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Laíño-Piñeiro MC, Rúa-Figueroa I, Jiménez N, Lozano MJC, Martínez-Barrio J, Serrano B, Galindo-Izquierdo M, Nack A, Loricera J, Tomero-Muriel E, Ibáñez-Barceló M, Vázquez NM, Manrique-Arija S, Lorenzo NA, Narváez J, Rosas J, Menor-Almagro R, Martínez-Taboada VM, Aurrecoechea-Aguinaga E, Horcada L, Ruiz-Lucea E, Raya E, Toyos FJ, Expósito L, Vela P, Freire-González M, Moriano-Morales C, Bonilla-Hernán G, Ibáñez TC, Lozano-Rivas N, Moreno M, Andreu JL, Ubiaga CLI, Torrente-Segarra V, Valls E, Velloso-Feijoo ML, Alcázar JL, Pego-Reigosa JM. Pregnancy outcomes in 1869 pregnancies in a large cohort from the Spanish Society of Rheumatology Lupus Register (RELESSER). Semin Arthritis Rheum 2023; 61:152232. [PMID: 37348350 DOI: 10.1016/j.semarthrit.2023.152232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 05/15/2023] [Accepted: 06/11/2023] [Indexed: 06/24/2023]
Abstract
INTRODUCTION Obstetric complications are more common in women with systemic lupus erythematosus (SLE) than in the general population. OBJECTIVE To assess pregnancy outcomes in women with SLE from the RELESSER cohort after 12 years of follow-up. METHODS A multicentre retrospective observational study was conducted. In addition to data from the RELESSER register, data were collected on obstetric/gynaecological variables and treatments received. The number of term pregnancies was compared between women with pregnancies before and after the diagnosis of SLE. Further, clinical and laboratory characteristics were compared between women with pregnancies before and after the diagnosis, on the one hand, and with and without complications during pregnancy, on the other. Bivariate and multivariate analyses were carried out to identify factors potentially associated with complications during pregnancy. RESULTS A total of 809 women were included, with 1869 pregnancies, of which 1395 reached term. Women with pregnancies before the diagnosis of SLE had more pregnancies (2.37 vs 1.87) and a higher rate of term pregnancies (76.8% vs 69.8%, p < 0.001) compared to those with pregnancies after the diagnosis. Women with pregnancies before the diagnosis were diagnosed at an older age (43.4 vs 34.1 years) and had more comorbidities. No differences were observed between the groups with pregnancies before and after diagnosis in antibody profile, including anti-dsDNA, anti-Sm, anti-Ro, anti-La, lupus anticoagulant, anticardiolipin or anti-beta-2-glycoprotein. Overall, 114 out of the 809 women included in the study experienced complications during pregnancy, including miscarriage, preeclampsia/eclampsia, foetal death, and/or preterm birth. Women with complications had higher rates of antiphospholipid syndrome (40.5% vs 9.9%, p < 0.001) and higher rates of positivity for IgG anticardiolipin (33.9% vs 21.3%, p = 0.005), IgG anti-beta 2 glycoprotein (26.1% vs 14%, p = 0.007), and IgM anti-beta 2 glycoprotein (26.1% vs 16%, p = 0.032) antibodies, although no differences were found regarding lupus anticoagulant. Among the treatments received, only heparin was more commonly used by women with pregnancy complications. We did not find differences in corticosteroid or hydroxychloroquine use. CONCLUSIONS The likelihood of term pregnancy is higher before the diagnosis of SLE. In our cohort, positivity for anticardiolipin IgG and anti-beta-2- glycoprotein IgG/IgM, but not lupus anticoagulant, was associated with a higher risk of poorer pregnancy outcomes.
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Affiliation(s)
| | - Iñigo Rúa-Figueroa
- Department of Rheumatology, Hospital Universitario Doctor Negrín, Las Palmas de Gran Canaria, Spain
| | - Norman Jiménez
- IRIDIS Group (Investigation in Rheumatology and Immune-Diseases), Galicia Sur Health Research Institute (IISGS), Vigo, Spain
| | | | | | - Belén Serrano
- Department of Rheumatology, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | | | - Annika Nack
- Department of Rheumatology, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Javier Loricera
- Department of Rheumatology, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Eva Tomero-Muriel
- Department of Rheumatology, Hospital Universitario La Princesa, Madrid, Spain
| | | | - Natalia Mena Vázquez
- Department of Rheumatology, Hospital Regional Universitario de Málaga, Málaga, Spain
| | - Sara Manrique-Arija
- Department of Rheumatology, Hospital Regional Universitario de Málaga, Málaga, Spain
| | - Nerea Alcorta Lorenzo
- Department of Rheumatology, Hospital Universitario de Donostia, San Sebastián, Spain
| | - Javier Narváez
- Department of Rheumatology, Hospital Universitario de Bellvitge, L'Hospitalet de Llobregat, Spain
| | - José Rosas
- Department of Rheumatology, Hospital Marina Baixa, Alicante, Spain
| | - Raúl Menor-Almagro
- Department of Rheumatology, Hospital Jerez de la Frontera, Jerez de la Frontera, Spain
| | | | | | - Loreto Horcada
- Department of Rheumatology, Hospital Universitario de Navarra, Pamplona, Spain
| | | | - Enrique Raya
- Department of Rheumatology, Hospital Universitario Clínico San Cecilio, Granada, Spain
| | - F Javier Toyos
- Department of Rheumatology, Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - Lorena Expósito
- Department of Rheumatology, Hospital Universitario de Canarias, Tenerife, Spain
| | - Paloma Vela
- Department of Rheumatology, Hospital General Universitario de Alicante, Alicante, Spain
| | | | | | | | - Tatiana Cobo Ibáñez
- Department of Rheumatology, Hospital Universitario Infanta Sofía, Madrid, Spain
| | - Nuria Lozano-Rivas
- Department of Rheumatology, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Mireia Moreno
- Department of Rheumatology, Hospital Universitario Parc Taulí, Sabadell, Spain
| | - José Luis Andreu
- Department of Rheumatology, Hospital Puerta de Hierro-Majadahonda, Madrid, Spain
| | | | - Vicenç Torrente-Segarra
- Department of Rheumatology, Hospital Comarcal Alt Penedès-Garraf, Vilafranca del Penedès, Spain
| | - Elia Valls
- Department of Rheumatology, Hospital Dr. Peset, Valencia, Spain
| | - M L Velloso-Feijoo
- Department of Rheumatology, Hospital Universitario de Valme, Sevilla, Spain
| | - Juan Luis Alcázar
- Department of Obstetrics and Gynecology, Clínica Universidad de Navarra, Pamplona, Spain
| | - José M Pego-Reigosa
- IRIDIS Group (Investigation in Rheumatology and Immune-Diseases), Galicia Sur Health Research Institute (IISGS), Vigo, Spain; Department of Rheumatology, Complejo Hospitalario Universitario de Vigo, Vigo, Spain
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Juliao P, Wurst K, Pimenta JM, Gemzoe K, Landy H, Moody MA, Tilson H, Covington D, Moore T, Marino R, Gilbride J, Liu A, Meizlik P, Petri M. Belimumab use during pregnancy: Interim results of the belimumab pregnancy registry. Birth Defects Res 2023; 115:188-204. [PMID: 36177676 PMCID: PMC10092734 DOI: 10.1002/bdr2.2091] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 08/25/2022] [Accepted: 09/04/2022] [Indexed: 01/28/2023]
Abstract
BACKGROUND Belimumab is approved for active, autoantibody-positive systemic lupus erythematosus (SLE) and lupus nephritis, but limited data exist regarding its use in pregnancy. The Belimumab Pregnancy Registry (BPR, GSK Study BEL114256; NCT01532310) was created to evaluate pregnancy and infant outcomes following belimumab exposure. METHODS Individuals with SLE exposed to belimumab from 4 months before and/or during pregnancy can enroll into the BPR. The primary outcome is major birth defects; secondary outcomes include miscarriages, stillbirths, elective termination, pre-term birth, neonatal death, small for gestational age, and adverse infant outcomes during the first year of life. Belimumab exposure timing, concomitant medications, and other potential confounding factors are also collected. Data up to March 8, 2021, are reported descriptively. RESULTS From an expected sample size target of 500 prospective pregnancies with a known outcome, only 55 were enrolled in the study. Among these, two pregnancy losses and 53 pregnancies with a live birth outcome were reported. Ten of the 53 live birth pregnancies resulted in a major birth defect. Ten pregnancies were enrolled after the pregnancy outcome occurred and were examined retrospectively (four live births with no defects, four miscarriages, and two elective terminations). There was no indication or pattern of birth defects associated with belimumab. CONCLUSIONS Low recruitment numbers for the BPR and incomplete information limit the conclusions regarding belimumab exposure during pregnancy. There was no pattern or common mechanism of birth defects associated with belimumab within the BPR data.
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Affiliation(s)
| | - Keele Wurst
- EpidemiologyGSKResearch Triangle ParkNorth CarolinaUSA
| | | | - Kim Gemzoe
- Value Evidence and OutcomesGSKStevenageHertfordshireUnited Kingdom
| | - Helain Landy
- Maternal And Fetal MedicineGeorgetown University Medical CenterWashingtonDCUSA
- Department of Obstetrics and GynecologyMedStar Georgetown University HospitalWashingtonDCUSA
| | - M. Anthony Moody
- Department of PediatricsDuke University School of MedicineDurhamNorth CarolinaUSA
| | - Hugh Tilson
- Department of EpidemiologyUniversity of North Carolina Gillings School of Global Public HealthChapel HillNorth CarolinaUSA
| | | | | | - Rebecca Marino
- US Case Management GroupGSKResearch Triangle ParkNorth CarolinaUSA
| | | | - Andrew Liu
- Global Clinical Safety and PharmacovigilanceGSKUxbridgeMiddlesexUnited Kingdom
| | | | - Michelle Petri
- RheumatologyJohns Hopkins University School of MedicineBaltimoreMarylandUSA
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Mohammed RHA, Mumtaz H, Sangah AB, Shaikh SS, Nasir N, Jabeen S. Pregnancy in lupus: an updated consensus to guide best practice strategies. EGYPTIAN RHEUMATOLOGY AND REHABILITATION 2022. [DOI: 10.1186/s43166-022-00167-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Abstract
Background
Systemic lupus erythematosus is a multifaceted chronic relapsing autoimmune disease of unknown etiology. The disease has always been a serious diagnosis in women being a multisystem pathology that is classically encountered during the childbearing age posing serious systemic comorbidities with a potential impact on the functional performance, psychosocial status, and survival. In this article, we review critical issues related to the decision to conceive in female with lupus highlighting the impact of the diagnosis and disease activity status on the mother and the fetus, attempting to suggest a consensus to guide safe decision making for pregnancy with SLE.
