Preeclampsia and scleroderma: a prospective nationwide analysis

Pregnancy complications and autoimmune diseases in women: systematic review and meta-analysis

BACKGROUND

Pregnancy complications might lead to the development of autoimmune diseases in women. This review aims to summarise studies evaluating the association between pregnancy complications and the development of autoimmune diseases in women.

METHODS

Medline, CINAHL, and Cochrane databases were searched up to January 2024. Nineteen pregnancy complications and 15 autoimmune conditions were included. Title, abstract, full-text screening, data extraction, and quality assessment were performed by two reviewers independently. Data were synthesised using narrative and quantitative methods. Results were presented using odds ratios (OR), relative risks (RR), incidence rate ratios (IRR), and 95% confidence intervals (CI).

RESULTS

Thirty studies were included. One study reported composite exposure to pregnancy complications had a risk of any autoimmune disease RR 3.20 (2.90-3.51) compared to women without pregnancy complications. Women with hyperemesis gravidarum had a higher risk of developing coeliac disease (n = 1) IRR 1.98 (1.27-2.94), Crohn's disease (n = 1) IRR 1.61 (1.25-2.04), psoriasis (n = 1) IRR 1.33 (1.01-1.71), and rheumatoid arthritis (n = 2) IRR 1.35 (1.09-1.64). Miscarriage associated with subsequent diagnosis of Sjogren syndrome (n = 2) IRR 1.33 (1.06-2.81) and rheumatoid arthritis (n = 4) OR 1.11 (1.04-1.20). Gestational hypertension/preeclampsia was linked with the development of systemic sclerosis (n = 2) IRR 2.60 (1.10-4.60) and T1DM (n = 2) IRR 2.37 (2.09-2.68). Stillbirth associated with composite autoimmune conditions (n = 2) RR 5.82 (95% CI 4.87-6.81) and aIRR 1.25 (1.12-1.40). Postpartum psychosis was associated with autoimmune thyroid disease (n = 1) aIRR2.26 (1.61-2.90).

CONCLUSIONS

Women with pregnancy complications subsequently had a higher risk of being diagnosed with autoimmune conditions. Whether this is due to pre-existing undiagnosed health conditions or being causally linked to pregnancy complications is not known.

History of pre-eclampsia does not appear to be a risk factor for vascular phenotype in women with systemic sclerosis

BACKGROUND

Vascular phenotype is associated with a poor prognosis in systemic sclerosis (SSc). The identification of its risk factors could facilitate its early detection.

OBJECTIVES

To explore risk factors for a vascular phenotype of SSc, among them a history of pre-eclampsia.

METHODS

This observational multicentre case-control study enrolled adult women fulfilling European Alliance of Associations for Rheumatology 2013 diagnosis criteria for SSc and having a pregnancy history≥6 months before SSc diagnosis in 14 French hospital-based recruiting centres from July 2020 to July 2022. Cases had specific vascular complications of SSc defined as history of digital ischaemic ulcers, pulmonary arterial hypertension, specific cardiac involvement or renal crisis. Women with SSc were included during their annual follow-up visit and filled in a self-administered questionnaire about pregnancy. A case report form was completed by their physician, reporting data on medical history, physical examination, clinical investigations and current medication. The main outcome was the presence/absence of a personal history of pre-eclampsia before SSc diagnosis, according to the validated pre-eclampsia questionnaire.

RESULTS

378 women were included: 129 cases with a vascular phenotype and 249 matched controls. A history of pre-eclampsia was reported in 5 (3.9%) cases and 12 (4.8%) controls and was not associated with a vascular phenotype (OR=0.96, 95% CI 0.28 to 3.34, p=0.9). Besides, Rodnan skin score and disease duration≥5 years were risk factors for vascular phenotype.

CONCLUSIONS

In women with SSc and a pregnancy history≥6 months before SSc, a history of pre-eclampsia is not associated with a vascular phenotype.

Rheumatic Diseases in Reproductive Age-the Possibilities and the Risks

The most common systemic connective tissue diseases (CTD), such as rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), antiphospholipid syndrome (APS), systemic sclerosis (SSc), and Sjögren's syndrome (SjS), affect many women of reproductive age. These diseases may strongly impact the course of pregnancy and increase the risk factors of incompatibility. A literature search was done on MEDLINE, PubMed, and Google Scholar in 2011-2021. The analysis included meta-analysis, randomized control trials, prospective and retrospective studies, and systematic reviews. The literature search allowed us to form conclusions and underline recommendations regarding pregnancy's risk and treatment possibilities in the course of rheumatic disease. Optimal control of CTD activity should be reached at least 6 months before conception. High-risk pregnancies are often accompanied by maternal-placental syndrome, which manifests as preeclampsia, eclampsia, fetal growth restriction, and prematurity. The flare of rheumatic disease can coexist with obstetrical complications, and differential diagnosis can be difficult. Medications that do not influence the risk of fetus complications should be applied before and during pregnancy. Teratogenic drugs (e.g., methotrexate, leflunomide, cyclophosphamide) must be withdrawn before pregnancy. Conventional medications such as hydroxychloroquine, sulfasalazine, colchicine, and the TNFα inhibitor certolizumab can be used safely at any stage of pregnancy. Corticosteroids should be tapered, and other biologics should be avoided due to teratogenicity or carefully administered due to the impact on the fetal immune system. Distinguishing between disease flare and obstetrical complications can be difficult in clinical practice; however, some clinical symptoms and serological markers can be helpful in the differential diagnosis.

