Predictors of maternal and fetal complications in SLE patients: a prospective study

Pregnancy outcomes in patients with systemic lupus erythematosus compared to a high-risk tertiary cohort and to standard population from the Austrian birth registry

INTRODUCTION

Women with systemic lupus erythematosus (SLE) have a higher risk for fetal and maternal complications. We aimed to investigate maternal and fetal complications in pregnant women with SLE compared to a high-risk pregnancy cohort (HR) from a tertiary university center and a standard-risk general population (SR) from the Austrian Birth Registry.

MATERIAL AND METHODS

In this retrospective data analysis, we compared the incidence of fetal/neonatal and maternal complications of pregnancies and deliveries of women with SLE to age, body mass index and delivery date-matched high-risk pregnancies from the same department, a progressive tertiary obstetric center and to a group of women, who represent pregnancies with standard obstetric risk from the Austrian Birth Registry.

RESULTS

One hundred women with SLE were compared to 300 women with high-risk pregnancies and 207 039 women with standard-risk pregnancies. The incidence of composite maternal complications (preeclampsia, Hemolysis, Elevated Liver enzymes and Low Platelets [HELLP] syndrome, pregnancy-related hypertension, gestational diabetes mellitus, maternal death, thromboembolic events) was significantly higher in the SLE as compared to the SR group (28% vs. 6.28% SLE vs. SR, p = 0.001). There was no difference between the SLE and the HR groups (28% vs. 29.6% SLE vs. HR group, p = 0.80). The incidence of composite fetal complications (preterm birth before 37 weeks of gestation, stillbirths, birth weight less than 2500 g, fetal growth restriction, large for gestational age, admission to neonatal intensive care unit, 5-min Apgar <7) was also higher in the SLE than in the SR group (55% vs. 25.54% SLE vs. SR p < 0.001) while the higher incidence of adverse fetal outcome was detected in the HR than in the SLE group (55% vs. 75% SLE vs. HR group, p = 0.0005).

CONCLUSIONS

Although composite fetal risk is higher in the SLE group than in the general population, it is still significantly lower as compared to high-risk pregnant women at a tertiary obstetric center. Prepregnancy counseling of women with SLE should put fetal and maternal risk in perspective, not only in relation to healthy, low risk cohorts, but also compared to mixed HR populations.

Modern Management of Pregnancy in Systemic Lupus Erythematosus: From Prenatal Counseling to Postpartum Support

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease that predominantly affects women of childbearing age. Pregnancy in SLE patients poses unique challenges due to the potential impact on maternal and fetal outcomes. We provide an overview of the management of SLE during pregnancy, including preconception risk stratification and counseling, treatment, and disease activity monitoring. These assessments are critical to minimize maternal and fetal adverse events in pregnant patients with SLE. Disease flares, preeclampsia, antiphospholipid syndrome complications, and maternal mortality are the major risks for a woman with SLE during gestation. Timely treatment of SLE relapse, differentiation of preeclampsia from lupus nephritis, and tailored management for antiphospholipid syndrome are essential for a successful pregnancy. Fetal outcomes include neonatal lupus (NL), preterm birth, cesarean delivery, fetal growth restriction (FGR), and small-for-gestational-age (SGA) infants. We focused on NL, linked to maternal anti-Ro/SS-A and anti-La/SS-B antibodies, which can lead to various manifestations, particularly cardiac abnormalities, in newborns. While there is a common consensus regarding the preventive effect of hydroxychloroquine, the role of echocardiographic monitoring and fluorinated steroid treatment is still debated. Finally, close postpartum monitoring and counseling for subsequent pregnancies are crucial aspects of care.

Hydroxychloroquine in obstetrics: potential implications of the prophylactic use of hydroxychloroquine for placental insufficiency during pregnancy

Proper placentation during early pregnancy is a key factor for maintaining a healthy pregnancy. Placental insufficiency leads to critical complications such as preeclampsia, fetal growth restriction, and fetal demise. These complications are often associated with pathological findings of restricted remodeling and obstructive lesions of the myometrial spiral arteries, which have high recurrence rates during subsequent pregnancies. Currently, there are no pharmacological interventions other than aspirin for the prevention of preeclampsia. Hydroxychloroquine (HCQ), a well-known antimalarial drug, reduces inflammatory and thrombotic changes in vessels. For decades, the use of HCQ for autoimmune diseases has resulted in the successful prevention of both arterial and venous thrombotic events and has been extended to the treatment of lupus and antiphospholipid antibody syndrome during pregnancy. HCQ reduces the risk of preeclampsia with lupus by up to 90%. Several recent studies have investigated whether HCQ improves pregnancy outcomes in women with a history of poor outcomes. In addition, in vitro and animal studies have demonstrated the beneficial effects of HCQ in improving endothelial dysfunction and alleviating hypertension and proteinuria. Therefore, we hypothesized that HCQ has the potential to attenuate the vascular inflammatory and thrombogenic pathways associated with placental insufficiency and conducted a multicenter clinical trial on the efficacy of combining aspirin with HCQ for pregnancies at high risk for preeclampsia in Korea. This study summarizes the potential effects of HCQ on pregnancies with placental insufficiency and the implications of HCQ treatment in the field of obstetrics.

Pregnancy in systemic lupus erythematosus

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease which frequently affects women of childbearing age. Nowadays, pregnancy is not contraindicated in cases of well-controlled disease activity, but pregnancies are still at higher risk of maternal and fetal complications compared to the general population. During pregnancy and puerperium patients are at risk of disease flare, and obstetric complications are more frequent in cases of active disease at conception/beginning of pregnancy, a history of lupus nephritis, and concomitant presence of antiphospholipid syndrome. To improve pregnancy outcomes in SLE patients, appropriate preconception counseling with changes in medication, if necessary, and close rheumatological and obstetrical monitoring are fundamental. This review aims to summarize the risk factors for adverse pregnancy outcomes and provide an update on developments in medical care for pregnancy in SLE patients.

Complement levels during the first trimester predict disease flare and adverse pregnancy outcomes in systemic lupus erythematosus: A network meta-analysis on 532 pregnancies

BACKGROUND

Complement levels have been proposed as candidate biomarkers of disease activity and obstetric risk in systemic lupus erythematosus (SLE) pregnancies, but their reliability has been questioned due to the physiologic fluctuations of complement during gestation. Thus, this network meta-analysis aimed at assessing the clinical significance of complement fluctuations in lupus pregnant women.

METHODS

Corresponding authors of 19 studies meeting inclusion criteria were invited to contribute with additional data including C3 and C4 levels [before pregnancy, at conception, in every trimester (T) and 3 months after delivery]; data were pooled together in a network meta-analysis.

RESULTS

A total of 532 lupus women from four studies were included in the analysis. In SLE women, C3 and C4 increased progressively during gestation: levels remained stable during T1 and peaked in T2 to decrease in T3. Patients with previous lupus nephritis (LN) and those who experienced flares during pregnancy had significantly lower mean levels of C3 and C4 at all timepoints. The lowest levels of complement were observed, particularly during T1, in patients with LN and gestational flare. Both reduction and the lack of increase of C3 and C4 levels at T1 versus conception were associated with gestational flares, particularly in LN patients. Pregnancies with flare had a statistically significant higher rate of maternal and fetal complications(60% versus 50.3%; p = 0.03).

CONCLUSIONS

Low complement levels, particularly in T1, were associated with a higher frequency of gestational flare. Either reduction or smaller increase of C3 and/or C4 levels, even within normal range, might predict flares especially in early gestation.

Maternal and fetal health outcomes in systemic lupus erythematosus pregnancies in the Emirati population: A comparative study

OBJECTIVES

To evaluate adverse pregnancy outcomes in patients with systemic lupus erythematosus (SLE), compare their maternal and fetal outcomes with those of age-matched pregnant women without SLE, and identify factors linked to increased risks of adverse outcomes.

METHODS

Medical records from Tawam Hospital were reviewed retrospectively to identify patients with SLE and a history of pregnancy. Demographics, clinical variables, and maternal and fetal outcomes were obtained. A one-to-one age-matched healthy control group was randomly selected. The outcomes and odd ratios of women with and without SLE were compared, and factors associated with adverse pregnancy outcomes were examined.