Main body
The pleomorphic dysregulated immune nature of lupus in the presence of uncontrolled disease carries a higher risk of complicated pregnancy. Therefore, SLE pregnancies should be well planned and are usually encouraged if the disease is inactive (at least 6 months prior to conception) to ensure immune quiescence towards a safer outcome.
Conclusion
With the proper implementation of preconception counseling strategy, choice of the correct timing of conception, close monitoring of SLE flares with tight control, and the appreciation of the value of multidisciplinary management to best practice most young women with SLE can carry on successful pregnancies with favorable outcome.
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El Miedany Y, Kamel NS, Abu-Zaid MH, El Hadidi K, Mahmoud GA, El Gaafary M, Sarhan E, Abdel-Nasser A, Abualfadl EM, Azim AA, Fathi NA, Mokbel A, Hassan W, Eissa M, Tabra SAA, Mortada M, Fouad NA, Elnemr R, Mansour AE, Elaraby I, Medhat BM, Mohamed SS, Abdelradi ER, Ibrahim RA, Saber S. Egyptian recommendations for treating to target of lupus nephritis: an evidence-based consensus on clinical practice recommendations for the management of lupus nephritis and pregnancy. EGYPTIAN RHEUMATOLOGY AND REHABILITATION 2022. [DOI: 10.1186/s43166-022-00142-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Nephritis is known to be one of the most serious complications of lupus and a strong predictor of poor outcome. This study was carried out aiming at setting up an up-to-date recommendation for the management of women living with lupus nephritis and planning for a family throughout conception, pregnancy, and the postpartum period.
Ten key clinical questions were identified by the scientific committee according to the Patient/Population, Intervention, Comparison, Outcomes and Timing (PICOT) approach. The literature review team performed a systematic review to summarise evidence advocating the benefits and harms of available pharmacologic and nonpharmacologic therapies for women living with lupus nephritis (LN) and planning for a family. Subsequently, recommendations were formulated. The level of evidence was determined for each section using the Oxford Centre for Evidence-Based Medicine (CEBM) system. A 2-round Delphi process was conducted with 24 experts. All rounds were conducted online. A consensus was achieved on the direction and the strength of the recommendations.
Results
An online questionnaire was sent to an expert panel who participated in the two rounds (response rate 100%). At the end of round 2, a total of 20 recommendation items, categorised into 10 domains to address the main LN with pregnancy categories, were obtained. The percentage of those who agreed with the recommendations (rank 7–9) ranged from 88.5 to 100%. On the phrasing of all the clinical standards defined by the scientific committee, a consensus was reached (i.e., 75% of respondents strongly agreed or agreed). An algorithm for the management of LN with pregnancy has been suggested.
Conclusion
These recommendations provide an updated consensus on the pharmacological treatment of LN with pregnancy and strategies to reach optimal outcomes for both the mother and newborn in common clinical scenarios, based on a combination of evidence and expert opinion. Best treatment decisions should be tailored to each individual patient’s situation.
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Braga A, Barros T, Faria R, Marinho A, Carvalheira G, Rocha G, Farinha F, Neves E, Vasconcelos C, Braga J. Systemic lupus erythematosus and pregnancy: A retrospective single-center study of 215 pregnancies from Portugal. Lupus 2021; 30:2165-2175. [PMID: 34693803 DOI: 10.1177/09612033211050340] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Systemic lupus erythematosus (SLE) is a life-threatening disorder that affects women at reproductive age. We evaluate the clinical impact of pregnancy in a cohort of Portuguese SLE patients and the risk factors associated with maternal and fetal adverse outcomes. METHODS A retrospective observational study that included all pregnant women with SLE managed at a Portuguese tertiary hospital, between January 1993 and December 2019. Baseline maternal information was collected, and maternal-fetal and neonatal outcomes were evaluated. Disease activity before and during pregnancy was assessed. RESULTS We included 215 pregnancies from 143 patients. Lupus nephritis was present in 20.0% and antiphospholipid syndrome (APS) in 21.9% of the cases. Preconception consultation was performed in 86.9% of the pregnancies, and 92.5% of the patients had no or low disease activity at conception. During gestation, 79.6% of the patients were under treatment, and hydroxychloroquine (HCQ) was the most commonly used drug (63.7%). Low-dose acetylsalicylic acid (ASA) was prescribed at conception in 87.9% of the patients. The live birth rate was 84.2%. An adverse pregnancy outcome (APO) occurred in 41.4% of the pregnancies. A miscarriage rate of 15.3% and a preterm delivery rate of 15.4% were found. Preeclampsia and fetal growth restriction complicated 13.1% and 14.0% of the gestations, respectively. Neonatal lupus occurred in 7.1% of the newborns, and there were 2 cases of congenital heart block. Significant risk factors for the development of AOP were disease activity at conception, lupus flare, hypocomplementemia, positivity for lupus anticoagulant, and APS. The use of ASA was significantly associated with a reduced incidence of miscarriage. An SLE flare was diagnosed in 16.3% of the cases. We identified as risk factors for lupus flares the presence of active disease at conception, a previous history of lupus nephritis, and the use of chronic medication. HCQ use during pregnancy was associated with a significant reduction of flare incidence during pregnancy and postpartum. CONCLUSIONS Pregnancy in an SLE patient is associated with an increased incidence of adverse obstetric outcomes. Good disease control before pregnancy and adequate treatment, especially with HCQ, is crucial to achieving the best obstetric results.
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Affiliation(s)
- António Braga
- Maternal Fetal Unit, 522166Centro Hospitalar Universitário do Porto, Centro Materno Infantil do Norte, Oporto, Portugal.,Instituto Ciências Biomédicas Abel Salazar, Oporto University, Oporto, Portugal
| | - Tânia Barros
- Maternal Fetal Unit, 522166Centro Hospitalar Universitário do Porto, Centro Materno Infantil do Norte, Oporto, Portugal
| | - Raquel Faria
- Instituto Ciências Biomédicas Abel Salazar, Oporto University, Oporto, Portugal.,Clinical Immunology Unit, 112085Centro Hospitalar Universitário do Porto, Oporto, Portugal
| | - António Marinho
- Instituto Ciências Biomédicas Abel Salazar, Oporto University, Oporto, Portugal.,Clinical Immunology Unit, 112085Centro Hospitalar Universitário do Porto, Oporto, Portugal
| | - Graziela Carvalheira
- Clinical Immunology Unit, 112085Centro Hospitalar Universitário do Porto, Oporto, Portugal
| | - Guilherme Rocha
- Instituto Ciências Biomédicas Abel Salazar, Oporto University, Oporto, Portugal.,Clinical Immunology Unit, 112085Centro Hospitalar Universitário do Porto, Oporto, Portugal.,Nephrology Department, 112085Centro Hospitalar Universitário do Porto, Oporto, Portugal
| | - Fátima Farinha
- Instituto Ciências Biomédicas Abel Salazar, Oporto University, Oporto, Portugal.,Clinical Immunology Unit, 112085Centro Hospitalar Universitário do Porto, Oporto, Portugal
| | - Esmeralda Neves
- Instituto Ciências Biomédicas Abel Salazar, Oporto University, Oporto, Portugal.,Clinical Immunology Unit, 112085Centro Hospitalar Universitário do Porto, Oporto, Portugal
| | - Carlos Vasconcelos
- Instituto Ciências Biomédicas Abel Salazar, Oporto University, Oporto, Portugal.,Clinical Immunology Unit, 112085Centro Hospitalar Universitário do Porto, Oporto, Portugal
| | - Jorge Braga
- Maternal Fetal Unit, 522166Centro Hospitalar Universitário do Porto, Centro Materno Infantil do Norte, Oporto, Portugal.,Instituto Ciências Biomédicas Abel Salazar, Oporto University, Oporto, Portugal.,Clinical Immunology Unit, 112085Centro Hospitalar Universitário do Porto, Oporto, Portugal
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Braga A, Barros T, Faria R, Marinho A, Rocha G, Farinha F, Neves E, Vasconcelos C, Braga J. Systemic Lupus Erythematosus and Pregnancy: a Portuguese Case-Control Study. Clin Rev Allergy Immunol 2021; 62:324-332. [PMID: 34519994 DOI: 10.1007/s12016-021-08893-y] [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] [Accepted: 08/24/2021] [Indexed: 12/29/2022]
Abstract
Pregnancy in systemic lupus erythematosus (SLE) patients is associated with an increased risk of adverse outcomes. During pregnancy, SLE patients have a higher rate of miscarriage, stillbirth, preterm delivery, fetal growth restriction, or hypertensive disorders of pregnancy. To date, only a few case-control studies were published with the purpose to evaluate the magnitude of risk associated with pregnancy in lupus patients. The aim of our study was to evaluate the maternal and fetal outcomes in a cohort of Portuguese SLE patients and to compare it with a group of healthy pregnant women. We conducted a retrospective case-control study that included all pregnant women with SLE managed at a Portuguese tertiary center, between 2010 and 2019. Pregnancy outcomes were compared between SLE patients and a group of matched healthy pregnant women. Baseline maternal data was collected, and maternal-fetal and neonatal outcomes were evaluated. One hundred twenty-four SLE pregnancies were included. Of the patients, 95.2% were in remission at conception. In 13.7% of cases, a lupus flare was diagnosed during gestation and in 17.9% in the postpartum period. The live birth rate was 84.6%, and the incidence of adverse outcomes was 40.3% (OR 2.64, 95% CI 1.67-4.18). Considering only patients in remission at conception, the presence of adverse outcomes remained significantly higher (36.8% vs. 20.3%, P < 0.01). Miscarriage rate was 15.3% (OR 5.85, 95% CI 2.57-13.34) and preterm delivery occurred in 12.4% of the patients (OR 1.72, 95% CI 0.83-3.57). Preeclampsia prevalence was higher in SLE patients (OR 3.92, 95% CI 1.32-11.57). In the SLE group, the newborn admission to an intensive care unit rate was increased (OR 4.99, 95% CI 1.47-16.90). No neonatal or maternal deaths were reported. In our study, pregnancy with SLE was associated with an increased incidence of adverse outcomes, even in a population of SLE patients with well-controlled disease.
