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Saavedra MÁ, Gracia-Aréchiga TS, Miranda-Hernández D, Sánchez A, Arrucha-Cozaya M, Cruz-Domínguez MDP. Active but not quiescent lupus nephritis during pregnancy is associated with a higher rate of adverse obstetric outcomes: Analysis of a prospective cohort. Int J Gynaecol Obstet 2024. [PMID: 38736284 DOI: 10.1002/ijgo.15601] [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: 08/06/2023] [Revised: 04/08/2024] [Accepted: 04/28/2024] [Indexed: 05/14/2024]
Abstract
OBJECTIVE To compare the maternal-fetal/neonatal outcome in patients with systemic lupus erythematosus (SLE) with and without lupus nephritis (LN) in remission or with active disease. METHODS A prospective cohort of pregnant patients with SLE (ACR 1997 criteria) was studied from January 2009 to December 2021. Demographic, clinical, biochemical, and immunological variables as well as the usual maternal-fetal/neonatal complications were recorded. We compared four groups according to the status of SLE during pregnancy: patients with quiescent SLE without lupus nephritis, patients with active SLE without lupus nephritis, patients with quiescent lupus nephritis, and patients with active lupus nephritis. Statistical analysis included descriptive statistics, bivariate analysis, and Cox regression analysis. RESULTS A total of 439 pregnancies were studied, with a median age of 28 ± 6, SLE duration of 60 months (interquartile range 36-120). A higher frequency of maternal and fetal/neonatal complications was observed in patients with active SLE with or without lupus nephritis. Multivariate analysis showed that active LN was a risk factor for gestational hypertension (hazard ratios [HR] 1.95; 95% confidence intervals [CI]: 1.01-6.39), premature rupture of membranes (HR 3.56; 95% CI: 1.79-16.05) and more frequent cesarean section (HR 1.82; 95% CI: 1.13-2.94). CONCLUSION LN is associated with a higher frequency of maternal complications, especially in those patients with active disease during pregnancy, and those maternal complications had an impact on poor fetal/neonatal outcomes. Strict control and timely care of LN could improve the obstetric prognosis.
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Affiliation(s)
- Miguel Ángel Saavedra
- División de Investigación en Salud, Hospital de Especialidades Dr. Antonio Fraga Mouret, Centro Médico Nacional La Raza, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - Tayde Sarahí Gracia-Aréchiga
- Departamento de Reumatología, Hospital de Especialidades Dr. Antonio Fraga Mouret, Centro Médico Nacional La Raza, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - Dafhne Miranda-Hernández
- Departamento de Reumatología, Hospital de Especialidades Dr. Antonio Fraga Mouret, Centro Médico Nacional La Raza, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - Antonio Sánchez
- Departamento de Reumatología, Hospital de Especialidades Dr. Antonio Fraga Mouret, Centro Médico Nacional La Raza, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | | | - María Del Pilar Cruz-Domínguez
- Dirección de Educación e Investigación en Salud, Hospital de Especialidades Dr. Antonio Fraga Mouret, Centro Médico Nacional La Raza, México City, Mexico
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Nakai T, Honda N, Soga E, Fukui S, Kitada A, Yokogawa N, Okada M. Effect of remission, clinical remission with active serology, and glucocorticoid dosage on the pregnancy outcome of pregnant patients with systemic lupus erythematosus. Arthritis Res Ther 2024; 26:63. [PMID: 38459603 PMCID: PMC10924338 DOI: 10.1186/s13075-024-03298-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 02/29/2024] [Indexed: 03/10/2024] Open
Abstract
BACKGROUND Remission is a key treatment target in systemic lupus erythematosus (SLE) management. Given the direct correlation between lupus flares and elevated risks of adverse pregnancy outcomes (APOs), securing remission before conception becomes crucial. However, the association between clinical remission with active serology, and the risk of APOs is not thoroughly understood. Additionally, determining the optimal glucocorticoid dosage during pregnancy to mitigate APO risks remains under-researched. This study investigated the risk of APOs in relation to remission/serological activity status in patients in clinical remission/glucocorticoid dosage. METHODS Pregnant patients with SLE, who were followed up at two Japanese tertiary referral centers, and had their remission status assessed at conception, were included in this study. We categorized the patients into two groups based on whether they achieved Zen/Doria remission at conception and analyzed the APO ratio. We also examined the influence of serological activity in pregnant patients