RESULTS

The outcomes of 78 SLE pregnancies in 39 women were analyzed. Adverse maternal outcomes, such as gestational diabetes mellitus (GDM), occurred in 32% of pregnancies, whereas adverse fetal outcomes, such as low-birth weight and preterm deliveries, occurred in 51% of pregnancies. Pregnant women with SLE had a 5-fold higher risk of GDM, had higher odds of maternal hypertension, and were more likely to deliver through cesarean section than those without SLE. Preterm deliveries and low-birth weight were also more common in SLE pregnancies. Steroid use during pregnancy was significantly associated with an increased risk of GDM development. Lupus nephritis, maternal hypertension, pre-eclampsia, and GDM were linked to preterm deliveries.

CONCLUSION

Pregnant women with SLE were at a higher risk for adverse maternal and fetal outcomes than age-matched pregnant women without SLE. These findings can guide clinical management and emphasize the need for close monitoring of SLE pregnancies.

Obstetric and Perinatal Outcomes in Pregnant Women with Lupus: Retrospective Study in a Portuguese Tertiary Center

OBJECTIVE

 Pregnancy in women with lupus poses a higher risk of complications compared with the general population. The present study aimed to determine and describe the obstetric and neonatal outcomes of pregnant women with lupus.

MATERIALS AND METHODS

 We conducted an observational retrospective study of pregnant women with the diagnosis of lupus, who were selected and followed at the Maternal-Fetal Medicine Clinic of our institution between January 2013 and July 2018. We analyzed 59 pregnancies and 52 newborns, and collected data regarding sociodemographic features, the preconception period, pregnancy, childbirth, postpartum and the newborn. A descriptive analysis of the variables was performed.

RESULTS

 In 58% of the cases, the pregnancy was uneventful. We registered flares in 25% of the cases, preeclampsia in 3%, fetal growth restriction in 12%, gestational loss in 10%, preterm labor in 10%, postpartum complications in 20%, and small for gestational age newborns in 17% of the cases.

CONCLUSIONS

 Most pregnancies in women with lupus have favorable obstetric and neonatal outcomes. Prenatal counseling, adequate multidisciplinary surveillance, and optimized treatment of the disease are fundamental pillars for these good results.

Tacrolimus use and renal function in pregnancy with lupus nephritis: Analysis of post-marketing surveillance data in Japan

OBJECTIVES

Tacrolimus may be administered to pregnant women with lupus nephritis in Japan if considered therapeutically beneficial, but supporting data are limited. We assessed the safety and effectiveness of tacrolimus before, during, and after pregnancy in women with lupus nephritis receiving tacrolimus.

METHODS

This was an ad hoc analysis of data from a post-marketing surveillance study of tacrolimus in patients with lupus nephritis in Japan. Pregnancy outcomes, nephritis status, and adverse events were assessed for up to 2 years postpartum.

RESULTS

Data were available for 23 births in 21 patients (two patients had two births each). Tacrolimus for lupus nephritis was continued during 11 births in nine patients (during and after pregnancy) and discontinued in 12 patients (when pregnancy was known or when approaching delivery). Renal function was generally maintained in patients who gave birth while receiving tacrolimus; however, there were cases of increased urine protein and decreased renal function over 2 years. There were no unexpected adverse events/safety concerns.

CONCLUSIONS

These data from clinical practice suggest that tacrolimus is a valid treatment option for lupus nephritis in fertile women in Japan and, with careful monitoring, pregnant women with lupus nephritis may continue their tacrolimus treatment.

Low-density granulocytes are related to shorter pregnancy duration but not to interferon alpha protein blood levels in systemic lupus erythematosus

BACKGROUND

An increased risk of pregnancy complications is seen in women with systemic lupus erythematosus (SLE), but the specific immunopathological drivers are still unclear. Hallmarks of SLE are granulocyte activation, type I interferon (IFN) overproduction, and autoantibodies. Here we examined whether low-density granulocytes (LDG) and granulocyte activation increase during pregnancy, and related the results to IFNα protein levels, autoantibody profile, and gestational age at birth.

METHODS

Repeated blood samples were collected during pregnancy in trimesters one, two, and three from 69 women with SLE and 27 healthy pregnant women (HC). Nineteen of the SLE women were also sampled late postpartum. LDG proportions and granulocyte activation (CD62L shedding) were measured by flow cytometry. Plasma IFNα protein concentrations were quantified by single molecule array (Simoa) immune assay. Clinical data were obtained from medical records.

RESULTS

Women with SLE had higher LDG proportions and increased IFNα protein levels compared to HC throughout pregnancy, but neither LDG fractions nor IFNα levels differed during pregnancy compared to postpartum in SLE. Granulocyte activation status was higher in SLE relative to HC pregnancies, and it was increased during pregnancy compared to after pregnancy in SLE. Higher LDG proportions in SLE were associated with antiphospholipid positivity but not to IFNα protein levels. Finally, higher LDG proportions in trimester three correlated independently with lower gestational age at birth in SLE.

CONCLUSION

Our results suggest that SLE pregnancy results in increased peripheral granulocyte priming, and that higher LDG proportions late in pregnancy are related to shorter pregnancy duration but not to IFNα blood levels in SLE.

Feto-maternal outcomes of pregnancies in women with SLE: Experience from a tertiary care center of Asia

OBJECTIVE

We aim to quantify the risk of maternal and fetal complications in patients with SLE in order to identify the impact of SLE on pregnancy and of pregnancy on SLE.

METHODS

This retrospective record review study was conducted in Aga khan university hospital, Karachi, from Jan 1998 to Dec 2019. All pregnant patients with SLE diagnosed and delivered during this time were included in the study. Categorical variables were analyzed by using chi-square test and fisher exact test. Whereas quantitative point estimate was estimated as mean and SD. We matched the data and computed crude odds ratio of pre-eclamptic patients with respect to age of conception, gravida, and body mass index in both case and control group.

RESULTS

The SLE disease activity was monitored during pregnancy under SLEDAI-2K Scoring system. The patients with mild (25.6%) and moderate (25.6%) disease activity were prevalent and most antenatal patients (51.7%) had flare up in third trimester. Adverse maternal outcomes include pre-eclampsia (28.8%), eclampsia (3.2%), cesarean section (57.6%), and thrombocytopenia (9.6%), whereas perinatal outcomes includes intrauterine growth retardation (24%), preterm birth <34 weeks (19.2%) and <37 weeks (63.2%), APGAR Score < 7 at 1 min (5.6%), and neonatal death (5.6%) found to be statistically significant in between two groups There were more high-risk patients (42) with positive IgG (88%), IgM (83.3%), and lupus anticoagulant (33.3%) as compared to low-risk APS group.

CONCLUSION

Planned pregnancy and less severe disease flares during pregnancy is associated with more favorable feto-maternal outcomes.

The SPROUT study: A survey on current management practice of reproductive aspects in women of childbearing age with systemic autoimmune rheumatic diseases

The SPROUT (Survey on reproduction in RheUmaTology) study explored current practice in women of childbearing age with systemic autoimmune rheumatic diseases, investigating the counselling on contraception, the prescription of low dose acetylsalicylic acid (LDASA) to pregnant patients and the management of disease activity in the post-partum period. The SPROUT questionnaire was designed ad hoc and promoted in the three months before the "11^th International Conference on Reproduction, Pregnancy and Rheumatic Disease". Between June and August 2021, 121 physicians responded to the survey. Even though 66.8% of the participants declared themselves to be confident in counselling surrounding birth control, only 62.8% of physicians always discuss contraception and family planning with women of childbearing age. Approximately 20% of respondents do not prescribe LDASA to pregnant women with rheumatic diseases, and wide heterogeneity exists in the dose and timing of LDASA prescription. Most respondents (43.8%) restart treatment with biological agents soon after delivery to prevent disease flares, opting for a drug compatible with breastfeeding while 41.3% of physicians continue biologics throughout pregnancy and post-partum. The SPROUT study highlighted the necessity to further foster physicians' education and identified the management of disease activity after delivery as a matter for discussion between all the clinicians involved in the care of pregnant women with rheumatic conditions.

A retrospective analysis of maternal complications and newborn outcomes of general anesthesia for cesarean delivery in a single tertiary hospital in China

Background

Either neuraxial anesthesia or general anesthesia can be performed for cesarean delivery. Generally, neuraxial anesthesia is the first choice with the risk and benefit balance for both the mother and fetus. However, general anesthesia is also applicable most commonly in the emergent setting. This study analyzed maternal complications associated with general anesthesia for cesarean delivery and suggested lowering pregnancy-related maternal and newborn adverse outcomes.

Methods

With the approval of the Institutional Ethics Review Board (No: 2017016), data on cesarean delivery and related anesthesia were collected from the Electronic Health Record System from 1/1/2013 to 12/31/2016. Statistical software STATA version 15.1 was used for data analyses. All statistical tests were two-sided, and a level significance of 0.05 was assumed.

