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Stefanski AL, Rincon-Arevalo H, Dressler-Steinbach I, Nomovi N, Mackert A, Aue A, Ritter J, Wiedemann A, Szelinski F, Schrezenmeier E, Kühl AA, Lino AC, Henrich W, Dörner T. Dysregulation of immune checkpoint molecules as a characteristic of autoimmune congenital heart block. Ann Rheum Dis 2024:ard-2024-226176. [PMID: 38997131 DOI: 10.1136/ard-2024-226176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2024] [Accepted: 07/06/2024] [Indexed: 07/14/2024]
Affiliation(s)
- Ana-Luisa Stefanski
- Department of Rheumatology and Clinical Immunology, Charité Universitätsmedizin, Berlin, Germany
- Deutsches Rheuma-Forschungszentrum (DRFZ), Berlin, Germany
| | - Hector Rincon-Arevalo
- Department of Rheumatology and Clinical Immunology, Charité Universitätsmedizin, Berlin, Germany
- Deutsches Rheuma-Forschungszentrum (DRFZ), Berlin, Germany
- Immunologia cellular e immunogenetica, Universidad de Antioquia, Medellin, Colombia
- Department of Nephrology and Intensive Medical Care, Charité Universitätsmedizin, Berlin, Germany
| | | | - Nadja Nomovi
- Department of Obstetrics, Charite Universitätsmedizin, Berlin, Germany
- Department of Obstetrics, Ernst von Bergmann Hospital, Potsdam, Brandenburg, Germany
| | - Alma Mackert
- Department of Obstetrics, Charite Universitätsmedizin, Berlin, Germany
| | - Arman Aue
- Department of Nephrology and Intensive Medical Care, Charité Universitätsmedizin, Berlin, Germany
| | - Jacob Ritter
- Department of Rheumatology and Clinical Immunology, Charité Universitätsmedizin, Berlin, Germany
- Deutsches Rheuma-Forschungszentrum (DRFZ), Berlin, Germany
| | - Annika Wiedemann
- Department of Rheumatology and Clinical Immunology, Charité Universitätsmedizin, Berlin, Germany
- Deutsches Rheuma-Forschungszentrum (DRFZ), Berlin, Germany
| | - Franziska Szelinski
- Department of Rheumatology and Clinical Immunology, Charité Universitätsmedizin, Berlin, Germany
- Deutsches Rheuma-Forschungszentrum (DRFZ), Berlin, Germany
| | - Eva Schrezenmeier
- Deutsches Rheuma-Forschungszentrum (DRFZ), Berlin, Germany
- Department of Nephrology and Intensive Medical Care, Charité Universitätsmedizin, Berlin, Germany
| | - Anja A Kühl
- iPATH, Core Unit of Charité, Charité Universitätsmedizin, Berlin, Germany
| | - Andreia C Lino
- Deutsches Rheuma-Forschungszentrum (DRFZ), Berlin, Germany
| | - Wolfgang Henrich
- Department of Obstetrics, Charite Universitätsmedizin, Berlin, Germany
| | - Thomas Dörner
- Department of Rheumatology and Clinical Immunology, Charité Universitätsmedizin, Berlin, Germany
- Deutsches Rheuma-Forschungszentrum (DRFZ), Berlin, Germany
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Di Ludovico A, Rinaldi M, Mainieri F, Di Michele S, Girlando V, Ciarelli F, La Bella S, Chiarelli F, Attanasi M, Mauro A, Bizzi E, Brucato A, Breda L. Molecular Mechanisms of Fetal and Neonatal Lupus: A Narrative Review of an Autoimmune Disease Transferal across the Placenta. Int J Mol Sci 2024; 25:5224. [PMID: 38791261 PMCID: PMC11120786 DOI: 10.3390/ijms25105224] [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: 04/11/2024] [Revised: 05/01/2024] [Accepted: 05/08/2024] [Indexed: 05/26/2024] Open
Abstract
This study, conducted by searching keywords such as "maternal lupus", "neonatal lupus", and "congenital heart block" in databases including PubMed and Scopus, provides a detailed narrative review on fetal and neonatal lupus. Autoantibodies like anti-Ro/SSA and anti-La/SSB may cross the placenta and cause complications in neonates, such as congenital heart block (CHB). Management options involve hydroxychloroquine, which is able to counteract some of the adverse events, although the drug needs to be used carefully because of its impact on the QTc interval. Advanced pacing strategies for neonates with CHB, especially in severe forms like hydrops, are also assessed. This review emphasizes the need for interdisciplinary care by rheumatologists, obstetricians, and pediatricians in order to achieve the best maternal and neonatal health in lupus pregnancies. This multidisciplinary approach seeks to improve the outcomes and management of the disease, decreasing the burden on mothers and their infants.
