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

Exposure to hydroxychloroquine in early pregnancy and incidence of pre-eclampsia and pre-term delivery in patients with systemic lupus erythematosus in Sweden: a nationwide population-based cohort study

BACKGROUND

Pregnant women with systemic lupus erythematosus (SLE) have elevated risks of pre-eclampsia and pre-term delivery. Hydroxychloroquine, the mainstay treatment during pregnancy in women with SLE, is currently a promising agent for pre-eclampsia prevention. We aimed to examine associations between hydroxychloroquine use and pre-eclampsia and pre-term delivery in pregnant women with SLE.

METHODS

In this nationwide population-based cohort study, we included all singleton pregnancies of women with prevalent SLE that lead to a delivery (livebirths and stillbirths) between Jan 1, 2007, and Dec 31, 2022, diagnosed in secondary or tertiary care centres in Sweden. Hydroxychloroquine exposure was defined as two or more dispensations from 3 months pre-pregnancy until the end of the first trimester. The primary outcomes were pre-eclampsia (diagnosed from 20+0 weeks of gestation to 6 weeks postpartum) and pre-term delivery (delivery before 37+0 weeks of gestation). Inverse probability of treatment weighting adjusted for measured confounders (eg, maternal smoking, BMI, reproductive characteristics, pre-gestational hypertension, glucocorticoid use) and modified Poisson models estimated risk ratios and 95% confidence intervals. We involved a person with lived experience of pregnancy with SLE in all aspects of the study.

FINDINGS

Between Jan 1, 2007, and Dec 31, 2022, we included 959 singleton pregnancies from 685 women with prevalent SLE in Sweden. 404 (42%) of 959 pregnancies were nulliparous pregnancies (232 [57%] were unexposed and 172 [43%] were hydroxychloroquine-exposed) and 555 (58%) were parous pregnancies (333 [60%] were unexposed and 222 [40%] were hydroxychloroquine-exposed). The mean maternal age was 32 years (SD 4·7). Pre-eclampsia was recorded in 19 (11%) of 172 hydroxychloroquine-exposed pregnancies and 30 (13%) of 232 unexposed pregnancies in the nulliparous group and 12 (5%) of 222 hydroxychloroquine-exposed pregnancies and 20 (6%) of 333 unexposed pregnancies in the parous group. Pre-term delivery was recorded in 33 (19%) of 172 hydroxychloroquine-exposed pregnancies and 34 (15%) of 232 in unexposed pregnancies in the nulliparous group and 26 (12%) of 222 hydroxychloroquine-exposed pregnancies and 41 (12%) of 333 unexposed pregnancies in the parous group. The adjusted risk ratio for pre-eclampsia in SLE pregnancies with hydroxychloroquine exposure versus those without exposure was 0·49 (95% CI 0·31-0·79) overall, 0·59 (0·33-1·08) in the nulliparous group, and 0·44 (0·22-0·89) in the parous group. Associations between hydroxychloroquine and pre-term delivery were unclear in the overall (risk ratio 0·95 [95% CI 0·67-1·34]), nulliparous (1·10 [0·68-1·80]), and parous (0·75 [0·47-1·24]) groups. Stratification by antiphospholipid syndrome, renal diseases, and hypertension showed similar results.

INTERPRETATION

In this large cohort of pregnant women with SLE, hydroxychloroquine exposure in early pregnancy was associated with a lower pre-eclampsia risk. However, the association with pre-term delivery was unclear.

FUNDING

US National Institutes of Health and the Ingegerd Johansson Donation.

Severe thrombocytopenia is associated with adverse pregnancy outcomes in patients with obstetric antiphospholipid syndrome

BACKGROUND

Thrombocytopenia is a common manifestation of antiphospholipid syndrome (APS). This study assesses the possible relationship between severe thrombocytopenia and adverse pregnancy outcomes (APOs) in obstetric APS (OAPS) patients.

METHODS

An observational, cohort study was conducted at Peking University People's Hospital, Beijing, China. The demographic, clinical, immunologic, and pregnancy outcomes of the OAPS patients were collected. Univariate and multivariate logistic regression analyses were applied to assess the association between APOs and severe thrombocytopenia (< 30 × 109/L). The threshold effect was explored using two piecewise linear regression models by the smoothing plot.

RESULTS

A total of 176 OAPS participants were included in the analysis, with 49 thrombocytopenia (< 100 × 109/L) and 9 severe thrombocytopenia (< 30 × 109/L). In the context of univariate logistic regression, severe thrombocytopenia demonstrated a significant association with increased APOs, encompassing preterm delivery before 34 weeks (OR, 8.74; 95%CI, 2.10-36.32, P = 0.0028), uteroplacental insufficiency (OR, 16.28; 95%CI, 1.99-133.53, P = 0.0093), preterm labor before 37 weeks (OR, 15.98; 95%CI, 3.16-80.80, P = 0.0008), and SGA (OR, 7.45; 95%CI, 1.87-29.73, P = 0.0045). A nonlinear relationship between the number of platelets and APOs was observed. The risk of APOs rose as platelet count decreased to a turning point (50 × 109/L) (P < 0.05). Beyond a platelet count of 50 × 109/L, no significant association was observed between platelet count and APO risk in OAPS patients.

CONCLUSION

The risk of adverse pregnancy outcomes in patients with OAPS is contingent upon the severity of thrombocytopenia. Maintaining platelet counts above 50 × 109/L is pivotal in mitigating this risk. The effective OAPS treatments may improve pregnancy outcomes.

Hydroxychloroquine improves pregnancy outcomes by inhibiting excessive autophagy in extravillous trophoblast caused by an anti-phospholipid syndrome

OBJECTIVES

This study aims to investigate the mechanism of hydroxychloroquine (HCQ) immunoregulation therapy in improving adverse pregnancy outcomes of recurrent miscarriages (RM) caused by antiphospholipid syndrome (APS).

METHODS

(i) Immunofluorescence staining was used to analyse the potential targets of antiphospholipid antibodies at the maternal-fetal interface in normal early pregnancy; (ii) Immunohistochemical and immunofluorescence techniques were used to compare and analyse the placenta vascular remodeling, villus tissue synthetic secretion function, trophoblastic autophagy and apoptosis levels in first trimester decidual tissue between normal and APS caused recurrent miscarriages (APS-RM) cases; (iii) HTR8/SVneo and BeWo cell lines were treated with serum from normal and APS-RM cases, and quantified by RT-PCR and Western blot to analysis the expression levels of cell invasion, secretion, autophagy and apoptosis-related molecules; (iv) After adding 0.1 μg/ml HCQ to the serum-treated cell line, the expression of autophagy and invasion-related proteins were detected, and invasion and tube formation of HTR8/SVneo cells was assessed by transwell experiments and tube formation assay.

RESULTS

(i)β2-glycoprotein Ⅰ antigen is expressed in all types of trophoblasts at the maternal-fetal interface in first trimester; (ii) The extravillous trophoblast cells (EVTs) have excessive autophagy in the decidual tissue of the APS-RM cases, and the uterine spiral artery was remodelled insufficiently; (iii) APS-RM cases serum can lead to cell excessive autophagy, and decrease cell invasion and tube formation in vitro; (iv) 0.1 μg/ml HCQ could rescue abnormal cell status caused by APS cases serum in HTR8/SVneo cells in vitro; (v) APS cases serum mainly affects the invasion and tube formation of EVTs, but has little effect on the function of villous trophoblast cells.

CONCLUSIONS

Antiphospholipid antibodies can lead to excessive autophagy in EVTs, thereby affecting ability of invasion and remodeling of spiral arteries, which is one of the mechanisms leading to adverse pregnancy outcomes. HCQ can rescue adverse pregnancy outcomes in APS patients by inhibiting excessive autophagy.

Investigating the association between antiphospholipid syndrome and ovarian reserve: A systematic review and meta-analysis of the literature

BackgroundAutoimmune diseases can reduce ovarian reserves. Women in reproductive ages are susceptible to an autoimmune disorder known as antiphospholipid syndrome (APS). The aim of this study is to investigate the association between APS and ovarian reserve (OR).MethodPubMed, Scopus, Web-of-Science, Science Direct, and the Google scholar search engine were searched (22 June 2024) for studies that investigated the effect of APS on OR. Literature screening, data extraction, and assessment of the risk of bias of the included studies were conducted by two reviewers independently. Mean differences were computed using a random effects model. Heterogeneity was assessed by I2%.ResultsFour cross-sectional studies were included in this meta-analysis. None of the studies had a high risk of bias. There was no significant association identified between primary (MD = -0.27, 95% CI, -1.42 to 0.87, p = 0.639) and secondary APS (SMD = -0.38, 95% CI, -2.46 to 1.69, p = 0.717) with antimullerian hormone amounts. The antral follicle count (AFC) was investigated in two studies revealed lower levels of AFC in women with primary APS. Regarding the levels of gonadotropins and estradiol in the participants' serum, the results are contradictory.ConclusionsThe results of this meta-analysis identified there is no relationship between primary and secondary APS with the reduction of ovarian reserves in women with APS. This issue should be considered in the reproductive health of women with APS, who can have children at the right time by consulting a rheumatologist and reproductive health specialist.

EULAR recommendations for use of antirheumatic drugs in reproduction, pregnancy, and lactation: 2024 update

OBJECTIVES

To update the existing European Alliance of Associations for Rheumatology (EULAR) points to consider (PtC) for use of antirheumatic drugs in reproduction, pregnancy, and lactation, including additional drugs and adverse outcomes as well as paternal drug safety.

METHODS

According to the EULAR standardised operating procedures, an international task force (TF) defined the questions for a systematic literature review, followed by formulation of the updated statements. A predefined voting process was applied to each overarching principle and statement. Level of evidence and strength of recommendation were assigned, and participants finally provided their level of agreement for each item.

