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Martínez López JA, García Vivar ML, Cáliz R, Freire M, Galindo M, Hernández MV, López Longo FJ, Martínez Taboada V, Pego Reigosa JM, Rubio E, Trujillo E, Vela-Casasempere P. Recommendations for the evaluation and management of patients with rheumatic autoimmune and inflammatory diseases during the reproductive age, pregnancy, postpartum and breastfeeding. ACTA ACUST UNITED AC 2016; 13:264-281. [PMID: 27321859 DOI: 10.1016/j.reuma.2016.05.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Revised: 05/02/2016] [Accepted: 05/07/2016] [Indexed: 01/18/2023]
Abstract
OBJECTIVE To develop recommendations on the evaluation and management of patients with rheumatic autoimmune and inflammatory diseases during the reproductive age, pregnancy, post-partum and breastfeeding based on the best evidence and experience. METHODS Recommendations were generated using nominal group and Delphi techniques. An expert panel of 12 rheumatologists was established. A systematic literature review and a narrative review (websites, clinical guidelines and other relevant documentation) were performed and presented to the panel in its 1st meeting to be discussed and to help define recommendations. A first draft of recommendations was generated and circulated for comments and wording refinement. A national survey analyzing different aspects of this topic was undertaken separately, followed by a Delphi process (2 rounds). Agreement with each recommendation was ranked on a scale of 1 (total disagreement) to 10 (total agreement), and was considered to be achieved if at least 70% voted≥7. The level of evidence and grade of recommendation were assessed using the Oxford Centre for Evidence-based Medicine Levels of Evidence. RESULTS A total of 14 recommendations were generated for the preconception period (oral and hormonal contraception, reproductive techniques), pregnancy (planning, treatment and follow-up), and breastfeeding (treatment and follow-up). High-risk situations such as lupus or antiphospholipid syndrome were included. A consensus>90% was reached for all but one recommendation. CONCLUSIONS These recommendations are intended to provide rheumatologists, patients, families and other stakeholders with a consensus on the evaluation and management of patients with autoimmune and inflammatory diseases during the reproductive age, pregnancy, postpartum and breastfeeding.
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Affiliation(s)
| | - M Luz García Vivar
- Servicio de Reumatología, Hospital Universitario Basurto, Bilbao, España
| | - Rafael Cáliz
- Unidad de Gestión de Reumatología, Complejo Hospitalario Universitario de Granada, Granada, España
| | - Mercedes Freire
- Servicio de Reumatología, Complexo hospitalario Universitario A Coruña (CHUAC), A Coruña, España
| | - María Galindo
- Servicio de Reumatología, Hospital Universitario 12 de Octubre, Madrid, España
| | | | | | - Víctor Martínez Taboada
- Servicio de Reumatología, Hospital Universitario Marqués de Valdecilla, Santander, España; Facultad de Medicina, Universidad de Cantabria, Santander, España
| | - Jose María Pego Reigosa
- Servicio de Reumatología, Hospital Meixoeiro-Complexo Hospitalario Universitario de Vigo, Vigo, España
| | - Esteban Rubio
- Servicio de Reumatología, Hospital Universitario Virgen del Rocío, Sevilla, España
| | - Elisa Trujillo
- Servicio de Reumatología, Hospital Universitario de Canarias, Santa Cruz de Tenerife, España
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Asorey-García A, Santos-Bueso E, Sáenz-Francés F, García-Feijoo J. Optic neuropathy in a pregnant patient with antiphospholipid syndrome. NEUROLOGÍA (ENGLISH EDITION) 2015. [DOI: 10.1016/j.nrleng.2015.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Saavedra Salinas MÁ, Barrera Cruz A, Cabral Castañeda AR, Jara Quezada LJ, Arce-Salinas CA, Álvarez Nemegyei J, Fraga Mouret A, Orozco Alcalá J, Salazar Páramo M, Cruz Reyes CV, Andrade Ortega L, Vera Lastra OL, Mendoza Pinto C, Sánchez González A, Cruz Cruz PDR, Morales Hernández S, Portela Hernández M, Pérez Cristóbal M, Medina García G, Hernández Romero N, Velarde Ochoa MDC, Navarro Zarza JE, Portillo Díaz V, Vargas Guerrero A, Goycochea Robles MV, García Figueroa JL, Barreira Mercado E, Amigo Castañeda MC. Guías de práctica clínica para la atención del embarazo en mujeres con enfermedades reumáticas autoinmunes del Colegio Mexicano de Reumatología. Parte II. ACTA ACUST UNITED AC 2015; 11:305-15. [DOI: 10.1016/j.reuma.2014.12.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Accepted: 12/12/2014] [Indexed: 12/14/2022]
