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Preparing for Pregnancy in Women with Systemic Lupus Erythematosus—A Multidisciplinary Approach. Medicina (B Aires) 2022; 58:medicina58101371. [DOI: 10.3390/medicina58101371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 09/22/2022] [Accepted: 09/23/2022] [Indexed: 11/17/2022] Open
Abstract
Pregnancy is one of the most challenging processes the human body is exposed to: the healthy mother can carry to term a genetically different new-born, while her immune system adapts to tolerate this new status and avoids rejection. In autoimmune disorders, motherhood is even more challenging, with additional medical counselling, mother care, and foetus development checks being necessary. While the aspects of supplementary mother care and pregnancy progress tracking are associated with well-established medical procedures and protocols, counselling, be it pre- or post-conception, is still underestimated and scarcely applied. Indeed, over the past decades, medical counselling for this particular population has changed significantly, but from a healthcare’s provider point of view, more is required to ensure a smooth, controllable pregnancy evolution. One of the most frequent autoimmune diseases affecting young females during their fertile years is Systemic Lupus Erythematosus (SLE). Like other heterogenous diseases, it exposes the mother to severe, organ-threatening complications and unpredictable evolution. Both the disease and its treatment can significantly affect the mother’s willingness to engage in a potentially risky pregnancy, as well as the likeliness to carry it to term without any impairments. A good collaboration between the patient’s rheumatologist and obstetrician is therefore mandatory in order to: (a) allow the mother to make an informed decision on pursuing with the pregnancy; (b) ensure a perfect synchronization between pregnancy terms and treatment; and (c) avoid or minimize potential complications. The best approach to achieve these outcomes is pregnancy planning. Moreover, knowing one desired prerequisite for a successful pregnancy evolution in SLE mothers is a stable, inactive, quiescent disease for at least six months prior to conception, planning becomes more than a recommended procedure. One particular aspect that requires attention before conception is the treatment scheme applied before delivery as autoantibodies can influence significantly the course of pregnancy. In this view, future SLE mothers should ideally benefit from preconception counselling within their agreed care pathway. A multidisciplinary team including at least the rheumatologist and obstetrician should be employed throughout the pregnancy, to decide on the appropriate timing of conception and compatible medication with respect to disease activity, as well as to monitor organ involvement and foetus development progress.
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Botta A, Rizzo F, Antonielli T, Ciliberti A, Garufi E, Lanzone A, Garufi C, De Carolis S. The Detrimental Effect of Thyroiditis on Pregnancy Outcome of Patients Affected by Autoimmune Diseases: An Open Question. Front Pharmacol 2022; 13:827735. [PMID: 35222042 PMCID: PMC8864307 DOI: 10.3389/fphar.2022.827735] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 01/14/2022] [Indexed: 11/16/2022] Open
Abstract
Few data are available evaluating obstetrical outcome when thyroiditis coexist with autoimmune diseases. Objectives of our study were: 1) To assess the prevalence of thyroiditis in pregnant women with autoimmune diseases; 2) To evaluate the effects on pregnancy outcome when different autoimmune diseases are associated with thyroiditis. Two groups of pregnant women were analysed: a study group of pregnant women with autoimmune diseases (n = 268) versus a control group of pregnant women (n = 1,150). In both groups the research for thyroid antibodies, anti-thyroid peroxidase antibodies and anti-thyroglobulin antibodies, was performed. The positivity had a prevalence of 17.54% in women with autoimmune diseases (n = 47) versus 5.57% in the control group (n = 64) (p-value < 0.00001). Only major rheumatic diseases (MRD) were analysed for pregnancy outcome (week of delivery, birth weight and birth weight percentile): systemic lupus erythematosus (SLE) n = 36, antiphospholipid syndrome (APS) n = 44 and connective tissue diseases (CTD) n = 23. MRD were divided according to positive or negative results for thyroid antibodies. Thyroiditis in CDT patients showed a detrimental effect on pregnancy outcome, in terms of earlier week of delivery: 37.86 ± 0.90 (mean ± SD) in CTD with thyroiditis versus 38.56 ± 0.73 (mean ± SD) in CTD without thyroiditis (p-value = 0.03) and lower birth weight: 2,790.71 g ± 257.17 SD in CTD with thyroiditis versus 3,019.33 g ± 305.48 g in CTD without thyroiditis (p-value < 0.05). In SLE and APS thyroiditis did not appear to influence pregnancy outcome. However, we suggest investigating anti-thyroid antibodies in all autoimmune diseases with special attention to pregnant women with thyroiditis and CTD.
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Affiliation(s)
- Angela Botta
- Dipartimento Scienze della Salute della Donna, Del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Francesca Rizzo
- Dipartimento Scienze della Salute della Donna, Del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Tatiana Antonielli
- Dipartimento Scienze della Salute della Donna, Del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Alessandra Ciliberti
- Dipartimento Scienze della Salute della Donna, Del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Ester Garufi
- Department of Anesthesiology and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Antonio Lanzone
- Dipartimento Scienze della Salute della Donna, Del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica Del Sacro Cuore, Rome, Italy
| | - Cristina Garufi
- Arthritis Center, Reumatologia, Dipartimento di Scienze Cliniche Internistiche, Anestesiologiche e Cardiovascolari, Sapienza Università di Roma, Roma, Italy
| | - Sara De Carolis
- Dipartimento Scienze della Salute della Donna, Del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica Del Sacro Cuore, Rome, Italy
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Affiliation(s)
- Riley Epp
- Department of Medicine University of Ottawa, Ottawa, Ontario, Canada
- Division of Endocrinology and Metabolism, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Janine Malcolm
- Department of Medicine University of Ottawa, Ottawa, Ontario, Canada
- Division of Endocrinology and Metabolism, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Khiera Jolin-Dahel
- Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | | | - Erin Keely
- Department of Medicine University of Ottawa, Ottawa, Ontario, Canada
- Division of Endocrinology and Metabolism, The Ottawa Hospital, Ottawa, Ontario, Canada
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Clinical features of new-onset systemic lupus erythematosus during pregnancy in Central China: a retrospective study of 68 pregnancies. Clin Rheumatol 2020; 40:2121-2131. [PMID: 33064224 DOI: 10.1007/s10067-020-05452-2] [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: 11/18/2019] [Revised: 09/30/2020] [Accepted: 10/06/2020] [Indexed: 01/01/2023]
Abstract
The aim of this study is to explore the clinical features and pregnancy outcomes of Chinese patients with new-onset systemic lupus erythematosus (SLE) during pregnancy or puerperium. We retrospectively evaluated the data of all pregnant women with SLE managed at the First Affiliated Hospital of Zhengzhou University between April 2013 and March 2017. Clinical characteristics, laboratory features, medication use, and pregnancy outcomes were compared between pregnant women with new-onset SLE and pregnant women with pre-existing SLE. Risk factors for adverse pregnancy outcomes were determined using binary regression analyses. Overall, 223 pregnancies in 216 patients were included; 148 (69.6%) patients had a history of SLE, and 68 (30.4%) were diagnosed with SLE during pregnancy or puerperium. Most cases of new-onset SLE (72.1%) occurred during the first and second trimesters. Thrombocytopaenia (especially severe thrombocytopaenia) (76.5% vs 54.2%, P = 0.008; 39.7% vs 15.5%, P = 0.001) and anaemia (especially moderate anaemia) (73.5% vs 56.9%, P = 0.007; 52.9% vs 35.2%, P = 0.035) were more common in women with new-onset SLE than in women with pre-existing SLE and active disease during pregnancy. Additionally, patients with new-onset SLE experienced higher rates of moderate-to-severe disease activity than patients with pre-existing SLE (P < 0.01); disease activity occurred mostly during the first and second trimesters (75.4%). Compared with pre-existing SLE patients, disease activity in new-onset SLE patients occurred mostly in the first trimester (33.3% vs 15.3%, P = 0.043) and less in the third trimester (21.1% vs 47.2%, P < 0.001). Pregnancy loss was significantly higher in patients with new-onset SLE than in patients with pre-existing SLE (62.4% vs 27.1%, P < 0.001), with most cases occurring during the first and second trimesters (95.3%). However, there were no significant differences in neonatal outcomes between new-onset and pre-existing SLE patients with active disease. Within the new-onset SLE group, active disease was an independent risk factor for pregnancy loss (odds ratio [OR] = 16.185, confidence interval [CI] = 1.895-138.232, P = 0.011), whereas disease onset at late gestation was a protective factor against pregnancy loss (OR = 0.589, CI = 0.435-0.796, P = 0.013). Patients with new-onset SLE suffered greater haematological involvement (mainly thrombocytopaenia and anaemia) and higher rates of moderate-to-severe disease activity and pregnancy loss than patients with pre-existing SLE. Controlling disease activity and extending gestational age may improve pregnancy outcomes in women with new-onset SLE. Key Points • The clinical features of new-onset SLE during pregnancy and its impact on pregnancy outcomes have rarely been reported, especially in Chinese patients. • New-onset SLE during pregnancy in Chinese women occurred primarily during the first and second trimesters and was characterised by haematological disorders, including thrombocytopaenia and anaemia. • Women with new-onset SLE during pregnancy had significantly higher disease activity scores and pregnancy loss rates than women with pre-existing SLE, especially during the first and second trimesters; controlling disease activity and prolonging gestational age may improve pregnancy outcomes in this setting.
