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Muñoz Muñoz C, Farinha F, McDonnell T, J'bari H, Nguyen H, Isenberg D, Rahman A, Williams D, Alijotas-Reig J, Giles I. Comparing pregnancy outcomes in patients with Systemic Lupus Erythematosus (SLE) and Undifferentiated Connective Tissue Disease (UCTD): a descriptive cohort study. Rev Clin Esp 2024; 224:357-365. [PMID: 38670225 DOI: 10.1016/j.rceng.2024.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Accepted: 04/13/2024] [Indexed: 04/28/2024]
Abstract
BACKGROUND Females diagnosed with systemic lupus erythematosus (SLE) face an elevated risk of adverse pregnancy outcomes (APOs). However, the evidence regarding whether a similar association exists in patients with undifferentiated connective tissue disease (UCTD) is inconclusive. METHODS We conducted a retrospective review (2006-2019) of pregnancy outcomes among patients with SLE (n = 51) and UCTD (n = 20) within our institution. We examined the occurrence of various APOs, encompassing miscarriage, stillbirth, termination, preterm birth, pre-eclampsia, eclampsia, HELLP syndrome, intrauterine growth restriction, abruption placentae, congenital heart block, or other cardiac abnormalities. RESULTS The mean age at pregnancy was 35 ± 7.0 years for patients with SLE and 35 ± 6.8 years for those with UCTD (p = 0.349). The proportion of Caucasian women was 47% in SLE and 80% in UCTD. Pregnancies in both groups were planned (81% in SLE and 77% in UCTD), and patients presented with inactive disease at conception (96% in SLE and 89% in UCTD). Hydroxychloroquine at conception was utilized by 86% of women with SLE, in contrast to 36% in the UCTD group. Both, SLE and UCTD cohorts exhibited low rates of disease flares during pregnancy and/or puerperium (14% vs. 10%). The incidence of APOs was 15.6% in SLE patients compared to 5% in those with UCTD (Risk difference 19.5%; 95% confidence interval: -3.9 to 43.1; p = 0.4237). CONCLUSION Our study underscores the importance of strategic pregnancy planning and the maintenance of appropriate treatment throughout pregnancy to ensure optimal disease management and minimize adverse outcomes in both SLE and UCTD pregnancies.
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Affiliation(s)
- Candido Muñoz Muñoz
- Centre for Rheumatology, Division of Medicine, University College London, London, UK; Systemic Autoimmune Disease Unit, Department of Medicine, Vall d'Hebron University Hospital, Barcelona, Spain.
| | - Filipa Farinha
- Centre for Rheumatology, Division of Medicine, University College London, London, UK; Rheumatology, Hospital Distrital de Santarém, Santarém, Portugal
| | - Thomas McDonnell
- Department of Biochemical Engineering, University College London, London, UK
| | - Hajar J'bari
- Centre for Rheumatology, Division of Medicine, University College London, London, UK
| | - Hanh Nguyen
- Centre for Rheumatology, Division of Medicine, University College London, London, UK
| | - David Isenberg
- Centre for Rheumatology, Division of Medicine, University College London, London, UK
| | - Anisur Rahman
- Centre for Rheumatology, Division of Medicine, University College London, London, UK
| | - David Williams
- Women's Health, University College London Hospital NHS Foundation Trust, London, UK
| | - Jaume Alijotas-Reig
- Systemic Autoimmune Disease Unit, Department of Medicine, Vall d'Hebron University Hospital, Barcelona, Spain.
| | - Ian Giles
- Centre for Rheumatology, Division of Medicine, University College London, London, UK
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Abheiden CNH, Blomjous BS, Slaager C, Landman AJEMC, Ket JCF, Salmon JE, Buyon JP, Heymans MW, de Vries JIP, Bultink IEM, de Boer MA. Systemic lupus erythematosus is associated with an increased frequency of spontaneous preterm births: systematic review and meta-analysis. Am J Obstet Gynecol 2024:S0002-9378(24)00439-3. [PMID: 38492714 DOI: 10.1016/j.ajog.2024.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 03/06/2024] [Accepted: 03/06/2024] [Indexed: 03/18/2024]
Abstract
OBJECTIVE Preterm birth is one of the most frequent complications of pregnancy in women with systemic lupus erythematosus. The high indicated preterm birth proportion due to hypertensive disorders of pregnancy and/or fetal growth restriction is well known, and preventive measures and screening for early detection are performed. The risk of spontaneous preterm birth is less well recognized. This study aimed to determine the proportions of spontaneous and indicated preterm birth in pregnancies of women with systemic lupus erythematosus. DATA SOURCES A systematic literature search using Pubmed, Embase, Web of Science, and Google Scholar was performed in June 2021. STUDY ELIGIBILITY CRITERIA Studies in pregnant women with systemic lupus erythematosus reporting spontaneous and indicated preterm birth rates were selected. Original research articles published from 1995 to June 2021 were included. METHODS Quality and risk of bias of the included studies were assessed using the Newcastle-Ottawa quality assessment scale. To estimate the pooled event rates and 95% confidence intervals, meta-analysis of single proportions with a random-effects model was performed. RESULTS We included 21 articles, containing data of 8157 pregnancies in women with systemic lupus erythematosus. On average, 31% (95% prediction interval, 0.14-0.50) of the pregnancies resulted in preterm birth, including 14% (95% prediction interval, 0.04-0.27) spontaneous and 16% (95% prediction interval, 0.03-0.35) indicated preterm birth. CONCLUSION In pregnant women with systemic lupus erythematosus, spontaneous and indicated preterm birth proportions are high. This information should be applied in (prepregnancy) counseling and management in pregnancy. The knowledge obtained by this meta-analysis paves the way for further research of associated risk factors and development of interventions to reduce spontaneous preterm birth in systemic lupus erythematosus pregnancies.
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Affiliation(s)
- Carolien N H Abheiden
- Department of Obstetrics and Gynaecology, Amsterdam University Medical Center, Amsterdam, the Netherlands; Amsterdam Reproduction and Development Research Institute, Amsterdam, the Netherlands.
| | - Birgit S Blomjous
- Department of Rheumatology and Clinical Immunology, Amsterdam Rheumatology and Immunology Center, Amsterdam University Medical Center, Amsterdam, the Netherlands; Amsterdam institute for Immunology and Infectious Diseases, Amsterdam, the Netherlands
| | - Ciska Slaager
- Department of Gynecology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Anadeijda J E M C Landman
- Department of Obstetrics and Gynaecology, Amsterdam University Medical Center, Amsterdam, the Netherlands; Amsterdam Reproduction and Development Research Institute, Amsterdam, the Netherlands
| | - Johannes C F Ket
- Medical Library, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Jane E Salmon
- Hospital for Special Surgery, Weill Cornell Medical College, New York, NY
| | - Jill P Buyon
- NYU Grossman School of Medicine, New York University, New York, NY
| | - Martijn W Heymans
- Department of Epidemiology and Data Science, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Johanna I P de Vries
- Department of Obstetrics and Gynaecology, Amsterdam University Medical Center, Amsterdam, the Netherlands; Amsterdam Reproduction and Development Research Institute, Amsterdam, the Netherlands
| | - Irene E M Bultink
- Department of Rheumatology and Clinical Immunology, Amsterdam Rheumatology and Immunology Center, Amsterdam University Medical Center, Amsterdam, the Netherlands; Amsterdam institute for Immunology and Infectious Diseases, Amsterdam, the Netherlands
| | - Marjon A de Boer
- Department of Obstetrics and Gynaecology, Amsterdam University Medical Center, Amsterdam, the Netherlands; Amsterdam Reproduction and Development Research Institute, Amsterdam, the Netherlands
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Sangah AB, Jabeen S, Hunde MZ, Devi S, Mumtaz H, Shaikh SS. Maternal and fetal outcomes of SLE in pregnancy: a literature review. J OBSTET GYNAECOL 2023; 43:2205513. [PMID: 37154805 DOI: 10.1080/01443615.2023.2205513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
Systemic Lupus Erythematosus (SLE) is an auto-immune disease in which the immune system assaults its tissues. We aimed to analyse the maternal and foetal outcomes during pregnancy in SLE mothers. A literature search was conducted by two investigators to assess SLE's outcomes on maternal and foetal during pregnancies. We searched PubMed/Medline, Embase, and Google scholar to collect evidence from different research studies, draw the conclusion, and report it. In our investigation, we found out that SLE could cause a spectrum of complications during pregnancy, not only for the mother but also for the foetus. It could affect fertility and cause difficult pregnancies for the couple as well which includes certain complications such as: preterm labour and delivery, high blood pressure (preeclampsia), placental insufficiency, miscarriage or stillbirth, whereas in the foetus SLE can cause mortality, preterm birth, and neonatal lupus (a temporary condition in the baby caused by SLE-related antibodies) and structural abnormalities. The literature suggests that SLE could prove fatal for the foetus and induce many complications in the mother. However, this could be avoided if pregnancy is planned right from the start and proper management is provided to the mother during pregnancy and delivery.p.
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Affiliation(s)
- Abdul Basit Sangah
- Liaquat National Hospital and Medical College Karachi, Karachi, Pakistan
| | - Sidra Jabeen
- Liaquat National Hospital and Medical College Karachi, Karachi, Pakistan
| | | | - Sunita Devi
- Liaquat National Hospital and Medical College Karachi, Karachi, Pakistan
| | - Hassan Mumtaz
- Senior Clinical Research Associate, Maroof International Hospital, Public Health Scholar, Health Services Academy, Islamabad, Pakistan
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Chock EY, Dahal S, Grimshaw AA, Suter L, Liew Z, Felson D. Offspring neurodevelopmental outcomes born to parents with chronic inflammatory arthritis using antirheumatic therapies: A scoping review. Semin Arthritis Rheum 2023; 61:152230. [PMID: 37295300 PMCID: PMC10521166 DOI: 10.1016/j.semarthrit.2023.152230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 05/15/2023] [Accepted: 05/31/2023] [Indexed: 06/12/2023]
Abstract
INTRODUCTION Most women with rheumatic diseases discontinue antirheumatic therapies in anticipation of, or during pregnancy due to concerns around medication safety and fetal wellbeing. OBJECTIVE We performed a scoping review of available evidence investigating the risks of adverse offspring neurodevelopmental outcomes amongst parents with chronic inflammatory arthritis, taking antirheumatic therapies during conception or pregnancy. METHODS We designed a scoping review protocol and search strategy a priori in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We performed an exhaustive search in Cochrane Library, Embase, Google Scholar, Medline, and Web of Science for relevant literature in January 2023. Articles needed to include offspring neurodevelopmental outcomes born to parents with CIA who took antirheumatic therapies during conception or pregnancy. Independent reviewers extracted data from eligible articles using a standard abstraction tool and performed critical appraisal of study quality. RESULTS Six studies were included for full data abstraction. Use of Nonsteroidal Anti-inflammatory Drugs, Tumor Necrosis Factor Alpha inhibitors, and exposure to methotrexate during early first trimester of pregnancy did not seem to increase risk for adverse offspring neurodevelopmental outcomes. Corticosteroid use during pregnancy seemed to pose an increased risk for attention deficit hyperactive disorders in offspring. CONCLUSION Use of some antirheumatic therapies during pregnancy may not be associated with adverse offspring neurodevelopmental outcomes. Further investigations are needed to elucidate if other confounding factors affect long term offspring health outcomes born to parents with chronic inflammatory arthritis.
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Affiliation(s)
- Eugenia Y Chock
- Section of Rheumatology, Yale School of Medicine, New Haven, CT, USA.
| | - Sovit Dahal
- Department of Internal Medicine, Griffin Hospital, Derby, CT, USA
| | - Alyssa A Grimshaw
- Harvey Cushing/John Hay Whitney Medical Library, Yale University, New Haven, CT, USA
| | - Lisa Suter
- Section of Rheumatology, Yale School of Medicine, New Haven, CT, USA; Veterans Health Administration, West, Haven, CT, USA
| | - Zeyan Liew
- Department of Environmental Health Sciences and Yale Center for Perinatal, Pediatric, and Environmental Epidemiology, Yale School of Public Health, New Haven, CT, USA
| | - David Felson
- Section of Rheumatology, Yale School of Medicine, New Haven, CT, USA; Section of Rheumatology, Boston University School of Medicine, Boston, MA, USA and Section of Rheumatology, Yale School of Medicine, New Haven, CT, USA
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Fierro JJ, Prins JR, Verstappen GM, Bootsma H, Westra J, de Leeuw K. Preconception clinical factors related to adverse pregnancy outcomes in patients with systemic lupus erythematosus or primary Sjögren's syndrome: a retrospective cohort study. RMD Open 2023; 9:e003439. [PMID: 37652559 PMCID: PMC10476138 DOI: 10.1136/rmdopen-2023-003439] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 08/17/2023] [Indexed: 09/02/2023] Open
Abstract
OBJECTIVE To identify preconception clinical factors associated with adverse pregnancy outcomes (APO) in patients with systemic lupus erythematosus (SLE) or primary Sjögren's syndrome (pSS). METHODS A single-centre, retrospective cohort study was conducted, which included pregnant women treated at the University Medical Center Groningen between January 2010 and August 2021 who fulfilled classification criteria for SLE or pSS. Demographic data, relevant comorbidities, disease duration, disease activity before and during pregnancy, APO, laboratory parameters and treatment regimens were recorded. Associations between the presence of APO and preconception characteristics were evaluated. RESULTS Our study population included 48 (70%) SLE and 21 (30%) pSS pregnancies concerning 70 fetuses (one twin). Preterm birth (n=9, 19%) was the most frequent APO in SLE pregnancies, while in pSS pregnancies this was miscarriages (n=3, 14%). There were no associations between the presence of APO in SLE pregnancies and clinical parameters, laboratory parameters or medication use prior to conception. In the pSS group, significant associations were found between the presence of APO and body mass index (p=0.010), parity (p=0.046), C4 (p=0.021) and low C4 levels (p=0.002). CONCLUSIONS No preconception risk factors related to APO were found in SLE pregnancies, whereas preconception complement levels were associated with APO development in patients with pSS.