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Affiliation(s)
- António Braga
- Maternal Fetal Unit, Centro Materno Infantil Do Norte, Centro Hospitalar Universitário Do Porto, Oporto, Portugal. .,Instituto Ciências Biomédicas Abel Salazar, Universidade do Porto, Oporto, Portugal.
| | - Tânia Barros
- Maternal Fetal Unit, Centro Materno Infantil Do Norte, Centro Hospitalar Universitário Do Porto, Oporto, Portugal
| | - Raquel Faria
- Instituto Ciências Biomédicas Abel Salazar, Universidade do Porto, Oporto, Portugal.,Clinical Immunology Unit, Centro Hospitalar Universitário Do Porto, Oporto, Portugal
| | - António Marinho
- Instituto Ciências Biomédicas Abel Salazar, Universidade do Porto, Oporto, Portugal.,Clinical Immunology Unit, Centro Hospitalar Universitário Do Porto, Oporto, Portugal
| | - Guilherme Rocha
- Instituto Ciências Biomédicas Abel Salazar, Universidade do Porto, Oporto, Portugal.,Clinical Immunology Unit, Centro Hospitalar Universitário Do Porto, Oporto, Portugal.,Nephrology Department, Centro Hospitalar Universitário Do Porto, Oporto, Portugal
| | - Fátima Farinha
- Instituto Ciências Biomédicas Abel Salazar, Universidade do Porto, Oporto, Portugal.,Clinical Immunology Unit, Centro Hospitalar Universitário Do Porto, Oporto, Portugal
| | - Esmeralda Neves
- Instituto Ciências Biomédicas Abel Salazar, Universidade do Porto, Oporto, Portugal.,Clinical Immunology Unit, Centro Hospitalar Universitário Do Porto, Oporto, Portugal
| | - Carlos Vasconcelos
- Instituto Ciências Biomédicas Abel Salazar, Universidade do Porto, Oporto, Portugal.,Clinical Immunology Unit, Centro Hospitalar Universitário Do Porto, Oporto, Portugal
| | - Jorge Braga
- Maternal Fetal Unit, Centro Materno Infantil Do Norte, Centro Hospitalar Universitário Do Porto, Oporto, Portugal.,Instituto Ciências Biomédicas Abel Salazar, Universidade do Porto, Oporto, Portugal.,Clinical Immunology Unit, Centro Hospitalar Universitário Do Porto, Oporto, Portugal
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Elnady B, Taha A, Desouky DE, Abd-Elmakoud SF, Rageh EM, Algethami AM, Algethami M, ten Klooster PM, Rasker JJ. Impact of sustained remission on quality of life among women with rheumatoid arthritis and systemic lupus erythematosus: a prospective observational study. EGYPTIAN RHEUMATOLOGY AND REHABILITATION 2021. [DOI: 10.1186/s43166-021-00072-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Abstract
Background
Health-related quality of life (HRQOL) as a patient reported outcome plays important roles in the life of patients with RA (rheumatoid arthritis) and SLE (Systemic lupus erythematosus) as well as their families. Evaluating the impact of sustained remission on HRQOL is important and could be of potential help in daily practice. Thus, we aimed to assess and compare prospectively the impact of sustained remission on HRQOL in Saudi RA and SLE female cohorts.
Results
Sixty-two female patients with active RA and 34 female patients with active SLE fulfilled the inclusion-, entry- and follow-up criteria. At baseline, the SLE patients had significantly better SF-36 scores than the RA patients. In both groups, significant correlations were found between disease activity and physical (PCS) and mental (MCS) components summary of the SF-36 (all p’s ≤ 0.001). In sustained remission, both SLE and RA patients showed significant improvements of the SF-36 scores (p < 0.001) compared to baseline. RA patients in sustained remission had a significantly better general health, bodily pain and physical functioning, and total PCS scores (p < 0.001) than those with SLE.
Conclusions
Both SLE and RA patients in sustained remission showed strongly improved HRQOL. In sustained remission, RA patients had comparable or better HRQOL than SLE patients.
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Muscle weakness of the lower limbs after epidural anesthesia in a pregnant woman with undiscovered systemic lupus erythematosus. Chin Med J (Engl) 2020; 133:621-622. [PMID: 32032082 PMCID: PMC7065854 DOI: 10.1097/cm9.0000000000000665] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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9
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Polić A, Običan SG. Pregnancy in systemic lupus erythematosus. Birth Defects Res 2020; 112:1115-1125. [PMID: 32902202 DOI: 10.1002/bdr2.1790] [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] [Received: 05/19/2020] [Revised: 07/05/2020] [Accepted: 07/30/2020] [Indexed: 01/17/2023]
Abstract
OBJECTIVES Systemic lupus erythematosus (SLE) is a chronic illness that often affects women of reproductive age. The objectives of this article are to review the impact of SLE on pregnancy and current management strategies, including commonly used therapies. METHODS We conducted a review of available literature on the clinical course of SLE, diagnosis, management and pregnancy complications. RESULTS SLE has a variable clinical course characterized by flares and periods of remission and can present unique challenges in the management of obstetric patients. Pregnancy in patients with SLE is associated with multiple risks, including fetal loss, preterm birth, fetal growth restriction, and hypertensive disease. With advancements in disease treatment, many women have favorable pregnancy outcomes, but appropriate preconception counseling and disease management remain important tools in reducing complications. CONCLUSION Given the implications SLE can have on women of reproductive age and in pregnancy, understanding the disease course and management is important in order to optimize pregnancy outcomes.
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Affiliation(s)
- Aleksandra Polić
- Department of Obstetrics and Gynecology, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
| | - Sarah G Običan
- Department of Obstetrics and Gynecology, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
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10
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Abstract
PURPOSE OF REVIEW This review summarizes recent research in the field of systemic lupus erythematosus (SLE) and pregnancy with focus on clinical and biochemical predictors of adverse pregnancy outcomes (APOs), accumulating evidence for the safety and efficacy of hydroxychloroquine (HCQ) in pregnancy, and the importance of preconception counseling. RECENT FINDINGS Ongoing research from PROMISSE investigators (Predictors of Pregnancy Outcome: Biomarkers in Antiphospholipid Antibody Syndrome and Systemic Lupus Erythematosus) adds to the understanding of risk factors for APOs in SLE pregnancies, including aberrant complement activation, incomplete downregulation of lupus-associated transcription factors, and lower socioeconomic status. Evidence supporting numerous advantages for continuing HCQ in pregnancy, as well as support for low-dose aspirin in preeclampsia prevention is reviewed. Practice gaps exist among rheumatologists in ensuring effective contraception when women of childbearing age are undergoing therapy with potentially fetotoxic medications. The publication of organizational guidelines provides evidence-based recommendations on lupus pregnancy management. SUMMARY Outcomes of lupus pregnancies continue to improve with understanding of risk factors that predict APOs as well as improvements in disease management. Rheumatologists caring for women with SLE should be familiar with the most up-to-date research in order to optimize pregnancy outcomes in this population.
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11
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Prepregnancy Endocrine, Autoimmune Disorders and the Risks of Gestational Hypertension-Preeclampsia in Primiparas: A Nationwide Population-Based Study in Taiwan. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17103657. [PMID: 32456015 PMCID: PMC7277106 DOI: 10.3390/ijerph17103657] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 05/19/2020] [Accepted: 05/21/2020] [Indexed: 12/11/2022]
Abstract
(1) Objective: To assess the risks of gestational hypertension/preeclampsia (GH-PE) in women with prepregnancy endocrine and autoimmune disorders such as polycystic ovarian syndrome (PCOS) and systemic lupus erythematosus (SLE). (2) Methods: In a nationwide population-based longitudinal study, data were retrieved from the 1998 to 2012 Taiwan National Health Insurance Research Database. ICD9-CM codes 256.4, 710.0, and 642.X were identified for the corresponding diagnoses of PCOS, SLE, and GH-PE, respectively, which were further confirmed by inspection of medical claims data for ultrasonography findings, laboratory tests, blood pressure measurements and examinations of urine protein to ensure the accuracy of the diagnoses. To clarify the risks of primiparous GH-PE, the study excluded women diagnosed with PCOS or SLE at <15 or >45 years of age, pre-existing chronic hypertension, GH-PE before PCOS and SLE, and abortion or termination before 20 weeks' gestation. For women affected by prepregnancy PCOS or SLE individually, each pregnant woman was age-matched to four pregnant women without PCOS or SLE. Logistic regression analyses were applied to report odds ratios (ORs) for the risks of GH-PE after adjustment for age, occupation, urbanization, economic status, and other co-morbidities. (3) Results: Among 8070 and 2430 women with prepregnancy PCOS and SLE retrieved from a population of 1,000,000 residents, 1953 (24.20%) and 820 (33.74%) had subsequent primiparous pregnancies that were analyzable and compared with 7812 and 3280 pregnancies without prepregnancy PCOS and SLE, respectively. GH-PE occurred more frequently in pregnancies with prepregnancy PCOS (5.79% vs. 2.23%, p < 0.0001) and SLE (3.41% vs. 1.80%, p < 0.01) as compared to those without PCOS and SLE. Further analysis revealed that prepregnancy PCOS (adjusted OR = 2.36; 95%CI: 1.83-3.05) and SLE (adjusted OR = 1.95; 95%CI: 1.23-3.10) were individually associated with GH-PE. The risk of GH-PE was not reduced in women with prepregnancy PCOS receiving metformin treatment (p = 0.22). (4) Conclusions: Prepregnancy PCOS and SLE are independent and significant risk factors for the occurrence of GH-PE. Because the peripartum complications are much higher among pregnancies with GH-PE, the at-risk woman should be informed and well-prepared during her pregnancy and delivery.