RESULTS

The TF proposes 5 overarching principles and 12 recommendations for the use of antirheumatic drugs before and during pregnancy, through lactation, and in male patients. The current evidence indicates that synthetic disease-modifying antirheumatic drugs (DMARDs) compatible with pregnancy include antimalarials, azathioprine, colchicine, cyclosporine, sulfasalazine, and tacrolimus. Regarding nonsteroidal anti-inflammatory drugs (NSAIDs) and glucocorticoids, a more restrictive approach to their use during pregnancy is recommended. Based on an individualised risk-benefit assessment, all tumour necrosis factor inhibitor (TNFi) biologic DMARDs (bDMARDs) can be used throughout pregnancy, and non-TNFi bDMARDs may be used if needed. In relation to lactation, compatible drugs include antimalarials, azathioprine, colchicine, cyclosporine, glucocorticoids, intravenous immunoglobulin (IVIG), NSAIDs, sulfasalazine, and tacrolimus. All bDMARDs are considered compatible with breastfeeding. Concerning the use of drugs in men, compatible options include antimalarials, azathioprine, colchicine, cyclosporine, IVIG, leflunomide, methotrexate, mycophenolate, NSAIDs, glucocorticoids, sildenafil, sulfasalazine, tacrolimus, and bDMARDs.

CONCLUSIONS

The updated recommendations provide consensus guidance and will help to improve the quality of care of patients during the phases of reproduction, pregnancy, and lactation.

Hydroxychloroquine for preventing hypertensive pregnancy disorders in recurrent spontaneous abortion: a retrospective cohort study in a single referral center

OBJECTIVE

We aimed to assess the effectiveness of hydroxychloroquine (HCQ) in preventing hypertensive pregnancy disorders (HPD) among women with recurrent spontaneous abortion (RSA).

STUDY DESIGN

This retrospective cohort study included 462 pregnant women with RSA. Inverse probability of treatment weighting (IPTW) and propensity score matching (PSM) were used to balance baseline characteristics between HCQ and non-HCQ groups. The primary outcome comprised a composite of HPD, including preeclampsia, eclampsia, and gestational hypertension. Secondary outcomes included maternal complications and neonatal outcomes.

RESULTS

HCQ was associated with a 62% decreased risk of HPD compared to no HCQ (weighted hazard ratio 0.38, 95% CI 0.16-0.94, P < 0.001). The cumulative incidence of HPD at 34 weeks was lower among HCQ users (5% vs 14%, P = 0.03). HCQ demonstrated greater efficacy in preventing HPD among women aged < 35 years, a body mass index (BMI) of ≥ 28, non-in vitro fertilization (IVF) pregnancies, and fewer than three prior miscarriages (P-interaction < 0.05). Notably, the risk of HPD was significantly lowered by 56 and 53% in combined HCQ and aspirin with/without low-molecular-weight heparin (LMWH) group compared with no HCQ counterpart, respectively.

CONCLUSIONS

HCQ demonstrated promising efficacy in reducing HPD, particularly when used in conjunction with aspirin and/or LMWH therapy.

Indications for fetal echocardiography: consensus and controversies among evidence-based national and international guidelines

OBJECTIVE

Fetal echocardiography (FE) is an indication-driven examination for pregnant women with a fetus at high risk for congenital heart disease (CHD). Several familial, maternal and fetal factors are reported to increase the risk of CHD. The aim of this study was to highlight the existing differences in recommended indications for FE among recently published guidelines and consensuses of experts.

METHODS

Guidelines and expert consensuses published from January 2008 to October 2023 were identified through a systematic literature search. FE guidelines and consensus statements were excluded if not written in the English language and if indications for FE were not reported. All familial, maternal and fetal risk factors for CHD reported in the consensuses and guidelines were listed and comparisons were made between documents. The agreement or disagreement for each risk factor between guidelines and consensuses was classified as: complete agreement (all analyzed documents reported the same indication); partial agreement (all documents considered a risk factor as an indication, but with inconsistency in its definition); or complete disagreement (inconsistency between documents for the considered risk factor as an indication).

RESULTS

Six guidelines and expert consensuses that met the inclusion criteria were identified. Overall, a total of 17 risk factors were identified as an indication for FE. Complete agreement was reached for 3/17 (17.6%) risk factors, all of which are fetal risk factors (suspected CHD at the anomaly scan, presence of major fetal extracardiac abnormality and non-immune hydrops fetalis). Partial agreement was recorded for 8/17 (47.1%) risk factors (family history of CHD, increased nuchal translucency, multiple gestation, maternal diabetes mellitus, maternal phenylketonuria, maternal infection, maternal autoimmune disease and autoantibody positivity, and teratogen exposure). Complete disagreement was recorded for 6/17 (35.3%) risk factors (inherited genetic disease associated with CHD, fetal genetic anomaly, suspected abnormality of heart rate or rhythm, first-trimester sonographic markers of CHD, abnormality of umbilical cord and venous system, and use of assisted reproductive technology).

CONCLUSIONS

Areas of controversy regarding which CHD risk factors warrant FE were greater in quantity than were the areas of consensus. An internationally standardized agreement would be valuable for physicians and guideline developers. For many risk factors, further evidence is needed to justify their use as an indication for FE. © 2025 International Society of Ultrasound in Obstetrics and Gynecology.

The impact of pregnancy on future health in Rheumatoid Arthritis: A systematic review of the literature

OBJECTIVES

To assess whether obstetric history predicts future rheumatoid arthritis (RA) diagnosis, severity, and/or maternal health beyond the immediate postpartum period.

METHODS

A systematic literature search was conducted on 01/07/24 (PubMed, Embase); PROSPERO ID CRD42024559893. Primary research examining health outcomes in RA-affected females, stratified on obstetric history pre- or post-RA onset, were selected for inclusion. Studies of overlapping cohorts were included if differing exposures/outcomes reported.

RESULTS

Out of 3333 articles screened, 95 studies were selected. Future health outcomes analysed included RA diagnosis (n = 66 studies), severity (n = 11), cardiovascular disease (n = 2), immunity (n = 9), and microchimerism (n = 7). Parity/gravidity (n = 67), infertility (n = 7), and pregnancy loss (n = 22) were not reliable predictors of subsequent RA. High parity (n = 2) was linked to increased cardiovascular disease risk in RA-affected females. Both pre-eclampsia (n = 4) and delivery of a low birthweight infant (n = 2) were associated with RA diagnosis/severity. A trend suggested increased RA risk after preterm birth (n = 3) and severe hyperemesis gravidarum (n = 3), but not for gestational diabetes (n = 1). No significant differences in post-translational modification of serum proteins were noted beyond 6 months postpartum, though persistent differences in anti-HLA antibodies and microchimerism were observed.

CONCLUSIONS

Research indicates that parity, gravidity, infertility, and pregnancy loss do not adversely affect RA development. Conversely, low birthweight delivery was associated with RA diagnosis and severity, while pre-eclampsia correlated with subsequent RA diagnosis. Differences in immune responses, as indicated by anti-HLA and microchimerism, may indicate immune sensitisation relevant to RA pathogenesis. The predictive impact of pre-eclampsia and gestational diabetes on cardiovascular health in RA-affected females remains unstudied.

Safety of Fertility Treatments in Women With Systemic Lupus Erythematosus: Data From a Prospective Population-Based Study

OBJECTIVE

To assess safety of fertility treatments in women with systemic lupus erythematosus (SLE).

DESIGN

Data from the multicentre French observational GR2 (Groupe de Recherche sur la Grossesse et les Maladies Rares) study (2014-ongoing).

SETTING

Seventy-six centres in France.

POPULATION

All pregnancies in women with SLE enrolled in the GR2 study, conceived before 1 August 2022, with available end-of-pregnancy data and known conception type, were included; that is, 577 spontaneous and 53 assisted pregnancies.

METHODS

A comparative analysis of spontaneous and assisted pregnancies was conducted. Logistic regression was used to determine if fertility treatments were independently associated with live birth prognosis, adjusting for confounders (e.g., maternal age). Kaplan-Meier analysis compared cumulative incidences of disease flares and adverse pregnancy outcomes (APOs), with confounding factors adjusted using a Cox regression model.

MAIN OUTCOME MEASURES

Live birth, disease flares, and APOs.

RESULTS

The mean age was older (35.8 vs. 32.3 years, p < 1 × 10-4), and twins were more frequent in assisted pregnancies (5/50, 10.0% vs. 20/554, 3.6%; p = 0.047). Lupus disease was clinically inactive at baseline in 51 (96.2%) assisted pregnancies (vs. n = 511, 89.6%; p = 0.15), with 35 of 45 (77.8%) having no chronic damage (vs. 448/513, 87.3%; p = 0.07). The live birth rate was similar between assisted and spontaneous pregnancies (n = 46, 86.8% vs. n = 505, 87.5%; p = 0.83), with no statistical difference in the incidence of lupus flares and APOs. These results remained consistent after adjusting for confounding factors.

CONCLUSIONS

Fertility treatments in women with mostly well-controlled SLE did not appear to increase risks of maternal and neonatal complications, supporting current recommendations. Trial Registration ClinicalTrials.gov identifier: NCT02450396.