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Affiliation(s)
- Juan J Fierro
- Rheumatology and Clinical Immunology, University Medical Center Groningen, Groningen, The Netherlands
- Microbiología y Parasitología, Grupo Reproduccion, Universidad de Antioquia UdeA, Medellin, Antioquia, Colombia
| | - Jelmer R Prins
- Obstetrics and Gynecology, University Medical Center Groningen, Groningen, The Netherlands
| | - Gwenny M Verstappen
- Rheumatology and Clinical Immunology, University Medical Center Groningen, Groningen, The Netherlands
| | - Hendrika Bootsma
- Rheumatology and Clinical Immunology, University Medical Center Groningen, Groningen, The Netherlands
| | - Johanna Westra
- Rheumatology and Clinical Immunology, University Medical Center Groningen, Groningen, The Netherlands
| | - Karina de Leeuw
- Rheumatology and Clinical Immunology, University Medical Center Groningen, Groningen, The Netherlands
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Shimada H, Wakiya R, Kameda T, Nakashima S, Miyagi T, Sugihara K, Ushio Y, Mino R, Mizusaki M, Chujo K, Kanenishi K, Kadowaki N, Dobashi H. Immunological disease activity parameters at conception are risk factors for preterm birth and low birth weight in patients with systemic lupus erythematosus. Lupus 2023:9612033231176268. [PMID: 37191954 DOI: 10.1177/09612033231176268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
OBJECTIVE This study aimed to identify which disease activity parameters may be risk factors for preterm birth (PB) and low birth weight (LBW) in patients with systemic lupus erythematosus (SLE). We also analyzed the extent to which these parameters affected PB and LBW. METHODS We collected the SLE Disease Activity Index (SLEDAI), the rate of lupus low disease activity state (LLDAS) attainment, complement levels, and the titer of anti-double stranded DNA (dsDNA) antibody as disease activity parameters. We retrospectively analyzed the associations of these parameters with PB and LBW. RESULTS Sixty pregnancies were included in this study. C3 levels and anti-dsDNA antibody titers at conception were strongly associated with PB (p = 0.03 and p = 0.01, respectively), whereas C3 and CH50 levels were associated with LBW (p = 0.02 and p = 0.03, respectively). A logistic regression analysis showed that the cutoff values of C3 and anti-dsDNA antibody for PB were 62.0 mg/dl and 5.4 IU/ml, respectively. The cutoff values of C3 and CH50 for LBW were 87.0 mg/dl and 41.8 U/ml, respectively. The risk of PB or LBW was increased when divided by the cutoff value, and the combination of these cutoff values showed a significantly higher risk of PB and LBW (p = 0.01 and p < 0.01, respectively). CONCLUSIONS PB and LBW are strongly associated with disease activity parameters in patients with SLE. Therefore, strictly monitoring and controlling these disease activity parameters, with or without clinical manifestation, is important for women who want to become mothers.
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Affiliation(s)
- Hiromi Shimada
- Department of Internal Medicine, Division of Hematology, Rheumatology and Respiratory Medicine, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Risa Wakiya
- Department of Internal Medicine, Division of Hematology, Rheumatology and Respiratory Medicine, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Tomohiro Kameda
- Department of Internal Medicine, Division of Hematology, Rheumatology and Respiratory Medicine, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Shusaku Nakashima
- Department of Internal Medicine, Division of Hematology, Rheumatology and Respiratory Medicine, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Taichi Miyagi
- Department of Internal Medicine, Division of Hematology, Rheumatology and Respiratory Medicine, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Koichi Sugihara
- Department of Internal Medicine, Division of Hematology, Rheumatology and Respiratory Medicine, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Yusuke Ushio
- Department of Internal Medicine, Division of Hematology, Rheumatology and Respiratory Medicine, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Rina Mino
- Department of Internal Medicine, Division of Hematology, Rheumatology and Respiratory Medicine, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Mao Mizusaki
- Department of Internal Medicine, Division of Hematology, Rheumatology and Respiratory Medicine, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Kanako Chujo
- Department of Internal Medicine, Division of Hematology, Rheumatology and Respiratory Medicine, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Kenji Kanenishi
- Department of Perinatology and Gynecology, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Norimitsu Kadowaki
- Department of Internal Medicine, Division of Hematology, Rheumatology and Respiratory Medicine, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Hiroaki Dobashi
- Department of Internal Medicine, Division of Hematology, Rheumatology and Respiratory Medicine, Faculty of Medicine, Kagawa University, Kagawa, Japan
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Petri M, Landy H, Clowse MEB, Gemzoe K, Khamashta M, Kurtinecz M, Levy RA, Liu A, Marino R, Meizlik P, Pimenta JM, Sumner K, Tilson H, Connolly MB, Wurst K, Harris J, Quasny H, Juliao P, Roth DA. Belimumab use during pregnancy: a summary of birth defects and pregnancy loss from belimumab clinical trials, a pregnancy registry and postmarketing reports. Ann Rheum Dis 2023; 82:217-225. [PMID: 36198440 PMCID: PMC9887359 DOI: 10.1136/ard-2022-222505] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 09/02/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Describe available data on birth defects and pregnancy loss in women with systemic lupus erythematosus (SLE) exposed to belimumab. METHODS Data collected from belimumab clinical trials, the Belimumab Pregnancy Registry (BPR), and postmarketing/spontaneous reports up to 8 March 2020 were described. Belimumab exposure timing, concomitant medications and potential confounding factors were summarised descriptively. RESULTS Among 319 pregnancies with known outcomes (excluding elective terminations), 223 ended in live births from which birth defects were identified in 4/72 (5.6%) in belimumab-exposed pregnancies and 0/9 placebo-exposed pregnancies across 18 clinical trials, 10/46 (21.7%) belimumab-exposed pregnancies in the BPR prospective cohort (enrolled prior to pregnancy outcome) and 0/4 belimumab-exposed pregnancies in the BPR retrospective cohort (enrolled after pregnancy outcome), and 1/92 (1.1%) in belimumab-exposed pregnancies from postmarketing/spontaneous reports. There was no consistent pattern of birth defects across datasets. Out of pregnancies with known outcomes (excluding elective terminations), pregnancy loss occurred in 31.8% (35/110) of belimumab-exposed women and 43.8% (7/16) of placebo-exposed women in clinical trials; 4.2% (2/48) of women in the BPR prospective cohort and 50% (4/8) in the BPR retrospective cohort; and 31.4% (43/137) of belimumab-exposed women from postmarketing/spontaneous reports. All belimumab-exposed women in clinical trials and the BPR received concomitant medications and had confounding factors and/or missing data. CONCLUSIONS Observations reported here add to limited data published on pregnancy outcomes following belimumab exposure. Low numbers of exposed pregnancies, presence of confounding factors/other biases, and incomplete information preclude informed recommendations regarding risk of birth defects and pregnancy loss with belimumab use.
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Affiliation(s)
- Michelle Petri
- Rheumatology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Helain Landy
- Maternal And Fetal Medicine, Georgetown University Medical Center, Northwest Washington, Washington, DC, USA
- Department of Obstetrics and Gynecology, MedStar Georgetown University Hospital, Northwest Washington, Washington, DC, USA
| | - Megan E B Clowse
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Kim Gemzoe
- Value Evidence and Outcomes, GSK, Stevenage, Hertfordshire, UK
| | | | | | - Roger A Levy
- Specialty Care, Global Medical Affairs, GSK, Collegeville, Pennsylvania, USA
| | - Andrew Liu
- Global Clinical Safety and Pharmacovigilance, GSK, Brentford, UK
| | - Rebecca Marino
- US Case Management Group, GSK, Research Triangle Park, North Carolina, USA
| | | | | | - Kelsey Sumner
- Value Evidence Outcomes Epidemiology, GSK, Research Triangle Park, North Carolina, USA
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Chapel Hill, North Carolina, USA
| | - Hugh Tilson
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Chapel Hill, North Carolina, USA
| | - Mary Beth Connolly
- Safety and Medical Governance, GSK, Research Triangle Park, North Carolina, USA
| | - Keele Wurst
- Epidemiology, GSK, Research Triangle Park, North Carolina, USA
| | | | - Holly Quasny
- Clinical Sciences, GSK, Research Triangle Park, North Carolina, USA
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Yashima K, Noda A, Ishikawa T, Matsuzaki F, Miyakoda K, Nishigori H, Mano N, Obara T. Safety evaluation of the use of calcineurin inhibitor to prenatal and postpartum women in Japan from a health administrative database. J Neonatal Perinatal Med 2023; 16:461-473. [PMID: 37742666 DOI: 10.3233/npm-230138] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/26/2023]
Abstract
BACKGROUND To investigate the use of calcineurin inhibitors (CNIs) in pregnant Japanese women and to evaluate their safety in infants. METHODS Data were extracted from the claims database of the Japan Medical Data Center. The prevalence of CNIs was evaluated 180 days before pregnancy onset, during pregnancy, and within180-days post partum. We investigated the characteristics of the infants, including the presence of major malformations and their diagnoses, for 1 year after birth. RESULTS A total of 91,865 pregnancies in 80,049 women were included. Fifty-three women were prescribed CNIs between 180-day before pregnancy onset and 180-day postpartum; 35 of the 53 women were prescribed the drugs during pregnancy, and 10 of their infants were born preterm. Three were diagnosed with major congenital malformations, such as patent ductus arteriosus. Six preterm infants presented with infant respiratory distress syndrome. CONCLUSIONS No congenital anomalies were clearly attributable to the use of CNIs during pregnancy.
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Affiliation(s)
- K Yashima
- Department of Pharmacy, Tohoku Medical and Pharmaceutical University Wakabayashi Hospital, Sendai, Japan
| | - A Noda
- Department of Pharmaceutical Sciences, Tohoku University Hospital, Sendai, Japan
- Department of Molecular Epidemiology, Tohoku University Graduate School of Medicine, Sendai, Japan
- Division of Preventive Medicine and Epidemiology, Tohoku Medical Megabank Organization, Tohoku University, Sendai, Japan
| | - T Ishikawa
- Laboratory of Biomolecule and Pathophysiological Chemistry, Graduate School of Medicine, Tohoku University, Sendai, Japan
| | - F Matsuzaki
- Department of Molecular Epidemiology, Tohoku University Graduate School of Medicine, Sendai, Japan
- Division of Preventive Medicine and Epidemiology, Tohoku Medical Megabank Organization, Tohoku University, Sendai, Japan
| | - K Miyakoda
- Clinical & Translational Research Center, Kobe University Hospital, Kobe, Japan
| | - H Nishigori
- Fukushima Medical Center for Children and Women, Fukushima Medical University, Fukushima, Japan
| | - N Mano
- Department of Pharmaceutical Sciences, Tohoku University Hospital, Sendai, Japan
- Laboratory of Biomolecule and Pathophysiological Chemistry, Graduate School of Medicine, Tohoku University, Sendai, Japan
| | - T Obara
- Department of Pharmaceutical Sciences, Tohoku University Hospital, Sendai, Japan
- Department of Molecular Epidemiology, Tohoku University Graduate School of Medicine, Sendai, Japan
- Division of Preventive Medicine and Epidemiology, Tohoku Medical Megabank Organization, Tohoku University, Sendai, Japan
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Angley M, Drews-Botsch C, Lewis TT, Badell M, Lim SS, Howards PP. Adverse Perinatal Outcomes Before and After Diagnosis with Systemic Lupus Erythematosus Among African American Women. Arthritis Care Res (Hoboken) 2021; 74:904-911. [PMID: 34931482 DOI: 10.1002/acr.24848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 12/01/2021] [Accepted: 12/16/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Women with systemic lupus erythematosus (SLE) may experience adverse perinatal outcomes in the years before an SLE diagnosis. Overall, there is limited research on perinatal outcomes among African American women with SLE. METHODS Women with SLE identified from the Georgia Lupus Registry and the Georgians Organized Against Lupus Cohort were linked with birth certificates by the Georgia Department of Public Health. Births were categorized into occurring more than 3 years before SLE diagnosis, 0-3 years before SLE diagnosis, 0-3 years after SLE diagnosis or more than 3 years after SLE diagnosis. Comparison births certificates to African American women in the same geographic area were obtained from the National Center for Health Statistics. We used log-risk models to compare the risk of preterm birth or small-for-gestational age among SLE births in each diagnosis timing category to the general population, adjusting for maternal age and education and parity. RESULTS Births to women with SLE were more likely to occur preterm 0-3 years before SLE diagnosis (risk ratio [RR]: 1.71, 95% confidence interval [CI]: 1.24, 2.35), 0-3 years after SLE diagnosis (RR: 2.29, 95% CI: 1.70, 3.09) and 3 or more years after diagnosis (RR: 2.83, 95% CI: 2.36, 3.38), but not 3 or more years before SLE diagnosis compared to the general population (RR: 1.03, 95% CI: 0.77, 1.38). Similar results were observed for small-for-gestational age births. CONCLUSION Our analysis, conducted among African American women, demonstrates an increased risk of adverse perinatal outcomes even before a clinical diagnosis of SLE.
