Surgery, CHU mère-enfant Sainte-Justine, Université de Montréal, Quebec, Canada (S.A., A.F., S.J.V., P.K.)
| | - Charles V Rohlicek
- Department of Cardiology, Montreal Children's Hospital, McGill University, Montreal, Quebec, Canada (S.A., C.V.R.)
| | - Philippe Romeo
- Department of Medicine and Pathology, Montreal Heart Institute, Université de Montréal, Québec, Canada (P.R., P.K.)
| | - Paul Khairy
- Divisions of Cardiology and Cardiac Surgery, CHU mère-enfant Sainte-Justine, Université de Montréal, Quebec, Canada (S.A., A.F., S.J.V., P.K.) Department of Medicine and Pathology, Montreal Heart Institute, Université de Montréal, Québec, Canada (P.R., P.K.)
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Levesque K, Morel N, Maltret A, Baron G, Masseau A, Orquevaux P, Piette JC, Barriere F, Le Bidois J, Fermont L, Fain O, Theulin A, Sassolas F, Pezard P, Amoura Z, Guettrot-Imbert G, Le Mercier D, Georgin-Lavialle S, Deligny C, Hachulla E, Mouthon L, Ravaud P, Villain E, Bonnet D, Costedoat-Chalumeau N, Bezanahary H, Bienvenu B, Blaison G, Blanche P, Bonnotte B, Cathebras P, Christides C, Cohen F, Cohen L, Devaud E, Diot E, Duhaut P, Dulac Y, Godeau B, Gournay V, Gronier C, Guillevin L, Hamidou M, Haroche J, Hayem G, Heitz F, Isnard R, Jallouli M, Korganow AS, Le Jeunne C, Lhote F, Lucron H, Lusson JR, Magnier S, Ninet J, Pangaud N, Papo T, Pellegrin JL, Pennaforte JL, Pouchot J, Sarrot-Reynauld F, Schleinitz N, Seve P, Stos B, Vital-Durand D, Wechsler B. Description of 214 cases of autoimmune congenital heart block: Results of the French neonatal lupus syndrome. Autoimmun Rev 2015; 14:1154-60. [DOI: 10.1016/j.autrev.2015.08.005] [Citation(s) in RCA: 95] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2015] [Accepted: 08/05/2015] [Indexed: 01/12/2023]
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46
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Ruffatti A, Favaro M, Brucato A, Ramoni V, Facchinetti M, Tonello M, Del Ross T, Calligaro A, Hoxha A, Grava C, De Silvestro G. Apheresis in high risk antiphospholipid syndrome pregnancy and autoimmune congenital heart block. Transfus Apher Sci 2015; 53:269-78. [DOI: 10.1016/j.transci.2015.11.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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47
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Izmirly PM, Saxena A, Sahl SK, Shah U, Friedman DM, Kim MY, Buyon JP. Assessment of fluorinated steroids to avert progression and mortality in anti-SSA/Ro-associated cardiac injury limited to the fetal conduction system. Ann Rheum Dis 2015; 75:1161-5. [PMID: 26835701 DOI: 10.1136/annrheumdis-2015-208311] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2015] [Accepted: 11/07/2015] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Extension of disease beyond the atrioventricular (AV) node is associated with increased mortality in cardiac neonatal lupus (NL). Treatment of isolated heart block with fluorinated steroids to prevent disease progression has been considered but published data are limited and discordant regarding efficacy. This study evaluated whether fluorinated steroids given to manage isolated advanced block prevented development of disease beyond the AV node and conferred a survival benefit. METHODS In this retrospective study of cases enrolled in the Research Registry for NL, inclusion was restricted to anti-SSA/Ro-exposed cases presenting with isolated advanced heart block in utero who either received fluorinated steroids within 1 week of detection (N=71) or no treatment (N=85). Outcomes evaluated were: development of endocardial fibroelastosis, dilated cardiomyopathy and/or hydrops fetalis; mortality and pacemaker implantation. RESULTS In Cox proportional hazards regression analyses, fluorinated steroids did not significantly prevent development of disease beyond the AV node (adjusted HR=0.90; 95% CI 0.43 to 1.85; p=0.77), reduce mortality (HR=1.63; 95% CI 0.43 to 6.14; p=0.47) or forestall/prevent pacemaker implantation (HR=0.87; 95% CI 0.57 to 1.33; p=0.53). No risk factors for development of disease beyond the AV node were identified. CONCLUSIONS These data do not provide evidence to support the use of fluorinated steroids to prevent disease progression or death in cases presenting with isolated heart block.