Eligibility criteria for the use menopausal hormone therapy (MHT) in women with medical conditions (II): Endometriosis, neurological and autoimmune diseases

This project developed eligibility criteria for menopausal hormone therapy in patients with medical conditions beyond those published in a previous report. A new consortium of scientific societies coordinated by the Spanish Menopause Society met to develop recommendations for the use of menopausal hormone therapy in patients with some medical conditions based on the best available evidence. The project was developed in two phases. As a first step, we conducted six systematic reviews and three meta-analyses on the safety of menopausal hormone therapy, addressing six clinical questions related to rheumatoid arthritis, systemic lupus erythematosus, antiphospholipid syndrome, multiple sclerosis, Parkinson's disease, and endometriosis. In the second step, the six systematic reviews and three meta-analyses (one on lupus erythematosus and two on Parkinson's disease) helped inform a structured process in which a panel of experts defined the eligibility criteria according to a specific framework, which facilitated the discussion and development process. The eligibility criteria were defined in accordance with the World Health Organization's international nomenclature for the categories of use of menopausal hormone therapy: The quality of evidence was classified as high (A), moderate (B), low (C), or very low (D). For the first time, a set of eligibility criteria, based on clinical evidence and developed according to the most rigorous methodological tools, has been defined. This will provide health professionals with a decision-making tool that can be used to manage menopausal symptoms.

Systemic lupus erythematosus and male reproductive health: A systematic review and meta-analysis

OBJECTIVE

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease that can affect various organs. Male SLE patients often face reproductive health challenges, but research on male sexual and reproductive health in SLE remains limited. This systematic review and meta-analysis aimed to explore the effects of SLE and its related factors on male sexual function and reproductive health.

METHODS

The PubMed, Cochrane library, Embase, Web of Science, Wanfang Data, and China National Knowledge Infrastructure (CNKI) databases were examined from January 2000 to December 2024. Data extraction and quality assessment were performed by two reviewers. Meta-analysis was carried out using Review Manager 5.3 software, and the risk of bias was assessed using the AHRQ checklist. The following outcomes were evaluated: sexual function, reproductive hormones and fertility.

RESULTS

In the literature search, 5002 articles were identified, of which 9 studies met the inclusion criteria. Meta-analysis showed a significantly higher incidence of erectile dysfunction (ED) in SLE patients (OR = 7.44; 95 % CI = 5.00 to 11.06, p < 0.001). SLE patients also had higher levels of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) compared to controls (FSH: MD = 4.02; 95 % CI = 1.47 to 6.57; p = 0.002; LH: MD = 2.21; 95 % CI = 1.10 to 3.32; p < 0.001). Semen analysis showed a significant decrease in sperm count in SLE patients (MD = -0.54; 95 % CI = -0.86 to -0.22; p < 0.001).

CONCLUSIONS

Male SLE patients are more likely to have problems with sexual function, reproductive hormones and sperm quality. These findings emphasize the need for increased clinical awareness and interventions focused on male sexual and reproductive health in SLE patients.

Antiphospholipid syndrome in pregnancy: a comprehensive literature review

BACKGROUND

Antiphospholipid syndrome (APS) is an autoimmune disorder associated with thrombotic events and adverse obstetric outcomes, particularly in its obstetric form (OAPS). Affecting approximately 0.5% of the population, APS is a leading contributor to recurrent pregnancy loss (RPL), preeclampsia (PE), and fetal growth restriction ((FGR). Despite advancements in understanding its pathophysiology and management, optimal treatment strategies for APS in pregnancy remain challenging and require systematic evaluation. This review synthesizes current evidence on APS mechanisms, diagnostic criteria, and therapeutic interventions, with a focus on maternal and fetal outcomes in OAPS.

METHODS

A comprehensive search of PubMed, was conducted to identify studies exploring APS pathogenesis, diagnostic standards, and treatment efficacy in obstetric settings. Inclusion criteria prioritized randomized controlled trials, cohort studies, and systematic reviews with a clear focus on APS and pregnancy.

RESULTS

The review confirmed that APS current accepted pathogenesis is governed by a "two-hit" model, where antiphospholipid antibodies (aPLs) initiate endothelial damage, culminating in thrombosis and placental insufficiency. Epidemiological analysis underscores the prevalence and severity of APS in obstetric contexts, with lupus anticoagulant (LA) emerging as a significant predictor of adverse outcomes. Evidence supports the use of low-dose aspirin (LDA) and heparin to reduce miscarriage rates, while adjunctive treatments, such as hydroxychloroquine (HCQ), have shown promise in improving live birth rates and reducing preterm delivery in high-risk cases. Emerging therapies, including tumoral necrosis factor (TNF-alpha) inhibitors and nitric oxide modulators, may offer additional benefits in refractory cases.

CONCLUSION

APS remains a critical determinant of adverse pregnancy outcomes, necessitating precise diagnostic criteria and tailored management approaches. This systematic review emphasizes the importance of individualized therapeutic regimens to optimize maternal and fetal health in OAPS and highlights areas for future research, particularly regarding novel pharmacological approaches. Further studies are essential to refine treatment protocols and improve clinical guidelines for managing APS in pregnancy.

A 1-year review of anti-Ro/La autoantibody testing in an obstetric population

OBJECTIVES

To evaluate current anti-Ro and anti-La autoantibody ordering patterns, clinical indications for performing these tests, and potential cost-benefit analysis.

METHODS

In this retrospective cohort study, patients who underwent autoantibody testing over 1 year were included. Necessary information was obtained from patient electronic records.

RESULTS

In total 47 patients underwent anti-Ro/La autoantibody testing. Of those tested, 11/47 (2%) had positive results and testing was clinically indicated in 26/47 (55%) patients, indicating minimal cost-benefits. The total rate of the cost prescription was €1644.96. The mean time to process tests was 5 days. In those with positive autoantibodies, two infants were diagnosed with congenital heart block and had pacemakers inserted after delivery.

CONCLUSION

This study found anti-Ro/La autoantibody tests were appropriately ordered in accordance with clinical guidelines. By identifying patients who were autoantibody negative, economic benefits were gained, in terms of antenatal management including reduced frequency of antenatal visits and fetal heart surveillance.

Unraveling shared diagnostic genes and cellular microenvironmental changes in endometriosis and recurrent implantation failure through multi-omics analysis

Endometriosis and Recurrent Implantation Failure (RIF) are both pivotal clinical issues within the realm of reproductive medicine, sharing significant overlap in their pathophysiological mechanisms. However, research exploring the commonalities between these two conditions remains relatively scarce, and reliable shared diagnostic biomarkers have yet to be identified. In this study, we integrated transcriptomic and single-cell sequencing data from the Gene Expression Omnibus (GEO) database to identify shared diagnostic genes and alterations in the cellular microenvironment between EMs and RIF. Differential expression analysis and weighted gene co-expression network analysis (WGCNA) were employed to identify key genes. Machine learning algorithms, including Random Forest (RF) and XGBoost, were utilized to screen for shared diagnostic genes, which were subsequently validated through receiver operating characteristic (ROC) analysis and clinical prediction models. Single-cell analysis was conducted to investigate the expression patterns of these diagnostic genes across various cellular subpopulations. Additionally, gene set enrichment analysis (GSEA) and competing endogenous RNA (ceRNA) network analysis were employed to further elucidate the biological functions and regulatory mechanisms of these genes. A total of 16 key genes were identified, which were predominantly expressed in fibroblasts. Through machine learning, the optimal model combining RF and XGBoost was selected to identify the shared diagnostic genes PDIA4 and PGBD5. Single-cell analysis revealed significant differences in the expression of these diagnostic genes in fibroblasts between normal and disease states. ROC analysis showed that the Area Under the Curve (AUC) values for individual genes in disease diagnosis were all above 0.7. The constructed clinical prediction model demonstrated robust predictive capacity for the disease. Immune infiltration analysis indicated that M2 macrophages and γδ T cells play important roles in the pathogenesis of EMs and RIF. GSEA revealed that these genes are involved in immune responses, vascular function, and hormone regulation, and are regulated by miR-3121-3p. This study provides comprehensive insights into the shared cellular microenvironmental alterations and molecular mechanisms underlying EMs and RIF. The identification of PDIA4 and PGBD5 as shared diagnostic biomarkers offers new avenues for early diagnosis and targeted treatment of EMs-related RIF. Future work will focus on validating these findings in larger cohorts and exploring their therapeutic potential.

Risk and protective factors of disease flare during pregnancy in systemic lupus erythematosus: a systematic review and meta-analysis

To synthesize available evidence on predictive factors associated with systemic lupus erythematosus (SLE) flares during pregnancy, we systematically searched MEDLINE, Embase, and the Cochrane Library through January 2024 for observational studies on risk and protective factors of SLE flares during pregnancy. Odds ratios (OR) and mean differences (MD), as well as their 95% confidence intervals (CI) were used to quantify effect sizes. We employed fixed-effect or random-effect models based on heterogeneity assessments (I2 statistics). Sensitivity analyses were performed using the leave-one-out method, and publication bias was assessed through Egger's test. Thirty-two studies were included in the meta-analysis. Significant baseline SLE characteristics associated with higher risks for flares during pregnancy were identified: thrombocytopenia (with OR [95%CI], 2.29 [1.14-4.58]), hypocomplementemia (1.70 [1.28-2.27]), anti-dsDNA positivity (1.43 [1.16-1.77]), and a history of lupus nephritis (2.34 [1.70-3.21]). Protective factors included achieving remission before pregnancy (0.32 [0.20-0.49]) and antimalarial use at baseline (0.71 [0.55-0.92]) and during pregnancy (0.44 [0.33-0.58]). Additional risk factors included baseline glucocorticoid usage (1.51 [1.17-1.94]), glucocorticoid administration during pregnancy (3.39 [1.90-6.06]), use of other immunosuppressive drugs at baseline (1.46 [1.00-2.12]), and hypertension (2.16 [1.45-3.23]). Furthermore, individuals in the flare group were younger, had higher baseline disease activity, and lower C3/C4 levels compared to the non-flare group. This study highlighted the critical role of managing SLE disease activity prior to pregnancy to minimize flare risks, and identified significant risk and protective factors associated with flares. These evidences facilitate better clinical management strategies for pregnant women with SLE. Key Points • Synthesizes existing evidence on the risk and protective factors associated with SLE flares during pregnancy. • Highlights the critical importance of effectively managing disease activity prior to conception. • Provides insights to enhance risk stratification and management strategies for pregnancies in patients with SLE.