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Asorey-García A, Santos-Bueso E, Sáenz-Francés F, García-Feijoo J. Optic neuropathy in a pregnant patient with antiphospholipid syndrome. Neurologia 2014; 30:518-9. [PMID: 24837337 DOI: 10.1016/j.nrl.2014.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2013] [Revised: 02/25/2014] [Accepted: 03/10/2014] [Indexed: 10/25/2022] Open
Affiliation(s)
- A Asorey-García
- Unidad de Neurooftalmología, Servicio de Oftalmología, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, España.
| | - E Santos-Bueso
- Unidad de Neurooftalmología, Servicio de Oftalmología, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, España
| | - F Sáenz-Francés
- Unidad de Neurooftalmología, Servicio de Oftalmología, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, España
| | - J García-Feijoo
- Unidad de Neurooftalmología, Servicio de Oftalmología, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, España
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5
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Desensitisation to aspirin in antiphospholipid antibody syndrome. Allergol Immunopathol (Madr) 2013; 41:420-2. [PMID: 23265266 DOI: 10.1016/j.aller.2012.07.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2012] [Revised: 06/30/2012] [Accepted: 07/06/2012] [Indexed: 11/20/2022]
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Tower C, Mathen S, Crocker I, Bruce IN. Regulatory T cells in systemic lupus erythematosus and pregnancy. Am J Reprod Immunol 2013; 69:588-95. [PMID: 23398158 DOI: 10.1111/aji.12081] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2013] [Accepted: 01/02/2013] [Indexed: 01/18/2023] Open
Abstract
Systemic lupus erythematosus (SLE) is a chronic multisystem autoimmune disorder that predominantly affects women of reproductive age. As clinical outcomes improve, pregnancy in these women is becoming more common. Although epidemiological data have documented an improvement in the prognosis of pregnancy in these women over recent years, they are still at significantly increased risk of pregnancy complications, such as miscarriage, stillbirth, pre-eclampsia and impaired foetal growth. The pathogenesis of SLE involves marked immune dysfunction, and in particular, the function of immunosuppressive elements of the immune system is impaired, including regulatory T-cell function. Because regulatory T cells are likely to be the key cell-modulating feto-maternal tolerance, this review overviews the possibility that regulatory T-cell impairments contribute to pregnancy pathology in women with SLE and contribute to the clinical challenge of managing these women during pregnancy.
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Affiliation(s)
- Clare Tower
- Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, St Mary's Hospital, and Faculty of Medical and Human Sciences, Maternal and Fetal Health Research Centre, Institute of Human Development, University of Manchester, Manchester, UK.
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Novel insights into pathogenesis, diagnosis and treatment of antiphospholipid syndrome. Curr Opin Rheumatol 2012; 24:473-81. [DOI: 10.1097/bor.0b013e328354ae8c] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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Abstract
The antiphospholipid syndrome (APS) is an autoimmune disorder presenting with tissue injury in various organs related to large- or small-vessel thrombosis associated with antiphospholipid and antiprotein/phospholipid complex antibodies. Although the pathophysiology, diagnosis, and clinical scenario may seem clear and straightforward, a more detailed examination reveals a more complex and uncertain picture related to the management of APS. This article reviews the current situation relating to APS therapy by evaluating the different clinical features of the syndrome ranging from thrombosis to pregnancy complications together with new strategies and pharmacological approaches.
