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Ravindran V, Bhadran S, Divakaran M, Reshma VM. Lupus pregnancy outcomes in women with previous adverse outcomes: a prospective cohort study. Clin Rheumatol 2024:10.1007/s10067-024-07069-1. [PMID: 39017917 DOI: 10.1007/s10067-024-07069-1] [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: 06/19/2024] [Revised: 07/09/2024] [Accepted: 07/11/2024] [Indexed: 07/18/2024]
Abstract
OBJECTIVES The primary objective of this prospective cohort study was to assess the usefulness of a predefined multidisciplinary care pathway-based management on pregnancy outcome(s) in women with SLE who already had at least one adverse obstetric outcome(s). METHODS Between March 2010 and March 2023, all consecutive, consenting women with SLE who already had at least one previous adverse obstetric outcome (preterm labour, pre-eclampsia, termination of pregnancy, miscarriage, intrauterine growth retardation (IUGR), preterm birth, low birth weight (LBW), intrauterine death (IUD) or stillbirth] were prospectively screened and counselled. The protocol comprised preconception and post-natal drug and disease status review, periodic ante-natal visits for the monitoring of pregnancy and drug and disease status review and post-natal drug and disease status review and contraception advice. Therapeutic changes were made as necessary at each visit. RESULTS A total of 213 women were screened and 197 women (age, 28 ± 6.34 years) were enrolled who had 226 pregnancies. Previous poor obstetric outcomes were miscarriage(s), 186; termination of pregnancy, 4; preterm labour, 51; IUGR, 36; IUD or stillbirth, 16; low birth weight (LBW), 44 and pre-eclampsia, 4. Seventy-seven (39%) women had secondary APS and 37 (19%) had a history of lupus nephritis. There were 194/226 (86%) live births [40 LBW (18%); caesarean section in 101 (45%)]. Thirty pregnancies culminated in miscarriages and 2 in IUDs (14%). Sixty-eight patients (30%) experienced lupus flare during pregnancy (36 mild, 20 moderate and 8 severe). CONCLUSION Our experience underscores the usefulness of a predefined multidisciplinary care pathway-based management for improving pregnancy outcomes in women with SLE who had previous adverse outcomes. Key Points • In women with SLE who had previous adverse obstetric outcome(s) a risk of poor outcome in subsequent pregnancy remains. • Good pregnancy outcomes in these women could be achieved by predefined multidisciplinary care pathways focussed on addressing all relevant issues. • Improved access to rheumatology services and collaboration between rheumatologists and obstetricians is key to improving outcomes in SLE pregnancies.
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Affiliation(s)
- Vinod Ravindran
- Centre for Rheumatology, Calicut, Kerala, India.
- Department of Medicine, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India.
| | - S Bhadran
- Department of Obstetrics, National Hospital, Calicut, Kerala, India
| | - Mini Divakaran
- Department of Obstetrics, PVS Hospital, Calicut, Kerala, India
| | - V M Reshma
- Department of Obstetrics, Indira Gandhi Hospital, Thalassery, Kerala, India
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Gholizadeh Ghozloujeh Z, Singh T, Jhaveri KD, Shah S, Lerma E, Abdipour A, Norouzi S. Lupus nephritis: management challenges during pregnancy. FRONTIERS IN NEPHROLOGY 2024; 4:1390783. [PMID: 38895665 PMCID: PMC11183321 DOI: 10.3389/fneph.2024.1390783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Accepted: 05/15/2024] [Indexed: 06/21/2024]
Abstract
Lupus nephritis (LN), a severe complication of systemic lupus erythematosus (SLE), leads to significant kidney inflammation and damage and drastically increases mortality risk. Predominantly impacting women in their reproductive years, LN poses specific risks during pregnancy, including pre-eclampsia, growth restrictions, stillbirth, and preterm delivery, exacerbated by lupus activity, specific antibodies, and pre-existing conditions like hypertension. Effective management of LN during pregnancy is crucial and involves carefully balancing disease control with the safety of the fetus. This includes pre-conception counseling and a multidisciplinary approach among specialists to navigate the complexities LN patients face during pregnancy, such as distinguishing LN flare-ups from pregnancy-induced conditions. This review focuses on exploring the complex dynamics between pregnancy and LN, emphasizing the management difficulties and the heightened risks pregnant women with LN encounter.
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Affiliation(s)
- Zohreh Gholizadeh Ghozloujeh
- Department of Medicine, Division of Nephrology, Loma Linda University School of Medicine, Loma Linda, CA, United States
| | - Tripti Singh
- Department of Medicine, Division of Nephrology, University of Wisconsin, Madison, WI, United States
| | - Kenar D. Jhaveri
- Department of Medicine, Division of Kidney Diseases and Hypertension, Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Great Neck, NY, United States
| | - Silvi Shah
- Department of Medicine, Division of Nephrology, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Edgar Lerma
- Department of Medicine, Division of Nephrology, Advocate Christ Medical Center, University of Illinois at Chicago, Oak Lawn, IL, United States
| | - Amir Abdipour
- Department of Medicine, Division of Nephrology, Loma Linda University School of Medicine, Loma Linda, CA, United States
| | - Sayna Norouzi
- Department of Medicine, Division of Nephrology, Loma Linda University School of Medicine, Loma Linda, CA, United States
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Elfving P, Kariniemi S, Kautiainen H, Rantalaiho V, Virta LJ, Puolakka K, Laine MK. Pregnancies in patients with systemic lupus erythematosus during 2000-2018 in Finland: a case-control study. Rheumatol Int 2024; 44:1101-1109. [PMID: 38565771 PMCID: PMC11108866 DOI: 10.1007/s00296-024-05564-x] [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: 12/22/2023] [Accepted: 02/21/2024] [Indexed: 04/04/2024]
Abstract
OBJECTIVES The aim was to investigate, how pregnancies proceed in patients with systemic lupus erythematosus (SLE) compared to their individually matched population controls. MATERIAL AND METHODS Adult incident SLE patients were identified from the register of new special reimbursement decisions for SLE drugs in 2000-2014. For each patient, 1-3 randomly selected controls from the Population Register Centre were matched. Data regarding pregnancies were obtained from the Finnish Medical Birth Register, Care Register and Register of Congenital Malformations until 2018. The study utilized data from the Drug Purchase Register and educational information from Statistic Finland. RESULTS A total of 163 deliveries for 103 mothers with SLE and 580 deliveries for 371 population controls were identified. The duration of pregnancies in SLE women was significantly shorter compared to controls (38.9 versus 39.6 weeks). There were more urgent Caesarean Sections. (15% versus 9%) and need for care at neonatal intensive care unit (NICU) (21% versus 11%) among deliveries in SLE mothers. No statistical difference was observed between SLE and control groups in the occurrence of preeclampsia or major congenital malformations. Gestational age was 2.5 weeks shorter when the mother experienced pre-eclampsia. Hydroxychloroquine was purchased by 30% of SLE mothers during pregnancy. CONCLUSION The course of pregnancies in Finnish SLE patients seems to be quite moderate compared to controls, and no new safety issues were detected. The low utilization of hydroxychloroquine indicates that the benefits of the drug to pregnancy and disease course are not optimally recognized by specialists treating SLE mothers.
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Affiliation(s)
- Pia Elfving
- Department of Medicine, Kuopio University Hospital, P.O. Box 100, 70029 KYS, Kuopio, Finland.
- Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland.
| | - Simo Kariniemi
- School of Medicine, University of Eastern Finland, Kuopio, Finland
- Jyväskylä Central Hospital, Jyväskylä, Finland
| | - Hannu Kautiainen
- Primary Health Care Unit, Kuopio University Hospital, Kuopio, Finland
- Folkhälsan Research Centre, Helsinki, Finland
| | - Vappu Rantalaiho
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Centre for Rheumatic Diseases, Tampere University Hospital, Tampere, Finland
- Kanta-Häme Central Hospital, Hämeenlinna, Finland
| | - Lauri J Virta
- Research Department, Social Insurance Institution, Helsinki, Finland
| | | | - Merja K Laine
- Folkhälsan Research Centre, Helsinki, Finland
- Department of General Practice and Primary Health Care, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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Dragoutsos G, Tsiggalou C, Oikonomou E, Bothou A, Trypsiannis G, Nikolettos K, Damaskos C, Garmpis N, Kyriakou D, Nalbanti T, Iatrakis G, Nikolettos N, Tsikouras P. Association of Anti-Ro/SSA and Anti-La/SSB Autoantibodies With Pregnancy Outcome in the General Population. Mater Sociomed 2024; 36:47-53. [PMID: 38590603 PMCID: PMC10999136 DOI: 10.5455/msm.2024.36.47-53] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 02/25/2024] [Indexed: 04/10/2024] Open
Abstract
Background Autoimmune diseases encompass a diverse array of disorders that disturb the optimal functioning of the immune system, which is to eliminate the 'foreign or/and dangerous' to mistakenly target the body's own tissues. Objective The aim of this research is to evaluate the most effective approach to managing autoimmune diseases within the framework of pregnancy. Methods The exact causes and etiologies of these diseases are multifactorial and mostly still unclear. Ro/SSA autoantibodies and La/SSB, could be found in Sjögren's disease (SJ), systemic lupus (SLE) and other autoimmune disorders. Smoking, stress, UV exposure, vitamin D deficiency, and other genetic and environmental factors have been identified as risk factors for rheumatic diseases. Results Over the years, an ever-increasing incidence of these diseases has been observed in the general population, with the female sex being at increased risk for their occurrence. This fact raises the question of what should be the management of these pathological entities during pregnancy. Taking into account the very significant impact on the quality of paitients'daily life and the seemingly augmented prevalence of autoimmune diseases, as well as their preference in the female population, the reasonable question arises as to what should be the optimal management of these diseases in the context of pregnancy. Conclusion Given the limited data of the global medical community regarding the etiological factors and mechanisms that trigger the onset of rheumatic diseases, the management of pregnant women is a complex conundrum that health professionals are challenged to face and solve.
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Affiliation(s)
- Georgios Dragoutsos
- Department of Obstetrics and Gynecology, Democritus University of Thrace, Greece
| | - Christina Tsiggalou
- Department of Medical Micobiology-Immunology Laboratory of Hygiene and Environmental Protection Democritus University of Thrace, Greece
| | - Efthymios Oikonomou
- Department of Obstetrics and Gynecology, Democritus University of Thrace, Greece
| | - Anastasia Bothou
- Department of Obstetrics and Gynecology, Democritus University of Thrace, Greece
| | | | | | - Christos Damaskos
- Experimental Surgery and Surgical Research, Medical School, National and Kapodistrian University of Athens, Greece and Renal Transplantation Unit, Laiko General Hospital, Athens, Greece
| | - Nikolaos Garmpis
- Laboratory of Experimental Surgery and Surgical Research, Medical School, National and Kapodistrian University of Athens, Greece
| | - Dimitrios Kyriakou
- Department of Obstetrics and Gynecology, Democritus University of Thrace, Greece
| | - Theopi Nalbanti
- Department of Obstetrics and Gynecology, Democritus University of Thrace, Greece
| | - Georgios Iatrakis
- Department of Obstetrics and Gynecology, Democritus University of Thrace, Greece
| | - Nikolaos Nikolettos
- Department of Obstetrics and Gynecology, Democritus University of Thrace, Greece
| | - Panagiotis Tsikouras
- Department of Obstetrics and Gynecology, Democritus University of Thrace, Greece
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Tan B, So PN, Krishnan A, Carriazo S, Bahamonde JR, Lamech TM, Hassanein M, Lerma E, Wiegley N. Approach to Pregnancy in Patients With Lupus Nephritis. Kidney Med 2023; 5:100724. [PMID: 37915962 PMCID: PMC10616386 DOI: 10.1016/j.xkme.2023.100724] [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] [Indexed: 11/03/2023] Open
Abstract
Active lupus nephritis (LN) in pregnancy is strongly associated with poor maternal and fetal outcomes and, therefore, has implications on the planning, timing, and management. Prepregnancy evaluation is essential for all LN patients with childbearing potential to ensure pregnancies proceed in a safe and timely manner. Both maternal and fetal risks are communicated to patient during the evaluation. Stratification into different risk profile groups is then made based on disease activity and organ impairment severity. Patients with LN are generally divided into 3 main groups. Patients with LN who become pregnant receive treatments that are nonteratogenic and optimal for fetal and maternal outcomes. Throughout the pregnancy period, these patients are monitored closely under surveillance by a multidisciplinary team of clinicians. The management of patients with LN in pregnancy can be challenging both diagnostically (distinguishing LN from pre-eclampsia and determining the role and timing of kidney biopsy) and therapeutically (LN flares during pregnancy and managing a newly diagnosed LN during pregnancy).