Noninvasive Multimodality Imaging and Special Treatment Considerations for Pericarditis in Pregnancy

Pericarditis in women who are pregnant or of childbearing age poses a challenge to clinicians. At present, there are no guidelines regarding the optimal approach for managing pericarditis in pregnancy regarding selecting the appropriate method of diagnostic imaging or tailoring the treatment regimen to gestational age. Pericarditis in pregnancy may manifest as an autoimmune or autoinflammatory phenotype but the predominant etiology is idiopathic. Transthoracic echocardiography and cardiac magnetic resonance are considered safe, but data are lacking on the use of gadolinium-based contrast agents. Shared decision-making is paramount to balance the risks and benefits of radiation and contrast exposure to the mother and fetus. The safety profile of treatment options differs at each time interval from preconception to the 3 trimesters and postpartum phase. A multidisciplinary approach using imaging guidance can improve outcomes in pregnant patients with pericarditis. Further studies are needed to ascertain the safety of interleukin-1 blocking agents in pregnancy.

Hydroxychloroquine levels in pregnancy and materno-fetal outcomes in systemic lupus erythematosus patients

OBJECTIVES

Data about hydroxychloroquine (HCQ) levels during pregnancy are sparse. We assessed HCQ whole-blood levels at first trimester of pregnancy as a potential predictor of maternal and obstetric/fetal outcomes in patients with systemic lupus erythematosus (SLE).

METHODS

We included pregnant SLE patients enrolled in the prospective GR2 study receiving HCQ, with at least one available first-trimester whole-blood HCQ assay. We evaluated several cut-offs for HCQ whole-blood levels, including ≤200 ng/ml for severe non-adherence. Primary outcomes were maternal flares during the second and third trimesters of pregnancy, and adverse pregnancy outcomes (APOs: fetal/neonatal death, placental insufficiency with preterm delivery, and small-for-gestational-age neonates).

RESULTS

We included 174 patients (median age: 32.1 years, IQR 28.8-35.2). Thirty (17.2%) patients had flares, four (2.3%) being severe. APOs occurred in 28 patients (16.1%). There were no significant differences in APOs by HCQ level for either those with subtherapeutic HCQ levels (≤500 ng/ml vs >500 ng/ml: 23.5% vs 14.3%, P = 0.19) or those with non-adherent HCQ levels (≤200 ng/ml vs >200 ng/ml: 20.0% vs 15.7%, P = 0.71). Similarly, the overall rate of maternal flares did not differ significantly by HCQ level cut-off, but patients with subtherapeutic (HCQ ≤500 ng/ml: 8.8% vs 0.7%, P = 0.02) and non-adherent HCQ levels (≤200 ng/ml: 13.3% vs 1.3%, P = 0.04) had significantly more severe flares.

CONCLUSION

In this large prospective study of pregnant SLE patients, first-trimester subtherapeutic (≤500 ng/ml) and severe non-adherent (≤200 ng/ml) HCQ levels were associated with severe maternal flares, but not with APOs.

TRIAL REGISTRATION

ClinicalTrials.gov, http://clinicaltrials.gov, NCT02450396.

[Human papillomavirus and systemic lupus erythematosus: A systematic review]

BACKGROUND

Human papillomavirus (HPV) infections cause cancer of the cervix, vagina, vulva, anus, penis and upper respiratory tract. The prevention of HPV-induced cancers is a public health issue. Patients with systemic lupus are at increased risk of persistent HPV infection and cervical cancer due to treatment-induced immunosuppression. HPV vaccination and screening for precancerous lesions are two effective means of preventing cervical cancer. Despite the demonstrated safety and efficacy of the HPV vaccine, coverage of HPV vaccination in SLE adults remains low. Screening for cervical cancer is only carried out as recommended in one lupus patient in two. Catch-up HPV vaccination, therapeutic vaccination and vaginal self-sampling are innovative prevention strategies adapted to patients at risk of HPV-induced cancer.

CONCLUSIONS

Measures to prevent HPV-induced cancers are insufficiently implemented in patients managed for systemic lupus. Healthcare professionals and patients need to be made aware of the importance of HPV preventing vaccination.

The Italian Society for Rheumatology guidelines on reproductive health in patients with rheumatic diseases

OBJECTIVE

To date, there is no shared national guideline in Italy for the management of reproductive health in rheumatic diseases (RHRD). The Italian Society for Rheumatology (SIR) has committed to developing clinical practice recommendations to provide guidance on both management and treatment regarding RHRD in Italy.

METHODS

Using the GRADE-ADOLOPMENT methodology, a systematic literature review was conducted to update the scientific evidence that emerged after the publication of the reference recommendations from the American College of Rheumatology. A multidisciplinary group of 18 clinicians with specialist experience in rheumatology, allergy and clinical immunology, internal medicine, nephrology, gynecology and obstetrics, and neonatology, a professional nurse, a clinical psychologist, and a representative from the National Association of Rheumatic Patients discussed the recommendations in collaboration with the evidence review working group. Subsequently, a group of stakeholders was consulted to examine and externally evaluate the developed recommendations.

RESULTS

Recommendations were formulated for each area of interest: contraception, assisted reproductive technology, preconception counseling, and use of drugs before, during, and after pregnancy and during breastfeeding, considering both paternal and maternal exposure.

CONCLUSIONS

The new SIR recommendations provide the rheumatology community with a practical guide based on updated scientific evidence for the management of RHRD.

The conditions that patients with systemic lupus erythematosus should fulfill before pregnancy to optimize outcomes: a large-scale multicenter cohort study from China

BACKGROUND

Systemic lupus erythematosus (SLE) is frequently associated with a lower rate of live birth and a higher incidence of adverse pregnancy outcomes (APOs), and pregnancy can also increase the risk of SLE flares. Comprehensive preconception assessment is critical for improved pregnancy outcomes in patients with SLE. Unfortunately, no global consensus on the conditions that patients with SLE should fulfill prior to pregnancy has yet been formed.

OBJECTIVE

This study aimed to investigate the conditions that patients with SLE should fulfill before pregnancy to optimize outcomes.

STUDY DESIGN

This was a retrospective study utilizing data from a multicenter Chinese SLE cohort. Information on demographics, obstetric history, SLE activity, clinical manifestations, autoantibody profiles, laboratory parameters, therapeutics, and pregnancy outcomes was collected. Logistic regression was used to explore the optimal conditions.

RESULTS

The study comprised 347 singleton pregnancies from 332 patients with SLE in total, with a mean maternal age at conception of 30.3 (SD 4.0) years. The analysis revealed that patients who were stable for at least 6 months, had no active vital organ involvement, were on nonfluorinated corticosteroids no more than the dose equivalent to prednisone 7.5 mg per day, and were on hydroxychloroquine displayed a significantly higher incidence of live birth (86.1% vs. 73.7%, p = 0.004) and a markedly decreased risk of APOs (29.4% vs. 52.1%, p < 0.001). Additionally, flares occurred less frequently during pregnancy (14.7% vs. 27.3%, p = 0.009), particularly for severe flares (5.8% vs. 14.8%, p = 0.011).

CONCLUSION

This study delineated the conditions that patients with SLE should fulfill before pregnancy, which provides better instructions for clinical practice.

The Critical Importance of Diagnosing Atypical Hemolytic Uremic Syndrome in Postpartum Renal Dysfunction in a Patient With Systemic Lupus Erythematosus: A Case Report and Comprehensive Review

This case report describes a rare instance of a 33-year-old woman with systemic lupus erythematosus (SLE) who experienced a pregnancy complicated by preeclampsia, eclampsia, and postpartum atypical hemolytic uremic syndrome (aHUS). At 28 weeks and four days of gestation, the patient presented with severe hypertension, proteinuria, and a loss of consciousness, leading to an emergency cesarean section. Postoperatively, the patient developed acute kidney injury, respiratory failure, and thrombotic microangiopathy (TMA). Although she exhibited the classic triad of hemolytic anemia, thrombocytopenia, and renal dysfunction, normal complement levels ruled out postpartum exacerbation of SLE, and aHUS was not diagnosed during hospitalization. Differential diagnoses, including HELLP (Hemolysis, Elevated Liver Enzyme levels, and Low Platelet levels) syndrome, thrombotic thrombocytopenic purpura, and Shiga toxin-producing Escherichia coli (STEC)-HUS, were excluded. Schistocytes appeared on postoperative day 5, leading to the cessation of tacrolimus and the initiation of prednisolone. Continuous hemodiafiltration and mechanical ventilation facilitated gradual recovery, and the patient was discharged on postoperative day 26. Post-discharge genetic testing revealed no pathogenic mutations; however, the clinical presentation supported a diagnosis of aHUS. aHUS driven by excessive complement activation requires prompt recognition and treatment with plasma exchange or anti-complement monoclonal antibodies (e.g., eculizumab). In this case, delayed recognition of aHUS precluded the use of such therapies. This case highlights the importance for clinicians to consider the possibility of aHUS in postpartum patients with severe renal dysfunction and TMA symptoms, even if the patient has an underlying SLE, as early diagnosis and treatment of aHUS is necessary to improve maternal outcomes.

Utilisation patterns of immunomodulators and pregnancy outcomes in systemic lupus erythematosus: Insights from Korean national data

OBJECTIVES

To investigate the trends in immunomodulator use and pregnancy outcomes among pregnant women with systemic lupus erythematosus (SLE), a condition requiring medication to maintain disease activity.