Results

The rate of general anesthesia for cesarean delivery increased steadily during 2013–2016, 3.71% in 2013 to 10.23% in 2016 (p < 0.001). Repeat cesarean delivery among general anesthesia group increased significantly from 16.22% in 2013 to 54.14% in 2016 (p < 0.001). Morbidly adherent placenta (MAP) was the first reason among pregnancy-related complications, which accounted for 33% in total in general anesthesia group (38% in 2013 to 44% in 2016). The laryngeal mask airway (LMA) was used in airway management, and the proportion of LMA increased from 28.38% in 2013 to 92.99% in 2016 (p < 0.001). There were significant differences in newborn outcomes between general anesthesia and neuraxial anesthesia groups, including newborn weight, newborn Apgar score at 1 min and 5 min and newborn admission to the NICU (p < 0.001).

Conclusions

The growing incidence of general anesthesia was consistent with the trend of rising repeat cesarean delivery and MAP. low newborn Apgar score and high newborn admission to the NICU in general anesthesia group compared with neuraxial anesthesia group. The LMA was performed safely for airway management with enough fasting and careful gastric volume evaluation.

The Impact of Preeclampsia in Lupus Nephritis

INTRODUCTION

Women with systemic lupus erythematosus (SLE), particularly those with lupus nephritis (LN), remain at high risk for adverse pregnancy outcome. Although in the last decades maternal and fetal outcomes have improved dramatically, preeclampsia remains a major cause of maternal and perinatal morbidity and mortality.

AREAS COVERED

A narrative review of literature was conducted, underlying the importance of pre-conception counseling, and focusing on the correlation between preeclampsia and LN. The clinical characteristics of preeclampsia were described, with emphasis on risk factors in LN and the differential diagnosis between preeclampsia and lupus flares. Additionally, the prevention and treatment of preeclampsia were discussed, as well as the management of short-term and long-term consequences of preeclampsia. We highlight the importance of a pre-pregnancy counseling from a multidisciplinary team to plan pregnancy during inactive SLE and LN.

EXPERT OPINION

Further studies are needed to evaluate the long-term consequences of pregnancy in LN. Considering that preeclamptic patients can be at high risk for long-term renal failure, we suggest renal checkup for at least 6-12 months after delivery in all patients.

Managing puerperium in patients with systemic autoimmune diseases: an update

INTRODUCTION

Puerperium is a critical period for patients affected by autoimmune rheumatic diseases for the risk of disease's flares and difficulties in treating lactating mothers. We want to summarize the literature data about psychological and pharmacological management of these patients and possible risk factors of disease's flares.

AREAS COVERED

We made a narrative review on recent studies about puerperium in rheumatic autoimmune diseases patients.

EXPERT OPINION

The physicians involved in management of patients during puerperium and in the follow-up of babies need to agree on maternal treatment because they need to reassure mothers about the safety of the prescribed medications. Furthermore, women with rheumatic diseases could present some musculoskeletal limitations and psychological problems, such as postpartum depression, which can lead to a sense of inadequacy to the mother's task. Families and physicians should be aware of these possible complications and support the new mothers providing correct counseling and practical help.

Quality of Life of Pregnant Women with Systemic Lupus Erythematosus

OBJECTIVE

 To assess the quality of life (QoL) of pregnant women with systemic lupus erythematosus (SLE) treated at a high-risk prenatal outpatient clinic during the third trimester of gestation.

METHODS

 An observational descriptive study was performed in a high-risk prenatal outpatient clinic. Women in the third trimester of pregnancy and undergoing antenatal care between July 2017 and July 2019 answered the abbreviated World Health Organization Quality of Life (WHOQOL-BREF) questionnaire, consisting of 26 questions divided into 4 domains (physical, psychological, social and environmental).

RESULTS

 We interviewed 50 pregnant women with a mean gestational age of 30 weeks (standard deviation [SD]: 10 weeks) who were diagnosed with SLE. The average age of the participants was 30 years (SD: 14.85), and the average time since the diagnosis of SLE was of 9.06 years (SD: 6.8 years). Most participants had a partner, did not plan their pregnancy (76%), and did not use contraception prior to pregnancy (80%). The score of each domain ranges from 0 (the worst score) to 100 (the best score). The means ±  SDs of the scores of the participants on each domain were: physical - 52.21 ±  18.44); psychological - 64.17 ±  18.56); social - 66.33 ±  27.09); and environmental - 64.56 (18.53). The means ±  SDs of the general QoL, and health-related QoL items were of 70.50 ±  24.06 and 70.00 ±  30.72 respectively.

CONCLUSION

 The physical domain presented the lowest scores compared with the other three domains. Pregnant women with SLE had high overall QoL scores, and their health-related QoL scores were also relatively high.

Premature rupture of membranes - A cause of foetal complications among lupus: A cohort study, systematic review and meta-analysis

OBJECTIVE

The present study aimed to analyse the frequency of premature rupture of membranes (PROMs) among 190 women with systemic lupus erythematosus (SLE) followed up at the Hospital Universitário Pedro Ernesto from 2011 to 2018 and to review the literature on PROM in patients with SLE.

METHODS

A cohort study of SLE patients was conducted by analysing the following variables: sociodemographic characteristics, clinical manifestations of lupus, modified disease activity index for pregnancy, drugs used during pregnancy, intercurrent maternal infections and obstetric outcomes. Additionally, seven electronic databases (PubMed, Embase, Cochrane, Scielo, Scielo Brazil, Virtual Health Library Regional Portal and Google Scholar) were systematically searched. The search was updated on 3 February 2020.

RESULTS

Infections (relative risk (RR): 3.26, 95% confidence interval (CI): 1.5-6.7, p = .001), history of serositis (RR: 2.59, 95% CI: 1.31-5.11, p = .006) and anti-RNP positivity (RR: 3.08, 95% CI: 1.39-6.78, p = .005) were associated risk factors for PROM, while anti-RNP positivity (RR: 3.37, 95% CI: 1.35-8.40; p = .009) were associated with premature PROM (PPROM). The prevalence of PROM and PPROM was 28.7% and 12.9%, respectively. In the systematic review, the prevalence of PROM and PPROM was 2.7%-35% (I² = 87.62%) and 2.8%-20% (I² = 79.56%), respectively.

CONCLUSIONS

PROM, both at term and preterm, occurs more frequently in women with lupus than in the general population. A history of serositis, anti-RN, infections and immunosuppression during pregnancy may increase the susceptibility to PROM. The systematic review did not find any study with the main objective of evaluating PROM/PPROM in women with lupus.

High-risk factors for adverse pregnancy outcomes in systemic lupus erythaematosus: a retrospective study of a Chinese population

OBJECTIVE

To clarify high-risk factors for adverse pregnancy outcomes (APOs) in systemic lupus erythaematosus (SLE).

DESIGN

A retrospective chart review study.

SETTING

Data were collected in a tertiary medical centre, Shanghai, China, from November 2010 to December 2018.

PARTICIPANTS

A total of 513 pregnancies with SLE were retrospectively analysed. Twenty-seven patients who underwent artificial abortions due to personal reasons were excluded.

PRIMARY OUTCOME MEASURES

APOs were primary outcomes, including foetal loss, premature birth, small for gestational age (SGA), asphyxia neonatorum, composite foetal APOs and hypertensive disorders of pregnancy (HDP). Multivariable logistic regression and Spearman correlation analysis were performed to determine the risk factors for APOs in SLE.

RESULTS

Risk factors for foetal loss included prepregnancy hypertension, hypocomplementaemia-C3, anticardiolipin antibodies-IgM positivity and disease flares during pregnancy. Risk factors for premature birth included disease flares, use of immunosuppressive agents and HDP. Moreover, twin pregnancy, disease flares and HDP were risk factors for SGA, and prepregnancy hypertension was an independent risk factor for asphyxia neonatorum. Independent risk factors for composite foetal APOs included twin pregnancy, prepregnancy hypertension, disease flares during pregnancy, HDP, hypocomplementaemia-C3 and the use of immunosuppressive agents. Risk factors for SLE complicated with HDP included prepregnancy hypertension, renal disorders and thrombocytopaenia. Conversely, the use of aspirin was a protective factor against foetal loss and premature birth. The ds-DNA value had a low diagnostic value for APOs, whereas the extent of complement reduction may predict the incidence of composite foetal APOs and foetal loss. Proteinuria occurring in the first 20 gestational weeks may lead to APOs.

CONCLUSION

Established risk factors for each APO were identified in this study. Indicators with more predictive significance have been screened out from conventional indicators, which may help clinicians predict the pregnancy outcome of patients with SLE more accurately and minimise the incidence of APOs.