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Affiliation(s)
- Benjamin Tan
- Nephrology Unit, Queen Elizabeth Hospital, Kota Kinabalu, Malaysia
| | | | | | - Sol Carriazo
- Department of Nephrology and Hypertension Department, Fundacion Jimenez Diaz Hospital, Madrid, Spain
| | | | | | - Mohamed Hassanein
- Division of Nephrology and Hypertension, University of Mississippi Medical Center, Jackson, MI
| | - Edgar Lerma
- Section of Nephrology, University of Illinois at Chicago, Chicago, IL
| | - Nasim Wiegley
- Division of Nephrology, University of California Davis School of Medicine, Sacramento, CA
| | - GlomCon Editorial Team
- Nephrology Unit, Queen Elizabeth Hospital, Kota Kinabalu, Malaysia
- Private Practice, Manila, Philippines
- Royal Perth Hospital, Perth, Australia
- Department of Nephrology and Hypertension Department, Fundacion Jimenez Diaz Hospital, Madrid, Spain
- Department of Nephrology, St Luke’s University Health Network, PA
- Institute of Nephrology, Madras Medical College, India
- Division of Nephrology and Hypertension, University of Mississippi Medical Center, Jackson, MI
- Section of Nephrology, University of Illinois at Chicago, Chicago, IL
- Division of Nephrology, University of California Davis School of Medicine, Sacramento, CA
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Zhang F, Zhang B, Fan R, Cheng T, Hu X, Liu Y, Cen X, Bu Y, Cao J, Chen F, Chen J. Clinical efficacy of plasma exchange in systemic lupus erythematosus during pregnancy. Immun Inflamm Dis 2023; 11:e1041. [PMID: 37904711 PMCID: PMC10566447 DOI: 10.1002/iid3.1041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 09/11/2023] [Accepted: 09/20/2023] [Indexed: 11/01/2023] Open
Abstract
OBJECTIVE To investigate the clinical efficacy of plasma exchange (PE) with or without prednisone and hydroxychloroquine (HCQ) for the treatment of systemic lupus erythematosus (SLE) during pregnancy. METHODS The clinical characteristics of 14 pregnant women with SLE admitted to our hospital were retrospectively analyzed, including 7 only treated with prednisone and HCQ (non-PE group) as well as 7 combined PE (PE group). The delivery situations of 14 patients were recorded. Data like erythrocyte sedimentation rate (ESR), urine protein, platelet count, and SLEDAI scores were compared between two groups before treatment and 3, 6, and 12 months after delivery. RESULTS Three patients in the non-PE group ended in miscarriage while all patients in the PE group were delivered successfully. Eleven successfully delivered fetuses in the two groups were healthy, and the Apgar scores were over 8. The ESR of the PE group was significantly lower than that of the non-PE group at 6 and 12 months after delivery, while there was no statistical difference in ESR between the two groups before treatment and 3 months after delivery. The ESR and urine protein were significantly higher in the non-PE group at months 3, 6, and 12 postpartum. There was a significant decrease in disease activity postpartum in the PE group compared to predelivery disease activity. The change in platelet counts between the two groups significantly increased over time in the PE group, while SLEDAI scores decreased. CONCLUSIONS The combination of PE and oral prednisone and HCQ is possibly a more effective treatment than oral prednisone and HCQ alone for patients with active SLE during pregnancy. This treatment option reduces pregnancy loss and promotes the patients' postpartum condition to a certain extent.
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Affiliation(s)
- Fen Zhang
- Department of RheumatologyThe Second Hospital of Shanxi Medical UniversityTaiyuan CityShanxi ProvinceChina
| | - Bing‐Ying Zhang
- Department of Respiratory MedicineXinzhou People's HospitalXinzhou CityShanxi ProvinceChina
| | - Ru Fan
- Department of RheumatologyThe Second Hospital of Shanxi Medical UniversityTaiyuan CityShanxi ProvinceChina
| | - Ting Cheng
- Department of RheumatologyThe Second Hospital of Shanxi Medical UniversityTaiyuan CityShanxi ProvinceChina
| | - Xiao‐Rong Hu
- Department of RheumatologyThe Second Hospital of Shanxi Medical UniversityTaiyuan CityShanxi ProvinceChina
| | - Yu‐Qing Liu
- Department of RheumatologyThe Second Hospital of Shanxi Medical UniversityTaiyuan CityShanxi ProvinceChina
| | - Xing Cen
- Department of RheumatologyThe Second Hospital of Shanxi Medical UniversityTaiyuan CityShanxi ProvinceChina
| | - Yu‐Jie Bu
- Department of RheumatologyThe Second Hospital of Shanxi Medical UniversityTaiyuan CityShanxi ProvinceChina
| | - Jian‐Ping Cao
- Department of RheumatologyThe Second Hospital of Shanxi Medical UniversityTaiyuan CityShanxi ProvinceChina
| | - Feng‐Wu Chen
- State Key Laboratory of Multiphase Flow in Power EngineeringXi'an Jiaotong UniversityXi'anShanxi ProvinceChina
| | - Jun‐Wei Chen
- Department of RheumatologyThe Second Hospital of Shanxi Medical UniversityTaiyuan CityShanxi ProvinceChina
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Suzuki K, Uno S, Wakasugi N. Tacrolimus use and renal function in pregnancy with lupus nephritis: Analysis of post-marketing surveillance data in Japan. Mod Rheumatol 2023; 33:944-952. [PMID: 35982545 DOI: 10.1093/mr/roac094] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 07/18/2022] [Accepted: 08/09/2022] [Indexed: 11/14/2022]
Abstract
OBJECTIVES Tacrolimus may be administered to pregnant women with lupus nephritis in Japan if considered therapeutically beneficial, but supporting data are limited. We assessed the safety and effectiveness of tacrolimus before, during, and after pregnancy in women with lupus nephritis receiving tacrolimus. METHODS This was an ad hoc analysis of data from a post-marketing surveillance study of tacrolimus in patients with lupus nephritis in Japan. Pregnancy outcomes, nephritis status, and adverse events were assessed for up to 2 years postpartum. RESULTS Data were available for 23 births in 21 patients (two patients had two births each). Tacrolimus for lupus nephritis was continued during 11 births in nine patients (during and after pregnancy) and discontinued in 12 patients (when pregnancy was known or when approaching delivery). Renal function was generally maintained in patients who gave birth while receiving tacrolimus; however, there were cases of increased urine protein and decreased renal function over 2 years. There were no unexpected adverse events/safety concerns. CONCLUSIONS These data from clinical practice suggest that tacrolimus is a valid treatment option for lupus nephritis in fertile women in Japan and, with careful monitoring, pregnant women with lupus nephritis may continue their tacrolimus treatment.
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Preeclampsia in women with lupus - Influence of aspirin and hydroxychloroquine on pregnancy outcome. Pregnancy Hypertens 2023; 31:14-16. [PMID: 36436478 DOI: 10.1016/j.preghy.2022.11.006] [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: 06/29/2022] [Revised: 10/30/2022] [Accepted: 11/17/2022] [Indexed: 11/21/2022]
Abstract
Systemic lupus erythematosus is associated with increased rates of preeclampsia. Both aspirin and hydroxychloroquine are recommended for preeclampsia prophylaxis in women with lupus but there are no studies examining related outcomes in an Australian cohort. This was a single centre retrospective study of lupus affected pregnancies. The association between hydroxychloroquine, aspirin and preeclampsia was examined using adjusted logistic regression models. In 95 pregnancies, hydroxychloroquine was associated with a significantly lower risk of preeclampsia (adjusted OR 0.16, 95 % CI 0.04-0.64) but there was no association between aspirin and preeclampsia (adjusted OR 1.34, 95 % CI 0.33-5.40).
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Petri M, Landy H, Clowse MEB, Gemzoe K, Khamashta M, Kurtinecz M, Levy RA, Liu A, Marino R, Meizlik P, Pimenta JM, Sumner K, Tilson H, Connolly MB, Wurst K, Harris J, Quasny H, Juliao P, Roth DA. Belimumab use during pregnancy: a summary of birth defects and pregnancy loss from belimumab clinical trials, a pregnancy registry and postmarketing reports. Ann Rheum Dis 2023; 82:217-225. [PMID: 36198440 PMCID: PMC9887359 DOI: 10.1136/ard-2022-222505] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 09/02/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Describe available data on birth defects and pregnancy loss in women with systemic lupus erythematosus (SLE) exposed to belimumab. METHODS Data collected from belimumab clinical trials, the Belimumab Pregnancy Registry (BPR), and postmarketing/spontaneous reports up to 8 March 2020 were described. Belimumab exposure timing, concomitant medications and potential confounding factors were summarised descriptively. RESULTS Among 319 pregnancies with known outcomes (excluding elective terminations), 223 ended in live births from which birth defects were identified in 4/72 (5.6%) in belimumab-exposed pregnancies and 0/9 placebo-exposed pregnancies across 18 clinical trials, 10/46 (21.7%) belimumab-exposed pregnancies in the BPR prospective cohort (enrolled prior to pregnancy outcome) and 0/4 belimumab-exposed pregnancies in the BPR retrospective cohort (enrolled after pregnancy outcome), and 1/92 (1.1%) in belimumab-exposed pregnancies from postmarketing/spontaneous reports. There was no consistent pattern of birth defects across datasets. Out of pregnancies with known outcomes (excluding elective terminations), pregnancy loss occurred in 31.8% (35/110) of belimumab-exposed women and 43.8% (7/16) of placebo-exposed women in clinical trials; 4.2% (2/48) of women in the BPR prospective cohort and 50% (4/8) in the BPR retrospective cohort; and 31.4% (43/137) of belimumab-exposed women from postmarketing/spontaneous reports. All belimumab-exposed women in clinical trials and the BPR received concomitant medications and had confounding factors and/or missing data. CONCLUSIONS Observations reported here add to limited data published on pregnancy outcomes following belimumab exposure. Low numbers of exposed pregnancies, presence of confounding factors/other biases, and incomplete information preclude informed recommendations regarding risk of birth defects and pregnancy loss with belimumab use.
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Affiliation(s)
- Michelle Petri
- Rheumatology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Helain Landy
- Maternal And Fetal Medicine, Georgetown University Medical Center, Northwest Washington, Washington, DC, USA,Department of Obstetrics and Gynecology, MedStar Georgetown University Hospital, Northwest Washington, Washington, DC, USA
| | - Megan E B Clowse
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Kim Gemzoe
- Value Evidence and Outcomes, GSK, Stevenage, Hertfordshire, UK
| | | | | | - Roger A Levy
- Specialty Care, Global Medical Affairs, GSK, Collegeville, Pennsylvania, USA
| | - Andrew Liu
- Global Clinical Safety and Pharmacovigilance, GSK, Brentford, UK
| | - Rebecca Marino
- US Case Management Group, GSK, Research Triangle Park, North Carolina, USA
| | | | | | - Kelsey Sumner
- Value Evidence Outcomes Epidemiology, GSK, Research Triangle Park, North Carolina, USA,Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Chapel Hill, North Carolina, USA
| | - Hugh Tilson
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Chapel Hill, North Carolina, USA
| | - Mary Beth Connolly
- Safety and Medical Governance, GSK, Research Triangle Park, North Carolina, USA
| | - Keele Wurst
- Epidemiology, GSK, Research Triangle Park, North Carolina, USA
| | | | - Holly Quasny
- Clinical Sciences, GSK, Research Triangle Park, North Carolina, USA
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Studying Pregnancy Outcome Risk in Patients with Systemic Lupus Erythematosus Based on Cluster Analysis. BIOMED RESEARCH INTERNATIONAL 2023. [DOI: 10.1155/2023/3668689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Background. Pregnancy in systemic lupus erythematosus (SLE) patients is a challenge due to the potential maternal and fetal complications. Therefore, a multidisciplinary assessment of disease risk before and during pregnancy is essential to improve pregnancy outcomes. Objectives. Our purpose was to (i) define clusters of patients with similar history and laboratory features and determine the associative maternal and perinatal outcomes and (ii) evaluate the risk spectrum of maternal and perinatal outcomes of pregnancy in SLE patients, represented by our established risk-assessment chart. Methods. Medical records of 119 patients in China were analyzed retrospectively. Significant variables with
were selected. The self-organizing map was used for clustering the data based on historical background and laboratory features. Results. Clustering was conducted using 21 maternal and perinatal features. Five clusters were recognized, and their prominent maternal manifestations were as follows: cluster 1 (including 27.73% of all patients): preeclampsia and lupus nephritis; cluster 2 (22.69%): oligohydramnios, uterus scar, and femoral head necrosis; cluster 3 (13.45%): upper respiratory tract infection; cluster 4 (15.97%): premature membrane rupture; and cluster 5 (20.17%): no problem. Conclusion. Pregnancy outcomes in SLE women fell into three categories, namely high risk, moderate risk, and low risk. Present manifestations, besides the medical records, are a potential assessment means for better management of pregnant SLE patients.