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Zhang X, Xu B, Liu Z, Gao Y, Wang Q, Liu R. Systemic lupus erythematosus with hypothyroidism as the initial clinical manifestation: A case report. Exp Ther Med 2020; 20:996-1002. [PMID: 32742342 PMCID: PMC7388410 DOI: 10.3892/etm.2020.8788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 02/04/2020] [Indexed: 11/06/2022] Open
Abstract
Systemic lupus erythematosus (SLE) is a multisystem autoimmune disease and hypothyroidism is an organ-specific autoimmune disease. The two diseases may occur successively or simultaneously. The majority of previous studies observed that thyroid disease was more frequent in patients with SLE than in the general population, particularly those who had a higher incidence of anti-thyroid antibodies. However, there are no reported cases of SLE with hypothyroidism as the initial clinical manifestation, to the best of our knowledge. The present study reported on a case of SLE with this unusual initial clinical manifestation and reviewed the literature to estimate the prevalence of clinical hypothyroidism in patients with SLE (range, 3.0-21.4%). The case of the present study had no obvious facial erythema, photosensitivity or recurrent oral ulcers, and only had hypothyroidism as the initial clinical symptom, but the laboratory examination supported the diagnosis of SLE. The present study suggested that in the clinical diagnosis, attention should be paid to screening for connective tissue diseases when diagnosing hypothyroidism, and the importance of thyroid dysfunction should also be recognized in the treatment of SLE.
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Affiliation(s)
- Xuejiao Zhang
- Department of Endocrinology, China-Japan Union Hospital of Jilin University, Changchun, Jilin 130033, P.R. China
| | - Baofeng Xu
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
| | - Ziwei Liu
- Department of Endocrinology, China-Japan Union Hospital of Jilin University, Changchun, Jilin 130033, P.R. China
| | - Yuanyuan Gao
- Department of Endocrinology, China-Japan Union Hospital of Jilin University, Changchun, Jilin 130033, P.R. China
| | - Qing Wang
- Department of Endocrinology, China-Japan Union Hospital of Jilin University, Changchun, Jilin 130033, P.R. China
| | - Rui Liu
- Department of VIP Unit, China-Japan Union Hospital of Jilin University, Changchun, Jilin 130033, P.R. China
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Petri M. Pregnancy and Systemic Lupus Erythematosus. Best Pract Res Clin Obstet Gynaecol 2020; 64:24-30. [PMID: 31677989 DOI: 10.1016/j.bpobgyn.2019.09.002] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 09/11/2019] [Accepted: 09/12/2019] [Indexed: 01/07/2023]
Abstract
As SLE onset is often in young adulthood, pregnancy is common and is usually successful. Pregnancy, though, is considered high-risk due to a combination of maternal (lupus flare, diabetes, pre-eclampsia) and fetal (miscarriage, intrauterine fetal demise, preterm birth, intrauterine growth restriction, congenital heart block) risks. Pregnancy should be planned for a time of good control of SLE (on allowable medications). The antimalarial hydroxychloroquine should be continued. The only permitted immunosuppressive drugs are azathioprine and tacrolimus. Of the antiphospholipid antibodies, only the lupus anticoagulant has been associated with adverse pregnancy outcomes in the largest prospective multicenter study, Predictors of Pregnancy Outcome: Biomarkers in Antiphospholipid Antibody Syndrome and Systemic Lupus Erythematosus (PROMISSE). Management of antiphospholipid syndrome in pregnancy is low molecular weight heparin and aspirin, although only 75% of pregnancies are successful.
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Affiliation(s)
- Michelle Petri
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Klionsky Y, Antonelli M. Thyroid Disease in Lupus: An Updated Review. ACR Open Rheumatol 2020; 2:74-78. [PMID: 32043833 PMCID: PMC7011406 DOI: 10.1002/acr2.11105] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Accepted: 11/05/2019] [Indexed: 01/25/2023] Open
Abstract
In the following review, we seek to provide an overview of the current understanding of various thyroid manifestations affecting patients with systemic lupus erythematosus (SLE), including topics ranging from thyroid‐related complications to SLE in pregnancy. Autoimmune diseases tend to coincide, and an association between thyroid disease and SLE has been reported for more than 50 years. There is no evidence that the coexistence of thyroid disease and lupus alters the disease course or manifestations of either. Both hypothyroidism and thyroid nodules are seen more frequently in patients with SLE than in the general population. The rate of thyroid cancer is twice as prevalent in patients with SLE compared with those without SLE. Several forms of thyroid disease are more common among patients with SLE, with adverse consequences in pregnancy. Future work will require delineating the mechanism behind these associations and understanding the role of antirheumatic agents with concomitant thyroid disease.
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Affiliation(s)
- Yael Klionsky
- Case Western Reserve University at MetroHealth Medical Center, Cleveland, Ohio
| | - Maria Antonelli
- Case Western Reserve University at MetroHealth Medical Center, Cleveland, Ohio
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Pörings AS, Lowin T, Dufner B, Grifka J, Straub RH. A thyroid hormone network exists in synovial fibroblasts of rheumatoid arthritis and osteoarthritis patients. Sci Rep 2019; 9:13235. [PMID: 31519956 PMCID: PMC6744488 DOI: 10.1038/s41598-019-49743-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 08/28/2019] [Indexed: 01/08/2023] Open
Abstract
While patients with rheumatoid arthritis (RA) sometimes demonstrate thyroidal illness, the role of thyroid hormones in inflamed synovial tissue is unknown. This is relevant because thyroid hormones stimulate immunity, and local cells can regulate thyroid hormone levels by deiodinases (DIO). The study followed the hypothesis that elements of a thyroid hormone network exist in synovial tissue. In 12 patients with RA and 32 with osteoarthritis (OA), we used serum, synovial fluid, synovial tissue, and synovial fibroblasts (SF) in order to characterize the local thyroid hormone network using ELISAs, immunohistochemistry, imaging methods, tissue superfusion studies, cell-based ELISAs, flow cytometry, and whole genome expression profiling. Serum/synovial fluid thyroid hormone levels were similar in RA and OA (inclusion criteria: no thyroidal illness). The degradation product termed reverse triiodothyronine (reverse T3) was much lower in serum compared to synovial fluid indicating biodegradation of thyroid hormones in the synovial environment. Superfusion experiments with synovial tissue also demonstrated biodegradation, particularly in RA. Cellular membrane transporters of thyroid hormones, DIOs, and thyroid hormone receptors were present in tissue and SF. Density of cells positive for degrading DIOs were higher in RA than OA. TNF increased protein expression of degrading DIOs in RASF and OASF. Gene expression studies of RASF revealed insignificant gene regulation by bioactive T3. RA and OA synovial tissue/SF show a local thyroid hormone network. Thyroid hormones undergo strong biodegradation in synovium. While bioactive T3 does not influence SF gene expression, SF seem to have a relay function for thyroid hormones.
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Affiliation(s)
- Anna-Sophia Pörings
- Laboratory of Experimental Rheumatology and Neuroendocrine Immunology, Dept. of Internal Medicine, University Hospital Regensburg, Regensburg, Germany
| | - Torsten Lowin
- Laboratory of Experimental Rheumatology and Neuroendocrine Immunology, Dept. of Internal Medicine, University Hospital Regensburg, Regensburg, Germany.,W. & B. Hiller Research Center of Rheumatology, Life Science Center, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Bianca Dufner
- Laboratory of Experimental Rheumatology and Neuroendocrine Immunology, Dept. of Internal Medicine, University Hospital Regensburg, Regensburg, Germany
| | - Joachim Grifka
- Department of Orthopedic Surgery, University Hospital Regensburg, Asklepios Clinic Bad Abbach, Bad Abbach, Germany
| | - Rainer H Straub
- Laboratory of Experimental Rheumatology and Neuroendocrine Immunology, Dept. of Internal Medicine, University Hospital Regensburg, Regensburg, Germany.