A Systematic Review of the safety of non-TNF inhibitor biologic and targeted synthetic drugs in rheumatic disease in pregnancy

INTRODUCTION

Despite increasing evidence to support safe use of tumour necrosis factor inhibitors (TNFi) and other biologic disease modifying anti-rheumatic drugs (bDMARDs) during pre-conception/pregnancy, there remains a paucity of evidence regarding the safety and compatibility of other non-TNFi and novel targeted synthetic (ts)DMARDs during pre-conception/pregnancy. Therefore, we conducted a systematic review to determine the compatibility of these drugs in pre-conception, during pregnancy and post-partum period.

METHOD

Databases including; EMBASE, Pubmed (MEDLINE), and Cochrane were searched up to 23rd October 2020 to find relevant peer-reviewed papers, using keywords including; rheumatic disease, pregnancy, conception/pre-conception, lactation/breastfeeding, childhood and vaccination/infection, and commonly prescribed non-TNFi drugs and tsDMARDs.

RESULTS

Our search yielded 1483 papers that were screened independently by two authors, and 109 full-text papers were eligible for final analysis. These studies reported 1291 maternal pregnancies exposed to non-TNFi bDMARDs and tsDMARDs with known outcomes, including 721 live births, 219 spontaneous miscarriages and 27 congenital abnormalities. Paternal exposures in 174 pregnancies had reassuring outcomes. A total of 48 breast-fed infants were exposed to non-TNFi bDMARDs and no adverse events reported upon long-term follow-up. Fifteen infants exposed to bDMARDs received normal vaccination regimes, including live vaccines, and had normal developmental outcomes, without any complications or infections.

CONCLUSION

Overall, the findings are reassuring and do not suggest a cause for any major concerns or an increased risk of adverse pregnancy outcomes for maternal or paternal exposures to non-TNFi bDMARDs or tsDMARDs. There were no major concerns for breastfeeding exposures to non-TNFi bDMARDs.

Self-concept and body image of people living with lupus: A systematic review

AIM

To summarize existing evidence regarding body image in patients with systemic lupus erythematosus, with the following considerations: (a) the perceptions patients have of their body changes; (b) how patients cope with changes in their body; (c) and what their perceptions are of body changes.

METHOD

A systematic review of literature integrating quantitative and qualitative studies. We searched databases (PubMed, CINAHL, Embase, SCOPUS, the Web of Science, Medline, Medline Complete, and Academic Search Premier) and publications from 2010 to 2020 with "Systemic Lupus Erythematosus" AND "Self-Concept" OR "Body Image" AND "Woman" as medical subheading terms. The studies included were subjected to a thematic content analysis, which allowed subjective interpretation of data through a systematic classification process for coding themes or patterns.

RESULTS

We identified 647 studies, of which 22 were analyzed in this study. Our results indicate that changes in the body image of people with lupus and their perception are issues that must be treated as characteristics of the disease; therefore, they need to receive the same attention as is given to physical disabilities and pain. The analysis identified 3 thematic categories: (a) depression and anxiety associated with body changes (hair loss, weight gain); (b) body image reflecting the disease; and (c) confrontations and interventions to promote acceptance and adaptation to the new image.

CONCLUSIONS

The dimensions of self-concept and body image are essential for assessing the quality of life of individuals with lupus. The formation of a adjusted self-concept can be managed by health professionals supporting these people.

Indications for Outpatient Antenatal Fetal Surveillance: ACOG Committee Opinion, Number 828

ABSTRACT

The purpose of this Committee Opinion is to offer guidance about indications for and timing and frequency of antenatal fetal surveillance in the outpatient setting. Antenatal fetal surveillance is performed to reduce the risk of stillbirth. However, because the pathway that results in increased risk of stillbirth for a given condition may not be known and antenatal fetal surveillance has not been shown to improve perinatal outcomes for all conditions associated with stillbirth, it is challenging to create a prescriptive list of all indications for which antenatal fetal surveillance should be considered. This Committee Opinion provides guidance on and suggests surveillance for conditions for which stillbirth is reported to occur more frequently than 0.8 per 1,000 (the false-negative rate of a biophysical profile) and which are associated with a relative risk or odds ratio for stillbirth of more than 2.0 compared with pregnancies without the condition. Table 1 presents suggestions for the timing and frequency of testing for specific conditions. As with all testing and interventions, shared decision making between the pregnant individual and the clinician is critically important when considering or offering antenatal fetal surveillance for individuals with pregnancies at high risk for stillbirth or with multiple comorbidities that increase the risk of stillbirth. It is important to emphasize that the guidance offered in this Committee Opinion should be construed only as suggestions; this guidance should not be construed as mandates or as all encompassing. Ultimately, individualization about if and when to offer antenatal fetal surveillance is advised.

Predicting factors of adverse pregnancy outcomes in Thai patients with systemic lupus erythematosus: A STROBE-compliant study

Studies on predicting factors for adverse pregnancy outcomes (APOs) in Thai patients with systemic lupus erythematosus (SLE) are limited. This retrospective observation study determined APOs and their predictors in Thai patients with SLE.Medical records of pregnant SLE patients in a lupus cohort, seen from January 1993 to June 2017, were reviewed.Ninety pregnancies (1 twin pregnancy) from 77 patients were identified. The mean age at conception was 26.94 ± 4.80 years. At conception, 33 patients (36.67%) had active disease, 23 (25.56%) hypertension, 20 (22.22%) renal involvement, and 6 of 43 (13.95%) positive anti-cardiolipin antibodies or lupus anti-coagulants, and 37 (41.11%) received hydroxychloroquine. Nineteen patients (21.11%) had pregnancy loss. Of 71 successful pregnancies, 28 (31.11%) infants were full-term, 42 (46.67%) pre-term and 1 (11.11%) post-term; 19 (26.39%) were small for gestational age (SGA), and 38 (52.58%) had low birth weight (LBW). Maternal complications occurred in 21 (23.33%) pregnancies [10 (11.11%) premature rupture of membrane (PROM), 8 (8.89%) pregnancy induced hypertension (PIH), 4 (4.44%) oligohydramnios, 2 (2.22%) post-partum hemorrhage, and 1 (1.11%) eclampsia]. Patients aged ≥ 25 years at pregnancy and those ever having renal involvement had predicted pregnancy loss with adjusted odds ratio (AOR) [95% CI] of 4.15 [1.10-15.72], P = .036 and 9.21 [1.03-82.51], P = .047, respectively. Renal involvement predicted prematurity (6.02 [1.77-20.52, P = .004), SGA (4.46 [1.44-13.78], P = .009), and LBW in infants (10.01 [3.07-32.62], P < .001). Prednisolone (>10 mg/day) and immunosuppressive drugs used at conception protected against prematurity (0.11 [0.02-0.85], P = .034). Flares and hematologic involvement predicted PROM (8.45 [1.58-45.30], P = .013) and PIH (9.24 [1.70-50.24], P = .010), respectively. Cutaneous vasculitis (33.87 [1.05-1,094.65], P = .047), and renal (31.89 [6.66-152.69], P < .001), mucocutaneous (9.17 [1.83-45.90], P = .007) and hematologic involvement (128.00 [4.60-3,564.46], P = .004) during pregnancy predicted flare; while prednisolone (>10 mg/day) and immunosuppressive drug use at conception reduced that risk (0.08 [0.01-0.68, P = .021).APOs remain a problem in Thai pregnant SLE patients. Renal involvement and SLE flares were associated with the risk of APOs.

