1
|
Rhein AK, Rabinovich A, Abuhasira R, Lubaton-Barshishat S, Erez O. Obstetric antiphospholipid syndrome carries an increased lifetime risk for obstetric and thrombotic complications-a population-based study. Res Pract Thromb Haemost 2024; 8:102430. [PMID: 38798792 PMCID: PMC11127162 DOI: 10.1016/j.rpth.2024.102430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Revised: 04/13/2024] [Accepted: 04/23/2024] [Indexed: 05/29/2024] Open
Abstract
Background Antiphospholipid syndrome (APS) can present with either a thromboembolic event (thrombotic APS, TAPS) or an obstetric complication (obstetric APS, OAPS). Data on long-term complications in the different APS phenotypes are limited. Objectives We aimed to compare obstetric history, antiphospholipid antibody profiles, obstetric and thromboembolic complications, and pregnancy outcomes between TAPS and OAPS. Methods This retrospective cohort study included women who delivered singleton pregnancies between 1998 and 2020. One hundred sixteen thousand four hundred nine women were included, resulting in 320,455 deliveries. Among the included patients, 71 were diagnosed with APS, 49 were classified as OAPS, and 22 as TAPS. The demographics, obstetric, neonatal, and thrombotic outcomes were compared among TAPS, OAPS, and the general obstetric population. Results OAPS patients had an increased risk of thrombotic events compared with the general obstetric population (odds ratio [OR] 18.0; 95% CI, 8.7-37.2). In pregnancies following the diagnosis of APS, despite standard antithrombotic treatment, OAPS patients exhibited an elevated risk of placenta-related and neonatal complications compared with the general obstetric population (late fetal loss [adjusted OR {aOR}, 15.3; 95% CI, 0.5-27.5], stillbirth [aOR, 5.9; 95% CI, 2.2-15.4], placental abruption [aOR, 4.8; 95% CI, 1.5-15.3], preeclampsia [aOR, 4.4; 95% CI, 2.5-7.7], fetal growth restriction [aOR, 4.3; 95% CI, 8.5-27.5], small for gestational age neonate [aOR, 4.0; 95% CI, 2.4-6.6], and low Apgar scores [Apgar'1: aOR, 2.6; 95% CI, 1.3-10.4; Apgar'5: aOR, 3.7; 95% CI, 1.3-10.4]). TAPS patients exhibited increased risk of preeclampsia (aOR, 3.1; 95% CI, 1.2-8). Conclusion OAPS patients exhibit a heightened risk of thrombotic events compared with the general obstetric population. Despite treatment, OAPS and TAPS still presented obstetric complications. These findings, after confirmation in prospective studies, need to be taken into consideration when planning the treatment approach for these patients.
Collapse
Affiliation(s)
- Ariel Katherine Rhein
- The Joyce & Irving Goldman Medical School, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Anat Rabinovich
- Thrombosis and Hemostasis Unit, Hematology Institute, Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Ran Abuhasira
- The Joyce & Irving Goldman Medical School, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
- Clinical Research Center, Soroka University Medical Center, Beer-Sheva, Israel
| | - Shir Lubaton-Barshishat
- Department of Obstetrics and Gynecology, Soroka University Medical Center, Beer-Sheva, Israel
| | - Offer Erez
- Department of Obstetrics and Gynecology, Soroka University Medical Center, Beer-Sheva, Israel
- Department of Obstetrics and Gynecology, Hutzel Women's Hospital, Wayne State University, Detroit, Michigan, USA
| |
Collapse
|
2
|
Cristodoro M, Dell’Avanzo M, Ghio M, Lalatta F, Vena W, Lania A, Sacchi L, Bravo M, Bulfoni A, Di Simone N, Inversetti A. Before Is Better: Innovative Multidisciplinary Preconception Care in Different Clinical Contexts. J Clin Med 2023; 12:6352. [PMID: 37834996 PMCID: PMC10573412 DOI: 10.3390/jcm12196352] [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: 08/29/2023] [Revised: 10/01/2023] [Accepted: 10/02/2023] [Indexed: 10/15/2023] Open
Abstract
CONTEXT Implementation of pre-conception care units is still very limited in Italy. Nowadays, the population's awareness of the reproductive risks that can be reduced or prevented is very low. Purpose and main findings: We presented a new personalized multidisciplinary model of preconception care aimed at identifying and possibly reducing adverse reproductive events. We analyzed three cohorts of population: couples from the general population, infertile or subfertile couples, and couples with a previous history of adverse reproductive events. The proposal involves a deep investigation regarding family history, the personal histories of both partners, and reproductive history. PRINCIPAL CONCLUSIONS Preconception care is still neglected in Italy and under-evaluated by clinicians involved in natural or in vitro reproduction. Adequate preconception counseling will improve maternal and fetal obstetrical outcomes.
Collapse
Affiliation(s)
- Martina Cristodoro
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072 Pieve Emanuele, Italy
- IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Milan, Italy
- Division of Obstetrics and Gynecology, Humanitas San Pio X Hospital, 20159 Milan, Italy
- Diabetes Center, Humanitas Gavazzeni Institute, Via M. Gavazzeni 21, 24100 Bergamo, Italy
| | - Marinella Dell’Avanzo
- Division of Obstetrics and Gynecology, Humanitas San Pio X Hospital, 20159 Milan, Italy
| | - Matilda Ghio
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072 Pieve Emanuele, Italy
| | - Faustina Lalatta
- Division of Obstetrics and Gynecology, Humanitas San Pio X Hospital, 20159 Milan, Italy
| | - Walter Vena
- Diabetes Center, Humanitas Gavazzeni Institute, Via M. Gavazzeni 21, 24100 Bergamo, Italy
| | - Andrea Lania
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072 Pieve Emanuele, Italy
| | - Laura Sacchi
- IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Milan, Italy
| | - Maria Bravo
- Division of Obstetrics and Gynecology, Humanitas San Pio X Hospital, 20159 Milan, Italy
| | - Alessandro Bulfoni
- Division of Obstetrics and Gynecology, Humanitas San Pio X Hospital, 20159 Milan, Italy
| | - Nicoletta Di Simone
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072 Pieve Emanuele, Italy
- IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Milan, Italy
- Division of Obstetrics and Gynecology, Humanitas San Pio X Hospital, 20159 Milan, Italy
- Diabetes Center, Humanitas Gavazzeni Institute, Via M. Gavazzeni 21, 24100 Bergamo, Italy
| | - Annalisa Inversetti
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072 Pieve Emanuele, Italy
- IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Milan, Italy
- Division of Obstetrics and Gynecology, Humanitas San Pio X Hospital, 20159 Milan, Italy
- Diabetes Center, Humanitas Gavazzeni Institute, Via M. Gavazzeni 21, 24100 Bergamo, Italy
| |
Collapse
|
3
|
Álvarez-López S, Ariza-Gómez MF, López-Montoya V, Cataño-Bedoya JU, Giraldo-Mendez D, Jaimes F. Demographic, Clinical, and Serological Characteristics of Antiphospholipid Syndrome Patients From the Anticoagulation Clinic of Hospital Universitario San Vicente Fundación, Medellín, Colombia. Cureus 2023; 15:e35114. [PMID: 36945288 PMCID: PMC10024950 DOI: 10.7759/cureus.35114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/14/2023] [Indexed: 02/19/2023] Open
Abstract
INTRODUCTION Antiphospholipid syndrome (APS) is an acquired autoimmune thrombophilia, characterized by vascular thrombosis or obstetric compromise, associated with the presence of antiphospholipid antibodies. Large international studies have analyzed the clinical/serological behavior of the disease and in Colombia, there are few cohorts that have been evaluated. OBJECTIVE The main objective is to characterize the patients with APS followed in the anticoagulation clinic of a tertiary care hospital and to determine the clinical manifestations and serological findings at diagnosis. MATERIALS AND METHODS A retrospective descriptive study was carried out to evaluate patients with a presumptive and/or confirmed diagnosis of APS, according to modified Sapporo criteria, which fulfilled the inclusion and exclusion criteria established by the authors. The information was collected from the review of medical records. RESULTS We included 103 patients, with the female sex being the most prevalent (86.6%). 54.3% of the patients (n = 56) had a diagnosis of primary APS. Venous thrombotic events occurred in 87.3% (n = 90) of the patients, 34.9% (n = 36) had arterial thrombosis (n = 36), and 3.9% (n = 4) had catastrophic APS (n = 4). 15 cases of Obstetric APS were documented. Lupus coagulation inhibitor (LA) positivity was the most prevalent marker in 84% (n = 68) of cases. CONCLUSIONS The clinical behavior in this cohort of patients is like that found in large international and national studies. Most patients have a probable diagnosis of APS, so they could overestimate the real prevalence and condition of long-term anticoagulant treatment.
Collapse
Affiliation(s)
| | | | | | | | | | - Fabian Jaimes
- Department of Internal Medicine, University of Antioquia, Medellín, COL
| |
Collapse
|
4
|
Arachchillage DJ, Laffan M, Pericleous C. Hydroxychloroquine as an Immunomodulatory and Antithrombotic Treatment in Antiphospholipid Syndrome. Int J Mol Sci 2023; 24:ijms24021331. [PMID: 36674847 PMCID: PMC9866802 DOI: 10.3390/ijms24021331] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 12/24/2022] [Accepted: 01/05/2023] [Indexed: 01/12/2023] Open
Abstract
Antiphospholipid syndrome (APS) is an acquired highly prothrombotic disorder in which thrombo-inflammatory antiphospholipid antibodies (aPL) cause thrombosis via multiple mechanisms, including endothelial damage and activation. Obstetric complications in APS are caused by placental thrombosis, inflammation and complement activation. Anticoagulation is poorly effective in some patients especially those with triple positive aPL who are at ~30% risk of thrombosis recurrence within 10 years. Increasing therapeutic anticoagulation intensity may be beneficial but leads to excess bleeding with serious complications, such as intracerebral haemorrhage. Nonetheless, anticoagulation is still the mainstay of treatment despite the autoimmune nature of APS. The antimalarial immunomodulatory drug hydroxychloroquine (HCQ) has been used for many years for the treatment of inflammatory rheumatic diseases. HCQ has complex pleiotropic mechanisms of action upon multiple cell types. The proposed biological processes that HCQ regulates support the hypothesis that it may be a successful adjunctive treatment in the prevention of recurrent thrombosis and pregnancy complications.
Collapse
Affiliation(s)
- Deepa J. Arachchillage
- Centre for Haematology, Department of Immunology and Inflammation, Imperial College London, London W12 0NN, UK
- Department of Haematology, Imperial College Healthcare NHS Trust, London W12 0HS, UK
- Correspondence: ; Tel.: +44-20-7351-8400; Fax: +44-20-7351-8402
| | - Mike Laffan
- Centre for Haematology, Department of Immunology and Inflammation, Imperial College London, London W12 0NN, UK
- Department of Haematology, Imperial College Healthcare NHS Trust, London W12 0HS, UK
| | - Charis Pericleous
- National Heart and Lung Institute, Imperial College London, London W12 0NN, UK
| |
Collapse
|
5
|
Ma J, Gao W, Li D. Recurrent implantation failure: A comprehensive summary from etiology to treatment. Front Endocrinol (Lausanne) 2023; 13:1061766. [PMID: 36686483 PMCID: PMC9849692 DOI: 10.3389/fendo.2022.1061766] [Citation(s) in RCA: 21] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 12/13/2022] [Indexed: 01/06/2023] Open
Abstract
Implantation is the first step in human reproduction. Successful implantation depends on the crosstalk between embryo and endometrium. Recurrent implantation failure (RIF) is a clinical phenomenon characterized by a lack of implantation after the transfer of several embryos and disturbs approximately 10% couples undergoing in vitro fertilization and embryo transfer. Despite increasing literature on RIF, there is still no widely accepted definition or standard protocol for the diagnosis and treatment of RIF. Progress in predicting and preventing RIF has been hampered by a lack of widely accepted definitions. Most couples with RIF can become pregnant after clinical intervention. The prognosis for couples with RIF is related to maternal age. RIF can be caused by immunology, thrombophilias, endometrial receptivity, microbiome, anatomical abnormalities, male factors, and embryo aneuploidy. It is important to determine the most possible etiologies, and individualized treatment aimed at the primary cause seems to be an effective method for increasing the implantation rate. Couples with RIF require psychological support and appropriate clinical intervention. Further studies are required to evaluate diagnostic method and he effectiveness of each therapy, and guide clinical treatment.
Collapse
Affiliation(s)
- Junying Ma
- Center of Reproductive Medicine, Shengjing Hospital of China Medical University, Shenyang, China
- Key Laboratory of Reproductive and Genetic Medicine, China Medical University, National Health Commission, Shenyang, China
- Shengjing Hospital of China Medical University, Key Laboratory of Reproductive Dysfunction Diseases and Fertility Remodeling of Liaoning Province, Shenyang, China
| | - Wenyan Gao
- Department of Obstetrics, the First Affiliated Hospital of China Medical University, Shenyang, China
| | - Da Li
- Center of Reproductive Medicine, Shengjing Hospital of China Medical University, Shenyang, China
- Key Laboratory of Reproductive and Genetic Medicine, China Medical University, National Health Commission, Shenyang, China
- Shengjing Hospital of China Medical University, Key Laboratory of Reproductive Dysfunction Diseases and Fertility Remodeling of Liaoning Province, Shenyang, China
| |
Collapse
|
6
|
Erton ZB, Sevim E, de Jesús GR, Cervera R, Ji L, Pengo V, Ugarte A, Andrade D, Andreoli L, Atsumi T, Fortin PR, Gerosa M, Zuo Y, Petri M, Sciascia S, Tektonidou MG, Aguirre-Zamorano MA, Branch DW, Erkan D. Pregnancy outcomes in antiphospholipid antibody positive patients: prospective results from the AntiPhospholipid Syndrome Alliance for Clinical Trials and InternatiOnal Networking (APS ACTION) Clinical Database and Repository ('Registry'). Lupus Sci Med 2022; 9:e000633. [PMID: 35701043 PMCID: PMC9198709 DOI: 10.1136/lupus-2021-000633] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 05/14/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVES To describe the outcomes of pregnancies in antiphospholipid antibody (aPL)-positive patients since the inception of the AntiPhospholipid Syndrome Alliance for Clinical Trials and InternatiOnal Networking Registry. METHODS We identified persistently aPL-positive patients recorded as 'pregnant' during prospective follow-up, and defined 'aPL-related outcome' as a composite of: (1) Preterm live delivery (PTLD) at or before 37th week due to pre-eclampsia (PEC), eclampsia, small-for-gestational age (SGA) and/or placental insufficiency (PI); or (2) Otherwise unexplained fetal death after the 10th week of gestation. The primary objective was to describe the characteristics of patients with and without aPL-related composite outcomes based on their first observed pregnancies following registry recruitment. RESULTS Of the 55 first pregnancies observed after registry recruitment among nulliparous and multiparous participants, 15 (27%) resulted in early pregnancy loss <10 weeks gestation. Of the remaining 40 pregnancies: (1) 26 (65%) resulted in term live delivery (TLD), 4 (10%) in PTLD between 34.0 weeks and 36.6 weeks, 5 (12.5%) in PTLD before 34th week, and 5 (12.5%) in fetal death (two associated with genetic anomalies); and (2) The aPL-related composite outcome occurred in 9 (23%). One of 26 (4%) pregnancies with TLD, 3/4 (75%) with PTLD between 34.0 weeks and 36.6 weeks, and 3/5 (60%) with PTLD before 34th week were complicated with PEC, SGA and/or PI. Fifty of 55 (91%) pregnancies were in lupus anticoagulant positive subjects, as well as all pregnancies with aPL-related composite outcome. CONCLUSION In our multicentre, international, aPL-positive cohort, of 55 first pregnancies observed prospectively, 15 (27%) were complicated by early pregnancy loss. Of the remaining 40 pregnancies, composite pregnancy morbidity was observed in 9 (23%) pregnancies.