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Affiliation(s)
- Armando Di Ludovico
- Paediatric Department, University of Chieti “G. D’Annunzio”, 66100 Chieti, Italy; (A.D.L.); (F.M.); (V.G.); (F.C.); (S.L.B.); (F.C.); (M.A.)
| | - Marta Rinaldi
- Paediatric Department, Buckinghamshire Healthcare NHS Trust, Aylesbury-Thames Valley Deanery, Aylesbury HP21 8AL, UK;
| | - Francesca Mainieri
- Paediatric Department, University of Chieti “G. D’Annunzio”, 66100 Chieti, Italy; (A.D.L.); (F.M.); (V.G.); (F.C.); (S.L.B.); (F.C.); (M.A.)
| | - Stefano Di Michele
- Department of Surgical Science, Division of Obstetrics and Gynecology, University of Cagliari, Cittadella Universitaria Blocco I, Asse didattico Medicina P2, Monserrato, 09042 Cagliari, Italy;
| | - Virginia Girlando
- Paediatric Department, University of Chieti “G. D’Annunzio”, 66100 Chieti, Italy; (A.D.L.); (F.M.); (V.G.); (F.C.); (S.L.B.); (F.C.); (M.A.)
| | - Francesca Ciarelli
- Paediatric Department, University of Chieti “G. D’Annunzio”, 66100 Chieti, Italy; (A.D.L.); (F.M.); (V.G.); (F.C.); (S.L.B.); (F.C.); (M.A.)
| | - Saverio La Bella
- Paediatric Department, University of Chieti “G. D’Annunzio”, 66100 Chieti, Italy; (A.D.L.); (F.M.); (V.G.); (F.C.); (S.L.B.); (F.C.); (M.A.)
| | - Francesco Chiarelli
- Paediatric Department, University of Chieti “G. D’Annunzio”, 66100 Chieti, Italy; (A.D.L.); (F.M.); (V.G.); (F.C.); (S.L.B.); (F.C.); (M.A.)
| | - Marina Attanasi
- Paediatric Department, University of Chieti “G. D’Annunzio”, 66100 Chieti, Italy; (A.D.L.); (F.M.); (V.G.); (F.C.); (S.L.B.); (F.C.); (M.A.)
| | - Angela Mauro
- Pediatric Rheumatology Unit, Department of Childhood and Developmental Medicine, Fatebenefratelli—Sacco Hospital, Piazzale Principessa Clotilde, 20121 Milan, Italy
| | - Emanuele Bizzi
- Division of Internal Medicine, ASST Fatebenefratelli Sacco, Fatebenefratelli Hospital, University of Milan, 20121 Milan, Italy; (E.B.); (A.B.)
| | - Antonio Brucato
- Division of Internal Medicine, ASST Fatebenefratelli Sacco, Fatebenefratelli Hospital, University of Milan, 20121 Milan, Italy; (E.B.); (A.B.)
- Department of Biomedical and Clinical Sciences “Sacco”, University of Milano, Ospedale Fatebenefratelli, 20121 Milan, Italy
| | - Luciana Breda
- Paediatric Department, University of Chieti “G. D’Annunzio”, 66100 Chieti, Italy; (A.D.L.); (F.M.); (V.G.); (F.C.); (S.L.B.); (F.C.); (M.A.)
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Limquiaco KNY, Salido EO. Complete Congenital Heart Block in the Offspring of an Asymptomatic Woman with Isolated High Titer Anti-Ro Antibody. ACTA MEDICA PHILIPPINA 2024; 58:84-89. [PMID: 38939855 PMCID: PMC11199349 DOI: 10.47895/amp.vi0.6358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/29/2024]
Abstract
Among pregnant women, 1-2% are anti-Ro positive and while half of them have symptoms of connective tissue disease, the rest are asymptomatic. The presence of anti-Ro is of concern because of the risk of congenital heart block in the child. We report the case of an asymptomatic 27-year-old G2P1(1001) woman, who presented with persistent fetal bradycardia in her 21st week of gestation (AOG) and was found to have elevated titers for anti-Ro (>320 U/ml). Hydroxychloroquine 200 mg/day and prednisone 10 mg/day were given from the 33rd week of gestation up until the delivery. At 37 weeks AOG, she delivered a live male neonate with a complete heart block. On the 6th day of life, the infant remained bradycardic, hence a pacemaker was inserted and heart rate maintained at 100-120 bpm. On subsequent follow-ups, the mother and child did not develop any systemic manifestations and the infant was thriving well. While a diseased condition may not be apparent in a pregnant anti-Ro positive woman, the risk of neonatal lupus (NL) is demonstrated in this patient's case. This report illustrates how prenatal care of an asymptomatic woman led to the discovery of a fetal abnormality and served to prepare the family and the medical team to ably handle the birth and subsequent care of a neonate with NL.
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Affiliation(s)
- Kristine Niña Y Limquiaco
- Division of Rheumatology, Department of Medicine, Philippine General Hospital, University of the Philippines Manila
| | - Evelyn O Salido
- Division of Rheumatology, Department of Medicine, Philippine General Hospital, University of the Philippines Manila
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Huang Y, Deng J, Liu J, Yang F, He Y. Autoimmune congenital heart block: a case report and review of the literature related to pathogenesis and pregnancy management. Arthritis Res Ther 2024; 26:8. [PMID: 38167489 PMCID: PMC10759413 DOI: 10.1186/s13075-023-03246-w] [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: 08/01/2023] [Accepted: 12/19/2023] [Indexed: 01/05/2024] Open
Abstract
Autoimmune congenital heart block (ACHB) is a passively acquired immune-mediated disease characterized by the presence of maternal antibodies against components of the Ro/SSA and La/SSB ribonucleoprotein complex that mainly affects the cardiac conducting system. ACHB occurs in 2% of women with positive anti-Ro/SSA and anti-La/SSB antibodies and causes a high risk of intrauterine fetal death, neonatal mortality, and long-term sequelae. In this review, we first describe a case of ACHB to provide preliminary knowledge. Then, we discuss the possible pathogenic mechanisms of ACHB; summarize the pregnancy management of patients with positive anti-Ro/SSA and anti-La/SSB antibodies and/or rheumatic diseases, the prevention of ACHB, and the treatment of ACHB fetuses; and propose routine screening of these antibodies for the general population. Careful follow-up, which consists of monitoring the fetal heart rate, is feasible and reassuring for pregnant women with positive anti-Ro/SSA and/or anti-La/SSB antibodies to lower the risk of ACHB in fetuses. Moreover, maternal administration of hydroxychloroquine may be useful in preventing ACHB in pregnant women with anti-Ro/SSA and/or anti-La/SSB antibodies.