Maternal and Fetal Outcomes in Systemic Lupus Erythematosus Pregnancies

Abstract Introduction: To describe the maternal and fetal outcomes in systemic lupus erythematosus (SLE) pregnancies followed-up in a single tertiary referral centre. Methods: We performed a retrospective cohort study of 75 SLE pregnancies who were followed up in Singapore General Hospital over a 16-year period from 2000 to 2016. Adverse fetal and maternal outcomes including preterm delivery, miscarriages, fetal growth restriction, congenital heart block, neonatal lupus, pre-eclampsia and SLE flares were obtained from the medical records. Results: The mean age at conception was 32 years old (SD 3.8). The mean SLE disease duration was 5.9 years (SD 5.2). The majority (88%) had quiescent SLE disease activity at baseline. Most pregnancies resulted in a live birth (74.7%). The mean gestational age at birth was 37.4 weeks (SD 3.4). Adverse fetal outcomes occurred in 53.3%. Preterm delivery (33.9%), miscarriages (20%) and fetal growth restriction (17.3%) were the most frequent adverse fetal outcomes. There was 1 neonatal death and SLE flares occurred in a third (33%). In the subgroup of SLE pregnancies with antiphospholipid syndrome, there were higher SLE flare rates (40%) and adverse fetal outcomes occurred in 8 pregnancies (80%). There were no predictive factors identified for all adverse fetal and maternal outcomes. In the subgroup analysis of preterm delivery, anti-Ro (SS-A) antibody positivity and hydroxychloroquine treatment were associated with a lower risk of preterm delivery. Conclusion: Although the majority had quiescent SLE disease activity at baseline, SLE pregnancies were associated with high rates of adverse fetal and maternal outcomes. Keywords: Antiphospholipid syndrome, anti-La (SS-B) antibody, anti-Ro (SS-A) antibody, lupus nephritis

Preeclampsia Risk Prediction Model for Chinese Pregnant Patients With Systemic Lupus Erythematosus

OBJECTIVE

To screen for a high risk of preeclampsia in women with systemic lupus erythematosus (SLE).

METHODS

A total of 513 antenatal care records of pregnant patients with SLE were obtained, and the data were randomly assigned to either a development set (n = 342) or a validation set (n = 171). Preeclampsia predictors were identified with stepwise regression, and a coefficient B of each variable was used to establish a prediction model and risk scoring system. Goodness-of-fit was assessed by the Hosmer-Lemeshow and Omnibus tests, and the area under the receiver operating characteristic curve (area under the curve) was used to assess discrimination. Validation was performed using the validation set.

RESULTS

The preeclampsia incidence was 14.4% in the pregnant patients with SLE. A mean arterial pressure (MAP) ≥96.5 mm Hg (odds ratio [OR] 213.15 [95% confidence interval (95% CI) 24.39-999.99]), prepregnancy hypertension (OR 18.19 [95% CI 2.67-125.01]), a hematologic disorder (OR 4.13 [95% CI 1.03-16.67]), positive IgM anticardiolipin antibodies (aCLs) (OR 19.85 [95% CI 1.11-333.33]), serum albumin <31.5 grams/liter (OR 9.88 [95% CI 2.07-47.62]), serum uric acid ≥303 μmoles/liter (OR 5.58 [95% CI 1.40-22.22]), and 24-hour urinary protein ≥0.286 grams (OR 14.39 [95% CI 2.43-83.33]) were selected for the preeclampsia prediction model. The area under the curve was 0.975. Preeclampsia prediction model scores >4 indicated a high risk of preeclampsia. For the validation set, the preeclampsia prediction accuracy was 93.6% (sensitivity 88.5%, specificity 94.5%).

CONCLUSION

A model for predicting the risk of preeclampsia in pregnant patients with SLE was established on the basis of MAP, prepregnancy hypertension, hematologic disorders, IgM aCLs, albumin, uric acid, and 24-hour urinary protein. The model had good predictive efficiency and can help clinicians improve pregnancy outcomes in high-risk women with early interventions.

2020 Chinese guidelines for the diagnosis and treatment of systemic lupus erythematosus

Systemic lupus erythematosus (SLE) is a heterogeneous autoimmune disease that represents a prodigious challenge of diagnosis and treatment. In 2019, under the leadership of the Chinese Rheumatology Association, a multidisciplinary guideline development group was established to develop an evidence-based diagnosis and treatment guideline for patients with SLE in PR China. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to evaluate the quality of evidence and the strength of recommendations. The guideline was reported following the Reporting Items for Practice Guidelines in Healthcare (RIGHT) checklist. In this guideline, we provided recommendations for SLE classification criteria, disease activity monitoring and assessment, medication administration and considerations for SLE patients with organs and systems involved, and management of special populations such as SLE patients in the setting of pregnancy. This guideline serves as an evidence-based tool for Chinese clinicians to diagnose and treat patients with SLE.

Perception of contraceptive counseling and contraceptive use among systemic lupus erythematosus patients

OBJECTIVES

(1) To evaluate the perception of contraceptive counseling and knowledge regarding the impact of unintended pregnancy and (2) examine the prevalence of, and predictors for contraceptive use among systemic lupus erythematosus (SLE) patients.

STUDY DESIGN

A cross-sectional survey was conducted at the Rheumatology Clinic of a university hospital. SLE patients who attended the clinic from April 2018 to January 2019 and at risk for unintended pregnancy and were invited to be interviewed. The structured interview guide consisted of three parts: personal and obstetric information, perception of contraceptive counseling and knowledge about the impact of unintended pregnancy, and contraceptive use.

RESULTS

The mean age of the 137 patients who gave informed consents was 34 ± 8 years, with 47 patients (34%) stating that they had received contraceptive counseling. Seventy-five patients (52%) reported practicing contraception. The intention to not become pregnant (Odds Ratio; 95% CI = 7.28; 1.75-30.27), perception of adequate contraceptive counseling (2.77; 1.06-7.20) and discussion with partners and physicians about contraception (3.95; 1.64-9.50) were predictors for contraceptive use (p < 0.05).

CONCLUSION

Most patients reported no contraceptive counseling with approximately half of the patients using contraceptive methods within the past three months. Desire to avoid pregnancy, perception of adequate contraceptive counseling, and the influence of partners and physicians were significant predictors for contraceptive use.

IMPLICATIONS

Contraceptive counseling should be routinely included in discussions about disease processes and treatment plans, including access issues. Best practices for contraceptive counseling and integrated, multi-disciplinary team services should be developed and provided in clinical settings.

The Influence of Pregnancy on the Clinical Evolution and Prognosis of Pre-Existing Inflammatory and Autoimmune Skin Disorders and Their Management

BACKGROUND

Although the possible occurrence of typical dermatoses during pregnancy is well recognized, little is known about the influence of pregnancy on the clinical evolution and prognosis of different pre-existing chronic dermatological disorders.

SUMMARY

In this study a comprehensive search of the available literature and reviews has been undertaken in order to collect and analyze articles reporting pre-existing chronic skin disorders in pregnant women and report current knowledge on their particular clinical and therapeutic aspects.

Pregnancy in systemic lupus erythematosus

OBJECTIVES

Systemic lupus erythematosus (SLE) is a chronic illness that often affects women of reproductive age. The objectives of this article are to review the impact of SLE on pregnancy and current management strategies, including commonly used therapies.

METHODS

We conducted a review of available literature on the clinical course of SLE, diagnosis, management and pregnancy complications.

RESULTS

SLE has a variable clinical course characterized by flares and periods of remission and can present unique challenges in the management of obstetric patients. Pregnancy in patients with SLE is associated with multiple risks, including fetal loss, preterm birth, fetal growth restriction, and hypertensive disease. With advancements in disease treatment, many women have favorable pregnancy outcomes, but appropriate preconception counseling and disease management remain important tools in reducing complications.

CONCLUSION

Given the implications SLE can have on women of reproductive age and in pregnancy, understanding the disease course and management is important in order to optimize pregnancy outcomes.

Adverse Pregnancy Outcomes after Multi-Professional Follow-Up of Women with Systemic Lupus Erythematosus: An Observational Study from a Single Centre in Sweden

While the management of pregnant patients with systemic lupus erythematosus (SLE) has improved over the last decades, the risk of maternal, foetal, and neonatal complications is still substantial. We evaluated the occurrence of adverse pregnancy outcomes (APO) occurring in 2002–2018 among patients with SLE from the catchment area of the Department of Rheumatology in Lund, Sweden. Longitudinal clinical and laboratory data were collected and analysed. Results were stratified according to the sequence of conception. We investigated a total of 59 pregnancies in 28 patients. Prior lupus nephritis was the clinical feature that, in a multivariable regression analysis, displayed the strongest association with APO overall (OR 6.0, p = 0.02). SLE combined with antiphospholipid syndrome (APS) was associated with the risk of miscarriage (OR 3.3, p = 0.04). The positivity of multiple antiphospholipid antibodies (aPL) was associated with APO overall (OR 3.3, p = 0.05). IgG anti-cardiolipin during pregnancy resulted in a higher risk of preterm delivery (OR 6.8, p = 0.03). Hypocomplementaemia was associated with several APO, but only in the first pregnancies. We conclude that, despite the close follow-up provided, a majority of pregnancies resulted in ≥1 APO, but a few of them were severe. Our study confirms the importance of previous lupus nephritis as a main risk factor for APO in patients with SLE.

Adverse pregnancy outcomes among multi-ethnic systemic lupus erythematosus patients in Malaysia

BACKGROUND

Despite the improvement in the live birth rate among patients with systemic lupus erythematosus (SLE), they are still at an increased risk of adverse pregnancy outcomes (APOs).

