Pregnancy in women with systemic lupus erythematosus

Gene polymorphisms within regions of complement component C1q in HIV associated preeclampsia

OBJECTIVE

This study investigates the association of C1q gene (rs292001 and rs294183) polymorphisms in HIV infected and uninfected preeclamptic women of African ancestry.

MATERIALS AND METHODS

The study population consisted of 325 pregnant women of African ancestry grouped into 145 normotensive pregnant women (72 HIV uninfected normotensive, 73 HIV infected normotensive) and 180 preeclamptic pregnant women (103 HIV uninfected preeclamptics, 77 HIV infected preeclamptics). Preeclamptic pregnant women were further sub-grouped into 79 early-onset preeclampsia (EOPE) (40 HIV uninfected EOPE, 39 HIV infected EOPE) and 101 late-onset preeclampsia (LOPE) (63 HIV uninfected LOPE, 38 HIV infected LOPE). Genotyping of complement C1q gene polymorphisms (rs292001 and rs294183) was detected using a TaqMan® SNP Genotyping assay from purified DNA.

RESULTS

No significant differences in allelic and genotype frequencies of rs292001 and rs294183 between preeclamptic and normotensive women were observed. Likewise, there were no significant differences in allelic and genotype frequencies between HIV infected normotensive vs HIV infected preeclampsia and HIV uninfected normotensive vs HIV uninfected preeclampsia for both SNPs. However, the odds ratio of preeclamptic women having the GA genotype was 1:2.

CONCLUSION

We demonstrate that SNPs of the C1q gene (rs292001 and rs294183) are not associated with the pathogenesis of PE development in women of African ancestry. The role ofC1qrs292001 heterozygous GA is highlighted (with and without HIV infection) may affect susceptibility to PE development. Notably, this dysregulation may affect C1q translation and protein output thus influencing the downstream role of the complement system and functional immunology in HIV infection comorbid with PE.

Risk of adverse pregnancy outcomes prior to the onset of an autoimmune rheumatic disease: a systematic review

OBJECTIVES

An increased risk of adverse maternal and foetal pregnancy complications (including pre-eclampsia, intrauterine growth restriction, and small for gestational age) is well described in women with autoimmune rheumatic disease (ARD) compared with the general population (GenPop). It is less clear, however, whether this risk of adverse pregnancy outcome (APO) also exists in women with 'preclinical ARD' (pre-ARD) before they are diagnosed with an ARD many years post-partum. Therefore, we have undertaken a systematic review of the available evidence on APO in patients who subsequently were diagnosed with a rheumatic disease to identify whether there is an increased risk in pre-ARD.

METHODS

The present study was reported in accordance with the guidance of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standard. A systematic literature review was performed using the online PubMed database. Pre-SLE and pre-RA patients were defined as those who, over the subsequent years, developed SLE or RA according to international classification criteria.

RESULTS

A total of 176 articles were screened, and 27 original articles were selected for final analysis. Pre-RA was the most studied group, with 15 studies and a total of >1600 pregnancies, and pre-SLE was the second-most studied pre-ARD in pregnancy, with 14 studies and a total of >1000 pregnancies. We found that patients who subsequently developed SLE had an increased burden of poor pregnancy outcomes compared with pregnant women from the GenPop, but fewer APOs compared with pregnancies of women with SLE. In contrast, a similar rate of APOs was found when pre-RA pregnancies were compared with GenPop pregnancies.

CONCLUSION

Our findings of an increased risk of APO in certain pre-ARDs highlights the relevance of taking an obstetric history during the first rheumatology appointment and the need for novel screening strategies for the prediction of APOs. Further research is required to elucidate the immune basis of APOs in preclinical and clinical ARD.

Placental damage in pregnancies with systemic lupus erythematosus: A narrative review

Systemic lupus erythematosus (SLE) is a chronic inflammatory autoimmune disease of unknown cause, which mainly affects women of childbearing age, especially between 15 and 55 years of age. During pregnancy, SLE is associated with a high risk of perinatal morbidity and mortality. Among the most frequent complications are spontaneous abortion, fetal death, prematurity, intrauterine Fetal growth restriction (FGR), and preeclampsia (PE). The pathophysiology underlying obstetric mortality and morbidity in SLE is still under investigation, but several studies in recent years have suggested that placental dysfunction may play a crucial role. Understanding this association will contribute to developing therapeutic options and improving patient management thus reducing the occurrence of adverse pregnancy outcomes in this group of women. In this review, we will focus on the relationship between SLE and placental insufficiency leading to adverse pregnancy outcomes.