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McDonald EG, Bissonette L, Ensworth S, Dayan N, Clarke AE, Keeling S, Bernatsky S, Vinet E. Monitoring of Systemic Lupus Erythematosus Pregnancies: A Systematic Literature Review. J Rheumatol 2018; 45:1477-1490. [PMID: 30008450 DOI: 10.3899/jrheum.171023] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/25/2018] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Few data exist to guide the frequency and type of monitoring in systemic lupus erythematosus (SLE) pregnancies. A systematic literature review was performed to address this gap in the literature. METHODS A systematic review of original articles (1975-2015) was performed using Medline, Embase, and Cochrane Library. We included search terms for SLE, pregnancy, and monitoring. We also hand-searched reference lists, review articles, and grey literature for additional relevant articles. RESULTS The search yielded a total of 1106 articles. After removing 117 duplicates, 929 articles that were evidently unrelated to our topic based on title and/or abstract, and 7 that were in a language other than English or French, 53 articles were included for full-text review. Following a more in-depth review, 15 were excluded: 6 did not use any measure of SLE activity and 6 did not specifically address SLE monitoring in pregnancy; 1 case series, 1 review, and 1 metaanalysis were removed. Among the 38 included studies, presence of active disease, antiphospholipid (aPL) antibodies positivity, and abnormal uterine and umbilical artery Doppler studies predicted poor pregnancy outcomes. No studies evaluated an evidence-based approach to the frequency of monitoring. CONCLUSION Few existing studies address monitoring for optimal care during SLE pregnancies. The available data imply roles for aPL antibodies measurement (prior to pregnancy and/or during the first trimester), uterine and umbilical artery Doppler studies in the second trimester, and following disease activity. Optimal frequency of monitoring is not addressed in the existing literature.
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Affiliation(s)
- Emily G McDonald
- From the Division of General Internal Medicine, and the Division of Rheumatology, Department of Medicine, McGill University Health Centre, Montréal; Division of Rheumatology, Department of Medicine, University of Sherbrooke, Sherbrooke, Québec; Division of Rheumatology, Mary Pack Arthritis Center, University of British Columbia, Vancouver, British Columbia; Division of Rheumatology, Department of Medicine, University of Alberta, Edmonton; Division of Rheumatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada.,E.G. McDonald, MD, MSc, Division of General Internal Medicine, Department of Medicine, McGill University Health Centre; L. Bissonette, MD, Division of Rheumatology, Department of Medicine, University of Sherbrooke; S. Ensworth, MD, Assistant Professor, Division of Rheumatology, University of British Columbia; N. Dayan, MD, MSc, Division of General Internal Medicine, Department of Medicine, McGill University Health Centre; A.E. Clarke, MD, MSc, Division of Rheumatology, Department of Medicine, University of Calgary; S. Keeling, MD, MSc, Division of Rheumatology, Department of Medicine, University of Alberta; S. Bernatsky, MD, PhD, Division of Rheumatology, Department of Medicine, McGill University Health Centre; E. Vinet, MD, PhD, Division of Rheumatology, Department of Medicine, McGill University Health Centre
| | - Lyne Bissonette
- From the Division of General Internal Medicine, and the Division of Rheumatology, Department of Medicine, McGill University Health Centre, Montréal; Division of Rheumatology, Department of Medicine, University of Sherbrooke, Sherbrooke, Québec; Division of Rheumatology, Mary Pack Arthritis Center, University of British Columbia, Vancouver, British Columbia; Division of Rheumatology, Department of Medicine, University of Alberta, Edmonton; Division of Rheumatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada.,E.G. McDonald, MD, MSc, Division of General Internal Medicine, Department of Medicine, McGill University Health Centre; L. Bissonette, MD, Division of Rheumatology, Department of Medicine, University of Sherbrooke; S. Ensworth, MD, Assistant Professor, Division of Rheumatology, University of British Columbia; N. Dayan, MD, MSc, Division of General Internal Medicine, Department of Medicine, McGill University Health Centre; A.E. Clarke, MD, MSc, Division of Rheumatology, Department of Medicine, University of Calgary; S. Keeling, MD, MSc, Division of Rheumatology, Department of Medicine, University of Alberta; S. Bernatsky, MD, PhD, Division of Rheumatology, Department of Medicine, McGill University Health Centre; E. Vinet, MD, PhD, Division of Rheumatology, Department of Medicine, McGill University Health Centre
| | - Stephanie Ensworth
- From the Division of General Internal Medicine, and the Division of Rheumatology, Department of Medicine, McGill University Health Centre, Montréal; Division of Rheumatology, Department of Medicine, University of Sherbrooke, Sherbrooke, Québec; Division of Rheumatology, Mary Pack Arthritis Center, University of British Columbia, Vancouver, British Columbia; Division of Rheumatology, Department of Medicine, University of Alberta, Edmonton; Division of Rheumatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada.,E.G. McDonald, MD, MSc, Division of General Internal Medicine, Department of Medicine, McGill University Health Centre; L. Bissonette, MD, Division of Rheumatology, Department of Medicine, University of Sherbrooke; S. Ensworth, MD, Assistant Professor, Division of Rheumatology, University of British Columbia; N. Dayan, MD, MSc, Division of General Internal Medicine, Department of Medicine, McGill University Health Centre; A.E. Clarke, MD, MSc, Division of Rheumatology, Department of Medicine, University of Calgary; S. Keeling, MD, MSc, Division of Rheumatology, Department of Medicine, University of Alberta; S. Bernatsky, MD, PhD, Division of Rheumatology, Department of Medicine, McGill University Health Centre; E. Vinet, MD, PhD, Division of Rheumatology, Department of Medicine, McGill University Health Centre
| | - Natalie Dayan
- From the Division of General Internal Medicine, and the Division of Rheumatology, Department of Medicine, McGill University Health Centre, Montréal; Division of Rheumatology, Department of Medicine, University of Sherbrooke, Sherbrooke, Québec; Division of Rheumatology, Mary Pack Arthritis Center, University of British Columbia, Vancouver, British Columbia; Division of Rheumatology, Department of Medicine, University of Alberta, Edmonton; Division of Rheumatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada.,E.G. McDonald, MD, MSc, Division of General Internal Medicine, Department of Medicine, McGill University Health Centre; L. Bissonette, MD, Division of Rheumatology, Department of Medicine, University of Sherbrooke; S. Ensworth, MD, Assistant Professor, Division of Rheumatology, University of British Columbia; N. Dayan, MD, MSc, Division of General Internal Medicine, Department of Medicine, McGill University Health Centre; A.E. Clarke, MD, MSc, Division of Rheumatology, Department of Medicine, University of Calgary; S. Keeling, MD, MSc, Division of Rheumatology, Department of Medicine, University of Alberta; S. Bernatsky, MD, PhD, Division of Rheumatology, Department of Medicine, McGill University Health Centre; E. Vinet, MD, PhD, Division of Rheumatology, Department of Medicine, McGill University Health Centre
| | - Ann E Clarke
- From the Division of General Internal Medicine, and the Division of Rheumatology, Department of Medicine, McGill University Health Centre, Montréal; Division of Rheumatology, Department of Medicine, University of Sherbrooke, Sherbrooke, Québec; Division of Rheumatology, Mary Pack Arthritis Center, University of British Columbia, Vancouver, British Columbia; Division of Rheumatology, Department of Medicine, University of Alberta, Edmonton; Division of Rheumatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada.,E.G. McDonald, MD, MSc, Division of General Internal Medicine, Department of Medicine, McGill University Health Centre; L. Bissonette, MD, Division of Rheumatology, Department of Medicine, University of Sherbrooke; S. Ensworth, MD, Assistant Professor, Division of Rheumatology, University of British Columbia; N. Dayan, MD, MSc, Division of General Internal Medicine, Department of Medicine, McGill University Health Centre; A.E. Clarke, MD, MSc, Division of Rheumatology, Department of Medicine, University of Calgary; S. Keeling, MD, MSc, Division of Rheumatology, Department of Medicine, University of Alberta; S. Bernatsky, MD, PhD, Division of Rheumatology, Department of Medicine, McGill University Health Centre; E. Vinet, MD, PhD, Division of Rheumatology, Department of Medicine, McGill University Health Centre