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Affiliation(s)
- Meghan Angley
- Department of Epidemiology, Rollins School of Public Health, Emory University
| | | | - Tené T Lewis
- Department of Epidemiology, Rollins School of Public Health, Emory University
| | - Martina Badell
- Division of Maternal-Fetal Medicine, Department of Gynecology and Obstetrics, Emory University School of Medicine
| | - S Sam Lim
- Department of Epidemiology, Rollins School of Public Health, Emory University.,Department of Medicine, Division of Rheumatology, Emory University School of Medicine
| | - Penelope P Howards
- Department of Epidemiology, Rollins School of Public Health, Emory University
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10
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Irino K, Arinobu Y, Ayano M, Kawano S, Kimoto Y, Mitoma H, Akahoshi M, Akashi K, Horiuchi T, Niiro H. Predictive factors of fetal and maternal pregnancy outcomes in Japanese patients with systemic lupus erythematosus. Lupus 2021; 30:1637-1643. [PMID: 34266321 DOI: 10.1177/09612033211031989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The number of pregnant and delivery cases in systemic lupus erythematosus (SLE) patients are increasing due to the advances in therapies. However, there are many problems such as the exacerbation of SLE during pregnancy and the risk of fetal complications. We investigated the impact of both pregnancy on lupus and lupus on pregnancy in Japanese patients. METHODS We retrospectively analyzed 64 pregnancies in 39 cases of lupus patients at Kyushu University Hospital, Japan, from October 2002 to July 2018 and then assessed the clinical profiles and maternal and fetal outcomes. RESULTS In terms of the impact of pregnancy on SLE, 29.7% of patients had lupus flare during pregnancy. Multivariate analysis showed that flare rates were significantly higher in patients who discontinued the immunosuppressants when pregnancy was detected or before pregnancy. Pregnancy results were 25.0% for preterm birth, 39.1% for low birth weight infants, and 31.3% for small-for-gestational-age infants. Regarding the effect of SLE on fetal death, the rates of stillbirth were significantly higher in cases whose C3 value at 12 weeks of gestation was lower than before conception. Preterm birth was associated with disease duration and lupus flare during pregnancy. CONCLUSIONS Discontinuation of immunosuppressive drugs was a predictive factor for lupus flare during pregnancy. Further, the decrease of C3 levels at 12 weeks of gestation from baseline was a predictive factor for fetal loss. It is essential for lupus pregnant patients to prevent flares, even with the use of immunosuppressive medications.
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Affiliation(s)
- Kensuke Irino
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Yojiro Arinobu
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Masahiro Ayano
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Shotaro Kawano
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Yasutaka Kimoto
- Faculty of Medical Sciences Medical Education, Kyushu University, Fukuoka, Japan
| | - Hiroki Mitoma
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Mitsuteru Akahoshi
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Koichi Akashi
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Takahiko Horiuchi
- Department of Internal Medicine, 73912Kyushu University Beppu Hospital, Kyushu University Beppu Hospital, Beppu, Japan
| | - Hiroaki Niiro
- Faculty of Medical Sciences Medical Education, Kyushu University, Fukuoka, Japan
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Eisfeld H, Glimm AM, Burmester GR, Ohrndorf S, Backhaus M. Pregnancy outcome in women with different rheumatic diseases: a retrospective analysis. Scand J Rheumatol 2021; 50:299-306. [PMID: 33622159 DOI: 10.1080/03009742.2020.1849788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2020] [Indexed: 10/22/2022]
Abstract
Objective: Pregnancy may influence the course of inflammatory rheumatic diseases and, conversely, rheumatic and musculoskeletal diseases (RMDs) can affect the outcome of pregnancy. This study aimed to retrospectively analyse the outcome of pregnancy and disease in women with RMDs.Method: Subjects were patients with high-risk pregnancy and connective tissue diseases (CTDs) or inflammatory joint diseases (IJDs) managed at a specialized rheumatology outpatient clinic from 2007 to 2014. Data from conception to 6 months postpartum were collected from medical records and a questionnaire, and analysed regarding clinical symptoms, medications, pregnancy complications, birth outcomes, and infant development. Generalized estimating equations were used to compare the groups (CTD vs IJD).Results: The eligible 66 pregnancies in 57 RMD patients were divided into two groups by RMD type: CTD (n = 48) or IJD (n = 18). The live birth rate was 97% overall. Pregnancy complications (excluding two twin pregnancies) were incurred in 39.1%: miscarriage (n = 2), premature delivery (n = 12), small-for-gestational-age infants (n = 5), and/or pregnancy-related diseases (n = 14). Three children born to women with CTDs had affected development (autism spectrum disorder, congenital heart disease, bronchopulmonary dysplasia). CTD infants had a significantly lower mean gestational age (in weeks) (p = 0.042), weight (p = 0.009), and length (p = 0.016) at birth than IJD infants.Conclusion: Although the live birth rate was high, complications occurred in 39.1% of pregnancies in this cohort. Therefore, interdisciplinary management of pregnant women with RMDs at specialized clinics is strongly recommended.
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Affiliation(s)
- H Eisfeld
- Department of Rheumatology and Clinical Immunology, Charité University Hospital, Berlin, Germany
| | - A M Glimm
- Department of Rheumatology and Clinical Immunology, Charité University Hospital, Berlin, Germany
| | - G R Burmester
- Department of Rheumatology and Clinical Immunology, Charité University Hospital, Berlin, Germany
| | - S Ohrndorf
- Department of Rheumatology and Clinical Immunology, Charité University Hospital, Berlin, Germany
| | - M Backhaus
- Department of Rheumatology and Clinical Immunology, Charité University Hospital, Berlin, Germany
- Department of Internal Medicine, Rheumatology and Clinical Immunology, Parkklinik Weißensee, Berlin, Germany
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12
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Hiramatsu Y, Isoda K, Kotani T, Nakamura E, Wada Y, Fujiki Y, Makino S, Fujita D, Takeuchi T. Pre-pregnancy serum complement C3 level is a predictor of preterm birth for pregnancies with systemic lupus erythematosus. Arthritis Res Ther 2021; 23:140. [PMID: 33980284 PMCID: PMC8114516 DOI: 10.1186/s13075-021-02522-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 04/26/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This study aimed to clarify predictors of preterm birth in pregnancy of women with systemic lupus erythematosus (SLE). We investigated the predictors of preterm birth before pregnancy from the perspective of the importance of preconception care. METHODS We analysed fetal outcomes of 108 pregnancies in 74 SLE patients in a retrospective study. We compared pre-pregnancy clinical characteristics and disease activity in these women between the preterm birth and full-term birth groups to select predictive factors for preterm birth before pregnancy. RESULTS Eighty-three of 108 pregnancies resulted in live births, of which 27 (25.0%) were preterm births. Pre-pregnancy serum complement 3 (C3) level was significantly lower in the preterm birth group (77.0 mg/dl) than the full-term birth group (87.5 mg/dl) (P = 0.029). Multivariate analysis identified history of lupus nephritis (odds ratio: 5.734, 95% CI 1.568-21.010, P = 0.008) and low C3 level (< 85 mg/dl) at pre-pregnancy (odds ratio 4.498, 95% CI 1.296-15.616, P = 0.018) as risk factors for preterm birth. The greater the number of these risk factors, the higher was the preterm birth rate (P = 0.0007). In the case of SLEDAI score ≤ 4, the preterm birth rate was higher in the pre-pregnancy low C3 group (< 85 mg/dl) (42.1%) than in the high C3 group (C3 ≥ 85 mg/dl) (14.7%) (P = 0.018). CONCLUSION For patients with a history of LN, treatment management focusing on pre-pregnancy serum complement levels is very important.
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Affiliation(s)
- Yuri Hiramatsu
- Department of Internal Medicine (IV), Osaka Medical College, Daigaku-Machi 2-7, Takatsuki, Osaka, 569-8686, Japan
| | - Kentaro Isoda
- Department of Internal Medicine (IV), Osaka Medical College, Daigaku-Machi 2-7, Takatsuki, Osaka, 569-8686, Japan.,Department of Rheumatology and Allergology, National Hospital Organization Osaka Minami Medical Center, Osaka, Japan
| | - Takuya Kotani
- Department of Internal Medicine (IV), Osaka Medical College, Daigaku-Machi 2-7, Takatsuki, Osaka, 569-8686, Japan.
| | - Eri Nakamura
- Department of Internal Medicine (IV), Osaka Medical College, Daigaku-Machi 2-7, Takatsuki, Osaka, 569-8686, Japan
| | - Yumiko Wada
- Department of Internal Medicine (IV), Osaka Medical College, Daigaku-Machi 2-7, Takatsuki, Osaka, 569-8686, Japan
| | - Youhei Fujiki
- Department of Internal Medicine, Yodogawa Christian Hospital, Osaka, Japan
| | - Shigeki Makino
- Department of Internal Medicine, Osaka Medical College Mishima-Minami Hospital, Osaka, Japan
| | - Daisuke Fujita
- Department of Obstetrics and Gynecology, Osaka Medical College, Osaka, Japan
| | - Tohru Takeuchi
- Department of Internal Medicine (IV), Osaka Medical College, Daigaku-Machi 2-7, Takatsuki, Osaka, 569-8686, Japan
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Chighizola CB, Lonati PA, Trespidi L, Meroni PL, Tedesco F. The Complement System in the Pathophysiology of Pregnancy and in Systemic Autoimmune Rheumatic Diseases During Pregnancy. Front Immunol 2020; 11:2084. [PMID: 32973817 PMCID: PMC7481445 DOI: 10.3389/fimmu.2020.02084] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 07/30/2020] [Indexed: 12/16/2022] Open
Abstract
The complement system plays a double role in pregnancy exerting both protective and damaging effects at placental level. Complement activation at fetal-maternal interface participates in protection against infectious agents and helps remove apoptotic and necrotic cells. Locally synthesized C1q contributes to the physiologic vascular remodeling of spiral arteries characterized by loss of smooth muscle cells and transformation into large dilated vessels. Complement activation triggered by the inflammatory process induced by embryo implantation can damage trophoblast and other decidual cells that may lead to pregnancy complications if the cells are not protected by the complement regulators CD55, CD46, and CD59 expressed on cell surface. However, uncontrolled complement activation induces placental alterations resulting in adverse pregnancy outcomes. This may occur in pathological conditions characterized by placental localization of complement fixing antibodies directed against beta2-glycoprotein 1, as in patients with anti-phospholipid syndrome, or circulating immune complexes deposited in placenta, as in patients with systemic lupus erythematosus. In other diseases, such as preeclampsia, the mechanism of complement activation responsible for complement deposits in placenta is unclear. Conflicting results have been reported on the relevance of complement assays as diagnostic and prognostic tools to assess complement involvement in pregnant patients with these disorders.
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Affiliation(s)
- Cecilia Beatrice Chighizola
- Experimental Laboratory of Immunological and Rheumatologic Researches, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Paola Adele Lonati
- Experimental Laboratory of Immunological and Rheumatologic Researches, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Laura Trespidi
- Department of Obstetrics and Gynaecology, Fondazione Cà Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Pier Luigi Meroni
- Experimental Laboratory of Immunological and Rheumatologic Researches, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Francesco Tedesco
- Experimental Laboratory of Immunological and Rheumatologic Researches, Istituto Auxologico Italiano, IRCCS, Milan, Italy
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14
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Zamani B, Shayestehpour M, Esfahanian F, Akbari H. The study of factors associated with pregnancy outcomes in patients with systemic lupus erythematosus. BMC Res Notes 2020; 13:185. [PMID: 32228711 PMCID: PMC7108499 DOI: 10.1186/s13104-020-05039-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Accepted: 03/21/2020] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVES Systemic lupus erythematosus (SLE) is an autoimmune disease that can lead to unfavorable pregnancy complications in women. This study aimed to evaluate the factors associated with pregnancy outcomes in patients with SLE. RESULTS Fifty-nine pregnant women with SLE (121 pregnancies) participated in this retrospective cohort study. The mean age of the patients was 33.74 ± 3.80 years (range 21 to 48 years). Fetal loss occurred in 43.8% of pregnancies. The most common laboratory findings in SLE patients were antinuclear antibody (81.4%) and anti-ds DNA positivity (54.2%). High levels of C-reactive protein (CRP) during pregnancy, renal involvement, anti-double-stranded DNA positivity, anti-phospholipid antibody (APA) positivity and younger age at disease onset were significantly correlated with unfavourable pregnancy outcomes. A significant difference was observed between duration of SLE and low birth weight (P = 0.003), pre-eclampsia (P = 0.012) and still birth (P = 0.036). High CRP, APA positivity, anti-dsDNA positivity and kidney involvement were predictors of adverse pregnancy outcomes in SLE patients. Renal involvement increased risk of pregnancy with complication 8.5 times (OR = 8.5, 95% CI 1.396-63.373, P = 0.017). Antiphospholipid syndrome (APS) also was associated with an odds ratio of 5.18 (95% CI 1.681-13.647, P = 0.001).