with clinical remission and analyzed the optimal glucocorticoid dosage to minimize the APO ratio. RESULTS Of the 96 pregnancies included, 59 achieved remission at conception. Pregnant patients who achieved remission showed a significant decrease in the APO ratio compared with those who did not. (overall APO: odds ratio (OR) 0.27, 95% confidence interval (CI) 0.11-0.65, p < 0.01, maternal APO: OR 0.34, 95%CI 0.13-0.85, p = 0.021, neonatal APO: OR 0.39, 95%CI 0.17-0.90, p = 0.028). Conversely, no statistical difference was observed in the APO ratio based on serological activity in pregnant patients with clinical remission. (overall APO: OR 0.62, 95%CI 0.21-1.79, p = 0.37, maternal APO: OR 1.25, 95%CI 0.32-4.85, p = 0.75, neonatal APO: OR 0.83, 95%CI 0.29-2.39, p = 0.73). A glucocorticoid dose of prednisolone equivalent ≥ 7.5 mg/day at conception correlated with increased APO. (overall APO: OR 3.01, 95%CI 1.23-7.39, p = 0.016, neonatal APO: OR 2.98, 95% CI:1.23-7.22, p = 0.016). CONCLUSIONS Even with active serology, achieving clinical remission can be a clinical target for reducing APOs in patients who wish to conceive. In addition, if clinically feasible, reducing the glucocorticoid dosage to < 7.5 mg/day before conception could be another predictive factor.
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Affiliation(s)
- Takehiro Nakai
- Immuno-Rheumatology Center, St. Luke's International Hospital, 9-1 Akashi-cho, Chuo-ku, Tokyo, Japan.
| | - Nanase Honda
- Department of Rheumatic Diseases, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Eri Soga
- Department of Obstetrics and Gynecology, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Sho Fukui
- Immuno-Rheumatology Center, St. Luke's International Hospital, 9-1 Akashi-cho, Chuo-ku, Tokyo, Japan
- Department of General Medicine, Kyorin University School of Medicine, Tokyo, Japan
- Division of Rheumatology, Inflammation, and Immunity, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Ayako Kitada
- Immuno-Rheumatology Center, St. Luke's International Hospital, 9-1 Akashi-cho, Chuo-ku, Tokyo, Japan
- Department of Rheumatology, Institute of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Naoto Yokogawa
- Department of Rheumatic Diseases, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Masato Okada
- Immuno-Rheumatology Center, St. Luke's International Hospital, 9-1 Akashi-cho, Chuo-ku, Tokyo, Japan
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3
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Le Guern V, Guettrot-Imbert G, Dupré A, Perol S, Pannier E, Morel N, Costedoat-Chalumeau N. Issues with pregnancy in systemic lupus. Joint Bone Spine 2024; 91:105713. [PMID: 38447695 DOI: 10.1016/j.jbspin.2024.105713] [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: 01/19/2024] [Revised: 02/15/2024] [Accepted: 02/20/2024] [Indexed: 03/08/2024]
Abstract
Systemic lupus erythematosus is a disease that affects a large number of young women of childbearing age. Today, pregnancy is considered safe in almost all women with lupus, especially when the disease is under control. However, pregnancies in this population have a higher risk of maternal complications than in the general population. It is therefore important to plan pregnancies as effectively as possible, using effective contraception and pre-pregnancy counselling. In fact, effective, well-tolerated contraception is essential for patients for whom pregnancy cannot be safely envisaged, particularly in the setting of teratogenic treatment or significant disease activity. Preconception counselling is essential and helps to anticipate several aspects of a future pregnancy. Several recent prospective studies have clearly identified risk factors for obstetric complications and disease flare. High level of lupus activity, low complement, primigravida and a history of lupus nephritis are predictive factors of disease flare when antiphospholipid syndrome or antiphospholipid antibodies (specifically for lupus anticoagulant), damage, activity of lupus are predictive for obstetric events. Appropriate therapeutic management is essential, based primarily on the continuation of hydroxychloroquine, although some recent warnings about its use in pregnancy have been discussed controversially. Corticosteroid therapy can be continued at the lowest possible dose, as can certain immunosuppressive drugs. In the case of a history of lupus nephritis, low-dose aspirin is also prescribed. Although still exceptional, the risk of neonatal lupus is also higher, in patients with anti-SSA and anti-SSB antibodies. The aim of this review is to summarise the risk factors for adverse obstetric outcomes and to improve medical and obstetric management in this population of pregnant women with lupus.