| | - Stephanie Keeling
- From the Division of General Internal Medicine, and the Division of Rheumatology, Department of Medicine, McGill University Health Centre, Montréal; Division of Rheumatology, Department of Medicine, University of Sherbrooke, Sherbrooke, Québec; Division of Rheumatology, Mary Pack Arthritis Center, University of British Columbia, Vancouver, British Columbia; Division of Rheumatology, Department of Medicine, University of Alberta, Edmonton; Division of Rheumatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada.,E.G. McDonald, MD, MSc, Division of General Internal Medicine, Department of Medicine, McGill University Health Centre; L. Bissonette, MD, Division of Rheumatology, Department of Medicine, University of Sherbrooke; S. Ensworth, MD, Assistant Professor, Division of Rheumatology, University of British Columbia; N. Dayan, MD, MSc, Division of General Internal Medicine, Department of Medicine, McGill University Health Centre; A.E. Clarke, MD, MSc, Division of Rheumatology, Department of Medicine, University of Calgary; S. Keeling, MD, MSc, Division of Rheumatology, Department of Medicine, University of Alberta; S. Bernatsky, MD, PhD, Division of Rheumatology, Department of Medicine, McGill University Health Centre; E. Vinet, MD, PhD, Division of Rheumatology, Department of Medicine, McGill University Health Centre
| | - Sasha Bernatsky
- From the Division of General Internal Medicine, and the Division of Rheumatology, Department of Medicine, McGill University Health Centre, Montréal; Division of Rheumatology, Department of Medicine, University of Sherbrooke, Sherbrooke, Québec; Division of Rheumatology, Mary Pack Arthritis Center, University of British Columbia, Vancouver, British Columbia; Division of Rheumatology, Department of Medicine, University of Alberta, Edmonton; Division of Rheumatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada.,E.G. McDonald, MD, MSc, Division of General Internal Medicine, Department of Medicine, McGill University Health Centre; L. Bissonette, MD, Division of Rheumatology, Department of Medicine, University of Sherbrooke; S. Ensworth, MD, Assistant Professor, Division of Rheumatology, University of British Columbia; N. Dayan, MD, MSc, Division of General Internal Medicine, Department of Medicine, McGill University Health Centre; A.E. Clarke, MD, MSc, Division of Rheumatology, Department of Medicine, University of Calgary; S. Keeling, MD, MSc, Division of Rheumatology, Department of Medicine, University of Alberta; S. Bernatsky, MD, PhD, Division of Rheumatology, Department of Medicine, McGill University Health Centre; E. Vinet, MD, PhD, Division of Rheumatology, Department of Medicine, McGill University Health Centre
| | - Evelyne Vinet
- From the Division of General Internal Medicine, and the Division of Rheumatology, Department of Medicine, McGill University Health Centre, Montréal; Division of Rheumatology, Department of Medicine, University of Sherbrooke, Sherbrooke, Québec; Division of Rheumatology, Mary Pack Arthritis Center, University of British Columbia, Vancouver, British Columbia; Division of Rheumatology, Department of Medicine, University of Alberta, Edmonton; Division of Rheumatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada. .,E.G. McDonald, MD, MSc, Division of General Internal Medicine, Department of Medicine, McGill University Health Centre; L. Bissonette, MD, Division of Rheumatology, Department of Medicine, University of Sherbrooke; S. Ensworth, MD, Assistant Professor, Division of Rheumatology, University of British Columbia; N. Dayan, MD, MSc, Division of General Internal Medicine, Department of Medicine, McGill University Health Centre; A.E. Clarke, MD, MSc, Division of Rheumatology, Department of Medicine, University of Calgary; S. Keeling, MD, MSc, Division of Rheumatology, Department of Medicine, University of Alberta; S. Bernatsky, MD, PhD, Division of Rheumatology, Department of Medicine, McGill University Health Centre; E. Vinet, MD, PhD, Division of Rheumatology, Department of Medicine, McGill University Health Centre.
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11
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Nonchev BI, Argatska AV, Pehlivanov BK, Orbetzova MM. Risk Factors for Postpartum Thyroid Dysfunction in Euthyroid Women Prior to Pregnancy. Folia Med (Plovdiv) 2017; 59:190-196. [PMID: 28704192 DOI: 10.1515/folmed-2017-0027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Accepted: 11/03/2016] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Thyroid dysfunction is common during the postpartum and the predisposing factors for its development are considered specific for the population studied. The aim of this study was to evaluate the risk factors for the occurrence of postpartum thyroid dysfunction (PPTD) in euthyroid women prior to pregnancy. MATERIALS AND METHODS Forty-five women with PPTD and 55 age-matched euthyroid postpartum women from Plovdiv, Bulgaria were included in the study. TSH, FT4, FT3, TPOAb, TgAb, TRAb were measured and ultrasound evaluation of the thyroid was performed in the first trimester of pregnancy and during the postpartum. RESULTS The study found higher risk of developing PPTD in women with family history of thyroid disease (OR 4.42; 95% CI 1.87,10.43), smokers (OR 4.01; 95% CI 1.72,9.35), personal history of autoimmune thyroid disease (OR 5.37; 95% CI 1.15,28.53), positive TPOAb (OR 18.12; 95% CI 4.93,66.65) and thyroid US hypoechogenicity during early pregnancy (OR 6.39; 95% CI 2.53,16.12) and those who needed levothyroxine during pregnancy (OR 3.69; 95% CI 1.28,10.61). BMI before pregnancy was significantly lower in women with PPTD than in euthyroid postpartum women (22.80±0.55 vs 26.25±0.97, p=0.013). The multivariate logistic regression analysis identified as most important independent risk factors for PPTD occurrence the TPOAb positivity during early pregnancy, family history of thyroid disease, smoking and lower BMI before pregnancy. CONCLUSION Our data suggest that in the population studied several factors are associated with an increased risk of PPTD and screening for thyroid disorders among those women can be beneficial.
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Affiliation(s)
- Boyan I Nonchev
- Section of Endocrinology, Department of Internal Diseases, Faculty of Medicine, Medical University of Plovdiv, Plovdiv, Bulgaria,Clinic of Endocrinology and Metabolic Diseases, St. George University Hospital, Plovdiv, Bulgaria
| | - Antoaneta V Argatska
- Section of Endocrinology, Department of Internal Diseases, Faculty of Medicine, Medical University of Plovdiv, Plovdiv, Bulgaria,Clinic of Endocrinology and Metabolic Diseases, St. George University Hospital, Plovdiv, Bulgaria
| | - Blagovest K Pehlivanov
- Department of Midwifery cares, Faculty of Public Health, Medical University of Plovdiv, Plovdiv, Bulgaria
| | - Maria M Orbetzova
- Section of Endocrinology, Department of Internal Diseases, Faculty of Medicine, Medical University of Plovdiv, Plovdiv, Bulgaria,Clinic of Endocrinology and Metabolic Diseases, St. George University Hospital, Plovdiv, Bulgaria
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12
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Abstract
Systemic lupus erythematosus (SLE) is an autoimmune disease with a strong female predilection. Pregnancy remains a commonly encountered but high-risk situation in this setting. Both maternal and fetal mortality and morbidity are still significantly increased despite improvements in outcomes. Maternal morbidity includes higher risk of disease flares, preeclampsia and other pregnancy-related complications. Fetal issues include higher rates of preterm birth, intrauterine growth restriction, and neonatal lupus syndromes. Treatment options during pregnancy are also limited and maternal benefit has to be weighed against fetal risk. A coordinated approach, with close monitoring by a multidisciplinary team, is essential for optimal outcomes.
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Affiliation(s)
- Aisha Lateef
- Division of Rheumatology, University Medicine Cluster, National University Hospital, National University Health System, 1E, Kent Ridge Road, Singapore 119074
| | - Michelle Petri
- Division of Rheumatology, Johns Hopkins Lupus Center, Johns Hopkins University School of Medicine, 1830 East Monument Street, Suite 7500, Baltimore, MD 21205, USA.