Collapse
Affiliation(s)
- Zeynep Belce Erton
- Divison of Rheumatology, Hospital for Special Surgery, New York, New York, USA
| | - Ecem Sevim
- Medicine, Yeshiva University Albert Einstein College of Medicine, Bronx, New York, USA
- Internal Medicine, Montefiore Medical Center, Bronx, New York, USA
| | - Guilherme Ramires de Jesús
- Department of Obstetrics, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Rio de Janeiro, Brazil
- Department of Obstetrics, Instituto Fernandes Figueira - FIOCRUZ, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Ricard Cervera
- Autoimmune Diseases, Hospital Clínic de Barcelona Institut Clínic de Medicina i Dermatologia, Barcelona, Spain
| | - Lanlan Ji
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing, Beijing, China
| | - Vittorio Pengo
- Cardiac Thoracic and Vascular Sciences, University of Padova, padua, Italy
| | - Amaia Ugarte
- Internal Medicine, Hospital de Cruces, Barkaldo, Spain
| | - Danieli Andrade
- Rheumatology, University of Sao Paulo, Sao Paulo, Sao Paulo, Brazil
| | - Laura Andreoli
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
- Unit of Rheumatology and Clinical Immunology, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Tatsuya Atsumi
- Medicine II, Hokkaido University School of Medicine, Sapporo, Japan
| | - Paul R Fortin
- Medicine - Rheumatology, Centre Hospitalier de l'Université Laval, Quebec City, Quebec, Canada
| | - Maria Gerosa
- Dept. of Clinical & Community Science University of Milano, Division of Rheumatology, Milano, Italy
| | - Yu Zuo
- Internal Medicine/Division of Rheumatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Michelle Petri
- Rheumatology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Savino Sciascia
- Dipartimento di Malattie Rare, Immunologiche, Ematologiche ed Immunoematologiche. Centro di Ricerche di Immunopatologia e Documentazione su Malattie Rare (CMID). Struttura Complessa a Direzione Universitaria di Immunologia Clinica, Ospedale Torino Nord Emergenza San G. Bosco ed Università di Torino, Torino, Italy
| | - Maria G Tektonidou
- First Department of Propaedeutic Internal Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | | | - D Ware Branch
- Maternal-Fetal Medicine, University of Utah Health Sciences Center, Salt Lake City, Utah, USA
- Maternal- Fetal Medicine, Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Doruk Erkan
- Rheumatology, Barbara Volcker Center for Women and Rheumatic Diseases, Hospital for Special Surgery, Weill Cornell Medicine, New York, New York, USA
| |
Collapse
|
7
|
Hoxha A, Tormene D, Campello E, Simioni P. Treatment of Refractory/High-Risk Pregnancies With Antiphospholipid Syndrome: A Systematic Review of the Literature. Front Pharmacol 2022; 13:849692. [PMID: 35662738 PMCID: PMC9160870 DOI: 10.3389/fphar.2022.849692] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 03/30/2022] [Indexed: 11/13/2022] Open
Abstract
Different treatment protocols have been employed to manage heparin/low-dose aspirin refractory or high-risk pregnancies in antiphospholipid antibody syndrome (APS) pregnancies. A systematic review of the literature on additional treatments used in refractory and/or high-risk APS pregnancies was conducted. Records from February 2006 to October 2021 were retrieved from PubMed, Web of Science, Cochrane, and the www.clinicaltrials.gov platform. Twenty-one studies met our eligibility criteria. Live birth rate is this study’s primary endpoint, while pregnancy complications and adverse events are secondary endpoints. A total of 434 pregnancies, 162 (37.3%) refractory and 272 (62.7%) high-risk/refractory pregnancies, were included. Both IVIG <2 gr/kg/monthly/HCQ/LDS and PEX/IA ± LDS led to 100% viable infants in refractory APS. Furthermore, HCQ 200–400 mg showed a higher live birth rate than HCQ + LDS (88.6% vs. 82.7%). Following treatment protocol with HCQ 200–400 mg and IVIG <2 gr/kg/monthly/HCQ/LDS, pregnancy complications rates of 16.7 and 83.3% were registered, respectively. Pravastatin 20 mg, IA weekly + IVIG 2 gr/monthly, and PEX weekly + IVIg 2 gr/kg/monthly showed higher live birth rates in high-risk APS pregnancies of 100, 100 and 92%, respectively, whereas the lower severe pregnancy complications were reported in pregnancies treated with PEX weekly + IVIg 2 gr/kg/monthly (11.1%). One (0.6%) case of dermatitis during treatment with HCQ was observed. The results of this study showed that HCQ 200–400 mg and PEX weekly + IVIG 2 gr/kg/monthly achieved a higher live birth rate in refractory APS and high-risk/refractory APS, respectively. The results presented provide clinicians with up-to-date knowledge in the management of APS pregnancies according to risk stratification.
Collapse
Affiliation(s)
- Ariela Hoxha
- Internal Medicine Unit, Department of Medicine, San Bortolo Hospital, Vicenza, Italy
- General Internal Medicine and Thrombotic and Hemorrhagic Unit, University of Padua, Padua, Italy
- *Correspondence: Ariela Hoxha,
| | - Daniela Tormene
- General Internal Medicine and Thrombotic and Hemorrhagic Unit, University of Padua, Padua, Italy
| | - Elena Campello
- General Internal Medicine and Thrombotic and Hemorrhagic Unit, University of Padua, Padua, Italy
| | - Paolo Simioni
- General Internal Medicine and Thrombotic and Hemorrhagic Unit, University of Padua, Padua, Italy
| |
Collapse
|
8
|
Edens C. The Impact of Pediatric Rheumatic Diseases on Sexual Health, Family Planning, and Pregnancy. Rheum Dis Clin North Am 2021; 48:113-140. [PMID: 34798942 DOI: 10.1016/j.rdc.2021.09.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
A comprehensive review of reproductive health subtopics, including sexual intercourse, romantic relationships, contraception, sexually transmitted infections, pregnancy, and infertility, as they pertain to patients with pediatric rheumatic diseases and those who care for them.
Collapse
Affiliation(s)
- Cuoghi Edens
- Department of Pediatrics, Section of Pediatric Rheumatology, University of Chicago Medicine, 5841 South Maryland Avenue, C104-A, MC5044, Chicago, IL 60637, USA; Department of Internal Medicine, Section of Rheumatology, University of Chicago Medicine, 5841 South Maryland Avenue, C104-A, MC5044, Chicago, IL 60637, USA.
| |
Collapse
|
9
|
Gerde M, Ibarra E, Mac Kenzie R, Fernandez Suarez C, Heer C, Alvarez R, Iglesias M, Balparda J, Beruti E, Rubinstein F. The impact of hydroxychloroquine on obstetric outcomes in refractory obstetric antiphospholipid syndrome. Thromb Res 2021; 206:104-110. [PMID: 34454240 DOI: 10.1016/j.thromres.2021.08.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Revised: 08/06/2021] [Accepted: 08/06/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND The use of low-dose aspirin (LDA) and heparin has improved pregnancy outcomes in women with antiphospholipid syndrome (APS). However, 20-30% still have adverse outcomes despite treatment. Recent retrospective studies showed a beneficial effect of hydroxychloroquine (HCQ) in APS due to its anti-inflammatory, immunomodulatory and antithrombotic properties. Data in refractory obstetric APS (OAPS) remain scarce and include heterogeneous populations with various concomitant treatments. OBJECTIVE The objective of this study was to assess the impact on the obstetric outcomes of adding HCQ to classical treatments for women with refractory primary obstetric APS. METHODS In a retrospective single-centre cohort study, we compared pregnancy outcomes in women with refractory primary OAPS (2004-2019) who received two different treatments in subsequent pregnancies. Group A received 400 mg HCQ + 60 mg enoxaparin + LDA, while Group B received 60 mg enoxaparin + LDA. The main outcome was live birth rates, while pregnancy complications (early and late pregnancy losses and placental-mediated complications) were the secondary outcome. RESULTS A total of 101 pregnancies in 87 refractory primary OAPS patients were included. The rate of live-born babies in Group A (HCQ) was 97.1% (67/69) vs. 62.5% (20/32) in Group B (RR: 1.55 [95% CI, 1.19-2.1]; p < 0.001). Pregnancy complications in Group A were 8.7% (6/69) vs. 37.5% (12/32) in Group B (RR 0.22 [95% CI, 0.15-0.30]; p < 0.001). CONCLUSION Hydroxychloroquine was associated with a higher rate of live births and a lower prevalence of pregnancy complications in refractory primary obstetric APS. The addition of HCQ to classical treatment may present a promising approach that needs to be confirmed with prospective studies.
Collapse
Affiliation(s)
- M Gerde
- Department of Obstetrics and Gynecology, Hospital Universitario Austral, Av., Juan Domingo Perón 1500, Pilar Centro, Provincia de Buenos Aires, Argentina.
| | - E Ibarra
- Department of Obstetrics and Gynecology, Hospital Universitario Austral, Av., Juan Domingo Perón 1500, Pilar Centro, Provincia de Buenos Aires, Argentina
| | - R Mac Kenzie
- Division of Vascular Surgery and Phlebology, FLENI, Montañeses 2325, Ciudad de Buenos Aires, Argentina
| | - C Fernandez Suarez
- Department of Obstetrics and Gynecology, Hospital Universitario Austral, Av., Juan Domingo Perón 1500, Pilar Centro, Provincia de Buenos Aires, Argentina
| | - C Heer
- Department of Obstetrics and Gynecology, Hospital Universitario Austral, Av., Juan Domingo Perón 1500, Pilar Centro, Provincia de Buenos Aires, Argentina
| | - R Alvarez
- Department of Obstetrics and Gynecology, Hospital Universitario Austral, Av., Juan Domingo Perón 1500, Pilar Centro, Provincia de Buenos Aires, Argentina
| | - M Iglesias
- Department of Obstetrics and Gynecology, Hospital Universitario Austral, Av., Juan Domingo Perón 1500, Pilar Centro, Provincia de Buenos Aires, Argentina
| | - J Balparda
- Department of Obstetrics and Gynecology, Hospital Universitario Austral, Av., Juan Domingo Perón 1500, Pilar Centro, Provincia de Buenos Aires, Argentina.
| | - E Beruti
- Department of Obstetrics and Gynecology, Hospital Universitario Austral, Av., Juan Domingo Perón 1500, Pilar Centro, Provincia de Buenos Aires, Argentina.
| | - F Rubinstein
- Departamento de Educación, Instituto de Efectividad Clínica y Sanitaria (IECS), Dr. Emilio Ravignani 2024, Ciudad de Buenos Aires, Argentina
| |
Collapse
|
10
|
Walter IJ, Klein Haneveld MJ, Lely AT, Bloemenkamp KWM, Limper M, Kooiman J. Pregnancy outcome predictors in antiphospholipid syndrome: A systematic review and meta-analysis. Autoimmun Rev 2021; 20:102901. [PMID: 34280554 DOI: 10.1016/j.autrev.2021.102901] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Accepted: 05/21/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To identify and assess the magnitude of effect of pregnancy outcome predictors in women with antiphospholipid syndrome (APS) by means of systematic review and meta-analysis. METHODS PubMed and Embase were searched (13th June 2020) for studies reporting on pre-pregnancy risk factors of pregnancy outcomes in APS patients. Literature screening and data extraction were conducted by two reviewers independently, in a blinded standardized manner. Pooled univariate odds ratios (OR) were computed using a random effects model. Heterogeneity was assessed by I2%. RESULTS The search yielded 3013 unique results; 27 records were included in this meta-analysis. Previous thrombosis was associated with a decreased live birth risk (OR 0.60, p < 0.01, I2 = 40%), increased neonatal mortality (OR 15.19, p < 0.01, I2 = 0%), an increased risk of antenatal or postpartum thrombosis (OR 6.26, p < 0.01, I2 = 0%) and an increased risk of delivering a small for gestational age neonate (SGA) (OR 2.60, p = 0.01, I2 = 0%). Patients with an APS laboratory category I (double or triple positivity) profile had a decreased live birth risk (OR 0.66, p < 0.01, I2 = 0%), an increased risk of SGA (OR 1.86, p = 0.01, I2 = 43%) and preterm birth (OR 1.35, p < 0.01, I2 = 49%). Triple positivity was associated with a decreased live birth risk (OR 0.33, p < 0.01, I2 = 68%), an increased risk of preeclampsia (OR 2.43, p = 0.02, I2 = 35%) and SGA (OR 2.47, p = 0.04, I2 = 61%). Patients with lupus anticoagulant positivity had an increased risk of preeclampsia (OR 2.10, p = 0.02, I2 = 48%), SGA (OR 1.78, p < 0.01, I2 = 0%) and preterm birth (OR 3.56, p = 0.01, I2 = 48%). Risk of bias assessment suggested considerable bias on study participation and statistical methods. CONCLUSIONS The results of this meta-analysis identified previous thrombosis, laboratory category I, triple positivity and lupus anticoagulant positivity as the most important predictors of adverse pregnancy outcomes. This up-to-date knowledge, can be used in preconception counseling and tailoring of obstetric care.