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Affiliation(s)
- Véronique Le Guern
- Service de médecine interne, Centre de références maladies auto-immunes et systémiques rares d'Île-de-France, Cochin, AP-HP, Paris, France.
| | - Gaelle Guettrot-Imbert
- Service de médecine interne, Centre de références maladies auto-immunes et systémiques rares d'Île-de-France, Cochin, AP-HP, Paris, France; Université Paris Cité, Paris, France
| | - Anastasia Dupré
- Service de médecine interne, Centre de références maladies auto-immunes et systémiques rares d'Île-de-France, Cochin, AP-HP, Paris, France
| | - Sandrine Perol
- Service de gynécologie médicale, Port-Royal, Cochin, AP-HP, Paris, France
| | | | - Nathalie Morel
- Service de médecine interne, Centre de références maladies auto-immunes et systémiques rares d'Île-de-France, Cochin, AP-HP, Paris, France
| | - Nathalie Costedoat-Chalumeau
- Service de médecine interne, Centre de références maladies auto-immunes et systémiques rares d'Île-de-France, Cochin, AP-HP, Paris, France; Université Paris Cité, Paris, France; Centre de recherche en épidémiologie et statistiques, université Paris Cité (CRESS), équipe Épidémiologie clinique appliquée aux maladies rhumatismales et musculosquelettiques (ECAMO), Inserm U1153, Paris, France
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Jiang Y, Tao M, Chen J, Luo L, You Q, Wu H, Zhang N. Calcineurin inhibitors in the treatment of systemic lupus erythematosus during pregnancy: A narrative review with emphasis on efficacy and safety. Eur J Obstet Gynecol Reprod Biol 2024; 294:148-155. [PMID: 38245953 DOI: 10.1016/j.ejogrb.2023.12.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Revised: 11/21/2023] [Accepted: 12/31/2023] [Indexed: 01/23/2024]
Abstract
Systemic lupus erythematosus (SLE) predominantly affects child-bearing women, leading to an elevated risk of maternal and fetal complications and adverse pregnancy outcomes. Since some medications can cross the placental barrier that persist a threat to both mother and fetus, the risk-benefit ratio of SLE medications should be taken into consideration during pregnancy. Calcineurin inhibitor (CNI), mainly including cyclosporin A, tacrolimus, and voclosporin, is a category of immunosuppressive agents that inhibit calcium/calmodulin-dependent phosphatase calcineurin to block T cell activation. Based on the current clinical evidence, CNI is an alternative in pregnant SLE patients with persistent disease activity (especially lupus nephritis patients) and non-responders to azathioprine. However, there is no comprehensive review that summarizes the efficacy and safety profile of CNI for SLE management during pregnancy. This review presents a summary on the utilization of CNI for SLE management during pregnancy, including the mechanism of action, gestational amelioration of lupus flare, and the balance of maternal benefit-fetal risk, which may provide more references for the management of SLE pregnancies.
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Affiliation(s)
- Yi Jiang
- Department of Rheumatology and Immunology, The First Hospital Affiliated to Army Medical University, Chongqing 400038, China
| | - Min Tao
- Department of Pediatrics, The First Hospital Affiliated to Army Medical University, Chongqing 400038, China
| | - Jingjing Chen
- Department of Rheumatology and Immunology, The First Hospital Affiliated to Army Medical University, Chongqing 400038, China
| | - Lihua Luo
- Department of Rheumatology and Immunology, The First Hospital Affiliated to Army Medical University, Chongqing 400038, China
| | - Qingxia You
- Department of Rheumatology and Immunology, The First Hospital Affiliated to Army Medical University, Chongqing 400038, China
| | - Hong Wu
- Department of Rheumatology and Immunology, The First Hospital Affiliated to Army Medical University, Chongqing 400038, China
| | - Nian Zhang
- Department of Traditional Chinese Medicine, The Second Hospital Affiliated to Army Medical University, Chongqing 400037, China.