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Juliao P, Wurst K, Pimenta JM, Gemzoe K, Landy H, Moody MA, Tilson H, Covington D, Moore T, Marino R, Gilbride J, Liu A, Meizlik P, Petri M. Belimumab use during pregnancy: Interim results of the belimumab pregnancy registry. Birth Defects Res 2023; 115:188-204. [PMID: 36177676 PMCID: PMC10092734 DOI: 10.1002/bdr2.2091] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 08/25/2022] [Accepted: 09/04/2022] [Indexed: 01/28/2023]
Abstract
BACKGROUND Belimumab is approved for active, autoantibody-positive systemic lupus erythematosus (SLE) and lupus nephritis, but limited data exist regarding its use in pregnancy. The Belimumab Pregnancy Registry (BPR, GSK Study BEL114256; NCT01532310) was created to evaluate pregnancy and infant outcomes following belimumab exposure. METHODS Individuals with SLE exposed to belimumab from 4 months before and/or during pregnancy can enroll into the BPR. The primary outcome is major birth defects; secondary outcomes include miscarriages, stillbirths, elective termination, pre-term birth, neonatal death, small for gestational age, and adverse infant outcomes during the first year of life. Belimumab exposure timing, concomitant medications, and other potential confounding factors are also collected. Data up to March 8, 2021, are reported descriptively. RESULTS From an expected sample size target of 500 prospective pregnancies with a known outcome, only 55 were enrolled in the study. Among these, two pregnancy losses and 53 pregnancies with a live birth outcome were reported. Ten of the 53 live birth pregnancies resulted in a major birth defect. Ten pregnancies were enrolled after the pregnancy outcome occurred and were examined retrospectively (four live births with no defects, four miscarriages, and two elective terminations). There was no indication or pattern of birth defects associated with belimumab. CONCLUSIONS Low recruitment numbers for the BPR and incomplete information limit the conclusions regarding belimumab exposure during pregnancy. There was no pattern or common mechanism of birth defects associated with belimumab within the BPR data.
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Affiliation(s)
| | - Keele Wurst
- EpidemiologyGSKResearch Triangle ParkNorth CarolinaUSA
| | | | - Kim Gemzoe
- Value Evidence and OutcomesGSKStevenageHertfordshireUnited Kingdom
| | - Helain Landy
- Maternal And Fetal MedicineGeorgetown University Medical CenterWashingtonDCUSA
- Department of Obstetrics and GynecologyMedStar Georgetown University HospitalWashingtonDCUSA
| | - M. Anthony Moody
- Department of PediatricsDuke University School of MedicineDurhamNorth CarolinaUSA
| | - Hugh Tilson
- Department of EpidemiologyUniversity of North Carolina Gillings School of Global Public HealthChapel HillNorth CarolinaUSA
| | | | | | - Rebecca Marino
- US Case Management GroupGSKResearch Triangle ParkNorth CarolinaUSA
| | | | - Andrew Liu
- Global Clinical Safety and PharmacovigilanceGSKUxbridgeMiddlesexUnited Kingdom
| | | | - Michelle Petri
- RheumatologyJohns Hopkins University School of MedicineBaltimoreMarylandUSA
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Rheumatic Diseases in Reproductive Age-the Possibilities and the Risks. Reprod Sci 2023; 30:111-123. [PMID: 35359225 DOI: 10.1007/s43032-022-00901-6] [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: 11/04/2021] [Accepted: 02/20/2022] [Indexed: 01/11/2023]
Abstract
The most common systemic connective tissue diseases (CTD), such as rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), antiphospholipid syndrome (APS), systemic sclerosis (SSc), and Sjögren's syndrome (SjS), affect many women of reproductive age. These diseases may strongly impact the course of pregnancy and increase the risk factors of incompatibility. A literature search was done on MEDLINE, PubMed, and Google Scholar in 2011-2021. The analysis included meta-analysis, randomized control trials, prospective and retrospective studies, and systematic reviews. The literature search allowed us to form conclusions and underline recommendations regarding pregnancy's risk and treatment possibilities in the course of rheumatic disease. Optimal control of CTD activity should be reached at least 6 months before conception. High-risk pregnancies are often accompanied by maternal-placental syndrome, which manifests as preeclampsia, eclampsia, fetal growth restriction, and prematurity. The flare of rheumatic disease can coexist with obstetrical complications, and differential diagnosis can be difficult. Medications that do not influence the risk of fetus complications should be applied before and during pregnancy. Teratogenic drugs (e.g., methotrexate, leflunomide, cyclophosphamide) must be withdrawn before pregnancy. Conventional medications such as hydroxychloroquine, sulfasalazine, colchicine, and the TNFα inhibitor certolizumab can be used safely at any stage of pregnancy. Corticosteroids should be tapered, and other biologics should be avoided due to teratogenicity or carefully administered due to the impact on the fetal immune system. Distinguishing between disease flare and obstetrical complications can be difficult in clinical practice; however, some clinical symptoms and serological markers can be helpful in the differential diagnosis.
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Mohammed RHA, Mumtaz H, Sangah AB, Shaikh SS, Nasir N, Jabeen S. Pregnancy in lupus: an updated consensus to guide best practice strategies. EGYPTIAN RHEUMATOLOGY AND REHABILITATION 2022. [DOI: 10.1186/s43166-022-00167-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Abstract
Background
Systemic lupus erythematosus is a multifaceted chronic relapsing autoimmune disease of unknown etiology. The disease has always been a serious diagnosis in women being a multisystem pathology that is classically encountered during the childbearing age posing serious systemic comorbidities with a potential impact on the functional performance, psychosocial status, and survival. In this article, we review critical issues related to the decision to conceive in female with lupus highlighting the impact of the diagnosis and disease activity status on the mother and the fetus, attempting to suggest a consensus to guide safe decision making for pregnancy with SLE.
Main body
The pleomorphic dysregulated immune nature of lupus in the presence of uncontrolled disease carries a higher risk of complicated pregnancy. Therefore, SLE pregnancies should be well planned and are usually encouraged if the disease is inactive (at least 6 months prior to conception) to ensure immune quiescence towards a safer outcome.
Conclusion
With the proper implementation of preconception counseling strategy, choice of the correct timing of conception, close monitoring of SLE flares with tight control, and the appreciation of the value of multidisciplinary management to best practice most young women with SLE can carry on successful pregnancies with favorable outcome.
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El Miedany Y, Kamel NS, Abu-Zaid MH, El Hadidi K, Mahmoud GA, El Gaafary M, Sarhan E, Abdel-Nasser A, Abualfadl EM, Azim AA, Fathi NA, Mokbel A, Hassan W, Eissa M, Tabra SAA, Mortada M, Fouad NA, Elnemr R, Mansour AE, Elaraby I, Medhat BM, Mohamed SS, Abdelradi ER, Ibrahim RA, Saber S. Egyptian recommendations for treating to target of lupus nephritis: an evidence-based consensus on clinical practice recommendations for the management of lupus nephritis and pregnancy. EGYPTIAN RHEUMATOLOGY AND REHABILITATION 2022. [DOI: 10.1186/s43166-022-00142-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Nephritis is known to be one of the most serious complications of lupus and a strong predictor of poor outcome. This study was carried out aiming at setting up an up-to-date recommendation for the management of women living with lupus nephritis and planning for a family throughout conception, pregnancy, and the postpartum period.
Ten key clinical questions were identified by the scientific committee according to the Patient/Population, Intervention, Comparison, Outcomes and Timing (PICOT) approach. The literature review team performed a systematic review to summarise evidence advocating the benefits and harms of available pharmacologic and nonpharmacologic therapies for women living with lupus nephritis (LN) and planning for a family. Subsequently, recommendations were formulated. The level of evidence was determined for each section using the Oxford Centre for Evidence-Based Medicine (CEBM) system. A 2-round Delphi process was conducted with 24 experts. All rounds were conducted online. A consensus was achieved on the direction and the strength of the recommendations.
Results
An online questionnaire was sent to an expert panel who participated in the two rounds (response rate 100%). At the end of round 2, a total of 20 recommendation items, categorised into 10 domains to address the main LN with pregnancy categories, were obtained. The percentage of those who agreed with the recommendations (rank 7–9) ranged from 88.5 to 100%. On the phrasing of all the clinical standards defined by the scientific committee, a consensus was reached (i.e., 75% of respondents strongly agreed or agreed). An algorithm for the management of LN with pregnancy has been suggested.
Conclusion
These recommendations provide an updated consensus on the pharmacological treatment of LN with pregnancy and strategies to reach optimal outcomes for both the mother and newborn in common clinical scenarios, based on a combination of evidence and expert opinion. Best treatment decisions should be tailored to each individual patient’s situation.
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Dai Z, Huang X, Yuan F, Li T, Xie B, Lin H, Yang P, Li X, Xu S, Zhao J, Wang Y, Peng X, Wei S, Huang W, Li J, Liang J, Liu X, Chu Y, Zhang Z, Zhang R, Lau EHY, Lin Z. Systemic lupus erythematosus in China: a cross-sectional survey-based study on healthcare-seeking behaviors, disease progression, medication, knowledge of and attitudes toward the disease (Preprint). JMIR Public Health Surveill 2022; 9:e44541. [PMID: 37027203 PMCID: PMC10131714 DOI: 10.2196/44541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 02/13/2023] [Accepted: 02/28/2023] [Indexed: 03/04/2023] Open
Abstract
BACKGROUND Systemic lupus erythematosus (SLE) is a systemic autoimmune disease involving multiple organs throughout the body. The health care-seeking behaviors, disease progression of SLE, and patients' knowledge of and attitudes toward SLE have not been characterized in China. OBJECTIVE The aim of this study was to depict the health care-seeking behaviors, disease progression, and medications in patients with SLE and to examine the factors associated with their disease flares, knowledge, and attitudes toward SLE in China. METHODS We conducted a cross-sectional survey in 27 provinces in China. Descriptive statistical methods were used to depict the demographic characteristics, health care-seeking behaviors, medications, and health status. Multivariable logistic regression models were used to identify the factors associated with disease flares, medication changes, and attitudes toward SLE. An ordinal regression model was used to examine the factors associated with the knowledge of the treatment guidelines. RESULTS We recruited 1509 patients with SLE, and 715 had lupus nephritis (LN). Approximately 39.96% (603/1509) of the patients with SLE were primarily diagnosed with LN, and 12.4% (112/906) developed LN (mean time 5.2 years) from non-LN. Patients whose registered permanent residences or workplaces in other cities from the same province and adjacent provinces seeking health care accounted for 66.9% (569/850) and 48.8% (479/981) of the patients with SLE in the provincial capital cities, respectively. Mycophenolate mofetil was the most commonly used immunosuppressive drug in patients without LN (185/794, 23.3%) and patients with LN (307/715, 42.9%). Femoral head necrosis (71/228, 31.1%) and hypertension (99/229, 43.2%) were the most common adverse event (AE) and chronic disease during treatment, respectively. Change of hospitals for medical consultation (odds ratio [OR] 1.90, 95% CI 1.24-2.90) and development of 1 chronic disease (OR 3.60, 95% CI 2.04-6.24) and AE (OR 2.06, 95% CI 1.46-2.92) and more were associated with disease flares. A pregnancy plan (OR 1.58, 95% CI 1.18-2.13) was associated with changes in medication. Only 242 (16.03%) patients with SLE were familiar with the treatment guidelines, and patients with LN tended to be more familiar with the disease (OR 2.20, 95% CI 1.81-2.68). After receiving treatment, 891 (59.04%) patients changed their attitudes toward SLE from fear to acceptance, and patients with college education or higher (OR 2.09, 95% CI 1.10-4.04) were associated with a positive attitude toward SLE. CONCLUSIONS A large proportion of patients seeking health care in the provincial capital cities of China migrated from other cities. Persistent monitoring of potential AEs and chronic diseases during SLE treatment and managing patients who changed hospitals for medical consultation are essential for controlling disease flares. Patients had insufficient knowledge about SLE treatment guidelines and would benefit from health education to maintain a positive attitude toward SLE.