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13
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Alexander EK, Pearce EN, Brent GA, Brown RS, Chen H, Dosiou C, Grobman WA, Laurberg P, Lazarus JH, Mandel SJ, Peeters RP, Sullivan S. 2017 Guidelines of the American Thyroid Association for the Diagnosis and Management of Thyroid Disease During Pregnancy and the Postpartum. Thyroid 2017; 27:315-389. [PMID: 28056690 DOI: 10.1089/thy.2016.0457] [Citation(s) in RCA: 1337] [Impact Index Per Article: 191.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Thyroid disease in pregnancy is a common clinical problem. Since the guidelines for the management of these disorders by the American Thyroid Association (ATA) were first published in 2011, significant clinical and scientific advances have occurred in the field. The aim of these guidelines is to inform clinicians, patients, researchers, and health policy makers on published evidence relating to the diagnosis and management of thyroid disease in women during pregnancy, preconception, and the postpartum period. METHODS The specific clinical questions addressed in these guidelines were based on prior versions of the guidelines, stakeholder input, and input of task force members. Task force panel members were educated on knowledge synthesis methods, including electronic database searching, review and selection of relevant citations, and critical appraisal of selected studies. Published English language articles were eligible for inclusion. The American College of Physicians Guideline Grading System was used for critical appraisal of evidence and grading strength of recommendations. The guideline task force had complete editorial independence from the ATA. Competing interests of guideline task force members were regularly updated, managed, and communicated to the ATA and task force members. RESULTS The revised guidelines for the management of thyroid disease in pregnancy include recommendations regarding the interpretation of thyroid function tests in pregnancy, iodine nutrition, thyroid autoantibodies and pregnancy complications, thyroid considerations in infertile women, hypothyroidism in pregnancy, thyrotoxicosis in pregnancy, thyroid nodules and cancer in pregnant women, fetal and neonatal considerations, thyroid disease and lactation, screening for thyroid dysfunction in pregnancy, and directions for future research. CONCLUSIONS We have developed evidence-based recommendations to inform clinical decision-making in the management of thyroid disease in pregnant and postpartum women. While all care must be individualized, such recommendations provide, in our opinion, optimal care paradigms for patients with these disorders.
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Affiliation(s)
- Erik K Alexander
- 1 Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital and Harvard Medical School , Boston, Massachusetts
| | - Elizabeth N Pearce
- 2 Section of Endocrinology, Diabetes, and Nutrition, Boston University School of Medicine , Boston, Massachusetts
| | - Gregory A Brent
- 3 Department of Medicine, VA Greater Los Angeles Healthcare System and David Geffen School of Medicine at UCLA , Los Angeles, California
| | - Rosalind S Brown
- 4 Division of Endocrinology, Boston Children's Hospital , Harvard Medical School, Boston, Massachusetts
| | - Herbert Chen
- 5 Department of Surgery, University of Alabama at Birmingham , Birmingham, Alabama
| | - Chrysoula Dosiou
- 6 Division of Endocrinology, Stanford University School of Medicine , Stanford, California
| | - William A Grobman
- 7 Department of Obstetrics and Gynecology, Northwestern University , Chicago, Illinois
| | - Peter Laurberg
- 8 Departments of Endocrinology & Clinical Medicine, Aalborg University Hospital , Aalborg, Denmark
| | - John H Lazarus
- 9 Institute of Molecular Medicine, Cardiff University , Cardiff, United Kingdom
| | - Susan J Mandel
- 10 Division of Endocrinology, Diabetes and Metabolism, Perelman School of Medicine, University of Pennsylvania , Philadelphia, Pennsylvania
| | - Robin P Peeters
- 11 Department of Internal Medicine and Rotterdam Thyroid Center, Erasmus Medical Center , Rotterdam, The Netherlands
| | - Scott Sullivan
- 12 Department of Obstetrics and Gynecology, Medical University of South Carolina , Charleston, South Carolina
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14
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Di Bari F, Granese R, Le Donne M, Vita R, Benvenga S. Autoimmune Abnormalities of Postpartum Thyroid Diseases. Front Endocrinol (Lausanne) 2017; 8:166. [PMID: 28751877 PMCID: PMC5507951 DOI: 10.3389/fendo.2017.00166] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Accepted: 06/27/2017] [Indexed: 01/08/2023] Open
Abstract
The year following parturition is a critical time for the de novo appearance or exacerbation of autoimmune diseases, including autoimmune thyroid disease. The vast majority of postpartum thyroid disease consists of postpartum thyroiditis (PPT) and the minority by Graves' disease and non-autoimmune thyroiditis. PPT has a worldwide prevalence ranging from 1 to 22% and averaging 5% based on a review published in 2012. Several factors confer risk for the development of PPT. Typically, the clinical course of PPT is characterized by three phases: thyrotoxic, hypothyroid, and euthyroid phase. Approximately half of PPT women will have permanent hypothyroidism. The best humoral marker for predictivity, already during the first trimester of gestation, is considered positivity for thyroperoxidase autoantibodies (TPOAb), though only one-third to half of such TPOAb-positive pregnant women will develop PPT. Nutraceuticals (such as selenium) or omega-3-fatty acid supplements seem to have a role in prevention of PPT. In a recent study on pregnant women with stable dietary habits, we found that the fish consumers had lower rates of positivity (and lower serum levels) of both TPOAb and thyroglobulin Ab compared to meat eaters. Finally, we remind the reader of other diseases that can be observed in the postpartum period, either autoimmune or non-autoimmune, thyroid or non-thyroid.
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Affiliation(s)
- Flavia Di Bari
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
- *Correspondence: Flavia Di Bari,
| | - Roberta Granese
- Department of Obstetrics and Gynecology, University Hospital “G. Martino”, Messina, Italy
| | - Maria Le Donne
- Department of Obstetrics and Gynecology, University Hospital “G. Martino”, Messina, Italy
| | - Roberto Vita
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Salvatore Benvenga
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
- Master Program on Childhood, Adolescent and Women’s Endocrine Health, University of Messina, Messina, Italy
- Interdepartmental Program of Molecular & Clinical Endocrinology, and Women’s Endocrine Health, University Hospital “G. Martino”, Messina, Italy
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15
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Ferrari SM, Elia G, Virili C, Centanni M, Antonelli A, Fallahi P. Systemic Lupus Erythematosus and Thyroid Autoimmunity. Front Endocrinol (Lausanne) 2017; 8:138. [PMID: 28674523 PMCID: PMC5474463 DOI: 10.3389/fendo.2017.00138] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Accepted: 06/02/2017] [Indexed: 12/26/2022] Open
Abstract
Most of the studies present in the literature show a high prevalence, and incidence, of new cases of hypothyroidism and autoimmune thyroiditis (AT) in systemic lupus erythematosus (SLE) patients, overall in female gender. A limited number of cases of Graves' disease have been also reported in SLE patients, in agreement with the higher prevalence of thyroid autoimmunity. It has been also demonstrated that a Th1 predominance is associated with AT in SLE patients. Furthermore, a higher prevalence of papillary thyroid cancer has been recently reported in SLE, in particular in the presence of thyroid autoimmunity. However, studies in larger number of SLE patients are needed to confirm findings about thyroid cancer. On the whole, data from literature strongly suggest that female SLE patients, with a high risk (a normal but at the higher limit thyroid-stimulating hormone value, positive antithyroid peroxidase antibodies, a hypoechoic pattern, and small thyroid), should undergo periodic thyroid function follow-up, and appropriate treatments when needed. A careful thyroid monitoring would be opportune during the follow-up of these patients.