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Affiliation(s)
- Batool Zamani
- Autoimmune Diseases Research Center, Kashan University of Medical Sciences, Kashan, Iran
| | - Mohammad Shayestehpour
- Autoimmune Diseases Research Center, Kashan University of Medical Sciences, Kashan, Iran.,Department of Microbiology and Immunology, Faculty of Medicine, Kashan University of Medical Sciences, Kashan, Iran
| | - Farifteh Esfahanian
- Autoimmune Diseases Research Center, Kashan University of Medical Sciences, Kashan, Iran
| | - Hossein Akbari
- Department of Biostatistics and Public Health, Faculty of Health, Kashan University of Medical Sciences, Pezeshk Blvd, 5th of Qotb-e Ravandi Blvd, P.O.Box: 8715973449, Kashan, Iran.
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15
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Tincani A, Nalli C, Khizroeva J, Bitsadze V, Lojacono A, Andreoli L, Shoenfeld Y, Makatsariya A. Autoimmune diseases and pregnancy. Best Pract Res Clin Endocrinol Metab 2019; 33:101322. [PMID: 31542218 DOI: 10.1016/j.beem.2019.101322] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Pregnancy in autoimmune diseases remains an argument of debate. In last years great improvements were done and with the correct medical support women with disease such as Systemic Lupus Erythematosus or Antiphospholipid Syndrome can afford a pregnancy and have healthy babies. The starting point is a good counselling. Women should be informed about risks that can occur taking some medications while pregnant and, on the other hand, that there are medications that can be safety assumed during pregnancy. Furthermore, there are known maternal risks factor such as the presence of antiphospholipid antibodies or anti-Ro/SSA antibodies that must be carefully manage by both rheumatologists and obstetrics. In addition, also disease activity during pregnancy can represent an issue. For all these reason, a multidisciplinary approach is mandatory in order to give our patients an optimal medical support, before, during and after pregnancy.
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Affiliation(s)
- Angela Tincani
- Rheumatology and Immunology Unit, Department of Clinical and Experimental Sciences, University of Brescia, ASST Spedali Civili, Brescia, Italy; I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), Russia.
| | - Cecilia Nalli
- Rheumatology and Immunology Unit, Department of Clinical and Experimental Sciences, University of Brescia, ASST Spedali Civili, Brescia, Italy
| | - Jamilya Khizroeva
- Department of Obstetrics and Gynecology of I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russia
| | - Victoria Bitsadze
- Department of Obstetrics and Gynecology of I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russia
| | - Andrea Lojacono
- Obstetric and Gynecology Unit, Department of Clinical and Experimental Science, University of Brescia, ASST Spedali Civili, Brescia, Italy
| | - Laura Andreoli
- Rheumatology and Immunology Unit, Department of Clinical and Experimental Sciences, University of Brescia, ASST Spedali Civili, Brescia, Italy
| | - Yehuda Shoenfeld
- I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), Russia; Department of Medicine 'B', The Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Ramat Gan, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv-Yafo, Israel
| | - Alexander Makatsariya
- Department of Obstetrics and Gynecology of I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russia
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16
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Zhang L, Li Y, Lin X, Jia C, Yu X. Liquid Chromatography/Mass Spectrometry based serum metabolomics study on recurrent abortion women with antiphospholipid syndrome. PLoS One 2019; 14:e0225463. [PMID: 31751406 PMCID: PMC6874207 DOI: 10.1371/journal.pone.0225463] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 11/05/2019] [Indexed: 12/05/2022] Open
Abstract
Objective The antiphospholipid syndrome (APS) is an important cause of acquired thromboembolic complications and pregnancy morbidity. The pathogenic mechanisms that damage the fetal–maternal unit and cause abnormal placental development are incompletely understood in APS patients. Liquid Chromatography/Mass Spectrometry (LC/MS) based metabolomics are applied for the mechanism of disease and further supporting the research of diagnosis and management in recent years. The aim of this research was to investigate the difference of serum metabolic profiles in recurrent abortion women with APS and healthy women to explore the mechanism of this disease. Methods Serum samples of 25 recurrent abortion women with APS and 25 healthy women were collected and analyzed by LC/MS in this study. Potential biomarkers were discovered by multivariate statistical analysis and then identified based on analysis results. Results Totally, we identified five biomarkers that involved in different metabolic pathway such as purine metabolism, amino acid metabolism and tyrosine metabolism. These biomarkers showed different roles in disease development. Conclusion Metabolomics was proved as a powerful tool in understanding the mechanism of recurrent abortion caused by APS.
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Affiliation(s)
- Lili Zhang
- Department of Ultrasonography, First Hospital, Jilin University, Changchun, China
| | - Ying Li
- Department of Neonatology, First Hospital, Jilin University, Changchun, China
| | - Xiuying Lin
- Center for Reproductive Medicine, Jilin Province People's Hospital, Changchun, China
| | - Chunshu Jia
- Centre for Reproductive Medicine, Centre for Prenatal Diagnosis, First Hospital, Jilin University, Changchun, China
- * E-mail: (CJ); (XY)
| | - Xiaowei Yu
- Centre for Reproductive Medicine, Centre for Prenatal Diagnosis, First Hospital, Jilin University, Changchun, China
- * E-mail: (CJ); (XY)
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Larosa M, Del Ross T, Calligaro A, Favaro M, Zanatta E, Iaccarino L, Doria A. Clinical outcomes and predictors of maternal and fetal complications in pregnancies of patients with systemic lupus erythematosus. Expert Rev Clin Immunol 2019; 15:617-627. [PMID: 30933534 DOI: 10.1080/1744666x.2019.1601557] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Systemic Lupus Erythematosus (SLE) mostly affects women during their childbearing years. Fertility is preserved in SLE patients, but pregnancy is often characterized by a high number of maternal and fetal complications. Adverse pregnancy outcomes (APO) have been widely studied over the last decades and several investigators have focused on the potential clinical and serological predictors of maternal and fetal complications. Areas covered: In this review, we analyzed maternal and fetal complications in SLE patients and predictors of APO. Active disease in the 6 months before conception, lupus nephritis, anti-phospholipid (aPL), anti-SSA/Ro and/or anti-SSB/La antibodies have been identified as the most consistent predictors of maternal and fetal complications to date. However, molecular mechanisms and underlying immunological pathways involved in APO still remain elusive. Expert opinion: Difficulties in assessing prevalence and predictors of APO in SLE patients are due to lack of uniformity in the definitions and methods used in the different studies. In addition, some maternal and fetal complications are difficult to diagnose and to differentiate from each other. Preconception counseling is paramount to prevent APO, and it should consider four main factors: disease activity/lupus nephritis, safety of drugs, aPL, anti-SSA/Ro, and/or anti-SSB/La antibodies.
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Affiliation(s)
- Maddalena Larosa
- a Department of Medicine - DIMED, Division of Rheumatology , University of Padova , Padova , Italy
| | - Teresa Del Ross
- a Department of Medicine - DIMED, Division of Rheumatology , University of Padova , Padova , Italy
| | - Antonia Calligaro
- a Department of Medicine - DIMED, Division of Rheumatology , University of Padova , Padova , Italy
| | - Maria Favaro
- a Department of Medicine - DIMED, Division of Rheumatology , University of Padova , Padova , Italy
| | - Elisabetta Zanatta
- a Department of Medicine - DIMED, Division of Rheumatology , University of Padova , Padova , Italy
| | - Luca Iaccarino
- a Department of Medicine - DIMED, Division of Rheumatology , University of Padova , Padova , Italy
| | - Andrea Doria
- a Department of Medicine - DIMED, Division of Rheumatology , University of Padova , Padova , Italy
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Systemic Lupus Erythematosus and Pregnancy: A Brief Review. J Obstet Gynaecol India 2019; 69:104-109. [PMID: 30956462 DOI: 10.1007/s13224-019-01212-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 02/21/2019] [Indexed: 01/21/2023] Open
Abstract
Systemic lupus erythematosus is a chronic multisystemic autoimmune disease that predominantly affects young women of childbearing age group. There is a complex immunologic interplay during pregnancy in patients with systemic lupus erythematosus. The pregnancy has direct impact on the disease where an increased rate of flares is noted, and lupus leads to increased risk of hypertensive diseases of pregnancy, preterm birth as well as miscarriages, particularly those with antiphospholipid antibodies. Neonates born to patients with lupus are at increased risk of neonatal lupus as well as heart block if born to patients with positive SSA/SSB. Despite the increased risk of morbidity, recent data suggest improved outcomes in pregnant patients with lupus. A multidisciplinary approach with careful monitoring of pregnancy and lupus could reduce adverse outcomes in these patients. This requires careful pregnancy planning, defining the clinical and serologic involvement of lupus, careful monitoring the patient for adverse pregnancy outcome as well as lupus flares and comprehensive understanding of the drugs that can be safely used in pregnancy. Fetuses should be carefully monitored for heart and neonates for neonatal lupus. Hydroxychloroquine, azathioprine and corticosteroids can be used during pregnancy and may reduce the risk of adverse outcomes. Similarly, appropriate therapy needs to be instituted for hypertensive diseases in pregnancy. Anticoagulant therapy may be necessary for patients with antiphospholipid syndrome.
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Harris N, Eudy A, Clowse M. Patient-Reported Disease Activity and Adverse Pregnancy Outcomes in Systemic Lupus Erythematosus and Rheumatoid Arthritis. Arthritis Care Res (Hoboken) 2019; 71:390-397. [DOI: 10.1002/acr.23621] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Accepted: 06/12/2018] [Indexed: 01/23/2023]
Affiliation(s)
| | - Amanda Eudy
- Duke University Medical Center; Durham North Carolina
| | - Megan Clowse
- Duke University Medical Center; Durham North Carolina
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20
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Fetal and Maternal Outcomes of Planned Pregnancy in Patients with Systemic Lupus Erythematosus: A Retrospective Multicenter Study. J Immunol Res 2018; 2018:2413637. [PMID: 30255104 PMCID: PMC6140277 DOI: 10.1155/2018/2413637] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Accepted: 07/11/2018] [Indexed: 11/17/2022] Open
Abstract
Objective To investigate the fetal and maternal outcomes as well as predictors of APOs in women with SLE who conceived when the disease was stable, the so-called "planned pregnancy." Methods. A retrospective multicenter study of 243 patients with SLE who underwent a planned pregnancy was performed. APOs in fetus and mothers were recorded. Results The average age at conception was 28.9 ± 3.9 years. Duration of SLE prior to pregnancy was 4.4 ± 4.3 years. Fetal APOs occurred in 86 (86/243, 35.4%) patients. Preterm births, intrauterine growth retardation (IUGR), fetal distress, and fetal loss accounted for 22.2%, 14.8%, 11.1%, and 4.9%, respectively. Forty-two preterm infants (42/54, 77.8%) were delivered after the 34th week of gestation. All the preterm infants were viable. Fifty-two patients (52/243, 21.4%) had disease flares, among which 45 cases (45/52, 86.5%) were mild, 6 (6/52, 11.5%) were moderate, and 1 (1/52, 1.9%) was severe. Disease flares were mainly presented as active lupus nephritis (41/52, 78.8%), thrombocytopenia (10/52, 19.2%), and skin/mucosa lesions (9/52, 17.3%). Pregnancy-induced hypertension (PIH) occurred in 29 patients, among which 3 were gestational hypertension and 26 were preeclampsia. Multiple analysis showed that disease flares (OR, 8.1; CI, 3.8-17.2) and anticardiolipin antibody positivity (OR, 7.4; CI, 2.5-21.8) were associated with composite fetal APOs. Conclusion Planned pregnancy improved fetal and maternal outcomes, presenting as a lower rate of fetal loss, more favorable outcomes for preterm infants, and less severe disease flares during pregnancy.
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21
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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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McDonald EG, Bissonette L, Ensworth S, Dayan N, Clarke AE, Keeling S, Bernatsky S, Vinet E. Monitoring of Systemic Lupus Erythematosus Pregnancies: A Systematic Literature Review. J Rheumatol 2018; 45:1477-1490. [PMID: 30008450 DOI: 10.3899/jrheum.171023] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/25/2018] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Few data exist to guide the frequency and type of monitoring in systemic lupus erythematosus (SLE) pregnancies. A systematic literature review was performed to address this gap in the literature. METHODS A systematic review of original articles (1975-2015) was performed using Medline, Embase, and Cochrane Library. We included search terms for SLE, pregnancy, and monitoring. We also hand-searched reference lists, review articles, and grey literature for additional relevant articles. RESULTS The search yielded a total of 1106 articles. After removing 117 duplicates, 929 articles that were evidently unrelated to our topic based on title and/or abstract, and 7 that were in a language other than English or French, 53 articles were included for full-text review. Following a more in-depth review, 15 were excluded: 6 did not use any measure of SLE activity and 6 did not specifically address SLE monitoring in pregnancy; 1 case series, 1 review, and 1 metaanalysis were removed. Among the 38 included studies, presence of active disease, antiphospholipid (aPL) antibodies positivity, and abnormal uterine and umbilical artery Doppler studies predicted poor pregnancy outcomes. No studies evaluated an evidence-based approach to the frequency of monitoring. CONCLUSION Few existing studies address monitoring for optimal care during SLE pregnancies. The available data imply roles for aPL antibodies measurement (prior to pregnancy and/or during the first trimester), uterine and umbilical artery Doppler studies in the second trimester, and following disease activity. Optimal frequency of monitoring is not addressed in the existing literature.
