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Andreoli L, Regola F, Caproli A, Crisafulli F, Fredi M, Lazzaroni MG, Nalli C, Piantoni S, Zatti S, Franceschini F, Tincani A. Pregnancy in antiphospholipid syndrome: what should a rheumatologist know? Rheumatology (Oxford) 2024; 63:SI86-SI95. [PMID: 38320595 DOI: 10.1093/rheumatology/kead537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 09/03/2023] [Indexed: 02/08/2024] Open
Abstract
This review focuses on the management of reproductive issues in women who have antiphospholipid syndrome (APS) or are carriers of antiphospholipid antibodies (aPL). The importance of aPL detection during preconception counselling relies on their pathogenic potential for placental insufficiency and related obstetric complications. The risk of adverse pregnancy outcomes can be minimized by individualized risk stratification and tailored treatment aimed at preventing placental insufficiency. Combination therapy of low-dose acetylsalicylic acid and heparin is the mainstay of prophylaxis during pregnancy; immunomodulation, especially with hydroxychloroquine, should be considered in refractory cases. Supplementary ultrasound surveillance is useful to detect fetal growth restriction and correctly tailor the time of delivery. The individual aPL profile must be considered in the stratification of thrombotic risk, such as during assisted reproduction techniques requiring hormonal ovarian stimulation or during the follow-up after pregnancy in order to prevent the first vascular event.
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Affiliation(s)
- Laura Andreoli
- Rheumatology and Clinical Immunology Unit - ERN ReCONNET, ASST Spedali Civili; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Francesca Regola
- Rheumatology and Clinical Immunology Unit - ERN ReCONNET, ASST Spedali Civili; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Alessia Caproli
- Rheumatology and Clinical Immunology Unit - ERN ReCONNET, ASST Spedali Civili; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Francesca Crisafulli
- Rheumatology and Clinical Immunology Unit - ERN ReCONNET, ASST Spedali Civili; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Micaela Fredi
- Rheumatology and Clinical Immunology Unit - ERN ReCONNET, ASST Spedali Civili; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Maria-Grazia Lazzaroni
- Rheumatology and Clinical Immunology Unit - ERN ReCONNET, ASST Spedali Civili; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Cecilia Nalli
- Rheumatology and Clinical Immunology Unit - ERN ReCONNET, ASST Spedali Civili; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Silvia Piantoni
- Rheumatology and Clinical Immunology Unit - ERN ReCONNET, ASST Spedali Civili; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Sonia Zatti
- Department of Obstetrics and Gynaecology, ASST Spedali Civili, Brescia, Italy
| | - Franco Franceschini
- Rheumatology and Clinical Immunology Unit - ERN ReCONNET, ASST Spedali Civili; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Angela Tincani
- Rheumatology and Clinical Immunology Unit - ERN ReCONNET, ASST Spedali Civili; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
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Rodriguez-Pintó I, Espinosa G, Cervera R. What we know and what we don't know about catastrophic antiphospholipid syndrome. Rheumatology (Oxford) 2024; 63:SI46-SI53. [PMID: 38320593 DOI: 10.1093/rheumatology/kead556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 08/16/2023] [Indexed: 02/08/2024] Open
Abstract
Catastrophic antiphospholipid syndrome (CAPS) is a severe condition with high mortality. Since its description in 1992, an important effort has been made to improve and disseminate knowledge on CAPS. Most of our current knowledge comes from the studies performed using the CAPS Registry, a database created in 2000 to gather as many cases as possible in order to better define this disease. It has demonstrated that this condition has multiple faces and is often triggered by a precipitating factor that leads to a thrombotic microangiopathy and cytokine storm involving almost any organ of the body. Analysis of the CAPS Registry has also shown that patients receiving anticoagulation, glucocorticoids and plasma exchange and/or IVIG have a better prognosis. However, there are still many unresolved questions. In this review we summarize what is known and what is still a matter of research in this condition.
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Affiliation(s)
- Ignasi Rodriguez-Pintó
- Autoimmune Diseases Unit, Hospital Universitari Mútua de Terrassa, Terrassa, Catalonia, Spain
| | - Gerard Espinosa
- Department of Autoimmune Diseases, Reference Centre for Systemic Autoimmune Diseases (UEC, CSUR) of the Catalan and Spanish Health Systems/Member of ERN-ReCONNET, Hospital Clínic, Barcelona, Catalonia, Spain
| | - Ricard Cervera
- Department of Autoimmune Diseases, Reference Centre for Systemic Autoimmune Diseases (UEC, CSUR) of the Catalan and Spanish Health Systems/Member of ERN-ReCONNET, Hospital Clínic, Barcelona, Catalonia, Spain
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Hooper A, Bacal V, Bedaiwy MA. Does adding hydroxychloroquine to empiric treatment improve the live birth rate in refractory obstetrical antiphospholipid syndrome? A systematic review. Am J Reprod Immunol 2023; 90:e13761. [PMID: 37641373 DOI: 10.1111/aji.13761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 07/04/2023] [Accepted: 07/24/2023] [Indexed: 08/31/2023] Open
Abstract
PROBLEM The current standard prevention of obstetric complications in patients with antiphospholipid antibody syndrome (APS) is the use of combination low-dose aspirin and low molecular weight heparin. However, 20-30% of women still experience refractory obstetrical APS. Hydroxychloroquine (HCQ) is an immunomodulatory agent that has been shown in laboratory studies to decrease thrombosis risk, support placentation, and minimize the destructive effects of antiphospholipid antibodies. The objective of this study was to evaluate the risk of pregnancy loss upon treatment with HCQ among women with refractory obstetrical APS. METHOD OF STUDY A systematic review was conducted according to PRISMA guidelines. Studies that evaluated the use of HCQ during pregnancy in women with primary APS were included. The primary outcomes of interest were live birth and pregnancy losses after treatment with HCQ. RESULTS Twelve studies met inclusion criteria. Three retrospective cohort studies demonstrated improved live birth rate, and four studies demonstrated a reduction in pregnancy loss rate. Two case reports also demonstrated a benefit in the use of HCQ compared to previous obstetrical outcomes. CONCLUSIONS Our findings suggest a significant benefit of HCQ in addition to aspirin and heparin for patients with APS to mitigate the risk of antiphospholipid antibody mediated obstetrical complications. Randomized controlled trials with standardized patient selection criteria need to be conducted to corroborate these findings.
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Affiliation(s)
- Allyssa Hooper
- Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Vanessa Bacal
- Department of Obstetrics & Gynaecology, The University of Toronto, Toronto, Ontario, Canada
- Mount Sinai Fertility, Toronto, Ontario, Canada
| | - Mohamed A Bedaiwy
- Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
- Department of Obstetrics & Gynecology, The University of British Columbia, Vancouver, British Columbia, Canada
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Murarasu A, Guettrot-Imbert G, Le Guern V, Yelnik C, Queyrel V, Schleinitz N, Ferreira-Maldent N, Diot E, Urbanski G, Pannier E, Lazaro E, Souchaud-Debouverie O, Orquevaux P, Belhomme N, Morel N, Chauvet E, Maurier F, Le Besnerais M, Abisror N, Goulenok T, Sarrot-Reynauld F, Deroux A, Pasquier E, de Moreuil C, Bezanahary H, Pérard L, Limal N, Langlois V, Calas A, Godeau B, Lavigne C, Hachulla E, Cohen F, Benhamou Y, Raffray L, de Menthon M, Tieulié N, Poindron V, Mouthon L, Larosa M, Eléfant E, Sentilhes L, Molto A, Deneux-Tharaux C, Costedoat-Chalumeau N. Characterisation of a high-risk profile for maternal thrombotic and severe haemorrhagic complications in pregnant women with antiphospholipid syndrome in France (GR2): a multicentre, prospective, observational study. THE LANCET. RHEUMATOLOGY 2022; 4:e842-e852. [PMID: 38261392 DOI: 10.1016/s2665-9913(22)00308-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 09/30/2022] [Accepted: 10/03/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Prospective data about the risks of thrombotic and severe haemorrhagic complications during pregnancy and post partum are unavailable for women with antiphospholipid syndrome. We aimed to assess thrombotic and haemorrhagic events in a prospective cohort of pregnant women with antiphospholipid syndrome. METHODS This multicentre, prospective, observational study was done at 76 centres in France. To be eligible for this study, women had to have diagnosis of antiphospholipid syndrome; have conceived before April 17, 2020; have an ongoing pregnancy that had reached 12 weeks of gestation; and be included in the study before 18 weeks of gestation. Exclusion criteria were active systemic lupus erythematosus nephropathy, or a multifetal pregnancy. Severe haemorrhage was defined as the need for red blood cell transfusion or maternal intensive care unit admission because of bleeding or invasive procedures, defined as interventional radiology or surgery, to control bleeding. The GR2 study is registered with ClinicalTrials.gov, NCT02450396. FINDINGS Between May 26, 2014, and April 17, 2020, 168 pregnancies in 27 centres met the inclusion criteria for the study. 89 (53%) of 168 women had a history of thrombosis. The median term at inclusion was 8 weeks gestation. 16 (10%) of 168 women (95%CI 5-15) had a thrombotic (six [4%] women; 95% CI 1-8) or severe haemorrhagic event (12 [7%] women; 95% CI 4-12). There were no deaths during the study. The main risk factors for thrombotic events were lupus anticoagulant positivity at inclusion (six [100%] of six women with thrombosis vs 78 [51%] of 152 of those with no thrombosis; p=0·030) and placental insufficiency (four [67%] of six women vs 28 [17%] of 162 women; p=0·013). The main risk factors for severe haemorrhagic events were pre-existing maternal hypertension (four [33%] of 12 women vs 11 [7%] of 156 women; p=0·014), lupus anticoagulant positivity at inclusion (12 [100%] of 12 women vs 72 [49%] of 146 women; p<0·0001) and during antiphospholipid history (12 [100%] of 12 women vs 104 [67%] of 156 women; p=0·019), triple antiphospholipid antibody positivity (eight [67%] of 12 women vs 36 [24%] of 147 women; p=0·0040), placental insufficiency (five [42%] of 12 women vs 27 [17%] of 156 women; p=0·038), and preterm delivery at 34 weeks or earlier (five [45%] of 11 women vs 12 [8%] of 145 women; p=0·0030). INTERPRETATION Despite treatment adhering to international recommendations, a proportion of women with antiphospholipid syndrome developed a thrombotic or severe haemorrhagic complication related to pregnancy, most frequently in the post-partum period. Lupus anticoagulant and placental insufficiency were risk factors for these life-threatening complications. These complications are difficult to prevent, but knowledge of the antenatal characteristics associated with them should increase awareness and help physicians manage these high-risk pregnancies. FUNDING Lupus France, association des Sclérodermiques de France, association Gougerot Sjögren, Association Francophone contre la Polychondrite chronique atrophiante, AFM-Telethon, the French Society of Internal Medicine and Rheumatology, Cochin Hospital, the French Health Ministry, FOREUM, the Association Prix Veronique Roualet, and UCB.