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Affiliation(s)
- Silvia Martina Ferrari
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
- *Correspondence: Silvia Martina Ferrari,
| | - Giusy Elia
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Camilla Virili
- Department of Medico-Surgical Sciences and Biotechnologies, “Sapienza” University of Rome, Latina, Italy
| | - Marco Centanni
- Department of Medico-Surgical Sciences and Biotechnologies, “Sapienza” University of Rome, Latina, Italy
| | - Alessandro Antonelli
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Poupak Fallahi
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
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16
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Lazzaroni MG, Dall’Ara F, Fredi M, Nalli C, Reggia R, Lojacono A, Ramazzotto F, Zatti S, Andreoli L, Tincani A. A comprehensive review of the clinical approach to pregnancy and systemic lupus erythematosus. J Autoimmun 2016; 74:106-117. [DOI: 10.1016/j.jaut.2016.06.016] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Accepted: 06/27/2016] [Indexed: 01/23/2023]
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17
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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]
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18
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Fredi M, Gregorini G, Zatti S, Lojacono A, Tincani A. Identifying and managing lupus nephritis during pregnancy. Expert Opin Orphan Drugs 2016. [DOI: 10.1080/21678707.2016.1228452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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19
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Andreoli L, Bertsias GK, Agmon-Levin N, Brown S, Cervera R, Costedoat-Chalumeau N, Doria A, Fischer-Betz R, Forger F, Moraes-Fontes MF, Khamashta M, King J, Lojacono A, Marchiori F, Meroni PL, Mosca M, Motta M, Ostensen M, Pamfil C, Raio L, Schneider M, Svenungsson E, Tektonidou M, Yavuz S, Boumpas D, Tincani A. EULAR recommendations for women's health and the management of family planning, assisted reproduction, pregnancy and menopause in patients with systemic lupus erythematosus and/or antiphospholipid syndrome. Ann Rheum Dis 2016; 76:476-485. [PMID: 27457513 PMCID: PMC5446003 DOI: 10.1136/annrheumdis-2016-209770] [Citation(s) in RCA: 465] [Impact Index Per Article: 58.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Revised: 06/13/2016] [Accepted: 06/25/2016] [Indexed: 12/26/2022]
Abstract
Objectives Develop recommendations for women's health issues and family planning in systemic lupus erythematosus (SLE) and/or antiphospholipid syndrome (APS). Methods Systematic review of evidence followed by modified Delphi method to compile questions, elicit expert opinions and reach consensus. Results Family planning should be discussed as early as possible after diagnosis. Most women can have successful pregnancies and measures can be taken to reduce the risks of adverse maternal or fetal outcomes. Risk stratification includes disease activity, autoantibody profile, previous vascular and pregnancy morbidity, hypertension and the use of drugs (emphasis on benefits from hydroxychloroquine and antiplatelets/anticoagulants). Hormonal contraception and menopause replacement therapy can be used in patients with stable/inactive disease and low risk of thrombosis. Fertility preservation with gonadotropin-releasing hormone analogues should be considered prior to the use of alkylating agents. Assisted reproduction techniques can be safely used in patients with stable/inactive disease; patients with positive antiphospholipid antibodies/APS should receive anticoagulation and/or low-dose aspirin. Assessment of disease activity, renal function and serological markers is important for diagnosing disease flares and monitoring for obstetrical adverse outcomes. Fetal monitoring includes Doppler ultrasonography and fetal biometry, particularly in the third trimester, to screen for placental insufficiency and small for gestational age fetuses. Screening for gynaecological malignancies is similar to the general population, with increased vigilance for cervical premalignant lesions if exposed to immunosuppressive drugs. Human papillomavirus immunisation can be used in women with stable/inactive disease. Conclusions Recommendations for women's health issues in SLE and/or APS were developed using an evidence-based approach followed by expert consensus.
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Affiliation(s)
- L Andreoli
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy.,Unit of Rheumatology and Clinical Immunology, Spedali Civili, Brescia, Italy
| | - G K Bertsias
- Department of Rheumatology, Clinical Immunology and Allergy, University of Crete Medical School, Heraklion, Greece
| | - N Agmon-Levin
- The Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel Hashomer, Israel.,The Faculty of Medicine, Tel Aviv University, Israel
| | - S Brown
- Royal National Hospital For Rheumatic Diseases, Bath, UK
| | - R Cervera
- Department of Autoimmune Diseases, Hospital Clínic, Barcelona, Catalonia, Spain
| | - N Costedoat-Chalumeau
- AP-HP, Hôpital Cochin, Centre de référence maladies auto-immunes et systémiques rares, Paris, France.,Université Paris Descartes-Sorbonne Paris Cité, Paris, France
| | - A Doria
- Rheumatology Unit, Department of Medicine, University of Padua, Italy
| | - R Fischer-Betz
- Policlinic of Rheumatology, Hiller Research Unit, University Clinic Duesseldorf, Heinrich-Heine-University Duesseldorf, Duesseldorf, Germany
| | - F Forger
- Department of Rheumatology, Immunology and Allergology, University Hospital of Bern, Bern, Switzerland
| | - M F Moraes-Fontes
- Unidade de Doenças Auto-imunes-Serviço Medicina Interna 7.2, Hospital Curry Cabral/Centro Hospitalar Lisboa Central, NEDAI/SPMI, Lisboa, Portugal
| | - M Khamashta
- Lupus Research Unit, The Rayne Institute, St. Thomas Hospital, London, UK.,Department of Rheumatology, Dubai Hospital, Dubai, United Arab Emirates
| | - J King
- EULAR PARE Patient Research Partner, London, UK
| | - A Lojacono
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy.,Unit of Obstetrics and Gynaecology, Spedali Civili, Brescia, Italy
| | - F Marchiori
- EULAR PARE Patient Research Partner, Rome, Italy
| | - P L Meroni
- Department of Clinical Sciences and Community Health, University of Milan, Istituto Auxologico Italiano, Milan, Italy
| | - M Mosca
- Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - M Motta
- Neonatology and Neonatal Intensive Care Unit, Spedali Civili, Brescia, Italy
| | - M Ostensen
- Norwegian National Advisory Unit on Pregnancy and Rheumatic Diseases, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - C Pamfil
- Department of Rheumatology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - L Raio
- Department of Obstetrics and Gynaecology, University Hospital of Bern, Inselspital, Switzerland
| | - M Schneider
- Policlinic of Rheumatology, Hiller Research Unit, University Clinic Duesseldorf, Heinrich-Heine-University Duesseldorf, Duesseldorf, Germany
| | - E Svenungsson
- Rheumatology Unit, Department of Medicine, Solna, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - M Tektonidou
- Rheumatology Unit, Joint Academic Rheumatology Programme, 1st Department of Propaedeutic Internal Medicine Athens, National and Kapodistrian University of Athens, Athens, Greece
| | - S Yavuz
- Department of Rheumatology, Istanbul Bilim University, Istanbul Florence Nightingale Hospital, Esentepe-Istanbul, Turkey
| | - D Boumpas
- 4th Department of Internal Medicine, 'Attikon' University Hospital, Medical School, University of Athens, Athens, Greece.,Joint Academic Rheumatology Program, National and Kapodestrian University of Athens, Athens, Greece
| | - A Tincani
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy.,Unit of Rheumatology and Clinical Immunology, Spedali Civili, Brescia, Italy
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20
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Jara LJ, Medina G, Cruz-Dominguez P, Navarro C, Vera-Lastra O, Saavedra MA. Risk factors of systemic lupus erythematosus flares during pregnancy. Immunol Res 2015; 60:184-92. [PMID: 25391611 DOI: 10.1007/s12026-014-8577-1] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
This review examines the risk factors for the development of systemic lupus erythematosus (SLE) flares during pregnancy. In preconception, anti-DNA, hypocomplementemia, previous thrombosis, triple antiphospholipid (aPL) antibody positivity, active lupus nephritis and discontinuation of medications such as hydroxychloroquine and azathioprine are factors associated with pregnancy failure. During pregnancy, SLE flares are associated with aPL antibodies, synergic changes of pregnancy on Th1 and TH2 cytokines, other cytokines and chemokines that interact with hormones such as estrogen and prolactin that amplify the inflammatory effect. From the clinical point of view, SLE activity at pregnancy onset, thrombocytopenia, lupus nephritis, arterial hypertension, aPL syndromes, preeclampsia is associated with lupus flares and fetal complications. In puerperium, the risk factors of flares are similar to pregnancy. Hyperactivity of immune system, autoantibodies, hyperprolactinemia, active lupus nephritis, decrease in TH2 cytokines with increase in TH1 cytokines probably participate in SLE flare. The SLE flares during pregnancy make the difference between an uncomplicated pregnancy and pregnancy with maternal and fetal complications. Therefore, the knowledge of risk factors leads the best treatment strategies to reduce flares and fetal complications in SLE patients.