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Affiliation(s)
- Zonglin Dai
- School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, Hong Kong
| | - Xinxiang Huang
- Department of Rheumatology and Immunology, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
| | - Fei Yuan
- Department of Rheumatology, Dongguan People's Hospital, Dongguan, China
| | - Tianwang Li
- Department of Rheumatology and Immunology, Guangdong Second Provincial General Hospital, Guangzhou, China
| | - Baozhao Xie
- Department of Rheumatology and Immunology, The Seventh Affiliated Hospital, Guangxi Medical University, Wuzhou, China
| | - He Lin
- Department of Rheumatology and Immunology, Fujian Provincial Hospital, Shengli Clinical Medical College of Fujian Medical University, Fujian, China
| | - Pingting Yang
- Department of Rheumatology and Immunology, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Xueyi Li
- Department of Rheumatology, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Shuiming Xu
- Department of Rheumatology and Immunology, Ganzhou Municipal Hospital, Ganzhou, China
| | - Jinjun Zhao
- Department of Rheumatology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yukai Wang
- Division of Rheumatology, Shantou Central Hospital, Shantou, China
| | - Xiang Peng
- Department of Rheumatology and Immunology, The Sixth Affiliated Hospital of Guangzhou Medical University (Qingyuan People's Hospital), Qingyuan, China
| | - Simin Wei
- Division of Rheumatology, Guigang People's Hospital, Guigang, China
| | - Wei Huang
- Department of Rheumatology and Immunology, Hainan General Hospital, Hainan Affiliated Hospital of Hainan Medical University, Haikou, China
| | - Jingyang Li
- Division of Rheumatology, The Affiliated Zhuzhou Hospital of Xiangya Medical College of Central South University, Zhuzhou, China
| | - Jing Liang
- Department of Rheumatology, Huadu Affiliated Hospital of Southern Medical University, Guangzhou, China
| | - Xiuhua Liu
- Division of Rheumatology, Liuzhou Worker's Hospital, The Fourth Affiliated Hospital of Guangxi Medical University, Liuzhou, China
| | - Yongliang Chu
- Division of Rheumatology, Guangdong Province Hospital of Traditional Chinese Medicine, Zhuhai Branch, Zhuhai, China
| | - Zhiming Zhang
- Division of Rheumatology, The Second Affiliated Hospital of Fujian University of Traditional Chinese Medicine, Fuzhou, China
| | - Renpeng Zhang
- Division of Rheumatology, The First People's Hospital of Zhaotong, Zhaotong, China
| | - Eric H Y Lau
- School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, Hong Kong
- Laboratory of Data Discovery for Health, Hong Kong Science Park, Hong Kong, Hong Kong
| | - Zhiming Lin
- Department of Rheumatology and Immunology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
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16
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Zhang S, Han X, Liu W, Wen Q, Wang J. Pregnancy in patients with systemic lupus erythematosus: a systematic review. Arch Gynecol Obstet 2022; 308:63-71. [PMID: 35913558 DOI: 10.1007/s00404-022-06718-7] [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: 06/26/2022] [Accepted: 07/18/2022] [Indexed: 11/28/2022]
Abstract
Systemic lupus erythematosus (SLE)-a most common disorder in women of reproductive age-has been described to be associated with adverse pregnancy outcomes. Despite the increased health risks for the mother (preeclampsia, lupus flare, arterial hypertension, gestational diabetes mellitus and thrombotic risk when antiphospholipid antibodies are present) and fetus (miscarriage, stillbirth, premature birth, intrauterine growth restriction and neonatal lupus), the majority of patients can deliver healthy neonates. With appropriate management by a multidisciplinary team, composing rheumatologists, obstetricians and neonatologists, women with SLE can achieve better pregnancy outcomes by monitoring associated predictive indicators, raising major concern for severe complications and somewhat early delivery if necessary. In this review, we summarize the latest advances in secondary infertility and pregnancy-related risk perception for lupus patients, with an emphasis on the safety of biological agents (mainly belimumab and rituximab) and traditional therapeutic regimens.
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Affiliation(s)
- Shumin Zhang
- Department of Rheumatiod and Immunology, The Affiliated Hospital of Qingdao University, Qingdao, 266000, China
| | - Xiao Han
- Department of Rheumatiod and Immunology, The Affiliated Hospital of Qingdao University, Qingdao, 266000, China
| | - Wenping Liu
- Department of Rheumatiod and Immunology, The Affiliated Hospital of Qingdao University, Qingdao, 266000, China
| | - Qiong Wen
- Department of Rheumatiod and Immunology, The Affiliated Hospital of Qingdao University, Qingdao, 266000, China
| | - Jibo Wang
- Department of Rheumatiod and Immunology, The Affiliated Hospital of Qingdao University, Qingdao, 266000, China.
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17
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Nikolopoulos D, Fotis L, Gioti O, Fanouriakis A. Tailored treatment strategies and future directions in systemic lupus erythematosus. Rheumatol Int 2022; 42:1307-1319. [PMID: 35449237 DOI: 10.1007/s00296-022-05133-0] [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: 03/07/2022] [Accepted: 04/02/2022] [Indexed: 10/18/2022]
Abstract
Systemic lupus erythematosus (SLE) represents a diagnostic and therapeutic challenge for physicians due to its protean manifestations and unpredictable course. The disease may manifest as multisystemic or organ-dominant and severity at presentation may vary according to age at onset (childhood-, adult- or late-onset SLE). Different manifestations may respond variably to different immunosuppressive medications and, even within the same organ-system, the severity of inflammation may vary from mild to organ-threatening. Current "state-of-the-art" in SLE treatment aims at remission or low disease activity in all organ systems. Apart from hydroxychloroquine and glucocorticoids (which should be used with caution), the choice of the appropriate immunosuppressive agent should be individualized and depend on the prevailing manifestation, severity stratification and patient childbearing potential. In this review, we provide an overview of therapeutic options for the various organ manifestations and severity patterns of the disease, different phenotypes (such as multisystem versus organ-dominant disease), as well as specific considerations, including lupus with antiphospholipid antibodies, childhood and late-onset disease, as well as treatment options during pregnancy and lactation.
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Affiliation(s)
- Dionysis Nikolopoulos
- Rheumatology and Clinical Immunology, 4th Department of Internal Medicine, "Attikon" University Hospital, Medical School National and Kapodistrian University of Athens, Athens, Greece.
| | - Lampros Fotis
- Department of Pediatrics, "Attikon" University Hospital, Medical School National and Kapodistrian University of Athens, Athens, Greece
| | - Ourania Gioti
- Department of Rheumatology, "Asklepieion" General Hospital, Athens, Greece
| | - Antonis Fanouriakis
- Rheumatology and Clinical Immunology, 4th Department of Internal Medicine, "Attikon" University Hospital, Medical School National and Kapodistrian University of Athens, Athens, Greece.,1st Department of Propaedeutic Internal Medicine, "Laikon" General Hospital, Medical School National Kapodistrian University of Athens, Athens, Greece
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18
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Valviesse DMDJ, Monteiro DLM, Jésus NRD, Jésus GRRD, Santos FC, Lacerda MI, Rodrigues NCP, Klumb EM. Risk factors associated with infections in pregnant women with systemic lupus erythematosus. Rev Assoc Med Bras (1992) 2022; 68:536-541. [DOI: 10.1590/1806-9282.20220074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 01/25/2022] [Indexed: 11/21/2022] Open
Affiliation(s)
| | | | - Nilson Ramires de Jésus
- Universidade do Estado do Rio de Janeiro, Brazil; Universidade Federal do Rio de Janeiro, Brazil
| | | | - Flavia Cunha Santos
- Universidade do Estado do Rio de Janeiro, Brazil; Universidade Federal do Rio de Janeiro, Brazil
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19
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Congenital atrioventricular heart block: From diagnosis to treatment. Rev Port Cardiol 2022; 41:231-240. [DOI: 10.1016/j.repc.2019.09.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 09/23/2019] [Indexed: 11/22/2022] Open
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20
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Braga A, Barros T, Faria R, Marinho A, Rocha G, Farinha F, Neves E, Vasconcelos C, Braga J. Systemic Lupus Erythematosus and Pregnancy: a Portuguese Case-Control Study. Clin Rev Allergy Immunol 2021; 62:324-332. [PMID: 34519994 DOI: 10.1007/s12016-021-08893-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/24/2021] [Indexed: 12/29/2022]
Abstract
Pregnancy in systemic lupus erythematosus (SLE) patients is associated with an increased risk of adverse outcomes. During pregnancy, SLE patients have a higher rate of miscarriage, stillbirth, preterm delivery, fetal growth restriction, or hypertensive disorders of pregnancy. To date, only a few case-control studies were published with the purpose to evaluate the magnitude of risk associated with pregnancy in lupus patients. The aim of our study was to evaluate the maternal and fetal outcomes in a cohort of Portuguese SLE patients and to compare it with a group of healthy pregnant women. We conducted a retrospective case-control study that included all pregnant women with SLE managed at a Portuguese tertiary center, between 2010 and 2019. Pregnancy outcomes were compared between SLE patients and a group of matched healthy pregnant women. Baseline maternal data was collected, and maternal-fetal and neonatal outcomes were evaluated. One hundred twenty-four SLE pregnancies were included. Of the patients, 95.2% were in remission at conception. In 13.7% of cases, a lupus flare was diagnosed during gestation and in 17.9% in the postpartum period. The live birth rate was 84.6%, and the incidence of adverse outcomes was 40.3% (OR 2.64, 95% CI 1.67-4.18). Considering only patients in remission at conception, the presence of adverse outcomes remained significantly higher (36.8% vs. 20.3%, P < 0.01). Miscarriage rate was 15.3% (OR 5.85, 95% CI 2.57-13.34) and preterm delivery occurred in 12.4% of the patients (OR 1.72, 95% CI 0.83-3.57). Preeclampsia prevalence was higher in SLE patients (OR 3.92, 95% CI 1.32-11.57). In the SLE group, the newborn admission to an intensive care unit rate was increased (OR 4.99, 95% CI 1.47-16.90). No neonatal or maternal deaths were reported. In our study, pregnancy with SLE was associated with an increased incidence of adverse outcomes, even in a population of SLE patients with well-controlled disease.