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Affiliation(s)
- Anne Murarasu
- Assistance Publique-Hôpitaux de Paris, Service de Médecine Interne, Centre de Référence Maladies Auto-immunes et Systémiques Rares, Hôpital Cochin, Université de Paris, Paris, France; Assistance Publique-Hôpitaux de Paris, Centre for Clinical Epidemiology, Hôpital Hôtel-Dieu, Université de Paris, Centre of Research in Epidemiology and Statistics, Paris, France
| | - Gaëlle Guettrot-Imbert
- Assistance Publique-Hôpitaux de Paris, Service de Médecine Interne, Centre de Référence Maladies Auto-immunes et Systémiques Rares, Hôpital Cochin, Université de Paris, Paris, France
| | - Véronique Le Guern
- Assistance Publique-Hôpitaux de Paris, Service de Médecine Interne, Centre de Référence Maladies Auto-immunes et Systémiques Rares, Hôpital Cochin, Université de Paris, Paris, France
| | - Cécile Yelnik
- Univ Lille, Inserm, CHU Lille, Service de Médecine Interne, U1167 RID-AGE, Lille, France
| | | | - Nicolas Schleinitz
- Service de Médecine Interne, Aix Marseille Université, APHM, Hôpital La Timone, Marseille, France
| | | | | | | | - Emmanuelle Pannier
- Assistance Publique-Hôpitaux de Paris, Service de Maternité Gynécologie Obstétrique Port-Royal, Université de Paris, Hôpital Cochin, Paris, France
| | - Estibaliz Lazaro
- Service de Médecine Interne, Hôpital du Haut-Lévêque, Pessac, France
| | | | | | - Nicolas Belhomme
- Service de Médecine Interne et Immunologie Clinique, Hôpital Sud, Rennes; Inserm, EHESP, Irset (Institut de recherche en santé, environnement et travail)-UMR_S 1085, Rennes, France
| | - Nathalie Morel
- Assistance Publique-Hôpitaux de Paris, Service de Médecine Interne, Centre de Référence Maladies Auto-immunes et Systémiques Rares, Hôpital Cochin, Université de Paris, Paris, France
| | - Elodie Chauvet
- Service de Médecine Interne, Centre Hospitalier Saint Jean, Perpignan, France
| | - François Maurier
- Service de Médecine Interne et Immunologie Clinique Groupe Hospitalier UNEOS Site Hôpital Robert Schuman, Vantoux, France
| | - Maëlle Le Besnerais
- Service de Médecine Interne, CHU Rouen, Rouen, France; INSERM U 905, Université de Rouen IFRMP, Institute for Biochemical Research, Centre Hospitalier Universitaire de Rouen, Rouen, France
| | - Noemie Abisror
- Sorbonne Université, Service de Médecine Interne, AP-HP, Hôpital Saint Antoine, Paris, France
| | - Tiphaine Goulenok
- Service de Médecine Interne, Hôpital Bichat Claude Bernard, AP-HP, Paris, France
| | | | - Alban Deroux
- Service de Médecine Interne, CHU Grenoble-Alpes, Grenoble, France
| | | | - Claire de Moreuil
- Service de Médecine Interne et Pneumologie, CHU de Brest, Brest, France
| | | | - Laurent Pérard
- Service de Médecine Interne, Centre Hospitalier Saint Joseph Saint Luc, Lyon, France
| | - Nicolas Limal
- Assistance Publique-Hôpitaux de Paris, Service de Médecine Interne, CHU Henri Mondor, Université Paris-Est Créteil, Créteil, France
| | - Vincent Langlois
- Service de Médecine Interne et Maladies Infectieuses, Hôpital Le Havre, Le Havre, France
| | - Anne Calas
- Service de Médecine Interne, Polyclinique Saint Laurent, Rennes, Frances
| | - Bertrand Godeau
- Assistance Publique-Hôpitaux de Paris, Service de Médecine Interne, CHU Henri Mondor, Université Paris-Est Créteil, Créteil, France
| | | | - Eric Hachulla
- Univ Lille, Inserm, CHU Lille, Service de Médecine Interne et Immunologie Clinique, Centre de référence des maladies autoimmunes systémiques rares du Nord et Nord-Ouest de France (CeRAINO), U1286-INFINITE-Institute for Translational Research in Inflammation, Lille, France
| | - Fleur Cohen
- Sorbonne Université, Assistance Publique Hôpitaux de Paris, Hôpital de la Pitié-Salpêtrière, Service de médecine interne 2, Centre national de référence maladies auto-immunes et systémiques rares, lupus et syndrome des anticorps antiphospholipides, Paris, France
| | - Ygal Benhamou
- Service de Médecine Interne, CHU Rouen, Rouen, France; INSERM U 905, Université de Rouen IFRMP, Institute for Biochemical Research, Centre Hospitalier Universitaire de Rouen, Rouen, France
| | - Loïc Raffray
- Service Médecine Interne et Dermatologie, CHU Réunion-Hôpital Félix Guyon, Saint Denis, France
| | - Mathilde de Menthon
- Assistance Publique Hôpitaux de Paris, Service de Médecine Interne et Immunologie Clinique, Hôpital Bicêtre, Le Kremlin Bicêtre, France
| | | | - Vincent Poindron
- Service d'Immunologie Clinique, Nouvel Hôpital Civil, Strasbourg, France; Centre de référence maladies autoimmunes rares Est Sud Ouest RESO, Strasbourg, France
| | - Luc Mouthon
- Assistance Publique-Hôpitaux de Paris, Service de Médecine Interne, Centre de Référence Maladies Auto-immunes et Systémiques Rares, Hôpital Cochin, Université de Paris, Paris, France
| | | | - Elisabeth Eléfant
- Centre de Reference sur les Agents Tératogènes (CRAT), Hôpital Armand-Trousseau, Paris, France
| | - Loic Sentilhes
- Service de Gynécologie Obstétrique, CHU de Bordeaux, Bordeaux, France
| | - Anna Molto
- Assistance Publique-Hôpitaux de Paris, Centre for Clinical Epidemiology, Hôpital Hôtel-Dieu, Université de Paris, Centre of Research in Epidemiology and Statistics, Paris, France; Assistance Publique-Hôpitaux de Paris, Service de Rhumatologie, Hôpital Cochin, Université de Paris, Paris, France
| | - Catherine Deneux-Tharaux
- Université de Paris, U1153 Centre for Epidemiology and Statistics Sorbonne Paris Cité (CRESS), Obstetrical Perinatal and Pediatric Epidemiology Research Team, EPOPé, INSERM, INRA, Paris, France
| | - Nathalie Costedoat-Chalumeau
- Assistance Publique-Hôpitaux de Paris, Service de Médecine Interne, Centre de Référence Maladies Auto-immunes et Systémiques Rares, Hôpital Cochin, Université de Paris, Paris, France; Assistance Publique-Hôpitaux de Paris, Centre for Clinical Epidemiology, Hôpital Hôtel-Dieu, Université de Paris, Centre of Research in Epidemiology and Statistics, Paris, France.
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5
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Morel N, Bonnet C, Mehawej H, Le Guern V, Pérard L, Roumier M, Brezin A, Godeau B, Haroche J, Benhamou Y, Lambert M, Yelnik CM, Maillard N, Bodaghi B, Piette JC, Costedoat-Chalumeau N. CATASTROPHIC ANTIPHOSPHOLIPID SYNDROME AND POSTERIOR OCULAR INVOLVEMENT: Case Series of 11 Patients and Literature Review. Retina 2021; 41:2332-2341. [PMID: 33840791 DOI: 10.1097/iae.0000000000003185] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To describe the posterior ophthalmic manifestations of catastrophic antiphospholipid syndrome. METHODS Retrospective case series of patients presenting with catastrophic antiphospholipid syndrome and posterior segment ocular manifestations. The main outcomes were the type of posterior segment manifestations at catastrophic antiphospholipid syndrome diagnosis, specifically retinal vascular occlusion, vasculitis, or choroidopathy, and the final best-corrected visual acuity. RESULTS This study included 23 patients (11 cases treated by the authors and 12 published case reports); 21 (91%) of them female. Their median age at diagnosis was 28 years (range, 16-79 years). Ophthalmologic manifestations were usually bilateral (n = 19, 83%) and involved vascular occlusive retinopathy (n = 17, 74%), choroidopathy (n = 11, 48%), or retinal vasculitis (n = 1, 4%). Final best-corrected visual acuity was not significantly worse than the best-corrected visual acuity at diagnosis (P = 0.16). Retinal vascular occlusions were associated with poorer final visual acuity than choroidopathy (P = 0.002). After a median follow-up of 14 months (range, 2-132 months), nearly half the patients (n = 11, 48%) had permanent vision loss including best-corrected visual acuity of <20/400 for 4 patients. CONCLUSION Posterior ophthalmic manifestations of catastrophic antiphospholipid syndrome were mainly bilateral retinal vascular occlusion, which had the worst visual prognosis, followed by choroidopathy and retinal vasculitis. Permanent visual loss was common.
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Affiliation(s)
- Nathalie Morel
- AP-HP, Cochin Hospital, Internal Medicine Department, Centre de Référence Maladies Auto-immunes et Systémiques Rares de l'Ile de France, AP-HP, Cochin Hospital, Paris, France
| | - Clémence Bonnet
- Université Paris-Descartes, Paris, France
- Ophthalmology Department, AP-HP, Cochin Hospital, Paris, France
| | - Hanane Mehawej
- AP-HP, Cochin Hospital, Internal Medicine Department, Centre de Référence Maladies Auto-immunes et Systémiques Rares de l'Ile de France, AP-HP, Cochin Hospital, Paris, France
| | - Véronique Le Guern
- AP-HP, Cochin Hospital, Internal Medicine Department, Centre de Référence Maladies Auto-immunes et Systémiques Rares de l'Ile de France, AP-HP, Cochin Hospital, Paris, France
| | - Laurent Pérard
- Centre Hospitalier Saint Joseph Saint Luc, Internal Medicine Department, Centre Hospitalier Saint Joseph Saint Luc, Lyon, France
| | | | - Antoine Brezin
- Ophthalmology Department, AP-HP, Cochin Hospital, Paris, France
| | - Bertrand Godeau
- Internal Medicine Department, AP-HP, Henri Mondor Hospital, Creteil, France
| | - Julien Haroche
- Internal Medicine Department, Centre de Référence Maladies Auto-immunes et Systémiques Rares de l'Ile de France, AP-HP, Louisiana Pitié-Salpêtrière Hospital, Paris, France
| | - Ygal Benhamou
- Department of Internal Medicine, Vascular and Thrombosis Unit, Normandie Université, UNIROUEN, Rouen University Hospital, Rouen, France
| | - Marc Lambert
- Internal Medicine Department, Centre National de Référence Maladies Systémiques et Auto-Immunes Rares, European Reference Network on Rare Connective Tissue and Musculoskeletal Diseases (ReCONNECT), University Lille, INSERM U1167, CHU Lille, Lille, France
| | - Cécile M Yelnik
- Internal Medicine Department, Centre National de Référence Maladies Systémiques et Auto-Immunes Rares, European Reference Network on Rare Connective Tissue and Musculoskeletal Diseases (ReCONNECT), University Lille, INSERM U1167, CHU Lille, Lille, France
| | - Nicolas Maillard
- Department of Internal Medicine, CHU, de Saint-Etienne, France; and
| | - Bahram Bodaghi
- Internal Medicine Department, Centre de Référence Maladies Auto-immunes et Systémiques Rares de l'Ile de France, AP-HP, Louisiana Pitié-Salpêtrière Hospital, Paris, France
| | - Jean-Charles Piette
- Internal Medicine Department, Centre de Référence Maladies Auto-immunes et Systémiques Rares de l'Ile de France, AP-HP, Louisiana Pitié-Salpêtrière Hospital, Paris, France
| | - Nathalie Costedoat-Chalumeau
- AP-HP, Cochin Hospital, Internal Medicine Department, Centre de Référence Maladies Auto-immunes et Systémiques Rares de l'Ile de France, AP-HP, Cochin Hospital, Paris, France
- AP-HP, Cochin Hospital, Internal Medicine department, Centre de référence maladies auto-immunes et systémiques rares de l'Ile de France, INSERM U 1153, Center for Epidemiology and Statistics, Sorbonne Paris Cité (CRESS), Université Paris Descartes-Sorbonne Paris Cité, Paris, France
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6
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Zununi Vahed S, Rahbar Saadat Y, Ardalan M. Thrombotic microangiopathy during pregnancy. Microvasc Res 2021; 138:104226. [PMID: 34252400 DOI: 10.1016/j.mvr.2021.104226] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 06/21/2021] [Accepted: 07/08/2021] [Indexed: 10/20/2022]
Abstract
Pregnancy is a high-risk time for the development of different kinds of thrombotic microangiopathy (TMA). Three major syndromes including TTP (thrombotic thrombocytopenic purpura), PE/HELLP (preeclampsia/hemolysis, elevated liver function tests, low platelets), and aHUS (atypical hemolytic- uremic syndrome) should be sought in pregnancy-TMA. These severe disorders share multiple clinical features and overlaps and even the coexistence of more than one pathologic mechanism. Each of these disorders finally ends in endothelial damage and fibrin thrombi formation within the microcirculation that fragments RBCs (schystocytes), aggregates platelets, and creates ischemic injury in the targeted organs i.e.; kidney and brain. Although the mechanisms of these severe disorders have been revealed, pregnancy-related TMA still interfaces with diagnostic and therapeutic challenges. Here, we highlight the current knowledge of diagnosis and management of these complications during pregnancy.