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de Jesus GRR, dos Santos FC, Oliveira CS, Mendes-Silva W, de Jesus NR, Levy RA. Management of Obstetric Antiphospholipid Syndrome. Curr Rheumatol Rep 2011; 14:79-86. [DOI: 10.1007/s11926-011-0218-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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10
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Danza A, Ruiz-Irastorza G, Khamashta M. Antiphospohlipid syndrome in obstetrics. Best Pract Res Clin Obstet Gynaecol 2011; 26:65-76. [PMID: 22079775 DOI: 10.1016/j.bpobgyn.2011.10.006] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2011] [Accepted: 10/05/2011] [Indexed: 10/15/2022]
Abstract
Antiphospholipid syndrome is characterised by a variety of clinical and immunological manifestations. The clinical hallmarks of this syndrome are thrombosis and poor obstetric outcomes, including miscarriages, fetal loss and severe pre-eclampsia. The main antiphospholipid antibodies include lupus anticoagulant, anticardiolipin and anti-β2-glycoprotein I. The combination of aspirin and heparin is considered the standard of care for women with antiphospholipid syndrome and embryo-fetal losses; however, aspirin in monotherapy may have a place in women with recurrent early miscarriage. A good benefit-risk ratio of low-molecular-weight heparin in pregnancy thrombosis treatment has been reported. Warfarin must be avoided if possible throughout the first trimester of pregnancy. Adequate pregnancy management of women with antiphospholipid syndrome should include co-ordinated medical-obstetrical care, a close follow-up protocol and a good neonatal unit. Close blood pressure control and early detection of proteinuria, together with Doppler studies of the utero-placental circulation should be included in the management protocol.
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Affiliation(s)
- Alvaro Danza
- Autoimmune Diseases Research Unit, Department of Internal Medicine, Hospital Universitario Cruces, University of the Basque Country, Bizkaia, Spain
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Abstract
Obstetric complications such as fetal death, premature delivery, preeclampsia and recurrent abortions (since chromosomal or anatomic defects have been excluded) are characteristic manifestations of antiphospholipid syndrome (APS). They can occur in patients with known APS with previous arterial or venous events in any tissue or organ, or be its first and only manifestation. Pregnancy in a patient with APS is considered high risk and the full prenatal clinical follow-up must be carried with this in mind, eliminating or minimizing concomitant thrombotic risk factors.
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Affiliation(s)
- R A Levy
- Department of Rheumatology, Faculdade de Ciências Médicas, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil.
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Ambrósio P, Lermann R, Cordeiro A, Borges A, Nogueira I, Serrano F. Lupus and pregnancy--15 years of experience in a tertiary center. Clin Rev Allergy Immunol 2010; 38:77-81. [PMID: 19557319 DOI: 10.1007/s12016-009-8139-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
This retrospective study was designed to evaluate the outcome of pregnancies in women diagnosed with systemic lupus erythematosus (SLE) followed in a tertiary fetal-maternal center. Data were collected from clinical charts between January 1993 and December 2007, with a total of 136 pregnancies (107 patients). Mean maternal age was 29 years, with the vast majority of patients being Caucasian. Most patients were in remission 6 months prior to pregnancy (93%) and the most frequently affected organs were the skin and joints. Renal lupus accounted for 14% of all cases. Twenty-nine percent of patients were positive for at least one antiphospholid antibody (aPL) and nearly 50% had positive SSa/SSb antibodies. All patients with positive aPL received low-dosage aspirin and low-molecular-weight heparin (LMWH). There were no pregnancy complications in more than 50% of cases and hypertensive disease and intrauterine growth restriction were the most common adverse events. There were 125 live births, one neonatal death, eight miscarriages, and three medical terminations of pregnancy. Preterm delivery occurred in 25% of pregnancies. Our results are probably the conjoined result of a multidisciplinary approach together with a systematic management of SLE pregnancies, with most patients keeping their prior SLE medication combined with low-dosage aspirin and LMWH in the presence of aPL.