Collapse
Affiliation(s)
- Isabel Johanna Walter
- University Medical Center Utrecht, Wilhelmina Children's Hospital, Department of Obstetrics, Lundlaan 6, 3584 EA Utrecht, the Netherlands
| | - Mirthe Jasmijn Klein Haneveld
- University Medical Center Utrecht, Wilhelmina Children's Hospital, Department of Obstetrics, Lundlaan 6, 3584 EA Utrecht, the Netherlands
| | - Anne Titia Lely
- University Medical Center Utrecht, Wilhelmina Children's Hospital, Department of Obstetrics, Lundlaan 6, 3584 EA Utrecht, the Netherlands
| | | | - Maarten Limper
- University Medical Center Utrecht, Department of Rheumatology and Clinical Immunology, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands
| | - Judith Kooiman
- University Medical Center Utrecht, Wilhelmina Children's Hospital, Department of Obstetrics, Lundlaan 6, 3584 EA Utrecht, the Netherlands.
| |
Collapse
|
11
|
Larosa M, Le Guern V, Morel N, Belhocine M, Ruffatti A, Silva NM, Paule R, Mouthon L, Dreyfus M, Piette JC, Souchaud-Debouverie O, Deneux-Tharaux C, Guettrot-Imbert G, Tsatsaris V, Pannier-Metzger E, Murarasu A, Doria A, Costedoat-Chalumeau N. Evaluation of the severe preeclampsia classification criterion for antiphospholipid syndrome in a study of 40 patients. Arthritis Res Ther 2021; 23:134. [PMID: 33947469 PMCID: PMC8094564 DOI: 10.1186/s13075-021-02518-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 04/21/2021] [Indexed: 11/24/2022] Open
Abstract
Background The criteria for antiphospholipid syndrome (APS) include severe preeclampsia and/or placental insufficiency leading to preterm delivery before 34 weeks of gestation, but this APS manifestation has been rarely studied. Thus, we report a series of severe preeclampsia occurred in patients with APS. Methods We retrospectively analysed data of women with APS (Sydney criteria) who experienced severe preeclampsia with delivery before 34 weeks’ gestation between 2000 and 2017 at five French internal medicine departments and one Italian rheumatology unit. Results The 40 women had a mean age of 30.5 ± 4.6 years at their first episode of preeclampsia; 21 were nulligravid (52.5%), 12 (30%) had already been diagnosed with APS, and 21 (52.5%) had a triple-positive antiphospholipid (aPL) antibody test. Preeclampsia occurred at a median gestational age of 25.5 weeks (IQR 23-29). It was associated with HELLP in 18 cases (45%), eclampsia in 6 (15%), placental abruption in 3 (7.5%), catastrophic APS in 3 (7.5%), and foetal and neonatal death in 11 and 15 cases. Overall, 14 (35%) children survived, born at a median gestational age of 31 weeks. Among other APS criteria, 16 women (40%) experienced at least one thrombosis, 17 (42.5%) an intrauterine foetal death, and 19 (47.5%) at least one episode of HELLP during follow-up (median 5 years, IQR = 2-8). None had three or more consecutive miscarriages. Notably, 12 women (30%) had systemic lupus erythematosus. Conclusions Severe preeclampsia led to high mortality in the offspring. Almost half of these women experienced other APS features, but not three consecutive miscarriages. Supplementary Information The online version contains supplementary material available at 10.1186/s13075-021-02518-7.
Collapse
Affiliation(s)
- Maddalena Larosa
- AP-HP, Cochin Hospital, Internal Medicine Department, Centre de référence maladies auto-immunes et systémiques rares d'Ile de France, Paris, France.,Division of Rheumatology, Department of Medicine-DIMED, University of Padova, Via Giustiniani 2, 35128, Padova, Italy
| | - Véronique Le Guern
- AP-HP, Cochin Hospital, Internal Medicine Department, Centre de référence maladies auto-immunes et systémiques rares d'Ile de France, Paris, France
| | - Nathalie Morel
- AP-HP, Cochin Hospital, Internal Medicine Department, Centre de référence maladies auto-immunes et systémiques rares d'Ile de France, Paris, France
| | - Mériem Belhocine
- AP-HP, Cochin Hospital, Internal Medicine Department, Centre de référence maladies auto-immunes et systémiques rares d'Ile de France, Paris, France.,Sacré-Coeur Hospital, Internal Medicine Department, University of Montréal, Montréal, Canada
| | - Amelia Ruffatti
- Division of Rheumatology, Department of Medicine-DIMED, University of Padova, Via Giustiniani 2, 35128, Padova, Italy
| | - Nicolas Martin Silva
- University Hospital Center of Caen, Department of Internal Medicine, Caen, France
| | - Romain Paule
- AP-HP, Cochin Hospital, Internal Medicine Department, Centre de référence maladies auto-immunes et systémiques rares d'Ile de France, Paris, France
| | - Luc Mouthon
- AP-HP, Cochin Hospital, Internal Medicine Department, Centre de référence maladies auto-immunes et systémiques rares d'Ile de France, Paris, France.,Université de Paris, 27 Rue du Faubourg Saint Jacques, 75014, Paris, France
| | - Michel Dreyfus
- University Hospital Center of Caen, Gynecology and Obstetrics Department, Caen, France
| | - Jean-Charles Piette
- AP-HP, Pitié-Salpétrière University Hospital, Internal Medicine and Clinical Immunology Department, Centre de référence maladies auto-immunes et systémiques rares de l'Ile de France, Paris, France
| | | | - Catherine Deneux-Tharaux
- INSERM U 1153, Obstetrical, Perinatal and Paediatric Epidemiology (EPOPé research team), DHU Risks in Pregnancy, Université de Paris, Paris, France
| | - Gaelle Guettrot-Imbert
- AP-HP, Cochin Hospital, Internal Medicine Department, Centre de référence maladies auto-immunes et systémiques rares d'Ile de France, Paris, France
| | - Vassilis Tsatsaris
- AP-HP, Cochin Broca Hôtel-Dieu Hospital, Port-Royal maternity, DHU Risk in Pregnancy, INSERM Unité 1139, Paris, France
| | - Emmanuelle Pannier-Metzger
- AP-HP, Cochin Broca Hôtel-Dieu Hospital, Port-Royal maternity, DHU Risk in Pregnancy, INSERM Unité 1139, Paris, France
| | - Anne Murarasu
- AP-HP, Cochin Hospital, Internal Medicine Department, Centre de référence maladies auto-immunes et systémiques rares d'Ile de France, Paris, France
| | - Andrea Doria
- Division of Rheumatology, Department of Medicine-DIMED, University of Padova, Via Giustiniani 2, 35128, Padova, Italy
| | - Nathalie Costedoat-Chalumeau
- AP-HP, Cochin Hospital, Internal Medicine Department, Centre de référence maladies auto-immunes et systémiques rares d'Ile de France, Paris, France. .,Université de Paris, 27 Rue du Faubourg Saint Jacques, 75014, Paris, France. .,INSERM U 1153, Center for Epidemiology and Statistics Sorbonne Paris Cité (CRESS), Paris, France.
| |
Collapse
|
12
|
Tian Y, Xu J, Chen D, Yang C, Peng B. The additional use of hydroxychloroquine can improve the live birth rate in pregnant women with persistent positive antiphospholipid antibodies: A systematic review and meta-analysis. J Gynecol Obstet Hum Reprod 2021; 50:102121. [PMID: 33746078 DOI: 10.1016/j.jogoh.2021.102121] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Revised: 03/03/2021] [Accepted: 03/15/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE To evaluate the efficacy of additional treatment with hydroxychloroquine (HCQ) for pregnant women with persistent positive antiphospholipid antibodies or antiphospholipid antibody syndrome (APS). METHOD We conducted a systematic search of the PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials databases from inception to 31th December 2019. Two authors performed study selection, data collection, and data analysis independently. RESULT Five retrospective studies involving 477 pregnancies were selected. The live birth rate was significantly improved in the experimental group (OR, 3.29; 95 % CI, 1.45-7.49; P = 0.004). Additionally, pregnancy loss was associated with the additional use of HCQ (OR, 0.30;95 % CI, 0.13-0.69; P = 0.004). However, HCQ had no significant association with preterm delivery (OR, 0.43; 95 % CI, 0.13-1.37; P = 0.16) and fetal growth restriction showed an OR of 0.22 (95 % CI, 0.13-1.88; P = 0.55). CONCLUSION These data suggest that receiving HCQ as an additional treatment can improve the live birth rate in pregnant women with persistent antiphospholipid antibodies.
Collapse
Affiliation(s)
- Yuan Tian
- Department of Obstetrics and Gynecology, West China Second University Hospital of Sichuan University, the Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, Sichuan, China; West China School of Medicine, Sichuan University, Chengdu, Sichuan, China
| | - Jinfeng Xu
- Department of Obstetrics and Gynecology, West China Second University Hospital of Sichuan University, the Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, Sichuan, China; West China School of Medicine, Sichuan University, Chengdu, Sichuan, China
| | - Daijuan Chen
- Department of Obstetrics and Gynecology, West China Second University Hospital of Sichuan University, the Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, Sichuan, China; West China School of Medicine, Sichuan University, Chengdu, Sichuan, China
| | - Chunsong Yang
- Department of Pharmacy, Evidence-based Pharmacy Center, West China Second Hospital, Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Chengdu, China
| | - Bing Peng
- Department of Obstetrics and Gynecology, West China Second University Hospital of Sichuan University, the Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, Sichuan, China.
| |
Collapse
|
13
|
Alecsandru D, Klimczak AM, Garcia Velasco JA, Pirtea P, Franasiak JM. Immunologic causes and thrombophilia in recurrent pregnancy loss. Fertil Steril 2021; 115:561-566. [PMID: 33610320 DOI: 10.1016/j.fertnstert.2021.01.017] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Revised: 01/10/2021] [Accepted: 01/12/2021] [Indexed: 12/16/2022]
Abstract
Certain miscarriages result from immunologic factors, but there is no clear identification of the precise causes of recurrent pregnancy loss (RPL). Miscarriages and RPL can arise from a disruption of maternal-fetal immune homeostasis. Remodeling of the maternal uterine spiral arteries is one of the key steps for normal growth and development of the fetus. An adequate oxygen supply is necessary for correct placentation, and it is accomplished by proper vascular changes. The development of fetal tissues creates a potential immunologic problem since the fetus can express paternal antigens and, in some cases, antigens of a gamete donor. The maternal immune system actively responds to fetal antigens, and dysregulation of this crosstalk could partly explain pregnancy complications such as miscarriages and RPL. RPL resulting from thrombophilia is primarily due to acquired thrombophilia, and therefore screening and treatment should be focused on antiphospholipid antibody syndrome.
Collapse
Affiliation(s)
- Diana Alecsandru
- Department of Immunology, IVI RMA Madrid, Spain; Rey Juan Carlos University, Madrid, Spain
| | | | - Juan A Garcia Velasco
- Rey Juan Carlos University, Madrid, Spain; Department of Reproductive Endocrinology and Infertility, IVI RMA Madrid; IVI Foundation, Health Research Institute La Fe, Valencia, Spain
| | - Paul Pirtea
- Department of Obstetrics and Gynecology, Hospital Foch, Paris, France.
| | | |
Collapse
|
14
|
Tasadduq R, Ajmal L, Batool F, Zafar T, Babar A, Riasat A, Shakoori AR. Interplay of immune components and their association with recurrent pregnancy loss. Hum Immunol 2021; 82:162-169. [PMID: 33581927 DOI: 10.1016/j.humimm.2021.01.013] [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: 09/02/2020] [Revised: 01/18/2021] [Accepted: 01/21/2021] [Indexed: 11/28/2022]
Abstract
Maintenance and progression of pregnancy is an intricate process governed by a variety of developmental cues. Recurrent pregnancy loss (RPL) is a complication experienced by expecting mothers that is defined as three or more consecutive pregnancy losses. This review focuses on the dysfunctions of the immune system as one of the key contributors towards RPL. The current data suggests that the alloimmune and autoimmune factors contribute to the loss of fetus. Such causes despite being recognized as a definitive reason for recurrent pregnancy loss, are still under extensive investigation with new parameters being discovered and scrutinized for their association with RPLs. More in-depth and high throughput studies are required for devising better diagnostic tools and management strategies for the affected female so that they can carry their pregnancy to term.
Collapse
Affiliation(s)
- Raazia Tasadduq
- Department of Biochemistry, Kinnaird College for Women, 93 Jail Road, G.O.R-1, Lahore, Pakistan.
| | - Laiba Ajmal
- Department of Biochemistry, Kinnaird College for Women, 93 Jail Road, G.O.R-1, Lahore, Pakistan
| | - Farhat Batool
- Department of Biochemistry, Kinnaird College for Women, 93 Jail Road, G.O.R-1, Lahore, Pakistan
| | - Tehniyat Zafar
- Department of Biochemistry, Kinnaird College for Women, 93 Jail Road, G.O.R-1, Lahore, Pakistan
| | - Aleena Babar
- Department of Biochemistry, Kinnaird College for Women, 93 Jail Road, G.O.R-1, Lahore, Pakistan
| | - Amna Riasat
- Department of Biochemistry, Kinnaird College for Women, 93 Jail Road, G.O.R-1, Lahore, Pakistan
| | | |
Collapse
|
15
|
Lee EE, Jun JK, Lee EB. Management of Women with Antiphospholipid Antibodies or Antiphospholipid Syndrome during Pregnancy. J Korean Med Sci 2021; 36:e24. [PMID: 33496084 PMCID: PMC7834901 DOI: 10.3346/jkms.2021.36.e24] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Accepted: 11/12/2020] [Indexed: 01/10/2023] Open
Abstract
Antiphospholipid syndrome (APS), which is characterized by the presence of antiphospholipid antibodies (aPL), is associated with increased risk of thrombosis and obstetric complications, including preterm delivery and recurrent pregnancy losses. APS shows diverse clinical manifestations and the risk of complications varies among clinical subtypes. Although these patients are usually treated with aspirin and anticoagulants, the optimal treatment in various clinical settings is unclear, as the risk of complications vary among clinical subtypes and the management strategy depends on whether the patient is pregnant or not. Also, there are unmet needs for the evidence-based, pregnancy-related treatment of asymptomatic women positive for aPL. This review focuses on the management of positive aPL or APS in pregnant and postpartum women, and in women attempting to become pregnant. For asymptomatic aPL positive women, no treatment, low dose aspirin (LDA) or LDA plus anticoagulants can be considered during antepartum and postpartum. In obstetric APS patients, preconceptional LDA is recommended. LDA plus low molecular weight heparin is administered after confirmation of pregnancy. Vascular APS patients should take frequent pregnancy test and receive heparin instead of warfarin after confirmation of pregnancy. During pregnancy, heparin plus LDA is recommended. Warfarin can be restarted 4 to 6 hours after vaginal delivery and 6 to 12 hours after cesarean delivery. Most importantly, a tailored approach and patient-oriented treatment are mandatory.
Collapse
Affiliation(s)
- Eunyoung Emily Lee
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Jong Kwan Jun
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea
| | - Eun Bong Lee
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
- Department of Molecular Medicine and Biopharmaceutical Sciences, Graduate School of Convergence Science and Technology, Seoul National University, Seoul, Korea.
| |
Collapse
|
16
|
Poh YJ, Yii IYL, Goh LH, Li HH, Yang L, Tan HK, Thumboo J, Tan LK. Maternal and Fetal Outcomes in Systemic Lupus Erythematosus Pregnancies. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2020. [DOI: 10.47102/annals-acadmedsg.2020373] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Abstract
Introduction: To describe the maternal and fetal outcomes in systemic lupus
erythematosus (SLE) pregnancies followed-up in a single tertiary referral centre.
Methods: We performed a retrospective cohort study of 75 SLE pregnancies who
were followed up in Singapore General Hospital over a 16-year period from 2000 to
2016. Adverse fetal and maternal outcomes including preterm delivery, miscarriages,
fetal growth restriction, congenital heart block, neonatal lupus, pre-eclampsia and SLE
flares were obtained from the medical records.
Results: The mean age at conception was 32 years old (SD 3.8). The mean SLE
disease duration was 5.9 years (SD 5.2). The majority (88%) had quiescent SLE
disease activity at baseline. Most pregnancies resulted in a live birth (74.7%). The mean
gestational age at birth was 37.4 weeks (SD 3.4). Adverse fetal outcomes occurred
in 53.3%. Preterm delivery (33.9%), miscarriages (20%) and fetal growth restriction
(17.3%) were the most frequent adverse fetal outcomes. There was 1 neonatal death
and SLE flares occurred in a third (33%). In the subgroup of SLE pregnancies with
antiphospholipid syndrome, there were higher SLE flare rates (40%) and adverse fetal
outcomes occurred in 8 pregnancies (80%). There were no predictive factors identified for
all adverse fetal and maternal outcomes. In the subgroup analysis of preterm delivery,
anti-Ro (SS-A) antibody positivity and hydroxychloroquine treatment were associated
with a lower risk of preterm delivery.