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Gubensek J, Ponikvar R, Premru Srsen T, Fabjan Vodusek V, Moertl MG, Lucovnik M. Therapeutic plasma exchange and dextran-sulfate plasma adsorption as extracorporeal treatments of extremely preterm preeclampsia with fetal growth restriction. J Clin Apher 2021; 36:595-605. [PMID: 33847403 DOI: 10.1002/jca.21899] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 02/26/2021] [Accepted: 03/29/2021] [Indexed: 11/07/2022]
Abstract
AIM To evaluate effectiveness and safety of therapeutic plasma exchange (TPE) and dextran-sulfate plasma adsorption (DSA) for extracorporeal removal of soluble Fms-like tyrosine kinase-1 (sFlt-1) as part of expectant management of preeclampsia at extremely preterm gestational age. METHODS Retrospective case series of six patients with preeclampsia at <28 weeks of gestation, treated with DSA or TPE. Laboratory results, clinical characteristics and neonatal outcomes were collected from charts and National Perinatal Information System. RESULTS Fetal growth restriction (FGR) was diagnosed in all cases. Pregnancy was prolonged for a median of 14 (range 5-74) days from admission and 10 (3-73) days from first apheresis. A mixed effects model showed a decrease in sFlt-1 and sFlt-1/PlGF ratio during DSA/TPE (significant effect of time [before/after]), which was comparable between DSA and TPE (no effect of procedure type). Median absolute reduction in sFlt-1 was 42% (inter-quartile range [IQR] 13%-57%) during DSA and 34% (16%-40%) during TPE; for sFlt-1/PlGF ratio it was 29% (22%-36%) and 38% (29%-42%), respectively. All procedures were well tolerated by fetuses. Anaphylactoid reaction, often with angioedema, occurred in 4/6 patients undergoing DSA and was attributed to bradykinin activation. One patient developed wound hematoma after cesarean section, possibly attributed to depletion coagulopathy. CONCLUSIONS As potential novel treatment of early preeclampsia, a non-selective and widely available TPE was comparable to DSA regarding sFlt-1 reduction but was associated with fewer side-effects. Both seem to allow maternal stabilization and pregnancy prolongation even when early preeclampsia is complicated by FGR.
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Affiliation(s)
- Jakob Gubensek
- Department of Nephrology, University Medical Centre Ljubljana, Ljubljana, Slovenia.,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Rafael Ponikvar
- Department of Nephrology, University Medical Centre Ljubljana, Ljubljana, Slovenia.,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Tanja Premru Srsen
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia.,Department of Perinatology, Division of Obstetrics and Gynecology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Vesna Fabjan Vodusek
- Department of Perinatology, Division of Obstetrics and Gynecology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | | | - Miha Lucovnik
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia.,Department of Perinatology, Division of Obstetrics and Gynecology, University Medical Centre Ljubljana, Ljubljana, Slovenia
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8
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Management of thrombotic microangiopathy in pregnancy and postpartum: report from an international working group. Blood 2021; 136:2103-2117. [PMID: 32808006 DOI: 10.1182/blood.2020005221] [Citation(s) in RCA: 64] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 07/23/2020] [Indexed: 12/20/2022] Open
Abstract
Pregnancy and postpartum are high-risk periods for different forms of thrombotic microangiopathy (TMA). However, the management of pregnancy-associated TMA remains ill defined. This report, by an international multidisciplinary working group of obstetricians, nephrologists, hematologists, intensivists, neonatologists, and complement biologists, summarizes the current knowledge of these potentially severe disorders and proposes a practical clinical approach to diagnose and manage an episode of pregnancy-associated TMA. This approach takes into account the timing of TMA in pregnancy or postpartum, coexisting symptoms, first-line laboratory workup, and probability-based assessment of possible causes of pregnancy-associated TMA. Its aims are: to rule thrombotic thrombocytopenic purpura (TTP) in or out, with urgency, using ADAMTS13 activity testing; to consider alternative disorders with features of TMA (preeclampsia/eclampsia; hemolysis elevated liver enzymes low platelets syndrome; antiphospholipid syndrome); or, ultimately, to diagnose complement-mediated atypical hemolytic uremic syndrome (aHUS; a diagnosis of exclusion). Although they are rare, diagnosing TTP and aHUS associated with pregnancy, and postpartum, is paramount as both require urgent specific treatment.
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9
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Rato IR, Barbosa AR, Afonso DJ, Beça S. Catastrophic antiphospholipid syndrome presented as ruptured papillary muscle during puerperium in a patient with systemic lupus erythematosus. Lupus 2021; 30:1017-1021. [PMID: 33736518 DOI: 10.1177/09612033211002273] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Catastrophic antiphospholipid syndrome (CAPS) is a rare and serious phenomenon that requires prompt recognition and treatment. CASE PRESENTATION The authors present the case of a puerperal woman with systemic lupus erythematosus (SLE) admitted to the emergency room with headache, blurred vision, thoracic pain, and purpuric lesions on both ears. Echocardiogram revealed global decrease in left ventricular function while cardiac and inflammatory markers were elevated. Three days after admission she developed cardiogenic shock due to rupture of mitral papillary muscle which required emergent cardiac surgery, with replacement of the mitral valve; treatment with anticoagulation, high-dose glucocorticoids, and intravenous immunoglobulins were initiated. Cardiac and brain MRI revealed signs of ischemic lesions in both organs. Histopathology analysis of the placenta and papillary muscle showed signs of ischemia secondary to microvascular thrombosis. Based on the clinical demonstration of thrombosis in three organs, and the presence of lupus anticoagulant antibodies, a diagnosis of probable CAPS was established. CONCLUSION This case highlights the importance of a high level of suspicion of CAPS, particularly in patients with risk factors, and the value of immediate adequate treatment. Moreover, the rupture of a papillary muscle with histologically consistent signs of antiphospholipid syndrome expands the spectrum of involvement of this disease and should be considered as a rare but life-threatening possibility in patients with myocardial injury.
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Affiliation(s)
- Inês Rueff Rato
- Department of Internal Medicine, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
| | - Ana Rita Barbosa
- Department of Internal Medicine, Centro Hospitalar Baixo Vouga, Aveiro, Portugal
| | - David João Afonso
- Department of Anatomic Pathology, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
| | - Sara Beça
- Department of Internal Medicine, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
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10
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Meibody F, Jamme M, Tsatsaris V, Provot F, Lambert J, Frémeaux-Bacchi V, Ducloy-Bouthors AS, Jourdain M, Delmas Y, Perez P, Darmian J, Wynckel A, Rebibou JM, Coppo P, Rafat C, Rondeau E, Frimat L, Hertig A. Post-partum acute kidney injury: sorting placental and non-placental thrombotic microangiopathies using the trajectory of biomarkers. Nephrol Dial Transplant 2021; 35:1538-1546. [PMID: 30805631 DOI: 10.1093/ndt/gfz025] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 01/17/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Among the severe complications of preeclampsia (PE), acute kidney injury (AKI) is problematic if features of thrombotic microangiopathy (TMA) are present. Although a haemolysis enzyme liver low-platelets syndrome is considerably more frequent, it is vital to rule out a flare of atypical haemolytic and uraemic syndrome (aHUS). Our objective was to improve differential diagnosis procedures in post-partum AKI. METHODS A total of 105 cases of post-partum AKI, admitted to nine different regional French intensive care units from 2011 to 2015, were analysed. Analysis included initial and final diagnosis, renal features, haemostasis and TMA parameters, with particular focus on the dynamics of each component within the first days following delivery. A classification and regression tree (CART) was used to construct a diagnostic algorithm. RESULTS AKI was attributed to severe PE (n = 40), post-partum haemorrhage (n = 33, including 13 renal cortical necrosis) and 'primary' TMA (n = 14, including 10 aHUS and 4 thrombotic thrombocytopenic purpura). Congruence between initial and final diagnosis was low (63%). The dynamics of haemoglobin, haptoglobin and liver enzymes were poorly discriminant. In contrast, the dynamic pattern of platelets was statistically different between primary TMA-related AKI and other groups. CART analysis independently highlighted the usefulness of platelet trajectory in the diagnostic algorithm. Limitations of this study include that only the most severe cases were included in this retrospective study, and the circumstantial complexity is high. CONCLUSION Trajectory of platelet count between admission and Day 3 helps to guide therapeutic decisions in cases of TMA-associated post-partum AKI. Our study also strongly suggests that during the post-partum period, there may be a risk of transient, slowly recovering TMA in cases of severe endothelial injury in women without a genetic mutation known to induce aHUS.
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Affiliation(s)
- Fleuria Meibody
- Department of Nephrology and Kidney Transplantation, University Hospital of Nancy, Vandoeuvre-les-Nancy, France
| | - Matthieu Jamme
- Sorbonne Université, Urgences Néphrologiques et Transplantation Rénale, Assistance Publique-Hôpital de Paris (APHP), Hôpital Tenon, Paris, France
| | - Vassilis Tsatsaris
- APHP, Department of Obstetrics and Gynecology, Port-Royal Maternity, University Hospital Center Cochin Broca Hôtel Dieu, Groupe Hospitalier Universitaire Ouest, Paris, France
| | - François Provot
- Department of Nephrology, Transplantation, Dialysis and Apheresis, Claude-Huriez Hospital, CHRU de Lille, Lille, France.,French Reference Center for Thrombotic Microangiopathies, APHP, Hôpital Saint-Antoine, Paris, France
| | - Jérôme Lambert
- Biostatistics Department, Saint Louis Teaching Hospital, APHP, Paris, France
| | | | | | - Mercédès Jourdain
- Intensive Care Unit, Pôle de Réanimation, University of Lille, CHU Lille, U1190, Lille, France
| | - Yahsou Delmas
- French Reference Center for Thrombotic Microangiopathies, APHP, Hôpital Saint-Antoine, Paris, France.,Department of Nephrology Transplantation-Dialysis, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Pierre Perez
- Department of Nephrology and Kidney Transplantation, University Hospital of Nancy, Vandoeuvre-les-Nancy, France.,French Reference Center for Thrombotic Microangiopathies, APHP, Hôpital Saint-Antoine, Paris, France
| | - Julien Darmian
- Department of Intensive Care, Centre Hospitalier Régional Metz-Thionville, Ars-Laquenexy, France
| | - Alain Wynckel
- Department of Nephrology, Centre Hospitalier Universitaire, Reims, France
| | | | - Paul Coppo
- French Reference Center for Thrombotic Microangiopathies, APHP, Hôpital Saint-Antoine, Paris, France.,Sorbonne Université, Hematology, APHP, Hôpital Saint-Antoine, Paris, France
| | - Cédric Rafat
- Sorbonne Université, Urgences Néphrologiques et Transplantation Rénale, Assistance Publique-Hôpital de Paris (APHP), Hôpital Tenon, Paris, France
| | - Eric Rondeau
- Sorbonne Université, Urgences Néphrologiques et Transplantation Rénale, Assistance Publique-Hôpital de Paris (APHP), Hôpital Tenon, Paris, France.,French Reference Center for Thrombotic Microangiopathies, APHP, Hôpital Saint-Antoine, Paris, France
| | - Luc Frimat
- Department of Nephrology and Kidney Transplantation, University Hospital of Nancy, Vandoeuvre-les-Nancy, France
| | - Alexandre Hertig
- Sorbonne Université, Urgences Néphrologiques et Transplantation Rénale, Assistance Publique-Hôpital de Paris (APHP), Hôpital Tenon, Paris, France
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11
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James TE, Martin LJ, Warkentin TE, Crowther MA. Catastrophic antiphospholipid syndrome refractory to high-dose intravenous immunoglobulin responsive to therapeutic plasma exchange. Platelets 2020; 32:828-831. [PMID: 32762580 DOI: 10.1080/09537104.2020.1802414] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Catastrophic antiphospholipid syndrome (CAPS) involves sudden multiorgan dysfunction from thrombosis due to antibodies that cause platelet activation and endothelial dysfunction. Treatment variably combines anticoagulation, corticosteroid use, therapeutic plasma exchange (TPE), and high-dose intravenous immunoglobulin (IVIG). A 42-year-old male with antiphospholipid syndrome (APS) presented with severe thrombocytopenia, encephalopathy, cardiac ischemia, and acral purpuric cutaneous lesions. CAPS was identified and he received heparin infusion, methylprednisolone, and IVIG. On day 7 he developed new purpuric lesions on his right foot despite detectable arterial pulses representing new microthrombosis refractory to IVIG. He was treated with TPE which resolved the right foot ischemia and eventually his CAPS. To our knowledge, this is the first patient with CAPS reported that failed initial treatment with IVIG and subsequently had excellent response to TPE. Our observations also support recent literature indicating that onset of thrombocytopenia in APS is a warning of progression to CAPS requiring treatment escalation.