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5
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Al Rayes H, AlOudah N, Alsolaimani R, Alharthi A, Attar M, Daghasi H, Albeity A, Afifi AM, AlQahtani A, Alkaff A, Alkhamesi SM, Elnady B. Adverse Impact of Systemic Lupus Erythematosus on Pregnancy Outcomes: A Saudi Arabia Retrospective Multi-Center Study. Open Access Rheumatol 2024; 16:31-41. [PMID: 38322608 PMCID: PMC10844007 DOI: 10.2147/oarrr.s448186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Accepted: 01/26/2024] [Indexed: 02/08/2024] Open
Abstract
Objective The current study aimed to determine the pregnancy outcomes complications in patients with SLE and its association with clinical, laboratory variables, disease activity, and medication use in the Saudi population, as well as pregnancy effect on disease activity. Methods A multicenter study included pregnant female patients with Systemic Lupus Erythematosus (SLE) from three tertiary centers in Saudi Arabia. The demographics, clinical, and laboratory variables, SLE disease activity index (SLEDAI), medication before, during, and after pregnancy, planned pregnancy, pregnancy-related outcomes, and complications in comparison to age-matched healthy female controls were noted. Results A total of 66 pregnant patients with SLE and 93 healthy age-matched pregnant controls were included in the study. A total of 77.3% had SLEDAI-2K ≤ 4 before conception, and 84.85% of pregnancies were planned. Age of conception, cesarean section, miscarriage, and low birth weight were statistically significant (p <0.05) higher in SLE patients than in healthy controls. Among all clinical and laboratory variables, SLEDAI-2K > 4 and active lupus nephritis during pregnancy were statistically associated with adverse outcomes (p <0.05), history of lupus nephritis was not associated with statistically adverse pregnancy outcomes. Higher SLEDAI-2K > 4 was an independent risk at least 4.87 times higher association with adverse pregnancy outcomes. (p <0.05). Conclusion SLE is intricately connected with unfavorable pregnancy outcomes. The preconception of high disease activity stands as a pivotal risk factor for adverse outcomes. Despite the disease remission and meticulous planning, SLE patients frequently grapple with disease exacerbations during pregnancy, culminating in unexpected and unfavorable pregnancy-related outcomes. This underscores the intricate and multifaceted nature of managing SLE during gestation.
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Affiliation(s)
- Hanan Al Rayes
- Department of Rheumatology, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Norah AlOudah
- Department of Rheumatology, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Roaa Alsolaimani
- Department of Medicine, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
- Department of Medicine, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | | | - Mohammed Attar
- Department of Rheumatology, Al Hada Armed Forces Hospital, Taif, Saudi Arabia
| | - Hassan Daghasi
- Department of Rheumatology, Al Hada Armed Forces Hospital, Taif, Saudi Arabia
| | - Abdurahman Albeity
- Department of Medicine, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
| | - Afnan M Afifi
- Department of Medicine, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
| | - Abdulelah AlQahtani
- Department of Rheumatology, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Alya Alkaff
- Obstetrics and Gynecology Department, King Faisal Specialist Hospital, and Research Center, Jeddah, Saudi Arabia
| | - Sultan M Alkhamesi
- Department of Medicine, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Basant Elnady
- Department of Rheumatology, Al Hada Armed Forces Hospital, Taif, Saudi Arabia
- Rheumatology and Rehabilitation Department, Faculty of Medicine, Benha University, Benha, Egypt
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Nakai T, Honda N, Soga E, Fukui S, Kitada A, Yokogawa N, Okada M. A retrospective analysis of the safety of tacrolimus use and its optimal cut-off concentration during pregnancy in women with systemic lupus erythematosus: study from two Japanese tertiary referral centers. Arthritis Res Ther 2024; 26:15. [PMID: 38178242 PMCID: PMC10765865 DOI: 10.1186/s13075-023-03256-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 12/27/2023] [Indexed: 01/06/2024] Open
Abstract