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Pastore DEA, Costa ML, Surita FG. Systemic lupus erythematosus and pregnancy: the challenge of improving antenatal care and outcomes. Lupus 2019; 28:1417-1426. [PMID: 31551036 DOI: 10.1177/0961203319877247] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVES The objective of this article is to describe maternal and perinatal outcomes in women with systemic lupus erythematosus (SLE) followed in a high-risk prenatal outpatient clinic at a referral center. METHODS This observational study included pregnant women with SLE who underwent prenatal follow-up and childbirth at the Women's Hospital, University of Campinas, from January 2012 to January 2018. All women were followed according to the institution's protocol for pregnant women with SLE. They were subdivided into two groups according to the presence of disease activity during the preconception and gestation periods, and evaluated according to the Systemic Lupus Erythematosus Disease Activity Index and Systemic Lupus Erythematosus Pregnancy Disease Activity Index scales. Data were retrieved from patients' medical records. Chi-square, Fisher exact and Mann-Whitney tests and multivariable analyses were performed. Statistical significance level was 5% (p < .05). RESULTS A total of 125 cases were initially included; those who were lost to follow-up or gave birth at another hospital were further excluded, with 102 pregnancies (of 95 women) remaining. The mean age of the women was 27.7 years (SD 5.44), and 48% were in their first gestation. The average duration of disease was 6.79 years (SD 5.38), with 92.1% receiving SLE-specific therapy. SLE flare occurred in 8.9% during the preconception period and 23.5% during gestation. Preterm premature rupture of membranes (16.6%), preeclampsia or eclampsia (15.6%) and preterm labor (12.7%) were the most frequent complications. The mean gestational age at birth was 34.4 weeks (SD 5.9); the preterm birth rate was 46.8%, the low birth weight rate was 35.1%, and intensive neonatal care admission was 40.4%. Four fetal deaths and one maternal death occurred, all of them in the group with SLE flares. Multivariable logistic regression analysis showed that preconception lupus activity had a six-fold increased rate of gestational loss (odds ratio (OR): 6.14 (95% confidence interval (CI) 1.26-29.99)), and lupus activity during pregnancy had a five-fold increased rate of prematurity at less than 34 weeks (OR: 5.02 (95% CI: 1.90-13.30)). CONCLUSIONS Despite the low percentages of women with pregestational and pregnancy-active disease, we found high incidences of maternal and perinatal complications. Preconception SLE activity increased gestational loss, and SLE activity during pregnancy increased prematurity. Effective immunosuppressive therapy was able to decrease clinical and laboratory activity of SLE; however, unfavorable perinatal outcomes still occurred, even when lupus activity was under control. Pregnancy in women with SLE is always a challenge.
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Affiliation(s)
- D E A Pastore
- Department of Obstetrics and Gynecology, University of Campinas (UNICAMP), School of Medical Sciences, Campinas, São Paulo, Brazil
| | - M L Costa
- Department of Obstetrics and Gynecology, University of Campinas (UNICAMP), School of Medical Sciences, Campinas, São Paulo, Brazil
| | - F G Surita
- Department of Obstetrics and Gynecology, University of Campinas (UNICAMP), School of Medical Sciences, Campinas, São Paulo, Brazil
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Predictors of SLE relapse in pregnancy and post-partum among multi-ethnic patients in Malaysia. PLoS One 2019; 14:e0222343. [PMID: 31539383 PMCID: PMC6754159 DOI: 10.1371/journal.pone.0222343] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 08/27/2019] [Indexed: 01/26/2023] Open
Abstract
Flare of Systemic Lupus Erythematosus (SLE) may occur during pregnancy and puerperium. We studied the prevalence and factors associated with SLE relapse during pregnancy and post-partum period in a multi-ethnic SLE cohort. Consecutive SLE patients who attended the outpatient clinic were reviewed for previous history of pregnancies in our institution. Patients who had a complete antenatal, delivery, and post-partum follow up were included. Their medical records were retrospectively analysed to assess the disease activity at pre-pregnancy/conception, during antenatal, and post-partum period. Presence of flare episodes during pregnancy and puerperium were recorded. The pregnancy outcomes recorded include live birth, foetal loss, prematurity and intra-uterine growth restrictions (IUGR). Univariate and multivariable logistic regression with generalized estimating equations (GEE) analyses were performed to determine the factors associated with disease relapse and the pregnancy outcomes. A total of 120 patients with 196 pregnancies were included, with a live birth rate of 78.6%. Four (2.0%) were diagnosed to have SLE during pregnancy. The flare rate in pregnancy was 40.1% while post-partum 17.4%. Majority of the relapse in pregnancy occurred in haematological system (62.3%) followed by renal (53.2%), musculoskeletal (22.1%), and mucocutaneous (14.3%). In GEE analyses, active disease at conception was the independent predictor of SLE relapse during and after pregnancy, whereas older maternal age and Malay ethnicity were associated with higher flare during post-partum. HCQ use was significantly associated with reduced risk of flare in univariate analysis but it was no longer significant in the GEE analyses. Presence of disease flare in pregnancy was significantly associated with prematurity. In conclusion, pregnancy in SLE need to be planned during quiescent state as pre-pregnant active disease was associated with disease relapse in both during and after pregnancy. Malay patients had an increased risk of post-partum flare but further larger prospective studies are needed to confirm the association between pregnancies in the different ancestral background.
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Chen D, Lao M, Cai X, Li H, Zhan Y, Wang X, Zhan Z. Hypertensive disorders of pregnancy associated with adverse pregnant outcomes in patients with systemic lupus erythematosus: a multicenter retrospective study. Clin Rheumatol 2019; 38:3501-3509. [PMID: 31377919 DOI: 10.1007/s10067-019-04696-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 06/03/2019] [Accepted: 07/15/2019] [Indexed: 12/31/2022]
Abstract
BACKGROUND Hypertension disorders in pregnancy (HDP) were common complications in women with systemic lupus erythematosus (SLE). However, the impact of HDP and the measures to prevent HDP-related fetal adverse pregnancy outcomes (APOs) remained to be explored. METHODS A multicenter retrospective study of 342 pregnant women with SLE was performed. Variables related to SLE and APOs were recorded. Fetal development was evaluated by umbilical artery Doppler ultrasonography. RESULTS HDP was diagnosed in 45 (13.2%) patients, including pre-eclampsia in 42 and gestational hypertension in 3. Patients with HDP had higher incidence of preterm birth (71.1% vs 20.9%, P < 0.001), intrauterine growth retardation (IUGR) (37.8% vs 11.8%, P < 0.001), low-birth-weight infants (62.2% vs 17.2%, P < 0.001), and very-low-birth-weight infants (37.8% vs 2.7%, P < 0.001), compared with lupus patients without HDP. A total of 35 (77.8%) HDP patients had disease activation during pregnancy. All the events occurred during the second and third trimesters, mainly presenting as moderate-to-high activity (65.7%). Active disease [odds ratios (OR) = 3.9, 95% confidential interval (CI) 1.5-9.7, P = 0.004] and positive anticardiolipin (aCL) antibody (OR = 7.6, 95% CI 2.7-18.6, P < 0.001) were independent risk factors for HDP in lupus patients. Doppler RI and S/D ratio predicted APOs in patients with HDP. The optimal cut-off values for RI and S/D ratio were 0.7 (sensitivity 48.1%, specificity 53.3%) and 3.4 (sensitivity 66.7%, specificity 100%), respectively. CONCLUSIONS HDP was a common pregnant complication and caused various fetal and maternal adverse outcomes in patients with SLE. Umbilical artery Doppler ultrasonography was effective in predicting fetal APOs in lupus patients with HDP.Key Points• HDP induced preterm birth, IUGR, low-birth-weight infants, and very-low-birth-weight infants in patients with SLE.• HDP led to lupus activation during the second and third trimesters.• Disease activation and aCL positivity were predictors for HDP.• RI and S/D ratio from umbilical artery Doppler predicted APOs in patients with HDP.
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Affiliation(s)
- Dongying Chen
- Department of Rheumatology, The First Affiliated Hospital of Sun Yat-sen University, No 58, Zhongshan 2nd Road, Guangzhou, 510080, China
| | - Minxi Lao
- Department of Rheumatology, The First Affiliated Hospital of Sun Yat-sen University, No 58, Zhongshan 2nd Road, Guangzhou, 510080, China.,Department of Geriatrics, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Xiaoyan Cai
- Department of Rheumatology, Guangzhou First People's Hospital, Guangzhou, China
| | - Hao Li
- Department of Rheumatology, The First Affiliated Hospital of Sun Yat-sen University, No 58, Zhongshan 2nd Road, Guangzhou, 510080, China
| | - Yanfeng Zhan
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Xiaodong Wang
- Department of Ultrasound, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, No 16, Jichang Road, Guangzhou, 510405, China.
| | - Zhongping Zhan
- Department of Rheumatology, The First Affiliated Hospital of Sun Yat-sen University, No 58, Zhongshan 2nd Road, Guangzhou, 510080, China.
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The effect of lupus disease on the pregnant women and embryos: a retrospective study from 2010 to 2014. Clin Rheumatol 2019; 38:3211-3215. [PMID: 31352646 DOI: 10.1007/s10067-019-04682-3] [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] [Received: 03/14/2019] [Revised: 06/29/2019] [Accepted: 07/05/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND AND AIMS Pregnancy in women with systemic lupus erythematosus (SLE) is one of the challenges of recent studies. Women should prevent the onset of relapses with medications before and after pregnancy, and on the other hand, the effect of these medicines considers the health and development of the fetus. In this retrospective study, the effects of anti-phospholipid syndrome and the use of common drugs such as methotrexate, cyclosporine, and azathioprine and their side effects on maternal health and ultimately the development of the fetus have been investigated. MATERIAL AND METHODS This study is a descriptive and retrospective epidemiologic study that was conducted in 2016 to investigate maternal and fetal complications in SLE patients. We prepared forms of data recording, including age, occupation, and other important information and then analyzed them in SPSS version 22. RESULT The results showed that the presence of anti-phospholipid syndrome in pregnant women can lead to abnormalities such as preterm, IUGR, abortion, and fetal death (P value 0.0001). It also leads to complications such as nephritis, arthritis, and preeclampsia in the mother (P value 0.003). This study suggests that methotrexate and cyclosporine medications could cause fetal developmental disorders. The P value of cyclosporine was 0.0001 and the P value of methotrexate was 0.001. CONCLUSION Anti-phospholipid syndrome in women with SLE who intend to become pregnant can disrupt the development of the embryo. The consumption of methotrexate and cyclosporine medications before and during the pregnancy can have irreparable effects on fetal growth. Key Points • Anti-phospholipid syndrome can disrupt the development of the embryo in women with SLE who intend to become pregnant. • Methotrexate and cyclosporine consumption before and during pregnancy can affect fetal growth. • 7 to 33% of patients whose disease had been suppressed and controlled 6 months before pregnancy seams to relapse during the pregnancy. • Taking medications to control the disease during pregnancy plays an important role in the progression of pregnancy and fetus health.