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Affiliation(s)
- Tyler E James
- Department of Medicine, McMaster University, Hamilton, Canada
| | - Leslie J Martin
- Department of Medicine, McMaster University, Hamilton, Canada
| | - Theodore E Warkentin
- Department of Medicine, McMaster University, Hamilton, Canada.,Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Canada.,Division of Hematology, Department of Medicine, McMaster University, Hamilton, Canada
| | - Mark A Crowther
- Department of Medicine, McMaster University, Hamilton, Canada.,Division of Hematology, Department of Medicine, McMaster University, Hamilton, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
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12
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Fiol AG, Fardelmann KL, McGuire PJ, Merriam AA, Miller A, Alian A. The Application of ROTEM in a Parturient With Antiphospholipid Syndrome in the Setting of Anticoagulation for Cesarean Delivery: A Case Report. A A Pract 2020; 14:e01182. [DOI: 10.1213/xaa.0000000000001182] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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13
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Collict M, Sciberras Buhagiar W, Mercieca C, Thake J. Catastrophic antiphospholipid syndrome in pregnancy: a life-threatening condition. BMJ Case Rep 2019; 12:12/9/e230863. [PMID: 31527209 DOI: 10.1136/bcr-2019-230863] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Catastrophic antiphospholipid syndrome (CAPS) is a rare and potentially life-threatening variant of the antiphospholipid syndrome which is characterised by multiple small vessel thrombosis which can lead to multiorgan failure. CAPS is a clinical emergency which all clinicians need to be aware of because early diagnosis and treatment may improve maternal and fetal outcome. Here, we report a case of CAPS in pregnancy in a 31-year-old female patient who presented at 28 weeks of gestation. A literature review of CAPS in pregnancy and the puerperium is also included.
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Affiliation(s)
- Mandy Collict
- Obstetrics and Gynaecology, Mater Dei Hospital, Msida, Malta
| | | | | | - John Thake
- Obstetrics and Gynaecology, Mater Dei Hospital, Msida, Malta
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14
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Catastrophic Antiphospholipid Antibody Syndrome: Clinical Presentation, Management, and Guidance for Future Pregnancy. MATERNAL-FETAL MEDICINE 2019. [DOI: 10.1097/fm9.0000000000000010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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15
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Belhocine M, Coutte L, Martin Silva N, Morel N, Guettrot-Imbert G, Paule R, Le Jeunne C, Fredi M, Dreyfus M, Piette JC, Souchaud-Debouverie O, Deneux-Tharaux C, Tsatsaris V, Pannier E, Le Guern V, Costedoat-Chalumeau N. Intrauterine fetal deaths related to antiphospholipid syndrome: a descriptive study of 65 women. Arthritis Res Ther 2018; 20:249. [PMID: 30400982 PMCID: PMC6235231 DOI: 10.1186/s13075-018-1745-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 10/15/2018] [Indexed: 12/18/2022] Open
Abstract
Objective Although one of the three obstetric manifestations of antiphospholipid syndrome (APS) is intrauterine fetal death (IUFD), little is known about it in this context. We report the first large series of patients with APS and IUFD. Methods We retrospectively analyzed the history and clinical data of women at four French hospitals. All had (1) APS diagnosis (Sydney criteria) and (2) IUFD at or after 10 weeks of gestation (weeks) between 2000 and 2016. Results The study included 65 women. Their median age at the index IUFD was 29 years (IQR 26–33); 38 (58%) were primigravidas. The index IUFD was the first APS clinical manifestation in 48 women (74%). Overall, 35% had a triple-positive antibody profile. IUFD occurred at a median gestational age of 24 weeks (IQR 18–27) and was associated with maternal obstetric complications in 16 women (25%), namely, preeclampsia (n = 12), hemolysis, elevated liver enzymes, and low platelet syndrome (HELLP) (n = 6), and/or placental abruption (n = 5). Half of the 50 women with available data had a small-for-gestational-age fetus. Overall, including during the follow-up period of 4 years (IQR 2–9), 28 women (43%) had at least one thrombosis, and 29% were diagnosed with systemic lupus erythematosus (SLE). Ultimately, 54 women (83%) had at least one live birth. Only one woman had three consecutive early miscarriages. Conclusion IUFD was most often the inaugural sign of APS. Of the APS classification criteria, IUFD, preeclampsia, and thromboses were common in this cohort, while the “3 consecutive early miscarriages” criterion was met only once. With treatment, most of the women successfully had at least one live birth.
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Affiliation(s)
- Mériem Belhocine
- AP-HP, Cochin Hospital, Internal Medicine Department, Centre de référence maladies auto-immunes et systémiques rares d'île de France, 27 Rue du Faubourg Saint Jacques, 75014, Paris, France
| | - Laetitia Coutte
- AP-HP, Cochin Hospital, Internal Medicine Department, Centre de référence maladies auto-immunes et systémiques rares d'île de France, 27 Rue du Faubourg Saint Jacques, 75014, Paris, France
| | | | - Nathalie Morel
- AP-HP, Cochin Hospital, Internal Medicine Department, Centre de référence maladies auto-immunes et systémiques rares d'île de France, 27 Rue du Faubourg Saint Jacques, 75014, Paris, France
| | - Gaëlle Guettrot-Imbert
- AP-HP, Cochin Hospital, Internal Medicine Department, Centre de référence maladies auto-immunes et systémiques rares d'île de France, 27 Rue du Faubourg Saint Jacques, 75014, Paris, France
| | - Romain Paule
- AP-HP, Cochin Hospital, Internal Medicine Department, Centre de référence maladies auto-immunes et systémiques rares d'île de France, 27 Rue du Faubourg Saint Jacques, 75014, Paris, France
| | - Claire Le Jeunne
- AP-HP, Cochin Hospital, Internal Medicine Department, Centre de référence maladies auto-immunes et systémiques rares d'île de France, 27 Rue du Faubourg Saint Jacques, 75014, Paris, France
| | - Micaela Fredi
- Spedali Civili di Brescia, Rheumatology and Clinical Immunology Department, Brescia, Italy
| | - Michel Dreyfus
- Caen University Hospital, Gynecology and Obstetrics Department, Caen, France
| | - Jean-Charles Piette
- AP-HP, Pitié-Salpétrière University Hospital, Internal Medicine and Clinical Immunology Department, Centre de référence maladies auto-immunes et systémiques rares de l'île de France, Université Paris 6, Paris, France
| | | | - Catherine Deneux-Tharaux
- INSERM U1153, Obstetrical, Perinatal and Paediatric Epidemiology (EPOPé research team), DHU Risks in Pregnancy, Université Paris Descartes, Paris, France
| | - Vassilis Tsatsaris
- AP-HP, Cochin Hospital, Port-Royal maternity, Gynecology and Obstetrics Department, DHU Risks in Pregnancy, INSERM U1139, Paris, France
| | - Emmanuelle Pannier
- AP-HP, Cochin Hospital, Port-Royal maternity, Gynecology and Obstetrics Department, DHU Risks in Pregnancy, INSERM U1139, Paris, France
| | - Véronique Le Guern
- AP-HP, Cochin Hospital, Internal Medicine Department, Centre de référence maladies auto-immunes et systémiques rares d'île de France, 27 Rue du Faubourg Saint Jacques, 75014, Paris, France
| | - Nathalie Costedoat-Chalumeau
- AP-HP, Cochin Hospital, Internal Medicine Department, Centre de référence maladies auto-immunes et systémiques rares d'île de France, 27 Rue du Faubourg Saint Jacques, 75014, Paris, France. .,INSERM U1153, Center for Epidemiology and Statistics Sorbonne Paris Cité (CRESS), Paris, France.
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16
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Piccoli GB, Zakharova E, Attini R, Ibarra Hernandez M, Orozco Guillien A, Alrukhaimi M, Liu ZH, Ashuntantang G, Covella B, Cabiddu G, Li PKT, Garcia-Garcia G, Levin A. Pregnancy in Chronic Kidney Disease: Need for Higher Awareness. A Pragmatic Review Focused on What Could Be Improved in the Different CKD Stages and Phases. J Clin Med 2018; 7:E415. [PMID: 30400594 PMCID: PMC6262338 DOI: 10.3390/jcm7110415] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Revised: 10/28/2018] [Accepted: 10/31/2018] [Indexed: 02/07/2023] Open
Abstract
Pregnancy is possible in all phases of chronic kidney disease (CKD), but its management may be difficult and the outcomes are not the same as in the overall population. The prevalence of CKD in pregnancy is estimated at about 3%, as high as that of pre-eclampsia (PE), a better-acknowledged risk for adverse pregnancy outcomes. When CKD is known, pregnancy should be considered as high risk and followed accordingly; furthermore, since CKD is often asymptomatic, pregnant women should be screened for the presence of CKD, allowing better management of pregnancy, and timely treatment after pregnancy. The differential diagnosis between CKD and PE is sometimes difficult, but making it may be important for pregnancy management. Pregnancy is possible, even if at high risk for complications, including preterm delivery and intrauterine growth restriction, superimposed PE, and pregnancy-induced hypertension. Results in all phases are strictly dependent upon the socio-sanitary system and the availability of renal and obstetric care and, especially for preterm children, of intensive care units. Women on dialysis should be aware of the possibility of conceiving and having a successful pregnancy, and intensive dialysis (up to daily, long-hours dialysis) is the clinical choice allowing the best results. Such a choice may, however, need adaptation where access to dialysis is limited or distances are prohibitive. After kidney transplantation, pregnancies should be followed up with great attention, to minimize the risks for mother, child, and for the graft. A research agenda supporting international comparisons is highly needed to ameliorate or provide knowledge on specific kidney diseases and to develop context-adapted treatment strategies to improve pregnancy outcomes in CKD women.
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Affiliation(s)
- Giorgina B Piccoli
- Department of Clinical and Biological Sciences, University of Torino, 10100 Torino, Italy.
- Néphrologie, Centre Hospitalier Le Mans, 72000 Le Mans, France.
| | - Elena Zakharova
- Nephrology, Moscow City Hospital n.a. S.P. Botkin, 101000 Moscow, Russia.
- Nephrology, Moscow State University of Medicine and Dentistry, 101000 Moscow, Russia.