Conclusion: Although the majority had quiescent SLE disease activity at baseline,
SLE pregnancies were associated with high rates of adverse fetal and maternal outcomes.
Keywords: Antiphospholipid syndrome, anti-La (SS-B) antibody, anti-Ro (SS-A) antibody,
lupus nephritis
Collapse
|
17
|
Ruffatti A, Tonello M, Favaro M, Del Ross T, Calligaro A, Ruffatti AT, Gervasi MT, Hoxha A. The efficacy and safety of second-line treatments of refractory and/or high risk pregnant antiphospholipid syndrome patients. A systematic literature review analyzing 313 pregnancies. Semin Arthritis Rheum 2020; 51:28-35. [PMID: 33360227 DOI: 10.1016/j.semarthrit.2020.10.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 09/23/2020] [Accepted: 10/16/2020] [Indexed: 01/10/2023]
Abstract
OBJECTIVE The most efficacious strategy to manage pregnant patients with antiphospholipid syndrome (APS) refractory to conventional heparin/low-dose aspirin treatment or at high risk of adverse pregnancy outcomes has not been determined with any degree of certainty. The study set out to evaluate the efficacy and safety of the second-line treatments most frequently used in addition to conventional therapy, and the data were analyzed to identify which is/are associated to the best pregnancy outcomes. METHODS A systematic review of the literature on studies concerning second-line treatments for refractory and/or high risk pregnant APS women published between February 2006 and February 2020 was conducted. The records were retrieved by searching Medline via Pubmed, the Web of Science platform, the Cochrane library database and clinicaltrials.gov. RESULTS Fourteen studies met the eligibility criteria of the review: six retrospective cohort studies, one case-control, one case-series and six case reports. The results of single treatment protocols based upon hydroxychloroquine (HCQ), low-dose steroids (LDS), intravenous immunoglobulins (IVIG), plasma exchange (PE) or pravastatin and of combination protocols based upon HCQ+LDS, IVIG+LDS, PE+LDS and PE+IVIG used during 313 pregnancies in 303 APS women were analyzed and compared. The second-line treatments produced 261/313 (83.4%) live births; severe pregnancy complications were registered in 75/313 (24%) pregnancies. Drug side-effects were observed in 3/313 (0.9%) pregnancies. Statistical analysis identified a significantly higher live birth rate and/or a significantly lower number of severe complications in the pregnancies treated with IVIG, HCQ, pravastatin, PE+IVIG and PE+LDS. CONCLUSION Our results suggest using low-dose IVIG (< 2 g/Kg/month) or HCQ 400 mg/day starting before pregnancy in women with APS refractory to conventional therapy, while high-dose IVIG (2 g/Kg/month) associated with PE or alone in those with high risk±refractory APS.
Collapse
Affiliation(s)
- Amelia Ruffatti
- Rheumatology Unit, Department of Medicine, University Hospital of Padua, Padua Italy.
| | - Marta Tonello
- Rheumatology Unit, Department of Medicine, University Hospital of Padua, Padua Italy
| | - Maria Favaro
- Rheumatology Unit, Department of Medicine, University Hospital of Padua, Padua Italy
| | - Teresa Del Ross
- Rheumatology Unit, Department of Medicine, University Hospital of Padua, Padua Italy
| | - Antonia Calligaro
- Rheumatology Unit, Department of Medicine, University Hospital of Padua, Padua Italy
| | - Alessandra Teresa Ruffatti
- Gynaecology and Obstetrics Unit, Department of Woman and Child Health, University Hospital of Padua, Padua, Italy
| | - Maria Teresa Gervasi
- Gynaecology and Obstetrics Unit, Department of Woman and Child Health, University Hospital of Padua, Padua, Italy
| | - Ariela Hoxha
- Rheumatology Unit, Department of Medicine, University Hospital of Padua, Padua Italy; Internal Medicine Unit, Department of Medicine, San Bortolo Hospital, Vicenza, Italy
| |
Collapse
|
18
|
The growing role of precision medicine for the treatment of autoimmune diseases; results of a systematic review of literature and Experts' Consensus. Autoimmun Rev 2020; 20:102738. [PMID: 33326854 DOI: 10.1016/j.autrev.2020.102738] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Accepted: 09/22/2020] [Indexed: 02/07/2023]
Abstract
Autoimmune diseases (AIDs) share similar serological, clinical, and radiological findings, but, behind these common features, there are different pathogenic mechanisms, immune cells dysfunctions, and targeted organs. In this context, multiple lines of evidence suggest the application of precision medicine principles to AIDs to reduce the treatment failure. Precision medicine refers to the tailoring of therapeutic strategies to the individual characteristics of each patient, thus it could be a new approach for management of AIDS which considers individual variability in genes, environmental exposure, and lifestyle. Precision medicine would also assist physicians in choosing the right treatment, the best timing of administration, consequently trying to maximize drug efficacy, and, possibly, reducing adverse events. In this work, the growing body of evidence is summarized regarding the predictive factors for drug response in patients with AIDs, applying the precision medicine principles to provide high-quality evidence for therapeutic opportunities in improving the management of these patients.
Collapse
|
19
|
Gwozdz AM, Doyle AJ, Hunt BJ, Tincknell LG, Jackson N, Saha P, Breen KA, Smith A, Cohen A, Black SA. Effect of thrombophilia on clinical outcomes of chronic post-thrombotic patients after iliofemoral stenting with nitinol venous stents. J Vasc Surg Venous Lymphat Disord 2020; 9:888-894. [PMID: 33186751 DOI: 10.1016/j.jvsv.2020.09.013] [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: 05/11/2020] [Accepted: 09/24/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Thrombophilia is a prothrombotic condition that increases the risk of venous thromboembolism. It is unclear whether the presence of thrombophilia alters the clinical outcomes after deep venous stenting. The aim of the present study was to examine the relationship between thrombophilia and outcomes after stenting for post-thrombotic syndrome. METHODS Consecutive patients (2012-2017) receiving a nitinol venous stent for chronic post-thrombotic venous occlusive disease with a minimum of 18 months of follow-up in one center using the same anticoagulation protocol were included. The clinical history and thrombophilia testing results were reviewed. The outcomes were stent patency, which was assessed using duplex ultrasonography at 24 hours, 2 and 6 weeks, 3 months, 6 months, and annually thereafter; and reinterventions, which were performed when the stent diameter was <50% or occluded. RESULTS Of the 136 patients who had undergone intervention, 55 (40%) had had a provoked deep vein thrombosis (DVT) and 81 (60%) had had an unprovoked DVT and had therefore undergone thrombophilia testing. Of the 81 patients, 38 (47%) had had either inherited (n = 19; 50%) or acquired (n = 19; 50%) thrombophilia. Of the 136 patients who had undergone stenting, 68 had required reintervention (50%) during follow-up to maintain stent patency. Of the 55 patients with a provoked DVT, 29 (53%) had required reintervention. Of the 81 patients with an unprovoked DVT, 39 (48%) had required reintervention (P = .420). Of the 38 patients with unprovoked DVT and thrombophilia, 17 (45%) had required reintervention. Of the 43 patients with unprovoked DVT and no thrombophilia, 22 (51%) had required reintervention (P = .766). The cumulative patency rate was 80% for patients with provoked DVT and 88% for those with unprovoked DVT (P = .193). The presence of thrombophilia was not associated with patency loss (92% cumulative patency for patients with thrombophilia and 84% for patients without thrombophilia; P = .307). CONCLUSIONS Using our anticoagulation protocol, patients with and without thrombophilia had similar clinical outcomes after deep venous stenting and should not be excluded from iliofemoral venous stenting. We found no significant differences in outcomes in conjunction with appropriate postoperative anticoagulation therapy.
Collapse
Affiliation(s)
- Adam M Gwozdz
- Cardiovascular Division, Academic Department of Vascular Surgery, School of Cardiovascular Medicine and Science, Guy's and St Thomas' NHS Trust, King's College London, London, United Kingdom
| | - Andrew J Doyle
- Thrombosis and Haemophilia Centre, Guy's and St Thomas' NHS Trust, London, United Kingdom
| | - Beverley J Hunt
- Thrombosis and Haemophilia Centre, Guy's and St Thomas' NHS Trust, London, United Kingdom
| | - Laura G Tincknell
- Cardiovascular Division, Academic Department of Vascular Surgery, School of Cardiovascular Medicine and Science, Guy's and St Thomas' NHS Trust, King's College London, London, United Kingdom
| | - Nick Jackson
- Cardiovascular Division, Academic Department of Vascular Surgery, School of Cardiovascular Medicine and Science, Guy's and St Thomas' NHS Trust, King's College London, London, United Kingdom
| | - Prakash Saha
- Cardiovascular Division, Academic Department of Vascular Surgery, School of Cardiovascular Medicine and Science, Guy's and St Thomas' NHS Trust, King's College London, London, United Kingdom
| | - Karen A Breen
- Thrombosis and Haemophilia Centre, Guy's and St Thomas' NHS Trust, London, United Kingdom
| | - Alberto Smith
- Cardiovascular Division, Academic Department of Vascular Surgery, School of Cardiovascular Medicine and Science, Guy's and St Thomas' NHS Trust, King's College London, London, United Kingdom
| | - Ander Cohen
- Thrombosis and Haemophilia Centre, Guy's and St Thomas' NHS Trust, London, United Kingdom
| | - Stephen A Black
- Cardiovascular Division, Academic Department of Vascular Surgery, School of Cardiovascular Medicine and Science, Guy's and St Thomas' NHS Trust, King's College London, London, United Kingdom.
| |
Collapse
|
20
|
Radin M, Cecchi I, Rubini E, Foddai SG, Barinotti A, Menegatti E, Roccatello D, Sciascia S. Treatment of antiphospholipid syndrome. Clin Immunol 2020; 221:108597. [PMID: 32961331 DOI: 10.1016/j.clim.2020.108597] [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: 05/14/2020] [Revised: 08/05/2020] [Accepted: 09/15/2020] [Indexed: 12/11/2022]
Abstract
Antiphospholipid syndrome (APS) is the most common acquired thrombophilia. The clinical manifestations of APS are mainly vascular thrombosis (venous and/or arterial) and/or recurrent pregnancy morbidity with the concomitant persistent presence of antiphospholipid antibodies (aPL). Therefore, the goals of the treatment of patients with APS are reducing the pregnancy morbidity and/or the prevention of thrombotic events during the follow-up. Optimal treatment of APS has long been discussed, due to the heterogeneity of the clinical manifestations and the consequent plurality in the medical specialties involved in managing this condition. This review summarizes the available evidence on primary thromboprophylaxis in aPL-positive individuals with no prior thrombotic events, secondary prophylaxis in patients with positive history for thrombotic events, the management of refractory or difficult cases and the current strategies for the management of APS during pregnancy.
Collapse
Affiliation(s)
- Massimo Radin
- Center of Research of Immunopathology and Rare Diseases- Coordinating Center of Piemonte and Aosta Valley Network for Rare Diseases, S. Giovanni Bosco Hospital, Department of Clinical and Biological Sciences, University of Turin, Italy; Nephrology and Dialysis, Department of Clinical and Biological Sciences, S. Giovanni Bosco Hospital, University of Turin, Italy
| | - Irene Cecchi
- Center of Research of Immunopathology and Rare Diseases- Coordinating Center of Piemonte and Aosta Valley Network for Rare Diseases, S. Giovanni Bosco Hospital, Department of Clinical and Biological Sciences, University of Turin, Italy
| | - Elena Rubini
- Center of Research of Immunopathology and Rare Diseases- Coordinating Center of Piemonte and Aosta Valley Network for Rare Diseases, S. Giovanni Bosco Hospital, Department of Clinical and Biological Sciences, University of Turin, Italy
| | - Silvia Grazietta Foddai
- Center of Research of Immunopathology and Rare Diseases- Coordinating Center of Piemonte and Aosta Valley Network for Rare Diseases, S. Giovanni Bosco Hospital, Department of Clinical and Biological Sciences, University of Turin, Italy; School of Specialization of Clinical Pathology, Department of Clinical and Biological Sciences, University of Turin, Italy
| | - Alice Barinotti
- Center of Research of Immunopathology and Rare Diseases- Coordinating Center of Piemonte and Aosta Valley Network for Rare Diseases, S. Giovanni Bosco Hospital, Department of Clinical and Biological Sciences, University of Turin, Italy; School of Specialization of Clinical Pathology, Department of Clinical and Biological Sciences, University of Turin, Italy
| | - Elisa Menegatti
- School of Specialization of Clinical Pathology, Department of Clinical and Biological Sciences, University of Turin, Italy
| | - Dario Roccatello
- Center of Research of Immunopathology and Rare Diseases- Coordinating Center of Piemonte and Aosta Valley Network for Rare Diseases, S. Giovanni Bosco Hospital, Department of Clinical and Biological Sciences, University of Turin, Italy; Nephrology and Dialysis, Department of Clinical and Biological Sciences, S. Giovanni Bosco Hospital, University of Turin, Italy
| | - Savino Sciascia
- Center of Research of Immunopathology and Rare Diseases- Coordinating Center of Piemonte and Aosta Valley Network for Rare Diseases, S. Giovanni Bosco Hospital, Department of Clinical and Biological Sciences, University of Turin, Italy; Nephrology and Dialysis, Department of Clinical and Biological Sciences, S. Giovanni Bosco Hospital, University of Turin, Italy.
| |
Collapse
|
21
|
Beltagy A, Trespidi L, Gerosa M, Ossola MW, Meroni PL, Chighizola CB. Anti-phospholipid antibodies and reproductive failures. Am J Reprod Immunol 2020; 85:e13258. [PMID: 32347616 DOI: 10.1111/aji.13258] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 04/21/2020] [Accepted: 04/22/2020] [Indexed: 12/16/2022] Open
Abstract
Anti-phospholipid syndrome (APS) recapitulates the link between autoimmunity and pregnancy failure: Acquired anti-phospholipid antibodies (aPL) play a pathogenic role in pregnancy complications. The diagnosis of obstetric APS can easily be pursued when women present with laboratory and clinical features fulfilling the international classification criteria. Standard therapeutic approach to obstetric APS consists in the association of anti-platelet agents and anticoagulants. Most patients achieve a live birth thanks to conventional treatment; however, approximately 20% fail to respond and are managed with additional therapeutic tools added on the top of conventional treatment. Surely, a refinement of risk stratification tools would allow early identification of high-risk pregnancies that warrant tailored treatment. In real life, obstetricians and rheumatologists face complex diagnostic scenarios including women with pregnancy morbidities other than those mentioned in classification criteria such as one or two early losses and premature birth after 34 weeks due to preeclampsia or placental insufficiency, women with low-titer aPL not fulfilling criteria laboratory requirements, women with positive non-criteria aPL, asymptomatic aPL carriers, and infertile women found to be aPL-positive. This review focuses on some of the several unanswered questions related to diagnostic, prognostic, and therapeutic aspects in obstetric APS.