OBJECTIVE

To determine the prevalence and factors associated with APOs in the multi-ethnic SLE populations in Malaysia.Methodology: This was a retrospective review of the consecutive SLE patients who attended the outpatient clinic in two major rheumatology centres from January 2016 until December 2019 with complete pre-pregnancy, antenatal and intra-partum records. APOs include pregnancy loss, prematurity, pre-eclampsia, intra-uterine growth restriction (IUGR) and maternal death. Univariate and multivariable logistic regression with generalised estimating equation (GEE) analyses were performed to determine the factors associated with APOs.

RESULTS

A total of 153 patients with 240 pregnancies were included and the majority of the patients were Malay (69.9%), followed by Chinese (24.2%) and Indian (5.9%). The prevalence of APOs was 61.7% with the commonest complication being prematurity (28.3%), followed by pregnancy loss (24.6%) and pre-eclampsia (21.8%). Logistic regression model-based GEE analysis revealed that the independent predictors of APOs were active haematological system during pregnancy, pre-pregnancy active disease, Indian patients and positive lupus anticoagulant. Hydroxychloroquine use was associated with lower APOs including pre-eclampsia, prematurity and IUGR in the univariate analyses but it was no longer significant in the GEE analysis.

CONCLUSION

The prevalence of APOs was high particularly among the Indian patients. Positive lupus anticoagulant and pre-pregnancy active disease were the factors strongly associated with APOs in our multi-ethnic cohort. Hydroxychloroquine may protect against APOs but further larger studies are needed to confirm this.

Update on pregnancy complications in systemic lupus erythematosus

PURPOSE OF REVIEW

This review summarizes recent research in the field of systemic lupus erythematosus (SLE) and pregnancy with focus on clinical and biochemical predictors of adverse pregnancy outcomes (APOs), accumulating evidence for the safety and efficacy of hydroxychloroquine (HCQ) in pregnancy, and the importance of preconception counseling.

RECENT FINDINGS

Ongoing research from PROMISSE investigators (Predictors of Pregnancy Outcome: Biomarkers in Antiphospholipid Antibody Syndrome and Systemic Lupus Erythematosus) adds to the understanding of risk factors for APOs in SLE pregnancies, including aberrant complement activation, incomplete downregulation of lupus-associated transcription factors, and lower socioeconomic status. Evidence supporting numerous advantages for continuing HCQ in pregnancy, as well as support for low-dose aspirin in preeclampsia prevention is reviewed. Practice gaps exist among rheumatologists in ensuring effective contraception when women of childbearing age are undergoing therapy with potentially fetotoxic medications. The publication of organizational guidelines provides evidence-based recommendations on lupus pregnancy management.

SUMMARY

Outcomes of lupus pregnancies continue to improve with understanding of risk factors that predict APOs as well as improvements in disease management. Rheumatologists caring for women with SLE should be familiar with the most up-to-date research in order to optimize pregnancy outcomes in this population.

Perceptions of women with systemic lupus erythematosus undergoing high-risk prenatal care: A qualitative study

BACKGROUND

Systemic lupus erythematosus (SLE) is a multisystem autoimmune disease that often leads to situations of harm to the mother-fetus binomial. Given the potential for complications and morbidities in these pregnant women, it is essential that a multidisciplinary team be involved in pregnancy planning, as well as monitoring the course of the pregnancy and the postpartum period. Owing to the imminent risks of disease worsening along with consequent disabilities, these women may experience psychological and psychosocial impacts conflicting with the psychological demands of pregnancy.

OBJECTIVE

To understand the meanings attributed to pregnancy by women with SLE.

DESIGN

A qualitative design with face-to-face interview following a semi-structured script of open-ended questions.

SETTING

A specialized outpatient clinic where during prenatal care, women with stable disease undergo scheduled appointments.

PARTICIPANTS

The sample was intentionally composed of women visiting a specialized outpatient clinic from July 2017 to July 2018. The participants (N = 26) were interviewed in depth, with no refusal. Thematic analysis according to the 7 steps of qualitative analysis was conducted using NVivo 11.

FINDINGS

Four categories were identified: (1) unplanned pregnancy and nonuse of contraception, (2) feeling healthy despite a doctor's warning of the disease worsening because of pregnancy, (3) joy coupled with fear of the future and pregnancy, and (4) self-perception and straight perception.

CONCLUSIONS

The experiences of pregnant women with SLE are permeated by ambiguous feelings. These women feel healthy because they can bear a child despite the chronic disease diagnosis and, at the same time, experience fear and insecurity owing to the imminent possibility of disease-related disabilities and limitations. They especially wish to experience motherhood, and they strive for safety and support.

IMPLICATIONS FOR PRACTICE

Health teams must be structured to welcome and advise these women in planning relationships and pregnancy, as well as choosing the best contraceptive methods and making optimal reproductive decisions. The development of strategies to deal with changes in the perinatal period may be helpful, as these women are willing to take care of themselves.

2020 American College of Rheumatology Guideline for the Management of Reproductive Health in Rheumatic and Musculoskeletal Diseases

OBJECTIVE

To develop an evidence-based guideline on contraception, assisted reproductive technologies (ART), fertility preservation with gonadotoxic therapy, use of menopausal hormone replacement therapy (HRT), pregnancy assessment and management, and medication use in patients with rheumatic and musculoskeletal disease (RMD).

METHODS

We conducted a systematic review of evidence relating to contraception, ART, fertility preservation, HRT, pregnancy and lactation, and medication use in RMD populations, using Grading of Recommendations Assessment, Development and Evaluation methodology to rate the quality of evidence and a group consensus process to determine final recommendations and grade their strength (conditional or strong). Good practice statements were agreed upon when indirect evidence was sufficiently compelling that a formal vote was unnecessary.

RESULTS

This American College of Rheumatology guideline provides 12 ungraded good practice statements and 131 graded recommendations for reproductive health care in RMD patients. These recommendations are intended to guide care for all patients with RMD, except where indicated as being specific for patients with systemic lupus erythematosus, those positive for antiphospholipid antibody, and/or those positive for anti-Ro/SSA and/or anti-La/SSB antibodies. Recommendations and good practice statements support several guiding principles: use of safe and effective contraception to prevent unplanned pregnancy, pre-pregnancy counseling to encourage conception during periods of disease quiescence and while receiving pregnancy-compatible medications, and ongoing physician-patient discussion with obstetrics/gynecology collaboration for all reproductive health issues, given the overall low level of available evidence that relates specifically to RMD.

CONCLUSION

This guideline provides evidence-based recommendations developed and reviewed by panels of experts and RMD patients. Many recommendations are conditional, reflecting a lack of data or low-level data. We intend that this guideline be used to inform a shared decision-making process between patients and their physicians on issues related to reproductive health that incorporates patients' values, preferences, and comorbidities.

Metabolic Biomarkers In Midtrimester Maternal Plasma Can Accurately Predict Adverse Pregnancy Outcome in Patients with SLE

Patients with systemic lupus erythematosus (SLE) are at increased risk for adverse pregnancy outcome (APO). Accurate prediction of APO is critical to identify, counsel, and manage these high-risk patients. We undertook this study to identify novel biomarkers in mid-trimester maternal plasma to identify pregnant patients with SLE at increased risk of APOs. The study population consisted of pregnant women whose plasma was taken in mid-trimester and available for metabolic signature: (1) SLE and normal pregnancy outcome (Group 1, n = 21); (2) SLE with APO (Group 2, n = 12); and (3) healthy pregnant controls (Group 3, n = 10). Mid-trimester maternal plasma was analyzed for integrative profiles of primary metabolite and phospholipid using gas chromatography time-of-flight mass spectrometry (GC-TOF MS) and liquid chromatography Orbitrap mass spectrometry (LC-Orbitrap MS). For performance comparison and validation, plasma samples were analyzed for sFlt-1/PlGF ratio. In the study population, APO developed in 12 of 33 women with SLE (36%). Metabolite profiling of mid-trimester maternal plasma samples identified a total of 327 metabolites using GC-TOF MS and LC-Orbitrap MS. Partial least squares discriminant analysis (PLS-DA) showed clear discrimination among the profiles of SLE groups and healthy pregnant controls (Groups 1/2 vs. 3). Moreover, direct comparison between Groups 1 and 2 demonstrated that 4 primary metabolites and 13 lipid molecules were significantly different. Binary logistic regression analysis suggested a potential metabolic biomarker model that could discriminate Groups 1 and 2. Receiver operating characteristic (ROC) analysis revealed the best predictability for APO with the combination model of two metabolites (LysoPC C22:5 and tryptophan) with AUC of 0.944, comparable to the AUC of sFlt-1/PlGF (AUC 0.857). In conclusion, metabolic biomarkers in mid-trimester maternal plasma can accurately predict APO in patients with SLE.