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Zusman EZ, Sayre EC, Aviña-Zubieta JA, De Vera MA. Patterns of medication use before, during and after pregnancy in women with systemic lupus erythematosus: a population-based cohort study. Lupus 2019; 28:1205-1213. [DOI: 10.1177/0961203319863111] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Objectives This study aimed to characterize the patterns of medication use before, during and after pregnancy in a population-based cohort of women with systemic lupus erythematosus (SLE). Methods Using population-based administrative data in British Columbia, Canada, with valid information on start date of pregnancy, we identified women with SLE who had singleton pregnancies ending in deliveries between January 1, 2002, and December 31, 2012. We assessed the proportion of SLE pregnancies exposed to SLE medications – namely antimalarials and immunosuppressants – as well as glucocorticosteroids, and nonsteroidal anti-inflammatory drugs (NSAIDs) 24 months before pregnancy, each trimester of pregnancy, and 12 months postpregnancy. We also assessed discontinuation of antimalarials and immunosuppressants, defined as no prescriptions in a given window following a prescription in a preceding window. Results Of 376 pregnancies (284 women) with SLE, 24.2% had one or more dispensing for antimalarials, 8.2% for azathioprine, 19.7% for glucocorticosteroids and 4.8% for NSAIDs during pregnancy. We observed a 16.7% discontinuation of antimalarials in the year prior to pregnancy, 29.8% in the first trimester, 9.7% in the second trimester, and 26.0% in the third trimester. We also observed a 29.2% discontinuation of azathioprine in the first trimester, 8.0% in the second trimester, and 9.1% in the third trimester. Conclusions These population-based data show frequent discontinuation of medications, particularly antimalarials, in SLE pregnancies. These findings suggest the importance of educating women with SLE who are pregnant or planning to become pregnant on the benefits and risks of medications during pregnancy.
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Affiliation(s)
- E Z Zusman
- University of British Columbia Faculty of Pharmaceutical Sciences, Vancouver, BC, Canada
- Collaboration for Outcomes Research and Evaluation, Vancouver, BC, Canada
- Arthritis Research Canada, Richmond, BC, Canada
| | - E C Sayre
- Arthritis Research Canada, Richmond, BC, Canada
| | - J A Aviña-Zubieta
- Arthritis Research Canada, Richmond, BC, Canada
- University of British Columbia Faculty of Medicine, Department of Medicine, Division of Rheumatology, Vancouver, BC, Canada
| | - M A De Vera
- University of British Columbia Faculty of Pharmaceutical Sciences, Vancouver, BC, Canada
- Collaboration for Outcomes Research and Evaluation, Vancouver, BC, Canada
- Arthritis Research Canada, Richmond, BC, Canada
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Wang M, Kong X, Xie Y, He C, Wang T, Zhou H. Role of TLR‑4 in anti‑β2‑glycoprotein I‑induced activation of peritoneal macrophages and vascular endothelial cells in mice. Mol Med Rep 2019; 19:4353-4363. [PMID: 30942412 PMCID: PMC6472140 DOI: 10.3892/mmr.2019.10084] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Accepted: 02/21/2019] [Indexed: 11/06/2022] Open
Abstract
Anti‑phospholipid syndrome (APS) is a systematic autoimmune disease that is associated with presence of antiphospholipid antibodies (aPL), recurrent thrombosis, and fetal morbidity in pregnancy. Toll‑like receptor‑4 (TLR‑4), a member of TLR family, is known to have a fundamental role in pathogen recognition and activation of innate immunity. The β2‑glycoprotein I (β2GPI), a protein circulating in the blood at a high concentration, is able of scavenging lipopolysaccharide (LPS) and clear unwanted anionic cellular remnants, such as microparticles, from the circulation. Our previous study demonstrated that TLR‑4 and its signaling pathways contribute to the upregulation of pro‑coagulant factors and pro‑inflammatory cytokines in monocytes induced by anti‑β2GPI in vitro. The present study aimed to define the roles of TLR‑4 in vivo. C3H/HeN mice (TLR‑4 intact) and C3H/HeJ mice (TLR‑4 defective) were stimulated with an intraperitoneal injection with anti‑β2GPI‑immunoglobulin G(IgG), then peritoneal macrophages and vascular endothelial cells (VECs) were extracted from treated mice, and analyses were conducted on the expression profiles of pro‑inflammatory cytokines and adhesion molecules. The results demonstrated that the expression of pro‑inflammatory cytokines, including tumor necrosis factor‑α (TNF‑α), interleukin (IL)‑1β and IL‑6, in the peritoneal macrophages, and adhesion molecules, including intercellular cell adhesion molecule‑1 (ICAM‑1), vascular cell adhesion molecule‑1 (VCAM‑1) and E‑selectin, in VECs of C3H/HeN mice (TLR‑4 intact) were significantly higher than those of C3H/HeJ mice (TLR‑4 defective). The phosphorylation levels of p38 mitogen‑activated protein kinase (MAPK) and nuclear factor‑κB (NF‑κB) p65 in peritoneal macrophages and VECs from C3H/HeN mice stimulated with anti‑β2GPI‑IgG were significantly increased compared with those from C3H/HeJ mice (TLR‑4 defective). The isotype control antibody (NR‑IgG) had no such effects on peritoneal macrophages and VECs. Furthermore, the inhibitors of TLR‑4, p38 MAPK and NF‑κB may significantly reduce the anti‑β2GPI‑IgG‑induced TNF‑α, IL‑1β and IL‑6 mRNAs expression in the peritoneal macrophages from TLR‑4 intact mice. The results indicated that a TLR‑4 signal transduction pathway is involved in anti‑β2GPI‑IgG‑induced activation of peritoneal macrophages and VECs. This study has provided a basis for subsequent investigations to elucidate the pathological mechanisms underlying anti‑phospholipid syndrome.
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Affiliation(s)
- Meiyun Wang
- Department of Internal Medicine, Affiliated Hospital of Jiangsu University, Zhenjiang, Jiangsu 212013, P.R. China
| | - Xiangmin Kong
- Department of Clinical Laboratory and Hematology, School of Medicine, Jiangsu University, Zhenjiang, Jiangsu 212013, P.R. China
| | - Yachao Xie
- Department of Clinical Laboratory and Hematology, School of Medicine, Jiangsu University, Zhenjiang, Jiangsu 212013, P.R. China
| | - Chao He
- Department of Clinical Laboratory and Hematology, School of Medicine, Jiangsu University, Zhenjiang, Jiangsu 212013, P.R. China
| | - Ting Wang
- Department of Clinical Laboratory and Hematology, School of Medicine, Jiangsu University, Zhenjiang, Jiangsu 212013, P.R. China
| | - Hong Zhou
- Department of Internal Medicine, Affiliated Hospital of Jiangsu University, Zhenjiang, Jiangsu 212013, P.R. China
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Nahal SK, Selmi C, Gershwin ME. Safety issues and recommendations for successful pregnancy outcome in systemic lupus erythematosus. J Autoimmun 2018; 93:16-23. [PMID: 30056945 DOI: 10.1016/j.jaut.2018.07.016] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2018] [Revised: 07/19/2018] [Accepted: 07/19/2018] [Indexed: 02/07/2023]
Abstract
Systemic lupus erythematosus (SLE) primarily affects women of childbearing age. One of the major changes in SLE focuses on the timing of a successful pregnancy. In the past, pregnancy was strongly discouraged in SLE, especially in the presence of risk factors such as nephritis, use of immunosuppressive therapies, or positivity of specific autoantibodies such as anti-phospholipids and anti-Ro/SSA, La/SSBA. Thanks to our better knowledge on the disease and management, pregnancy success rates in SLE patients have significantly improved care by the a multidisciplinary team which fosters a successful pregnancy with minimal complications for the mother and fetus when the disease is inactive or in remission. This approach is based on a counseling phase before pregnancy, to assess SLE activity phase, specific medications, risk factors, and continues through pregnancy and lactation with significantly improved pregnancy outcomes. Further, we can now better define the risk of disease flares during pregnancy based on a better understanding of the changes in maternal immunity and its relationship with SLE-associated autoimmunity and chronic inflammation. There is wide consensus that women with SLE can have successful pregnancies as long as conception is planned in a phase of inactive disease, and when the patient is closely managed by a rheumatologist, high-risk OB/GYN, neonatologist, and other medical specialists as indicated. Preconception counseling is essential to assess the risk of both fetal and maternal complications as well as identify life-threatening contraindications. Particular attention should be used in those SLE cases that have nephritis, APS or positivity for aPL, pulmonary hypertension, and positive anti-Ro/SSA or anti-La/SSB antibodies. In conclusion, the use of specific guidelines on the management of SLE before and during pregnancy and lactation, and a better understanding of the use of immunosuppressive therapies have significantly increased pregnancy success.
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Affiliation(s)
- Simran Kaur Nahal
- Division of Rheumatology, Allergy, and Clinical Immunology, University of California, Davis, CA, USA
| | - Carlo Selmi
- Division of Rheumatology and Clinical Immunology, Humanitas Research Hospital, Rozzano, Milan, Italy; Department of Biomedical Science and Translational Medicine, University of Milan, Italy.
| | - M Eric Gershwin
- Division of Rheumatology, Allergy, and Clinical Immunology, University of California, Davis, CA, USA.
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Maternal and Perinatal Outcome in Women with Systemic Lupus Erythematosus: A Retrospective Bicenter Cohort Study. J Immunol Res 2017; 2017:8245879. [PMID: 29094052 PMCID: PMC5637847 DOI: 10.1155/2017/8245879] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Revised: 07/28/2017] [Accepted: 08/08/2017] [Indexed: 01/19/2023] Open
Abstract
Objective To investigate disease activity around and during pregnancy and pregnancy outcome in women with systemic lupus erythematosus (SLE) considering antiphospholipid antibody status. Moreover, differences between first and consecutive pregnancies were examined. Methods Pregnancies > 16 weeks gestation of SLE patients receiving joint care from rheumatologists and gynecologists in two tertiary centers in the Netherlands between 2000 and 2015 were included. Disease activity, flare rate, and pregnancy outcomes and complications were assessed. Results Ninety-six women (84% Caucasian) with 144 pregnancies were included. The median SLE(P)DAI score was 2 before, during, and after pregnancy. Flare rates were 6.3%, 20.1%, and 15.3%, respectively. Severe hypertensive disorder of pregnancy, intrauterine fetal death, preterm birth, and small-for-gestational age infants occurred in 18.1%, 4.1%, 32.7%, and 14.8%, respectively. Complication rates were similar in the first and consecutive pregnancies. Half of the women did not experience any pregnancy complication whereas 42.7% developed a complication during all pregnancies. Mean number of pregnancies was 2.4 and live births 1.7. Conclusion In this SLE population with low disease activity, pregnancy complications were present irrespective of antiphospholipid antibody status. Furthermore, there were no differences in complication rates between the first and consecutive pregnancies as seen in healthy mothers. This information is useful for patient counseling.