BACKGROUND Tacrolimus is one of the major treatment options for systemic lupus erythematosus (SLE) and is considered to be a pregnancy-compatible medication. Since little is known about tacrolimus safety during pregnancy complicated by SLE, this study was designed. METHODS We included SLE pregnant patients who were followed up at two Japanese tertiary referral centers. We performed multivariate logistic regression analysis to assess each adverse pregnancy outcome (APO) risk. Moreover, we assessed the influence of tacrolimus on the APO ratio in pregnant patients with lupus nephritis, and the impact of combined tacrolimus-aspirin therapy on the APO ratio relative to patients exclusively administered tacrolimus. RESULTS Of the 124 pregnancies, 29 were exposed to tacrolimus. Multivariate analysis showed no statistical difference in APO ratio. (overall APO: adjusted odds ratio [aOR], 0.69; 95% confidence interval [CI], 0.23-2.03; p = 0.50; maternal APO: aOR, 1.17; 95% CI, 0.36-3.83; p = 0.80; neonatal APO: aOR, 1.10; 95% CI, 0.38-3.21; p = 0.86; PROMISSE APO: aOR, 0.50; 95% CI, 0.14-1.74; p = 0.27). Blood pressure and estimated glomerular filtration rate (eGFR) during pregnancy and after delivery did not differ between the two groups. Receiver operating characteristic (ROC) curve showed that tacrolimus concentration > 2.6 ng/ml was related to reduced preterm birth rate. (AUC = 0.85, 95% CI: 0.61-1.00, sensitivity: 93% and specificity: 75%). Regarding effect of tacrolimus on lupus nephritis during pregnancy, tacrolimus showed no increased risk of APO, blood pressure or eGFR during pregnancy and after delivery. (overall APO: OR, 1.00; 95% CI, 0.25-4.08; p = 0.98; maternal APO: OR 1.60, 95% CI, 0.39-6.64; p = 0.51; neonatal APO: OR, 0.71; 95% CI, 0.17-3.03; p = 0.65, PROMISSE APO: OR, 0.50; 95% CI, 0.08-3.22; p = 0.47). Tacrolimus-aspirin combination therapy showed a protective tendency against hypertensive disorders during pregnancy, preeclampsia and low birth weight. CONCLUSIONS Tacrolimus use during pregnancy with SLE and lupus nephritis showed no significant influence on APO, blood pressure, or renal function; therefore tacrolimus may be suitable for controlling lupus activity during pregnancy. In addition, when using tacrolimus during pregnancy, we should aim its trough concentration ≥ 2.6 ng/ml while paying careful attention to possible maternal side effects of tacrolimus. TRIAL REGISTRATION Retrospectively registered.
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Affiliation(s)
- Takehiro Nakai
- Immuno-Rheumatology Center, St. Luke's International Hospital, 9-1 Akashi-Cho, Chuo-Ku, Tokyo, Japan.
| | - Nanase Honda
- Department of Rheumatic Diseases, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Eri Soga
- Department of Obstetrics and Gynecology, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Sho Fukui
- Immuno-Rheumatology Center, St. Luke's International Hospital, 9-1 Akashi-Cho, Chuo-Ku, Tokyo, Japan
- Department of General Medicine, Kyorin University School of Medicine, Tokyo, Japan
- Division of Rheumatology, Inflammation, and Immunity, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Ayako Kitada
- Immuno-Rheumatology Center, St. Luke's International Hospital, 9-1 Akashi-Cho, Chuo-Ku, Tokyo, Japan
- Department of Rheumatology, Institute of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Naoto Yokogawa
- Department of Rheumatic Diseases, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Masato Okada
- Immuno-Rheumatology Center, St. Luke's International Hospital, 9-1 Akashi-Cho, Chuo-Ku, Tokyo, Japan
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Clowse MEB, Oates J, Barnado A, Kirchoff K, Blaske A, Sheikh SZ, Crofford LJ, Eudy AM. Implications of the accuracy of diagnostic algorithms for systemic lupus on our understanding of racial disparities in pregnancy outcomes. Rheumatology (Oxford) 2024; 63:119-126. [PMID: 37225388 PMCID: PMC10765149 DOI: 10.1093/rheumatology/kead178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 03/24/2023] [Accepted: 04/04/2023] [Indexed: 05/26/2023] Open
Abstract
OBJECTIVE Disparities in pregnancy outcomes among women with SLE remain understudied, with few available racially diverse datasets. We sought to identify disparities between Black and White women in pregnancy outcomes within academic institutions in the United States. METHODS Using the Common Data Model electronic medical record (EMR)-based datasets within the Carolinas Collaborative, we identified women with pregnancy delivery data (2014-2019) and ≥1 SLE International Classification of Diseases 9 or 10 code (ICD9/10) code. From this dataset, we identified four cohorts of SLE pregnancies, three based on EMR-based algorithms and one confirmed with chart review. We compared the pregnancy outcomes identified in each of these cohorts for Black and White women. RESULTS Of 172 pregnancies in women with ≥1 SLE ICD9/10 code, 49% had confirmed SLE. Adverse pregnancy outcomes occurred in 40% of pregnancies in women with ≥1 ICD9/10 SLE code and 52% of pregnancies with confirmed SLE. SLE was frequently over-diagnosed in women who were White, resulting in 40-75% lower rates of adverse pregnancy outcomes in EMR-derived vs confirmed SLE cohorts. Over-diagnosis was less common for Black women with pregnancy outcomes 12-20% lower in EMR-derived vs confirmed SLE cohorts. Black women had higher rates of adverse pregnancy outcomes than White women in the EMR-derived, but not the confirmed cohorts. CONCLUSION EMR-derived cohorts of pregnancies in women who are Black, but not White, provided accurate estimations of pregnancy outcomes. The data from the confirmed SLE pregnancies suggest that all women with SLE, regardless of race, referred to academic centres remain at very high risk for adverse pregnancy outcome.