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Affiliation(s)
- Ying Huang
- Department of Rheumatology and Immunology, The Third Affiliated Hospital, Southern Medical University, No. 183, Zhongshan Avenue West, Tianhe District, Guangzhou, 510630, China
- Institute of Clinical Immunology, Academy of Orthopedics, Guangdong Province, Guangzhou, China
| | - Jialin Deng
- Department of Rheumatology and Immunology, The Third Affiliated Hospital, Southern Medical University, No. 183, Zhongshan Avenue West, Tianhe District, Guangzhou, 510630, China
- Institute of Clinical Immunology, Academy of Orthopedics, Guangdong Province, Guangzhou, China
| | - Jinghua Liu
- Department of Pediatrics, The Third Affiliated Hospital, Southern Medical University, Guangzhou, China
| | - Fangyuan Yang
- Department of Rheumatology and Immunology, The Third Affiliated Hospital, Southern Medical University, No. 183, Zhongshan Avenue West, Tianhe District, Guangzhou, 510630, China.
- Institute of Clinical Immunology, Academy of Orthopedics, Guangdong Province, Guangzhou, China.
| | - Yi He
- Department of Rheumatology and Immunology, The Third Affiliated Hospital, Southern Medical University, No. 183, Zhongshan Avenue West, Tianhe District, Guangzhou, 510630, China.
- Institute of Clinical Immunology, Academy of Orthopedics, Guangdong Province, Guangzhou, China.
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Kotecha MK, Merchant K, Chan CJ, Choo JTL, Gopagondanahalli KR, Zhang DZ, Tan TH, Sundararaghavan S. Endocardial Fibroelastosis as an Independent Predictor of Atrioventricular Valve Rupture in Maternal Autoimmune Antibody Exposed Fetus: A Systematic Review with Clinicopathologic Analysis. Diagnostics (Basel) 2023; 13:diagnostics13081481. [PMID: 37189582 DOI: 10.3390/diagnostics13081481] [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: 02/16/2023] [Revised: 04/12/2023] [Accepted: 04/13/2023] [Indexed: 05/17/2023] Open
Abstract
BACKGROUND Neonatal lupus (NL) is a clinical syndrome that develops in the fetus as a result of maternal autoimmune antibodies. Congenital complete heart block (CHB) is the most common manifestation, while extranodal cardiac manifestations of NL, such as endocardial fibroelastosis (EFE) and myocarditis, are rare but more serious. Less is known about this atrioventricular valve rupture due to valvulitis as a consequence of maternal autoantibodies. We have described a case of cardiac neonatal lupus with an antenatally detected CHB patient who developed mitral and tricuspid valve chordal rupture at 45 days of age. We compared the cardiac histopathology and the fetal cardiac echocardiographic findings of this case with another fetus that was aborted after being antenatally diagnosed with CHB but without valvar rupture. A narrative analysis after a systematic review of the literature regarding atrioventricular valve apparatus rupture due to autoimmune etiology along with maternal characteristics, presentation, treatment, and outcome have been discussed in this article. OBJECTIVES To describe published data on atrioventricular valve rupture in neonatal lupus, including clinical presentation, diagnostic evaluation, management, and outcomes. METHODS We conducted a PRISMA-compliant descriptive systematic examination of case reports that included accounts of lupus during pregnancy or in the newborn period that resulted in an atrioventricular valve rupture. We gathered information on the patient's demographics, the details of the valve rupture and other comorbidities, the maternal therapy, the clinical course, and the results. We also used a standardized method to evaluate the cases' quality. A total of 12 cases were investigated, with 11 cases drawn from 10 case reports or case series and 1 from our own experience. RESULTS Tricuspid valve rupture (50%) is more common than mitral valve rupture (17%). Unlike mitral valve rupture, which occurs postnatally, the timing of tricuspid valve rupture is perinatal. A total of 33% of the patients had concomitant complete heart block, while 75% of the patients had endocardial fibroelastosis on an antenatal ultrasound. Antenatal changes pertaining to endocardial fibroelastosis can be seen as early as 19 weeks of gestation. Patients with both valve ruptures generally have a poor prognosis, especially if they occur at close intervals. CONCLUSION Atrioventricular valve rupture in neonatal lupus is rare. A majority of patients with valve rupture had antenatally detected endocardial fibroelastosis in the valvar apparatus. Appropriate and expedited surgical repair of ruptured atrioventricular valves is feasible and has a low mortality risk. Rupture of both atrioventricular valves occurring at close intervals carries a high mortality risk.
