Systemic sclerosis and pregnancy

Pregnancy in Systemic Sclerosis: Results of a Systematic Review and Metaanalysis

OBJECTIVE

Through a systematic literature search (SLR) and metaanalysis, to determine maternal and fetal outcomes in pregnancies involving systemic sclerosis (SSc), to analyze the effect of pregnancy on disease activity, and to examine predictors of fetal and maternal outcomes.

METHODS

An SLR was performed for articles on SSc and pregnancy published between 1950 and February 1, 2018. Reviewers double-extracted articles to obtain agreement on > 95% of predefined critical outcomes.

RESULTS

Out of 461 publications identified, 16 were included in the metaanalysis. The metaanalysis showed that pregnancies involving SSc were at higher risk of miscarriage (OR 1.6, 95% CI 1.22-2.22), fetuses with intrauterine growth retardation (IUGR; OR 3.2, 95% CI 2.21-4.53), preterm births (OR 2.4, 95% CI 1.14-4.86), and newborns with low birth weight (OR 3.8, 95% CI 2.16-6.56). Patients with SSc had a 2.8 times higher chance of developing gestational hypertension (HTN; OR 2.8, 95% CI 2.28-3.39) and a 2.3 times higher chance of cesarean delivery compared to controls (OR 2.3, 95% CI 1.37-3.8). The definitions of disease worsening/new visceral organ involvement were too inexact to have any confidence in the results, although worsening or new disease manifestations during pregnancy in 44/307 cases (14.3%) and 6 months postpartum in 32/306 cases (10.5%) were reported. The data did not permit definition of predictors of disease progression and of maternal and fetal outcomes.

CONCLUSION

Pregnancies involving SSc have increased frequency of miscarriages, IUGR, preterm deliveries, and newborns with low birth weight compared to healthy controls. Women with SSc were more prone to develop gestational HTN and to undergo cesarean delivery. Disease manifestations seem to remain stable or improve in most patients.

The association between reproductive factors and systemic sclerosis in Chinese women: A case-control study and meta-analysis

AIM

To examine the associations between female menstrual or reproductive factors and the development of systemic sclerosis (SSc) in China.

METHODS

In this hospital-based case-control study, for each subject, data on reproductive and menstrual factors such as number of births, abortions, and age at menarche were obtained by structured questionnaire. Risk estimates, measured by the odds ratio (OR) and 95% confidence interval (CI), were obtained by unconditional logistics regression. Furthermore, meta-analysis was performed and pooled OR with 95% CI for the number of pregnancies and abortions were calculated.

RESULTS

There were 166 SSc and 392 female controls seen during the study period. The results showed women with late menarche age (≥17 years) were less likely than those with earlier age at menarche to develop SSc (OR 0.347, 95% CI 0.174-0.693) and compared with women without abortion, women with abortion (1 time) were at reduced risk of developing SSc (P = .036). After adjusting for potential confounders such as occupation and body mass index (BMI), late age at menarche (≥17 years) was associated with a decreased risk of SSc (OR 0.187, 95% CI 0.068-0.513), but abortions were not significantly related to SSc. The meta-analysis revealed there was no association between SSc and abortions or number of pregnancies. No significant publication bias was observed (P > .05).

CONCLUSION

Late age at menarche was associated with a reduced risk of SSc but abortion may not be an independent risk factor for SSc. Further investigations are required to verify our findings.

Systemic sclerosis

Systemic sclerosis (SSc) presents with a great deal of variability from patient to patient and classification and subset criteria will be analysed and discussed. SSc has been reported in people from all over the world. The prevalence and incidence, however, varies from country to country and within the same country in different ethnic groups. These differences will be elucidated. Genetic and environmental factors associated with the disease will be discussed.SSc is predominantly a female disease, with the female:male ratio ranging from 3:1 to 8:1 and being higher in childbearing years. Progenitor cells acquired during pregnancy have been suggested to play a role by inducing a graft-versus-host disease (microchimerism). Recent epidemiological studies on the relationship between SSc and previous pregnancies will be discussed. SSc is associated with a significant morbidity and mortality. Survival has improved in the last 15 years. Factors associated with such improvement will be analysed.

Spinal anaesthesia for caesarean section in a patient with systemic sclerosis

We describe the management of a diabetic primigravid woman with systemic sclerosis and thrombocytopaenia who required Caesarean section for pre-eclampsia. This was performed successfully under spinal anaesthesia.

Maternal scleroderma: placental findings and perinatal outcome

Pregnancy after the onset of scleroderma is uncommon; therefore, placental findings and perinatal outcome have rarely been correlated. The histopathologic features of placentas from 13 pregnancies in eight women with scleroderma were recorded and correlated with the clinical features of the mother and fetus. Adverse perinatal outcome included intrauterine fetal demise in five, and previable or preterm delivery in four. A decidual vasculopathy was seen in 5 of the 13 placentas, four of which were associated with intrauterine fetal demise. Decidual blood vessels in the scleroderma patients were evaluated immunohistochemically for platelet-derived growth factor (PDGF), transforming growth factor beta1 (TGF-beta1), T-helper and T-suppressor lymphocytes, macrophages, immunoglobulin (Ig) M, and IgG, and compared with those from hypertensive and uncomplicated third-trimester pregnancies. The atherotic blood vessels in scleroderma were characterized by mural macrophages and IgM and IgG deposition and were similar to those seen in placentas from hypertensive pregnancies. CD8-positive T cells predominated in normal and hypertensive decidua compared with scleroderma, in which CD4-positive T cells were more frequent. No difference in PDGF or TGF-beta1 staining was found between scleroderma and control groups. In conclusion, decidual vasculopathy is common in scleroderma, is similar to that seen in hypertension, and is associated with poor perinatal outcome. A trend toward a reversed ratio of decidual CD4 to CD8-positive T cells is seen in scleroderma compared with hypertension and uncomplicated pregnancies. PDGF and TGF-beta1 do not appear to be involved in the pathogenesis of decidual vasculopathy in scleroderma.

Pregnancy and scleroderma

Scleroderma is a rare disease with a marked female excess in incidence. The pattern of age of onset, together with the effects of the disease, are such that the majority of women with scleroderma experience pregnancy prior to diagnosis. There are three questions of interest: (1) Does pregnancy adversely affect the prognosis of scleroderma? Isolated case reports suggest that renal disease, and in particular hypertensive crises, are associated with pregnancy in the absence of any renal abnormality before pregnancy. However, such events are rare. (2) Does scleroderma adversely affect either fertility or the outcome of pregnancy? Women with established scleroderma, again in case series, have a high rate of spontaneous miscarriage which is not found consistently in epidemiological studies. Prematurity and low birth rates are more frequent problems. (3) Does reproductive history influence disease and particularly Raynaud's phenomenon may antedate diagnosis by many years and might influence reproductive outcome, in general reproductive outcome is similar to that seen after diagnosis, although fertility appears to be reduced.