- Nephrology, Russian Medical Academy of Continuous Professional Education, 101000 Moscow, Russia.
| | - Rossella Attini
- Obstetrics, Department of Surgery, University of Torino, 10100 Torino, Italy.
| | - Margarita Ibarra Hernandez
- Nephrology Service, Hospital Civil de Guadalajara "Fray Antonio Alcalde", University of Guadalajara Health Sciences Center, Guadalajara, Jal 44100, Mexico.
| | | | - Mona Alrukhaimi
- Department of Medicine, Dubai Medical College, P.O. Box 20170, Dubai, UAE.
| | - Zhi-Hong Liu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing 210000, China. zhihong--
| | - Gloria Ashuntantang
- Yaounde General Hospital & Faculty of Medicine and Biomedical Sciences, University of Yaounde I, P.O. Box 337, Yaounde, Cameroon.
| | - Bianca Covella
- Néphrologie, Centre Hospitalier Le Mans, 72000 Le Mans, France.
| | | | - Philip Kam Tao Li
- Prince of Wales Hospital, Department of Medicine and Therapeutics, Chinese University of Hong Kong, Hong Kong.
| | - Guillermo Garcia-Garcia
- Nephrology Service, Hospital Civil de Guadalajara "Fray Antonio Alcalde", University of Guadalajara Health Sciences Center, Guadalajara, Jal 44100, Mexico.
| | - Adeera Levin
- Department of Medicine, Division of Nephrology, University of British Columbia, Vancouver, BC V6T 1Z4, Canada.
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17
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Sadick V, Lane S, Fischer E, Seppelt I, Shetty A, McLean A. Post-partum catastrophic antiphospholipid syndrome presenting with shock and digital ischaemia - A diagnostic and management challenge. J Intensive Care Soc 2018; 19:357-364. [PMID: 30515245 PMCID: PMC6259081 DOI: 10.1177/1751143718762343] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Catastrophic antiphospholipid syndrome is a rare multisystem autoimmune condition characterised by rapid development of widespread thrombotic disease and subsequent multi-organ failure. It is the most severe complication of antiphospholipid syndrome, carrying significant morbidity and mortality. We report a patient with post-partum catastrophic antiphospholipid syndrome with cardiac, hepatic, renal and cutaneous manifestations. The diagnostic challenges in establishing a definitive diagnosis in catastrophic antiphospholipid syndrome is discussed, along with the difficulties in managing these patients in the intensive care unit.
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Affiliation(s)
- Victoria Sadick
- Intensive Care Unit,
Nepean
Hospital, Kingswood, NSW, Australia
| | - Stuart Lane
- Intensive Care Medicine,
Nepean
Hospital, Kingswood, NSW, Australia
- Sydney Medical School, Kingswood, NSW,
Australia
| | - Eddy Fischer
- Department of Renal Medicine,
Nepean
Hospital, Kingswood, NSW, Australia
| | - Ian Seppelt
- Intensive Care Medicine,
Nepean
Hospital, Kingswood, NSW, Australia
| | - Anita Shetty
- Department of Haematology,
Nepean
Hospital, Kingswood, NSW, Australia
| | - Anthony McLean
- Intensive Care Medicine,
Nepean
Hospital, Kingswood, NSW, Australia
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18
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Piccoli GB, Zakharova E, Attini R, Ibarra Hernandez M, Covella B, Alrukhaimi M, Liu ZH, Ashuntantang G, Orozco Guillen A, Cabiddu G, Li PKT, Garcia-Garcia G, Levin A. Acute Kidney Injury in Pregnancy: The Need for Higher Awareness. A Pragmatic Review Focused on What Could Be Improved in the Prevention and Care of Pregnancy-Related AKI, in the Year Dedicated to Women and Kidney Diseases. J Clin Med 2018; 7:jcm7100318. [PMID: 30275392 PMCID: PMC6210235 DOI: 10.3390/jcm7100318] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 09/18/2018] [Accepted: 09/19/2018] [Indexed: 12/14/2022] Open
Abstract
Pregnancy-related acute kidney injury (pAKI), preeclampsia (PE), and the hypertensive disorders of pregnancy are closely related conditions, which are, in turn, frequently linked to pre-existing and often non-diagnosed chronic kidney disease (CKD). The current literature and research mainly underline the effects of pregnancy complications on the offspring; this review strongly emphasizes the maternal health as well. These conditions not only negatively affect pregnancy outcomes, but have a relevant effect on the future health of affected mothers and their children. Therefore, dedicated diagnostic and follow-up programs are needed, for optimizing materno-foetal health and reducing the impact of pregnancy-related problems in the mothers and in the new generations. This narrative review, performed on the occasion of the 2018 World Kidney Day dedicated to women’s health, focuses on three aspects of the problem. Firstly, the risk of AKI in the hypertensive disorders of pregnancy (the risk is the highest in developing countries; however PE is the main cause of pregnancy related AKI worldwide). Secondly, the effect of AKI and the hypertensive disorders of pregnancy on the development of CKD in the mother and offspring: long-term risks are increased; the entity and the trajectories are still unknown. Thirdly, the role of CKD in the pathogenesis of AKI and the hypertensive disorders of pregnancy: CKD is a major risk factor and the most important element in the differential diagnosis; pregnancy is a precious occasion for early diagnosis of CKD. Higher awareness on the importance of AKI in pregnancy is needed to improve short and long term outcomes in mothers and children.
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Affiliation(s)
- Giorgina Barbara Piccoli
- Department of Clinical and Biological Sciences, University of Torino, 10100 Torino, Italy.
- Néphrologie, Centre Hospitalier Le Mans, 72000 Le Mans, France.
| | - Elena Zakharova
- Nephrology, Moscow City Hospital n.a. S.P. Botkin, 101000 Moscow, Russia.
- Nephrology, Moscow State University of Medicine and Dentistry, 101000 Moscow, Russia.
- Nephrology, Russian Medical Academy of Continuous Professional Education, 101000 Moscow, Russia.
| | - Rossella Attini
- Obstetrics, Department of Surgery, University of Torino, 10100 Torino, Italy.
| | - Margarita Ibarra Hernandez
- Nephrology Service, Hospital Civil de Guadalajara "Fray Antonio Alcalde", University of Guadalajara Health Sciences Center, 44100 Guadalajara Jal, Mexico.
| | - Bianca Covella
- Néphrologie, Centre Hospitalier Le Mans, 72000 Le Mans, France.
| | - Mona Alrukhaimi
- Department of Medicine, Dubai Medical College, P.O. Box 20170, Dubai, UAE.
| | - Zhi-Hong Liu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing 210000, China. zhihong--
| | - Gloria Ashuntantang
- Yaounde General Hospital & Faculty of Medicine and Biomedical Sciences, University of Yaounde I, P.O. Box 337, Yaounde, Cameroon.
| | | | | | - Philip Kam Tao Li
- Prince of Wales Hospital, Department of Medicine and Therapeutics, Chinese University of Hong Kong, Hong Kong.
| | - Gulliermo Garcia-Garcia
- Nephrology Service, Hospital Civil de Guadalajara "Fray Antonio Alcalde", University of Guadalajara Health Sciences Center, 44100 Guadalajara Jal, Mexico.
| | - Adeera Levin
- Department of Medicine, Division of Nephrology, University of British Columbia, Vancouver, BC V6T 1Z4, Canada.
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19
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Legault K, Schunemann H, Hillis C, Yeung C, Akl EA, Carrier M, Cervera R, Crowther M, Dentali F, Erkan D, Espinosa G, Khamashta M, Meerpohl JJ, Moffat K, O'Brien S, Pengo V, Rand JH, Rodriguez Pinto I, Thom L, Iorio A. McMaster RARE-Bestpractices clinical practice guideline on diagnosis and management of the catastrophic antiphospholipid syndrome. J Thromb Haemost 2018; 16:1656-1664. [PMID: 29978552 DOI: 10.1111/jth.14192] [Citation(s) in RCA: 86] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Indexed: 01/24/2023]
Abstract
Background The McMaster RARE-Bestpractices project group selected the catastrophic antiphospholipid syndrome (CAPS) for a pilot exercise in guideline development for a rare disease. Objectives The objectives of this exercise were to provide a proof of principle that guidelines can be developed for rare diseases and assist in clinical decision making for CAPS. Patients/Methods The GIN-McMaster Guideline Development checklist and GRADE methodology were followed throughout the guideline process. The CAPS guideline was coordinated by a steering committee, and the guideline panel was formed with representation from all relevant stakeholder groups. Systematic reviews were performed for the key questions. To supplement the published evidence, we piloted novel methods, including use of an expert-based evidence elicitation process and ad hoc analysis of registry data. Results This paper describes the CAPS guideline recommendations, including evidence appraisal and discussion of special circumstances and implementation barriers identified by the panel. Many of these recommendations are conditional, because of subgroup considerations in this heterogeneous disease, as well as variability in patient values and preferences. Conclusions The CAPS clinical practice guideline initiative met the objective of the successful development of a clinical practice guideline in a rare disease using GRADE methodology. We expect that clinicians caring for patients with suspected CAPS will find the guideline useful in assisting with diagnosis and management of this rare disease.
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Affiliation(s)
- K Legault
- McMaster University, Hamilton, Canada
| | | | - C Hillis
- McMaster University, Hamilton, Canada
| | - C Yeung
- McMaster University, Hamilton, Canada
| | - E A Akl
- McMaster University, Hamilton, Canada
- American University of Beirut, Beirut, Lebanon
| | - M Carrier
- University of Ottawa, Ottawa, Canada
| | - R Cervera
- University of Barcelona, Barcelona, Spain
| | | | - F Dentali
- Insubria University, Insubria, Italy
| | - D Erkan
- Weill Cornell Medicine College, New York, USA
| | - G Espinosa
- University of Barcelona, Barcelona, Spain
| | | | - J J Meerpohl
- Cochrane Germany, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - K Moffat
- McMaster University, Hamilton, Canada
- Hamilton Regional Laboratory Medicine Program, Hamilton, Canada
| | - S O'Brien
- Nationwide Children's Hospital, Columbus, USA
| | - V Pengo
- University of Padova, Padua, Italy
| | - J H Rand
- Weill Cornell Medicine College, New York, USA
| | | | | | - A Iorio
- McMaster University, Hamilton, Canada
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20
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Yelnik CM, Lambert M, Drumez E, Le Guern V, Bacri JL, Guerra MM, Laskin CA, Branch DW, Sammaritano LR, Morel N, Guettrot-Imbert G, Launay D, Hachulla E, Hatron PY, Salmon JE, Costedoat-Chalumeau N. Bleeding complications and antithrombotic treatment in 264 pregnancies in antiphospholipid syndrome. Lupus 2018; 27:1679-1686. [PMID: 30016929 DOI: 10.1177/0961203318787032] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose The purpose of this study was to evaluate the safety of antithrombotic treatments prescribed during pregnancy in patients with antiphospholipid syndrome (APS). Methods This international, multicenter study included two cohorts of patients: a retrospective French cohort and a prospective US cohort (PROMISSE study). Inclusion criteria were (1) APS (Sydney criteria), (2) live pregnancy at 12 weeks of gestation (WG) with (3) follow-up data until six weeks post-partum. According to APS standard of care, patients were treated with aspirin and/or low-molecular weight heparin (LMWH) at prophylactic (pure obstetric APS) or therapeutic doses (history of thrombosis). Major bleeding was defined as abnormal blood loss during the pregnancy and/or post-partum period requiring intervention for hemostasis or transfusion, or during the peripartum period greater than 500 mL and/or requiring surgery or transfusion. Other bleeding events were classified as minor. Results Two hundred and sixty-four pregnancies (87 prospectively collected) in 204 patients were included (46% with history of thrombosis, 23% with associated systemic lupus). During pregnancy, treatment included LMWH ( n = 253; 96%) or low-dose aspirin ( n = 223; 84%), and 215 (81%) patients received both therapies. The live birth rate was 89% and 82% in the retrospective and prospective cohorts, respectively. Adverse pregnancy outcomes occurred in 28% of the retrospective cohort and in 40% of the prospective cohort. No maternal death was observed in either cohort. A combined total of 45 hemorrhagic events (25%) occurred in the retrospective cohort, but major bleeding was reported in only six pregnancies (3%). Neither heparin nor aspirin alone nor combined therapy increased the risk of hemorrhage. We also did not observe an increased rate of bleeding in the case of a short interval between last LMWH (less than 24 hours) or aspirin (less than five days) doses and delivery. Only emergency Caesarean section was significantly associated with an increased risk of bleeding (odds ratio (OR) 5.03 (1.41-17.96); p=.016). In the prospective cohort, only one minor bleeding event was reported (vaginal bleeding). Conclusion Our findings support the safety of antithrombotic therapy with aspirin and/or LMWH during pregnancy in high-risk women with APS, and highlight the need for better treatments to improve pregnancy outcomes in APS. PROMISSE Study ClinicalTrials.gov identifier: NCT00198068.