METHODS

This descriptive study used data from the National Health Information Database in Korea from 2002 to 2018. We included 5,044 pregnancies initiated between 2005 and 2017 in 3,120 SLE patients. Annual trends in SLE therapy, drug utilisation patterns during the preconception and pregnancy periods, and pregnancy outcomes were analysed.

RESULTS

Pregnancy compatible immunosuppressant (PC-IS) and hydroxychloroquine use during the first trimester were 10.7% and 41.4%, respectively. Most SLE medications exhibited a decline in usage from the preconception period to the first trimester. A prescription rate of 0.9% for pregnancy incompatible immunosuppressants (PIC-IS) was observed during the first trimester, and the incidence of live births, stillbirths, and abortions remained consistent from 2005 to 2017.

CONCLUSIONS

Insufficient usage of hydroxychloroquine and PC-IS, along with a reduction in PIC-IS usage primarily during early pregnancy rather than before conception, highlights the unmet need for preconceptional family planning with appropriate medication management strategies in SLE pregnancies.

Treatment options for preventing autoimmune-mediated congenital heart block: a systematic review

OBJECTIVE

Complete congenital heart block (CHB) due to anti-Ro/La antibodies in pregnancy can lead to adverse fetal outcomes and neonatal death. National and international guidelines do not recommend specific treatment for women identified with anti-Ro antibodies while pregnant.

DESIGN

Systematic review of studies of pregnant women with anti-Ro/La antibodies undertaking treatment(s) to prevent CHB. Studies solely focused on treating developing or established CHB were excluded.

MAIN OUTCOME MEASURE

CHB incidence.

RESULTS

Of 1049 articles, 20 studies were eligible, of which 13 were retrospective. Sixteen studies contained usable data comparing various treatments (seven hydroxychloroquine (HCQ), six corticosteroids, two intravenous immunoglobulin (IVIG) and one each on combined HCQ and corticosteroids and plasmapheresis), including 2134 women and 2915 pregnancies. Meta-analysis was not possible due to heterogeneity. HCQ as primary prophylaxis showed protective effect on CHB incidence in four of five studies, whereas for preventing recurrence, only one study had a comparator arm, which showed a protective effect. Corticosteroids showed protective effect on CHB incidence as primary prophylaxis in two of three studies, whereas in recurrence, only one study showed protective effect. The IVIG study with a comparator showed no protective effect on CHB recurrence. Two studies (IVIG and plasmapheresis) had no comparator. The long-term toxicity of treatments was poorly investigated.

CONCLUSION

HCQ showed the most evidence among various treatment options to prevent CHB in babies of women with anti-Ro/La antibodies. However, included studies had high risk of bias and imprecision. Future studies should be prospective, compare existing treatments and capture adverse effects.PROSPERO registration number CRD42023492934.

Sexual and reproductive health from the perspective of patients with autoimmune rheumatic diseases in Mexico: a qualitative study

OBJECTIVES

To explore the experiences and perspectives of female patients with autoimmune rheumatic diseases (ARDs) regarding sexual and reproductive health, including contraception, family planning, and pregnancy.

DESIGN

Qualitative descriptive study using semi-structured interviews.

SETTING

Specialised rheumatology clinic in a tertiary hospital in Monterrey, Mexico.

PARTICIPANTS

21 female patients aged 18-49 with a confirmed ARD diagnosis who were receiving care at the clinic. Participants were selected using convenience sampling, ensuring diversity in age, disease type and stage, socio-economic and cultural background, sexuality and disability status. All participants completed the study.

RESULTS

Four main themes emerged from the analysis. First, participants expressed confusion and concern about the safety and effectiveness of contraceptive methods in the context of their disease and treatment. Second, many participants shared anxiety about infertility, heredity and the risks of pregnancy associated with their ARDs, leading to uncertainty in pregnancy planning. Third, there was concern about the safety of medications during pregnancy and breastfeeding, indicating a lack of guidance and information from healthcare providers. Lastly, patients often deferred decision-making about contraception and medication to their rheumatologists but recognised the importance of a multidisciplinary care approach for comprehensive sexual and reproductive health management.

CONCLUSIONS

The study revealed that women with ARDs experience significant challenges and unmet needs related to sexual and reproductive health, particularly in understanding safe contraception, pregnancy planning and medication use during pregnancy and lactation. These findings emphasise the need for rheumatologists to provide clearer guidance on these issues and collaborate closely with gynaecologists and other specialists to ensure comprehensive, patient-centred care. Enhancing communication and education strategies in rheumatology consultations could address these gaps and improve the sexual and reproductive health outcomes and decision-making processes of women with ARDs.

Increasing Contraception Documentation in an Academic Rheumatology Clinic: A Quality Improvement Approach

OBJECTIVE

This quality improvement initiative aimed to increase the rate of provider screening and documentation of contraception use for reproductive-aged women seen in an academic rheumatology fellows' clinic to >50% by 24 weeks, with sustained improvement at one year.

METHODS

With a multidisciplinary team, we devised and implemented six interventional cycles over 24 weeks informed by key stakeholder survey responses. The primary outcome measure was the percentage of eligible visits with contraception information documented in the structured electronic health record field. The smoking status documentation rate was tracked as a balancing measure, and the percentage of contraception documenters who were non-medical doctor (MD) clinical staff, the target group for the intervention, was tracked as a process measure. Outcome, process, and balancing measures were assessed every two weeks over one year.

RESULTS

Over 24 weeks, the rate of contraception documentation increased from 11% to 54% (median 30%), and the median smoking status documentation rate was 88% (68%-97% range); the median rate of non-MD clinical staff documenters was 92% (70%-100% range). Interventions included an introductory educational session with documentation instruction and scripts to guide screening, email reminders from nursing leadership, and interim educational sessions. At one year, the contraception documentation rate was sustained at 50%.

CONCLUSION

A multicycle educational intervention led to an increase in the contraception documentation rate from 11% to 54% for reproductive-aged women seen in an academic rheumatology fellows' clinic over 24 weeks, with sustained improvement at one year. Future interventions will focus on increasing contraception counseling and referrals for patients in rheumatology clinics who were high risk.

Lupus activity and pregnancy outcomes in systemic lupus erythematosus patients undergoing assisted reproductive therapy: A systematic review and meta-analysis

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease primarily impacting women of childbearing age. While pregnancy and hormonal stress can trigger SLE flare-ups, the effects of assisted reproductive therapies (ARTs) on SLE patients are not well defined. We conducted a search of PubMed/Medline, Embase, and CENTRAL until March 20, 2024, to find observational studies assessing the prevalence of SLE flares and pregnancy outcomes following ARTs. Our analysis included random-effects meta-analysis and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach for evaluating evidence quality. Five studies involving 237 SLE women who underwent ARTs were eligible. The meta-analysis indicated a prevalence of SLE flares at 17% (95% CI: 10-25%) with moderate-quality evidence. The pooled prevalence of arthritis flares was 7% (95% CI: 0-25%) with low-quality evidence. Successful pregnancy rates were 58% (95% CI: 43-72%), and live birth rates were 96% (95% CI: 83-100%), both with low-quality evidence. Moderate-quality evidence showed pregnancy complications, including preterm premature rupture of membranes (PPROM) at 8% (95% CI: 3-16%), miscarriages at 2% (95% CI: 0-9%), intrauterine fetal demise (IUFD) at 4% (95% CI: 0-11%), and preeclampsia at 7% (95% CI: 1-17%). Low-quality evidence showed preterm labor at 10% (95% CI: 0-32%) and ovarian hyperstimulation syndrome (OHSS) at 2% (95% CI: 0-11%). SLE flares, as well as pregnancy complications such as IUFD, miscarriage, PPROM, and preeclampsia in ART recipients, are equivalent to those in spontaneous conception. This indicates that ART is relatively safe for SLE patients with meticulous pregnancy planning. Key Points • Systemic lupus erythematosus (SLE) is a chronic autoimmune disease primarily impacting women of childbearing age. • Pregnancy in women with SLE poses elevated maternal and fetal risks compared to healthy women. • SLE flares and pregnancy complications while receiving ART are equivalent to those in spontaneous conception and ART is relatively safe for SLE patients.

Saudi National Clinical Practice Guidelines for Management of Adult Systemic Lupus Erythematosus

OBJECTIVE

To provide evidence-based clinical practice recommendations for managing Systemic Lupus Erythematosus (SLE) in Saudi Arabia.

METHODS

This EULAR-adapted national guideline in which a multidisciplinary task force utilized the modified Delphi method to develop 31 clinical key questions. A systematic literature review was conducted to update the evidence since the EULAR publication. After reaching a consensus agreement, two rounds of voting and group discussion were conducted to generate consolidated recommendations/ statements.

RESULTS

A significant number of patients in Saudi Arabia experience delays in accessing rheumatologists, highlighting the significance of timely referral to SLE specialists or rheumatologists to ensure accurate diagnosis and prompt treatment. The primary goal of Glucocorticoid (GC) therapy in SLE patients is to establish disease control with a minimum dose and duration. Steroid-sparing agent utilization facilitates steroid-sparing goals. Hydroxychloroquine is recommended for all SLE patients, though physicians must carefully monitor toxicity and prioritize regular medication adherence assessment. SLE management during pregnancy starts from preconception time by assessing disease activity, major organ involvement, hypercoagulability status, and concomitant diseases that may negatively impact maternal and fetal outcomes. Multidisciplinary care with close monitoring may optimize both maternal and fetal outcomes. For patients with antiphospholipid antibodies, low-dose aspirin prophylaxis is recommended. Also, Long-term anticoagulant medications are fundamental to prevent secondary antiphospholipid syndrome due to high thrombosis recurrence.

CONCLUSION

This Saudi National Clinical Practice guidelines for SLE management provide evidence- based recommendations and guidance for healthcare providers in Saudi Arabia who are managing patients with SLE. These guidelines will help to standardize healthcare service, improve provider education, and perhaps lead to better treatment outcomes for SLE patients.