Impact of extractable nuclear antigen, anti-double stranded DNA, antiphospholipid antibody, and anticardiolipin antibody positivity on obstetrical complications and pregnancy outcomes

BACKGROUND

Extractable nuclear antigen (ENA) and anti-double stranded DNA (anti-dsDNA) positivity and related diseases like systemic lupus erythematosus, Sjögren syndrome, and other autoimmune diseases are known to be associated with obstetrical complications and poor perinatal outcomes.

OBJECTIVE

To demonstrate the importance of ENA, anti-dsDNA, antiphospholipid (APL), and anticardiolipin (ACL) antibody positivity on pregnancy outcomes.

METHODS

Ninety one pregnant women with known ENA, anti-dsDNA, APL IgG and IgM, and ACL IgG and IgM antibody positivity were retrospectively compared with 91 randomly selected pregnant woman in terms of obstetrical complications and pregnancy outcomes. Beksac Obstetrics Index-pregnancy (BOIp), calculated as (number of children + (π/10))/gravidity in the current pregnancy, was used to compare the risk level between groups.

RESULTS

Significant differences were found in the median maternal age, gravidity, number of previous miscarriages, and BOIp between the groups (p= 0.04, p< 0.001, p< 0.001, and p< 0.001, respectively). Significant differences were also found between the study and control groups in the median gestational age at birth, birth weight, and APGAR1 score (p< 0.001 for all). Similarly, significant differences were found between groups in the rates of intra-uterine growth restriction, oligohydramnios, and gestational hypertension (p< 0.001, p= 0.05, and p= 0.05, respectively). There were 3 (3.3%) stillbirths in the study group and none in the control group (p= 0.123).

CONCLUSION

We evaluated the impact of anti-dsDNA, ENA, APL, and ACL antibody positivity, which may cause immunologic inflammation at placenta and thereby affect pregnancy outcomes.

Clinical outcomes and predictors of maternal and fetal complications in pregnancies of patients with systemic lupus erythematosus

INTRODUCTION

Systemic Lupus Erythematosus (SLE) mostly affects women during their childbearing years. Fertility is preserved in SLE patients, but pregnancy is often characterized by a high number of maternal and fetal complications. Adverse pregnancy outcomes (APO) have been widely studied over the last decades and several investigators have focused on the potential clinical and serological predictors of maternal and fetal complications. Areas covered: In this review, we analyzed maternal and fetal complications in SLE patients and predictors of APO. Active disease in the 6 months before conception, lupus nephritis, anti-phospholipid (aPL), anti-SSA/Ro and/or anti-SSB/La antibodies have been identified as the most consistent predictors of maternal and fetal complications to date. However, molecular mechanisms and underlying immunological pathways involved in APO still remain elusive. Expert opinion: Difficulties in assessing prevalence and predictors of APO in SLE patients are due to lack of uniformity in the definitions and methods used in the different studies. In addition, some maternal and fetal complications are difficult to diagnose and to differentiate from each other. Preconception counseling is paramount to prevent APO, and it should consider four main factors: disease activity/lupus nephritis, safety of drugs, aPL, anti-SSA/Ro, and/or anti-SSB/La antibodies.

Autoimmunity in obstetrics and autoimmune diseases in pregnancy

Autoimmune diseases (AIDs) are associated with strong female preponderance and often present before or during the reproductive years; consequently, pregnancy and breastfeeding are topics of major interest for these patients. AIDs show different responses to pregnancy: some ameliorate, while others remain unchanged, and several AIDs aggravate. The response of the AIDs to the hormonal and immunological alterations of pregnancy reflects the different pathophysiology of each disease. Systemic lupus erythematosus (SLE) and antiphospholipid syndrome (APS) are associated with multiple autoantibodies, multiorgan involvement, more aggressive therapy, and increased impact on pregnancy outcome. For the management of pregnancy in patients with SLE and/or APS, it is important to individuate the correct risk profile for each woman and timing for treatment. The optimal timing for starting or modulating treatment is at preconception assessment to influence the placentation. In this chapter, we discuss the management of pregnancy in patients with AIDs.

The impact of different classes of lupus nephritis on maternal and fetal outcomes: a cohort study of 147 pregnancies

OBJECTIVE

To analyze the impact of different classes of lupus nephritis as risk variables for maternal and fetal adverse outcomes in a cohort of pregnant lupus patients.

METHODS

This is a cohort study with retrospective and prospective data collection, conducted at the University Hospital of State University of Rio de Janeiro, Brazil, from 2011 to 2016. A total of 147 pregnancies of 137 systemic lupus erythematosus patients of whom 66 had lupus nephritis were included. Demographic and clinical features, as well as maternal and fetal outcomes were observed for each nephritis histological class among systemic lupus erythematosus patients and compared with those without nephritis. Categorical variables were expressed as absolute and relative frequencies and numerical variables as means and standard deviation. The chi-square test with Fisher's correction and Student's t-test were used for statistical analysis. A pvalue < 0.05 was considered statistically significant.

RESULTS

Systemic lupus erythematosus patients with proliferative nephritis (classes III/IV, n = 54) presented more frequent disease flares ( p = 0.02), continuous active disease during pregnancy and puerperium ( p = 0.006), hospitalization due to systemic lupus erythematosus ( p < 0.001), hospitalization not directly associated to systemic lupus erythematosus ( p = 0.04), higher frequency of cesarean delivery ( p = 0.03) and preeclampsia ( p = 0.01) than patients without nephritis. Permanent damage measured by Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index was more frequent in classes III/IV than among the other patients. The frequency of adverse fetal outcomes such as prematurity and admission to neonatal intensive care unit were not different among systemic lupus erythematosus patients with or without nephritis. However, perinatal deaths were more frequent in patients with all classes of nephritis ( p = 0.003).

CONCLUSION

Systemic lupus erythematosus patients with proliferative nephritis (classes III/IV) have a higher frequency of adverse maternal outcomes. This is probably due to the major impact of proliferative forms of nephritis on women's global heath, which is corroborated by the higher Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index findings, although we cannot exclude the negative influence of disease activity for the maternal adverse events. The findings indicate a need for further lupus nephritis classification beyond the nonspecific term nephritis in the context of lupus pregnancy as the impact on maternal and fetal outcomes varies according to histological class.

Safety issues and recommendations for successful pregnancy outcome in systemic lupus erythematosus

Systemic lupus erythematosus (SLE) primarily affects women of childbearing age. One of the major changes in SLE focuses on the timing of a successful pregnancy. In the past, pregnancy was strongly discouraged in SLE, especially in the presence of risk factors such as nephritis, use of immunosuppressive therapies, or positivity of specific autoantibodies such as anti-phospholipids and anti-Ro/SSA, La/SSBA. Thanks to our better knowledge on the disease and management, pregnancy success rates in SLE patients have significantly improved care by the a multidisciplinary team which fosters a successful pregnancy with minimal complications for the mother and fetus when the disease is inactive or in remission. This approach is based on a counseling phase before pregnancy, to assess SLE activity phase, specific medications, risk factors, and continues through pregnancy and lactation with significantly improved pregnancy outcomes. Further, we can now better define the risk of disease flares during pregnancy based on a better understanding of the changes in maternal immunity and its relationship with SLE-associated autoimmunity and chronic inflammation. There is wide consensus that women with SLE can have successful pregnancies as long as conception is planned in a phase of inactive disease, and when the patient is closely managed by a rheumatologist, high-risk OB/GYN, neonatologist, and other medical specialists as indicated. Preconception counseling is essential to assess the risk of both fetal and maternal complications as well as identify life-threatening contraindications. Particular attention should be used in those SLE cases that have nephritis, APS or positivity for aPL, pulmonary hypertension, and positive anti-Ro/SSA or anti-La/SSB antibodies. In conclusion, the use of specific guidelines on the management of SLE before and during pregnancy and lactation, and a better understanding of the use of immunosuppressive therapies have significantly increased pregnancy success.