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Affiliation(s)
- António Braga
- Maternal Fetal Unit, Centro Materno Infantil Do Norte, Centro Hospitalar Universitário Do Porto, Oporto, Portugal. .,Instituto Ciências Biomédicas Abel Salazar, Universidade do Porto, Oporto, Portugal.
| | - Tânia Barros
- Maternal Fetal Unit, Centro Materno Infantil Do Norte, Centro Hospitalar Universitário Do Porto, Oporto, Portugal
| | - Raquel Faria
- Instituto Ciências Biomédicas Abel Salazar, Universidade do Porto, Oporto, Portugal.,Clinical Immunology Unit, Centro Hospitalar Universitário Do Porto, Oporto, Portugal
| | - António Marinho
- Instituto Ciências Biomédicas Abel Salazar, Universidade do Porto, Oporto, Portugal.,Clinical Immunology Unit, Centro Hospitalar Universitário Do Porto, Oporto, Portugal
| | - Guilherme Rocha
- Instituto Ciências Biomédicas Abel Salazar, Universidade do Porto, Oporto, Portugal.,Clinical Immunology Unit, Centro Hospitalar Universitário Do Porto, Oporto, Portugal.,Nephrology Department, Centro Hospitalar Universitário Do Porto, Oporto, Portugal
| | - Fátima Farinha
- Instituto Ciências Biomédicas Abel Salazar, Universidade do Porto, Oporto, Portugal.,Clinical Immunology Unit, Centro Hospitalar Universitário Do Porto, Oporto, Portugal
| | - Esmeralda Neves
- Instituto Ciências Biomédicas Abel Salazar, Universidade do Porto, Oporto, Portugal.,Clinical Immunology Unit, Centro Hospitalar Universitário Do Porto, Oporto, Portugal
| | - Carlos Vasconcelos
- Instituto Ciências Biomédicas Abel Salazar, Universidade do Porto, Oporto, Portugal.,Clinical Immunology Unit, Centro Hospitalar Universitário Do Porto, Oporto, Portugal
| | - Jorge Braga
- Maternal Fetal Unit, Centro Materno Infantil Do Norte, Centro Hospitalar Universitário Do Porto, Oporto, Portugal.,Instituto Ciências Biomédicas Abel Salazar, Universidade do Porto, Oporto, Portugal.,Clinical Immunology Unit, Centro Hospitalar Universitário Do Porto, Oporto, Portugal
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21
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Miranda-Hernández D, Sánchez A, Sánchez-Briones RE, Rivas-Ruiz R, Cruz-Reynoso L, Cruz-Domínguez P, Jara LJ, Saavedra MÁ. Impact of Systemic Lupus Erythematosus on Pregnancy: Analysis of a Large 10-Year Longitudinal Mexican Cohort. J Clin Rheumatol 2021; 27:S217-S223. [PMID: 33264243 DOI: 10.1097/rhu.0000000000001626] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Pregnancy in patients with systemic lupus erythematosus is considered a high risk one since it is associated with a higher rate of maternal-fetal complications compared with the pregnancies in healthy women. OBJECTIVES The aim of this study was to describe the maternal-fetal outcomes in a cohort of Mexican patients with systemic lupus erythematosus and to identify risk factors associated with adverse maternal and fetal outcomes. PATIENTS AND METHODS A cohort of pregnant lupus patients was analyzed. Maternal-fetal complications were described, and clinical, biochemical, and immunological variables associated with obstetric adverse outcomes were studied. Descriptive statistics, comparison of variables using appropriate tests, and finally logistic regression analysis were performed to identify potential risk factors for adverse maternal and fetal outcomes. RESULTS A total of 351 pregnancies were included in a 10-year period. The most frequently observed maternal adverse outcomes were lupus flare (35%) and preeclampsia (14.5%). Active lupus before pregnancy (hazards ratio [HR], 3.7; 95% confidence interval [CI], 1.1-12.5; p = 0.003) was a predictor for these complications, whereas the use of antimalarial drugs (HR, 0.4; 95% CI, 0.2-0.7; p = 0.007) was a protective factor. The most frequent fetal adverse outcomes were preterm birth (38.1%), miscarriages (10%), and low birth weight babies (28%), and very low birth weight newborns (11%). Proteinuria in early pregnancy (HR, 7.1; 95% CI, 1.01-50.3; p = 0.04) and preeclampsia (HR, 9.3; 95% CI, 1.7-49.7; p = 0.009) were risk factors associated with these complications. CONCLUSIONS Variables related to systemic lupus erythematosus activity predict an adverse maternal outcome, whereas proteinuria in early pregnancy and preeclampsia are associated with an adverse fetal outcome.
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Affiliation(s)
- Dafhne Miranda-Hernández
- From the Rheumatology Unit, Hospital de Especialidades Dr. Antonio Fraga Mouret, Centro Médico Nacional La Raza
| | - Antonio Sánchez
- From the Rheumatology Unit, Hospital de Especialidades Dr. Antonio Fraga Mouret, Centro Médico Nacional La Raza
| | - Reyna E Sánchez-Briones
- From the Rheumatology Unit, Hospital de Especialidades Dr. Antonio Fraga Mouret, Centro Médico Nacional La Raza
| | | | | | | | - Luis Javier Jara
- Direction of Education and Health Research, Hospital de Especialidades Dr. Antonio Fraga Mouret, Centro Médico Nacional La Raza, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - Miguel Ángel Saavedra
- From the Rheumatology Unit, Hospital de Especialidades Dr. Antonio Fraga Mouret, Centro Médico Nacional La Raza
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22
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Blomjous BS, Johanna I P DV, Zijlstra E, Cramer K, Voskuyl AE, Bultink AIEM. Desire to have children and preferences regarding to pre-pregnancy counselling in women with SLE. Rheumatology (Oxford) 2021; 60:2706-2713. [PMID: 33241288 PMCID: PMC8489423 DOI: 10.1093/rheumatology/keaa684] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 09/17/2020] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Pre-pregnancy counselling in women with systemic lupus erythematosus (SLE) is important in order to improve knowledge on the risks of pregnancy and to optimize pregnancy outcomes. Knowledge on the preferences of women with SLE regarding pre-pregnancy counselling have not yet been studied. In a closely monitored cohort of women with SLE we enquired about the present status of their wish to have children, and wish for and experiences with pre-pregnancy counselling. METHODS A questionnaire developed by physicians in collaboration with two women with SLE was sent to all (n = 177) women participating in the Amsterdam SLE cohort. The questionnaire comprised 32 items, of which 15 focused on the above-mentioned three themes. RESULTS A total of 124 women (70%) returned the questionnaire. The median disease duration was 13 years (interquartile range 9-19). Childlessness occurred in 51 women and 31% declared this was due to SLE [conscious decision (21%), stringent medical advice (6%), infertility due to medication (4%)]. Half of the women preferred the first pre-pregnancy counselling immediately after the SLE diagnosis (53%), together with their partner (69%). Information given by healthcare providers (81%) was preferred over information provided via brochures (35%) or the internet (26%). Pre-pregnancy face-to-face counselling from a rheumatologist and/or gynaecologist separately was preferred in 54%. CONCLUSION One-third of women attributed their childlessness to SLE-related reasons. Pre-pregnancy counselling was preferred shortly after the onset of the disease in a non-multidisciplinary setting. The results of this study underline the importance of timely pre-conceptional counselling by healthcare providers on fertility, risks and pregnancy outcomes in women with SLE.
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Affiliation(s)
- Birgit S Blomjous
- Department of Rheumatology and Clinical Immunology, Amsterdam Rheumatology and immunology Center, Amsterdam Infection & Immunity, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.,Department of Obstetrics and Gynecology, Amsterdam Reproduction & Development, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - de Vries Johanna I P
- Department of Obstetrics and Gynecology, Amsterdam Reproduction & Development, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | | | - Kyra Cramer
- Patient Research Partner, Amsterdam, The Netherlands
| | - Alexandre E Voskuyl
- Department of Rheumatology and Clinical Immunology, Amsterdam Rheumatology and immunology Center, Amsterdam Infection & Immunity, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - And Irene E M Bultink
- Department of Rheumatology and Clinical Immunology, Amsterdam Rheumatology and immunology Center, Amsterdam Infection & Immunity, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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23
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Abstract
Systemic lupus erythematosus is a chronic autoimmune disorder that causes a wide range of mild to life-threatening conditions that require hospitalization and critical care. The morbidity and mortality of systemic lupus erythematosus are associated with the organ system damage caused by intermittent or chronic disease activity and with the complications of long-term and toxic immunosuppressant medication regimens. This article reviews the epidemiologic, clinical, diagnostic, and therapeutic information essential for critical care clinicians who provide care to patients with systemic lupus erythematosus.
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Affiliation(s)
- Erin K Gasser
- Erin K. Gasser is Critical Care Nurse Practitioner at University of California, San Francisco Health, San Francisco, California
| | - Hildy M Schell-Chaple
- Hildy M. Schell-Chaple is Clinical Nurse Specialist at University of California, San Francisco Health and Clinical Professor, UCSF School of Nursing, 505 Parnassus Ave, L-976, San Francisco, CA 94143
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Wind M, Hendriks M, van Brussel BTJ, Eikenboom J, Allaart CF, Lamb HJ, Siebelink HMJ, Ninaber MK, van Geloven N, van Lith JMM, Huizinga TWJ, Rabelink TJ, Sueters M, Teng YKO. Effectiveness of a multidisciplinary clinical pathway for women with systemic lupus erythematosus and/or antiphospholipid syndrome. Lupus Sci Med 2021; 8:8/1/e000472. [PMID: 33952625 PMCID: PMC8103373 DOI: 10.1136/lupus-2020-000472] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 03/05/2021] [Accepted: 04/18/2021] [Indexed: 11/03/2022]
Abstract
OBJECTIVES SLE and/or antiphospholipid syndrome (SLE/APS) are complex and rare systemic autoimmune diseases that predominantly affect women of childbearing age. Women with SLE/APS are at high risk of developing complications during pregnancy. Therefore, clinical practice guidelines recommend that patients with SLE/APS should receive multidisciplinary counselling before getting pregnant. We investigated the clinical effectiveness of implementing a multidisciplinary clinical pathway including prepregnancy counselling of patients with SLE/APS. METHODS A clinical pathway with specific evaluation and prepregnancy counselling for patients with SLE/APS was developed and implemented in a tertiary, academic hospital setting. Patients were prospectively managed within the clinical pathway from 2014 onwards and compared with a retrospective cohort of patients that was not managed in a clinical pathway. Primary outcome was a combined outcome of disease flares for SLE and thromboembolic events for APS. Secondary outcomes were maternal and fetal pregnancy complications. RESULTS Seventy-eight patients with 112 pregnancies were included in this study. The primary combined outcome was significantly lower in the pathway cohort (adjusted OR (aOR) 0.20 (95% CI 0.06 to 0.75)) which was predominantly determined by a fivefold risk reduction of SLE flares (aOR 0.22 (95% CI 0.04 to 1.09)). Maternal and fetal pregnancy complications were not different between the cohorts (respectively, aOR 0.91 (95% CI 0.38 to 2.17) and aOR 1.26 (95% CI 0.55 to 2.88)). CONCLUSIONS The outcomes of this study suggest that patients with SLE/APS with a pregnancy wish benefit from a multidisciplinary clinical pathway including prepregnancy counselling.
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Affiliation(s)
- Merlijn Wind
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Maike Hendriks
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Jeroen Eikenboom
- Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Cornelia F Allaart
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Hildo J Lamb
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Maarten K Ninaber
- Department of Pulmonology, Leiden University Medical Center, Leiden, The Netherlands
| | - Nan van Geloven
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Jan M M van Lith
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Tom W J Huizinga
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Ton J Rabelink
- Nephrology, Leiden University Medical Center, Leiden, The Netherlands
| | - Marieke Sueters
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Y K Onno Teng
- Nephrology, Leiden University Medical Center, Leiden, The Netherlands
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Rezaieyazdi Z, Mohammadi M, Yousefi Z, Jafari H, Khodashahi M. Outcomes of planned pregnancy in patients with systemic lupus erythematosus and their neonates. THE EGYPTIAN RHEUMATOLOGIST 2021. [DOI: 10.1016/j.ejr.2021.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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26
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Kaimal A, Norton ME. Society for Maternal-Fetal Medicine Consult Series #55: Counseling women at increased risk of maternal morbidity and mortality. Am J Obstet Gynecol 2021; 224:B16-B23. [PMID: 33309561 DOI: 10.1016/j.ajog.2020.12.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Women should be provided with evidence-based information when considering options for contraception and pregnancy management. When counseling about health conditions and available treatments, healthcare practitioners should employ strategies that encourage the incorporation of informed patient preferences into a shared decision-making process with the patient. To optimize the health of women at risk of experiencing adverse health outcomes during or after pregnancy, counseling should be a continuous process throughout the reproductive life course. The purpose of this Consult is to provide guidance for all healthcare practitioners about counseling reproductive-aged women who may be at high risk of experiencing maternal morbidity or mortality.