Hydroxychloroquine in lupus or rheumatoid arthritis pregnancy and risk of major congenital malformations: a population-based cohort study

OBJECTIVES

To assess the infant risk of major congenital malformations (MCM) associated with first-trimester exposure to hydroxychloroquine (HCQ) among mothers with systemic lupus erythematosus (SLE) or rheumatoid arthritis (RA).

METHODS

This population-based cohort study utilized Swedish nationwide registers and included all singleton births (2006-2021) among individuals with prevalent SLE or RA in Sweden. The exposure was filling ≥1 HCQ prescription during the first trimester. The outcome was infant MCM within 1 year of birth. Inverse probability of treatment weighting was applied to adjust for potential confounders (e.g. maternal smoking, body mass index, pregestational diabetes and corticosteroids). Modified Poisson regression models with robust variance were used to estimate risk ratios (RR) and 95% CI.

RESULTS

We included 1007 births (453 exposed) and 2500 births (144 exposed) in the SLE and RA cohorts, respectively. The MCM risks in the SLE overall cohort, exposed and unexposed groups were 3.6%, 3.7% and 3.4%, respectively. The corresponding figures in the RA cohort were 4.4%, 5.6% and 4.3%, respectively. The adjusted RRs (95% CI) were 1.29 (0.65, 2.56) in the SLE cohort, 1.32 (0.56, 3.13) in the RA cohort and 1.30 (0.76, 2.23) in the pooled analysis. The adjusted risk difference (exposed vs unexposed) was small (0.9% in SLE and 1.3% in RA). Sensitivity analyses examining different exposure and outcome windows yielded similar findings.

CONCLUSION

First-trimester exposure to HCQ was not associated with a significantly increased risk of MCM. HCQ's benefits may outweigh the risks in managing SLE or RA during pregnancy.

Recommendations for the diagnosis and treatment of anti-neutrophil cytoplasmic autoantibody associated vasculitis

Anti-neutrophil cytoplasmic autoantibody (ANCA)-associated vasculitis is characterised by small vessel necrotising inflammatory vasculitis. Prior to immunosupressant therapy availability it usually led to a fatal outcome. Current treatment has changed ANCA-associated vasculitis into a condition with a significant response rate, although with a not negligible relapse occurrence and cumulative organ lesions, mostly due to drug-related toxicities. The use of glucocorticoids, cyclophosphamide and other immunosupressants (such as azathioprine, mychophenolate and methotrexate) was optimised in a series of clinical trials that established the treatment of reference. In recent years, a better knowledge of B lymphocyte function and the role of complement inhibition has transformed the course of this disease while minimising treatment-related adverse effects. This multidisciplinary document of recommendations is based on the consensus of three scientific societies (Internal Medicine, Nephrology and Rheumatology) and on the best available evidence on diagnosis, treatment and follow-up of patients with ANCA-associated vasculitis, including some special situations. The aim of this document is to provide updated information and well-grounded clinical recommendations to practising physicians as to how to improve the diagnosis and treatment outcome of our patients.

The 100 top-cited studies in systemic lupus erythematosus: A bibliometric analysis

Systemic lupus erythematosus (SLE) is an autoimmune inflammatory tissue disease. In view of the explosive growth in research on SLE, bibliometrics was performed to evaluate the 100 top-cited papers in this realm. We performed the search with terms "systemic lupus erythematosus" the Web of Science Core Collection database on May 3, 2023. Relevant literatures were screened. Data were extracted and analyzed by SPSS. The citations of 100 top-cited SLE studies spanned from 472 to 13,557. Most studies (60 out of 100) were conducted in the United States. Total citation times were positively associated with ACY, which was negatively correlated with the length of time since publication. Approximately half of the studies focused on the underlying mechanisms of SLE. New biologic therapies garnered attention and development. Our findings provide valuable insights into the developments in crucial areas of SLE and shed contributions to future studies.

Relationship of lupus nephritis and pregnancy: A narrative review

Pregnancy in women with lupus, particularly those with lupus nephritis (LN), carries an increased risk of adverse outcomes. Women with active LN at the time of conception are at a high risk of poor maternal and fetal outcomes. Recent studies indicate that even in the presence of quiescent disease, factors such as hypertension and positive lupus anticoagulant are predictors of worse pregnancy outcomes. Consequently, pre-conception evaluation is essential to ensure that pursuing pregnancy is safe and timely, and to facilitate proper planning for optimizing medical regimens, discontinuing teratogenic agents, and treating active disease. Additionally, pre-existing LN is associated with higher rates of preeclampsia and hemolysis, elevated liver enzymes, and low platelet count syndrome. Women with lupus and prior LN can have successful pregnancies, but a multidisciplinary approach with close monitoring is essential for optimal outcomes. By systematically reviewing the available evidence, this narrative review aims to provide a comprehensive update on the complex interaction between LN and pregnancy, offering insights to guide clinical practice and future research in this field.

Prevalence of Antiphospholipid Antibody Syndrome Among Patients with Recurrent Pregnancy Loss: Impact of the Revised 2023 ACR/EULAR Antiphospholipid Syndrome Criteria

Objectives: Current guidelines recommend systematic screening for rheumatic diseases (RDs), including antiphospholipid syndrome (APS), in patients with recurrent pregnancy loss (RPL). However, these recommendations are based on limited evidence, as data on the prevalence of RD in this specific population remain scarce. In particular, the impact of the recent update to the ACR/EULAR classification criteria for APS on the prevalence of RD among RPL patients has yet to be clarified. To address these gaps, this study aims to (i) assess the impact of the 2023 ACR/EULAR APS classification criteria in patients with recurrent pregnancy loss (RPL); and (ii) analyze the prevalence of RD in these patients. Methods: We conducted a retrospective cohort study at Rennes University Hospital. From January 2010 to December 2021, all patients referred to the Clinical Immunology Department for RPL were included. Patients were eligible if they had undergone a full RPL evaluation, according to guidelines. Results: We included 165 women with RPL. APS according to the Sydney criteria was found in 24 (14.5%) patients. No significant differences in obstetric history or clinical signs were observed between APS-positive and APS-negative individuals. Only two patients fulfilled the updated 2023 APS criteria, resulting in 163 (98.8%) patients being classified as having unexplained recurrent pregnancy loss (uRPL). Among them, 108 had a new pregnancy following uRPL, resulting in 87 (81%) live births and 21 (19%) recurrent miscarriages. We did not identify any prognostic factor associated with subsequent pregnancy outcomes, including the patients' antiphospholipid biological profile. We found a prevalence of non-APS RD of only 2.4% in the study population, including systemic lupus erythematosus, rheumatoid arthritis, and Behçet's disease. Conclusions: APS was identified in 14.5% of the patients based on the former Sydney criteria and 1.2% according to the revised criteria. The lack of clinical differences between APS and non-APS patients aligns with previously reported limitations of the Sydney criteria in accurately identifying aPLA-related RPL. According to the rarity of APS as per the updated criteria, future large collaborative trials will be needed to further characterize APS-related RPL patients and to determine the best treatment strategy for future pregnancies.

Increased risk of subsequent antiphospholipid syndrome in patients with endometriosis

BACKGROUND

Although autoimmune abnormalities are common in patients with endometriosis, it is unknown whether patients with endometriosis have a higher risk of developing antiphospholipid syndrome (APS).

METHODS

We conducted a retrospective cohort study by using the multi-institutional research network TriNetX from 1 January 2012 to 31 December 2021. A total of 13 131 782 women aged 20-60 years from networks within the USA were included. The risks of APS were compared between an endometriosis cohort and a non-endometriosis cohort in subgroup analyses by age, obesity and systemic lupus erythematosus (SLE), and the sensitivity analysis was stratified by the presence or absence of a history of surgery of the uterus.

RESULTS

After 1:1 propensity score matching, the endometriosis and non-endometriosis cohorts each included 50 078 participants. Compared to individuals without endometriosis, patients with endometriosis had a higher risk of incident APS (log-rank test, P < 0.001). The hazard ratios (HRs) ranged from 1.82 [APS within 30 days to 1 year after the index date, 95% confidence intervals (CIs) 1.40-2.53] to 2.44 (APS within 30 days to any time after the index date, 95% CI 1.65-3.61). In the subgroup analyses, an increased risk of APS was observed in all ages, White race, and subgroups without smoking, obesity, asthma, inflammatory bowel disease and SLE (HR range 1.85-2.84). Sensitivity analyses revealed that the risk of APS increased in patients without surgery history of the uterus.

CONCLUSIONS

Patients with endometriosis had a higher risk (2.84-fold) of developing APS. Future large-scale prospective studies are warranted to confirm our results.

Estrogen, progestin, and beyond: thrombotic risk and contraceptive choices

Hormonal contraceptive therapy (estrogens and/or progestogens) includes different formulations associated with varying venous thromboembolism (VTE) risks. The thrombogenicity of combined hormonal contraceptives (CHCs) is due at least in part to multiple changes in clotting factors and the vasculature and is dependent on both estrogen dose and type of progestin. Transdermal patch and vaginal ring users have similar or higher VTE risk as combined oral contraceptive users. Progestin-only agents have varying VTE risk. While depot medroxyprogesterone acetate appears to increase VTE risk, the levonorgestrel-based intrauterine system and low-dose progestin-only pills have no additional VTE risk. There are less data for the subdermal progestin-only implant. This article reviews contraceptive-related VTE risk by agent and by clinical scenario, including in patients with inherited thrombophilia, systemic lupus erythematosus with or without antiphospholipid antibodies or antiphospholipid syndrome, and sickle cell disease. Relevant clinical practice guidelines are reviewed. A multidisciplinary approach to counseling is needed for patient-focused decision-making.

