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Di Ludovico A, Rinaldi M, Mainieri F, Di Michele S, Girlando V, Ciarelli F, La Bella S, Chiarelli F, Attanasi M, Mauro A, Bizzi E, Brucato A, Breda L. Molecular Mechanisms of Fetal and Neonatal Lupus: A Narrative Review of an Autoimmune Disease Transferal across the Placenta. Int J Mol Sci 2024; 25:5224. [PMID: 38791261 PMCID: PMC11120786 DOI: 10.3390/ijms25105224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Revised: 05/01/2024] [Accepted: 05/08/2024] [Indexed: 05/26/2024] Open
Abstract
This study, conducted by searching keywords such as "maternal lupus", "neonatal lupus", and "congenital heart block" in databases including PubMed and Scopus, provides a detailed narrative review on fetal and neonatal lupus. Autoantibodies like anti-Ro/SSA and anti-La/SSB may cross the placenta and cause complications in neonates, such as congenital heart block (CHB). Management options involve hydroxychloroquine, which is able to counteract some of the adverse events, although the drug needs to be used carefully because of its impact on the QTc interval. Advanced pacing strategies for neonates with CHB, especially in severe forms like hydrops, are also assessed. This review emphasizes the need for interdisciplinary care by rheumatologists, obstetricians, and pediatricians in order to achieve the best maternal and neonatal health in lupus pregnancies. This multidisciplinary approach seeks to improve the outcomes and management of the disease, decreasing the burden on mothers and their infants.
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Affiliation(s)
- Armando Di Ludovico
- Paediatric Department, University of Chieti “G. D’Annunzio”, 66100 Chieti, Italy; (A.D.L.); (F.M.); (V.G.); (F.C.); (S.L.B.); (F.C.); (M.A.)
| | - Marta Rinaldi
- Paediatric Department, Buckinghamshire Healthcare NHS Trust, Aylesbury-Thames Valley Deanery, Aylesbury HP21 8AL, UK;
| | - Francesca Mainieri
- Paediatric Department, University of Chieti “G. D’Annunzio”, 66100 Chieti, Italy; (A.D.L.); (F.M.); (V.G.); (F.C.); (S.L.B.); (F.C.); (M.A.)
| | - Stefano Di Michele
- Department of Surgical Science, Division of Obstetrics and Gynecology, University of Cagliari, Cittadella Universitaria Blocco I, Asse didattico Medicina P2, Monserrato, 09042 Cagliari, Italy;
| | - Virginia Girlando
- Paediatric Department, University of Chieti “G. D’Annunzio”, 66100 Chieti, Italy; (A.D.L.); (F.M.); (V.G.); (F.C.); (S.L.B.); (F.C.); (M.A.)
| | - Francesca Ciarelli
- Paediatric Department, University of Chieti “G. D’Annunzio”, 66100 Chieti, Italy; (A.D.L.); (F.M.); (V.G.); (F.C.); (S.L.B.); (F.C.); (M.A.)
| | - Saverio La Bella
- Paediatric Department, University of Chieti “G. D’Annunzio”, 66100 Chieti, Italy; (A.D.L.); (F.M.); (V.G.); (F.C.); (S.L.B.); (F.C.); (M.A.)
| | - Francesco Chiarelli
- Paediatric Department, University of Chieti “G. D’Annunzio”, 66100 Chieti, Italy; (A.D.L.); (F.M.); (V.G.); (F.C.); (S.L.B.); (F.C.); (M.A.)
| | - Marina Attanasi
- Paediatric Department, University of Chieti “G. D’Annunzio”, 66100 Chieti, Italy; (A.D.L.); (F.M.); (V.G.); (F.C.); (S.L.B.); (F.C.); (M.A.)
| | - Angela Mauro
- Pediatric Rheumatology Unit, Department of Childhood and Developmental Medicine, Fatebenefratelli—Sacco Hospital, Piazzale Principessa Clotilde, 20121 Milan, Italy
| | - Emanuele Bizzi
- Division of Internal Medicine, ASST Fatebenefratelli Sacco, Fatebenefratelli Hospital, University of Milan, 20121 Milan, Italy; (E.B.); (A.B.)
| | - Antonio Brucato
- Division of Internal Medicine, ASST Fatebenefratelli Sacco, Fatebenefratelli Hospital, University of Milan, 20121 Milan, Italy; (E.B.); (A.B.)
- Department of Biomedical and Clinical Sciences “Sacco”, University of Milano, Ospedale Fatebenefratelli, 20121 Milan, Italy
| | - Luciana Breda
- Paediatric Department, University of Chieti “G. D’Annunzio”, 66100 Chieti, Italy; (A.D.L.); (F.M.); (V.G.); (F.C.); (S.L.B.); (F.C.); (M.A.)