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Affiliation(s)
- Monika Kantilal Kotecha
- Department of Paediatric Subspecialties, Cardiology Service, KK Women's and Children's Hospital, Singapore 229899, Singapore
| | - Khurshid Merchant
- Department of Pathology and Laboratory Medicine, KK Women's and Children's Hospital, Singapore 229899, Singapore
| | - Charmaine Jiahui Chan
- Department of Paediatric Subspecialties, Cardiology Service, KK Women's and Children's Hospital, Singapore 229899, Singapore
| | - Jonathan Tze Liang Choo
- Department of Paediatric Subspecialties, Cardiology Service, KK Women's and Children's Hospital, Singapore 229899, Singapore
| | | | - Dyan Zhewei Zhang
- Department of Paediatric Subspecialties, Cardiology Service, KK Women's and Children's Hospital, Singapore 229899, Singapore
| | - Teng Hong Tan
- Department of Paediatric Subspecialties, Cardiology Service, KK Women's and Children's Hospital, Singapore 229899, Singapore
| | - Sreekanthan Sundararaghavan
- Department of Paediatric Subspecialties, Cardiology Service, KK Women's and Children's Hospital, Singapore 229899, Singapore
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Firl CEM, Halushka M, Fraser N, Masson M, Cuneo BF, Saxena A, Clancy R, Buyon J. Contribution of S100A4-expressing fibroblasts to anti-SSA/Ro-associated atrioventricular nodal calcification and soluble S100A4 as a biomarker of clinical severity. Front Immunol 2023; 14:1114808. [PMID: 37090702 PMCID: PMC10117984 DOI: 10.3389/fimmu.2023.1114808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 03/06/2023] [Indexed: 04/25/2023] Open
Abstract
Background Fibrosis and dystrophic calcification disrupting conduction tissue architecture are histopathological lesions characterizing cardiac manifestations of neonatal lupus (cardiac-NL) associated with maternal anti-SSA/Ro antibodies. Objectives Increased appreciation of heterogeneity in fibroblasts encourages re-examination of existing models with the consideration of multiple fibroblast subtypes (and their unique functional differences) in mind. This study addressed fibroblast heterogeneity by examining expression of α-Smooth Muscle Actin (myofibroblasts) and of S100 Calcium-Binding Protein A4 (S100A4). Methods Using a previously established model of rheumatic scarring/fibrosis in vitro, supported by the evaluation of cord blood from cardiac-NL neonates and their healthy (anti-SSA/Ro-exposed) counterparts, and autopsy tissue from fetuses dying with cardiac-NL, the current study was initiated to more clearly define and distinguish the S100A4-positive fibroblast in the fetal cardiac environment. Results S100A4 immunostaining was observed in 4 cardiac-NL hearts with positional identity in the conduction system at regions of dystrophic calcification but not fibrotic zones, the latter containing only myofibroblasts. In vitro, fibroblasts cultured with supernatants of macrophages transfected with hY3 (noncoding ssRNA) differentiated into myofibroblasts or S100A4+ fibroblasts. Myofibroblasts expressed collagen while S100A4+ fibroblasts expressed pro-angiogenic cytokines and proteases that degrade collagen. Cord blood levels of S100A4 in anti-SSA/Ro-exposed neonates tracked disease severity and, in discordant twins, distinguished affected from unaffected. Conclusions These findings position the S100A4+ fibroblast alongside the canonical myofibroblast in the pathogenesis of cardiac-NL. Neonatal S100A4 levels support a novel biomarker of poor prognosis.
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Affiliation(s)
- Christina E. M. Firl
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, New York, NY, United States
| | - Marc Halushka
- Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, MD, United States
| | - Nicola Fraser
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, New York, NY, United States
| | - Mala Masson
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, New York, NY, United States
| | - Bettina F. Cuneo
- Department of Obstetrics and Gynecology, University of Colorado Anschultz Medical Campus, Aurora, CO, United States
| | - Amit Saxena
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, New York, NY, United States
| | - Robert Clancy
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, New York, NY, United States
| | - Jill Buyon
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, New York, NY, United States
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Gryka-Marton M, Szukiewicz D, Teliga-Czajkowska J, Olesinska M. An Overview of Neonatal Lupus with Anti-Ro Characteristics. Int J Mol Sci 2021; 22:9281. [PMID: 34502221 PMCID: PMC8431034 DOI: 10.3390/ijms22179281] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 08/23/2021] [Accepted: 08/23/2021] [Indexed: 01/23/2023] Open
Abstract
Neonatal lupus erythematosus (NLE) is a syndrome of clinical symptoms observed in neonates born to mothers with antibodies to soluble antigens of the cell nucleus. The main factors contributing to the pathogenesis of this disease are anti-Sjögren Syndrome A (anti-SS-A) antibodies, known as anti-Ro, and anti-Sjögren Syndrome B (anti-SS-B) antibodies, known as anti-La. Recent publications have also shown the significant role of anti-ribonucleoprotein antibodies (anti-RNP). Seropositive mothers may have a diagnosed rheumatic disease or they can be asymptomatic without diagnosis at the time of childbirth. These antibodies, after crossing the placenta, may trigger a cascade of inflammatory reactions. The symptoms of NLE can be divided into reversible symptoms, which concern skin, hematological, and hepatological changes, but 2% of children develop irreversible symptoms, which include disturbances of the cardiac stimulatory and conduction system. Preconceptive care and pharmacological prophylaxis of NLE in the case of mothers from the risk group are important, as well as the monitoring of the clinical condition of the mother and fetus throughout pregnancy and the neonatal period. The aim of this manuscript is to summarize the previous literature and current state of knowledge about neonatal lupus and to discuss the role of anti-Ro in the inflammatory process.