Pregnancy with mixed connective tissue disease: Exploration of factors influencing live birth outcomes

Mixed connective tissue disease (MCTD) predominantly affects women in their reproductive age (30-40 years). This study is aimed to analyze a case series of MCTD-complicated pregnancies. The study design utilized a combined case-series and case-control approach. Pregnant women with MCTD were included and categorized into two groups: the live-birth and non-live birth (encompassing miscarriages at <12 weeks and stillbirths at ≥12 weeks) groups. Primary outcomes included delivery outcomes and factors associated with live births. A total of 57 pregnancies from 34 mothers (median age: 33.0 years) were included. Regarding delivery outcomes, the rates for live birth, miscarriage, and stillbirth were 64.9, 29.8, and 5.3%, respectively. Additionally, the respective rates of preterm delivery, fetal growth restriction (FGR), and small-for-gestational-age (SGA) were 18.9, 18.9, and 27.0%. Higher steroid usage (62.2 vs. 30.0%, p = 0.02) and lower prednisolone dosage in the live birth group (median dose: 7 vs. 10 mg, p = 0.03) were found to be significant factors contributing to live births. MCTD during pregnancy was associated with increased risks of miscarriage, stillbirth, preterm delivery, FGR, and SGA. Notably, low-dose steroid therapy was identified as a contributing factor to successful live births.

Need for individualized counseling regarding psoriasis systemic therapy in women of childbearing age: analysis of the PsoFem study at the University Medical Center Hamburg

Background

For patients with moderate-to-severe psoriasis and current childbearing/pregnancy, the choice of therapy is limited.

Objectives

The present study compared the disease burden and treatment choices in women of childbearing age (WoCBA) with and without a current wish for pregnancy.

Methods

Female patients aged 18 to 45 years, with moderate-to-severe psoriasis vulgaris, were consecutively recruited. The patients reported on sociodemographic/reproductive characteristics and quality of life impairments. The physicians assessed disease severity, comorbidities, and current treatment(s). Both patients' and dermatologists' perceptions of shared decision-making for the current systemic treatment were surveyed.

Results

Participants were 145 WoCBA with psoriasis: 73 were pregnant or reported a desire to conceive (group CB+) and 72 reported no wish to have (more) children (group CB-). Patients without childbearing wishes were older and often had previous children; no significant differences in clinical features or quality of life impairments were found. A significantly higher proportion of patients in the CB+ group were prescribed tumor necrosis factor alpha blockers, particularly certolizumab pegol. This treatment option was associated with previous children and the desire to conceive, but not with disease variables. Family planning was more often discussed and considered in the clinical decision for the CB+ group, but patient-doctor agreement for shared decision-making was fair-to-moderate.

Limitations

The small sample size prevented comparative analyses between patients planning a pregnancy in the short- vs long-term future. In addition, specific variables related to the decision-making process for the current therapy need to be assessed and examined in more detail in further research.

Conclusion

For WoCBA with childbearing wishes, tumor necrosis factor alpha blockers were most frequently prescribed, in accordance with current guidelines/recommendations. Decision-making for continuing or changing systemic therapy during pregnancy must take into account medication specificities and the vulnerable stages in pregnancy, as well as the limited amount of pregnancy-compatible drugs.

Issues with pregnancy in systemic lupus

Systemic lupus erythematosus is a disease that affects a large number of young women of childbearing age. Today, pregnancy is considered safe in almost all women with lupus, especially when the disease is under control. However, pregnancies in this population have a higher risk of maternal complications than in the general population. It is therefore important to plan pregnancies as effectively as possible, using effective contraception and pre-pregnancy counselling. In fact, effective, well-tolerated contraception is essential for patients for whom pregnancy cannot be safely envisaged, particularly in the setting of teratogenic treatment or significant disease activity. Preconception counselling is essential and helps to anticipate several aspects of a future pregnancy. Several recent prospective studies have clearly identified risk factors for obstetric complications and disease flare. High level of lupus activity, low complement, primigravida and a history of lupus nephritis are predictive factors of disease flare when antiphospholipid syndrome or antiphospholipid antibodies (specifically for lupus anticoagulant), damage, activity of lupus are predictive for obstetric events. Appropriate therapeutic management is essential, based primarily on the continuation of hydroxychloroquine, although some recent warnings about its use in pregnancy have been discussed controversially. Corticosteroid therapy can be continued at the lowest possible dose, as can certain immunosuppressive drugs. In the case of a history of lupus nephritis, low-dose aspirin is also prescribed. Although still exceptional, the risk of neonatal lupus is also higher, in patients with anti-SSA and anti-SSB antibodies. The aim of this review is to summarise the risk factors for adverse obstetric outcomes and to improve medical and obstetric management in this population of pregnant women with lupus.

Pediatric antiphospholipid syndrome: is it the same as an adult?

IMPORTANCE

Antiphospholipid syndrome in neonates and children is a rare, but in some cases life-threatening condition with arterial and/or venous thrombosis and/or non-thrombotic neurological, skin, ophthalmological and other manifestations.

OBSERVATIONS

This review highlights the available information about the features of pediatric APS, including the rare catastrophic form, the differences between pediatric and adult APS, and the role of genetic thrombophilia in APS manifestation.

CONCLUSIONS AND RELEVANCE

The clinical manifestations and treatment options for APS in children may differ from those in adults, and prescribing therapy can be challenging due to the unique clinical and morphological characteristics of the pediatric patient. Pediatric APS may be a predictor of the development of certain autoimmune diseases and classic manifestations of APS in adulthood, therefore, a revision of the existing criteria for the diagnosis and treatment of APS in children is necessary.

Isolated thrombocytopenia in pregnancy: A monocentric retrospective study of 63 pregnancies in 59 women

Thrombocytopenia during pregnancy is often thought to be associated with severe bleeding manifestations. Three are the main disorders associated with this condition: gestational thrombocytopenia (GT), immune thrombocytopenia (ITP), and inherited thrombocytopenias (ITs). Reaching the correct diagnosis of this condition has relevant therapeutic and outcome implications. We performed a retrospective, observational, monocentric study enrolling 59 consecutive women with isolated thrombocytopenia, attended to our referral center in the last 3 years. Together with personal and family history, platelet (PLT) count trend and mean platelet volume (MPV) in pregnancy are helpful for the diagnosis, with the highest PLT count in GT and lowest in ITs, with different timing of count decrease. MPV is significantly increased in both ITs and ITP. Misdiagnosis with ITP was responsible for unnecessary and unsuccessful therapy in some GT or ITs pregnant women, determining relevant side effects. Excluding inherited platelet function disorders (IPFDs), the bleeding risk for mother with thrombocytopenia and their newborns is similar to the general population. Vaginal delivery is associated with a lower risk of bleeding than cesarean section and therefore is preferable whenever obstetrical-gynecological conditions permit.

Diagnosis and management of antiphospholipid syndrome

Antiphospholipid syndrome is an autoimmune disease characterised by thrombotic and/or obstetric manifestations with persistent antiphospholipid antibodies. Diagnosis involves confirming the persistence of antiphospholipid antibodies in symptomatic patients, using validated classification criteria as a guide. The likelihood of obtaining false-positive or false-negative test results in certain settings, and the lack of standardisation between laboratory methods, are important considerations. Patients who have had thrombotic manifestations require lifelong anticoagulation from the first thrombotic event, typically with warfarin. Patients with a history of thrombotic and/or obstetric manifestations who become pregnant should receive low-molecular-weight heparin and low-dose aspirin during pregnancy and postpartum. Testing asymptomatic people is not recommended, except in the context of systemic lupus erythematosus. Management of asymptomatic people with persistent antiphospholipid antibodies depends on their individual antibody profile and risk factors.

Risk of flare in patients with SLE in remission after hydroxychloroquine or chloroquine withdrawal

OBJECTIVE

Previous studies have provided evidence that the discontinuation of hydroxychloroquine (HCQ), and chloroquine (CQ), in patients with systemic lupus erythematosus (SLE) is associated with an increased risk of disease flares, with limited information on the level of disease activity at the time of HCQ/CQ discontinuation. Here we aimed to describe the risk of SLE flare after withdrawal of HCQ or CQ in patients with SLE in remission.

METHODS

Case-control study (1:2) comparing the evolution of patients with SLE after HCQ/CQ withdrawal for antimalarial retinopathy (cases) with patients with SLE matched for sex, antimalarial treatment duration and age at SLE diagnosis, whose antimalarial treatment was continued throughout the entire follow-up period (controls). To be included in the study, patients had to be in remission for at least one year according to the DORIS classification. The primary endpoint was the proportion of patient experiencing a flare according to the SELENA-SLEDAI Flare Index after a 36-month follow-up.

RESULTS

We studied 48 cases and 96 controls. The proportion of patients experiencing a flare was significantly higher in the HCQ/CQ withdrawal group as compared to the maintenance group (15 [31.3%] patients versus 12 [12.5%]; OR 3.1 [95%CI 1.2-8.2], P=0.01). Withdrawal of HCQ/CQ was inferior with respect to occurrence of severe SLE flare (12 [25.0%] vs 11 [11.5%]; OR 2.5 [95%CI 0.9-6.9], P=0.053) and time to first flare (HR 6.3 [2.0-19.9], P<0.005). Elevated serum levels of anti-dsDNA antibodies were identified as a risk factor for SLE flare following HCQ/CQ discontinuation (HR 5.4 [1.5-18.7], P<0.01).

CONCLUSION

Withdrawal of HCQ or CQ in patients with SLE in remission is associated with a 3-fold increased risk of relapse.