Intestinal macrophages in mucosal immunity and their role in systemic lupus erythematosus disease

Monocytes play an important role in inducing host systemic immunity against invading pathogens and inflammatory responses. After activation, monocytes migrate to tissue sites, where they initiate both innate and adaptive immune responses, and become macrophages. Although mucosal macrophages produce inflammatory cytokines in response to pathogens, the perturbations in innate immune signaling pathway have been implicated in autoimmune diseases such as systemic lupus erythematosus (SLE). In this review, we focus on the role of human macrophages in intestinal innate immune responses, homeostasis, and SLE disease. We further discuss sex differences in the intestinal macrophages and their role in the physiology and pathogenesis of SLE.

[Immunity impact of pregnancy on the experience of the Obstetrics and Gynecology Department of Moulay Ismail Military Hospital]

L'influence du statut hormonal au cours des maladies auto-immunes est clairement établie, avec une prévalence maximale pendant la période d'activité génitale d'où l'intérêt de notre étude rétrospective de 32 dossiers de patientes enceintes présentant des pathologies auto-immunes. Les rechutes de la maladie au cours de la grossesse sont surtout observées chez les gestantes présentant le Lupus érythémateux disséminé et la maladie de Behçet alors qu'en poste partum les complications sont observées en cas de polyarthrite rhumatoïde, sclérose en plaque et la sclérodermie. Les complications fœtales dépendent du stade et du type de la maladie auto immune ainsi que l'association à d'autres pathologies. La prise en charge multi disciplinaire et l'ajustement du traitement abouti à stabiliser la maladie auto immune et améliore le pronostique fœtale.

[Systemic autoimmune disorders and pregnancy]

The coincidence of systemic autoimmune diseases and pregnancy may modify the outcome of the disease and the pregnancy due to the background immunologic and hormonal processes. The great majority of patients with autoimmune diseases are young females in their reproductive years, willing to have babies. Consequently, we have to prepare for this special situation. Our concept on childbearing in autoimmune women has changed within the last 30 years. Earlier, systemic lupus erythematosus flared in about 50% of patients during pregnancy, but the flare rate has significantly decreased recently. This improvement can be attributed to increased attention to low diseases activity at the time of conception, which might reduce to the half of the risk for flare. Tight control of patients and appropriate use of corticosteroids also contribute to the better results. The adequate use of anti-thrombotic agents resulted in a significant amelioration of pregnancy outcome in antiphospholipid syndrome. The earlier use of methotrexate and the introduction of tumor necrosis factor-alpha inhibitors in the treatment of rheumatoid arthritis have changed the natural characteristics of the disease. The increase in remission rate indirectly has beneficial effect on the number of planned and carried out pregnancies. Authors review the connection between systemic autoimmune disorders and pregnancy as well as the possibilities of medical treatment of such diseases during pregnancy.

[Pregnancy and lupus nephritis: report of 20 cases]

AIM

Pregnancies in women with lupus nephritis (LN) are a high-risk situation. The aim of this study is to evaluate the impact of pregnancy on LN on either maternal and fetal prognosis.

PATIENTS AND METHODS

It is a retrospective study of 20 pregnancies in 12 women with lupus nephritis.

RESULTS

There were 19 live births and five fetal losses. LN flares were observed in 50 % of the cases during pregnancy and 25 % after delivery.

CONCLUSION

Pregnancies in women with LN require a multidisciplinary monitoring and intense maternal and fetal care.