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Affiliation(s)
- Malgorzata Gryka-Marton
- Department of Biophysics, Physiology and Pathophysiology, Faculty of Health Sciences, Medical University of Warsaw, 02-004 Warsaw, Poland;
- Department of Systemic Connective Tissue Diseases, National Institute of Geriatrics, Rheumatology and Rehabilitation, 02-637 Warsaw, Poland;
| | - Dariusz Szukiewicz
- Department of Biophysics, Physiology and Pathophysiology, Faculty of Health Sciences, Medical University of Warsaw, 02-004 Warsaw, Poland;
| | - Justyna Teliga-Czajkowska
- Department of Obstetrics and Gynecology Didactics, Faculty of Health Sciences, Medical University of Warsaw, 00-315 Warsaw, Poland;
| | - Marzena Olesinska
- Department of Systemic Connective Tissue Diseases, National Institute of Geriatrics, Rheumatology and Rehabilitation, 02-637 Warsaw, Poland;
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Milazzo R, Ligato E, Laoreti A, Ferri G, Basili L, Serati L, Brucato A, Cetin I. Home fetal heart rate monitoring in anti Ro/SSA positive pregnancies: Literature review and case report. Eur J Obstet Gynecol Reprod Biol 2021; 259:1-6. [PMID: 33556767 DOI: 10.1016/j.ejogrb.2021.01.031] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 01/18/2021] [Indexed: 10/22/2022]
Abstract
Anti-Ro/SSA antibodies are associated with a risk of 1-2 % to develop complete atrioventricular block (AVB) in fetuses of positive mothers. Complete AVB is irreversible, but studies suggest that anti-inflammatory treatment during the transition period from a normal fetal heart rate (FHR) to an AVB might stop this progression and restore sinus rhythm. The most efficient method for diagnostic evaluation of this arrhythmia is the pulsed-Doppler fetal echocardiography. However, weekly or bi-weekly recommended fetal echocardiographic surveillance can rarely identify an AVB in time for treatment success, also because the transition from a normal rhythm to a third degree AVB is very fast. Daily FHR monitoring in a medical facility could increase the chances of identifying the AVB onset but is difficult to realize. For this reason, an alternative method of FHR monitoring, performed directly by mothers in their home context, has been recently proposed. We present a case report utilizing this approach and review the current evidence about this condition.
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Affiliation(s)
- Roberta Milazzo
- Department of Woman, Mother and Neonate, "V. Buzzi" Children Hospital, ASST Fatebenefratelli Sacco, Milan, Italy.
| | - Elisa Ligato
- Department of Woman, Mother and Neonate, "V. Buzzi" Children Hospital, ASST Fatebenefratelli Sacco, Milan, Italy
| | - Arianna Laoreti
- Department of Woman, Mother and Neonate, "V. Buzzi" Children Hospital, ASST Fatebenefratelli Sacco, Milan, Italy
| | - Giulia Ferri
- Department of Woman, Mother and Neonate, "V. Buzzi" Children Hospital, ASST Fatebenefratelli Sacco, Milan, Italy
| | - Ludovica Basili
- Department of Woman, Mother and Neonate, "V. Buzzi" Children Hospital, ASST Fatebenefratelli Sacco, Milan, Italy
| | - Lisa Serati
- Internal Medicine, Fatebenefratelli Hospital, Milan, Italy
| | | | - Irene Cetin
- Department of Woman, Mother and Neonate, "V. Buzzi" Children Hospital, ASST Fatebenefratelli Sacco, Milan, Italy; Department of Biomedical and Clinical Sciences "Luigi Sacco", University of Milan, Milan, Italy
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Izmirly P, Kim M, Friedman DM, Costedoat-Chalumeau N, Clancy R, Copel JA, Phoon CKL, Cuneo BF, Cohen RE, Robins K, Masson M, Wainwright BJ, Zahr N, Saxena A, Buyon JP. Hydroxychloroquine to Prevent Recurrent Congenital Heart Block in Fetuses of Anti-SSA/Ro-Positive Mothers. J Am Coll Cardiol 2021; 76:292-302. [PMID: 32674792 DOI: 10.1016/j.jacc.2020.05.045] [Citation(s) in RCA: 93] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 05/15/2020] [Accepted: 05/18/2020] [Indexed: 01/03/2023]
Abstract
BACKGROUND Experimental and clinical evidence support the role of macrophage Toll-like receptor signaling in maternal anti-SSA/Ro-mediated congenital heart block (CHB). OBJECTIVES Hydroxychloroquine (HCQ), an orally administered Toll-like receptor antagonist widely used in lupus including during pregnancy, was evaluated for efficacy in reducing the historical 18% recurrence rate of CHB. METHODS This multicenter, open-label, single-arm, 2-stage clinical trial was designed using Simon's optimal approach. Anti-SSA/Ro-positive mothers with a previous pregnancy complicated by CHB were recruited (n = 19 Stage 1; n = 35 Stage 2). Patients received 400 mg daily of HCQ prior to completion of gestational week 10, which was maintained through pregnancy. The primary outcome was 2° or 3° CHB any time during pregnancy, and secondary outcomes included isolated endocardial fibroelastosis, 1° CHB at birth and skin rash. RESULTS By intention-to-treat (ITT) analysis, 4 of 54 evaluable pregnancies resulted in a primary outcome (7.4%; 90% confidence interval: 3.4% to 15.9%). Because 9 mothers took potentially confounding medications (fluorinated glucocorticoids and/or intravenous immunoglobulin) after enrollment but prior to a primary outcome, to evaluate HCQ alone, 9 additional mothers were recruited and followed the identical protocol. In the per-protocol analysis restricted to pregnancies exposed to HCQ alone, 4 of 54 (7.4%) fetuses developed a primary outcome as in the ITT. Secondary outcomes included mild endocardial fibroelastosis (n = 1) and cutaneous neonatal lupus (n = 4). CONCLUSIONS These prospective data support that HCQ significantly reduces the recurrence of CHB below the historical rate by >50%, suggesting that this drug should be prescribed for secondary prevention of fetal cardiac disease in anti-SSA/Ro-exposed pregnancies. (Preventive Approach to Congenital Heart Block With Hydroxychloroquine [PATCH]; NCT01379573).