The new FDA labeling rule: impact on prescribing rheumatological medications during pregnancy

After several decades of deliberation, the US Food and Drug Administration updated the Pregnancy and Lactation Labeling Rule in 2015, eliminating the prior A, B, C, D, X grading system for medication use in pregnancy. Although physicians and patients liked the relative ease of use of this system, it was often misconstrued and not updated to include new data suggesting greater compatibility of medications with pregnancy. The new label is designed to include more clinically relevant data, including data from human studies and registries, and fewer animal data. A key goal of the new label is to assist physicians and patients as they weigh the risks and benefits of medications vs the risks of pregnancy in a woman with a chronic, untreated illness. As such, each label now includes a section outlining the pregnancy risks of the diseases that the medication treats. This review includes a historical perspective on the label change and a guide to the interpretation of the new label. It also includes an assessment of the baseline risk of pregnancy in women with SLE and RA, to help balance the consideration of medication risks and benefits in pregnancy.

Important considerations in pregnant patients with lupus nephritis

INTRODUCTION

In the last few decades, identification of predictors of pregnancy outcome and appropriate pregnancy planning have significantly reduced the maternal and fetal risks in pregnant women with lupus nephritis. Areas covered: Successful pregnancies have been reported even in women with chronic renal disease and renal insufficiency. However, refractory hypertension and severe renal or cardiac chronic dysfunction are still considered contraindications to pregnancy. Pre-term delivery and fetal growth restriction may still occur in SLE patients more frequently than in healthy women, even in pregnancies regularly planned and monitored by a team of nephrologists and gynaecologists. Expert commentary: Stable disease remission is the most important factor for a successful pregnancy. In case of flare-ups of lupus, timely diagnosis and appropriate management may ensure a successful outcome in the majority of pregnant women. The negative role of anti-phospholipid antibodies and of chronic arterial hypertension may be countered with appropriate anticoagulation and anti-hypertensive therapy. Further studies are needed to better assess the possible impact of pregnancy on the long-term outcome of lupus nephritis.

Severe Maternal Morbidity Associated with Systemic Lupus Erythematosus Flare in the Second Trimester of Pregnancy

Pregnancy in women with systemic lupus erythematosus (SLE) is associated with an increased risk of adverse maternal and fetal outcomes. Here, we present a case of severe maternal morbidity in a 23-year-old primigravida with SLE and secondary Sjögren's syndrome who experienced a life-threatening multisystem flare at 17 weeks of gestational age. She presented to the emergency department complaining of cough with hemoptysis and shortness of breath. She developed hypoxic respiratory failure and was admitted to the intensive care unit. Bronchoscopy confirmed diffuse alveolar hemorrhage. Physical exam and laboratory evaluation were consistent with an active SLE flare, pancytopenia, and new-onset lupus nephritis. After counseling regarding disease severity, poor prognosis, and recommendation for therapy with cytotoxic agents, she agreed to interruption of pregnancy which was achieved by medical induction. Her course was further complicated by thrombotic microangiopathy and generalized tonic-clonic seizures attributable to posterior reversible encephalopathy syndrome versus neuropsychiatric SLE. This case represents one of the most extreme manifestations of lupus disease activity associated with pregnancy that has been reported in the literature and emphasizes the importance of preconception evaluation and counseling and a multidisciplinary management approach in cases with a complex and evolving clinical course.

Associations between maternal clinical features and fetal outcomes in pregnancies of mothers with connective tissue diseases

OBJECTIVES

The purpose of this study is to clarify associations between maternal clinical features and adverse pregnancy outcomes (APOs) in mothers with connective tissue diseases (CTDs).

METHODS

We retrospectively examined maternal clinical features including backgrounds, autoantibodies, CTD flare-ups, and therapies during pregnancies as well as fetal outcomes in 90 pregnancies (66 mothers) at our hospital from January 2006 to September 2016.

RESULTS

Underlying CTDs were SLE (N = 41), MCTD (N = 10), RA (N = 15), SS (N = 10), and others (N = 14). Anti-SS-A antibody was detected in 60.3%, lupus anticoagulant (LAC) was in 11.4%, and anti-cardiolipin-β2glycoprotein1 antibody was in 18.5%. Flare-ups of CTDs occurred in 20 pregnancies (22.2%). Corticosteroids (CS) was administered in 73 pregnancies, immunosuppressants in four, and biologics in one. Among the 85 pregnancies other than five early abortions within 12 weeks of gestational age, 33 cases had APOs while the remaining 52 cases were normal. Although disease duration, MCTD, high dose of CS, flare-ups of CTDs, and positive LAC significantly correlated with APOs by univariate analysis, only MCTD was a significant independent predictor for APOs by multivariate analysis.

CONCLUSION

Disease duration, MCTD, high dose of CS, flare-ups of CTDs, and LAC might be possible predictive risk factors for APOs in pregnancies with CTDs. Of these, MCTD was a significant independent risk factor.

Neonatal and Obstetrical Outcomes of Pregnancies in Systemic Lupus Erythematosus

Objectives

Systemic lupus erythematous (SLE) is a chronic autoimmune disease that affects women primarily of childbearing age. The objective of this study was to determine the neonatal and maternal outcomes of pregnancies in SLE patients compared to pregnancies in healthy controls.

Methods

We conducted a retrospective cohort study in a tertiary care hospital in Oman between January 2007 and December 2013. We analyzed 147 pregnancies and compared 56 (38.0%) pregnancies in women with SLE with 91 (61.9%) pregnancies in healthy control women. Disease activity was determined using the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI).

Results

The mean age of the cohort was 30.0±5.0 years ranging from 19 to 44 years old. Patients with SLE were treated with hydroxychloroquine (n = 41; 73.2%), prednisolone (n = 38; 67.8%), and azathioprine (n = 17; 30.3%). There was no disease activity in 39.2% (n = 22) of patients while 41.0% (n = 23), 12.5% (n = 7), and 7.1% (n = 4) had mild (SLEDAI 1-5), moderate (SLEDAI 6-10), and severe (SLEDAI ³ 11) disease activity, respectively, at onset of pregnancy. Pregnancies in patients with SLE were associated with higher abortions (42.8% vs. 15.3%; p < 0.001), gestational diabetes (28.3% vs. 10.2%; p = 0.004), polyhydramnios (7.1% vs. 0.0%; p = 0.020), previous preterm pregnancies (8.9% vs. 1.0%; p = 0.030), and intrauterine growth retardation (21.4% vs. 0.0%; p < 0.001) when compared to pregnancies in healthy control women. Furthermore, the neonates born to mothers with SLE were more likely to be preterm (28.5% vs. 1.0%; p < 0.001), have a low birth weight (< 2 500 g) (32.1% vs. 1.0%; p < 0.001), and were associated with stillbirth (7.1% vs. 0.0%; p = 0.010) when compared to neonates born to healthy control mothers.

Conclusions

Pregnancies in women with SLE were associated with higher neonatal and maternal complications. Therefore, pregnant women with SLE should have their pregnancy accurately planned, monitored, and managed according to a multidisciplinary treatment schedule.

What to Expect When Expecting With Systemic Lupus Erythematosus (SLE): A Population-Based Study of Maternal and Fetal Outcomes in SLE and Pre-SLE

Objective

To assess maternal and fetal outcomes associated with subclinical (pre‐systemic lupus erythematosus [SLE] and SLE presenting up to 5 years postpartum) and prevalent maternal SLE during pregnancy compared with the general population.

Methods

This prospective cohort study used population‐based Swedish registers to identify 13,598 women with first singleton pregnancies registered in the Medical Birth Register (551 prevalent SLE, 65 pre‐SLE within 0–2 years, 133 pre‐SLE within 2–5 years, and 12,847 general population). SLE was defined as ≥2 SLE‐coded discharge diagnoses in the patient register with ≥1 diagnosis from a specialist. Unadjusted risks of adverse pregnancy or birth outcomes were calculated by SLE status, and Cochran‐Armitage tests evaluated trend across exposure groups.

Results

Maternal outcomes such as preeclampsia, hypothyroidism, stroke, and infection were more common among women with SLE. Sixteen percent of prevalent‐SLE pregnancies were diagnosed with preeclampsia compared with 5% of those from the general population. Among the pre‐SLE women, preeclampsia was found in 26% of those with SLE within 2 years postpartum and 13% in those with SLE within 2–5 years postpartum. Similarly, infant outcomes, such as preterm birth, infection, and mortality, were worse among those born to mothers with prevalent SLE and pre‐SLE during pregnancy. The test for trend was significant for most outcomes.

Conclusion

Our data demonstrate that adverse maternal and fetal outcomes are more common in SLE pregnancies. Furthermore, these unfavorable outcomes are observed in pregnancies occurring prior to the diagnosis of SLE. Thus, the underlying immunologic profile of SLE and alterations preceding clinical SLE may contribute to these pregnancy complications.