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Affiliation(s)
- C M Yelnik
- 1 INSERM U995 LIRIC-Inflammation Research International Centre, CHU Lille, Département de Médecine Interne et d'Immunologie clinique, Centre National de Référence Maladies Systémiques et Auto-Immunes Rares, European Reference Network on Rare Connective Tissue and Musculoskeletal Diseases (ReCONNECT), University of Lille, France
| | - M Lambert
- 1 INSERM U995 LIRIC-Inflammation Research International Centre, CHU Lille, Département de Médecine Interne et d'Immunologie clinique, Centre National de Référence Maladies Systémiques et Auto-Immunes Rares, European Reference Network on Rare Connective Tissue and Musculoskeletal Diseases (ReCONNECT), University of Lille, France
| | - E Drumez
- 2 CHU Lille, EA 2694 - Santé publique: épidémiologie et qualité des soins, Département de Biostatistique, University of Lille, France
| | - V Le Guern
- 3 Service de Médecine Interne, Centre de Référence des Maladies Systémiques et Auto-Immunes Rares, Hôpital Cochin, Paris, France
| | - J-L Bacri
- 4 Service de Médecine Interne, Centre Hospitalier de Valenciennes, Valenciennes, France
| | - M M Guerra
- 5 Rheumatology, Hospital for Special Surgery, New York, USA
| | - C A Laskin
- 6 University of Toronto and Trio Fertility, Toronto, Canada
| | - D W Branch
- 7 University of Utah and Intermountain Healthcare, Salt Lake City, USA
| | | | - N Morel
- 3 Service de Médecine Interne, Centre de Référence des Maladies Systémiques et Auto-Immunes Rares, Hôpital Cochin, Paris, France
| | - G Guettrot-Imbert
- 3 Service de Médecine Interne, Centre de Référence des Maladies Systémiques et Auto-Immunes Rares, Hôpital Cochin, Paris, France
| | - D Launay
- 1 INSERM U995 LIRIC-Inflammation Research International Centre, CHU Lille, Département de Médecine Interne et d'Immunologie clinique, Centre National de Référence Maladies Systémiques et Auto-Immunes Rares, European Reference Network on Rare Connective Tissue and Musculoskeletal Diseases (ReCONNECT), University of Lille, France
| | - E Hachulla
- 1 INSERM U995 LIRIC-Inflammation Research International Centre, CHU Lille, Département de Médecine Interne et d'Immunologie clinique, Centre National de Référence Maladies Systémiques et Auto-Immunes Rares, European Reference Network on Rare Connective Tissue and Musculoskeletal Diseases (ReCONNECT), University of Lille, France
| | - P-Y Hatron
- 1 INSERM U995 LIRIC-Inflammation Research International Centre, CHU Lille, Département de Médecine Interne et d'Immunologie clinique, Centre National de Référence Maladies Systémiques et Auto-Immunes Rares, European Reference Network on Rare Connective Tissue and Musculoskeletal Diseases (ReCONNECT), University of Lille, France
| | - J E Salmon
- 5 Rheumatology, Hospital for Special Surgery, New York, USA
| | - N Costedoat-Chalumeau
- 3 Service de Médecine Interne, Centre de Référence des Maladies Systémiques et Auto-Immunes Rares, Hôpital Cochin, Paris, France.,8 Université Paris Descartes-Sorbonne Paris Cité, Paris, France.,9 INSERM U 1153, Center for Epidemiology and Statistics, Sorbonne Paris Cité (CRESS), Paris, France
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21
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Fredi M, Andreoli L, Aggogeri E, Bettiga E, Lazzaroni MG, Le Guern V, Lojacono A, Morel N, Piette JC, Zatti S, Costedoat-Chalumeau N, Tincani A. Risk Factors for Adverse Maternal and Fetal Outcomes in Women With Confirmed aPL Positivity: Results From a Multicenter Study of 283 Pregnancies. Front Immunol 2018; 9:864. [PMID: 29867924 PMCID: PMC5949611 DOI: 10.3389/fimmu.2018.00864] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2018] [Accepted: 04/09/2018] [Indexed: 01/24/2023] Open
Abstract
Objective Antiphospholipid antibodies positivity (aPL) is considered as a risk factor for adverse pregnancy outcome (APO). The aim of this study was to determine the risk factors for APO in patients with confirmed aPL positivity, isolated (aPL carriers) or associated with a definite primary antiphospholipid syndrome (PAPS). Methods The clinical and laboratory features of 283 pregnancies occurring between 2000 and 2014 in 200 women were collected in three institutions. Results The rate of live birth was 87.9% and APO was observed in 50 cases (17.7%). Multivariate analysis showed that the independent variables related to APO were the concomitant diagnosis of an organ-specific autoimmune disease (p = 0.012, odds ratio (OR) 3.29, confidence interval (CI) 95% 1.29–8.38) and the presence of low complement levels during the first trimester (p = 0.02, OR 2.3, CI 95% 1.17–9.15). No statistical differences were found in APO occurrence among patients treated with low-dose aspirin (LDA) versus those treated with LDA plus heparin (LMWH), but LDA + LMWH was more frequently administered in patients with triple aPL positivity (p = 0.001, OR 3.21, CI 95% 1.48–7.11) and with PAPS (p < 0.001, OR 8.08, CI 95% 4.3–15.4). Based on clinical history, the patients were divided into four groups: obstetric, thrombotic, non-criteria antiphospholipid syndrome (clinical non-criteria), and aPL carriers. APOs were more frequent in the thrombotic group (24%). Seven patients had a thrombotic event during pregnancy or puerperium (2.4%). Conclusion Maternal and fetal complications were observed in some aPL-positive patients despite their efficient management according to the current recommendations. A higher risk of APO was observed in patients with a previous thrombosis and/or more complex autoimmune phenotype.
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Affiliation(s)
- Micaela Fredi
- Rheumatology and Clinical Immunology Unit, ASST Spedali Civili di Brescia, Brescia, Italy.,Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Laura Andreoli
- Rheumatology and Clinical Immunology Unit, ASST Spedali Civili di Brescia, Brescia, Italy.,Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Elena Aggogeri
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Elisa Bettiga
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Maria Grazia Lazzaroni
- Rheumatology and Clinical Immunology Unit, ASST Spedali Civili di Brescia, Brescia, Italy.,Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Véronique Le Guern
- Internal Medicine Department, Cochin Hospital, Paris Descartes University, Paris, France
| | - Andrea Lojacono
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy.,Obstetrics and Gynecology Department, ASST Spedali Civili di Brescia and University of Brescia, Brescia, Italy
| | - Nathalie Morel
- Internal Medicine Department, Cochin Hospital, Paris Descartes University, Paris, France
| | - Jean Charles Piette
- Centre de référence maladies auto-immunes et systémiques rares d'Ile de France, Internal Medicine Department, Pitié-Salpêtrière Hospital, Assistance Publique Hopitaux De Paris (AP-HP), Paris, France.,Université Pierre et Marie Curie, Paris, France
| | - Sonia Zatti
- Obstetrics and Gynecology Department, ASST Spedali Civili di Brescia and University of Brescia, Brescia, Italy
| | - Nathalie Costedoat-Chalumeau
- Centre de référence maladies auto-immunes et systémiques rares d'Ile de France, Internal Medicine Department, Cochin Hospital, Assistance Publique Hopitaux De Paris (AP-HP), Paris, France.,Université Paris Descartes-Sorbonne Paris Cité, Paris, France.,INSERM U 1153, Center for Epidemiology and Statistics Sorbonne Paris Cité (CRESS), Paris, France
| | - Angela Tincani
- Rheumatology and Clinical Immunology Unit, ASST Spedali Civili di Brescia, Brescia, Italy.,Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
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22
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Abstract
Catastrophic antiphospholipid syndrome (CAPS) is a rare but life-threatening condition that may be precipitated by pregnancy. The condition can be hard to diagnose since it mimics other thrombotic microangiopathies that are associated with pregnancy. Accurate and timely diagnosis is critical for effective treatment. In this review, we highlight pertinent clinical features of CAPS so that obstetricians will be able to recognize and treat the condition.
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Affiliation(s)
- Robert M Silver
- Department of Obstetrics and Gynecology, University of Utah Health Sciences Center, Room 2B200 SOM, 50 North Medical Dr, Salt Lake City, UT 84132.
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23
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Vigneron C, Hertig A. Micro-angiopathies thrombotiques du péripartum : physiopathologie, diagnostic et traitement. MEDECINE INTENSIVE REANIMATION 2017. [DOI: 10.1007/s13546-017-1287-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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24
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Carmi O, Berla M, Shoenfeld Y, Levy Y. Diagnosis and management of catastrophic antiphospholipid syndrome. Expert Rev Hematol 2017; 10:365-374. [DOI: 10.1080/17474086.2017.1300522] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Or Carmi
- Department of Medicine E, Meir Medical Center, Kfar Saba, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
| | - Maya Berla
- Department of Medicine E, Meir Medical Center, Kfar Saba, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
| | - Yehuda Shoenfeld
- Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
- The Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel Hashomer, Israel
| | - Yair Levy
- Department of Medicine E, Meir Medical Center, Kfar Saba, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
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25
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Girish B, Gainder S, Saha SC, Krishnappa D. Rare Presentation of Catastrophic Antiphospholipid Syndrome with Myocarditis in Post-partum Period: Case Report and Review of Literature. J Obstet Gynaecol India 2017; 68:70-72. [PMID: 29391679 DOI: 10.1007/s13224-017-0974-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Accepted: 02/11/2017] [Indexed: 10/20/2022] Open
Affiliation(s)
- Bhavana Girish
- 1Department of Obstetrics and Gynaecology, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012 India.,3Present Address: All India Institute of Medical Sciences, New Delhi, India
| | - Shalini Gainder
- 1Department of Obstetrics and Gynaecology, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012 India
| | - S C Saha
- 1Department of Obstetrics and Gynaecology, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012 India
| | - Darshan Krishnappa
- 2Department of Cardiology, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012 India
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26
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Abstract
PURPOSE OF REVIEW Catastrophic antiphospholipid syndrome (CAPS) is a severe manifestation of antiphospholipid syndrome (APS). Although affecting only 1% of patients with APS, the condition is frequently fatal if not recognized and treated early. Here, we will review the current approach to diagnosis and treatment of CAPS. RECENT FINDINGS Data from the international 'CAPS registry', spearheaded by the European Forum on Antiphospholipid Antibodies, have improved our understanding of at-risk patients, typical clinical features, and precipitating diagnoses. Current guidelines also continue to support the role of anticoagulants and glucocorticoids as foundation therapy in all patients. Finally, new basic science and case series suggest that novel therapies, such as rituximab and eculizumab, warrant further study. SUMMARY Attention to associated diagnoses, such as infection and systemic lupus erythematosus (SLE), is critical at the time of diagnosis. All patients should be treated with anticoagulants, corticosteroids, and possibly plasma exchange. In patients with SLE, cyclophosphamide should be considered. In refractory or relapsing cases, new therapies, such as rituximab and possibly eculizumab, may be options, but need further study.