Fetal-hope study: Home monitoring of fetal heart rate in SSA + pregnant women: Rationale and design

INTRODUCTION

Worldwide, approximately 0.5-1 % of women of childbearing age are positive for anti-Ro/SSA antibodies and anti-La/SSB. The presence of these antibodies may be responsible for the appearance of Neonatal Lupus. The pathogenesis of this disease is probably mediated by the binding of these antibodies to fetal myocardiocytes. The typical manifestation is atrioventricular block (AVB), which in most cases is complete (CHB). AVB commonly develops between 16 and 26 weeks of gestation and is cause of severe heart failure. CHB appears to be irreversible, but anecdotal reports suggest that treatment of second-degree AVB can restore sinus rhythm.

OBJECTIVE

The aim of the study is to evaluate the reliability of home monitoraing of fetal heart rate by the use of a hand-held device, extablishing the incidence of fetal AVB in pregnant women positive for anti-Ro/SSA autoantibodies and to evaluate whether early treatment can influence the course of the disease.

METHODS

Anti-Ro/SAA positive pregnant women are currently recruited from 11 Italian centers in a prospective observational study. Patients are instructed to use a portable doppler between 16 and 34 weeks of gestation and to monitor the fetal heart rate (FHR) every 8 h. In case of FHR anomalies patients will contact the reference center which will guarantee an echocardiogram within 8 h and in case of anomalies, adequate treatment. All patients will undergo check-ups at 20, 26 and 32 weeks of gestation, with the collection of information on the course of the maternal disease, on the use of drugs and on instrumental monitoring progress. After birth, data will be collected on the outcome of pregnancy and the methods of delivery. Newborns will also be evaluated for the possible appearance of clinical signs of Neonatal Lupus.

RESULTS

Fetal-Hope is actually enrolling Patients from involved Centers.

CONCLUSIONS

Fetal-Hope is the first European study assessing the reliability of home monitoring of fetal heart rate using a handheld device, determining the incidence of fetal atrioventricular block (AVB) in pregnant women positive for anti-Ro/SSA autoantibodies and assessing whether early intervention can alter the disease's progression.

The impact of hormones in autoimmune cutaneous diseases

INTRODUCTION

Dermatomyositis, systemic and cutaneous lupus erythematosus have a significantly higher prevalence in women than men, emphasizing the relevance of exploring the relationship between sex hormones and autoimmune skin diseases. This review analyzes the interplay between sex hormones and these two skin diseases.

MATERIALS AND METHODS

We performed an extensive literature search using the PubMed database from July to August 2023. Search terms included 'contraceptives', 'pregnancy', 'hormone replacement', 'tamoxifen', and 'aromatase inhibitors'.

RESULTS AND DISCUSSION

This comprehensive literature review shows that there remains considerable debate regarding the use of hormonal contraceptives and hormonal replacement therapy in individuals with autoimmune skin conditions. Nonetheless, it is well established that their use is contraindicated in patients with antiphospholipid syndrome or when antiphospholipid antibodies are positive. Individuals experiencing disease flares and uncontrolled symptoms should also avoid these interventions. Pregnancy planning should be timed to coincide with well-managed disease states to minimize obstetric and neonatal complications. Hormonal breast cancer treatment requires close skin monitoring.

CONCLUSION

Pregnancy, menopause, contraceptive use, hormone replacement therapy, and breast cancer treatment drugs result in substantial shifts in hormone levels. Additionally, hormone levels are altered by aromatase inhibitors and anti-estrogen medications. These fluctuations can modulate mechanisms influencing autoimmune skin abnormalities.

Clinical Practice Mexican Guidelines for the Treatment of Systemic Lupus Erythematosus: 2024 Update

Herein we present the update for the Mexican Guidelines for the Treatment of Systemic Lupus Erythematosus. It involves the participation of several experts along the country, following the GRADE system. We included aspects regarding vaccines, pregnancy and cardiovascular risk which were not presented in the previous guidelines in 2017.

Outcomes of IVF treatments in women with antiphospholipid antibodies or antiphospholipid syndrome

BACKGROUND

Ovulation induction for in vitro fertilization (IVF) may increase intravascular thromboses among patients with antiphospholipid autoantibodies (aPLs) or antiphospholipid syndrome (APS) due to the high estrogen levels. While natural or modified natural IVF treatment cycles (MNC) are sometimes used instead of stimulated cycles with empiric anticoagulant treatment among these infertile patients, their efficacy is unclear.

MATERIALS AND METHODS

A retrospective cohort study including all IVF cycles of patients diagnosed with aPLs or APS in a tertiary, university-affiliated hospital between 2012 and 2022. The outcomes of stimulated cycles with anticoagulants and MNC and natural IVF cycle attempts were compared.

RESULTS

121 oocyte retrievals from 38 women were analyzed: 93 stimulated and 28 MNC or natural IVF cycles. The rates of cycle cancellation (0 % vs. 17.9 %, p < 0.001) and cycles in which no oocytes were retrieved (0 % vs. 43.5 %, p < 0.001) were significantly lower following stimulated cycles vs. natural and MNC. In parallel, positive β-hCG (31.9 % vs. 10.9 %, p = 0.03), clinical pregnancy rate (23.6 % and 3.6 %, p < 0.001) and live birth rates (18.1 % vs. 3.6 %, p = 0.01) were significantly higher following stimulated cycles. No thrombotic events or bleeding occurred in any cycle.

CONCLUSION

Ovarian stimulation for IVF is more effective for successful pregnancy and delivery than natural cycles and MNC and can be safely undertaken in aPLs or APS women undergoing IVF. Rates of complication from hormonal treatment are not increased when treated with LMWH during ovarian stimulation.

Use of intravenous immunoglobulin in antiphospholipid antibody positive patients with high risk of miscarriage: a systematic review and meta-analysis

Objective

The purpose of the present study was to evaluate whether intravenous immunoglobulin (IVIG) increases live birth rates and improves neonatal results in patients with antiphospholipid antibodies (aPL) at high-risk for miscarriage.

Background

Positivity of aPL in pregnant women is a high-risk factor for miscarriage, and IVIG treatment has emerged as a potential intervention.

Methods

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline was employed to search multiple electronic databases for articles published until August 20, 2023, including PubMed, Web of Science, Embase, Scopus and Medline. The inclusion criteria encompassed studies assessing the efficacy of IVIG in aPL-positive patients with a high risk of miscarriage. Relevant articles were assessed for the quality and data were extracted for analysis. Two independent reviewers performed study selection, data extraction, and quality assessments. The risk of bias was evaluated according to the Cochrane risk of bias tool. All analyses were conducted using Review Manager 5.3.

Results

This systematic review included nine randomized controlled trials, with 366 aPL-positive women at high risk of miscarriage. These studies included in this review were randomized controlled trials. The primary outcome measures were successful pregnancy outcomes and live birth rates. The secondary outcomes included obstetric complications, and neonatal outcomes (such as birth weight and live-birth rate). The comparison between the intervention and control groups revealed no significant differences in terms of obstetric complications and neonatal outcomes. The group receiving IVIG treatment had a higher prevalence of preterm deliveries than controls (OR = 2.05, I2 = 46%, 95% CI [0.58-5.24]), but also exhibited a partial improvement in live birth rates (OR = 2.86, I2 = 52%, 95% CI [1.04-7.90]), because it reduced the number of miscarriages (OR = 0.35, I2 = 52%, 95% CI [0.13-0.96]).

Conclusion

Based on the available evidence, IVIG intervention appears to be a potentially effective approach for managing of aPL-positive pregnant women with high risk of miscarriage. While IVIG shows significant potential in tripling the chances of having a live-born child, further large-scale randomized controlled trials are necessary, preferably comparing IVIG with hydroxychloroquine or lifestyle and dietary interventions, to refine treatment protocols and ensure the most effective application.

Effect of hydroxychloroquine on pregnancy outcome in patients with SLE: a systematic review and meta-analysis

OBJECTIVE

Hydroxychloroquine (HCQ) is an antimalarial drug employed in the treatment of systemic lupus erythematosus (SLE). Prior studies reported inconsistent results regarding the association between HCQ use during pregnancy and adverse pregnancy outcomes. This study aimed to evaluate the impact of HCQ on pregnancy-related outcomes in women with SLE.

METHODS

We conducted a systematic search for studies associating pregnancy outcomes with HCQ use in PubMed, EMBASE, Cochrane Library, Web of Science, CNKI, Wanfang database and VIP from inception to 22 September 2022. Random or fixed effect models were used to estimate the pooled effect based on I2 measurement of heterogeneity.

RESULTS

Twenty-one studies were included, encompassing 929 and 1031 patients in HCQ and non-HCQ groups, respectively. We found that HCQ use was significantly associated with reduced risks of Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) scores (second trimester: mean difference (MD) -1.80, 95% CI -2.46 to -1.13; third trimester: MD -2.30, 95% CI -3.31 to -1.29), flare (OR 0.57, 95% CI 0.33 to 0.97), preterm birth (OR 0.57, 95% CI 0.46 to 0.72), intrauterine growth retardation (IUGR) (OR 0.48, 95% CI 0.31 to 0.72), gestational hypertension (OR 0.19, 95% CI 0.08 to 0.42), pre-eclampsia (OR 0.46, 95% CI 0.29 to 0.72). In contrast, a positive correlation was observed between full-term birth and HCQ use (OR 2.01, 95% CI 1.52 to 2.65). However, the result for disease flare exhibited high heterogeneity (p=0.01, I2=59%). In addition, publication bias was detected in the meta-analysis of full-term birth using the Egger's test.

CONCLUSIONS

This meta-analysis offers a comprehensive assessment of the relationship between disease activity, pregnancy-related outcomes and HCQ use, providing supportive evidence for the therapeutic effectiveness of HCQ in pregnant women with SLE.

PROSPERO REGISTRATION NUMBER

CRD42022374468.