Collapse
Affiliation(s)
- Asmaa Beltagy
- Experimental Laboratory of Immunological and Rheumatologic Researches, Istituto Auxologico Italiano, IRCCS, Cusano Milanino, Milan, Italy.,Immunology and Rheumatology Unit, San Luca Hospital, Istituto Auxologico Italiano, IRCCS, Milan, Italy.,Rheumatology and Clinical Immunology Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Laura Trespidi
- Department of Obstetrics and Gynaecology, Fondazione Cà Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Maria Gerosa
- Division of Clinical Rheumatology, Research Center for Adult and Pediatric Rheumatic Diseases, ASST G. Pini & CTO, Milan, Italy.,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Manuela Wally Ossola
- Department of Obstetrics and Gynaecology, Fondazione Cà Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Pier Luigi Meroni
- Experimental Laboratory of Immunological and Rheumatologic Researches, Istituto Auxologico Italiano, IRCCS, Cusano Milanino, Milan, Italy.,Immunology and Rheumatology Unit, San Luca Hospital, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Cecilia B Chighizola
- Experimental Laboratory of Immunological and Rheumatologic Researches, Istituto Auxologico Italiano, IRCCS, Cusano Milanino, Milan, Italy.,Immunology and Rheumatology Unit, San Luca Hospital, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| |
Collapse
|
22
|
Schreiber K, Hunt BJ. Managing antiphospholipid syndrome in pregnancy. Thromb Res 2020; 181 Suppl 1:S41-S46. [PMID: 31477227 DOI: 10.1016/s0049-3848(19)30366-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 05/31/2019] [Accepted: 06/03/2019] [Indexed: 02/06/2023]
Abstract
Antiphospholipid syndrome (APS) is an autoimmune disease characterised by the presence of antiphospholipid antibodies (aPL). The antibodies currently included in the classification criteria include lupus anticoagulant (LA), anticardiolipin antibodies (aCL) and anti-^2-glycoprotein 1 antibodies (^2GPI). APS can present with a variety of clinical phenotypes, including thrombosis in the veins, arteries and microvasculature and obstetrical complications. Pregnancy complications in obstetric APS (OAPS) include unexplained recurrent early pregnancy loss, fetal death, or premature birth due to severe preeclampsia, eclampsia, intrauterine growth restriction or other consequences of placental insufficiency. Careful, well monitored obstetric care with the use of aspirin and heparin has likely improved the pregnancy outcome in obstetric APS and currently approximately 70-80% of pregnant women with APS have a successful pregnancy outcome. However, the current standard of care does not prevent all pregnancy complications as the current treatment fails in 20-30% of APS pregnancies. Other treatments options are currently being explored and retrospective studies suggest that trials with hydroxychloroquine and possibly pravastatin are warranted in pregnant women with aPL. In this review will focus on the current treatment of OAPS.
Collapse
Affiliation(s)
- Karen Schreiber
- The Thrombosis & Haemophilia Centre, Guy's & St Thomas' NHS Foundation Trust, London SE1 7EH, UK; Copenhagen Lupus and Vasculitis Clinic, Center for Rheumatology and Spine Diseases, Copenhagen, Denmark
| | - Beverley J Hunt
- The Thrombosis & Haemophilia Centre, Guy's & St Thomas' NHS Foundation Trust, London SE1 7EH, UK.
| |
Collapse
|
23
|
Tektonidou MG, Andreoli L, Limper M, Amoura Z, Cervera R, Costedoat-Chalumeau N, Cuadrado MJ, Dörner T, Ferrer-Oliveras R, Hambly K, Khamashta MA, King J, Marchiori F, Meroni PL, Mosca M, Pengo V, Raio L, Ruiz-Irastorza G, Shoenfeld Y, Stojanovich L, Svenungsson E, Wahl D, Tincani A, Ward MM. EULAR recommendations for the management of antiphospholipid syndrome in adults. Ann Rheum Dis 2019; 78:1296-1304. [PMID: 31092409 PMCID: PMC11034817 DOI: 10.1136/annrheumdis-2019-215213] [Citation(s) in RCA: 585] [Impact Index Per Article: 117.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Revised: 04/16/2019] [Accepted: 04/18/2019] [Indexed: 01/04/2023]
Abstract
The objective was to develop evidence-based recommendations for the management of antiphospholipid syndrome (APS) in adults. Based on evidence from a systematic literature review and expert opinion, overarching principles and recommendations were formulated and voted. High-risk antiphospholipid antibody (aPL) profile is associated with greater risk for thrombotic and obstetric APS. Risk modification includes screening for and management of cardiovascular and venous thrombosis risk factors, patient education about treatment adherence, and lifestyle counselling. Low-dose aspirin (LDA) is recommended for asymptomatic aPL carriers, patients with systemic lupus erythematosus without prior thrombotic or obstetric APS, and non-pregnant women with a history of obstetric APS only, all with high-risk aPL profiles. Patients with APS and first unprovoked venous thrombosis should receive long-term treatment with vitamin K antagonists (VKA) with a target international normalised ratio (INR) of 2-3. In patients with APS with first arterial thrombosis, treatment with VKA with INR 2-3 or INR 3-4 is recommended, considering the individual's bleeding/thrombosis risk. Rivaroxaban should not be used in patients with APS with triple aPL positivity. For patients with recurrent arterial or venous thrombosis despite adequate treatment, addition of LDA, increase of INR target to 3-4 or switch to low molecular weight heparin may be considered. In women with prior obstetric APS, combination treatment with LDA and prophylactic dosage heparin during pregnancy is recommended. In patients with recurrent pregnancy complications, increase of heparin to therapeutic dose, addition of hydroxychloroquine or addition of low-dose prednisolone in the first trimester may be considered. These recommendations aim to guide treatment in adults with APS. High-quality evidence is limited, indicating a need for more research.
Collapse
Affiliation(s)
- Maria G Tektonidou
- First Department of Propaedeutic Internal Medicine, Joint Rheumatology program, National and Kapodistrian University of Athens, Athens, Greece
| | - Laura Andreoli
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Marteen Limper
- Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Zahir Amoura
- Sorbonne University, French National Center for SLE and Aps, Service de Medecine Interne 2, InstitutE3M, Pitié Salpétrière, Paris, France
| | - Ricard Cervera
- Autoimmune Diseases, Hospital Clinic, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Nathalie Costedoat-Chalumeau
- Centre de référence maladies auto-immunes et systémiques rares de l'île deFrance, Cochin Hospital, Université Paris Descartes-Sorbonne Paris Cité;INSERM U 1153, CRESS, Paris, France
| | | | - Thomas Dörner
- Department of Med/Rheumatology and Clinical Immunology, Charite University Hospital, Berlin, Germany
| | - Raquel Ferrer-Oliveras
- Obstetrics and Gynecology Department and Systemic Diseases Research Unit, Vall ďHebron Research Institute-VHIR, Barcelona, Spain
| | - Karen Hambly
- School of Sport and Exercise Sciences, University of Kent, Chatham, UK
| | | | - Judith King
- EULAR PARE Patient Research Partner, London, UK
| | | | - Pier Luigi Meroni
- MaACR, Immunorheumatology Research Laboratory, Istituto Auxologico Italiano, Milan, Italy
| | - Marta Mosca
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Vittorio Pengo
- Department of Cardiac Thoracic and Vascular Sciences and Public Health, University of Padova, Padua, Italy
| | - Luigi Raio
- Department of Obstetrics and Gynaecology, University Hospital of Bern, Inselspital, Bern, Switzerland
| | | | - Yehuda Shoenfeld
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Aviv University, Israel
| | | | - Elisabet Svenungsson
- Department of Medicine, Solna, Rheumatology Unit, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Denis Wahl
- Vascular Medicine Division and Regional Competence Center for Rare Vascular and Systemic Autoimmune Diseases and Vascular Medicine Division, Nancy University Hospital, INSERM UMR-S 1116 University of Lorraine, Nancy, France
| | - Angela Tincani
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Michael M Ward
- Intramural Research Program, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, Maryland, USA
| |
Collapse
|
24
|
Högdén A, Antovic A, Berg E, Bremme K, Chaireti R. Obstetric outcomes in patients with primary thrombotic and obstetric antiphospholipid syndrome and its relation to the antiphospholipid antibody profile. Lupus 2019; 28:868-877. [DOI: 10.1177/0961203319852155] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Introduction: Previous studies suggested different obstetric outcomes between patients with thrombotic or obstetric antiphospholipid syndrome, but the data are inconclusive. Aims: To investigate obstetric outcomes and their relation to the antiphospholipid antibody profile in primary thrombotic or obstetric antiphospholipid syndrome patients and compare those to a control population. Materials and methods: A retrospective single-centre study on a cohort of 30 pregnant women with primary antiphospholipid syndrome treated at Karolinska University Hospital Solna, Sweden between 2000 and 2016. The pregnancy outcomes were compared to the outcomes of all pregnancies in Stockholm County during the same period. Results: Preeclampsia ( p < 0.001), low birth weight at delivery ( p = 0.001), Apgar < 7 at 5 minutes ( p < 0.001) and small infants ( p < 0.001) were more common in antiphospholipid syndrome patients compared to controls. Obstetric antiphospholipid syndrome patients had a higher incidence of small infants ( p = 0.023), lower birth weight ( p = 0.013) and infants born with complications ( p=0.004) compared to thrombotic antiphospholipid syndrome. Mothers with triple antibody positivity had a higher incidence of preeclampsia ( p = 0.03), preterm delivery ( p = 0.011), small infants ( p=0.002) and infants born with complications ( p = 0.012). Conclusions: Patients with primary antiphospholipid syndrome, especially those with obstetric antiphospholipid syndrome and triple antibody positivity, are at higher risk for adverse pregnancy outcomes, even under antithrombotic treatment. More frequent antenatal controls in high-risk patients can further improve outcomes.
Collapse
Affiliation(s)
- A Högdén
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - A Antovic
- Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - E Berg
- LIME/MedStat, Karolinska Institutet, Stockholm, Sweden
| | - K Bremme
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - R Chaireti
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Solna, Sweden
- Department of Hematology, Karolinska University Hospital, Stockholm, Sweden
| |
Collapse
|
25
|
Tektonidou MG, Andreoli L, Limper M, Tincani A, Ward MM. Management of thrombotic and obstetric antiphospholipid syndrome: a systematic literature review informing the EULAR recommendations for the management of antiphospholipid syndrome in adults. RMD Open 2019; 5:e000924. [PMID: 31168416 PMCID: PMC6525610 DOI: 10.1136/rmdopen-2019-000924] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Revised: 03/26/2019] [Accepted: 03/27/2019] [Indexed: 01/31/2023] Open
Abstract
Objective To perform a systematic literature review (SLR) informing the European Lmmendations for the management of antiphospholipid syndrome (APS) in adults. Methods A SLR through January 2018 was performed. Research questions were constructed using the Patient, Intervention, Comparator, Outcome (PICO) format. We included data from articles that reported on each relevant intervention. Summary effect estimates were calculated for direct comparison studies that matched the PICO question exactly, and for studies with the relevant intervention and comparator. When meta-analyses were available, we used these estimates. Results From 7534 retrieved articles (+15 from hand searches), 188 articles were included in the review. In individuals with high-risk antiphospholipid antibody (aPL) profile without prior thrombotic or obstetric APS, two meta-analyses showed a protective effect of low-dose aspirin (LDA) against thrombosis. Two randomised controlled trials (RCTs) and three cohort studies showed no additional benefit of treatment with vitamin K antagonists at target international normalised ratio (INR) 3–4 versus INR 2–3 in patients with venous thrombosis. In patients with arterial thrombosis, two RCTs and two cohort studies showed no difference in risk of recurrent thrombosis between the two target INR groups. One open-label trial showed higher rates of thrombosis recurrences in triple aPL-positive patients treated with rivaroxaban than those treated with warfarin. RCTs and cohort studies showed that combination treatment with LDA and heparin was more effective than LDA alone in several types of obstetric APS. SLR results were limited by the indirect evidence and the heterogeneity of patient groups for some treatments, and only a few high-quality RCTs. Conclusion Well-designed studies of homogeneous APS patient populations are needed.
Collapse
Affiliation(s)
- Maria G Tektonidou
- Rheumatology Unit, First Department of Propaedeutic Internal Medicine, University of Athens, Athens, Greece
| | - Laura Andreoli
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Marteen Limper
- Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Angela Tincani
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Michael M Ward
- Intramural Research Program, NIAMS/NIH, Bethesda, Maryland, USA
| |
Collapse
|
26
|
Ruffatti A, Favaro M, Calligaro A, Zambon A, Del Ross T. Management of pregnant women with antiphospholipid antibodies. Expert Rev Clin Immunol 2019; 15:347-358. [DOI: 10.1080/1744666x.2019.1565995] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Affiliation(s)
- Amelia Ruffatti
- Rheumatology Unit, Department of Medicine, University Hospital of Padua, Padua, Italy
| | - Maria Favaro
- Rheumatology Unit, Department of Medicine, University Hospital of Padua, Padua, Italy
| | - Antonia Calligaro
- Rheumatology Unit, Department of Medicine, University Hospital of Padua, Padua, Italy
| | - Alessandra Zambon
- Obstetrics and Gynecology Unit, Department of Woman’s and Child’s Health, University Hospital of Padua, Padua, Italy
| | - Teresa Del Ross
- Rheumatology Unit, Department of Medicine, University Hospital of Padua, Padua, Italy
| |
Collapse
|
27
|
Belhocine M, Coutte L, Martin Silva N, Morel N, Guettrot-Imbert G, Paule R, Le Jeunne C, Fredi M, Dreyfus M, Piette JC, Souchaud-Debouverie O, Deneux-Tharaux C, Tsatsaris V, Pannier E, Le Guern V, Costedoat-Chalumeau N. Intrauterine fetal deaths related to antiphospholipid syndrome: a descriptive study of 65 women. Arthritis Res Ther 2018; 20:249. [PMID: 30400982 PMCID: PMC6235231 DOI: 10.1186/s13075-018-1745-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 10/15/2018] [Indexed: 12/18/2022] Open
Abstract
Objective Although one of the three obstetric manifestations of antiphospholipid syndrome (APS) is intrauterine fetal death (IUFD), little is known about it in this context. We report the first large series of patients with APS and IUFD. Methods We retrospectively analyzed the history and clinical data of women at four French hospitals. All had (1) APS diagnosis (Sydney criteria) and (2) IUFD at or after 10 weeks of gestation (weeks) between 2000 and 2016. Results The study included 65 women. Their median age at the index IUFD was 29 years (IQR 26–33); 38 (58%) were primigravidas. The index IUFD was the first APS clinical manifestation in 48 women (74%). Overall, 35% had a triple-positive antibody profile. IUFD occurred at a median gestational age of 24 weeks (IQR 18–27) and was associated with maternal obstetric complications in 16 women (25%), namely, preeclampsia (n = 12), hemolysis, elevated liver enzymes, and low platelet syndrome (HELLP) (n = 6), and/or placental abruption (n = 5). Half of the 50 women with available data had a small-for-gestational-age fetus. Overall, including during the follow-up period of 4 years (IQR 2–9), 28 women (43%) had at least one thrombosis, and 29% were diagnosed with systemic lupus erythematosus (SLE). Ultimately, 54 women (83%) had at least one live birth. Only one woman had three consecutive early miscarriages. Conclusion IUFD was most often the inaugural sign of APS. Of the APS classification criteria, IUFD, preeclampsia, and thromboses were common in this cohort, while the “3 consecutive early miscarriages” criterion was met only once. With treatment, most of the women successfully had at least one live birth.