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Affiliation(s)
- Peter Izmirly
- New York University School of Medicine, New York, New York.
| | - Mimi Kim
- Albert Einstein College of Medicine, Bronx, New York
| | | | | | - Robert Clancy
- New York University School of Medicine, New York, New York
| | | | | | | | | | | | - Mala Masson
- New York University School of Medicine, New York, New York
| | | | - Noel Zahr
- Pitié-Salpêtrière University Hospital, Paris, France
| | - Amit Saxena
- New York University School of Medicine, New York, New York
| | - Jill P Buyon
- New York University School of Medicine, New York, New York. https://twitter.com/JillBuyonMD
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Ambrosi A, Thorlacius GE, Sonesson SE, Wahren-Herlenius M. Interferons and innate immune activation in autoimmune congenital heart block. Scand J Immunol 2021; 93:e12995. [PMID: 33188653 DOI: 10.1111/sji.12995] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 10/26/2020] [Accepted: 11/06/2020] [Indexed: 12/12/2022]
Abstract
Autoimmune congenital heart block (CHB) may develop in foetuses of women carrying anti-Ro/SSA and La/SSB autoantibodies and is characterized by disruption of signal conduction at the atrioventricular (AV) node, resulting in partial or complete AV block. If not fatal in utero, complete CHB typically requires lifelong cardiac pacing. No treatment has so far been unequivocally demonstrated to prevent or treat autoimmune CHB, and the relatively low incidence (1%-5%) and recurrence (12%-16%) rates of second/third-degree AV block add to the complexity of managing pregnancies in women with anti-Ro/La antibodies. Altogether, a better understanding of events leading to development of autoimmune CHB is needed to improve surveillance and treatment strategies. In the past decade, studies have started to look beyond the role of maternal autoantibodies in disease pathogenesis to assess other contributing factors such as foetal genetics and, more recently, immune responses in foetuses and neonates of anti-Ro/La antibody-positive women. In this review, we provide an update on the epidemiology, clinical presentation and current treatment approaches of autoimmune CHB, summarize the previously proposed pathogenic mechanisms implicating maternal autoantibodies, and discuss the recent findings of type I interferon (IFN) and innate immune activation in foetuses with autoimmune CHB and in neonates of anti-Ro/La antibody-positive mothers, and how these may contribute to autoimmune CHB pathogenesis.
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Affiliation(s)
- Aurelie Ambrosi
- Division of Rheumatology, Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Gudny Ella Thorlacius
- Division of Rheumatology, Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Sven-Erik Sonesson
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Marie Wahren-Herlenius
- Division of Rheumatology, Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.,Broegelmann Research Laboratory, Department of Clinical Science, University of Bergen, Bergen, Norway
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11
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Ivanchenko M, Thorlacius GE, Hedlund M, Ottosson V, Meneghel L, Björkander S, Ossoinak A, Tingström J, Bremme K, Sverremark-Ekström E, Gemzell-Danielsson K, Sonesson SE, Chemin K, Wahren-Herlenius M. Natural killer cells and type II interferon in Ro/SSA and La/SSB autoantibody-exposed newborns at risk of congenital heart block. Ann Rheum Dis 2020; 80:194-202. [PMID: 33004330 DOI: 10.1136/annrheumdis-2019-216786] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Revised: 08/17/2020] [Accepted: 08/18/2020] [Indexed: 11/04/2022]
Abstract
OBJECTIVE Congenital heart block (CHB) with immune cell infiltration develops in the fetus after exposure to maternal Ro/La autoantibodies. CHB-related serology has been extensively studied, but reports on immune-cell profiles of anti-Ro/La-exposed neonates are lacking. In the current study, we characterised circulating immune-cell populations in anti-Ro/La+mothers and newborns, and explored potential downstream effects of skewed neonatal cell populations. METHODS In total, blood from mothers (n=43) and neonates (n=66) was sampled at birth from anti-Ro/La+ (n=36) and control (n=30) pregnancies with or without rheumatic disease and CHB. Flow cytometry, microarrays and ELISA were used for characterising cells and plasma. RESULTS Similar to non-pregnant systemic lupus erythematosus and Sjögren-patients, anti-Ro/La+mothers had altered B-cell subset frequencies, relative T-cell lymphopenia and lower natural killer (NK)-cell frequencies. Surprisingly, their anti-Ro/La exposed neonates presented higher frequencies of CD56dimCD16hi NK cells (p<0.01), but no other cell frequency differences compared with controls. Type I and II interferon (IFN) gene-signatures were revealed in neonates of anti-Ro/La+ pregnancy, and exposure of fetal cardiomyocytes to type I IFN induced upregulation of several NK-cell chemoattractants and activating ligands. Intracellular flow cytometry revealed IFNγ production by NK cells, CD8+ and CD4+ T cells in anti-Ro/La exposed neonates. IFNγ was also detectable in their plasma. CONCLUSION Our study demonstrates an increased frequency of NK cells in anti-Ro/La exposed neonates, footprints of type I and II IFN and an upregulation of ligands activating NK cells in fetal cardiac cells after type I IFN exposure. These novel observations demonstrate innate immune activation in neonates of anti-Ro/La+pregnancy, which could contribute to the risk of CHB.