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Affiliation(s)
- Anjali Kaimal
- Society for Maternal-Fetal Medicine, 409 12 St. SW, Washington, DC 20024, USA.
| | - Mary E Norton
- Society for Maternal-Fetal Medicine, 409 12 St. SW, Washington, DC 20024, USA.
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Taulaigo AV, Moschetti L, Ganhão S, Gerardi MC, Franceschini F, Tincani A, Andreoli L. Safety considerations when using drugs in pregnant patients with systemic lupus erythematosus. Expert Opin Drug Saf 2021; 20:523-536. [PMID: 33599570 DOI: 10.1080/14740338.2021.1893298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Introduction: Systemic lupus erythematosus (SLE) mainly affects young females during childbearing age; therefore, reproductive issues are of major interest.Areas covered: Pregnancy planning is crucial to adjust the treatment toward drugs that are safe throughout pregnancy and breastfeeding. The evidence about drug safety is limited to post-marketing surveillance, registries, case series, and case reports, as pregnant patients are excluded from randomized clinical trials. The aim of this review is to report the safety considerations when treating pregnant SLE patients. Regarding maternal side effects of drugs, we focused on metabolic, infectious, and hemorrhagic complications. Fetal safety was analyzed looking at drugs teratogenicity, their possible effects on immune system, and on the long-term neuropsychological development of children.Expert opinion: The management of pregnancy in SLE has changed when knowledge about the safety of drugs has become available. Keeping SLE disease activity under control before, during and after pregnancy is of fundamental importance to ensure the best possible outcomes for mother and child. All these issues must be discussed with the patient and her family during preconception counseling. International efforts in terms of pregnancy registries and reproductive health guidelines help physicians improve their communication with SLE patients.
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Affiliation(s)
- Anna Viola Taulaigo
- Unidade De Doenças Auto-imunes/Medicina 7.2, Hospital Curry Cabral, Centro Hospitalar Universitário De Lisboa Central, Lisboa, Portugal
| | - Liala Moschetti
- Unit of Rheumatology and Clinical Immunology, ASST Spedali Civili; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Sara Ganhão
- Rheumatology Department, Centro Hospitalar E Universitário De São João, Porto, Portugal
| | - Maria-Chiara Gerardi
- Unit of Rheumatology and Clinical Immunology, ASST Spedali Civili; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Franco Franceschini
- Unit of Rheumatology and Clinical Immunology, ASST Spedali Civili; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Angela Tincani
- Unit of Rheumatology and Clinical Immunology, ASST Spedali Civili; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy.,Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation, Moscow, Russia
| | - Laura Andreoli
- Unit of Rheumatology and Clinical Immunology, ASST Spedali Civili; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
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Willekens B, Kleffner I. Susac syndrome and pregnancy: a review of published cases and considerations for patient management. Ther Adv Neurol Disord 2021; 14:1756286420981352. [PMID: 33796140 PMCID: PMC7970706 DOI: 10.1177/1756286420981352] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 11/24/2020] [Indexed: 12/31/2022] Open
Abstract
Susac syndrome (SuS) is a rare autoimmune endotheliopathy leading to hearing loss, branch retinal artery occlusions and encephalopathy. Young females are more frequently affected than males, making counselling for family planning an important issue. We reviewed published cases on SuS during pregnancy or in the postpartum period, and selected 27 reports describing the details of 33 patients with SuS. Treatment options and implications for pregnancy and breastfeeding are discussed. We propose new areas for research and suggest a management strategy.
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Affiliation(s)
- Barbara Willekens
- Department of Neurology, Antwerp University Hospital, Drie Eikenstraat 655, Edegem, 2650, Belgium
| | - Ilka Kleffner
- University Hospital Knappschaftskrankenhaus Bochum, Ruhr University Bochum, Bochum, Germany
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Leng Q, Wang W, Wang Y, Wu L. Treatment of severe thrombocytopenia associated with systemic lupus erythematosus in pregnancy with eltrombopag: A case report and literature review. J Clin Pharm Ther 2020; 46:532-538. [PMID: 33277725 DOI: 10.1111/jcpt.13321] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Revised: 11/10/2020] [Accepted: 11/15/2020] [Indexed: 12/20/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Severe thrombocytopenia associated with systemic lupus erythematosus (SLE) in pregnancy is infrequent. Its occurrence can lead to serious adverse pregnancy consequences and perinatal complications. The thrombopoietin (TPO) analogue eltrombopag has been successfully used in the treatment of autoimmune thrombocytopenia, but its safety and efficacy in severe thrombocytopenia during pregnancy remain unclear. CASE SUMMARY We report a 33-year-old woman with SLE at 29 + 3 weeks gestational age who developed severe thrombocytopenia with complaints of epistaxis, gum bleeding and haematuresis. Most conventional treatments including glucocorticoids, intravenous immunoglobulin (IVIG) and cyclosporine did not elevate her platelets, but eltrombopag worked well and her platelet count gradually recovered, allowing her to deliver a healthy baby at 36 + 3 weeks gestational age. WHAT IS NEW AND CONCLUSION This suggests that eltrombopag in combination with glucocorticoids has a good safety and efficacy profile in pregnant patients with SLE complicated by severe thrombocytopenia.
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Affiliation(s)
- Qianru Leng
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Key Laboratory of Genetics and Molecular Mechanism of Cardiologic Disorders, Wuhan, China
| | - Wei Wang
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Key Laboratory of Genetics and Molecular Mechanism of Cardiologic Disorders, Wuhan, China
| | - Yan Wang
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Key Laboratory of Genetics and Molecular Mechanism of Cardiologic Disorders, Wuhan, China
| | - Lujin Wu
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Key Laboratory of Genetics and Molecular Mechanism of Cardiologic Disorders, Wuhan, China
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30
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2020 Chinese guidelines for the diagnosis and treatment of systemic lupus erythematosus. RHEUMATOLOGY AND IMMUNOLOGY RESEARCH 2020; 1:5-23. [DOI: 10.2478/rir-2020-0009] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 08/12/2020] [Indexed: 02/05/2023]
Abstract
Abstract
Systemic lupus erythematosus (SLE) is a heterogeneous autoimmune disease that represents a prodigious challenge of diagnosis and treatment. In 2019, under the leadership of the Chinese Rheumatology Association, a multidisciplinary guideline development group was established to develop an evidence-based diagnosis and treatment guideline for patients with SLE in PR China. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to evaluate the quality of evidence and the strength of recommendations. The guideline was reported following the Reporting Items for Practice Guidelines in Healthcare (RIGHT) checklist. In this guideline, we provided recommendations for SLE classification criteria, disease activity monitoring and assessment, medication administration and considerations for SLE patients with organs and systems involved, and management of special populations such as SLE patients in the setting of pregnancy. This guideline serves as an evidence-based tool for Chinese clinicians to diagnose and treat patients with SLE.
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31
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Kim JW, Jung JY, Kim HA, Yang JI, Kwak DW, Suh CH. Lupus Low Disease Activity State Achievement Is Important for Reducing Adverse Outcomes in Pregnant Patients With Systemic Lupus Erythematosus. J Rheumatol 2020; 48:707-716. [PMID: 33060317 DOI: 10.3899/jrheum.200802] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/22/2020] [Indexed: 12/22/2022]
Abstract
OBJECTIVE This study aimed to examine the frequency and risk factors of complications during pregnancy in women with systemic lupus erythematosus (SLE). METHODS The medical records of patients with SLE and age-matched controls at Ajou University Hospital were collected. Clinical features and pregnancy complications in women with SLE were compared to those of the controls. Multivariate logistic regression analysis was performed to determine the predictors of adverse maternal and fetal outcomes. RESULTS We analyzed 163 pregnancies in patients with SLE and 596 pregnancies in the general population; no significant differences regarding demographic characteristics were noted. Patients with SLE experienced a higher rate of stillbirth (OR 13.2), preeclampsia (OR 4.3), preterm delivery (OR 2.8), intrauterine growth retardation (OR 2.5), admission to neonatal intensive care unit (OR 2.2), and emergency cesarean section (OR 1.9) than the control group. Multivariate regression analysis revealed that thrombocytopenia, low complement, high proteinuria, high SLE Disease Activity Index (SLEDAI), low Lupus Low Disease Activity State (LLDAS) achievement rate, and high corticosteroid (CS) dose were associated with adverse pregnancy outcomes. In the receiver-operating characteristic curve analysis, the optimal cutoff value for the cumulative and mean CS doses were 3500 mg and 6 mg, respectively. CONCLUSION Pregnant women with SLE have a higher risk of adverse pregnancy outcomes. Pregnancies are recommended to be delayed until achieving LLDAS and should be closely monitored with the lowest possible dose of CS.
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Affiliation(s)
- Ji-Won Kim
- J.W. Kim, MD, J.Y. Jung, MD, PhD, H.A. Kim, MD, PhD, C.H. Suh, MD, PhD, Department of Rheumatology, Ajou University School of Medicine, Suwon
| | - Ju-Yang Jung
- J.W. Kim, MD, J.Y. Jung, MD, PhD, H.A. Kim, MD, PhD, C.H. Suh, MD, PhD, Department of Rheumatology, Ajou University School of Medicine, Suwon
| | - Hyoun-Ah Kim
- J.W. Kim, MD, J.Y. Jung, MD, PhD, H.A. Kim, MD, PhD, C.H. Suh, MD, PhD, Department of Rheumatology, Ajou University School of Medicine, Suwon
| | - Jeong I Yang
- J.I. Yang, MD, PhD, D.W. Kwak, MD, PhD, Department of Obstetrics and Gynecology, Ajou University School of Medicine, Suwon, Korea
| | - Dong W Kwak
- J.I. Yang, MD, PhD, D.W. Kwak, MD, PhD, Department of Obstetrics and Gynecology, Ajou University School of Medicine, Suwon, Korea
| | - Chang-Hee Suh
- J.W. Kim, MD, J.Y. Jung, MD, PhD, H.A. Kim, MD, PhD, C.H. Suh, MD, PhD, Department of Rheumatology, Ajou University School of Medicine, Suwon;
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32
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Konstantinov NK, Pearson DR. Systemic Lupus Erythematosus: Considerations in Diagnosis and Management for the Inpatient Dermatologist. CURRENT DERMATOLOGY REPORTS 2020. [DOI: 10.1007/s13671-020-00312-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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33
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Shaharir SS, Maulana SA, Shahril NS, Mohd R, Mustafar R, Said MSM, Rahman RA. Adverse pregnancy outcomes among multi-ethnic systemic lupus erythematosus patients in Malaysia. Lupus 2020; 29:1305-1313. [PMID: 32660312 DOI: 10.1177/0961203320938871] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Despite the improvement in the live birth rate among patients with systemic lupus erythematosus (SLE), they are still at an increased risk of adverse pregnancy outcomes (APOs). OBJECTIVE To determine the prevalence and factors associated with APOs in the multi-ethnic SLE populations in Malaysia.Methodology: This was a retrospective review of the consecutive SLE patients who attended the outpatient clinic in two major rheumatology centres from January 2016 until December 2019 with complete pre-pregnancy, antenatal and intra-partum records. APOs include pregnancy loss, prematurity, pre-eclampsia, intra-uterine growth restriction (IUGR) and maternal death. Univariate and multivariable logistic regression with generalised estimating equation (GEE) analyses were performed to determine the factors associated with APOs. RESULTS A total of 153 patients with 240 pregnancies were included and the majority of the patients were Malay (69.9%), followed by Chinese (24.2%) and Indian (5.9%). The prevalence of APOs was 61.7% with the commonest complication being prematurity (28.3%), followed by pregnancy loss (24.6%) and pre-eclampsia (21.8%). Logistic regression model-based GEE analysis revealed that the independent predictors of APOs were active haematological system during pregnancy, pre-pregnancy active disease, Indian patients and positive lupus anticoagulant. Hydroxychloroquine use was associated with lower APOs including pre-eclampsia, prematurity and IUGR in the univariate analyses but it was no longer significant in the GEE analysis. CONCLUSION The prevalence of APOs was high particularly among the Indian patients. Positive lupus anticoagulant and pre-pregnancy active disease were the factors strongly associated with APOs in our multi-ethnic cohort. Hydroxychloroquine may protect against APOs but further larger studies are needed to confirm this.