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27
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Kew GS, Cho J, Lateef A. Microangiopathic antiphospholipid antibody-associated syndrome in a pregnant lady. Lupus 2016; 26:435-437. [PMID: 27694537 DOI: 10.1177/0961203316659548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
We describe a gravid 37-year-old Chinese lady with known triple positive primary antiphospholipid syndrome with previous recurrent deep vein thrombosis and early spontaneous miscarriages. She was managed with low-molecular weight heparin, aspirin, hydroxychloroquine, prednisolone and monthly intravenous immunoglobulin. She presented with recurrent per-vaginal bleeding at 22 weeks of gestation and was found to have abruptio placentae. Anti-coagulation was held off. She subsequently delivered a stillborn at 24 weeks and anti-coagulation was restarted. Day 5 post-delivery, she developed HELLP, with hemolytic anaemia (Hb 10.1 g/dL, haptoglobin <30 g/L, LDH 2206 U/L), elevated transaminases (AST 1196 U/L, ALT 1130 U/L) and thrombocytopenia (platelet 28 × 10^9/L). There were also episodes of acute severe headache and abdominal pain assessed to be secondary to microvascular ischemia as CT did not reveal any thrombosis. Her blood pressure hovered persistently above systolic 180 mmHg, and required at least three anti-hypertensives. These were coupled with a new onset proteinuria of 2 to 3 g/day. There was no evidence of disseminated intravascular coagulation. She was assessed to have microangiopathic antiphospholipid syndrome and was started on plasmapheresis. On Day 10 post-partum, the patient complained of foul-smelling vaginal discharge and was found to have retained products of conception, which was immediately evacuated. Her course was followed by poly-microbial sepsis secondary to Enterococcus fecalis, Klebsiella Pneumoniae and Escherichia coli. The patient was further treated with imipenem and she completed eight exchanges of plasmapheresis followed by five days of intravenous immunoglobulins with good clinical and biochemical improvement.
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Affiliation(s)
- G S Kew
- Division of Rheumatology, Department of Medicine, National University Hospital, Singapore
| | - J Cho
- Division of Rheumatology, Department of Medicine, National University Hospital, Singapore
| | - A Lateef
- Division of Rheumatology, Department of Medicine, National University Hospital, Singapore
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28
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Pregnancy and contraception in systemic and cutaneous lupus erythematosus. Ann Dermatol Venereol 2016; 143:590-600. [DOI: 10.1016/j.annder.2015.07.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Revised: 02/03/2015] [Accepted: 07/08/2015] [Indexed: 12/30/2022]
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29
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Hepatic infarction in a pregnant woman with antiphospholipid syndrome and triple antibody positivity: A case report focusing on catastrophic antiphospholipid syndrome. Obstet Gynecol Sci 2016; 59:397-402. [PMID: 27668204 PMCID: PMC5028648 DOI: 10.5468/ogs.2016.59.5.397] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Revised: 02/25/2016] [Accepted: 03/30/2016] [Indexed: 11/24/2022] Open
Abstract
Pregnant women with antiphospholipid syndrome (APS) carry a high risk of arterial or venous thrombosis. Such thrombotic conditions occur more frequently in patients with triple positivity to antiphospholipid antibodies or with high antibody titers. Hepatic infarction is a rare complication in pregnant women with APS, and it sometimes mimics HELLP syndrome. This report describes a preeclamptic pregnant woman with APS who had high titers of three antiphospholipid antibodies. She experienced severe epigastric pain with elevated liver enzymes; in addition, she had tachycardia and tachypnea. The clinical findings suggested hepatic infarction and pulmonary thromboembolism, a partial manifestation of catastrophic APS. Therefore, she underwent emergent cesarean section at 25+2 weeks of gestation. After the delivery, her laboratory test indicated HELLP-like features, and computed tomography confirmed hepatic infarction and pulmonary micro-thromboembolism. Here, we report a case of a partial manifestation of catastrophic APS in a pregnant woman with triple antibody positivity, including a brief literature review.
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30
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Costedoat-Chalumeau N, Coutte L, Le Guern V, Morel N, Leroux G, Paule R, Mouthon L, Piette JC. [2016 review on catastrophic antiphospholipid syndrome]. Presse Med 2016; 45:1084-1092. [PMID: 27617783 DOI: 10.1016/j.lpm.2016.07.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Revised: 05/10/2016] [Accepted: 07/25/2016] [Indexed: 12/24/2022] Open
Abstract
The catastrophic antiphospholipid syndrome (CAPS) develops in at least 1% of patients with antiphospholipid syndrome, either primary or associated with systemic lupus erythematosus. CAPS reveals the antiphospholipid syndrome in about 50% of cases. The CAPS is characterized by rapidly-progressive widespread thromboses mainly affecting the microvasculature in the presence of antiphospholipid antibodies. In a few days, the patients develop multiorgan failure with renal insufficiency with severe hypertension, pulmonary, cerebral, cardiac, digestive and/or cutaneous involvement. The vital prognosis is frequently engaged. CAPS is often precipitated by infectious diseases, surgical procedures and/or withdrawal or modification of the anticoagulation. CAPS overall mortality rate has decreased and is currently below 30%. The main differential diagnoses are other thrombotic microangiopathies, and heparin-induced thrombocytopenia. The treatment of CAPS consists of the association of anticoagulation and steroids, plus plasma exchange and/or intravenous immunoglobulins. Cyclophosphamide is added only in patients with active systemic lupus erythematosus. The potential contribution of some additional therapies (rituximab, eculizumab or sirolimus) needs to be assessed. The prevention of CAPS is essential and is based upon the adequate management of the perioperative period when surgery cannot be avoided, the prompt treatment and the prevention with immunization of infections and the education of patients with antiphospholipid syndrome, especially for the management of oral anticoagulants.
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Affiliation(s)
- Nathalie Costedoat-Chalumeau
- Assistance publique-Hôpitaux de Paris, université Paris-Descartes, hôpital Cochin, centre de référence maladies auto-immunes et systémiques rares, service de médecine interne, pôle médecine, 27, rue du Faubourg-Saint-Jacques, 75679 Paris cedex 14, France.
| | - Laetitia Coutte
- Assistance publique-Hôpitaux de Paris, université Paris-Descartes, hôpital Cochin, centre de référence maladies auto-immunes et systémiques rares, service de médecine interne, pôle médecine, 27, rue du Faubourg-Saint-Jacques, 75679 Paris cedex 14, France
| | - Véronique Le Guern
- Assistance publique-Hôpitaux de Paris, université Paris-Descartes, hôpital Cochin, centre de référence maladies auto-immunes et systémiques rares, service de médecine interne, pôle médecine, 27, rue du Faubourg-Saint-Jacques, 75679 Paris cedex 14, France
| | - Nathalie Morel
- Assistance publique-Hôpitaux de Paris, université Paris-Descartes, hôpital Cochin, centre de référence maladies auto-immunes et systémiques rares, service de médecine interne, pôle médecine, 27, rue du Faubourg-Saint-Jacques, 75679 Paris cedex 14, France
| | - Gaelle Leroux
- Assistance publique-Hôpitaux de Paris, université Pierre-et-Marie-Curie, hôpital Pitié-Salpêtrière, centre de référence national pour le lupus systémique et le syndrome des antiphospholipides, département de médecine interne et d'immunologie clinique, 47-83, boulevard de l'Hôpital, 75651 Paris cedex 13, France
| | - Romain Paule
- Assistance publique-Hôpitaux de Paris, université Paris-Descartes, hôpital Cochin, centre de référence maladies auto-immunes et systémiques rares, service de médecine interne, pôle médecine, 27, rue du Faubourg-Saint-Jacques, 75679 Paris cedex 14, France
| | - Luc Mouthon
- Assistance publique-Hôpitaux de Paris, université Paris-Descartes, hôpital Cochin, centre de référence maladies auto-immunes et systémiques rares, service de médecine interne, pôle médecine, 27, rue du Faubourg-Saint-Jacques, 75679 Paris cedex 14, France
| | - Jean-Charles Piette
- Assistance publique-Hôpitaux de Paris, université Pierre-et-Marie-Curie, hôpital Pitié-Salpêtrière, centre de référence national pour le lupus systémique et le syndrome des antiphospholipides, département de médecine interne et d'immunologie clinique, 47-83, boulevard de l'Hôpital, 75651 Paris cedex 13, France
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31
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Hoayek JG, Moussa HN, Rehman HA, Nasab SH, Blackwell SC, Sibai BM. Catastrophic antiphospholipid syndrome in pregnancy, a diagnosis that should not be missed. J Matern Fetal Neonatal Med 2016; 29:3950-5. [DOI: 10.3109/14767058.2016.1160047] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Jennifer G. Hoayek
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Hind N. Moussa
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Hina A. Rehman
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Susan Hosseini Nasab
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Sean C. Blackwell
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Baha M. Sibai
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Texas Health Science Center at Houston, Houston, TX, USA
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Papiris SA, Manali ED, Kolilekas L, Kagouridis K, Maniati M, Filippatos G, Bouros D. Acute Respiratory Events in Connective Tissue Disorders. Respiration 2016; 91:181-201. [PMID: 26938462 DOI: 10.1159/000444535] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Subacute-acute, hyperacute, or even catastrophic and fulminant respiratory events occur in almost all classic connective tissue disorders (CTDs); they may share systemic life-threatening manifestations, may precipitously lead to respiratory failure requiring ventilatory support as well as a combination of specific therapeutic measures, and in most affected patients constitute the devastating end-of-life event. In CTDs, acute respiratory events may be related to any respiratory compartment including the airways, lung parenchyma, alveolar capillaries, lung vessels, pleura, and ventilatory muscles. Acute respiratory events may also precipitate disease-specific extrapulmonary organ involvement such as aspiration pneumonia and lead to digestive tract involvement and heart-related respiratory events. Finally, antirheumatic drug-related acute respiratory toxicity as well as lung infections related to the rheumatic disease and/or to immunosuppression complete the spectrum of acute respiratory events. Overall, in CTDs the lungs significantly contribute to morbidity and mortality, since they constitute a common site of disease involvement; a major site of infections related to the 'mater' disease; a major site of drug-related toxicity, and a common site of treatment-related infectious complications. The extreme spectrum of the abovementioned events, as well as the 'vicious' coexistence of most of the aforementioned manifestations, requires skills, specific diagnostic and therapeutic means, and most of all a multidisciplinary approach of adequately prepared and expert scientists. Avoiding lung disease might represent a major concern for future advancements in the treatment of autoimmune disorders.
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Affiliation(s)
- Spyros A Papiris
- 2nd Department of Pneumonology, x2018;Attikon' University Hospital, Athens Medical School, National and Kapodistrian University of Athens, Athens, Greece
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How I treat catastrophic thrombotic syndromes. Blood 2015; 126:1285-93. [DOI: 10.1182/blood-2014-09-551978] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Accepted: 07/02/2015] [Indexed: 12/21/2022] Open
Abstract
Abstract
Catastrophic thrombotic syndromes are characterized by rapid onset of multiple thromboembolic occlusions affecting diverse vascular beds. Patients may have multiple events on presentation, or develop them rapidly over days to weeks. Several disorders can present with this extreme clinical phenotype, including catastrophic antiphospholipid syndrome (APS), atypical presentations of thrombotic thrombocytopenic purpura (TTP) or heparin-induced thrombocytopenia (HIT), and Trousseau syndrome, but some patients present with multiple thrombotic events in the absence of associated prothrombotic disorders. Diagnostic workup must rapidly determine which, if any, of these syndromes are present because therapeutic management is driven by the underlying disorder. With the exception of atypical presentations of TTP, which are treated with plasma exchange, anticoagulation is the most important therapeutic intervention in these patients. Effective anticoagulation may require laboratory confirmation with anti–factor Xa levels in patients treated with heparin, especially if the baseline (pretreatment) activated partial thromboplastin time is prolonged. Patients with catastrophic APS also benefit from immunosuppressive therapy and/or plasma exchange, whereas patients with HIT need an alternative anticoagulant to replace heparin. Progressive thrombotic events despite therapeutic anticoagulation may necessitate an alternative therapeutic strategy. If the thrombotic process can be controlled, these patients can recover, but indefinite anticoagulant therapy may be appropriate to prevent recurrent events.