Hypertensive diseases of pregnancy and risk of breast cancer in the Black Women's Health Study

PURPOSE

Compared to white women, Black women have increased risk of developing hypertensive diseases of pregnancy (HDOP) and have a higher incidence of aggressive breast cancer subtypes. Few studies of HDOP and breast cancer risk have included large numbers of Black women. This study examined the relation of HDOP to incidence of breast cancer overall and by estrogen receptor (ER) status in Black women.

METHODS

We followed 42,982 parous women in the Black Women's Health Study, a nationwide prospective study of Black women. Multivariable Cox proportional hazards regression models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) to assess associations of self-reported HDOP, including preeclampsia and gestational hypertension, with breast cancer incidence overall and by ER subtype, adjusted for age and established breast cancer risk factors.

RESULTS

Over 20 years of follow-up, we identified 2376 incident breast cancer cases. History of HDOP (11.7%) was not associated with breast cancer risk overall (HR 0.98; 95% CI 0.87, 1.11). HRs for invasive ER+ and ER- breast cancer were 1.11 (95% CI 0.93, 1.34) and 0.81 (95% CI 0.61, 1.07), respectively.

CONCLUSIONS

HDOP was not associated with risk of overall breast cancer in Black women. A suggestive inverse association with ER- breast cancer may reflect an anti-tumorigenic hormone profile in HDOP, but those results require confirmation in other studies.

Increased Rates of Obstetric Complications Prior to Systemic Sclerosis Diagnosis

OBJECTIVE

To investigate whether obstetric complications prior to systemic sclerosis (SSc) diagnosis are more common compared to the general obstetric population.

METHODS

A case-control study was performed at Kaiser Permanente Northern California to compare prior obstetric complications in adult women who later developed SSc (cases) with women from the general obstetric population who did not develop SSc (controls; matched 10:1 by age and year of delivery) from 2007-2016. Exposures included past hypertensive disorders of pregnancy (preeclampsia, eclampsia, gestational hypertension), premature rupture of membranes (PROM), intrauterine growth restriction (IUGR), maternal infections, neonatal intensive care unit (NICU) admission, and preterm birth. Fischer's exact tests were used to compare categorical variables. Conditional logistic regression models estimated the odds ratio (OR) and corresponding 95% confidence intervals for the outcome SSc.

RESULTS

Seventeen SSc cases and 170 non-SSc controls were identified, with median maternal age at delivery 34 years (range 23-46 years) and median time from delivery to SSc diagnosis 2 years (range 0.2-7.3 years). SSc cases were more likely to be Hispanic and Black. Prior obstetric complications appeared higher in women with an eventual SSc diagnosis compared to controls (70.6% vs. 50%), including hypertensive disorders (17.7% vs. 9.4%), PROM (11.8% vs. 4.1%), IUGR (5.9% vs 1.8%), maternal infection (29.4% vs. 14.1%), NICU admissions (23.5% vs. 7.7%), and preterm delivery (29.4% vs. 21.8%). Cases had a higher odds of delivering infants requiring NICU admission (OR=4.7, 95% CI 1.2-18.8).

CONCLUSIONS

Women who eventually develop SSc had trends towards more complicated pregnancy histories before overt diagnosis.

Nature's endless wonder: unexpected motherhood after pediatric allogeneic stem cell transplantation and severe late effects

Infertility and endocrine late effects (LE) are common sequelae after pediatric allogeneic hematopoietic stem cell transplantation (HSCT) after myeloablative conditioning. Nevertheless, the individual risk for these LE is not always easy to predict and therefore these issues are of ongoing interest to the clinical research community dealing with HSCT aftercare. This article describes the case of a young woman who received polychemotherapy and total body irradiation (TBI) containing conditioning for HSCT for a relapsed anaplastic large cell lymphoma (ALCL). She developed severe sclerotic chronic graft-versus-host disease (GVHD) with irreversible joint contractures and multiorgan involvement, requiring long-term multimodal immunosuppressive treatment. Subsequently showing a considerable number of LE including hypergonadotropic hypogonadism, she accepted that infertility would be quite likely. Her courageous personal life planning included part-time working and a partnership but not motherhood. This article reports the unexpected and spontaneous pregnancy and the extreme preterm birth of a surprisingly adequately developing child.

Feto-Maternal Microchimerism: The Pre-eclampsia Conundrum

Feto-maternal microchimerism (FMM) involves bidirectional cross-placental trafficking during pregnancy, leading to a micro-chimeric state that can persist for decades. In this manner a pregnant woman will harbor cells from her mother, as well as, cells from her child. Historically, eclampsia, a severe disorder of pregnancy provided the basis for FMM following the detection of trophoblast cells in the lungs of deceased women. Bi-directional cell trafficking between mother and fetus is also altered in pre-eclampsia and has been suggested to contribute to the underlying etiology. FMM has been implicated in tolerance promotion, remission of auto-inflammatory disorders during pregnancy, or the development of autoimmune conditions post-partum. The underlying mechanism whereby the host immune system is modulated is unclear but appears to involve HLA class II molecules, in that incompatibility between mother and fetus promotes remission of rheumatoid arthritis, whereas feto-maternal HLA compatibility may assist in the post-partum initiation of scleroderma. Couples having a high degree of HLA class II compatibility have an increased risk for pre-eclampsia, while the occurrence of scleroderma and rheumatoid arthritis is greater in pre-eclamptic cases than in women with normal pregnancies, suggesting a long term autoimmune predisposition. Since pregnant women with pre-eclampsia exhibit significantly lower levels of maternally-derived micro-chimerism, the question arises whether pre-eclampsia and post-partum development of autoimmune conditions occur due to the failure of the grandmothers cells to adequately regulate an inappropriate micro-chimeric constellation.