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Affiliation(s)
- Emily G McDonald
- From the Division of General Internal Medicine, and the Division of Rheumatology, Department of Medicine, McGill University Health Centre, Montréal; Division of Rheumatology, Department of Medicine, University of Sherbrooke, Sherbrooke, Québec; Division of Rheumatology, Mary Pack Arthritis Center, University of British Columbia, Vancouver, British Columbia; Division of Rheumatology, Department of Medicine, University of Alberta, Edmonton; Division of Rheumatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada.,E.G. McDonald, MD, MSc, Division of General Internal Medicine, Department of Medicine, McGill University Health Centre; L. Bissonette, MD, Division of Rheumatology, Department of Medicine, University of Sherbrooke; S. Ensworth, MD, Assistant Professor, Division of Rheumatology, University of British Columbia; N. Dayan, MD, MSc, Division of General Internal Medicine, Department of Medicine, McGill University Health Centre; A.E. Clarke, MD, MSc, Division of Rheumatology, Department of Medicine, University of Calgary; S. Keeling, MD, MSc, Division of Rheumatology, Department of Medicine, University of Alberta; S. Bernatsky, MD, PhD, Division of Rheumatology, Department of Medicine, McGill University Health Centre; E. Vinet, MD, PhD, Division of Rheumatology, Department of Medicine, McGill University Health Centre
| | - Lyne Bissonette
- From the Division of General Internal Medicine, and the Division of Rheumatology, Department of Medicine, McGill University Health Centre, Montréal; Division of Rheumatology, Department of Medicine, University of Sherbrooke, Sherbrooke, Québec; Division of Rheumatology, Mary Pack Arthritis Center, University of British Columbia, Vancouver, British Columbia; Division of Rheumatology, Department of Medicine, University of Alberta, Edmonton; Division of Rheumatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada.,E.G. McDonald, MD, MSc, Division of General Internal Medicine, Department of Medicine, McGill University Health Centre; L. Bissonette, MD, Division of Rheumatology, Department of Medicine, University of Sherbrooke; S. Ensworth, MD, Assistant Professor, Division of Rheumatology, University of British Columbia; N. Dayan, MD, MSc, Division of General Internal Medicine, Department of Medicine, McGill University Health Centre; A.E. Clarke, MD, MSc, Division of Rheumatology, Department of Medicine, University of Calgary; S. Keeling, MD, MSc, Division of Rheumatology, Department of Medicine, University of Alberta; S. Bernatsky, MD, PhD, Division of Rheumatology, Department of Medicine, McGill University Health Centre; E. Vinet, MD, PhD, Division of Rheumatology, Department of Medicine, McGill University Health Centre
| | - Stephanie Ensworth
- From the Division of General Internal Medicine, and the Division of Rheumatology, Department of Medicine, McGill University Health Centre, Montréal; Division of Rheumatology, Department of Medicine, University of Sherbrooke, Sherbrooke, Québec; Division of Rheumatology, Mary Pack Arthritis Center, University of British Columbia, Vancouver, British Columbia; Division of Rheumatology, Department of Medicine, University of Alberta, Edmonton; Division of Rheumatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada.,E.G. McDonald, MD, MSc, Division of General Internal Medicine, Department of Medicine, McGill University Health Centre; L. Bissonette, MD, Division of Rheumatology, Department of Medicine, University of Sherbrooke; S. Ensworth, MD, Assistant Professor, Division of Rheumatology, University of British Columbia; N. Dayan, MD, MSc, Division of General Internal Medicine, Department of Medicine, McGill University Health Centre; A.E. Clarke, MD, MSc, Division of Rheumatology, Department of Medicine, University of Calgary; S. Keeling, MD, MSc, Division of Rheumatology, Department of Medicine, University of Alberta; S. Bernatsky, MD, PhD, Division of Rheumatology, Department of Medicine, McGill University Health Centre; E. Vinet, MD, PhD, Division of Rheumatology, Department of Medicine, McGill University Health Centre
| | - Natalie Dayan
- From the Division of General Internal Medicine, and the Division of Rheumatology, Department of Medicine, McGill University Health Centre, Montréal; Division of Rheumatology, Department of Medicine, University of Sherbrooke, Sherbrooke, Québec; Division of Rheumatology, Mary Pack Arthritis Center, University of British Columbia, Vancouver, British Columbia; Division of Rheumatology, Department of Medicine, University of Alberta, Edmonton; Division of Rheumatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada.,E.G. McDonald, MD, MSc, Division of General Internal Medicine, Department of Medicine, McGill University Health Centre; L. Bissonette, MD, Division of Rheumatology, Department of Medicine, University of Sherbrooke; S. Ensworth, MD, Assistant Professor, Division of Rheumatology, University of British Columbia; N. Dayan, MD, MSc, Division of General Internal Medicine, Department of Medicine, McGill University Health Centre; A.E. Clarke, MD, MSc, Division of Rheumatology, Department of Medicine, University of Calgary; S. Keeling, MD, MSc, Division of Rheumatology, Department of Medicine, University of Alberta; S. Bernatsky, MD, PhD, Division of Rheumatology, Department of Medicine, McGill University Health Centre; E. Vinet, MD, PhD, Division of Rheumatology, Department of Medicine, McGill University Health Centre
| | - Ann E Clarke
- From the Division of General Internal Medicine, and the Division of Rheumatology, Department of Medicine, McGill University Health Centre, Montréal; Division of Rheumatology, Department of Medicine, University of Sherbrooke, Sherbrooke, Québec; Division of Rheumatology, Mary Pack Arthritis Center, University of British Columbia, Vancouver, British Columbia; Division of Rheumatology, Department of Medicine, University of Alberta, Edmonton; Division of Rheumatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada.,E.G. McDonald, MD, MSc, Division of General Internal Medicine, Department of Medicine, McGill University Health Centre; L. Bissonette, MD, Division of Rheumatology, Department of Medicine, University of Sherbrooke; S. Ensworth, MD, Assistant Professor, Division of Rheumatology, University of British Columbia; N. Dayan, MD, MSc, Division of General Internal Medicine, Department of Medicine, McGill University Health Centre; A.E. Clarke, MD, MSc, Division of Rheumatology, Department of Medicine, University of Calgary; S. Keeling, MD, MSc, Division of Rheumatology, Department of Medicine, University of Alberta; S. Bernatsky, MD, PhD, Division of Rheumatology, Department of Medicine, McGill University Health Centre; E. Vinet, MD, PhD, Division of Rheumatology, Department of Medicine, McGill University Health Centre
| | - Stephanie Keeling
- From the Division of General Internal Medicine, and the Division of Rheumatology, Department of Medicine, McGill University Health Centre, Montréal; Division of Rheumatology, Department of Medicine, University of Sherbrooke, Sherbrooke, Québec; Division of Rheumatology, Mary Pack Arthritis Center, University of British Columbia, Vancouver, British Columbia; Division of Rheumatology, Department of Medicine, University of Alberta, Edmonton; Division of Rheumatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada.,E.G. McDonald, MD, MSc, Division of General Internal Medicine, Department of Medicine, McGill University Health Centre; L. Bissonette, MD, Division of Rheumatology, Department of Medicine, University of Sherbrooke; S. Ensworth, MD, Assistant Professor, Division of Rheumatology, University of British Columbia; N. Dayan, MD, MSc, Division of General Internal Medicine, Department of Medicine, McGill University Health Centre; A.E. Clarke, MD, MSc, Division of Rheumatology, Department of Medicine, University of Calgary; S. Keeling, MD, MSc, Division of Rheumatology, Department of Medicine, University of Alberta; S. Bernatsky, MD, PhD, Division of Rheumatology, Department of Medicine, McGill University Health Centre; E. Vinet, MD, PhD, Division of Rheumatology, Department of Medicine, McGill University Health Centre
| | - Sasha Bernatsky
- From the Division of General Internal Medicine, and the Division of Rheumatology, Department of Medicine, McGill University Health Centre, Montréal; Division of Rheumatology, Department of Medicine, University of Sherbrooke, Sherbrooke, Québec; Division of Rheumatology, Mary Pack Arthritis Center, University of British Columbia, Vancouver, British Columbia; Division of Rheumatology, Department of Medicine, University of Alberta, Edmonton; Division of Rheumatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada.,E.G. McDonald, MD, MSc, Division of General Internal Medicine, Department of Medicine, McGill University Health Centre; L. Bissonette, MD, Division of Rheumatology, Department of Medicine, University of Sherbrooke; S. Ensworth, MD, Assistant Professor, Division of Rheumatology, University of British Columbia; N. Dayan, MD, MSc, Division of General Internal Medicine, Department of Medicine, McGill University Health Centre; A.E. Clarke, MD, MSc, Division of Rheumatology, Department of Medicine, University of Calgary; S. Keeling, MD, MSc, Division of Rheumatology, Department of Medicine, University of Alberta; S. Bernatsky, MD, PhD, Division of Rheumatology, Department of Medicine, McGill University Health Centre; E. Vinet, MD, PhD, Division of Rheumatology, Department of Medicine, McGill University Health Centre
| | - Evelyne Vinet
- From the Division of General Internal Medicine, and the Division of Rheumatology, Department of Medicine, McGill University Health Centre, Montréal; Division of Rheumatology, Department of Medicine, University of Sherbrooke, Sherbrooke, Québec; Division of Rheumatology, Mary Pack Arthritis Center, University of British Columbia, Vancouver, British Columbia; Division of Rheumatology, Department of Medicine, University of Alberta, Edmonton; Division of Rheumatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada. .,E.G. McDonald, MD, MSc, Division of General Internal Medicine, Department of Medicine, McGill University Health Centre; L. Bissonette, MD, Division of Rheumatology, Department of Medicine, University of Sherbrooke; S. Ensworth, MD, Assistant Professor, Division of Rheumatology, University of British Columbia; N. Dayan, MD, MSc, Division of General Internal Medicine, Department of Medicine, McGill University Health Centre; A.E. Clarke, MD, MSc, Division of Rheumatology, Department of Medicine, University of Calgary; S. Keeling, MD, MSc, Division of Rheumatology, Department of Medicine, University of Alberta; S. Bernatsky, MD, PhD, Division of Rheumatology, Department of Medicine, McGill University Health Centre; E. Vinet, MD, PhD, Division of Rheumatology, Department of Medicine, McGill University Health Centre.
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Deguchi M, Maesawa Y, Kubota S, Morizane M, Tanimura K, Ebina Y, Yamada H. Factors associated with adverse pregnancy outcomes in women with systematic lupus erythematosus. J Reprod Immunol 2018; 125:39-44. [DOI: 10.1016/j.jri.2017.11.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Revised: 10/25/2017] [Accepted: 11/27/2017] [Indexed: 11/17/2022]
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25
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Abrahams VM, Chamley LW, Salmon JE. Emerging Treatment Models in Rheumatology: Antiphospholipid Syndrome and Pregnancy: Pathogenesis to Translation. Arthritis Rheumatol 2017; 69:1710-1721. [PMID: 28445926 DOI: 10.1002/art.40136] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Accepted: 04/20/2017] [Indexed: 02/06/2023]
Affiliation(s)
| | | | - Jane E Salmon
- Hospital for Special Surgery, Weill Cornell Medicine, New York, New York
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26
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Götestam Skorpen C, Lydersen S, Gilboe I, Skomsvoll JF, Salvesen KÅ, Palm Ø, Koksvik HSS, Jakobsen B, Wallenius M. Disease Activity During Pregnancy and the First Year Postpartum in Women With Systemic Lupus Erythematosus. Arthritis Care Res (Hoboken) 2017; 69:1201-1208. [DOI: 10.1002/acr.23102] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Revised: 09/05/2016] [Accepted: 09/27/2016] [Indexed: 11/09/2022]
Affiliation(s)
- Carina Götestam Skorpen
- Trondheim University Hospital and Norwegian University of Science and Technology, Trondheim, and Helse Møre og Romsdal, Ålesund HospitalÅlesund Norway
| | - Stian Lydersen
- Norwegian University of Science and TechnologyTrondheim Norway
| | | | | | | | - Øyvind Palm
- Oslo University Hospital RikshospitaletOslo Norway
| | | | | | - Marianne Wallenius
- Trondheim University Hospital and Norwegian University of Science and TechnologyTrondheim Norway
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27
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Zhan Z, Yang Y, Zhan Y, Chen D, Liang L, Yang X. Fetal outcomes and associated factors of adverse outcomes of pregnancy in southern Chinese women with systemic lupus erythematosus. PLoS One 2017; 12:e0176457. [PMID: 28441446 PMCID: PMC5404768 DOI: 10.1371/journal.pone.0176457] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Accepted: 04/11/2017] [Indexed: 11/28/2022] Open
Abstract
This study aims to investigate the fetal outcomes and associated factors of adverse pregnancy outcomes (APOs) in pregnant women with systemic lupus erythematosus (SLE). Clinical data from 251 SLE patients with 263 pregnancies from 2001 to 2015 were analyzed retrospectively. APOs occurred in 70.0% of pregnancies, in which pregnancy loss occurred in 28.5%; preterm delivery occurred in 21.3%; intrauterine growth retardation occurred in 12.2%; and fetal distress occurred in 8.0%. Over time, the rate of APOs decreased from 82.8% during 2001~2005 to 59.6% during 2011~2015. In multivariate analysis, predictors of APOs included positive antiphospholipid antibodies (OR 8.4, 95% CI 1.7~40.8, P = 0.008), lower complement (OR 3.6, 95% CI 1.3~9.9, P = 0.01), hypoalbuminemia (OR 3.2, 95% CI 1.2~8.3, P = 0.02), and hypertension (OR 14.6, 95% CI 1.5~141.6, P = 0.02). The use of antimalarial medications was associated with lower risk for APOs (OR 0.3, 95% CI 0.1~0.7, P = 0.01). In total, 109 patients underwent fetal umbilical artery Doppler in the third trimester. The The adjusted systole/diastole (S/D) ratio, pulsatility index (PI) and resistance index (RI) of SLE patients with APOs were higher than that of patients without APOs (2.9±0.9 vs. 2.4±0.5, P = 0.001). Lupus pregnancy was still at high risk of APOs in terms of pregnancy loss and preterm delivery. Umbilical artery Doppler was a good monitor method for APOs in the third trimester.