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Autoimmune connective tissue diseases. Best Pract Res Clin Obstet Gynaecol 2015; 29:658-70. [DOI: 10.1016/j.bpobgyn.2015.03.003] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Revised: 03/02/2015] [Accepted: 03/06/2015] [Indexed: 11/17/2022]
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Guettrot-Imbert G, Le Guern V, Morel N, Vauthier D, Tsatsaris V, Pannier E, Piette JC, Costedoat-Chalumeau N. Lupus systémique et syndrome des antiphospholipides : comment prendre en charge la grossesse ? Rev Med Interne 2015; 36:173-81. [DOI: 10.1016/j.revmed.2014.12.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Accepted: 12/15/2014] [Indexed: 10/24/2022]
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Østensen M, Andreoli L, Brucato A, Cetin I, Chambers C, Clowse MEB, Costedoat-Chalumeau N, Cutolo M, Dolhain R, Fenstad MH, Förger F, Wahren-Herlenius M, Ruiz-Irastorza G, Koksvik H, Nelson-Piercy C, Shoenfeld Y, Tincani A, Villiger PM, Wallenius M, von Wolff M. State of the art: Reproduction and pregnancy in rheumatic diseases. Autoimmun Rev 2014; 14:376-86. [PMID: 25555818 DOI: 10.1016/j.autrev.2014.12.011] [Citation(s) in RCA: 129] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Accepted: 12/23/2014] [Indexed: 12/13/2022]
Abstract
Throughout the last decade, increasing awareness has been raised on issues related to reproduction in rheumatic diseases including basic research to clarify the important role of estrogens in the etiology and pathophysiology of immune/inflammatory diseases. Sub- or infertility is a heterogeneous condition that can be related to immunological mechanisms, to pregnancy loss, to disease burden, to therapy, and to choices in regard to family size. Progress in reproductive medicine has made it possible for more patients with rheumatic disease to have children. Active disease in women with rheumatoid arthritis (RA) affects their children's birth weight and may have long-term effects on their future health status. Pregnancy complications as preeclampsia and intrauterine growth restriction are still increased in patients with systemic lupus erythematosus (SLE) and antiphospholipid syndrome (APS), however, biomarkers can monitor adverse events, and several new therapies may improve outcomes. Pregnancies in women with APS remain a challenge, and better therapies for the obstetric APS are needed. New prospective studies indicate improved outcomes for pregnancies in women with rare diseases like systemic sclerosis and vasculitis. TNF inhibitors hold promise for maintaining remission in rheumatological patients and may be continued at least in the first half of pregnancy. Pre-conceptional counseling and interdisciplinary management of pregnancies are essential for ensuring optimal pregnancy outcomes.
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Affiliation(s)
- Monika Østensen
- National Advisory Unit on Pregnancy and Rheumatic Diseases, Department of Rheumatology, St. Olavs Hospital, University Hospital of Trondheim, Norway.
| | - Laura Andreoli
- Rheumatology and Clinical Immunology, Spedali Civili of Brescia, Department of Clinical and Experimental Sciences, University of Brescia, Italy
| | - Antonio Brucato
- Department of Internal Medicine, Ospedale papa Giovanni XXIII Bergamo, Italy
| | - Irene Cetin
- Department of Mother and Child, Hospital Luigi Sacco, University of Milano, Italy
| | - Christina Chambers
- Department of Pediatrics, University of California San Diego, La Jolla, CA 92093-0828, USA
| | - Megan E B Clowse
- Division of Rheumatology, Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Nathalie Costedoat-Chalumeau
- Université Paris-Descartes, Paris, France; AP-HP, Hôpital Cochin, Centre de référence maladies auto-immunes et systémiques rares, Service de médecine interne, Paris, France
| | - Maurizio Cutolo
- Research Laboratories and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, Genova, Italy
| | - Radboud Dolhain
- Department of Rheumatology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - M H Fenstad
- Department of Immunology and Transfusion Medicine, St. Olavs Hospital, Trondheim, Norway
| | - Frauke Förger
- Department of Rheumatology and Clinical Immunology/Allergology, University Hospital of Bern, CH-3010 Bern, Switzerland
| | - Marie Wahren-Herlenius
- Department of Medicine, Centre for Molecular Medicine, Karolinska Universitetssjukhuset, Stockholm, Sweden
| | - Guillermo Ruiz-Irastorza
- Autoimmune Diseases Research Unit, Department of Internal Medicine, Biocruces Health Research Institute, Hospital Universitario Cruces, University of the Basque Country, Bizkaia, Spain
| | - Hege Koksvik
- National Advisory Unit on Pregnancy and Rheumatic Diseases, Department of Rheumatology, St. Olavs Hospital, University Hospital of Trondheim, Norway
| | | | - Yehuda Shoenfeld
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Aviv University, Tel-Hashomer, Israel
| | - Angela Tincani
- Department of Rheumatology and Clinical Immunology, Ospedale Civile and University of Brescia, Brescia, Italy
| | - Peter M Villiger
- Department of Rheumatology and Clinical Immunology/Allergology, University Hospital of Bern, Bern, Switzerland
| | - Marianne Wallenius
- National Service for Pregnancy and Rheumatic Diseases, Department of Rheumatology, Trondheim University Hospital, Trondheim, Norway; Dept of Neuroscience, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Michael von Wolff
- University Women's Hospital, Division of Gynaecological Endocrinology and Reproductive Medicine, University of Berne, Berne, Switzerland
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Mekinian A, Costedoat-Chalumeau N, Masseau A, Tincani A, De Caroli S, Alijotas-Reig J, Ruffatti A, Ambrozic A, Botta A, Le Guern V, Fritsch-Stork R, Nicaise-Roland P, Carbonne B, Carbillon L, Fain O. Obstetrical APS: is there a place for hydroxychloroquine to improve the pregnancy outcome? Autoimmun Rev 2014; 14:23-9. [PMID: 25179813 DOI: 10.1016/j.autrev.2014.08.040] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2014] [Accepted: 08/25/2014] [Indexed: 01/12/2023]
Abstract
The use of the conventional APS treatment (the combination of low-dose aspirin and LMWH) dramatically improved the obstetrical prognosis in primary obstetrical APS (OAPS). The persistence of adverse pregnancy outcome raises the need to find other drugs to improve obstetrical outcome. Hydroxychloroquine is widely used in patients with various autoimmune diseases, particularly SLE. Antimalarials have many anti-inflammatory, anti-aggregant and immune-regulatory properties: they inhibit phospholipase activity, stabilize lysosomal membranes, block the production of several pro-inflammatory cytokines and, in addition, impair complement-dependent antigen-antibody reactions. There is ample evidence of protective effects of hydroxychloroquine in OAPS similar to the situation in SLE arising from in vitro studies of pathophysiological working mechanism of hydroxychloroquine. However, the clinical data on the use of hydroxychloroquine in primary APS are lacking and prospective studies are necessary.
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Affiliation(s)
- Arsene Mekinian
- AP-HP, Hôpital Saint-Antoine, Service de médecine interne, Inflammation-Immunopathology-Biotherapy Department (DHU i2B), Sorbonne Universités, UPMC Univ Paris 06, F-75012 Paris, France.
| | - Nathalie Costedoat-Chalumeau
- Université René Descartes, Paris, France; APHP, Centre de reference malades auto-immunes et systemiques rares, Service de médecine interne, Hopital Cochin, Paris, France
| | - Agathe Masseau
- Université Nantes, Nantes, France; Service de médecine interne, Hopital Nantes, Nantes, France
| | - Angela Tincani
- Rheumatology and Clinical Immunology, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Sara De Caroli
- Department of Obstetrics, Gynaecology, and Pediatrics, Catholic University of Sacred Heart, Rome, Italy
| | - Jaume Alijotas-Reig
- Systemic Autoimmune Disease Unit, Department of Internal Medicine I, Vall d'Hebrón University Hospital, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Amelia Ruffatti
- Rheumatology Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Ales Ambrozic
- Department of Rheumatology, University Medical Centre Ljubljana, Slovenia
| | - Angela Botta
- Department of Obstetrics, Gynaecology, and Pediatrics, Catholic University of Sacred Heart, Rome, Italy
| | - Véronique Le Guern
- Université René Descartes, Paris, France; APHP, Centre de reference malades auto-immunes et systemiques rares, Service de médecine interne, Hopital Cochin, Paris, France
| | - Ruth Fritsch-Stork
- Department of Rheumatology and Clinical Immunology, University Medical Center, Utrecht, Netherlands
| | - Pascale Nicaise-Roland
- Université Paris 7, Paris, France; AP-HP, Unité Fonctionnelles d'Immunologie «Auto-immunité et Hypersensibilités», Hôpital Bichat-Claude Bernard, Paris, France
| | - Bruno Carbonne
- Université Paris 7, Paris, France; AP-HP, Service de gynécologie obstétrique, Hôpital Trousseau Paris, France
| | - Lionel Carbillon
- Université Paris 13, Bondy, France; AP-HP, Service de gynécologie-obstétrique, Hôpital Jean Verdier, 93140 Bondy, France
| | - Olivier Fain
- AP-HP, Hôpital Saint-Antoine, Service de médecine interne, Inflammation-Immunopathology-Biotherapy Department (DHU i2B), Sorbonne Universités, UPMC Univ Paris 06, F-75012 Paris, France
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Cervera R, Rodríguez-Pintó I, Colafrancesco S, Conti F, Valesini G, Rosário C, Agmon-Levin N, Shoenfeld Y, Ferrão C, Faria R, Vasconcelos C, Signorelli F, Espinosa G. 14th International Congress on Antiphospholipid Antibodies Task Force Report on Catastrophic Antiphospholipid Syndrome. Autoimmun Rev 2014; 13:699-707. [PMID: 24657970 DOI: 10.1016/j.autrev.2014.03.002] [Citation(s) in RCA: 133] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2014] [Accepted: 02/28/2014] [Indexed: 12/24/2022]
Abstract
The 'Task Force on Catastrophic Antiphospholipid Syndrome (CAPS)' was developed on the occasion of the 14th International Congress on Antiphospholipid Antibodies. The objectives of this Task Force were to assess the current knowledge on pathogenesis, clinical and laboratory features, diagnosis and classification, precipitating factors and treatment of this condition in order to address recommendations for future research. This article summarizes the studies analyzed by the Task Force, its recommendations and the future research agenda.
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Affiliation(s)
- Ricard Cervera
- Department of Autoimmune Diseases, Hospital Clínic, Barcelona, Catalonia, Spain.
| | | | - Serena Colafrancesco
- Dipartimento di Medicina Interna e Specialità Mediche, Sapienza Università di Roma, Rome, Italy
| | - Fabrizio Conti
- Dipartimento di Medicina Interna e Specialità Mediche, Sapienza Università di Roma, Rome, Italy
| | - Guido Valesini
- Dipartimento di Medicina Interna e Specialità Mediche, Sapienza Università di Roma, Rome, Italy
| | - Cristina Rosário
- Internal Medicine Department, Hospital de Pedro Hispano, Matosinhos, Portugal
| | - Nancy Agmon-Levin
- The Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Israel
| | - Yehuda Shoenfeld
- The Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Israel; Incumbent of the Laura Schwarz-Kipp Chair for Research of Autoimmune Diseases, Tel-Aviv University, Israel
| | - Claudia Ferrão
- Unidade de Imunologia Clínica, Hospital Santo António, Centro Hospitalar do Porto, ICBAS, Instituto Biomédicas Abel Salazar, Universidade do Porto, Porto, Portugal
| | - Raquel Faria
- Unidade de Imunologia Clínica, Hospital Santo António, Centro Hospitalar do Porto, ICBAS, Instituto Biomédicas Abel Salazar, Universidade do Porto, Porto, Portugal
| | - Carlos Vasconcelos
- Unidade de Imunologia Clínica, Hospital Santo António, Centro Hospitalar do Porto, ICBAS, Instituto Biomédicas Abel Salazar, Universidade do Porto, Porto, Portugal
| | - Flavio Signorelli
- Hospital Universitário Pedro Ernesto, Universidade do Estado do Rio de Janeiro, Brazil
| | - Gerard Espinosa
- Department of Autoimmune Diseases, Hospital Clínic, Barcelona, Catalonia, Spain
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