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Affiliation(s)
- Luis J Jara
- Direction of Education and Research, Hospital de Especialidades, Centro Médico La Raza, Instituto Mexicano del Seguro Social, Universidad Nacional Autónoma de México, Seris/Zaachila s/n, Colonia La Raza, 02990, Mexico City, Mexico,
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21
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Autoimmune connective tissue diseases. Best Pract Res Clin Obstet Gynaecol 2015; 29:658-70. [DOI: 10.1016/j.bpobgyn.2015.03.003] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Revised: 03/02/2015] [Accepted: 03/06/2015] [Indexed: 11/17/2022]
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22
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Guettrot-Imbert G, Le Guern V, Morel N, Vauthier D, Tsatsaris V, Pannier E, Piette JC, Costedoat-Chalumeau N. Lupus systémique et syndrome des antiphospholipides : comment prendre en charge la grossesse ? Rev Med Interne 2015; 36:173-81. [DOI: 10.1016/j.revmed.2014.12.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Accepted: 12/15/2014] [Indexed: 10/24/2022]
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23
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Nalli C, Iodice A, Andreoli L, Lojacono A, Motta M, Fazzi E, Tincani A. The effects of lupus and antiphospholipid antibody syndrome on foetal outcomes. Lupus 2014; 23:507-17. [PMID: 24763535 DOI: 10.1177/0961203313501402] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Systemic lupus erythematosus (SLE) is a multi-organ autoimmune disease that primarily affects women of childbearing-age. Antiphospholipid syndrome (APS) is a systemic autoimmune disorder defined by the occurrence of venous and arterial thrombosis, often multiple, and pregnancy morbidity in the presence of antiphospholipid antibodies (aPL). Recently, the long-term outcome of children born to patients with lupus and APS has become a major topic of interest both to patients and physicians. One of the major problems related to maternal disease is preterm delivery with all the consequences that this condition may bring. Prematurity may also be due to the presence of aPL; however, aPL do not generally display any thrombotic potential on neonates. Another complication may be neonatal lupus (NL), mediated by the presence of maternal antibodies (anti-Ro/SSA and anti-La/SSB). In addition, behaviour and neuropsychological outcomes have also been a matter of interest, but there are currently few data available. Beyond the biological influence of both maternal disease and autoimmune background, it is important to focus on the possible influence of maternal chronic illness on the neuropsychological development of her children. Whether aPL exposure could have a direct effect on brain development is still being debated. In children of mothers with APS, language delays have been noted and learning disabilities were described with a higher rate than the general age-school population. Several studies were performed on children born to lupus mothers: even if maternal lupus does not seem to impair intelligence levels, it may increase the occurrence of learning disabilities and particularly dyslexia in male children. To the best of our knowledge, no studies are available on the long-term outcome of children born to mothers with lupus or APS and particularly regarding the development of autoimmune diseases. Nevertheless, common experience of experts in the field is that these children do not show a significantly increased risk of displaying the same autoimmune disease as their mothers. The purpose of this paper is to answer the frequently asked questions of patients with lupus and APS who desire to become mothers, based on the little information available.
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Affiliation(s)
- C Nalli
- 1Rheumatology and Clinical Immunology, Department of Clinical and Experimental Sciences, Spedali Civili and University of Brescia, Italy
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24
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Peltier MR, Koo HC, Getahun D, Menon R. Does exposure to flame retardants increase the risk for preterm birth? J Reprod Immunol 2014; 107:20-5. [PMID: 25542760 DOI: 10.1016/j.jri.2014.11.002] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Revised: 10/18/2014] [Accepted: 11/12/2014] [Indexed: 10/24/2022]
Abstract
During the past 40 years, polybrominated diphenyl ethers (PBDEs) have been widely used as flame retardants and nearly all women have some level of exposure. PBDEs have been isolated from amniotic fluid and cord plasma indicating vertical transmission; however, their effects on pregnancy outcome are largely unknown. Therefore, we quantified PBDE-47, the most common congener in maternal plasma samples collected at the time of labor from women who subsequently had term or preterm birth (PTB). Women were then scored based on whether or not they had very low, low, medium, high or very high peripheral plasma concentrations of PBDE-47. Probit regression analysis suggested that women in the PTB group had a greater chance of scoring higher on this scale (P<0.001). Women with high (OR=3.8, CI: 1.6, 9.7; P=0.003) or very high PBDE-47 concentrations were at greater odds (OR=5.6, CI: 2.2, 15.2; P<0.001) for PTB than women with very low levels of PBDE-47. Results became even more significant after adjustment for maternal race, age, and marital status. These findings suggest that high levels of maternal exposure to PBDEs might increase the risk for PTB.
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Affiliation(s)
- Morgan R Peltier
- Women and Children's Health Research Laboratory, Winthrop University Hospital, Mineola, NY, USA; Department of Obstetrics and Gynecology, Winthrop University Hospital, Mineola, NY, USA.
| | - Hschi-Chi Koo
- Women and Children's Health Research Laboratory, Winthrop University Hospital, Mineola, NY, USA; Department of Pediatrics, Winthrop University Hospital, Minoela, NY, USA
| | - Darios Getahun
- Department of Research and Evaluation, Kaiser Permenante Southern California Medical Group, Pasadena, CA, USA
| | - Ramkumar Menon
- Department of Obstetrics and Gynecology, The University of Texas Medical Branch at Galveston, Galveston, TX, USA
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25
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Abstract
Pregnancy poses an important challenge for doctors looking after women with systemic lupus erythematosus. Knowledge about safety of medications, the effect of pregnancy on such disease, and vice versa, together with multidisciplinary team care, are basic cornerstones needed to provide the best obstetric and medical care to these women. Pre-conceptional counselling constitutes the ideal scenario where a patient's previous obstetric history, organ damage, disease activity, serological profile and additional medical history can be summarized. Important issues regarding medication adjustment, planned scans and visits, and main risks discussion should also be raised at this stage. Planned pregnancies lead to better outcomes for both mothers and babies. Close surveillance throughout pregnancy and the puerperium, and tailored management approach guarantee the highest rates of successful pregnancies in these women.
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Affiliation(s)
- O Ateka-Barrutia
- Lupus Research Unit, Women's Health Division, King's College London, UK
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26
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Abstract
Thyroid disorders are common in pregnancy and in nonpregnant women of childbearing age, but can be missed because of nonspecific symptoms and normal changes in thyroid gland physiology during pregnancy. The prevalence of overt hyperthyroidism complicating pregnancy has been reported to range between 0.4% and 1.7%, and an estimated 2% to 3% of women are hypothyroid during pregnancy. Abnormalities in maternal thyroid function are associated with complications during pregnancy, and may affect maternal and fetal outcomes. Thus it is important to identify thyroid disorders before pregnancy or early in pregnancy so that appropriate treatment can be initiated.
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Affiliation(s)
- Nisha Nathan
- Department of Endocrinology, Medstar Georgetown University Hospital and Medstar Washington Hospital Center, 110 Irving Street Northwest, Suite 2A-72, Washington, DC 20010, USA
| | - Shannon D Sullivan
- Department of Endocrinology, Medstar Georgetown University Hospital and Medstar Washington Hospital Center, 110 Irving Street Northwest, Suite 2A-72, Washington, DC 20010, USA.
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27
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Abstract
Systemic lupus erythematosus (SLE) is an auto-immune disease, primarily affecting young females. Pregnancy in a woman with SLE remains a high-risk situation with higher maternal and foetal mortality and morbidity. Although live births are achieved in majority of the pregnancies, active disease and major organ involvement can negatively affect the outcomes. A higher risk of foetal loss, pre-term birth, intra-uterine growth restriction (IUGR) and neonatal lupus syndromes (NLSs) are major foetal issues. Mothers are faced with disease flares, pre-eclampsia and other complications. Disease flares during SLE pregnancy pose the unique issue of recognition and differentiation between physiologic changes and disease state. Similarly, pre-eclampsia and lupus nephritis may lead to diagnostic confusion. Treatment choices during pregnancy are limited to a few safe drugs, further restricting the options. Refractory pregnancy loss associated with anti-phospholipid antibodies (aPLs) and complete heart block associated with anti-Ro antibodies remain unresolved issues. A multidisciplinary approach, with close monitoring, is essential for optimal outcomes.
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Affiliation(s)
- Aisha Lateef
- Division of Rheumatology, University Medicine Cluster, National University Health System, 1E, Kent Ridge, Singapore 119074, Singapore.