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Affiliation(s)
- Peter M Izmirly
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York, New York, USA
| | - Amit Saxena
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York, New York, USA
| | - Sara K Sahl
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York, New York, USA
| | - Ummara Shah
- Division of Rheumatology, Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, New York, USA
| | - Deborah M Friedman
- Division of Pediatric Cardiology, Department of Pediatrics, New York Medical College, Valhalla, New York, USA
| | - Mimi Y Kim
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Jill P Buyon
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York, New York, USA
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48
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Tonello M, Ruffatti A, Marson P, Tison T, Marozio L, Hoxha A, De Silvestro G, Punzi L. Plasma exchange effectively removes 52- and 60-kDa anti-Ro/SSA and anti-La/SSB antibodies in pregnant women with congenital heart block. Transfusion 2015; 55:1782-6. [DOI: 10.1111/trf.13046] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2014] [Revised: 11/21/2014] [Accepted: 12/07/2014] [Indexed: 01/27/2023]
Affiliation(s)
- Marta Tonello
- Department of Medicine, Rheumatology Unit; University of Padua; Padua Italy
| | - Amelia Ruffatti
- Department of Medicine, Rheumatology Unit; University of Padua; Padua Italy
| | - Piero Marson
- Blood Transfusion Unit; University Hospital of Padua; Padua Italy
| | - Tiziana Tison
- Blood Transfusion Unit; University Hospital of Padua; Padua Italy
| | - Luca Marozio
- Department of Obstetrics and Gynecology; University of Turin; Turin Italy
| | - Ariela Hoxha
- Department of Medicine, Rheumatology Unit; University of Padua; Padua Italy
| | | | - Leonardo Punzi
- Department of Medicine, Rheumatology Unit; University of Padua; Padua Italy
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49
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Abstract
Autoimmune congenital heart block (CHB) is an immune-mediated acquired disease that is associated with the placental transference of maternal antibodies specific for Ro and La autoantigens. The disease develops in a fetal heart without anatomical abnormalities that could otherwise explain the block, and which is usually diagnosed in utero, but also at birth or within the neonatal period. Autoantibody-mediated damage of fetal conduction tissues causes inflammation and fibrosis and leads to blockage of signal conduction at the atrioventricular (AV) node. Irreversible complete AV block is the principal cardiac manifestation of CHB, although some babies might develop other severe cardiac complications, such as endocardial fibroelastosis or valvular insufficiency, even in the absence of cardiac block. In this Review, we discuss the epidemiology, classification and management of women whose pregnancies are affected by autoimmune CHB, with a particular focus on the autoantibodies associated with autoimmune CHB and how we should test for these antibodies and diagnose this disease. Without confirmed effective preventive or therapeutic strategies and further research on the aetiopathogenic mechanisms, autoimmune CHB will remain a severe life-threatening disorder.
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50
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Kuleva M, Le Bidois J, Decaudin A, Villain E, Costedoat-Chalumeau N, Lemercier D, Dumez Y, Ville Y, Bonnet D, Salomon LJ. Clinical course and outcome of antenatally detected atrioventricular block: experience of a single tertiary centre and review of the literature. Prenat Diagn 2015; 35:354-61. [PMID: 25487821 DOI: 10.1002/pd.4547] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Revised: 12/03/2014] [Accepted: 12/03/2014] [Indexed: 01/20/2023]
Abstract
OBJECTIVE The objective is to study the course and outcome of fetuses with congenital atrioventricular block (AVB) in a single centre. METHODS Retrospective analysis of cases diagnosed prenatally with second and third degree AVB. The clinical characteristics and outcome of fetal AVB were evaluated including in utero treatment. RESULTS Sixty-two cases were studied. AVB was associated with a congenital heart defect (CHD-AVB) in 17 cases (27%), whereas it was isolated (i-AVB) in 45 (73%), 42 of which were associated with maternal antibodies. There were nine (52.9%) live births in the CHD-AVB group, five of which (55%) resulted in infant deaths. In the i-AVB group, there were 40/45 (88.9%) live births and 1/40 (2.5%) infant death; 36 (90%) babies required a permanent pacemaker. The only factor predictive of postnatal death was the presence of CHD (5/9 vs 1/39 or 48.7 [3.6; 1457.7], p < 0.001). Nineteen fetuses (40.5%) with i-AVB received steroids in utero. No difference in outcome was found between the AVB treated in utero versus the no-treatment group in terms of permanent pacemaker placement, postnatal death or development of dilated cardiomyopathy. CONCLUSION The most important prognostic factor for congenital AVB is the association with CHD. In utero treatment remains questionable.
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Affiliation(s)
- M Kuleva
- Department of Obstetrics and Gynecology, M3C-Necker, Hôpital Necker Enfants malades, 75015, Paris, France
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