Neonatal lupus erythematosus associated with maternal mixed connective tissue disease

Pregnancy outcomes in mixed connective tissue disease: a multicentre study

Objectives

In this study we aimed to investigate foetal and maternal pregnancy outcomes from a large multicentre cohort of women diagnosed with MCTD and anti-U1RNP antibodies.

Methods

This multicentre retrospective cohort study describes the outcomes of 203 pregnancies in 94 consecutive women ever pregnant who fulfilled the established criteria for MCTD with confirmed U1RNP positivity.

Results

The foetal outcomes in 203 pregnancies were as follows: 146 (71.9%) live births, 38 (18.7%) miscarriages (first trimester pregnancy loss of <12 weeks gestation), 18 (8.9%) stillbirths (pregnancy loss after 20 weeks gestation) and 11 (5.4%) cases with intrauterine growth restriction. Maternal pregnancy outcomes were as follows: 8 (3.9%) developed pre-eclampsia, 2 (0.9%) developed eclampsia, 31 (15.3%) developed gestational hypertension and 3 (1.5%) developed gestational diabetes. Women with MCTD and aPL and pulmonary or muscular involvement had worse foetal outcomes compared with those without. Moreover, we report a case of complete congenital heart block (0.45%) and a case of cutaneous neonatal lupus, both born to a mother with positive isolated anti-U1RNP and negative anti-Ro/SSA antibodies.

Conclusion

In our multicentre cohort, women with MCTD had a live birth rate of 72%. While the true frequency of heart block associated with anti-U1RNP remains to be determined, this study might raise the consideration of echocardiographic surveillance in this setting. Pregnancy counselling should be considered in women with MCTD.

Mixed connective tissue disease in pregnancy: A case series and systematic literature review

OBJECTIVE

To investigate the impact of medical and obstetric complications associated with mixed connective tissue disease (MCTD) in pregnancy.

METHOD

We analyzed 68 pregnancies from a systematic literature review and 12 pregnancies affected by MCTD at our centre between 1986 and 2015 for medical and obstetric complications.

RESULTS

During pregnancy 37.1% had active MCTD and 26.7% had relapsed. Maternal complications included caesarean section (31.1%, n = 19), preeclampsia (17.6%, n = 13), thromboembolism events, and death (2.5%, n = 2 for each). Fetal complications included prematurity (48.1%, n = 25), intrauterine growth restriction (38.3%, n = 19), and neonatal lupus (28.6%, n = 18, including chondrodysplasia punctata). More than half (n = 10) of the neonatal lupus cases were explained by anti-U1RNP only. The perinatal mortality rate was 17.7% (n = 14). Pregnant women with active disease had higher rates of prematurity (OR = 7.60; 95%CI [1.93; 29.95]) and perinatal death (OR = 16.83; 95%CI [1.90; 147.70]).

CONCLUSION

MCTD in pregnancy puts women at risk of medical and obstetric complications, and disease activity probably increases this risk.

Neonatal lupus syndrome associated with ribonucleoprotein antibodies

Neonatal lupus erythematosus (NLE) is a rare acquired autoimmune disease caused by transplacental transfer of maternal immunoglobulin G antibodies to the fetus. NLE has well-recognized cutaneous features and may also manifest in other organs. The majority of cases are associated with Ro/SSA and La/SSB antibodies. Neonatal lupus due to antiribonucleoprotein (RNP) antibodies has rarely been reported. On rare occasions RNP has been found in association with other antibodies. We report a case of NLE occurring solely due to RNP antibodies presenting as varicelliform lesions at birth. We recorded the features in our case and 14 additional cases identified in the literature. It is important to recognize that maternal transfer of RNP antibodies may produce the classic cutaneous features of neonatal lupus. The limited case reports of this condition suggest that manifestations are limited to the skin; specifically, there are no reports of cardiac involvement. The long-term outcome remains unknown. RNP-positive, Ro/La-negative NLE seems to represent a different clinical subset of NLE. The recognition of RNP antibody NLE as a benign condition limited to the skin is helpful in planning antenatal care for subsequent pregnancies.