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Krasselt M, Baerwald C. Sex, Symptom Severity, and Quality of Life in Rheumatology. Clin Rev Allergy Immunol 2017; 56:346-361. [DOI: 10.1007/s12016-017-8631-6] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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An ever-challenging relationship: lupus and pregnancy. Reumatologia 2017; 55:29-37. [PMID: 28386140 PMCID: PMC5380770 DOI: 10.5114/reum.2017.66685] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2017] [Accepted: 02/11/2017] [Indexed: 11/17/2022] Open
Abstract
Systemic lupus erythematous (SLE) is a chronic inflammatory disease with an unknown etiology and an autoimmune pathogenesis, and its clinical manifestations can involve multiple organs through polymorphic biological changes. Nowadays, pregnancy is possible for most patients with SLE, and good outcomes can be expected for both mother and child. This became possible as a consequence of increasingly better monitoring and treatment of pregnant women with SLE. The following article outlines the problems associated with fertility, course of pregnancy, and breastfeeding in women with SLE.
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Knight CL, Nelson-Piercy C. Management of systemic lupus erythematosus during pregnancy: challenges and solutions. Open Access Rheumatol 2017; 9:37-53. [PMID: 28331377 PMCID: PMC5354538 DOI: 10.2147/oarrr.s87828] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Systemic lupus erythematosus (SLE) is a chronic, multisystem autoimmune disease predominantly affecting women, particularly those of childbearing age. SLE provides challenges in the prepregnancy, antenatal, intrapartum, and postpartum periods for these women, and for the medical, obstetric, and midwifery teams who provide their care. As with many medical conditions in pregnancy, the best maternal and fetal-neonatal outcomes are obtained with a planned pregnancy and a cohesive multidisciplinary approach. Effective prepregnancy risk assessment and counseling includes exploration of factors for poor pregnancy outcome, discussion of risks, and appropriate planning for pregnancy, with consideration of discussion of relative contraindications to pregnancy. In pregnancy, early referral for hospital-coordinated care, involvement of obstetricians and rheumatologists (and other specialists as required), an individual management plan, regular reviews, and early recognition of flares and complications are all important. Women are at risk of lupus flares, worsening renal impairment, onset of or worsening hypertension, preeclampsia, and/or venous thromboembolism, and miscarriage, intrauterine growth restriction, preterm delivery, and/or neonatal lupus syndrome (congenital heart block or neonatal lupus erythematosus). A cesarean section may be required in certain obstetric contexts (such as urgent preterm delivery for maternal and/or fetal well-being), but vaginal birth should be the aim for the majority of women. Postnatally, an ongoing individual management plan remains important, with neonatal management where necessary and rheumatology followup. This article explores the challenges at each stage of pregnancy, discusses the effect of SLE on pregnancy and vice versa, and reviews antirheumatic medications with the latest guidance about their use and safety in pregnancy. Such information is required to effectively and safely manage each stage of pregnancy in women with SLE.
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Affiliation(s)
- Caroline L Knight
- Division of Women’s Health, Women’s Health Academic Centre, King’s College London and King’s Health Partners, St Thomas’ Hospital, London, UK
| | - Catherine Nelson-Piercy
- Division of Women’s Health, Women’s Health Academic Centre, King’s College London and King’s Health Partners, St Thomas’ Hospital, London, UK
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Pregnancy-Related Challenges in Systemic Autoimmune Diseases. JOURNAL OF INFUSION NURSING 2017; 38:360-8. [PMID: 26339942 DOI: 10.1097/nan.0000000000000124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The awareness of pregnancy-related physiologic changes and complications is critical for the appropriate assessment and management of pregnant patients with systemic autoimmune diseases. The overlapping features of physiologic and pathological changes, selected autoantibodies, and the use of potentially teratogenic medications can complicate their management during pregnancy. While pregnancy in lupus patients presents an additional risk to an already complex situation, in patients with no disease activity, the risk of a future pregnancy-related complication is relatively low. Anti-Ro and anti-La antibodies increase the risk of neonatal lupus erythematosus, eg, photosensitive rash and irreversible congenital heart block. Antiphospholipid antibodies increase the risk of pregnancy morbidity, eg, fetal loss and early preeclampsia. Pregnancy usually has a positive effect on rheumatoid arthritis; however, a disease flare is common during the postpartum period. Both the rheumatologist and the obstetrician should partner throughout the pregnancy to manage patients for successful outcomes.
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Tumor Necrosis Factor-Alpha and Pregnancy: Focus on Biologics. An Updated and Comprehensive Review. Clin Rev Allergy Immunol 2017; 53:40-53. [DOI: 10.1007/s12016-016-8596-x] [Citation(s) in RCA: 90] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Fredi M, Gregorini G, Zatti S, Lojacono A, Tincani A. Identifying and managing lupus nephritis during pregnancy. Expert Opin Orphan Drugs 2016. [DOI: 10.1080/21678707.2016.1228452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Yamamoto Y, Aoki S. Systemic lupus erythematosus: strategies to improve pregnancy outcomes. Int J Womens Health 2016; 8:265-72. [PMID: 27468250 PMCID: PMC4944915 DOI: 10.2147/ijwh.s90157] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Systemic lupus erythematosus (SLE) is a chronic autoimmune inflammatory disease with a high prevalence in females of childbearing age. Thus, reproduction in SLE patients is a major concern for clinicians. In the past, SLE patients were advised to defer pregnancy because of poor pregnancy outcomes and fear of SLE flares during pregnancy. Investigations to date show that maternal and fetal risks are higher in females with SLE than in the general population. However, with appropriate management of the disease, sufferers may have a relatively uncomplicated pregnancy course. Factors such as appropriate preconception counseling and medication adjustment, strict disease control prior to pregnancy, intensive surveillance during and after pregnancy by both the obstetrician and rheumatologist, and appropriate interventions when necessary play a key role. This review describes the strategies to improve pregnancy outcomes in SLE patients at different time points in the reproduction cycle (preconception, during pregnancy, and postpartum period) and also details the neonatal concerns.
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Affiliation(s)
- Yuriko Yamamoto
- Perinatal Center for Maternity and Neonate, Yokohama City University Medical Center, Yokohama, Kanagawa Prefecture, Japan
| | - Shigeru Aoki
- Perinatal Center for Maternity and Neonate, Yokohama City University Medical Center, Yokohama, Kanagawa Prefecture, Japan
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Martínez López JA, García Vivar ML, Cáliz R, Freire M, Galindo M, Hernández MV, López Longo FJ, Martínez Taboada V, Pego Reigosa JM, Rubio E, Trujillo E, Vela-Casasempere P. Recommendations for the evaluation and management of patients with rheumatic autoimmune and inflammatory diseases during the reproductive age, pregnancy, postpartum and breastfeeding. ACTA ACUST UNITED AC 2016; 13:264-281. [PMID: 27321859 DOI: 10.1016/j.reuma.2016.05.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Revised: 05/02/2016] [Accepted: 05/07/2016] [Indexed: 01/18/2023]
Abstract
OBJECTIVE To develop recommendations on the evaluation and management of patients with rheumatic autoimmune and inflammatory diseases during the reproductive age, pregnancy, post-partum and breastfeeding based on the best evidence and experience. METHODS Recommendations were generated using nominal group and Delphi techniques. An expert panel of 12 rheumatologists was established. A systematic literature review and a narrative review (websites, clinical guidelines and other relevant documentation) were performed and presented to the panel in its 1st meeting to be discussed and to help define recommendations. A first draft of recommendations was generated and circulated for comments and wording refinement. A national survey analyzing different aspects of this topic was undertaken separately, followed by a Delphi process (2 rounds). Agreement with each recommendation was ranked on a scale of 1 (total disagreement) to 10 (total agreement), and was considered to be achieved if at least 70% voted≥7. The level of evidence and grade of recommendation were assessed using the Oxford Centre for Evidence-based Medicine Levels of Evidence. RESULTS A total of 14 recommendations were generated for the preconception period (oral and hormonal contraception, reproductive techniques), pregnancy (planning, treatment and follow-up), and breastfeeding (treatment and follow-up). High-risk situations such as lupus or antiphospholipid syndrome were included. A consensus>90% was reached for all but one recommendation. CONCLUSIONS These recommendations are intended to provide rheumatologists, patients, families and other stakeholders with a consensus on the evaluation and management of patients with autoimmune and inflammatory diseases during the reproductive age, pregnancy, postpartum and breastfeeding.
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Affiliation(s)
| | - M Luz García Vivar
- Servicio de Reumatología, Hospital Universitario Basurto, Bilbao, España
| | - Rafael Cáliz
- Unidad de Gestión de Reumatología, Complejo Hospitalario Universitario de Granada, Granada, España
| | - Mercedes Freire
- Servicio de Reumatología, Complexo hospitalario Universitario A Coruña (CHUAC), A Coruña, España
| | - María Galindo
- Servicio de Reumatología, Hospital Universitario 12 de Octubre, Madrid, España
| | | | | | - Víctor Martínez Taboada
- Servicio de Reumatología, Hospital Universitario Marqués de Valdecilla, Santander, España; Facultad de Medicina, Universidad de Cantabria, Santander, España
| | - Jose María Pego Reigosa
- Servicio de Reumatología, Hospital Meixoeiro-Complexo Hospitalario Universitario de Vigo, Vigo, España
| | - Esteban Rubio
- Servicio de Reumatología, Hospital Universitario Virgen del Rocío, Sevilla, España
| | - Elisa Trujillo
- Servicio de Reumatología, Hospital Universitario de Canarias, Santa Cruz de Tenerife, España
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Danza Á, Ruiz-Irastorza G, Khamashta M. [Pregnancy in systemic autoimmune diseases: Myths, certainties and doubts]. Med Clin (Barc) 2016; 147:306-12. [PMID: 27143525 DOI: 10.1016/j.medcli.2016.03.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Accepted: 03/07/2016] [Indexed: 02/04/2023]
Abstract
Systemic autoimmune diseases especially affect young women during childbearing age. The aim of this review is to update systemic lupus erythematosus, antiphospholipid syndrome and systemic sclerosis management during pregnancy. These diseases present variable maternal and fetal risks. Studies show that an appropriate disease control and a reasonable remission period prior to pregnancy are associated with satisfactory obstetric outcomes. Antiphospholipid autoantibodies profile, anti-Ro/anti-La antibodies, pulmonary pressure and activity evaluation are crucial to assess the pregnancy risk. Monitoring requires a multidisciplinary team, serial analytic controls and Doppler ultrasound of maternal and fetal circulation. Evaluation of the activity of the disease is essential.