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Affiliation(s)
- Megan E B Clowse
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - James Oates
- Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - April Barnado
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Katie Kirchoff
- Biomedical Informatics Center, Medical University of South Carolina, Charleston, SC, USA
| | - Ashley Blaske
- Department of Internal Medicine, East Tennessee State University College of Medicine, Johnson City, TN, USA
| | - Saira Z Sheikh
- Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Leslie J Crofford
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Amanda M Eudy
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
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8
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Al-Husban N, Abu-Hassan DW, Saleem RAA, Al-Abdallat L, Alhusban AE, Adwan MH. Therapeutic changes of systemic lupus erythematosus (SLE) patients in pregnancy and feto-maternal outcomes: a retrospective cohort study. J Int Med Res 2024; 52:3000605231225349. [PMID: 38263912 PMCID: PMC10807327 DOI: 10.1177/03000605231225349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 12/20/2023] [Indexed: 01/25/2024] Open
Abstract
OBJECTIVES Patients with systemic lupus erythematosus (SLE) frequently show non-compliance with their medication. We evaluated the compliance of patients with SLE in Jordan with their medication and the relationships with fetal and maternal outcomes. METHODS We performed a retrospective cohort study of patients with SLE who had no co-morbidities or antiphospholipid syndrome; and were taking only prednisolone, hydroxychloroquine, and/or antiplatelet and anticoagulant medication. RESULTS We studied 173 pregnancies. Prednisolone was administered around pregnancy in 50 (28.9%) of these. The compliance with hydroxychloroquine, prednisolone, and anticoagulant and antiplatelet medication was 87.5%, 91.4%, and 97.3%, respectively. Non-compliance with anticoagulant/antiplatelet therapy was significantly associated with pregnancy-related complications. No complications developed in participants who were non-compliant with prednisolone therapy. The mean pre-pregnancy Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) for the pregnancies was 3.7, indicating low disease activity. Pregnancies with high pre-pregnancy SLEDAI scores tended to be more likely to have preterm deliveries, intrauterine growth restriction, and stillbirth. Postpartum relapse tended to be associated with higher pre-pregnancy SLEDAI. CONCLUSIONS In patients with pre-conceptional low SLE activity, changes in therapeutic compliance during pregnancy are not associated with adverse outcomes. In addition, post-partum relapse is not associated with pre-pregnancy SLEDAI score in therapeutically compliant patients.
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Affiliation(s)
- Naser Al-Husban
- Department of Obstetrics and Gynecology, School of Medicine, The University of Jordan, Amman, Jordan
| | - Diala Walid Abu-Hassan
- Department of Physiology and Biochemistry, School of Medicine, The University of Jordan Amman, Jordan
| | | | | | | | - Marwan H Adwan
- Department of Medicine, Division of Rheumatology, The University of Jordan, Amman, Jordan
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Sims CA, Eudy AM, Doss J, Rogers JL, Sadun RE, Criscione-Schreiber L, Sun K, Clowse ME. The impact of pregnancy planning and medical readiness on reproductive outcomes in women with systemic lupus erythematosus. Lupus 2023; 32:1666-1674. [PMID: 37966369 DOI: 10.1177/09612033231216602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2023]
Abstract
Women with systemic lupus erythematosus (SLE) who get pregnant while SLE is active or while on teratogens have higher risk of poor pregnancy outcomes. The American College of Rheumatology (ACR) Reproductive Health Guidelines recommend women conceive when SLE is well controlled and treated with pregnancy-compatible medications. The Healthy Outcomes in Pregnancy with SLE Through Education of Providers (HOP-STEP) Intervention was created to ascertain pregnancy interest and contraceptive use followed by a personalized pregnancy prevention and/or planning discussion (https://www.LupusPregnancy.org). All study participants were adult females enrolled in a prospective registry who met ACR or SLICC criteria. Women were defined as "not medically ready for pregnancy" if they were currently prescribed a teratogen, had proteinuria ≥500 mg, or had elevated SLE activity according to the physician's global assessment. Two time periods were assessed: 2/2018-12/2019 and 10/2020-4/2021 to evaluate pre- and post-pandemic periods, with some post-pandemic visits taking place via telehealth. The interest in pregnancy was similar between the first time period (17%) and the second time period, whether in-person (18%) or virtual (18%). Pregnancy interest was assessed significantly more frequently during in-person visits (90%) compared to virtual encounters (67%) (p = .02). Contraceptive use was not significantly different during either time period with use of a teratogen or increased SLE activity. Of the 52 women in both time periods who were not medically ready for pregnancy and were not on effective contraception, three women (5.8%) conceived. None of the women who were using moderate or highly effective contraception became pregnant. Pregnancy outcomes were similar between unintended or high-risk and well-timed pregnancies. The HOP-STEP Intervention effectively identified pregnancy interest, giving rheumatologists the opportunity to address patient reproductive goals, optimize disease activity, and adjust medication regimens prior to conception.