Identification of rare anti-phospholipid/protein co-factor autoantibodies in patients with systemic lupus erythematosus

Lupus anticoagulant (LA) and beta2-glikoprotein I (b2GPI) dependent anti-cardiolipin (aCL) are part of the diagnostic criteria both of systemic lupus erythematosus (SLE) and anti-phospholipid syndrome (APS). Anti-phospholipid antibodies (aPL) may also bind to other phospholipids and/or protein co-factors. In the present study, besides aCL and anti-b2GPI, antibodies directed against phosphatidylserine, prothrombin (PT) and annexin V (aANX) were measured in 85 randomly selected SLE patients, 14 suffering from secondary APS. LA was detected by hemostasis tests. Correlations were determined between rare aPLs and clinical manifestations, including thrombotic events. Anti-cardiolipin IgG was positive in 14 patients, aCL IgM in 8, anti-b2GPI IgG in 4 and IgM in 5 patients. LA was detected in nine cases. Seven patients were positive for anti-phosphatidylserine (aPS) IgG, nine for aPS IgM, while anti-PT (aPT) IgG was positive in nine cases. aPT IgM and anti-aANX were negative in all patients. Correlation was found between aPS and aCL antibodies. The frequency and concentration of rare anti-phospholipid/co-factor antibodies was higher in patients with secondary APS. The presence of such rare aPLs cumulated in APS patients, their presence increased the frequency of thrombotic events in the entire study population, furthermore in patients positive for LA or aCL. Rare anti-phospholipid/co-factor antibodies were found in 12% of an un-selected lupus patient population. Their presence was more frequent in patients with secondary APS, and further increased the risk of thrombotic complications.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

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

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

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

Management of the High-Risk Lupus Pregnant Patient

Pregnancy in the lupus patient presents a unique clinical challenge. Pregnancy may interact with lupus nephritis and adds preeclampsia to the differential diagnosis of hypertension. Lupus may result in pregnancy loss, fetal growth restriction, and prematurity. The obstetric management of these complex issues is presented for the nonobstetrician.

Systemic lupus erythematosus and pregnancy: clinical evolution, maternal and perinatal outcomes and placental findings

CONTEXT AND OBJECTIVE

Systemic lupus erythematosus is a chronic disease that is more frequent in women of reproductive age. The relationship between lupus and pregnancy is problematic: maternal and fetal outcomes are worse than in the general population, and the management of flare-ups is difficult during this period. The aim here was to compare the outcomes of 76 pregnancies in 67 women with lupus, according to the occurrence or absence of flare-ups.

DESIGN AND SETTING

An observational cohort clinical study evaluating the evolution of pregnant women with lupus who were receiving care at the prenatal outpatient clinic, Centro de Atenção Integral à Saúde da Mulher, Universidade Estadual de Campinas (CAISM/Unicamp), between 1995 and 2002.

METHODS

Data were collected on a precoded form. The women were divided into two groups according to the occurrence or absence of flare-ups, as defined by the systemic lupus erythematosus disease activity index (SLEDAI). The presence or absence of flare-ups and renal involvement was considered to be the independent variable and the other results were dependent variables.

RESULTS

Flare-ups occurred in 85.3% of cases, and were most significant when there was renal involvement. This was related to greater numbers of women with preeclampsia and poor perinatal outcome. Intrauterine growth restriction was more common in the women with active disease. Placental weight was significantly lower in the women with renal involvement.

CONCLUSIONS

Flare-ups and renal involvement in lupus patients during pregnancy are associated with increased maternal and perinatal complications.

Outcome of pregnancy in patients with systemic lupus erythematosus

OBJECTIVE

To study the maternal and fetal outcomes in women with systemic lupus erythematosus (SLE).

MATERIALS AND METHODS

Over a period of 10 years, 24 pregnancies in 17 females with SLE in a single center were enrolled. Fetal and maternal outcomes were studied retrospectively.

RESULTS

The mean patient age was 27.7 years. Twenty-one of the 24 pregnancies occurred in the period of disease remission at the time of conception. Proteinuria presented in 12 pregnancies; however, no patient developed acute renal failure or deterioration of renal function. There were three cases of preeclampsia in this study. Two patients had their disease flare up and delivered stillborns. One woman with secondary antiphospholipid syndrome (APS) had a fetal loss. There was no maternal mortality. The mean gestation age was 34.3 weeks (range, 17-41 weeks), and the mean birth weight was 2,179 g. The mean APGAR scores were 8 and 9 at 1 and 5 minutes, respectively. One baby with congenital atrioventricular block was born to a mother with positive anti-SSA antibody. There were five cases (20.8%) of intrauterine growth retardation and 10 preterm deliveries (41.6%) in this study.