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Affiliation(s)
- Syahrul S Shaharir
- Rheumatology Unit, Department of Internal Medicine, UKM Medical Centre, Kuala Lumpur, Malaysia
| | - Suhaida A Maulana
- Department of Medicine, Tengku Ampuan Rahimah Hospital, Klang, Malaysia
| | - Nor S Shahril
- Department of Medicine, Putrajaya Hospital, Putrajaya, Malaysia.,Department of Medicine, Cyberjaya University College of Medical Sciences, Cyberjaya, Malaysia
| | - Rozita Mohd
- Nephrology Unit, Department of Internal Medicine, UKM Medical Centre, Kuala Lumpur, Malaysia
| | - Ruslinda Mustafar
- Nephrology Unit, Department of Internal Medicine, UKM Medical Centre, Kuala Lumpur, Malaysia
| | - Mohd S Mohamed Said
- Rheumatology Unit, Department of Internal Medicine, UKM Medical Centre, Kuala Lumpur, Malaysia
| | - Rahana A Rahman
- Department of Obstetrics and Gynaecology, UKM Medical Centre, Kuala Lumpur, Malaysia
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Nagy D, Shaheen NH, Selim HM, Sherif MM, Saed SM, Youssef HR, Osman O, Gaafar T. MicroRNA-126 and 146a as potential biomarkers in systemic lupus erythematosus patients with secondary antiphospholipid syndrome. EGYPTIAN RHEUMATOLOGIST 2020. [DOI: 10.1016/j.ejr.2020.05.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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35
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Green LJ, O’Neill L, Frise CJ. Antisynthetase syndrome in pregnancy: A case and review of the literature. Obstet Med 2020; 13:96-100. [PMID: 32714443 PMCID: PMC7359659 DOI: 10.1177/1753495x18808646] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2018] [Accepted: 09/28/2018] [Indexed: 12/13/2022] Open
Abstract
Antisynthetase syndrome is a rare autoimmune, multisystem, inflammatory condition, characterised by autoantibodies against aminoacyl tRNA synthetases. The predominant features are myositis and interstitial lung disease but other symptoms such as Raynaud's phenomenon may also be present. Described here is a 36-year-old woman with antisynthetase syndrome who planned and underwent a successful pregnancy, during which a multidisciplinary team approach secured a good outcome for both mother and baby.
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Affiliation(s)
- Lauren J Green
- Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
| | - Lorraine O’Neill
- Department of Rheumatology, Oxford University Hospitals NHS Foundation Trust, Nuffield Orthopaedic Centre, Oxford, UK
| | - Charlotte J Frise
- Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
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36
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Rodrigues L, Alves VLP, Sim-Simc MMF, Surita FG. Perceptions of women with systemic lupus erythematosus undergoing high-risk prenatal care: A qualitative study. Midwifery 2020; 87:102715. [PMID: 32447183 DOI: 10.1016/j.midw.2020.102715] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 02/23/2020] [Accepted: 03/30/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Systemic lupus erythematosus (SLE) is a multisystem autoimmune disease that often leads to situations of harm to the mother-fetus binomial. Given the potential for complications and morbidities in these pregnant women, it is essential that a multidisciplinary team be involved in pregnancy planning, as well as monitoring the course of the pregnancy and the postpartum period. Owing to the imminent risks of disease worsening along with consequent disabilities, these women may experience psychological and psychosocial impacts conflicting with the psychological demands of pregnancy. OBJECTIVE To understand the meanings attributed to pregnancy by women with SLE. DESIGN A qualitative design with face-to-face interview following a semi-structured script of open-ended questions. SETTING A specialized outpatient clinic where during prenatal care, women with stable disease undergo scheduled appointments. PARTICIPANTS The sample was intentionally composed of women visiting a specialized outpatient clinic from July 2017 to July 2018. The participants (N = 26) were interviewed in depth, with no refusal. Thematic analysis according to the 7 steps of qualitative analysis was conducted using NVivo 11. FINDINGS Four categories were identified: (1) unplanned pregnancy and nonuse of contraception, (2) feeling healthy despite a doctor's warning of the disease worsening because of pregnancy, (3) joy coupled with fear of the future and pregnancy, and (4) self-perception and straight perception. CONCLUSIONS The experiences of pregnant women with SLE are permeated by ambiguous feelings. These women feel healthy because they can bear a child despite the chronic disease diagnosis and, at the same time, experience fear and insecurity owing to the imminent possibility of disease-related disabilities and limitations. They especially wish to experience motherhood, and they strive for safety and support. IMPLICATIONS FOR PRACTICE Health teams must be structured to welcome and advise these women in planning relationships and pregnancy, as well as choosing the best contraceptive methods and making optimal reproductive decisions. The development of strategies to deal with changes in the perinatal period may be helpful, as these women are willing to take care of themselves.
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Affiliation(s)
- Larissa Rodrigues
- School of Medical Science, University of Campinas (UNICAMP), Brazil.
| | | | | | - Fernanda Garanhani Surita
- Department of Gynecology and Obstetrics, School of Medical Science University of Campinas (UNICAMP), Brazil. R. Alexander Fleming 101, ZIP: 13083-881, Campinas, SP, Brazil.
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Liu J, Liu C, Zuo X, Teng Y. Pernicious placenta previa/placenta percreta complicating active systemic lupus erythematosus resulting in postoperative artery thrombosis. J Int Med Res 2019; 47:6365-6373. [PMID: 31773999 PMCID: PMC7045675 DOI: 10.1177/0300060519886991] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Systemic lupus erythematosus (SLE) increases the risk of adverse pregnancy outcomes and fetal complications. Placenta percreta, involving placental attachment to another organ, is a rare but severe placental abnormality. We report a 26-year-old woman, G2P1, with a 6-year history of SLE with coexisting pernicious placenta previa and placenta percreta detected by second trimester ultrasound. She discontinued prednisone 5 months before admission, without consultation, and active SLE was diagnosed on admission. Because of her progressive condition, the patient underwent infrarenal abdominal aorta balloon occlusion and double J ureteral catheter placement, followed by elective cesarean at 27+6 weeks gestation. Despite aggressive management, she experienced severe bleeding requiring internal iliac artery ligation and peripartum hysterectomy. The placenta had penetrated the uterus walls and attached to the bladder apex, necessitating bladder repair. Thrombosis was detected in the common iliac artery and common femoral artery in the right leg 1 day postoperatively. Conservative antithrombotic therapy had little effect, and embolectomy by arteriotomy was performed on the 6th post-cesarean day, and an arterial thrombus was removed. Infrarenal abdominal aorta balloon occlusion may increase the risk of postoperative thrombosis in pregnant women with active SLE and coagulation disorders. These patients therefore require close monitoring and timely anticoagulation.
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Affiliation(s)
- Jiahuang Liu
- Department of General Surgery, The First Affiliated Hospital of Xi' an Jiaotong University, Xi'an, China
| | - Chao Liu
- Department of Vascular Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | | | - Yue Teng
- Department of Obstetrics and Gynecology, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
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Abstract
Pregnancy, a challenging physiological state, requires shuffling of conventional immune work-sets. Strategies to tolerate the semi-allogenic fetus in normal human pregnancy are multivariate with perfect modulation of the immune cells. Pregnancy is marked by B cell lymphocytopenia accompanied by reduced responsiveness to infectious agents. Besides this old age concept, plenty of research confirms that B cells have other crucial roles in pregnancy and undergo a wide range of modifications in terms of its proliferation, switching between its subtypes, variation in antibody productions, shifting the tides of cytokines as well as regulating other immune cells. B cells establish tolerant environment in pregnancy by producing protective antibodies to encounter the foreign paternal antigens. Regulatory B cells (Bregs) have adopted anti-inflammatory characteristics to sustain normal pregnancy. Moreover, the colossal physiological alterations during human pregnancy also include synchronized changes in the cross-talks between the pregnancy hormones and B cells. These aspects of pregnancy from the view point of B cell functions have so far appeared individually in discrete reports. This review finds its novelty in concisely presenting every facet of association of B cell with human pregnancy.
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Affiliation(s)
- Sulagna Dutta
- Department of Oral Biology and Biomedical Sciences, Faculty of Dentistry, MAHSA University, Jenjarom, Malaysia
| | - Pallav Sengupta
- Department of Physiology, Faculty of Medicine, MAHSA University, Jenjarom, Malaysia
| | - Nazmul Haque
- Department of Oral Biology and Biomedical Sciences, Faculty of Dentistry, MAHSA University, Jenjarom, Malaysia
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39
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Pastore DEA, Costa ML, Surita FG. Systemic lupus erythematosus and pregnancy: the challenge of improving antenatal care and outcomes. Lupus 2019; 28:1417-1426. [PMID: 31551036 DOI: 10.1177/0961203319877247] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVES The objective of this article is to describe maternal and perinatal outcomes in women with systemic lupus erythematosus (SLE) followed in a high-risk prenatal outpatient clinic at a referral center. METHODS This observational study included pregnant women with SLE who underwent prenatal follow-up and childbirth at the Women's Hospital, University of Campinas, from January 2012 to January 2018. All women were followed according to the institution's protocol for pregnant women with SLE. They were subdivided into two groups according to the presence of disease activity during the preconception and gestation periods, and evaluated according to the Systemic Lupus Erythematosus Disease Activity Index and Systemic Lupus Erythematosus Pregnancy Disease Activity Index scales. Data were retrieved from patients' medical records. Chi-square, Fisher exact and Mann-Whitney tests and multivariable analyses were performed. Statistical significance level was 5% (p < .05). RESULTS A total of 125 cases were initially included; those who were lost to follow-up or gave birth at another hospital were further excluded, with 102 pregnancies (of 95 women) remaining. The mean age of the women was 27.7 years (SD 5.44), and 48% were in their first gestation. The average duration of disease was 6.79 years (SD 5.38), with 92.1% receiving SLE-specific therapy. SLE flare occurred in 8.9% during the preconception period and 23.5% during gestation. Preterm premature rupture of membranes (16.6%), preeclampsia or eclampsia (15.6%) and preterm labor (12.7%) were the most frequent complications. The mean gestational age at birth was 34.4 weeks (SD 5.9); the preterm birth rate was 46.8%, the low birth weight rate was 35.1%, and intensive neonatal care admission was 40.4%. Four fetal deaths and one maternal death occurred, all of them in the group with SLE flares. Multivariable logistic regression analysis showed that preconception lupus activity had a six-fold increased rate of gestational loss (odds ratio (OR): 6.14 (95% confidence interval (CI) 1.26-29.99)), and lupus activity during pregnancy had a five-fold increased rate of prematurity at less than 34 weeks (OR: 5.02 (95% CI: 1.90-13.30)). CONCLUSIONS Despite the low percentages of women with pregestational and pregnancy-active disease, we found high incidences of maternal and perinatal complications. Preconception SLE activity increased gestational loss, and SLE activity during pregnancy increased prematurity. Effective immunosuppressive therapy was able to decrease clinical and laboratory activity of SLE; however, unfavorable perinatal outcomes still occurred, even when lupus activity was under control. Pregnancy in women with SLE is always a challenge.