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Affiliation(s)
- Álvaro Danza
- Unidad Docente Asistencial en Enfermedades Autoinmunes Sistémicas y Reumatológicas, Clínica Médica, Hospital Pasteur, Departamento de Medicina, Facultad de Medicina, Universidad de la República, Administración de Servicios de Salud del Estado (ASSE), Montevideo, Uruguay; Unidad de Investigación de Enfermedades Autoinmunes, Servicio de Medicina Interna, BioCruces Health Research Institute, Hospital Universitario Cruces, Universidad del País Vasco (UPV)/Euskal Herriko Unibertsitatea (EHU), Barakaldo, Vizcaya, España.
| | - Guillermo Ruiz-Irastorza
- Unidad de Investigación de Enfermedades Autoinmunes, Servicio de Medicina Interna, BioCruces Health Research Institute, Hospital Universitario Cruces, Universidad del País Vasco (UPV)/Euskal Herriko Unibertsitatea (EHU), Barakaldo, Vizcaya, España
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Costa ML. Preeclampsia: Reflections on How to Counsel About Preventing Recurrence. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2016; 37:887-93. [PMID: 26606702 DOI: 10.1016/s1701-2163(16)30023-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Preeclampsia is one of the most challenging diseases of pregnancy, with unclear etiology, no specific marker for prediction, and no precise treatment besides delivery of the placenta. Many risk factors have been identified, and diagnostic and management tools have improved in recent years. However, this disease remains one of the leading causes of maternal morbidity and mortality worldwide, especially in under-resourced settings. A history of previous preeclampsia is a known risk factor for a new event in a future pregnancy, with recurrence rates varying from less than 10% to 65%, depending on the population or methodology considered. A recent review that performed an individual participant data meta-analysis on the recurrence of hypertensive disorders of pregnancy in over 99 000 women showed an overall recurrence rate of 20.7%; when specifically considering preeclampsia, it was 13.8%, with milder disease upon recurrence. Prevention of recurrent preeclampsia has been attempted by changes in lifestyle, dietary supplementation, antihypertensive drugs, antithrombotic agents, and others, with much uncertainty about benefit. It is always challenging to treat and counsel a woman with a previous history of preeclampsia; this review will be based on hypothetical clinical cases, using common scenarios in obstetrical practice to consider the available evidence on how to counsel each woman during pre-conception and prenatal consultations.
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Affiliation(s)
- Maria Laura Costa
- Department of Obstetrics and Gynecology, University of Campinas (UNICAMP), School of Medicine, Campinas, São Paulo, Brazil
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Saavedra Salinas MÁ, Barrera Cruz A, Cabral Castañeda AR, Jara Quezada LJ, Arce-Salinas CA, Álvarez Nemegyei J, Fraga Mouret A, Orozco Alcalá J, Salazar Páramo M, Cruz Reyes CV, Andrade Ortega L, Vera Lastra OL, Mendoza Pinto C, Sánchez González A, Cruz Cruz PDR, Morales Hernández S, Portela Hernández M, Pérez Cristóbal M, Medina García G, Hernández Romero N, Velarde Ochoa MDC, Navarro Zarza JE, Portillo Díaz V, Vargas Guerrero A, Goycochea Robles MV, García Figueroa JL, Barreira Mercado E, Amigo Castañeda MC. Guías de práctica clínica para la atención del embarazo en mujeres con enfermedades reumáticas autoinmunes del Colegio Mexicano de Reumatología. Parte I. ACTA ACUST UNITED AC 2015; 11:295-304. [DOI: 10.1016/j.reuma.2014.11.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2014] [Revised: 10/07/2014] [Accepted: 11/08/2014] [Indexed: 10/24/2022]
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Understanding and Managing Pregnancy in Patients with Lupus. Autoimmune Dis 2015; 2015:943490. [PMID: 26246905 PMCID: PMC4515284 DOI: 10.1155/2015/943490] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Accepted: 05/31/2015] [Indexed: 12/16/2022] Open
Abstract
Systemic lupus erythematosus (SLE) is a chronic, multisystemic autoimmune disease that occurs predominantly in women of fertile age. The association of SLE and pregnancy, mainly with active disease and especially with nephritis, has poorer pregnancy outcomes, with increased frequency of preeclampsia, fetal loss, prematurity, growth restriction, and newborns small for gestational age. Therefore, SLE pregnancies are considered high risk condition, should be monitored frequently during pregnancy and delivery should occur in a controlled setting. Pregnancy induces dramatic immune and neuroendocrine changes in the maternal body in order to protect the fetus from immunologic attack and these modifications can be affected by SLE. The risk of flares depends on the level of maternal disease activity in the 6–12 months before conception and is higher in women with repeated flares before conception, in those who discontinue useful medications and in women with active glomerulonephritis at conception. It is a challenge to differentiate lupus nephritis from preeclampsia and, in this context, the angiogenic and antiangiogenic cytokines are promising. Prenatal care of pregnant patients with SLE requires close collaboration between rheumatologist and obstetrician. Planning pregnancy is essential to increase the probability of successful pregnancies.
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Tian X, Li M, Ye Z, Zhang X, Liu S, Wu L, Ma L, Bi L, Zuo X, Sun L, Huang C, Zhao J, Zhang F, Zhao Y, Zeng X. Related factors of fetal loss in Chinese women with systemic lupus erythematosus: data from Chinese SLE Treatment and Research Group registry IV. Int J Rheum Dis 2014; 18:654-60. [PMID: 25546582 DOI: 10.1111/1756-185x.12542] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To study the factors associated with fetal loss in Chinese women with systemic lupus erythematosus (SLE) in a large cohort of SLE patients in the CSTAR (Chinese SLE Treatment and Research Group) registry. METHODS We compared the clinical characteristics and auto-antibody profiles between SLE patients with fetal loss and SLE patients with normal pregnancies. The relationship between selected variables and fetal loss was examined by univariate analysis and binary logistic regression analysis. RESULTS A total of 992 patients with 2026 pregnancies were recruited. Fifty women experienced fetal loss, including 49 spontaneous abortion, eight stillbirths and three neonatal deaths. The overall fetal loss rate was 3.0% (60/2026). Arthritis and serositis were observed significantly more frequently (P < 0.05) in normal pregnancy women. The rate of thrombocytopenia was significantly increased in patients with fetal loss (30.0% vs. 16.1%, P = 0.010), while there was no statistically significant difference in the frequency of nephropathy, central nervous system involvement between the normal pregnancy group and fetal loss group. Factors that associated with fetal loss included anti-phospholipid antibodies (aPL) (OR 2.299; 95% CI 1.058-4.993; P = 0.035) and anti-Sjögren syndrome antigen A (SSA) antibody (OR 2.283; 95% CI 1.275-4.088; P = 0.005), and thrombocytopenia (OR 2.241; 95% CI 1.192-4.213; P = 0.012). However, arthritis (OR 0.544, 95% CI 0.307-0.965, P = 0.037) was associated with favorable fetal outcome. CONCLUSIONS Both univariate analysis and binary logistic regression analysis suggest that thrombocytopenia, aPL antibodies and anti-SSA antibody are associated with fetal loss in Chinese SLE women, while arthritis may be a possible factor related to favorable pregnancy outcome.
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Affiliation(s)
- Xinping Tian
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Mengtao Li
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Zhizhong Ye
- Department of Rheumatology, the Fourth People's Hospital of Shenzhen Affiliated to Guangdong Medical College, Shenzhen, China
| | - Xiao Zhang
- Department of Rheumatology, Guangdong Provincial People's Hospital, Guangzhou, China
| | - Shengyun Liu
- Department of Rheumatology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Lijun Wu
- Department of Rheumatology, the People's Hospital of Xinjiang Autonomous, Urumqi, China
| | - Li Ma
- Department of Rheumatology, China-Japan Friendship Hospital Affiliated to the Ministry of Health of PRC, Beijing, China
| | - Liqi Bi
- Department of Rheumatology, Sino-Japanese friendship Hospital of Jilin University, Changchun, China
| | - Xiaoxia Zuo
- Department of Rheumatology, Xiangya Hospital, Central South University, Changsha, China
| | - Lingyun Sun
- Department of Rheumatology, the Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
| | - Cibo Huang
- Department of Rheumatology, Beijing Hospital Affiliated to the Ministry of Health of PRC, Beijing, China
| | - Jiuliang Zhao
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Fengchun Zhang
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Yan Zhao
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Xiaofeng Zeng
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
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Park EJ, Jung H, Hwang J, Kim H, Lee J, Ahn JK, Cha HS, Koh EM. Pregnancy outcomes in patients with systemic lupus erythematosus: a retrospective review of 62 pregnancies at a single tertiary center in South Korea. Int J Rheum Dis 2014; 17:887-97. [DOI: 10.1111/1756-185x.12435] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Eun-Jung Park
- Division of Rheumatology; Department of Medicine; Samsung Medical Center; Sungkyunkwan University School of Medicine; Seoul Korea
| | - Hyemin Jung
- Division of Rheumatology; Department of Medicine; Samsung Medical Center; Sungkyunkwan University School of Medicine; Seoul Korea
| | - Jiwon Hwang
- Division of Rheumatology; Department of Medicine; Samsung Medical Center; Sungkyunkwan University School of Medicine; Seoul Korea
| | - Hyungjin Kim
- Division of Rheumatology; Department of Medicine; Samsung Medical Center; Sungkyunkwan University School of Medicine; Seoul Korea
| | - Jaejoon Lee
- Division of Rheumatology; Department of Medicine; Samsung Medical Center; Sungkyunkwan University School of Medicine; Seoul Korea
| | - Joong Kyong Ahn
- Division of Rheumatology; Department of Medicine; Kangbuk Samsung Hospital; Sungkyunkwan University School of Medicine; Seoul Korea
| | - Hoon-Suk Cha
- Division of Rheumatology; Department of Medicine; Samsung Medical Center; Sungkyunkwan University School of Medicine; Seoul Korea
| | - Eun-Mi Koh
- Division of Rheumatology; Department of Medicine; Samsung Medical Center; Sungkyunkwan University School of Medicine; Seoul Korea
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Abstract
Pregnancy poses an important challenge for doctors looking after women with systemic lupus erythematosus. Knowledge about safety of medications, the effect of pregnancy on such disease, and vice versa, together with multidisciplinary team care, are basic cornerstones needed to provide the best obstetric and medical care to these women. Pre-conceptional counselling constitutes the ideal scenario where a patient's previous obstetric history, organ damage, disease activity, serological profile and additional medical history can be summarized. Important issues regarding medication adjustment, planned scans and visits, and main risks discussion should also be raised at this stage. Planned pregnancies lead to better outcomes for both mothers and babies. Close surveillance throughout pregnancy and the puerperium, and tailored management approach guarantee the highest rates of successful pregnancies in these women.