CONCLUSION

Pregnancy is relatively safe in women with SLE in remission but should be considered as a high-risk pregnancy. APS is associated with poor pregnancy outcome. The patient needs to cooperate with obstetricians and physicians for optimal disease control and detailed monitoring throughout the gestation.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Hypertensive disease in pregnancies complicated by systemic lupus erythematosus

OBJECTIVE

The purpose of this study was to assess the percentage of hypertensive disease in pregnancies complicated by systemic lupus erythematosus at a single institution.

STUDY DESIGN

We conducted a retrospective analysis of medical records between 1992 and 2003 of 68 pregnancies that were complicated by systemic lupus erythematosus from 48 parturients. Patients were categorized into 3 groups: no chronic hypertension (n = 49 women), chronic hypertension-no medication (n = 6 women) and chronic hypertension-treated (n = 13 women). Analyses of variance (with Tukey-Kramer adjusted follow-up evaluation) and chi-squared/Fisher's exact tests were used for the analyses of continuous and categoric variables, respectively. Significance was defined by a probability value of < or = .05.

RESULTS

Chronic hypertension complicated 28% of systemic lupus erythematosus pregnancies. Mean systolic blood pressures at intake were significantly different between the normotensive and no chronic hypertension groups and between the chronic hypertension-no medication and chronic hypertension-treated groups; the differences in diastolic pressures reached significance only between the no chronic hypertension and the chronic hypertension-treated groups. Maternal age, gestational age at delivery, birth weight, lowest platelet count, and highest serum creatinine levels were similar between the hypertensive and the nonhypertensive groups. There were no differences in the percentage of aspirin or heparin treatments among the groups, but the percentage of the chronic hypertension-treated group who received steroids was significantly greater than the percentage of women who received steroids in the other 2 groups (P < .05). Preeclampsia developed in 23% of the no chronic hypertension pregnancies and in 32% of the hypertensive pregnancies (P = .54). When pregnancies that were treated with prednisone (n = 34 pregnancies) were compared with those pregnancies that were managed with other agents (n = 34 pregnancies), the percentages of preeclampsia were similar (26% and 24%, respectively; P = .78).

CONCLUSION

The percentage of parturients with systemic lupus erythematosus in whom preeclampsia develops is increased, regardless of the presence of underlying chronic hypertension. Prednisone therapy was not associated with a higher risk of preeclampsia in this series.

Pregnancy outcomes before and after a diagnosis of systemic lupus erythematosus

OBJECTIVE

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

STUDY DESIGN

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

RESULTS

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

CONCLUSION

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

Association of rheumatologic disease with preeclampsia

OBJECTIVE

To determine whether maternal rheumatologic disease is associated with an increased risk of adverse obstetric or neonatal outcomes.

METHODS

Using an institutional database, we identified all women with diagnosed rheumatologic disease (n = 114) who delivered a baby at our institution during a 33-month period. We compared the incidence of adverse obstetric and neonatal outcomes among these women with the incidence among women without rheumatologic diseases (n = 18,534).

RESULTS

Women with rheumatologic diseases were more likely to have preeclampsia than women without rheumatologic disease (8.8% versus 2.3%, P <.001) Women with rheumatologic diseases were also at increased risk of preterm delivery (15.2% versus 7.8%, P =.002) and small-for-gestational-age infants (8.0% versus 3.1%, P =.001) compared with women without rheumatologic disease.

CONCLUSION

The finding that women with rheumatologic diseases are at increased risk of adverse obstetric outcomes suggests a need for heightened clinical vigilance and further research into the common pathophysiologic correlates.

LEVEL OF EVIDENCE

II-2

Henoch-Schonlein purpura in pregnancy

Henoch-Schönlein purpura (HSP) is an IgA-mediated small vessel vasculitis which commonly involves the skin, gastrointestinal system and kidneys. Numerous HSP triggers have been identified, and pregnancy has been reported as an exacerbating factor. After a pregnant woman had been diagnosed as having new-onset HSP, we reviewed all cases of immunofluorescence-proven HSP evaluated by the Department of Dermatology at the Johns Hopkins Hospital between 1990 and 2002, and report three cases of HSP occurring during pregnancy. Two patients developed new-onset HSP, one at 16 weeks gestation and one at 22 weeks, while the third developed a recurrence of HSP at 12 weeks gestation after 19 years of remission. We conclude that pregnancy may be a trigger for HSP onset or recurrence in susceptible individuals.