Collapse
Affiliation(s)
- Mériem Belhocine
- AP-HP, Cochin Hospital, Internal Medicine Department, Centre de référence maladies auto-immunes et systémiques rares d'île de France, 27 Rue du Faubourg Saint Jacques, 75014, Paris, France
| | - Laetitia Coutte
- AP-HP, Cochin Hospital, Internal Medicine Department, Centre de référence maladies auto-immunes et systémiques rares d'île de France, 27 Rue du Faubourg Saint Jacques, 75014, Paris, France
| | | | - Nathalie Morel
- AP-HP, Cochin Hospital, Internal Medicine Department, Centre de référence maladies auto-immunes et systémiques rares d'île de France, 27 Rue du Faubourg Saint Jacques, 75014, Paris, France
| | - Gaëlle Guettrot-Imbert
- AP-HP, Cochin Hospital, Internal Medicine Department, Centre de référence maladies auto-immunes et systémiques rares d'île de France, 27 Rue du Faubourg Saint Jacques, 75014, Paris, France
| | - Romain Paule
- AP-HP, Cochin Hospital, Internal Medicine Department, Centre de référence maladies auto-immunes et systémiques rares d'île de France, 27 Rue du Faubourg Saint Jacques, 75014, Paris, France
| | - Claire Le Jeunne
- AP-HP, Cochin Hospital, Internal Medicine Department, Centre de référence maladies auto-immunes et systémiques rares d'île de France, 27 Rue du Faubourg Saint Jacques, 75014, Paris, France
| | - Micaela Fredi
- Spedali Civili di Brescia, Rheumatology and Clinical Immunology Department, Brescia, Italy
| | - Michel Dreyfus
- Caen University Hospital, Gynecology and Obstetrics Department, Caen, France
| | - Jean-Charles Piette
- AP-HP, Pitié-Salpétrière University Hospital, Internal Medicine and Clinical Immunology Department, Centre de référence maladies auto-immunes et systémiques rares de l'île de France, Université Paris 6, Paris, France
| | | | - Catherine Deneux-Tharaux
- INSERM U1153, Obstetrical, Perinatal and Paediatric Epidemiology (EPOPé research team), DHU Risks in Pregnancy, Université Paris Descartes, Paris, France
| | - Vassilis Tsatsaris
- AP-HP, Cochin Hospital, Port-Royal maternity, Gynecology and Obstetrics Department, DHU Risks in Pregnancy, INSERM U1139, Paris, France
| | - Emmanuelle Pannier
- AP-HP, Cochin Hospital, Port-Royal maternity, Gynecology and Obstetrics Department, DHU Risks in Pregnancy, INSERM U1139, Paris, France
| | - Véronique Le Guern
- AP-HP, Cochin Hospital, Internal Medicine Department, Centre de référence maladies auto-immunes et systémiques rares d'île de France, 27 Rue du Faubourg Saint Jacques, 75014, Paris, France
| | - Nathalie Costedoat-Chalumeau
- AP-HP, Cochin Hospital, Internal Medicine Department, Centre de référence maladies auto-immunes et systémiques rares d'île de France, 27 Rue du Faubourg Saint Jacques, 75014, Paris, France. .,INSERM U1153, Center for Epidemiology and Statistics Sorbonne Paris Cité (CRESS), Paris, France.
| |
Collapse
|
28
|
Abstract
Abstract. Antiphospholipid syndrome (APS) is an autoantibody-mediated acquired thrombophilia. It is characterized by the presence of antiphospholipid antibodies (APL) that are directed against phospholipid-binding plasma proteins, such as beta-2-glycoprotein I (b2GPI). Its main manifestations are recurrent vascular thromboses (so-called “thrombotic APS”) and pregnancy complications (“obstetric APS”). According to the current consensus criteria, a persistently positive functional lupus anticoagulant (LA) assay and/or the presence of anti-b2GPI and/or anti-cardiolipin antibodies, together with clinical symptoms, is mandatory for the diagnosis of APS. Other clinical features, such as thrombocytopenia, Coombs-positive haemolytic anaemia, heart valve disease, renal microangiopathy and neurologic disorders are also common in APL-positive patients. APS can be associated with other autoimmune disorders, such as systemic lupus erythematosus. In rare cases, catastrophic APS (CAPS) occurs, with the development of excessive thrombosis at multiple sites, usually affecting small vessels and leading to multi-organ dysfunction and organ failure. Treatment usually comprises antithrombotic therapy using antiplatelet and anticoagulant agents. However, there is no consensus concerning the intensity or duration of therapy. Despite apparently adequate anticoagulation, the risk of recurrent thrombosis remains high. For patients with CAPS, a combined therapeutic approach that includes anticoagulation, glucocorticoids, plasma exchange and/or intravenous immunoglobulin seems to be the best treatment option. Keywords: Antiphospholipid syndrome, lupus anticoagulants, anti-cardiolipin, anti-beta-2-glycoprotein I, vascular thrombosis, pregnancy complication
Collapse
Affiliation(s)
- Birgit Linnemann
- Division of Angiology, East Bavarian Center of Vascular Medicine, University Hospital Regensburg, Regensburg, Germany
| |
Collapse
|
29
|
Antiphospholipid syndrome: An update on risk factors for pregnancy outcome. Autoimmun Rev 2018; 17:956-966. [PMID: 30118899 DOI: 10.1016/j.autrev.2018.03.018] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Accepted: 03/28/2018] [Indexed: 11/22/2022]
Abstract
BACKGROUND The optimal treatment of women with primary antiphospholipid syndrome (APS) is still debated. About 20-30% of women with APS remain unable to give birth to healthy neonates despite conventional treatment, consisting of prophylactic-dose heparin and low-dose aspirin. These cases are defined "refractory obstetric APS". The early identification of risk factors associated with poor pregnancy outcome could be the optimal strategy to establish criteria for additional therapies, such as hydroxychloroquine, steroids, intravenous immunoglobulin, and plasma exchange. PURPOSE The aim of the present study was to review current literature about risk factors for poor pregnancy outcome. SEARCH METHODS The PubMed database was used to search for peer-reviewed original and review articles concerning risk factors for pregnancy outcome in APS from 1st January 1990 to 15th January 2018. OUTCOMES History of pregnancy morbidity and/or thrombosis, the association with SLE and/or other autoimmune diseases are well known history-based predictive factors for obstetrical complications, such as miscarriage, maternal venous thromboembolism, intrauterine foetal demise, preeclampsia, and neonatal death. Moreover, laboratory findings associated with poor pregnancy outcome are:triple antiphospholipid antibodies aPL positivity, double aPL positivity, single aPL positivity, false-positive IgM for CMV, and hypocomplementemia. Triple positivity is confirmed as the most significant risk factor by a large body of evidence. Furthermore, the abnormal uterine arteries Doppler velocimetry results are confirmed to be strongly associated with poor pregnancy outcomes in APS. The good performance of the uterine arteries velocimetry, as a negative predictive factor, was reported by different studies. On the contrary, in case of abnormal uterine arteries results, the relevance of a careful surveillance is highlighted for the high risk of maternal-foetal complications. Nevertheless, this tool is a late indicator to suggest any additional treatments. CONCLUSIONS In order to prevent obstetrical complications and establish the optimal combination therapy, the knowledge at preconception or at the beginning of pregnancy of risk factors associated with poor pregnancy outcome could be a crucial step for management and treatment of APS. In addition, in the preconception assessment a regimen with low-dose aspirin, folic acid, and vitamin D supplementation should be offered, and a treatment strategy has to be established (conventional vs additional therapy). In fact, additional treatment has to be tailored for each patient.
Collapse
|
30
|
Yelnik CM, Lambert M, Drumez E, Le Guern V, Bacri JL, Guerra MM, Laskin CA, Branch DW, Sammaritano LR, Morel N, Guettrot-Imbert G, Launay D, Hachulla E, Hatron PY, Salmon JE, Costedoat-Chalumeau N. Bleeding complications and antithrombotic treatment in 264 pregnancies in antiphospholipid syndrome. Lupus 2018; 27:1679-1686. [PMID: 30016929 DOI: 10.1177/0961203318787032] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose The purpose of this study was to evaluate the safety of antithrombotic treatments prescribed during pregnancy in patients with antiphospholipid syndrome (APS). Methods This international, multicenter study included two cohorts of patients: a retrospective French cohort and a prospective US cohort (PROMISSE study). Inclusion criteria were (1) APS (Sydney criteria), (2) live pregnancy at 12 weeks of gestation (WG) with (3) follow-up data until six weeks post-partum. According to APS standard of care, patients were treated with aspirin and/or low-molecular weight heparin (LMWH) at prophylactic (pure obstetric APS) or therapeutic doses (history of thrombosis). Major bleeding was defined as abnormal blood loss during the pregnancy and/or post-partum period requiring intervention for hemostasis or transfusion, or during the peripartum period greater than 500 mL and/or requiring surgery or transfusion. Other bleeding events were classified as minor. Results Two hundred and sixty-four pregnancies (87 prospectively collected) in 204 patients were included (46% with history of thrombosis, 23% with associated systemic lupus). During pregnancy, treatment included LMWH ( n = 253; 96%) or low-dose aspirin ( n = 223; 84%), and 215 (81%) patients received both therapies. The live birth rate was 89% and 82% in the retrospective and prospective cohorts, respectively. Adverse pregnancy outcomes occurred in 28% of the retrospective cohort and in 40% of the prospective cohort. No maternal death was observed in either cohort. A combined total of 45 hemorrhagic events (25%) occurred in the retrospective cohort, but major bleeding was reported in only six pregnancies (3%). Neither heparin nor aspirin alone nor combined therapy increased the risk of hemorrhage. We also did not observe an increased rate of bleeding in the case of a short interval between last LMWH (less than 24 hours) or aspirin (less than five days) doses and delivery. Only emergency Caesarean section was significantly associated with an increased risk of bleeding (odds ratio (OR) 5.03 (1.41-17.96); p=.016). In the prospective cohort, only one minor bleeding event was reported (vaginal bleeding). Conclusion Our findings support the safety of antithrombotic therapy with aspirin and/or LMWH during pregnancy in high-risk women with APS, and highlight the need for better treatments to improve pregnancy outcomes in APS. PROMISSE Study ClinicalTrials.gov identifier: NCT00198068.
Collapse
Affiliation(s)
- C M Yelnik
- 1 INSERM U995 LIRIC-Inflammation Research International Centre, CHU Lille, Département de Médecine Interne et d'Immunologie clinique, Centre National de Référence Maladies Systémiques et Auto-Immunes Rares, European Reference Network on Rare Connective Tissue and Musculoskeletal Diseases (ReCONNECT), University of Lille, France
| | - M Lambert
- 1 INSERM U995 LIRIC-Inflammation Research International Centre, CHU Lille, Département de Médecine Interne et d'Immunologie clinique, Centre National de Référence Maladies Systémiques et Auto-Immunes Rares, European Reference Network on Rare Connective Tissue and Musculoskeletal Diseases (ReCONNECT), University of Lille, France
| | - E Drumez
- 2 CHU Lille, EA 2694 - Santé publique: épidémiologie et qualité des soins, Département de Biostatistique, University of Lille, France
| | - V Le Guern
- 3 Service de Médecine Interne, Centre de Référence des Maladies Systémiques et Auto-Immunes Rares, Hôpital Cochin, Paris, France
| | - J-L Bacri
- 4 Service de Médecine Interne, Centre Hospitalier de Valenciennes, Valenciennes, France
| | - M M Guerra
- 5 Rheumatology, Hospital for Special Surgery, New York, USA
| | - C A Laskin
- 6 University of Toronto and Trio Fertility, Toronto, Canada
| | - D W Branch
- 7 University of Utah and Intermountain Healthcare, Salt Lake City, USA
| | | | - N Morel
- 3 Service de Médecine Interne, Centre de Référence des Maladies Systémiques et Auto-Immunes Rares, Hôpital Cochin, Paris, France
| | - G Guettrot-Imbert
- 3 Service de Médecine Interne, Centre de Référence des Maladies Systémiques et Auto-Immunes Rares, Hôpital Cochin, Paris, France
| | - D Launay
- 1 INSERM U995 LIRIC-Inflammation Research International Centre, CHU Lille, Département de Médecine Interne et d'Immunologie clinique, Centre National de Référence Maladies Systémiques et Auto-Immunes Rares, European Reference Network on Rare Connective Tissue and Musculoskeletal Diseases (ReCONNECT), University of Lille, France
| | - E Hachulla
- 1 INSERM U995 LIRIC-Inflammation Research International Centre, CHU Lille, Département de Médecine Interne et d'Immunologie clinique, Centre National de Référence Maladies Systémiques et Auto-Immunes Rares, European Reference Network on Rare Connective Tissue and Musculoskeletal Diseases (ReCONNECT), University of Lille, France
| | - P-Y Hatron
- 1 INSERM U995 LIRIC-Inflammation Research International Centre, CHU Lille, Département de Médecine Interne et d'Immunologie clinique, Centre National de Référence Maladies Systémiques et Auto-Immunes Rares, European Reference Network on Rare Connective Tissue and Musculoskeletal Diseases (ReCONNECT), University of Lille, France
| | - J E Salmon
- 5 Rheumatology, Hospital for Special Surgery, New York, USA
| | - N Costedoat-Chalumeau
- 3 Service de Médecine Interne, Centre de Référence des Maladies Systémiques et Auto-Immunes Rares, Hôpital Cochin, Paris, France.,8 Université Paris Descartes-Sorbonne Paris Cité, Paris, France.,9 INSERM U 1153, Center for Epidemiology and Statistics, Sorbonne Paris Cité (CRESS), Paris, France
| |
Collapse
|
31
|
Abstract
PURPOSE OF REVIEW Antiphospholipid syndrome (APS) is defined as the association of thrombotic events and/or obstetric morbidity in patients persistently positive for antiphospholipid antibodies (aPL). In this review, we will highlight the most important clinical presentations of APS with a focus on the obstetric morbidity, the current management strategies and the outlook for the future. RECENT FINDINGS The use of aspirin and heparin has improved the pregnancy outcome in obstetric APS and approximately 70% of pregnant women with APS have a successful pregnancy outcome. Unfortunately, the current standard of care does not prevent all pregnancy complications as the current treatment fails in 20-30% of APS pregnancies. This therefore highlights the need for alternative treatments to improve obstetrical outcome. Other treatment options are currently explored and retrospective studies show that pravastatin for example is beneficial in women with aPL-related early preeclampsia. Moreover, the immunmodulator hydroxychloroquine may play a beneficial role in the prevention of aPL-related pregnancy complications. SUMMARY APS is among the most frequent acquired risk factors for a treatable cause of recurrent pregnancy loss and increases the risk of conditions associated with ischaemic placental dysfunction, such as fetal growth restriction, preeclampsia, premature birth and intrauterine death. Current treatment is mainly based on aspirin and heparin. Studies to inform on alternative treatment options are urgently needed.