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Affiliation(s)
- Zhongping Zhan
- Department of Rheumatology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Ying Yang
- Department of Rheumatology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Yanfeng Zhan
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Dongying Chen
- Department of Rheumatology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
- * E-mail:
| | - Liuqin Liang
- Department of Rheumatology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Xiuyan Yang
- Department of Rheumatology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
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28
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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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29
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Wei S, Lai K, Yang Z, Zeng K. Systemic lupus erythematosus and risk of preterm birth: a systematic review and meta-analysis of observational studies. Lupus 2017; 26:563-571. [PMID: 28121241 DOI: 10.1177/0961203316686704] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We performed a meta-analysis to identify the association between systemic lupus erythematosus (SLE) and preterm birth. In this study, we studied the effects of SLE, SLE disease activity, a history of nephritis and active nephritis on preterm birth. Searches were conducted before 20 May 2016 of PubMed, Embase, Medline and Cochrane Library of literature and article reference lists. Eleven observational case-control studies and thirteen cohort studies met the inclusion criteria. The pooled relative risk (RR) for the risk of preterm birth in SLE patients versus controls was 2.05 (95% confidence interval (CI): 1.72-3.32); for active SLE patients versus inactive was 2.98 (95% CI: 2.32-3.83); for SLE patients with a history of lupus nephritis versus those without nephritis it was 1.62 (95% CI: 1.35-1.95); and for SLE patients with active nephritis versus those with quiescent nephritis it was 1.78 (95% CI: 1.17-2.70). In summary, this study identified a significant association in the above results. This association was more significant in active SLE patients versus inactive. With respect to SLE itself, active inflammation (such as disease activity) may be more hazardous for the management of the pregnancy. This suggests that it is essential to control disease activity in order to achieve a better outcome of SLE pregnancy.
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Affiliation(s)
- S Wei
- Department of Dermatology, Nanfang Hospital, Southern Medical University, Guangzhou, PR China
| | - K Lai
- Department of Dermatology, Nanfang Hospital, Southern Medical University, Guangzhou, PR China
| | - Z Yang
- Department of Dermatology, Nanfang Hospital, Southern Medical University, Guangzhou, PR China
| | - K Zeng
- Department of Dermatology, Nanfang Hospital, Southern Medical University, Guangzhou, PR China
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30
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Moroni G, Doria A, Giglio E, Tani C, Zen M, Strigini F, Zaina B, Tincani A, de Liso F, Matinato C, Grossi C, Gatto M, Castellana P, Limardo M, Meroni PL, Messa P, Ravani P, Mosca M. Fetal outcome and recommendations of pregnancies in lupus nephritis in the 21st century. A prospective multicenter study. J Autoimmun 2016; 74:6-12. [PMID: 27496151 DOI: 10.1016/j.jaut.2016.07.010] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Revised: 07/24/2016] [Accepted: 07/25/2016] [Indexed: 01/12/2023]
Abstract
The aim of this multicenter study was to assess the present risk of fetal complications and the inherent risk factors in pregnant women with lupus nephritis. Seventy-one pregnancies in 61women (59 Caucasians and 2 Asians) with lupus nephritis were prospectively followed between October 2006 and December 2013. All patients received a counselling visit within 3 months before the beginning of pregnancy and were followed by a multidisciplinary team. At baseline mild active nephritis was present in 15 cases (21.1%). Six pregnancies (8.4%) resulted in fetal loss. Arterial hypertension at baseline (P = 0.003), positivity for lupus anticoagulant (P = 0.001), anticardiolipin IgG antibodies (P = 0.007), antibeta2 IgG (P = 0.018) and the triple positivity for antiphospholipid antibodies (P = 0.004) predicted fetal loss. Twenty pregnancies (28.2%) ended pre-term and 12 newborns (16.4%) were small for gestational age. Among the characteristics at baseline, high SLE disease activity index (SLEDAI) score (P = 0.027), proteinuria (P = 0.045), history of renal flares (P = 0.004), arterial hypertension (P = 0.009) and active lupus nephritis (P = 0.000) increased the probability of preterm delivery. Odds for preterm delivery increased by 60% for each quarterly unit increase in SLEDAI and by 15% for each quarterly increase in proteinuria by 1 g per day. The probability of having a small for gestational age baby was reduced by 85% in women who received hydroxychloroquine therapy (P = 0.023). In this study, the rate of fetal loss was low and mainly associated with the presence of antiphospholipid antibodies. Preterm delivery remains a frequent complication of pregnancies in lupus. SLE and lupus nephritis activity are the main risk factors for premature birth. Arterial hypertension predicted both fetal loss and preterm delivery. Based on our results the key for a successful pregnancy in lupus nephritis is a multidisciplinary approach with close medical, obstetric and neonatal monitoring. This entails: a) a preconception evaluation to establish and inform women about pregnancy risks; b) planning pregnancy during inactive lupus nephritis, maintained inactive with the lowest possible dosage of allowed drugs; c) adequate treatment of known risk factors (arterial hypertension, antiphospholipid and antibodies); d) close monitoring during and after pregnancy to rapidly identify and treat SLE flares and obstetric complications.
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Affiliation(s)
- Gabriella Moroni
- Nephrological Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
| | - Andrea Doria
- Department of Medicine-DIMED, Division of Rheumatology, University of Padova, Italy
| | - Elisa Giglio
- Nephrological Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Chiara Tani
- Department of Clinical and Experimental Medicine, Rheumatology Unit, University of Pisa, Italy
| | - Margherita Zen
- Department of Medicine-DIMED, Division of Rheumatology, University of Padova, Italy
| | - Francesca Strigini
- Department of Reproductive Medicine and Child Development Division of Obstetrics and Gynecology, University of Pisa, Italy
| | - Barbara Zaina
- Department of Obstetrics and Gynecology Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Angela Tincani
- Rheumatology and Clinical Immunology Unit, Spedali Civili of Brescia, Italy
| | - Federica de Liso
- Laboratory of Clinical Chemistry and Microbiology, Fondazione IRCCS Ca' Granda Ospedale, Maggiore Policlinico, Milan, Italy
| | - Caterina Matinato
- Laboratory of Clinical Chemistry and Microbiology, Fondazione IRCCS Ca' Granda Ospedale, Maggiore Policlinico, Milan, Italy
| | - Claudia Grossi
- Experimental Laboratory of Immunological and Rheumatologic Researches, IRCCS Istituto, Auxologico Italiano, Milan, Italy
| | - Mariele Gatto
- Department of Medicine-DIMED, Division of Rheumatology, University of Padova, Italy
| | - Paola Castellana
- Dipartimento di Scienze della Salute, Azienda Ospedaliera San Paolo, Milan, Italy
| | - Monica Limardo
- Nephrology, Azienda Ospedaliera della Provincia di Lecco, Lecco, Italy
| | - Pier Luigi Meroni
- Experimental Laboratory of Immunological and Rheumatologic Researches, IRCCS Istituto, Auxologico Italiano, Milan, Italy; Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Piergiorgio Messa
- Nephrological Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Pietro Ravani
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Canada; Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Marta Mosca
- Department of Clinical and Experimental Medicine, Rheumatology Unit, University of Pisa, Italy
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31
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Andreoli L, Bertsias GK, Agmon-Levin N, Brown S, Cervera R, Costedoat-Chalumeau N, Doria A, Fischer-Betz R, Forger F, Moraes-Fontes MF, Khamashta M, King J, Lojacono A, Marchiori F, Meroni PL, Mosca M, Motta M, Ostensen M, Pamfil C, Raio L, Schneider M, Svenungsson E, Tektonidou M, Yavuz S, Boumpas D, Tincani A. EULAR recommendations for women's health and the management of family planning, assisted reproduction, pregnancy and menopause in patients with systemic lupus erythematosus and/or antiphospholipid syndrome. Ann Rheum Dis 2016; 76:476-485. [PMID: 27457513 PMCID: PMC5446003 DOI: 10.1136/annrheumdis-2016-209770] [Citation(s) in RCA: 461] [Impact Index Per Article: 57.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Revised: 06/13/2016] [Accepted: 06/25/2016] [Indexed: 12/26/2022]
Abstract
Objectives Develop recommendations for women's health issues and family planning in systemic lupus erythematosus (SLE) and/or antiphospholipid syndrome (APS). Methods Systematic review of evidence followed by modified Delphi method to compile questions, elicit expert opinions and reach consensus. Results Family planning should be discussed as early as possible after diagnosis. Most women can have successful pregnancies and measures can be taken to reduce the risks of adverse maternal or fetal outcomes. Risk stratification includes disease activity, autoantibody profile, previous vascular and pregnancy morbidity, hypertension and the use of drugs (emphasis on benefits from hydroxychloroquine and antiplatelets/anticoagulants). Hormonal contraception and menopause replacement therapy can be used in patients with stable/inactive disease and low risk of thrombosis. Fertility preservation with gonadotropin-releasing hormone analogues should be considered prior to the use of alkylating agents. Assisted reproduction techniques can be safely used in patients with stable/inactive disease; patients with positive antiphospholipid antibodies/APS should receive anticoagulation and/or low-dose aspirin. Assessment of disease activity, renal function and serological markers is important for diagnosing disease flares and monitoring for obstetrical adverse outcomes. Fetal monitoring includes Doppler ultrasonography and fetal biometry, particularly in the third trimester, to screen for placental insufficiency and small for gestational age fetuses. Screening for gynaecological malignancies is similar to the general population, with increased vigilance for cervical premalignant lesions if exposed to immunosuppressive drugs. Human papillomavirus immunisation can be used in women with stable/inactive disease. Conclusions Recommendations for women's health issues in SLE and/or APS were developed using an evidence-based approach followed by expert consensus.