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Affiliation(s)
- Margarita Ivanchenko
- Division of Rheumatology, Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Gudny Ella Thorlacius
- Division of Rheumatology, Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Malin Hedlund
- Division of Rheumatology, Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Vijole Ottosson
- Division of Rheumatology, Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Lauro Meneghel
- Division of Rheumatology, Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Sophia Björkander
- Department of Molecular Biosciences, The Wenner-Gren Institute, Stockholm University, Stockholm, Sweden
| | - Amina Ossoinak
- Division of Rheumatology, Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Joanna Tingström
- Division of Rheumatology, Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Katarina Bremme
- Division of Obstetrics and Gynecology, Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Eva Sverremark-Ekström
- Department of Molecular Biosciences, The Wenner-Gren Institute, Stockholm University, Stockholm, Sweden
| | - Kristina Gemzell-Danielsson
- Division of Obstetrics and Gynecology, Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Sven-Erik Sonesson
- Division of Pediatric Cardiology, Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Karine Chemin
- Division of Rheumatology, Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Marie Wahren-Herlenius
- Division of Rheumatology, Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden .,Broegelmann Research Laboratory, Department of Clinical Science, University of Bergen, Bergen, Hordaland, Norway
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12
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Popescu MR, Dudu A, Jurcut C, Ciobanu AM, Zagrean AM, Panaitescu AM. A Broader Perspective on Anti-Ro Antibodies and Their Fetal Consequences-A Case Report and Literature Review. Diagnostics (Basel) 2020; 10:E478. [PMID: 32674462 PMCID: PMC7399931 DOI: 10.3390/diagnostics10070478] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Revised: 07/11/2020] [Accepted: 07/12/2020] [Indexed: 12/20/2022] Open
Abstract
The presence of maternal Anti-Ro/Anti-La antibodies causes a passively acquired autoimmunity that may be associated with serious fetal complications. The classic example is the autoimmune-mediated congenital heart block (CHB) which is due in most cases to the transplacental passage of Anti-Ro/Anti-La antibodies. The exact mechanisms through which these pathologic events arise are linked to disturbances in calcium channels function, impairment of calcium homeostasis and ultimately apoptosis, inflammation and fibrosis. CHB still represents a challenging diagnosis and a source of debate regarding the best management. As the third-degree block is usually irreversible, the best strategy is risk awareness and prevention. Although CHB is a rare occurrence, it affects one in 20,000 live births, with a high overall mortality rate (up to 20%, with 70% of in utero deaths). There is also concern over the lifelong consequences, as most babies need a pacemaker. This review aims to offer, apart from the data needed for a better understanding of the issue at hand, a broader perspective of the specialists directly involved in managing this pathology: the rheumatologist, the maternal-fetal specialist and the cardiologist. To better illustrate the theoretical facts presented, we also include a representative clinical case.
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Affiliation(s)
- Mihaela Roxana Popescu
- Cardiology Department, Elias University Hospital, “Carol Davila” University of Medicine and Pharmacy, 011461 Bucharest, Romania
| | - Andreea Dudu
- Internal Medicine Department, “Dr Carol Davila” Central Emergency University Military Hospital, 010825 Bucharest, Romania; (A.D.); (C.J.)
| | - Ciprian Jurcut
- Internal Medicine Department, “Dr Carol Davila” Central Emergency University Military Hospital, 010825 Bucharest, Romania; (A.D.); (C.J.)
| | - Anca Marina Ciobanu
- Department of Obstetrics and Gynecology, Filantropia Clinical Hospital, “Carol Davila” University of Medicine and Pharmacy, 011171 Bucharest, Romania; (A.M.C.); (A.M.P.)
| | - Ana-Maria Zagrean
- Division of Physiology and Neuroscience, Department of Functional Sciences, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania;
| | - Anca Maria Panaitescu
- Department of Obstetrics and Gynecology, Filantropia Clinical Hospital, “Carol Davila” University of Medicine and Pharmacy, 011171 Bucharest, Romania; (A.M.C.); (A.M.P.)