Collapse
|
32
|
Lapoirie J, Contis A, Guy A, Lifermann F, Viallard JF, Sentilhes L, James C, Duffau P. Management and outcomes of 27 pregnancies in women with myeloproliferative neoplasms. J Matern Fetal Neonatal Med 2018; 33:49-56. [PMID: 29945475 DOI: 10.1080/14767058.2018.1484097] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Introduction: Philadelphia-negative myeloproliferative neoplasms (MPNs) greatly increase the risk of maternal and fetal complications during pregnancy. Currently, international agreements regarding the management of these women are lacking.Patients and methods: Our study aimed to assess the current management and outcomes of MPN pregnancies in a French cohort. We retrospectively analyzed 27 pregnancies in women with MPNs that were associated with a specific mutation. Nineteen pregnancies in nine women with essential thrombocythemia and eight pregnancies in five women with polycythemia vera were identified.Results: Our study showed 70% live births, but only 30% uneventful pregnancies. Fetal complications were mainly early spontaneous abortions (22%), fetal growth restriction (15%), and premature delivery (15%). Maternal issues were divided between thrombosis (15%) and hemorrhages (11%). High rates of preeclampsia and hemolysis, elevated liver enzymes, and low platelet count syndrome (15%) were reported. Uterine artery Doppler was performed in 70% pregnancies. Abnormal Doppler results were found in 43% pregnancies. Pregnancies with high platelet counts and packed cell volume remaining static or increasing ended with fetal death and utero-placental dysfunction. According to expert consensus, most of the pregnancies (67%) could be stratified in the high risk group and had a bad obstetrical outcome, with 50% standard-risk pregnancies versus 22% high-risk pregnancies that were uneventful. Higher risk pregnancies were prescribed heparin and/or interferon α in 72%.Conclusions: The prognosis of these pregnancies remains very bad and may be improved by a more effective collaboration between specialists as well as a therapeutic intensification including heparin and interferon α.
Collapse
Affiliation(s)
- Joëlle Lapoirie
- Department of Internal Medicine and Clinical Immunology, Hôpital Saint-André, CHU de Bordeaux, Bordeaux, France
| | - Anne Contis
- Department of Internal Medicine and Clinical Immunology, Hôpital Saint-André, CHU de Bordeaux, Bordeaux, France
| | - Alexandre Guy
- Laboratory of Hematology, Hôpital Haut-Lévèque, CHU de Bordeaux, Pessac, France.,INSERM U1034, Biology of Cardiovascular Diseases, Pessac, France
| | | | - Jean-François Viallard
- INSERM U1034, Biology of Cardiovascular Diseases, Pessac, France.,Department of Internal Medicine, Hôpital Haut-Lévèque, CHU de Bordeaux, Pessac, France
| | - Loïc Sentilhes
- Department of Obstetrics and Gynecology, Hôpital Pellegrin, CHU de Bordeaux, Bordeaux, France
| | - Chloé James
- Laboratory of Hematology, Hôpital Haut-Lévèque, CHU de Bordeaux, Pessac, France.,INSERM U1034, Biology of Cardiovascular Diseases, Pessac, France
| | - Pierre Duffau
- Department of Internal Medicine and Clinical Immunology, Hôpital Saint-André, CHU de Bordeaux, Bordeaux, France.,ImmunoConcept, UMR CNRS 5164, Université de Bordeaux, Pessac, France
| |
Collapse
|
33
|
Antiphospholipid antibody profile-based outcome of purely vascular and purely obstetric antiphospholipid syndrome. J Thromb Thrombolysis 2018; 46:166-173. [DOI: 10.1007/s11239-018-1672-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
|
34
|
Ruffatti A, Hoxha A, Favaro M, Tonello M, Colpo A, Cucchini U, Banzato A, Pengo V. Additional Treatments for High-Risk Obstetric Antiphospholipid Syndrome: a Comprehensive Review. Clin Rev Allergy Immunol 2018; 53:28-39. [PMID: 27342460 DOI: 10.1007/s12016-016-8571-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Most investigators currently advocate prophylactic-dose heparin plus low-dose aspirin as the preferred treatment of otherwise healthy women with obstetric antiphospholipid syndrome, whilst women with a history of vascular thrombosis alone or associated with pregnancy morbidity are usually treated with therapeutic heparin doses in association with low-dose aspirin in an attempt to prevent both thrombosis and pregnancy morbidity. However, the protocols outlined above fail in about 20 % of pregnant women with antiphospholipid syndrome. Identifying risk factors associated with pregnancy failure when conventional therapies are utilized is an important step in establishing guidelines to manage these high-risk patients. Some clinical and laboratory risk factors have been found to be related to maternal-foetal complications in pregnant women on conventional therapy. However, the most efficacious treatments to administer to high-risk antiphospholipid syndrome women in addition to conventional therapy in order to avoid pregnancy complications are as yet unestablished. This is a comprehensive review on this topic and an invitation to participate in a multicentre study in order to identify the best additional treatments to be used in this subset of antiphospholipid syndrome patients.
Collapse
Affiliation(s)
- Amelia Ruffatti
- Rheumatology Unit, Department of Medicine, University of Padua, Padua, Italy.
- Reumatologia, Policlinico Universitario, Via Giustiniani, 2-35128, Padova, Italy.
| | - Ariela Hoxha
- Rheumatology Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Maria Favaro
- Rheumatology Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Marta Tonello
- Rheumatology Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Anna Colpo
- Blood Transfusion Unit, University-Hospital of Padua, Padua, Italy
| | - Umberto Cucchini
- Cardiology Unit, Department of Cardio-Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Alessandra Banzato
- Cardiology Unit, Department of Cardio-Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Vittorio Pengo
- Cardiology Unit, Department of Cardio-Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| |
Collapse
|
35
|
Pregnancy Outcome in Women with Obstetric and Thrombotic Antiphospholipid Syndrome-A Retrospective Analysis and a Review of Additional Treatment in Pregnancy. Clin Rev Allergy Immunol 2018; 53:54-67. [PMID: 27395067 DOI: 10.1007/s12016-016-8569-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Antiphospholipid syndrome (APS) is associated with pregnancy complications such as recurrent early fetal loss (RFL), fetal death, preeclampsia (PE), and intrauterine growth restriction (obstetric APS/OAPS). Other clinical manifestations are venous and/or arterial thromboses (thrombotic APS/TAPS). The data of 37 pregnancies with OAPS and 37 pregnancies with TAPS were analyzed and compared. Overall, the most frequent APS antibodies (aPl) were LA as well as "triple-positivity"; LA antibodies were significantly more frequent in women with TAPS (67.6 % TAPS vs. 29.7 % OAPS, p < 0.010), whereas "triple-positivity" was significantly more seen in women with OAPS (40.5 % OAPS vs. 13.5 % TAPS, p < 0.010). Adequate therapy has been administered in nearly all pregnancies with TAPS, whereas in 18.9 % of pregnancies with OPS, no therapy has been given at all. One woman in OAPS and four women in TAPS were treated with plasmapheresis and immunoadsorption. There was no significant association between adverse obstetric outcome and therapy. The most frequent pregnancy complications were RFL in the OAPS group (32.4 vs. 13.5 % in TAPS) and PE in the TAPS group (18.9 % in OAPS and TAPS, respectively). The data of our study showed that pregnancies with OAPS and TAPS have a similar rate of pregnancy complications. However, pregnancies with OAPS tend to have rather RFL. Although we were not able to reveal a significant association with adverse obstetric outcome, it seems that the current adequate therapy for APS in pregnancy, consisting of LDA and LMWH, might rather prevent the development of RFL. Additionally, it might be considered to divide the obstetric APS into obstetric APS with early pregnancy complications and obstetric APS with late pregnancy complications. The division into two groups of obstetric APS might facilitate the choice of additional therapy in these women.
Collapse
|
36
|
Cavazzana I, Andreoli L, Limper M, Franceschini F, Tincani A. Update on Antiphospholipid Syndrome: Ten Topics in 2017. Curr Rheumatol Rep 2018. [DOI: 10.1007/s11926-018-0718-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
|
37
|
Chighizola CB, Andreoli L, Gerosa M, Tincani A, Ruffatti A, Meroni PL. The treatment of anti-phospholipid syndrome: A comprehensive clinical approach. J Autoimmun 2018; 90:1-27. [PMID: 29449131 DOI: 10.1016/j.jaut.2018.02.003] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 02/06/2018] [Indexed: 01/02/2023]
Abstract
Anti-phospholipid syndrome (APS) is an acquired pro-thrombotic autoimmune disease that predisposes to thrombotic events and/or obstetric complications, in the persistent presence of anti-phospholipid antibodies (aPL). Life long moderate-intensity anticoagulation is the option of choice for aPL-positive patients with a previous thrombosis; critical issues concern the management of those with a history of arterial event due to the high rate of recurrence. Alternatives comprise anti-platelet agents and high-intensity anticoagulation. Low dose aspirin (LDASA) and low molecular weight heparin provide the mainstay of the treatment of obstetric APS, allowing a birth rate in 70% of cases. The management of refractory APS, thrombotic as well as obstetric, is highly debated, but an increasing burden of evidence points towards the beneficial effects of multiple treatments. Similarly, a management envisaging multiple drugs (anticoagulation, steroids, plasma exchange and/or intravenous immunoglobulins) is the most effective approach in catastrophic APS. Asymptomatic aPL carriers are at higher risk of thrombotic and obstetric complications compared to the general population, thus potentially benefitting of a pharmacological intervention. LDASA and hydroxychloroquine can be considered as options, in particular in case of high risk aPL profile, concomitant cardiovascular risk factors or associated autoimmune disease. APS is apparently a simple condition, but its multifaceted nature requires a complex and tailored treatment.
Collapse
Affiliation(s)
- Cecilia Beatrice Chighizola
- Department of Clinical Sciences and Community Health, University of Milan, Via Festa del Perdono 7, 20122, Milan, Italy; Experimental Laboratory of Immunological and Rheumatologic Researches, IRCCS Istituto Auxologico Italiano, Via Zucchi 18, 20095 Cusano Milanino, Milan, Italy; Allergology, Clinical Immunology and Rheumatology, Piazzale Brescia 20, 20149, Milan, Italy.
| | - Laura Andreoli
- Rheumatology and Clinical Immunology, Spedali Civili of Brescia, Department of Clinical and Experimental Sciences, University of Brescia, Piazzale Spedali Civili 1, 25123, Brescia, Italy
| | - Maria Gerosa
- Department of Clinical Sciences and Community Health, University of Milan, Via Festa del Perdono 7, 20122, Milan, Italy; Experimental Laboratory of Immunological and Rheumatologic Researches, IRCCS Istituto Auxologico Italiano, Via Zucchi 18, 20095 Cusano Milanino, Milan, Italy; Department of Rheumatology, ASST Istituto Gaetano Pini & CTO, Piazza Cardinal Ferrari, 1 20122, Milan, Italy
| | - Angela Tincani
- Rheumatology and Clinical Immunology, Spedali Civili of Brescia, Department of Clinical and Experimental Sciences, University of Brescia, Piazzale Spedali Civili 1, 25123, Brescia, Italy
| | - Amelia Ruffatti
- Rheumatology Unit, Department of Medicine, University of Padua, Via Giustiniani 2, 35128, Padua, Italy
| | - Pier Luigi Meroni
- Experimental Laboratory of Immunological and Rheumatologic Researches, IRCCS Istituto Auxologico Italiano, Via Zucchi 18, 20095 Cusano Milanino, Milan, Italy
| |
Collapse
|
38
|
|
39
|
Genetic risk factors in thrombotic primary antiphospholipid syndrome: A systematic review with bioinformatic analyses. Autoimmun Rev 2018; 17:226-243. [PMID: 29355608 DOI: 10.1016/j.autrev.2017.10.014] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Accepted: 10/20/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND Antiphospholipid Syndrome (APS) is an autoimmune multifactorial disorder. Genetics is believed to play a contributory role in the pathogenesis of APS, especially in thrombosis development and pregnancy morbidity. In the last 20 years, extensive research on genetic contribution on APS indicates that APS is a polygenic disorder, where a number of genes are involved in the development of its clinical manifestations. AIMS The aim of this systematic review is to evaluate the genetic risk factors in thrombotic primary APS. Additionally, to assess the common molecular functions, biological processes, pathways, interrelations with the gene encoded proteins and RNA-Seq-derived expression patterns over different organs of the associated genes via bioinformatic analyses. METHODS Without restricting the year, a systematic search of English articles was conducted (up to 4th September 2017) using Web of Science, PubMed, Scopus, ScienceDirect and Google Scholar databases. Eligible studies were selected based on the inclusion criteria. Two researchers independently extracted the data from the included studies. Quality assessment of the included studies was carried out using a modified New-Castle Ottawa scale (NOS). RESULTS From an initial search result of 2673 articles, 22 studies were included (1268 primary APS patients and 1649 healthy controls). Twenty-two genes were identified in which 16 were significantly associated with thrombosis in primary APS whereas six genes showed no significant association with thrombosis. Based on the NOS, 14 studies were of high quality while 6 were low quality studies. From the bioinformatic analyses, thrombin-activated receptor activity (q = 6.77 × 10-7), blood coagulation (q = 2.63 × 10-15), formation of fibrin clot (q = 9.76 × 10-10) were the top hit for molecular function, biological process and pathway categories, respectively. With the highest confidence interaction score of 0.900, all of the thrombosis-associated gene encoded proteins of APS were found to be interconnected except for two. Based on the pathway analysis, cumulatively all the genes affect haemostasis [false discovery rate (FDR) = 1.01 × 10-8] and the immune system [FDR = 9.93 × 10-2]. Gene expression analysis from RNA-Seq data revealed that almost all the genes were expressed in 32 different tissues in the human body. CONCLUSION According to our systematic review, 16 genes contribute significantly in patients with thrombotic primary APS when compared with controls. Bioinformatic analyses of these genes revealed their molecular interconnectivity in protein levels largely by affecting blood coagulation and immune system. These genes are expressed in 32 different organs and may pose higher risk of developing thrombosis anywhere in the body of primary APS patients.
Collapse
|
40
|
Abstract
Antiphospholipid syndrome (APS) is an autoimmune disease characterized by the presence of antiphospholipid antibodies, such as lupus anticoagulant, anticardiolipin antibodies and anti-β2-glycoprotein 1 antibodies. APS can present with a variety of clinical phenotypes, including thrombosis in the veins, arteries and microvasculature as well as obstetrical complications. The pathophysiological hallmark is thrombosis, but other factors such as complement activation might be important. Prevention of thrombotic manifestations associated with APS includes lifestyle changes and, in individuals at high risk, low-dose aspirin. Prevention and treatment of thrombotic events are dependent mainly on the use of vitamin K antagonists. Immunosuppression and anticomplement therapy have been used anecdotally but have not been adequately tested. Pregnancy morbidity includes unexplained recurrent early miscarriage, fetal death and late obstetrical manifestation such as pre-eclampsia, premature birth or fetal growth restriction associated with placental insufficiency. Current treatment to prevent obstetrical morbidity is based on low-dose aspirin and/or low-molecular-weight heparin and has improved pregnancy outcomes to achieve successful live birth in >70% of pregnancies. Although hydroxychloroquine and pravastatin might further improve pregnancy outcomes, prospective clinical trials are required to confirm these findings.