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Affiliation(s)
- L Andreoli
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy.,Unit of Rheumatology and Clinical Immunology, Spedali Civili, Brescia, Italy
| | - G K Bertsias
- Department of Rheumatology, Clinical Immunology and Allergy, University of Crete Medical School, Heraklion, Greece
| | - N Agmon-Levin
- The Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel Hashomer, Israel.,The Faculty of Medicine, Tel Aviv University, Israel
| | - S Brown
- Royal National Hospital For Rheumatic Diseases, Bath, UK
| | - R Cervera
- Department of Autoimmune Diseases, Hospital Clínic, Barcelona, Catalonia, Spain
| | - N Costedoat-Chalumeau
- AP-HP, Hôpital Cochin, Centre de référence maladies auto-immunes et systémiques rares, Paris, France.,Université Paris Descartes-Sorbonne Paris Cité, Paris, France
| | - A Doria
- Rheumatology Unit, Department of Medicine, University of Padua, Italy
| | - R Fischer-Betz
- Policlinic of Rheumatology, Hiller Research Unit, University Clinic Duesseldorf, Heinrich-Heine-University Duesseldorf, Duesseldorf, Germany
| | - F Forger
- Department of Rheumatology, Immunology and Allergology, University Hospital of Bern, Bern, Switzerland
| | - M F Moraes-Fontes
- Unidade de Doenças Auto-imunes-Serviço Medicina Interna 7.2, Hospital Curry Cabral/Centro Hospitalar Lisboa Central, NEDAI/SPMI, Lisboa, Portugal
| | - M Khamashta
- Lupus Research Unit, The Rayne Institute, St. Thomas Hospital, London, UK.,Department of Rheumatology, Dubai Hospital, Dubai, United Arab Emirates
| | - J King
- EULAR PARE Patient Research Partner, London, UK
| | - A Lojacono
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy.,Unit of Obstetrics and Gynaecology, Spedali Civili, Brescia, Italy
| | - F Marchiori
- EULAR PARE Patient Research Partner, Rome, Italy
| | - P L Meroni
- Department of Clinical Sciences and Community Health, University of Milan, Istituto Auxologico Italiano, Milan, Italy
| | - M Mosca
- Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - M Motta
- Neonatology and Neonatal Intensive Care Unit, Spedali Civili, Brescia, Italy
| | - M Ostensen
- Norwegian National Advisory Unit on Pregnancy and Rheumatic Diseases, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - C Pamfil
- Department of Rheumatology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - L Raio
- Department of Obstetrics and Gynaecology, University Hospital of Bern, Inselspital, Switzerland
| | - M Schneider
- Policlinic of Rheumatology, Hiller Research Unit, University Clinic Duesseldorf, Heinrich-Heine-University Duesseldorf, Duesseldorf, Germany
| | - E Svenungsson
- Rheumatology Unit, Department of Medicine, Solna, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - M Tektonidou
- Rheumatology Unit, Joint Academic Rheumatology Programme, 1st Department of Propaedeutic Internal Medicine Athens, National and Kapodistrian University of Athens, Athens, Greece
| | - S Yavuz
- Department of Rheumatology, Istanbul Bilim University, Istanbul Florence Nightingale Hospital, Esentepe-Istanbul, Turkey
| | - D Boumpas
- 4th Department of Internal Medicine, 'Attikon' University Hospital, Medical School, University of Athens, Athens, Greece.,Joint Academic Rheumatology Program, National and Kapodestrian University of Athens, Athens, Greece
| | - A Tincani
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy.,Unit of Rheumatology and Clinical Immunology, Spedali Civili, Brescia, Italy
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Jara LJ, Medina G, Cruz-Dominguez P, Navarro C, Vera-Lastra O, Saavedra MA. Risk factors of systemic lupus erythematosus flares during pregnancy. Immunol Res 2015; 60:184-92. [PMID: 25391611 DOI: 10.1007/s12026-014-8577-1] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
This review examines the risk factors for the development of systemic lupus erythematosus (SLE) flares during pregnancy. In preconception, anti-DNA, hypocomplementemia, previous thrombosis, triple antiphospholipid (aPL) antibody positivity, active lupus nephritis and discontinuation of medications such as hydroxychloroquine and azathioprine are factors associated with pregnancy failure. During pregnancy, SLE flares are associated with aPL antibodies, synergic changes of pregnancy on Th1 and TH2 cytokines, other cytokines and chemokines that interact with hormones such as estrogen and prolactin that amplify the inflammatory effect. From the clinical point of view, SLE activity at pregnancy onset, thrombocytopenia, lupus nephritis, arterial hypertension, aPL syndromes, preeclampsia is associated with lupus flares and fetal complications. In puerperium, the risk factors of flares are similar to pregnancy. Hyperactivity of immune system, autoantibodies, hyperprolactinemia, active lupus nephritis, decrease in TH2 cytokines with increase in TH1 cytokines probably participate in SLE flare. The SLE flares during pregnancy make the difference between an uncomplicated pregnancy and pregnancy with maternal and fetal complications. Therefore, the knowledge of risk factors leads the best treatment strategies to reduce flares and fetal complications in SLE patients.
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Affiliation(s)
- Luis J Jara
- Direction of Education and Research, Hospital de Especialidades, Centro Médico La Raza, Instituto Mexicano del Seguro Social, Universidad Nacional Autónoma de México, Seris/Zaachila s/n, Colonia La Raza, 02990, Mexico City, Mexico,
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Buyon JP, Kim MY, Guerra MM, Laskin CA, Petri M, Lockshin MD, Sammaritano L, Branch DW, Porter TF, Sawitzke A, Merrill JT, Stephenson MD, Cohn E, Garabet L, Salmon JE. Predictors of Pregnancy Outcomes in Patients With Lupus: A Cohort Study. Ann Intern Med 2015; 163:153-63. [PMID: 26098843 PMCID: PMC5113288 DOI: 10.7326/m14-2235] [Citation(s) in RCA: 345] [Impact Index Per Article: 38.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Because systemic lupus erythematosus (SLE) affects women of reproductive age, pregnancy is a major concern. OBJECTIVE To identify predictors of adverse pregnancy outcomes (APOs) in patients with inactive or stable active SLE. DESIGN Prospective cohort. SETTING Multicenter. PATIENTS 385 patients (49% non-Hispanic white; 31% with prior nephritis) with SLE in the PROMISSE (Predictors of Pregnancy Outcome: Biomarkers in Antiphospholipid Antibody Syndrome and Systemic Lupus Erythematosus) study. Exclusion criteria were urinary protein-creatinine ratio greater than 1000 mg/g, creatinine level greater than 1.2 mg/dL, prednisone use greater than 20 mg/d, and multifetal pregnancy. MEASUREMENTS APOs included fetal or neonatal death; birth before 36 weeks due to placental insufficiency, hypertension, or preeclampsia; and small-for-gestational-age (SGA) neonate (birthweight below the fifth percentile). Disease activity was assessed with the Systemic Lupus Erythematosus Pregnancy Disease Activity Index and the Physician's Global Assessment (PGA). RESULTS APOs occurred in 19.0% (95% CI, 15.2% to 23.2%) of pregnancies; fetal death occurred in 4%, neonatal death occurred in 1%, preterm delivery occurred in 9%, and SGA neonate occurred in 10%. Severe flares in the second and third trimesters occurred in 2.5% and 3.0%, respectively. Baseline predictors of APOs included presence of lupus anticoagulant (LAC) (odds ratio [OR], 8.32 [CI, 3.59 to 19.26]), antihypertensive use (OR, 7.05 [CI, 3.05 to 16.31]), PGA score greater than 1 (OR, 4.02 [CI, 1.84 to 8.82]), and low platelet count (OR, 1.33 [CI, 1.09 to 1.63] per decrease of 50 × 109 cells/L). Non-Hispanic white race was protective (OR, 0.45 [CI, 0.24 to 0.84]). Maternal flares, higher disease activity, and smaller increases in C3 level later in pregnancy also predicted APOs. Among women without baseline risk factors, the APO rate was 7.8%. For those who either were LAC-positive or were LAC-negative but nonwhite or Hispanic and using antihypertensives, the APO rate was 58.0% and fetal or neonatal mortality was 22.0%. LIMITATION Patients with high disease activity were excluded. CONCLUSION In pregnant patients with inactive or stable mild/moderate SLE, severe flares are infrequent and, absent specific risk factors, outcomes are favorable. PRIMARY FUNDING SOURCE National Institutes of Health.
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Affiliation(s)
- Jill P. Buyon
- From New York University School of Medicine, Hospital for Special Surgery, Albert Einstein College of Medicine, and Weill Cornell Medical College, New York, New York; University of Utah Health Sciences Center and Intermountain Healthcare, Salt Lake City, Utah; Oestfold Hospital Trust, Fredrikstad, Norway; University of Toronto, Toronto, Ontario, Canada; Oklahoma Medical Research Foundation and the University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
- Johns Hopkins University School of Medicine, Baltimore, Maryland; and University of Illinois at Chicago, Chicago, Illinois
| | - Mimi Y. Kim
- From New York University School of Medicine, Hospital for Special Surgery, Albert Einstein College of Medicine, and Weill Cornell Medical College, New York, New York; University of Utah Health Sciences Center and Intermountain Healthcare, Salt Lake City, Utah; Oestfold Hospital Trust, Fredrikstad, Norway; University of Toronto, Toronto, Ontario, Canada; Oklahoma Medical Research Foundation and the University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
- Johns Hopkins University School of Medicine, Baltimore, Maryland; and University of Illinois at Chicago, Chicago, Illinois
| | - Marta M. Guerra
- From New York University School of Medicine, Hospital for Special Surgery, Albert Einstein College of Medicine, and Weill Cornell Medical College, New York, New York; University of Utah Health Sciences Center and Intermountain Healthcare, Salt Lake City, Utah; Oestfold Hospital Trust, Fredrikstad, Norway; University of Toronto, Toronto, Ontario, Canada; Oklahoma Medical Research Foundation and the University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
- Johns Hopkins University School of Medicine, Baltimore, Maryland; and University of Illinois at Chicago, Chicago, Illinois
| | - Carl A. Laskin
- From New York University School of Medicine, Hospital for Special Surgery, Albert Einstein College of Medicine, and Weill Cornell Medical College, New York, New York; University of Utah Health Sciences Center and Intermountain Healthcare, Salt Lake City, Utah; Oestfold Hospital Trust, Fredrikstad, Norway; University of Toronto, Toronto, Ontario, Canada; Oklahoma Medical Research Foundation and the University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
- Johns Hopkins University School of Medicine, Baltimore, Maryland; and University of Illinois at Chicago, Chicago, Illinois
| | - Michelle Petri
- From New York University School of Medicine, Hospital for Special Surgery, Albert Einstein College of Medicine, and Weill Cornell Medical College, New York, New York; University of Utah Health Sciences Center and Intermountain Healthcare, Salt Lake City, Utah; Oestfold Hospital Trust, Fredrikstad, Norway; University of Toronto, Toronto, Ontario, Canada; Oklahoma Medical Research Foundation and the University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
- Johns Hopkins University School of Medicine, Baltimore, Maryland; and University of Illinois at Chicago, Chicago, Illinois
| | - Michael D. Lockshin
- From New York University School of Medicine, Hospital for Special Surgery, Albert Einstein College of Medicine, and Weill Cornell Medical College, New York, New York; University of Utah Health Sciences Center and Intermountain Healthcare, Salt Lake City, Utah; Oestfold Hospital Trust, Fredrikstad, Norway; University of Toronto, Toronto, Ontario, Canada; Oklahoma Medical Research Foundation and the University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
- Johns Hopkins University School of Medicine, Baltimore, Maryland; and University of Illinois at Chicago, Chicago, Illinois
| | - Lisa Sammaritano
- From New York University School of Medicine, Hospital for Special Surgery, Albert Einstein College of Medicine, and Weill Cornell Medical College, New York, New York; University of Utah Health Sciences Center and Intermountain Healthcare, Salt Lake City, Utah; Oestfold Hospital Trust, Fredrikstad, Norway; University of Toronto, Toronto, Ontario, Canada; Oklahoma Medical Research Foundation and the University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
- Johns Hopkins University School of Medicine, Baltimore, Maryland; and University of Illinois at Chicago, Chicago, Illinois
| | - D. Ware Branch
- From New York University School of Medicine, Hospital for Special Surgery, Albert Einstein College of Medicine, and Weill Cornell Medical College, New York, New York; University of Utah Health Sciences Center and Intermountain Healthcare, Salt Lake City, Utah; Oestfold Hospital Trust, Fredrikstad, Norway; University of Toronto, Toronto, Ontario, Canada; Oklahoma Medical Research Foundation and the University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
- Johns Hopkins University School of Medicine, Baltimore, Maryland; and University of Illinois at Chicago, Chicago, Illinois
| | - T. Flint Porter
- From New York University School of Medicine, Hospital for Special Surgery, Albert Einstein College of Medicine, and Weill Cornell Medical College, New York, New York; University of Utah Health Sciences Center and Intermountain Healthcare, Salt Lake City, Utah; Oestfold Hospital Trust, Fredrikstad, Norway; University of Toronto, Toronto, Ontario, Canada; Oklahoma Medical Research Foundation and the University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
- Johns Hopkins University School of Medicine, Baltimore, Maryland; and University of Illinois at Chicago, Chicago, Illinois
| | - Allen Sawitzke
- From New York University School of Medicine, Hospital for Special Surgery, Albert Einstein College of Medicine, and Weill Cornell Medical College, New York, New York; University of Utah Health Sciences Center and Intermountain Healthcare, Salt Lake City, Utah; Oestfold Hospital Trust, Fredrikstad, Norway; University of Toronto, Toronto, Ontario, Canada; Oklahoma Medical Research Foundation and the University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
- Johns Hopkins University School of Medicine, Baltimore, Maryland; and University of Illinois at Chicago, Chicago, Illinois
| | - Joan T. Merrill
- From New York University School of Medicine, Hospital for Special Surgery, Albert Einstein College of Medicine, and Weill Cornell Medical College, New York, New York; University of Utah Health Sciences Center and Intermountain Healthcare, Salt Lake City, Utah; Oestfold Hospital Trust, Fredrikstad, Norway; University of Toronto, Toronto, Ontario, Canada; Oklahoma Medical Research Foundation and the University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
- Johns Hopkins University School of Medicine, Baltimore, Maryland; and University of Illinois at Chicago, Chicago, Illinois
| | - Mary D. Stephenson