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13
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Berggren O, Pucholt P, Amcoff C, Rönnblom L, Eloranta ML. Activation of plasmacytoid dendritic cells and B cells with two structurally different Toll-like receptor 7 agonists. Scand J Immunol 2020; 91:e12880. [PMID: 32219875 DOI: 10.1111/sji.12880] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 03/17/2020] [Accepted: 03/18/2020] [Indexed: 12/12/2022]
Abstract
Synthetic Toll-like receptor (TLR) 7 agonists have been suggested as immune modulators in a range of conditions. In contrast, self-derived TLR7 activators, such as RNA-containing immune complexes (RNA-IC), can contribute to autoimmune diseases due to endogenous immune activation. The exact difference in immune cell response between synthetic and endogenous TLR7 triggers is only partly known. An understanding of these differences could aid in the development of new therapeutic agents and provide insights into autoimmune disease mechanisms. We therefore compared the stimulatory capacity of two TLR7 agonists, RNA-IC and a synthetic small molecule DSR-6434, on blood leucocytes, plasmacytoid dendritic cells (pDCs) and B cells from healthy individuals. IFN-α, IL-6, IL-8 and TNF levels were measured by immunoassays, and gene expression in pDCs was analysed by an expression array. DSR-6434 triggered 20-fold lower levels of IFN-α by pDCs, but higher production of IL-6, IL-8 and TNF, compared to RNA-IC. Furthermore, IFN-α and TNF production were increased with exogenous IFN-α2b priming, whereas IL-8 synthesis by B cells was reduced for both stimuli. Cocultivation of pDCs and B cells increased the RNA-IC-stimulated IFN-α and TNF levels, while only IL-6 production was enhanced in the DSR-6434-stimulated cocultures. When comparing pDCs stimulated with RNA-IC and DSR-6434, twelve genes were differentially expressed (log2 fold change >2, adjusted P-value <.05). In conclusion, RNA-IC, which mimics an endogenous TLR7 stimulator, and the synthetic TLR7 agonist DSR-6434 trigger distinct inflammatory profiles in immune cells. This demonstrates the importance of using relevant stimuli when targeting the TLR7 pathway for therapeutic purposes.
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Affiliation(s)
- Olof Berggren
- Department of Medical Sciences, Rheumatology, Science for Life Laboratory, Uppsala University, Uppsala, Sweden
| | - Pascal Pucholt
- Department of Medical Sciences, Rheumatology, Science for Life Laboratory, Uppsala University, Uppsala, Sweden
| | - Cane Amcoff
- Department of Medical Sciences, Rheumatology, Science for Life Laboratory, Uppsala University, Uppsala, Sweden
| | - Lars Rönnblom
- Department of Medical Sciences, Rheumatology, Science for Life Laboratory, Uppsala University, Uppsala, Sweden
| | - Maija-Leena Eloranta
- Department of Medical Sciences, Rheumatology, Science for Life Laboratory, Uppsala University, Uppsala, Sweden
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De Carolis S, Garufi C, Garufi E, De Carolis MP, Botta A, Tabacco S, Salvi S. Autoimmune Congenital Heart Block: A Review of Biomarkers and Management of Pregnancy. Front Pediatr 2020; 8:607515. [PMID: 33415090 PMCID: PMC7784711 DOI: 10.3389/fped.2020.607515] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 11/30/2020] [Indexed: 11/13/2022] Open
Abstract
Autoimmune Congenital Heart Block (CHB) is an immune-mediated disease due to transplacental passage of circulating anti-Ro/SSA and anti-La/SSB autoantibodies. It occurs in 2% of anti-Ro/SSA-exposed pregnancies, and recurrence rate is nine times higher in subsequent pregnancies. Aim of this review is to identify biomarkers of CHB and treatment strategies. The Ro-system is constituted by two polypeptides targeted by the anti-Ro52 and anti-Ro60 autoantibodies. The central portion of Ro52 (p200), more than the full amino-acid sequence of Ro-52, is recognized to be the fine specificity of anti-Ro associated to the highest risk of cardiac damage. If anti-p200 antibody should be tested, as biomarker of CHB, over standard commercial ELISAs is still debated. Recent studies indicate that type I-Interferon (IFN) can activate fibroblasts in fetal heart. In the mother the anti-Ro/La antibodies activate the type I IFN-signature, and maternal IFN-regulated genes correlate with a similar neonatal IFN-gene expression. Evaluation of maternal IFN-signature could be used as novel biomarker of CHB. The measurement of "mechanical" PR interval with weekly fetal echocardiogram (ECHO) from 16 to at least 24 weeks of gestation is strongly recommended for CHB prenatal diagnosis. However, ECHO screening presents some limitations due to difficult identification of first-degree block and possible occurrence of a complete block from a normal rhythm in few days. Maternal administration of Hydroxychloroquine from the tenth week of gestation, modulating toll-like receptor and autoantibody-dependent type I IFN activation on the fetus, has an important role in preventing CHB in pregnant women with high risk for recurrent CHB.
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Affiliation(s)
- Sara De Carolis
- Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Department of Obstetrics, Gynaecology and Pediatrics, Rome, Italy
| | - Cristina Garufi
- Dipartimento di Scienze Cliniche, Internistiche, Anestesiologiche e Cardiovascolari, UOC Reumatologia, Sapienza University of Rome, Rome, Italy
| | - Ester Garufi
- Medical School, University of Florence, Florence, Italy
| | - Maria Pia De Carolis
- Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Department of Obstetrics, Gynaecology and Pediatrics, Rome, Italy
| | - Angela Botta
- Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Department of Obstetrics, Gynaecology and Pediatrics, Rome, Italy
| | - Sara Tabacco
- Department of Gynecological Sciences, Sapienza University of Rome, Rome, Italy
| | - Silvia Salvi
- Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Department of Obstetrics, Gynaecology and Pediatrics, Rome, Italy
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