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Affiliation(s)
- D E A Pastore
- Department of Obstetrics and Gynecology, University of Campinas (UNICAMP), School of Medical Sciences, Campinas, São Paulo, Brazil
| | - M L Costa
- Department of Obstetrics and Gynecology, University of Campinas (UNICAMP), School of Medical Sciences, Campinas, São Paulo, Brazil
| | - F G Surita
- Department of Obstetrics and Gynecology, University of Campinas (UNICAMP), School of Medical Sciences, Campinas, São Paulo, Brazil
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What is the best time to assess the antiphospholipid antibodies (aPL) profile to better predict the obstetric outcome in antiphospholipid syndrome (APS) patients? Immunol Res 2019; 66:577-583. [PMID: 30159862 DOI: 10.1007/s12026-018-9024-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Serological risk factors are the most important determinant in predicting unsuccessful pregnancy in obstetric antiphospholipid antibodies syndrome (OAPS) despite conventional treatment. It is not clear if changes in the profile of antiphospholipid antibodies (aPL) during pregnancy modify the risk associated with a poor response to conventional treatment. The aim of our study was to compare the value of a serological tag for aPL obtained before and during the first trimester of pregnancy to predict the response to conventional treatment. We carefully selected 97 pregnancies in women who were included in our study only if they were diagnosed with OAPS prior to a new pregnancy (basal serological risk), retested for aPL during the first trimester of pregnancy (serological risk during pregnancy), and treated with conventional therapy. High baseline serological risk was associated with pregnancy failure in 62.1% of cases (18/29) and predicted 82.5% of pregnancy outcomes with conventional treatment: OR = 16.9, CI = 5.5-52.1, p < 0.001. High serological risk during pregnancy was associated with pregnancy failure in 86.3% of cases (19/22) and predicted 91.8% of pregnancy outcomes with conventional treatment: OR = 88.7, CI = 19.4-404.8, p < 0.001. According to these results, we found that risk categorization performed during pregnancy was better in predicting pregnancy outcome (82.5 vs. 91.8%). Moreover, risk categorization during pregnancy had an increased specificity regarding the prediction: 84.9% at baseline and 95.9% during pregnancy (p = 0.024). Our findings suggest that it is important to perform aPL during the first trimester of pregnancy since that is the best time to establish the serological risk factors.
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Abstract
Pregnancy presents challenges for women with autoimmune diseases. It is associated with significant physiological, hormonal and immunomodulatory changes which are complex and vary according to the stage of pregnancy Pregnancy planning and counselling should be offered Autoimmune diseases such as rheumatoid arthritis tend to improve in pregnancy while systemic lupus erythematosus may increase in activity During pregnancy the chosen regimen should control or prevent underlying disease activity and minimise risk to the fetus. Ideally, women should be on a stable regimen before conception Poorly controlled disease is associated with poor outcomes for both mother and fetus, such as higher risks of pre-eclampsia, early delivery and growth restriction of the fetus Postpartum, there is a sudden fall in hormone concentrations, and a switch to a pro-inflammatory state. This increases the risk of relapse of many autoimmune diseases in particular rheumatoid arthritis, Crohn’s disease and autoimmune hepatitis Many drugs are compatible with breastfeeding, but there are limited data on many of the new drugs
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Affiliation(s)
- Kathy Paizis
- Mercy Hospital for Women, Western Health Sunshine, Austin Health, Melbourne
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Larosa M, Del Ross T, Calligaro A, Favaro M, Zanatta E, Iaccarino L, Doria A. Clinical outcomes and predictors of maternal and fetal complications in pregnancies of patients with systemic lupus erythematosus. Expert Rev Clin Immunol 2019; 15:617-627. [PMID: 30933534 DOI: 10.1080/1744666x.2019.1601557] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Systemic Lupus Erythematosus (SLE) mostly affects women during their childbearing years. Fertility is preserved in SLE patients, but pregnancy is often characterized by a high number of maternal and fetal complications. Adverse pregnancy outcomes (APO) have been widely studied over the last decades and several investigators have focused on the potential clinical and serological predictors of maternal and fetal complications. Areas covered: In this review, we analyzed maternal and fetal complications in SLE patients and predictors of APO. Active disease in the 6 months before conception, lupus nephritis, anti-phospholipid (aPL), anti-SSA/Ro and/or anti-SSB/La antibodies have been identified as the most consistent predictors of maternal and fetal complications to date. However, molecular mechanisms and underlying immunological pathways involved in APO still remain elusive. Expert opinion: Difficulties in assessing prevalence and predictors of APO in SLE patients are due to lack of uniformity in the definitions and methods used in the different studies. In addition, some maternal and fetal complications are difficult to diagnose and to differentiate from each other. Preconception counseling is paramount to prevent APO, and it should consider four main factors: disease activity/lupus nephritis, safety of drugs, aPL, anti-SSA/Ro, and/or anti-SSB/La antibodies.
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Affiliation(s)
- Maddalena Larosa
- a Department of Medicine - DIMED, Division of Rheumatology , University of Padova , Padova , Italy
| | - Teresa Del Ross
- a Department of Medicine - DIMED, Division of Rheumatology , University of Padova , Padova , Italy
| | - Antonia Calligaro
- a Department of Medicine - DIMED, Division of Rheumatology , University of Padova , Padova , Italy
| | - Maria Favaro
- a Department of Medicine - DIMED, Division of Rheumatology , University of Padova , Padova , Italy
| | - Elisabetta Zanatta
- a Department of Medicine - DIMED, Division of Rheumatology , University of Padova , Padova , Italy
| | - Luca Iaccarino
- a Department of Medicine - DIMED, Division of Rheumatology , University of Padova , Padova , Italy
| | - Andrea Doria
- a Department of Medicine - DIMED, Division of Rheumatology , University of Padova , Padova , Italy
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Choi SS, Jang E, Oh YK, Jang K, Cho ML, Park SH, Youn J. Aged Sanroque Mice Spontaneously Develop Sjögren's Syndrome-like Disease. Immune Netw 2019; 19:e7. [PMID: 30838162 PMCID: PMC6399093 DOI: 10.4110/in.2019.19.e7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2018] [Revised: 01/28/2019] [Accepted: 01/29/2019] [Indexed: 12/16/2022] Open
Abstract
Sjögren's syndrome (SS) is a chronic inflammatory autoimmune disorder that affects mainly salivary and lacrimal glands, but its cause remains largely unknown. Clinical data indicating that SS occurs in a substantial proportion of patients with lupus points to common pathogenic mechanisms underlying the two diseases. To address this idea, we asked whether SS develops in the lupus-prone mouse strain sanroque (SAN). Owing to hyper-activation of follicular helper T (Tfh) cells, female SAN mice developed lupus-like symptoms at approximately 20 wk of age but there were no signs of SS at that time. However, symptoms typical of SS were evident at approximately 40 wk of age, as judged by reduced saliva flow rate, sialadenitis, and IgG deposits in the salivary glands. Increases in serum titers of SS-related autoantibodies and numbers of autoantibody-secreting cells in cervical lymph nodes (LNs) preceded the pathologic manifestations of SS and were accompanied by expansion of Tfh cells and their downstream effector cells. Thus, our results suggest that chronic dysregulation of Tfh cells in salivary gland-draining LNs is sufficient to drive the development of SS in lupus-prone mice.
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Affiliation(s)
- Suk San Choi
- Laboratory of Autoimmunology, Department of Anatomy and Cell Biology, Hanyang University College of Medicine, Seoul 04763, Korea
| | - Eunkyeong Jang
- Laboratory of Autoimmunology, Department of Anatomy and Cell Biology, Hanyang University College of Medicine, Seoul 04763, Korea
| | - Yeon-Kyung Oh
- Laboratory of Autoimmunology, Department of Anatomy and Cell Biology, Hanyang University College of Medicine, Seoul 04763, Korea
| | - Kiseok Jang
- Department of Pathology, Hanyang University College of Medicine, Seoul 04763, Korea
| | - Mi-La Cho
- Department of Medical Life Science, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea
| | - Sung-Hwan Park
- Division of Rheumatology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea
| | - Jeehee Youn
- Laboratory of Autoimmunology, Department of Anatomy and Cell Biology, Hanyang University College of Medicine, Seoul 04763, Korea
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Karachalios C, Bakas P, Beta A, Deligeoroglou E. Postpartum nephrotic syndrome related to new onset of systemic lupus erythematosus: A case report. Case Rep Womens Health 2018; 20:e00083. [PMID: 30425933 PMCID: PMC6222280 DOI: 10.1016/j.crwh.2018.e00083] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 10/11/2018] [Accepted: 10/15/2018] [Indexed: 12/13/2022] Open
Abstract
Postpartum nephrotic syndrome in a pregnant woman with rheumatoid arthritis in long-standing remission is rare. Systemic lupus erythematosus can remain undiagnosed, especially in the absence of clinical manifestations. We present the case of a 34-year-old woman (gravida 2, para 1) who underwent a lower-segment cesarean section at 34 weeks and 6 days of gestation because she had developed preeclampsia and nephrotic syndrome. The concomitant presence of significant hypoproteinemia, hypoalbuminemia, uremia, elevated creatinine serum levels, hyperuricemia and hypertriglyceridemia is indicative of impaired renal function and nephrotic syndrome. This woman was diagnosed with systemic lupus erythematosus nephritis. It is imperative for clinicians to investigate the exact pathophysiological causes of nephrotic syndrome with onset in the puerperium and implement the appropriate therapeutic regimens. New onset of systemic lupus erythematosus rarely leads to postpartum nephrotic syndrome in women with rheumatoid arthritis. Lupus flares can also occur in the puerperium and often involve renal function.
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Affiliation(s)
- Charalampos Karachalios
- Second Department of Obstetrics and Gynecology, Aretaieio University Hospital, Vasilissis Sofias 76, Greece
| | - Panagiotis Bakas
- Second Department of Obstetrics and Gynecology, Aretaieio University Hospital, Vasilissis Sofias 76, Greece
| | - Anastasia Beta
- Second Department of Obstetrics and Gynecology, Aretaieio University Hospital, Vasilissis Sofias 76, Greece
| | - Efthimios Deligeoroglou
- Second Department of Obstetrics and Gynecology, Aretaieio University Hospital, Vasilissis Sofias 76, Greece
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Pulmonary Systemic Lupus Erythematosus Mimicking a Pneumonia in a Postpartum Female. Case Rep Rheumatol 2018; 2018:5379192. [PMID: 30140480 PMCID: PMC6081512 DOI: 10.1155/2018/5379192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 07/10/2018] [Indexed: 11/18/2022] Open
Abstract
The pulmonary manifestations of systemic lupus erythematosus can range in severity from mild to life threatening and can be particularly marked in women who are recently postpartum. We present below a seventeen-year-old female patient, one month postpartum, who had findings consistent with an acute infectious pneumonia whom upon further query and passage of time was diagnosed with severe pneumonitis due to systemic lupus erythematosus.
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Moroni G, Ponticelli C. Important considerations in pregnant patients with lupus nephritis. Expert Rev Clin Immunol 2018; 14:489-498. [PMID: 29764231 DOI: 10.1080/1744666x.2018.1476139] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
INTRODUCTION In the last few decades, identification of predictors of pregnancy outcome and appropriate pregnancy planning have significantly reduced the maternal and fetal risks in pregnant women with lupus nephritis. Areas covered: Successful pregnancies have been reported even in women with chronic renal disease and renal insufficiency. However, refractory hypertension and severe renal or cardiac chronic dysfunction are still considered contraindications to pregnancy. Pre-term delivery and fetal growth restriction may still occur in SLE patients more frequently than in healthy women, even in pregnancies regularly planned and monitored by a team of nephrologists and gynaecologists. Expert commentary: Stable disease remission is the most important factor for a successful pregnancy. In case of flare-ups of lupus, timely diagnosis and appropriate management may ensure a successful outcome in the majority of pregnant women. The negative role of anti-phospholipid antibodies and of chronic arterial hypertension may be countered with appropriate anticoagulation and anti-hypertensive therapy. Further studies are needed to better assess the possible impact of pregnancy on the long-term outcome of lupus nephritis.
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Affiliation(s)
- Gabriella Moroni
- a Nephrology Unit , Fondazione Ca' Granda IRCCS Ospdale Maggiore Policlinico Milano , Milano , Italy
| | - Claudio Ponticelli
- a Nephrology Unit , Fondazione Ca' Granda IRCCS Ospdale Maggiore Policlinico Milano , Milano , Italy
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Non-obstetrical indications for cesarean section: a state-of-the-art review. Arch Gynecol Obstet 2018; 298:9-16. [DOI: 10.1007/s00404-018-4742-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Accepted: 03/04/2018] [Indexed: 01/31/2023]
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