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28
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Alves IGN, da Cruz KML, Mota CMD, de Santana DS, Gaujac DP, de Carvalho VCB, Reis LC, Sluka KA, Quintans-Junior LJ, Antoniolli AR, Desantana JM, Badauê-Passos D, de Santana-Filho VJ. Experimental hypothyroidism during pregnancy affects nociception and locomotor performance of offspring in rats. Eur J Pain 2013; 17:1291-8. [PMID: 23536325 DOI: 10.1002/j.1532-2149.2013.00306.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/27/2013] [Indexed: 11/09/2022]
Abstract
BACKGROUND Thyroid hormones (THs) play a crucial role in the development of several organic systems. An adequate support of maternal THs may be required to ensure a normal nociceptive function of offspring into adulthood. We investigated the impact of experimental gestational hypothyroidism (EGH) on nociceptive threshold and motor performance in the offspring at different post-natal days (PND) in both male and female rats. METHODS EGH was induced by the administration of 0.02% methimazole (MMI) in the drinking water from the ninth day of gestation until birth. The offspring from MMI-treated dams (OMTDs) or from water-treated dams (OWTDs) were assessed for thermal and mechanical nociception using the tail-flick test and von Frey filaments, respectively. Both rota-rod and grip strength were used to assess motor function. RESULTS OMTD had reduced thermal (p<0.05) but not mechanical threshold at all studied ages (60 and 120 PND). Sixty-day-old OMTD presented reduced latency to the tail-flick test (p=0.01). Grip strength in 120-day-old OMTD was reduced (p<0.01). However, only male OMTD presented a lower locomotor performance on the rota-rod test when analysed on the 60th PND (p<0.01). CONCLUSIONS EGH promotes hypersensitivity to noxious thermal but not mechanical stimulus. Moreover, motor force is similarly reduced in male and female OMTDs, whereas motor performance is reduced only in mature male OMTD, suggesting the presence of a protective factor in females.
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Affiliation(s)
- I G N Alves
- Departamento de Fisiologia, Universidade Federal de Sergipe, Aracaju, Brazil
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29
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Østensen M. Counseling women with systemic lupus erythematosus who desire children. ACTA ACUST UNITED AC 2013. [DOI: 10.2217/ijr.12.78] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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30
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Abstract
The thyroid gland is substantially challenged during pregnancy. Total T(3) and T(4) levels increase by 50% during pregnancy owing to a 50% increase in thyroxine-binding globulin levels. Serum TSH levels decrease in the first trimester and increase in the second and third trimesters; however, not to prepregnancy levels. Hypothyroidism is present in up to 3% of all pregnant women. Subclinical hypothyroidism during pregnancy is associated with an increased rate of miscarriage and preterm delivery, and a decrease in the IQ of the child. Overt hyperthyroidism is present in less than 1% of pregnant women but is linked to increased rates of miscarriage, preterm delivery and maternal congestive heart failure. In women who are euthyroid, thyroid autoantibodies are associated with an increased risk of spontaneous miscarriage and preterm delivery. Postpartum thyroiditis occurs in 5.4% of all women following pregnancy; moreover, 50% of women who are euthyroid in the first trimester of pregnancy but test positive for thyroid autoantibodies will develop postpartum thyroiditis. The need for the essential nutrient iodine increases during pregnancy and in women who are breastfeeding, and the effect of treatment of mild iodine deficiency on maternal and fetal outcomes is consequently being evaluated in a prospective study. The debate regarding the pros and cons of universal screening for thyroid disease during pregnancy is ongoing.
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Affiliation(s)
- Alex Stagnaro-Green
- Department of Medicine, George Washington University School of Medicine and Health Sciences, 2300 I Street Northwest, Ross Hall-Suite 712, Washington, DC 20037, USA.
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31
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Ateka-Barrutia O, Nelson-Piercy C. Management of rheumatologic diseases in pregnancy. ACTA ACUST UNITED AC 2012. [DOI: 10.2217/ijr.12.54] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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32
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Abstract
Systemic lupus erythematosus (SLE) is an autoantibody-mediated systemic autoimmune disease, predominantly affecting young females. Pregnancy is increasingly common in the setting of SLE, as survival and quality of life of patients improve. Although live births can be achieved in the most cases, pregnancy in patients with SLE remains a high-risk condition. Maternal and fetal mortality and morbidity are considerably increased, compared with the general population. Aberrations in pregnancy-related maternal immune adaptations are likely contributors. Active maternal disease, renal involvement, specific autoantibody subsets and advanced organ damage are predictors of poor outcome. Therapeutic options are limited during pregnancy as maternal benefit has to be weighed against fetal risk. Prevention of preterm birth and refractory pregnancy loss, as well as management of established neonatal heart block remain unmet needs. Further research should address these important issues that affect young patients with SLE and their babies.
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33
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Santos SO, Loureiro SMA, Alves IGN, Jesus CSD, Santos PRD, Santos MRVD, Dias DPM, Santana-Filho VJ, Badauê-Passos D. Experimental gestational hypothyroidism evokes hypertension in adult offspring rats. Auton Neurosci 2012; 170:36-41. [PMID: 22878215 DOI: 10.1016/j.autneu.2012.07.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2012] [Revised: 07/15/2012] [Accepted: 07/16/2012] [Indexed: 11/29/2022]
Abstract
Gestational hypothyroidism is a prevalent disorder in pregnant women. We aimed to investigate the impact of experimental gestational hypothyroidism (EGH) on cardiovascular and autonomic nervous systems (ANS) in the offspring of rats. EGH was induced with methimazole (MMI) 0.02% in drinking water from day 9 of gestation until birth. Sixty day old offspring from MMI-treated dams (OMTD, n=13) or water-treated dams (OWTD, n=13) had femoral arteries surgically assessed for the measurements of heart rate (HR), mean (MAP), systolic (SAP) and diastolic arterial pressure (DAP), and spontaneous baroreflex sensitivity (BRS). To investigate the balance of ANS, we established the high (HF) and low frequency (LF) bands of pulse interval (PI) and LF band of SAP spectrum. OMTD had increased MAP (130.2 ± 2.0 vs 108.8 ± 3.0 mmHg, p<0.001), SAP (157.3 ± 2.9 vs 135.7 ± 4.5mm Hg, p<0.001) and DAP (109.7 ± 1.9 vs 88.4 ± 2.6 mmHg, p<0.001) when compared to OWTD, and had lower HR (355.1 ± 8.9 vs 386.8 ± 9.2 bpm, p<0.05). After spectral analysis of PI and SAP, only LF band of SAP spectrum was higher (7.2 ± 0.8 vs 4.0 ± 0.6 mmHg(2), p<0.01) in OMTD under spontaneous condition. Despite bradycardia, EGH promotes spontaneous hypertension in 60 day old offspring, probably due to increased sympathetic modulation of vessels, which is suggested by the higher LF of SAP. These findings suggest a critical role of maternal THs in the development of fetal cardiovascular and autonomic nervous systems.
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34
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Pregnancy implications for systemic lupus erythematosus and the antiphospholipid syndrome. J Autoimmun 2012; 38:J197-208. [DOI: 10.1016/j.jaut.2011.11.010] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2011] [Accepted: 11/22/2011] [Indexed: 01/01/2023]
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35
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Abstract
Thyroid disorders are common in women during pregnancy. If left untreated, both hypothyroidism and hyperthyroidism are associated with adverse effects on pregnancy and fetal outcomes. It is important to correctly identify these disorders and treat them appropriately to prevent pregnancy-related complications. Levothyroxine is the indicated treatment for hypothyroidism, and thionamides are the treatment of choice for hyperthyroidism; thyroidectomy may be indicated in select cases. When thyroid cancer is diagnosed during pregnancy, a decision must be made regarding performing thyroidectomy during the pregnancy or postponing surgical resection until the postpartum period. Radioactive iodine is absolutely contraindicated during pregnancy and lactation.
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Affiliation(s)
- Cynthia F Yazbeck
- Division of Endocrinology, University of Pittsburgh Medical Center, Pittsburgh, PA 15261, USA
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36
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Perricone C, de Carolis C, Perricone R. Pregnancy and autoimmunity: A common problem. Best Pract Res Clin Rheumatol 2012; 26:47-60. [DOI: 10.1016/j.berh.2012.01.014] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2012] [Accepted: 01/12/2012] [Indexed: 12/15/2022]
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37
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Mousa AA, Ghonem M, Hegazy A, El-Baiomy AA, El-Diasty A. Thyroid Function and Auto-antibodies in Egyptian Patients with Systemic Lupus Erythematosus and Rheumatoid Arthritis. ACTA ACUST UNITED AC 2012. [DOI: 10.3923/tmr.2012.25.33] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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38
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Stagnaro-Green A, Abalovich M, Alexander E, Azizi F, Mestman J, Negro R, Nixon A, Pearce EN, Soldin OP, Sullivan S, Wiersinga W. Guidelines of the American Thyroid Association for the diagnosis and management of thyroid disease during pregnancy and postpartum. Thyroid 2011; 21:1081-125. [PMID: 21787128 PMCID: PMC3472679 DOI: 10.1089/thy.2011.0087] [Citation(s) in RCA: 965] [Impact Index Per Article: 74.2] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Alex Stagnaro-Green
- Department of Medicine, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia 20037, USA.
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