Collapse
|
41
|
Arachchillage DRJ, Laffan M. Pathogenesis and management of antiphospholipid syndrome. Br J Haematol 2017; 178:181-195. [PMID: 28339096 DOI: 10.1111/bjh.14632] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Antiphospholipid antibodies are a heterogeneous group of autoantibodies that have clear associations with thrombosis and pregnancy morbidity, and which together constitute the 'antiphospholipid syndrome' (APS). However, the pathophysiology of these complications is not well understood and their heterogeneity suggests that more than one pathogenic process may be involved. Diagnosis remains a combination of laboratory analysis and clinical observation but there have been significant advances in identifying specific pathogenic features, such as domain I-specific anti-β2-glycoprotein-I antibodies. This in turn has pointed to endothelial and complement activation as important factors in the pathogenesis of APS. Consequently, although anticoagulation remains the standard treatment for thrombotic APS and during pregnancy, the realisation that these additional pathways are involved in the pathogenesis of APS has significant implications for treatment: agents acting outside the coagulation system, such as hydroxychloroquine for pregnancy complications and sirolimus as an inhibitor of the mammalian target of rapamycin (mTOR) pathway, are now under evaluation and represent a radical change in thinking for haematologists. Conventional anticoagulation is also under challenge from new, direct acting anticoagulants. This review will provide a comprehensive overview of the evolving understanding of APS pathogenesis and how this and novel therapeutics will alter diagnosis and management.
Collapse
Affiliation(s)
- Deepa R J Arachchillage
- Department of Haematology, Imperial College Healthcare NHS Trust and Imperial College London, Hammersmith Hospital, London, UK
| | - Mike Laffan
- Department of Haematology, Imperial College Healthcare NHS Trust and Imperial College London, Hammersmith Hospital, London, UK
| |
Collapse
|
42
|
Gustavsen A, Skattum L, Bergseth G, Lorentzen B, Floisand Y, Bosnes V, Mollnes TE, Barratt-Due A. Effect on mother and child of eculizumab given before caesarean section in a patient with severe antiphospholipid syndrome: A case report. Medicine (Baltimore) 2017; 96:e6338. [PMID: 28296762 PMCID: PMC5369917 DOI: 10.1097/md.0000000000006338] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
RATIONALE Antiphospholipid syndrome (APS) in pregnancy may trigger the life-threatening catastrophic antiphospholipid syndrome (CAPS). Complement activation is implicated in the pathogenesis, and inhibition of complement factor C5 is suggested as an additional treatment option. PATIENT CONCERNS, DIAGNOSIS AND INTERVENTIONS We present a pregnant patient treated with the C5-inhibitor eculizumab due to high risk of developing devastating APS-related complications. The complement inhibitory effects of the treatment were examined both in the patient and the premature infant. OUTCOMES Complement activity in the mother recovered considerably faster than anticipated; however, no new thrombosis or CAPS developed during the last week of pregnancy or postpartum. Blood sampling from the umbilical vein and artery, and from the infant after delivery showed low complement activity; however, only 0.3% of the eculizumab concentration detected in the mother, consistent with low placental passage of eculizumab. LESSONS The data underscore the importance of close monitoring of complement inhibition and individualizing dosage regimens in pregnant patients receiving eculizumab. We document how traditional functional complement activity tests cannot assess the effect of eculizumab in premature infants due to the very low levels of complement factors detected in this infant born in gestational week 33. Only trace amounts of eculizumab passed the placenta. In conclusion, complement C5 inhibition might be a safe candidate treatment option for APS during pregnancy and delivery, and additionally, enables prolongation of pregnancy with important weeks.
Collapse
Affiliation(s)
- Alice Gustavsen
- Department of Immunology, Oslo University Hospital, and K.G. Jebsen IRC, University of Oslo, Oslo, Norway
| | - Lillemor Skattum
- Department of Laboratory Medicine, Section of Microbiology, Immunology and Glycobiology, Lund University and Clinical Immunology and Transfusion Medicine, Region Skane, Lund, Sweden
| | - Grethe Bergseth
- Research Laboratory, Nordland Hospital Bodø, and K.G. Jebsen TREC, University of Tromsø
| | | | | | - Vidar Bosnes
- Department of Immunology, Section of Medical Immunology, Oslo University Hospital, Oslo
| | - Tom Eirik Mollnes
- Department of Immunology, Oslo University Hospital, and K.G. Jebsen IRC, University of Oslo, Oslo, Norway
- Research Laboratory, Nordland Hospital Bodø, and K.G. Jebsen TREC, University of Tromsø
- Centre of Molecular Inflammation Research, Norwegian University of Science and Technology, Trondheim
| | - Andreas Barratt-Due
- Department of Immunology, Oslo University Hospital, and K.G. Jebsen IRC, University of Oslo, Oslo, Norway
- Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
| |
Collapse
|
43
|
Pregnancy and contraception in systemic and cutaneous lupus erythematosus. Ann Dermatol Venereol 2016; 143:590-600. [DOI: 10.1016/j.annder.2015.07.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Revised: 02/03/2015] [Accepted: 07/08/2015] [Indexed: 12/30/2022]
|
44
|
Pregnancy and autoimmune connective tissue diseases. Best Pract Res Clin Rheumatol 2016; 30:63-80. [PMID: 27421217 DOI: 10.1016/j.berh.2016.05.002] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Revised: 05/24/2016] [Accepted: 05/29/2016] [Indexed: 12/28/2022]
Abstract
Autoimmune connective tissue diseases predominantly affect women and often occur during the reproductive years. Thus, specialized issues in pregnancy planning and management are commonly encountered in this patient population. This chapter provides a current overview of pregnancy as a risk factor for onset of autoimmune disease, considerations related to the course of pregnancy in several autoimmune connective tissue diseases, and disease management and medication issues before pregnancy, during pregnancy, and in the postpartum period. A major theme that has emerged across these inflammatory diseases is that active maternal disease during pregnancy is associated with adverse pregnancy outcomes, and that maternal and fetal health can be optimized when conception is planned during times of inactive disease and through maintaining treatment regimens compatible with pregnancy.
Collapse
|
45
|
Negrini S, Pappalardo F, Murdaca G, Indiveri F, Puppo F. The antiphospholipid syndrome: from pathophysiology to treatment. Clin Exp Med 2016; 17:257-267. [PMID: 27334977 DOI: 10.1007/s10238-016-0430-5] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2016] [Accepted: 06/15/2016] [Indexed: 01/19/2023]
Abstract
Antiphospholipid antibody syndrome (APS) is an autoimmune acquired thrombophilia characterized by recurrent thrombosis and pregnancy morbidity in the presence of antiphospholipid antibodies (aPL). APS can be primary, if it occurs in the absence of any underlying disease, or secondary, if it is associated with another autoimmune disorder, most commonly systemic lupus erythematosus. The exact pathogenetic mechanism of APS is unknown, but different, not mutually exclusive, models have been proposed to explain how anti-PL autoantibodies might lead to thrombosis and pregnancy morbidity. Diagnosis of APS requires that a patient has both a clinical manifestation (arterial or venous thrombosis and/or pregnancy morbidity) and persistently positive aPL, but the clinical spectrum of the disease encompasses additional manifestations which may affect every organ and cannot be explained exclusively by a prothrombotic state. Treatment for aPL-positive patients is based on the patient's clinical status, presence of an underlying autoimmune disease, and history of thrombotic events. In case of aPL positivity without previous thrombotic events, the treatment is mainly focused on reduction of additional vascular risk factors, while treatment of patients with definite APS is based on long-term anticoagulation. Pregnancy complications are usually managed with low-dose aspirin in association with low molecular weight heparin. Refractory forms of APS could benefit from adding hydroxychloroquine and/or intravenous immunoglobulin to anticoagulation therapy. Promising novel treatments include anti-B cell monoclonal antibodies, new-generation anticoagulants, and complement cascade inhibitors. The objective of this review paper is to summarize the recent literature on APS from pathogenesis to current therapeutic options.
Collapse
Affiliation(s)
- Simone Negrini
- Department of Internal Medicine, Clinical Immunology Unit, University of Genoa, Viale Benedetto XV, 6, 16132, Genoa, Italy.
- Centre of Excellence for Biomedical Research, University of Genoa, Genoa, Italy.
| | | | - Giuseppe Murdaca
- Department of Internal Medicine, Clinical Immunology Unit, University of Genoa, Viale Benedetto XV, 6, 16132, Genoa, Italy
| | - Francesco Indiveri
- Department of Internal Medicine, Clinical Immunology Unit, University of Genoa, Viale Benedetto XV, 6, 16132, Genoa, Italy
| | - Francesco Puppo
- Department of Internal Medicine, Clinical Immunology Unit, University of Genoa, Viale Benedetto XV, 6, 16132, Genoa, Italy
| |
Collapse
|
46
|
Apheresis and intravenous immunoglobulins used in addition to conventional therapy to treat high-risk pregnant antiphospholipid antibody syndrome patients. A prospective study. J Reprod Immunol 2016; 115:14-9. [DOI: 10.1016/j.jri.2016.03.004] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2015] [Revised: 03/19/2016] [Accepted: 03/28/2016] [Indexed: 11/19/2022]
|
47
|
Danza Á, Ruiz-Irastorza G, Khamashta M. [Pregnancy in systemic autoimmune diseases: Myths, certainties and doubts]. Med Clin (Barc) 2016; 147:306-12. [PMID: 27143525 DOI: 10.1016/j.medcli.2016.03.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Accepted: 03/07/2016] [Indexed: 02/04/2023]
Abstract
Systemic autoimmune diseases especially affect young women during childbearing age. The aim of this review is to update systemic lupus erythematosus, antiphospholipid syndrome and systemic sclerosis management during pregnancy. These diseases present variable maternal and fetal risks. Studies show that an appropriate disease control and a reasonable remission period prior to pregnancy are associated with satisfactory obstetric outcomes. Antiphospholipid autoantibodies profile, anti-Ro/anti-La antibodies, pulmonary pressure and activity evaluation are crucial to assess the pregnancy risk. Monitoring requires a multidisciplinary team, serial analytic controls and Doppler ultrasound of maternal and fetal circulation. Evaluation of the activity of the disease is essential.
Collapse
Affiliation(s)
- Álvaro Danza
- Unidad Docente Asistencial en Enfermedades Autoinmunes Sistémicas y Reumatológicas, Clínica Médica, Hospital Pasteur, Departamento de Medicina, Facultad de Medicina, Universidad de la República, Administración de Servicios de Salud del Estado (ASSE), Montevideo, Uruguay; Unidad de Investigación de Enfermedades Autoinmunes, Servicio de Medicina Interna, BioCruces Health Research Institute, Hospital Universitario Cruces, Universidad del País Vasco (UPV)/Euskal Herriko Unibertsitatea (EHU), Barakaldo, Vizcaya, España.
| | - Guillermo Ruiz-Irastorza
- Unidad de Investigación de Enfermedades Autoinmunes, Servicio de Medicina Interna, BioCruces Health Research Institute, Hospital Universitario Cruces, Universidad del País Vasco (UPV)/Euskal Herriko Unibertsitatea (EHU), Barakaldo, Vizcaya, España
| | | |
Collapse
|
48
|
The impact of hydroxychloroquine treatment on pregnancy outcome in women with antiphospholipid antibodies. Am J Obstet Gynecol 2016; 214:273.e1-273.e8. [PMID: 26429521 DOI: 10.1016/j.ajog.2015.09.078] [Citation(s) in RCA: 109] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Revised: 09/03/2015] [Accepted: 09/21/2015] [Indexed: 11/21/2022]
Abstract
BACKGROUND Antiphospholipid syndrome is defined by the combination of thrombotic events and/or obstetric morbidity in patients who have tested positive persistently for antiphospholipid antibodies. With good treatment, approximately 70% of pregnant women with antiphospholipid syndrome will deliver a viable live infant. However, current management does not prevent all maternal, fetal, and neonatal complications of antiphospholipid syndrome. OBJECTIVES This observational, retrospective, single-center cohort study aimed to assess pregnancy outcome in women with antiphospholipid antibodies who were treated with hydroxychloroquine in addition to conventional treatment during pregnancy. STUDY DESIGN One-hundred seventy pregnancies in 96 women with persistent antiphospholipid antibodies were analyzed: (1) 51 pregnancies that occurred in 31 women were treated with hydroxychloroquine for at least 6 months before pregnancy, and the therapy continued throughout gestation (group A); (2) 119 pregnancies that occurred in 65 women with antiphospholipid antibodies that were not treated with hydroxychloroquine were included as controls (group B). RESULTS Hydroxychloroquine-treatment was associated with a higher rate of live births (67% group A vs 57% group B; P = .05) and a lower prevalence of antiphospholipid antibodies-related pregnancy morbidity (47% group A vs 63% B; P = .004). The association of hydroxychloroquine with a lower rate of any complication in pregnancy was confirmed after multivariate analysis (odds ratio, 2.2; 95% confidence interval, 1.2-136; P = .04). Fetal losses at >10 weeks of gestation (2% vs 11%; P = .05) and placenta-mediated complications (2% vs 11%; P = .05) were less frequent in group A than group B. Pregnancy duration was longer in group A than group B (27.6 [6-40] vs 21.5 [6-40] weeks; P = .03). There was a higher rate of spontaneous vaginal labor in hydroxychloroquine-treated women compared with group B (37.3% vs 14.3%; P = .01). CONCLUSIONS Despite the heterogeneity in the 2 groups in terms of systemic lupus erythematosus prevalence and previous pregnancy history, our results support the concept that women with antiphospholipid antibodies may benefit from treatment with hydroxychloroquine during pregnancy to improve pregnancy outcome. The addition of hydroxychloroquine to conventional treatment is worthy of further assessment in a proper designed randomized controlled trial.
Collapse
|
49
|
Ruffatti A, Favaro M, Brucato A, Ramoni V, Facchinetti M, Tonello M, Del Ross T, Calligaro A, Hoxha A, Grava C, De Silvestro G. Apheresis in high risk antiphospholipid syndrome pregnancy and autoimmune congenital heart block. Transfus Apher Sci 2015; 53:269-78. [DOI: 10.1016/j.transci.2015.11.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
50
|
Abstract
Pregnancy increases the risk of thrombosis four- to five-fold. Seventy-five to eighty percent of pregnancy-related thrombotic events are venous and twenty to -twenty-five percent are arterial. The main reason for the increased risk is hypercoagulability. Women are hypercoagulable because they have evolved so that they are protected against the bleeding challenges of pregnancy, miscarriage, or childbirth. Both genetic and acquired risk factors can further increase the risk of thrombosis. The maternal consequences of thrombosis of pregnancy include permanent vascular damage, disability, and death. While the maternal outcomes of thrombosis can be modified by anticoagulation therapy, management of thrombosis during pregnancy is the subject of another paper in this issue (see paper by B. Konkle). This review will focus on the epidemiology, pathophysiology, risk factors, and maternal consequences of thrombosis in pregnancy.
Collapse
Affiliation(s)
- Andra H James
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina
| |
Collapse
|