Peripartum bilateral uterine rupture in a patient with mixed connective tissue disease with favorable outcome for the severely asphyctic newborn after hypothermia

PURPOSE

Information about fetal and maternal outcome in pregnant women with mixed connective tissue disease (MCTD) is rare and in part contradictory. The purpose of this study is to review published literature about MCTD in pregnancy in the context of a rare case of peripartum bilateral uterine rupture in a patient with MCTD with favorable outcome for the severely asphyctic newborn after hypothermia.

METHOD

The study included a selective literature review based on a PubMed search using the search terms MCTD, Sharp syndrome, uterine rupture and hypothermia, and a detailed report of our case with regard to the MCTD of the patient.

RESULTS

Rupture to the backside of the uterus during delivery, independent of prior cesarean section, was unpredictable and its cause remains unclear. The clinical outcome of the newborn was surprisingly favorable and there were no signs of neurodevelopmental sequelae in spite of the fact that the newborn was asphyctic and had a large excess of acids in the umbilical cord blood gas analysis. The favorable outcome is due to treatment with whole body hypothermia.

CONCLUSIONS

Any type of prior surgery of the uterus puts the patient at risk during delivery. MCTD might be a risk factor during birth. These patients should be followed closely during pregnancy and should deliver at a center, which provides all options for immediate surgical and neonatological intervention.

Autoantibodies in the Pathogenesis of Mixed Connective Tissue Disease

Antibodies to U1-RNP are part of the clinical definition of mixed connective tissue disease (MCTD). These antibodies and other well-defined antibodies tend to arise together in affected patients. Although still speculative, hypotheses that link U1-RNP antibodies to the development of autoimmunity in MCTD and that associate U1-RNP antibodies with mechanisms of tissue injury in MCTD have emerged and are being tested. Salient features of these hypotheses include: (1) an antigen-driven response that is due to impaired clearance of potentially immunogenic self-antigens, (2) inadequate B- and T-cell tolerance to RNP autoantigens, and (3) immunogenic properties of the RNA component of targeted ribonucleoproteins. Further studies are needed to establish whether anti-RNP antibodies have prognostic importance that is relevant to practicing clinicians.

Neonatal lupus erythematosus presenting as papules on the feet

We describe a case of neonatal lupus erythematosus in a 4-week-old male baby presenting with nodules/papules on the plantar surface of both feet. Skin histology of the right foot papule was consistent with lupus erythematosus. Annular lesions more typical of this condition then appeared later and maternal antibodies were positive for speckled antinuclear antibodies (1:5120), anti-Ro/SSA and anti-La/SSB(+), rheumatoid factor 1380.0 IU/mL. The patient had no evidence of cardiac, haematological or hepatobilary involvement. Although the mother was asymptomatic, the maternal grandmother had recently been diagnosed with Sjögren's syndrome.

Pregnancy in Mixed Connective Tissue Disease

This article discusses fetal and maternal morbidity in women who have mixed connective tissue disease.

[Neonatal lupus syndrome]

Neonatal lupus syndrome is a passively acquired autoimmune syndrome in which pathogenic autoantibodies (anti-SSA/Ro, anti-SSB/La, and both, or rarely anti-U(1)RNP antibodies) are transmitted from a mother to her fetus through the placenta. The major clinical manifestations in the infants are cardiac (congenital heart block), dermatologic (skin lesion), hepatic (elevated hepatic enzymes), and hematologic (cytopenia). Congenital complete heart block (CCHB) is irreversible, while noncardiac manifestations are transient, resolving by one-year-old of age without specific treatments. Two prospective studies show that the prevalence of CCHB in children from a woman previously known to have anti-SSA/Ro antibodies is approximately 2%. However, when the previous pregnancy is complicated by CCHB and skin lesion, the recurrence rates of these symptoms go much higher to 10.5% and 26%, respectively, in the subsequent pregnancy.