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Affiliation(s)
- Paula Ambrósio
- Department of Fetal-Maternal Medicine, Maternidade Dr. Alfredo da Costa, Lisbon, Portugal.
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13
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Tuthill JI, Khamashta MA. Management of antiphospholipid syndrome. J Autoimmun 2009; 33:92-8. [DOI: 10.1016/j.jaut.2009.05.002] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2009] [Accepted: 05/25/2009] [Indexed: 10/20/2022]
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Ruiz-Irastorza G, Martinez-Berriotxoa A, Egurbide M. Síndrome antifosfolipídico en el siglo xxi. Med Clin (Barc) 2009; 133:390-6. [DOI: 10.1016/j.medcli.2008.10.046] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2008] [Accepted: 10/21/2008] [Indexed: 01/09/2023]
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Demaestri M, Sciascia S, Kuzenko A, Bergia R, Barberis L, Lanza MG, Bertero MT. Neonatal lupus in triplet pregnancy of a patient with undifferentiated connective tissue disease evolving to systemic lupus erythematosus. Lupus 2009; 18:368-71. [PMID: 19276307 DOI: 10.1177/0961203308097512] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Pregnancy in patients suffering from undifferentiated connective tissue disease (UCTD) represents a risk situation for both the mother and the child. SSA/SSB autoantibodies can determine neonatal lupus (NL) in the foetus, regardless of the maternal disease. Furthermore, pregnancy increases the risk of flares and evolution to differentiated connective tissue disease (CTD). We report an uncommon case in which these complications occurred in a mother and in her foetuses. A 37-year-old woman affected by UCTD developed systemic lupus erythematosus (SLE) after her triplet pregnancy. The only manifestation of neonatal lupus we observed in the three newborns was SSA positivity associated with asymptomatic transient neutropenia.
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Affiliation(s)
- M Demaestri
- Master Malattie Rare, Università degli Studi di Torino, Turin, Italy
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Ahmed K, Darakhshan A, Au E, Khamashta MA, Katsoulis IE. Postpartum spontaneous colonic perforation due to antiphospholipid syndrome. World J Gastroenterol 2009; 15:502-5. [PMID: 19152458 PMCID: PMC2653374 DOI: 10.3748/wjg.15.502] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The antiphospholipid syndrome (APS) is a multi-systemic disease being characterized by the presence of antiphospholipid antibodies that involves both arterial and venous systems resulting in arterial or venous thrombosis, fetal loss, thrombocytopenia, leg ulcers, livedo reticularis, chorea, and migraine. We document a previously unreported case of a 37-year-old female in whom APS was first manifested by infarction and cecal perforation following cesarean section. At laparotomy the underlying cause of colonic perforation was not clear and after resection of the affected bowel an ileo-colostomy was performed. The diagnosis of APS was established during post-operative hospital stay and the patient was commenced on warfarin. Eventually, she made a full recovery and had her stoma reversed after 4 mo. Pregnancy poses an increased risk of complications in women with APS and requires a more aggressive approach to the obstetric care. This should include full anticoagulation in the puerperium and frequent doppler ultrasound monitoring of uterine and umbilical arteries to detect complications such as pre-eclampsia and placental insufficiency.
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Mehrani T, Petri M. Chapter 2 Epidemiology of the Antiphospholipid Syndrome. HANDBOOK OF SYSTEMIC AUTOIMMUNE DISEASES 2009. [DOI: 10.1016/s1571-5078(08)00402-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Le Guern V, Goffinet F. Grossesse et anticorps antiphospholipides. Presse Med 2008; 37:1666-75. [DOI: 10.1016/j.lpm.2008.08.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2008] [Accepted: 08/27/2008] [Indexed: 10/21/2022] Open
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