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Affiliation(s)
- O Ateka-Barrutia
- Lupus Research Unit, Women's Health Division, King's College London, UK
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Abstract
Connective tissue diseases (CTD) include a variety of chronic multisystem disorders with a high percentage of autoimmune conditions. Many of these conditions affect women of childbearing age and, therefore, pregnancy poses an important challenge for doctors looking after such women. Knowledge of medication safety, the effect of pregnancy on such diseases and vice versa, together with preconception counselling and multidisciplinary team care, are the basic pillars needed to provide the best obstetric and medical care to these women. In this review, we discuss the management of the most common autoimmune CTD before, during and after pregnancy, along with the most relevant issues regarding appropriate medication.
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Cavallasca JA, Costa CA, Maliandi MDR, Musuruana JL. Hot topics in lupus pregnancy. World J Rheumatol 2013; 3:32-39. [DOI: 10.5499/wjr.v3.i3.32] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2013] [Revised: 08/30/2013] [Accepted: 11/03/2013] [Indexed: 02/06/2023] Open
Abstract
Systemic lupus erythematosus (SLE) typically affects women in their childbearing age, who have the same fertility rates as the healthy population. The effect of pregnancy on the disease and the effect of SLE on pregnancy and the fetus are highly important issues for the attending physician. Whether lupus flares are more frequent during pregnancy remains controversial. Among the possible effects of SLE on pregnancy are a greater number of abortions, fetal loss, pre-term deliveries and perinatal mortality. The newborn may be affected by the onset of neonatal lupus erythematosus (neonatal LE), either as a skin or blood disease, or by the presence of congenital heart block. The frequent association between SLE and antiphospholipid syndrome represents another risk situation for the mother and the product of conception. Multiples drugs used in SLE patients should be evaluated. Those with teratogenic potential should be withdrawn before pregnancy, and when necessary, appropriate medications should be indicated to treat the mother without compromising the safety of the baby. In conclusion, pregnancies in lupus patients represent a challenge for the physician and must be closely followed up and treated if necessary, during all trimesters and in the puerperium period, to improve outcome.
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Evaluation and management of systemic lupus erythematosus and rheumatoid arthritis during pregnancy. Clin Immunol 2013; 149:225-35. [DOI: 10.1016/j.clim.2013.05.006] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2012] [Revised: 05/09/2013] [Accepted: 05/11/2013] [Indexed: 11/19/2022]
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Fischer-Betz R, Specker C, Brinks R, Aringer M, Schneider M. Low risk of renal flares and negative outcomes in women with lupus nephritis conceiving after switching from mycophenolate mofetil to azathioprine. Rheumatology (Oxford) 2013; 52:1070-6. [PMID: 23382355 DOI: 10.1093/rheumatology/kes425] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVE MMF is teratogenic and needs to be replaced before pregnancy. This change may lead to flares. Our aim was to determine the risk of renal flares in women with LN who switched treatment from MMF to AZA before conception and to evaluate the outcome of their pregnancies. METHODS Medical records of women with LN counselled for pregnancy wish were reviewed. Women receiving treatment with either MMF or AZA (control group), with inactive lupus (SLEDAI ≤ 4) and quiescent LN (serum creatinine <1.5 mg/dl, inactive sediment and proteinuria <1 g/24 h for the preceding 6 months) were eligible for this study. RESULTS We identified 54 women [23 treated with MMF (group 1) and 31 treated with AZA (group 2)]. MMF dosage was tapered and subsequently transferred to AZA, which was maintained throughout pregnancy. Three (13%) patients (group 1) vs none (group 2) developed a renal flare 3-6 months after transitioning from MMF to AZA (P = 0.14) before pregnancy ensued. The only parameter with a significant difference in those with flare compared with those without was younger age (median 27 vs 30 years; P = 0.03). Risk for adverse outcome within 48 pregnancies (pre-eclampsia 9%, preterm delivery 20.5%) increased with every milligramme of prednisone dosage [odds ratio (OR) 2.03] and every single unit of SLEDAI score (OR 3.92). Renal flares occurred post-partum in two women. No patient developed worsening of renal function. CONCLUSION Replacing MMF with AZA in patients with quiescent LN for pregnancy planning rarely leads to renal flares. Pregnancy outcome was favourable.
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Affiliation(s)
- Rebecca Fischer-Betz
- Department of Rheumatology, Heinrich-Heine-University, Moorenstr. 5, 40225 Düsseldorf, Germany.
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Østensen M. Counseling women with systemic lupus erythematosus who desire children. ACTA ACUST UNITED AC 2013. [DOI: 10.2217/ijr.12.78] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Treatment of refractory obstetric antiphospholipid syndrome: the state of the art and new trends in the therapeutic management. Lupus 2012; 22:6-17. [DOI: 10.1177/0961203312465782] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Objective To date, there are no reliable data regarding the actual treatment received by women with refractory obstetric antiphospholipid syndrome (OAPS). The aim of this study was to assess current clinical evidence and new trends in the treatment of refractory OAPS. Methods A non-systematic but comprehensive literature search using relevant keywords was made to identify relevant articles published in English from different computerized databases: PubMed (Medline), Google Scholar electronic database search and The Cochrane Library, from January 2000 to March 2012. Studies on the treatment of poor obstetric outcomes in women with OAPS were included. Prospective randomized clinical trials, cohort studies, reviews, systematic reviews and meta-analysis were retrieved. Results A total of 130 articles were finally selected for this review, including 17 randomized clinical trials and four meta-analyses. The majority of articles were non-randomized original papers and basic and clinical reviews. Conclusion Up to 20% of women with OAPS do not receive the currently recommended therapeutic regimen. Unfortunately, well-designed studies regarding the usefulness of new drugs in refractory OAPS are scarce. Hydroxychloroquine and low-dose prednisolone appear to be useful when added to standard therapy. Current data do not support the use of intravenous immunoglobulins in this field. The role played by double anti-aggregant therapy, fondaparinux, vitamin D, pentoxifylline and TNF-targeted therapies should be tested in well-designed studies.
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Pregnancy implications for systemic lupus erythematosus and the antiphospholipid syndrome. J Autoimmun 2012; 38:J197-208. [DOI: 10.1016/j.jaut.2011.11.010] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2011] [Accepted: 11/22/2011] [Indexed: 01/01/2023]
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Current world literature. Curr Opin Pediatr 2012; 24:277-84. [PMID: 22414891 DOI: 10.1097/mop.0b013e328351e459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Ugarte A, Villar I, Ruiz-Irastorza G. [Management of pregnancy in patients with systemic lupus erythematosus]. Rev Clin Esp 2012; 212:491-8. [PMID: 22245369 DOI: 10.1016/j.rce.2011.11.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2011] [Revised: 10/02/2011] [Accepted: 11/07/2011] [Indexed: 11/15/2022]
Abstract
Patients with systemic lupus erythematosus are exposed to a remarkably high number of maternal-fetal complications during pregnancy. Knowledge regarding the reciprocal influence between lupus and pregnancy is the starting point to assure that these patients are correctly monitored. It is also important to carry out comprehensive preconception evaluation to individually evaluate the risk of each patient. The immunological profile, history of nephritis, presence of chronic damage and disease activity are the basic data that will determine the specific individual risk profile. Finally, correct drug management must be assured during this period, based on the safety profile of the different treatments during pregnancy and lactation.
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Affiliation(s)
- A Ugarte
- Unidad de Investigación de Enfermedades Autoinmunes, Servicio de Medicina Interna, Hospital de Cruces, Barakaldo, Bizkaia, Spain
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Berencsi III G. Fetal and Neonatal Illnesses Caused or Influenced by Maternal Transplacental IgG and/or Therapeutic Antibodies Applied During Pregnancy. MATERNAL FETAL TRANSMISSION OF HUMAN VIRUSES AND THEIR INFLUENCE ON TUMORIGENESIS 2012. [PMCID: PMC7121401 DOI: 10.1007/978-94-007-4216-1_9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The human fetus is protected by the mother’s antibodies. At the end of the pregnancy, the concentration of maternal antibodies is higher in the cord blood, than in the maternal circulation. Simultaneously, the immune system of the fetus begins to work and from the second trimester, fetal IgM is produced by the fetal immune system specific to microorganisms and antigens passing the maternal-fetal barrier. The same time the fetal immune system has to cope and develop tolerance and TREG cells to the maternal microchimeric cells, latent virus-carrier maternal cells and microorganisms transported through the maternal-fetal barrier. The maternal phenotypic inheritance may hide risks for the newborn, too. Antibody mediated enhancement results in dengue shock syndrome in the first 8 month of age of the baby. A series of pathologic maternal antibodies may elicit neonatal illnesses upon birth usually recovering during the first months of the life of the offspring. Certain antibodies, however, may impair the fetal or neonatal tissues or organs resulting prolonged recovery or initiating prolonged pathological processes of the children. The importance of maternal anti-idiotypic antibodies are believed to prime the fetal immune system with epitopes of etiologic agents infected the mother during her whole life before pregnancy and delivery. The chemotherapeutical and biological substances used for the therapy of the mother will be transcytosed into the fetal body during the last two trimesters of pregnancy. The long series of the therapeutic monoclonal antibodies and conjugates has not been tested systematically yet. The available data are summarised in this chapter. The innate immunity plays an important role in fetal defence. The concentration of interferon is relative high in the placenta. This is probably one reason, why the therapeutic interferon treatment of the mother does not impair the fetal development.
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Affiliation(s)
- György Berencsi III
- , Division of Virology, National Center for Epidemiology, Gyáli Street 2-6, Budapest, 1096 Hungary
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46
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[Pregnancy and kidney diseases]. Internist (Berl) 2011; 52:1167-77. [PMID: 21935640 DOI: 10.1007/s00108-011-2824-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
The prevalence of chronic kidney disease in women of childbearing age reaches approximately 0.2%. Under physiological conditions pregnancy results in important hemodynamic changes on the maternal organism. In the case of chronic kidney disease these adaptations often are only partial. Physiological changes of immune response during pregnancy may contribute to the progress of renal disease. Regardless of the underlying kidney disease, one can assume that the better the glomerular filtration rate and blood pressure are the more favorable the course of pregnancy will be with the chance for a healthy child and stable renal function. To achieve this goal, a close interaction is required between gynecologist, nephrologist, and other specialists in a center with appropriate experience.
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Canti V, Castiglioni MT, Rosa S, Franchini S, Sabbadini MG, Manfredi AA, Rovere-Querini P. Pregnancy outcomes in patients with systemic autoimmunity. Autoimmunity 2011; 45:169-75. [DOI: 10.3109/08916934.2011.593600] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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