- From New York University School of Medicine, Hospital for Special Surgery, Albert Einstein College of Medicine, and Weill Cornell Medical College, New York, New York; University of Utah Health Sciences Center and Intermountain Healthcare, Salt Lake City, Utah; Oestfold Hospital Trust, Fredrikstad, Norway; University of Toronto, Toronto, Ontario, Canada; Oklahoma Medical Research Foundation and the University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
- Johns Hopkins University School of Medicine, Baltimore, Maryland; and University of Illinois at Chicago, Chicago, Illinois
| | - Elisabeth Cohn
- From New York University School of Medicine, Hospital for Special Surgery, Albert Einstein College of Medicine, and Weill Cornell Medical College, New York, New York; University of Utah Health Sciences Center and Intermountain Healthcare, Salt Lake City, Utah; Oestfold Hospital Trust, Fredrikstad, Norway; University of Toronto, Toronto, Ontario, Canada; Oklahoma Medical Research Foundation and the University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
- Johns Hopkins University School of Medicine, Baltimore, Maryland; and University of Illinois at Chicago, Chicago, Illinois
| | - Lamya Garabet
- From New York University School of Medicine, Hospital for Special Surgery, Albert Einstein College of Medicine, and Weill Cornell Medical College, New York, New York; University of Utah Health Sciences Center and Intermountain Healthcare, Salt Lake City, Utah; Oestfold Hospital Trust, Fredrikstad, Norway; University of Toronto, Toronto, Ontario, Canada; Oklahoma Medical Research Foundation and the University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
- Johns Hopkins University School of Medicine, Baltimore, Maryland; and University of Illinois at Chicago, Chicago, Illinois
| | - Jane E. Salmon
- From New York University School of Medicine, Hospital for Special Surgery, Albert Einstein College of Medicine, and Weill Cornell Medical College, New York, New York; University of Utah Health Sciences Center and Intermountain Healthcare, Salt Lake City, Utah; Oestfold Hospital Trust, Fredrikstad, Norway; University of Toronto, Toronto, Ontario, Canada; Oklahoma Medical Research Foundation and the University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
- Johns Hopkins University School of Medicine, Baltimore, Maryland; and University of Illinois at Chicago, Chicago, Illinois
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34
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Autoimmune connective tissue diseases. Best Pract Res Clin Obstet Gynaecol 2015; 29:658-70. [DOI: 10.1016/j.bpobgyn.2015.03.003] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Revised: 03/02/2015] [Accepted: 03/06/2015] [Indexed: 11/17/2022]
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Guettrot-Imbert G, Le Guern V, Morel N, Vauthier D, Tsatsaris V, Pannier E, Piette JC, Costedoat-Chalumeau N. Lupus systémique et syndrome des antiphospholipides : comment prendre en charge la grossesse ? Rev Med Interne 2015; 36:173-81. [DOI: 10.1016/j.revmed.2014.12.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Accepted: 12/15/2014] [Indexed: 10/24/2022]
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36
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Østensen M, Andreoli L, Brucato A, Cetin I, Chambers C, Clowse MEB, Costedoat-Chalumeau N, Cutolo M, Dolhain R, Fenstad MH, Förger F, Wahren-Herlenius M, Ruiz-Irastorza G, Koksvik H, Nelson-Piercy C, Shoenfeld Y, Tincani A, Villiger PM, Wallenius M, von Wolff M. State of the art: Reproduction and pregnancy in rheumatic diseases. Autoimmun Rev 2014; 14:376-86. [PMID: 25555818 DOI: 10.1016/j.autrev.2014.12.011] [Citation(s) in RCA: 134] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Accepted: 12/23/2014] [Indexed: 12/13/2022]
Abstract
Throughout the last decade, increasing awareness has been raised on issues related to reproduction in rheumatic diseases including basic research to clarify the important role of estrogens in the etiology and pathophysiology of immune/inflammatory diseases. Sub- or infertility is a heterogeneous condition that can be related to immunological mechanisms, to pregnancy loss, to disease burden, to therapy, and to choices in regard to family size. Progress in reproductive medicine has made it possible for more patients with rheumatic disease to have children. Active disease in women with rheumatoid arthritis (RA) affects their children's birth weight and may have long-term effects on their future health status. Pregnancy complications as preeclampsia and intrauterine growth restriction are still increased in patients with systemic lupus erythematosus (SLE) and antiphospholipid syndrome (APS), however, biomarkers can monitor adverse events, and several new therapies may improve outcomes. Pregnancies in women with APS remain a challenge, and better therapies for the obstetric APS are needed. New prospective studies indicate improved outcomes for pregnancies in women with rare diseases like systemic sclerosis and vasculitis. TNF inhibitors hold promise for maintaining remission in rheumatological patients and may be continued at least in the first half of pregnancy. Pre-conceptional counseling and interdisciplinary management of pregnancies are essential for ensuring optimal pregnancy outcomes.
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Affiliation(s)
- Monika Østensen
- National Advisory Unit on Pregnancy and Rheumatic Diseases, Department of Rheumatology, St. Olavs Hospital, University Hospital of Trondheim, Norway.
| | - Laura Andreoli
- Rheumatology and Clinical Immunology, Spedali Civili of Brescia, Department of Clinical and Experimental Sciences, University of Brescia, Italy
| | - Antonio Brucato
- Department of Internal Medicine, Ospedale papa Giovanni XXIII Bergamo, Italy
| | - Irene Cetin
- Department of Mother and Child, Hospital Luigi Sacco, University of Milano, Italy
| | - Christina Chambers
- Department of Pediatrics, University of California San Diego, La Jolla, CA 92093-0828, USA
| | - Megan E B Clowse
- Division of Rheumatology, Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Nathalie Costedoat-Chalumeau
- Université Paris-Descartes, Paris, France; AP-HP, Hôpital Cochin, Centre de référence maladies auto-immunes et systémiques rares, Service de médecine interne, Paris, France
| | - Maurizio Cutolo
- Research Laboratories and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, Genova, Italy
| | - Radboud Dolhain
- Department of Rheumatology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - M H Fenstad
- Department of Immunology and Transfusion Medicine, St. Olavs Hospital, Trondheim, Norway
| | - Frauke Förger
- Department of Rheumatology and Clinical Immunology/Allergology, University Hospital of Bern, CH-3010 Bern, Switzerland
| | - Marie Wahren-Herlenius
- Department of Medicine, Centre for Molecular Medicine, Karolinska Universitetssjukhuset, Stockholm, Sweden
| | - Guillermo Ruiz-Irastorza
- Autoimmune Diseases Research Unit, Department of Internal Medicine, Biocruces Health Research Institute, Hospital Universitario Cruces, University of the Basque Country, Bizkaia, Spain
| | - Hege Koksvik
- National Advisory Unit on Pregnancy and Rheumatic Diseases, Department of Rheumatology, St. Olavs Hospital, University Hospital of Trondheim, Norway
| | | | - Yehuda Shoenfeld
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Aviv University, Tel-Hashomer, Israel
| | - Angela Tincani
- Department of Rheumatology and Clinical Immunology, Ospedale Civile and University of Brescia, Brescia, Italy
| | - Peter M Villiger
- Department of Rheumatology and Clinical Immunology/Allergology, University Hospital of Bern, Bern, Switzerland
| | - Marianne Wallenius
- National Service for Pregnancy and Rheumatic Diseases, Department of Rheumatology, Trondheim University Hospital, Trondheim, Norway; Dept of Neuroscience, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Michael von Wolff
- University Women's Hospital, Division of Gynaecological Endocrinology and Reproductive Medicine, University of Berne, Berne, Switzerland
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Singh AG, Chowdhary VR. Pregnancy-related issues in women with systemic lupus erythematosus. Int J Rheum Dis 2014; 18:172-81. [DOI: 10.1111/1756-185x.12524] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Abha G. Singh
- Division of Rheumatology; Department of Internal Medicine; Mayo Clinic; Rochester Minnesota USA
| | - Vaidehi R. Chowdhary
- Division of Rheumatology; Department of Internal Medicine; Mayo Clinic; Rochester Minnesota USA
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Considerations in using registry and health plan data for studying pregnancy in rheumatic diseases. Curr Opin Rheumatol 2014; 26:315-20. [PMID: 24667289 DOI: 10.1097/bor.0000000000000056] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review is to critically evaluate the strengths and limitations of different data sources for pregnancy-related research in patients with rheumatic diseases. We describe challenges in studying adverse pregnancy outcomes in the setting of observational research, with a particular focus on the studies of maternal drug exposures. RECENT FINDINGS We discuss potential threats to validity in the assessment of exposure and outcomes and controlling for confounding; present findings from selected pregnancy-related observational studies conducted using data from registries and health plans; and highlight future research opportunities for pregnancy research. SUMMARY Registry and health plan data contribute complementary information to each other. Used together, linked data sources may allow clinicians, researchers, and patients to obtain a more complete understanding of the risk and benefits associated with maternal drug exposure and of the risk factors associated with adverse birth outcomes in women with rheumatic disease.
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39
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40
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Koh JH, Ko HS, Kwok SK, Ju JH, Park SH. Hydroxychloroquine and pregnancy on lupus flares in Korean patients with systemic lupus erythematosus. Lupus 2014; 24:210-7. [DOI: 10.1177/0961203314555352] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We investigated the clinical and laboratory characteristics of pregnancies with systemic lupus erythematosus (SLE) and identified lupus flare predictors during pregnancy. Additionally, we examined lupus activity and pregnancy outcomes in SLE patients who continued, discontinued or underwent no hydroxychloroquine (HCQ) treatment during pregnancy. We retrospectively analyzed 179 pregnancies in 128 SLE patients at Seoul St. Mary’s Hospital, Korea, between 1998 and 2012 and then assessed the clinical profiles and maternal and fetal outcomes. Overall, 90.5% of pregnancies resulted in a successful delivery and were divided into two groups: those who experienced lupus flares (80 pregnancies, 44.7%) and those who did not (99 pregnancies, 55.3%). Increased preeclampsia, preterm births, low birth weight, intrauterine growth restriction (IUGR), and low 1-minute Apgar scores occurred in pregnancies with lupus flares compared to pregnancies in quiescent disease. Lupus flares were predicted by HCQ discontinuation, a history of lupus nephritis, high pre-pregnancy serum uric acid and low C4 levels. Our study indicates that achieving pre-pregnancy remission and continuing HCQ treatment during pregnancy are important for preventing lupus flares.
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Affiliation(s)
- J H Koh
- Division of Rheumatology, Department of Internal Medicine, School of Medicine
| | - H S Ko
- Department of Obstetrics and Gynecology, Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul, South Korea
| | - S-K Kwok
- Division of Rheumatology, Department of Internal Medicine, School of Medicine
| | - J H Ju
- Division of Rheumatology, Department of Internal Medicine, School of Medicine
| | - S-H Park
- Division of Rheumatology, Department of Internal Medicine, School of Medicine
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Saavedra MA, Sánchez A, Morales S, Navarro-Zarza JE, Ángeles U, Jara LJ. Primigravida is associated with flare in women with systemic lupus erythematosus. Lupus 2014; 24:180-5. [PMID: 25253570 DOI: 10.1177/0961203314552116] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The objective of this study was to identify risk factors associated with flare during pregnancy in women with systemic lupus erythematosus (SLE). We performed a retrospective analysis of pregnant women with SLE in a referral hospital. Flare was considered according to predetermined definitions. We analyzed 15 clinical, biochemical and immunological variables with a potential predictive value for relapse during pregnancy. We included 124 lupus pregnancies in 120 women. The relapse rate during pregnancy was 37.9% (47 episodes). The most common manifestations of flare were renal, joint, cutaneous and hematological. Patients with flare during pregnancy developed a higher frequency of preeclampsia and preterm delivery. In multivariate analysis, primigravida was a risk factor associated with any type of flare during pregnancy (OR 2.3, 95% CI 0.99-5.52, p = 0.05); on the other hand, primigravida (OR 3.6, 95% CI 1.19-11.3, p = 0.02), activity prior to pregnancy (OR 3.7, 95% CI 0.97-14.1, p = 0.05), and previous renal disease (OR 5.8, 95% CI 1.95-17.6, p = 0.001) were the principal risk factors associated with renal flare. The first pregnancy in women with SLE is associated with any type of flare. Disease activity is associated with preeclampsia and preterm delivery. Close monitoring is mandatory to identify relapses and timely treatment.
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Affiliation(s)
- M A Saavedra
- Rheumatology Department, Hospital de Especialidades Dr. Antonio Fraga Mouret, Centro Médico Nacional La Raza, Instituto Mexicano del Seguro Social, Mexico City, México Universidad Nacional Autónoma de México, México City, Mexico
| | - A Sánchez
- Rheumatology Department, Hospital de Especialidades Dr. Antonio Fraga Mouret, Centro Médico Nacional La Raza, Instituto Mexicano del Seguro Social, Mexico City, México
| | - S Morales
- Perinatology Department, Hospital de Gineco-Obstetricia No. 3, Centro Médico Nacional La Raza, Instituto Mexicano del Seguro Social, Mexico City, México
| | - J E Navarro-Zarza
- Hospital General de Chilpancingo Raymundo Abarca Alarcón, Chilpancingo, Guerrero, México
| | - U Ángeles
- Epidemiology Division, Hospital de Especialidades Dr. Antonio Fraga Mouret, Centro Médico Nacional La Raza, Instituto Mexicano del Seguro Social, Mexico City, México
| | - L J Jara
- Direction of Education and Research, Hospital de Especialidades Dr. Antonio Fraga Mouret, Centro Médico Nacional La Raza, Instituto Mexicano del Seguro Social, Mexico City, México Universidad Nacional Autónoma de México, México City, Mexico
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Clinical research in rheumatology 2012-2013: methodologic considerations in study design. Curr Opin Rheumatol 2014; 26:109-10. [PMID: 24445480 DOI: 10.1097/bor.0000000000000039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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