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Affiliation(s)
- Catherine A Sims
- Department of Rheumatology, Duke University, Durham, NC, United States
| | - Amanda M Eudy
- Department of Rheumatology, Duke University, Durham, NC, United States
| | - Jayanth Doss
- Department of Rheumatology, Duke University, Durham, NC, United States
| | - Jennifer L Rogers
- Department of Rheumatology, Duke University, Durham, NC, United States
| | - Rebecca E Sadun
- Department of Rheumatology, Duke University, Durham, NC, United States
| | | | - Kai Sun
- Department of Rheumatology, Duke University, Durham, NC, United States
| | - Megan Eb Clowse
- Department of Rheumatology, Duke University, Durham, NC, United States
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Andreoli L, Chighizola CB, Iaccarino L, Botta A, Gerosa M, Ramoni V, Tani C, Bermas B, Brucato A, Buyon J, Cetin I, Chambers CD, Clowse MEB, Costedoat-Chalumeau N, Cutolo M, De Carolis S, Dolhain R, Fazzi EM, Förger F, Giles I, Haase I, Khamashta M, Levy RA, Meroni PL, Mosca M, Nelson-Piercy C, Raio L, Salmon J, Villiger P, Wahren-Herlenius M, Wallenius M, Zanardini C, Shoenfeld Y, Tincani A. Immunology of pregnancy and reproductive health in autoimmune rheumatic diseases. Update from the 11 th International Conference on Reproduction, Pregnancy and Rheumatic Diseases. Autoimmun Rev 2023; 22:103259. [PMID: 36549355 DOI: 10.1016/j.autrev.2022.103259] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 12/18/2022] [Indexed: 12/24/2022]
Abstract
Autoimmune rheumatic diseases (ARD) can affect women and men during fertile age, therefore reproductive health is a priority issue in rheumatology. Many topics need to be considered during preconception counselling: fertility, the impact of disease-related factors on pregnancy outcomes, the influence of pregnancy on disease activity, the compatibility of medications with pregnancy and breastfeeding. Risk stratification and individualized treatment approach elaborated by a multidisciplinary team minimize the risk of adverse pregnancy outcomes (APO). Research has been focused on identifying biomarkers that can be predictive of APO. Specifically, preeclampsia and hypertensive disorders of pregnancy tend to develop more frequently in women with ARD. Placental insufficiency can lead to intrauterine growth restriction and small-for-gestational age newborns. Such APO have been shown to be associated with maternal disease activity in different ARD. Therefore, a key message to be addressed to the woman wishing for a pregnancy and to her family is that treatment with compatible drugs is the best way to ensure maternal and fetal wellbeing. An increasing number of medications have entered the management of ARD, but data about their use in pregnancy and lactation are scarce. More information is needed for most biologic drugs and their biosimilars, and for the so-called small molecules, while there is sufficient evidence to recommend the use of TNF inhibitors if needed for keeping maternal disease under control. Other issues related to the reproductive journey have emerged as "unmet needs", such as sexual dysfunction, contraception, medically assisted reproduction techniques, long-term outcome of children, and they will be addressed in this review paper. Collaborative research has been instrumental to reach current knowledge and the future will bring novel insights thanks to pregnancy registries and prospective studies that have been established in several Countries and to their joint efforts in merging data.
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Affiliation(s)
- Laura Andreoli
- Rheumatology and Clinical Immunology Unit, ASST Spedali Civili, Brescia, Italy; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Cecilia B Chighizola
- Paediatric Rheumatology Unit, ASST G. Pini & CTO, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Luca Iaccarino
- Rheumatology Unit, Department of Medicine-DIMED, University of Padova, Padova, Italy
| | - Angela Botta
- Department of Obstetrics, Gynaecology and Pediatrics, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Maria Gerosa
- Division of Clinical Rheumatology, ASST Gaetano Pini-CTO, Research Center for Adult and Pediatric Rheumatic Diseases, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Véronique Ramoni
- Medicina Generale Lodi, ASST Lodi-Ospedale Maggiore, Lodi, Italy
| | - Chiara Tani
- Rheumatology Unit, Azienda Ospedaliero Universitaria Pisana and Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | | | - Antonio Brucato
- Internal Medicine, Fatebenefratelli Hospital, Milan, Italy; Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
| | - Jill Buyon
- Division of Rheumatology, New York University Grossman School of Medicine, New York, NY, USA
| | - Irene Cetin
- Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy; Department of Woman, Mother and Child, Luigi Sacco and Vittore Buzzi Children Hospitals, ASST Fatebenefratelli-Sacco, Milan, Italy
| | - Christina D Chambers
- Department of Pediatrics, University of California, Herbert Wertheim School of Public Health and Longevity Science, University of California, San Diego, La Jolla, CA, USA
| | - Megan E B Clowse
- Division of Rheumatology & Immunology, Duke University School of Medicine, Durham, NC, USA
| | - Nathalie Costedoat-Chalumeau
- Internal Medicine Department, Cochin Hospital, Referral center for rare autoimmune and systemic diseases, Université de Paris, CRESS, INSERM, INRA, Paris, France
| | - Maurizio Cutolo
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal M edicine, University of Genoa, IRCSS San Martino Polyclinic, Genoa, Italy
| | - Sara De Carolis
- Department of Obstetrics, Gynaecology and Pediatrics, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Radboud Dolhain
- Department of Rheumatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Elisa M Fazzi
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy; Child Neurology and Psychiatry Unit, ASST Spedali Civili, Brescia, Italy
| | - Frauke Förger
- Department of Rheumatology and Immunology, University Hospital (Inselspitaland University of Bern, Bern, Switzerland
| | - Ian Giles
- Centre for Rheumatology, Department of Inflammation, Division of Medicine, University College London, Department of rheumatology, University College London Hospital, London, UK
| | - Isabell Haase
- Department for Rheumatology and Hiller Research Institute, Heinrich-Heine-University, Düsseldorf, Germany
| | - Munther Khamashta
- Women & Children's Health, King's College, London, UK; GlaxoSmithKline Global Medical Expert, Dubai, United Arab Emirates
| | - Roger A Levy
- Universidade do Estado de Rio de Janeiro, Rio de Janeiro, Brazil; GlaxoSmithKline Global Medical Expert, Collegeville, PA, USA
| | - Pier Luigi Meroni
- IRCCS Istituto Auxologico Italiano, Immunorheumatology Research Laboratory, Milan, Italy
| | - Marta Mosca
- Rheumatology Unit, Azienda Ospedaliero Universitaria Pisana and Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | | | - Luigi Raio
- Department of Obstetrics and Gynaecology, University Hospital (Inselspitaland University of Bern, Bern, Switzerland
| | - Jane Salmon
- Division of Rheumatology, Department of Medicine, Hospital for Special Surgery and Weill Cornell Medicine, New York, NY, USA
| | - Peter Villiger
- Rheumatology and Clinical Immunology, Medical Center Monbijou, Bern, Switzerland
| | - Marie Wahren-Herlenius
- Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Marianne Wallenius
- National Advisory Unit on Pregnancy and Rheumatic Diseases, St Olavs Hospital, Trondheim, University Hospital and Institute of Neuromedicine and Movement Science, NTNU, Norwegian University of Science and Technology, Trondheim, Norway
| | - Cristina Zanardini
- Department of Obstetrics and Gynecology, ASST Spedali Civili, Brescia, Italy
| | - Yehuda Shoenfeld
- Sackler Faculty of Medicine, Ariel University, Ariel, Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel
| | - Angela Tincani
- Rheumatology and Clinical Immunology Unit, ASST Spedali Civili, Brescia, Italy; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy.
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