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Duman D, Tunca Sahin G, Stuart G, Walsh M, Caputo M, Parry A, Beattie B, Conner C, Uzun O. Influence of improved antenatal detection on the outcomes of complete atrioventricular block diagnosed in fetal-neonatal life and childhood periods - a single-centre experience in South Wales for 55 years. Cardiol Young 2024; 34:412-420. [PMID: 38149337 DOI: 10.1017/s1047951123003967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2023]
Abstract
OBJECTIVE This study aimed to analyse the influence of improved antenatal detection on the course, contemporary outcomes, and mortality risk factors of the complete atrioventricular block during fetal-neonatal and childhood periods in South Wales. METHODS The clinical characteristics and outcomes of complete atrioventricular block in patients without structural heart disease at the University Hospital of Wales from January 1966 to April 2021 were studied. Patients were divided into two groups according to their age at diagnosis: I-fetal-neonatal and II-childhood. Contemporary outcomes during the post-2001 era were compared with historical data preceding fetal service development and hence earlier detection. RESULTS There were 64 patients: 26 were identified in the fetal-neonatal period and the remaining 38 in the childhood period. Maternal antibodies/systemic lupus erythematosus disease (anti-Ro/Sjögren's-syndrome-related Antigen A and/or anti-La/Sjögren's-syndrome-related Antigen B) were present in 15 (57.7%) of the fetal-neonatal. Fetal/neonatal and early diagnosis increased after 2001 with an incidence of 1:25000 pregnancies. Pacemaker implantation was required in 34 patients, of whom 13 were diagnosed in the fetal-neonatal group. Survival rates in cases identified before 2001 were at 96.3% (26/27), whereas it was 83.8% (31/37) in patients diagnosed after 2001 (P > 0.05). Other mortality risk factors comprised a lower gestational week at birth, maternal antibodies, and an average ventricular heart rate of < 55 bpm. CONCLUSIONS Fetal diagnosis of complete atrioventricular block is still portends high fetal and neonatal mortality and morbidity despite significantly improved antenatal detection after 2001. Pacemaker intervention is needed earlier in the fetal-neonatal group. Whether routine antenatal medical treatment might alter this outcome calls for further prospective multicentre studies.
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Affiliation(s)
| | | | | | - Mark Walsh
- Bristol Royal Children's Hospital, Bristol, UK
| | | | | | | | | | - Orhan Uzun
- University Hospital of Wales, Cardiff, UK
- Cardiff University, School of Medicine, Cardiff, UK
- Swansea University, School of Engineering and Sport Sciences, Swansea, UK
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Mawad W, Hornberger L, Cuneo B, Raboisson MJ, Moon-Grady AJ, Lougheed J, Diab K, Parkman J, Silverman E, Jaeggi E. Outcome of Antibody-Mediated Fetal Heart Disease With Standardized Anti-Inflammatory Transplacental Treatment. J Am Heart Assoc 2022; 11:e023000. [PMID: 35001672 PMCID: PMC9238501 DOI: 10.1161/jaha.121.023000] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Background Transplacental fetal treatment of immune-mediated fetal heart disease, including third-degree atrioventricular block (AVB III) and endocardial fibroelastosis, is controversial. Methods and Results To study the impact of routine transplacental fetal treatment, we reviewed 130 consecutive cases, including 108 with AVB III and 22 with other diagnoses (first-degree/second-degree atrioventricular block [n=10]; isolated endocardial fibroelastosis [n=9]; atrial bradycardia [n=3]). Dexamethasone was started at a median of 22.4 gestational weeks. Additional treatment for AVB III included the use of a β-agonist (n=47) and intravenous immune globulin (n=34). Fetal, neonatal, and 1-year survival rates with AVB III were 95%, 93%, and 89%, respectively. Variables present at diagnosis that were associated with perinatal death included an atrial rate <90 beats per minute (odds ratio [OR], 258.4; 95% CI, 11.5-5798.9; P<0.001), endocardial fibroelastosis (OR, 28.9; 95% CI, 1.6-521.7; P<0.001), fetal hydrops (OR, 25.5; 95% CI, 4.4-145.3; P<0.001), ventricular dysfunction (OR, 7.6; 95% CI, 1.5-39.4; P=0.03), and a ventricular rate <45 beats per minute (OR, 12.9; 95% CI, 1.75-95.8; P=0.034). At a median follow-up of 5.9 years, 85 of 100 neonatal survivors were paced, and 1 required a heart transplant for dilated cardiomyopathy. Cotreatment with intravenous immune globulin was used in 16 of 22 fetuses with diagnoses other than AVB III. Neonatal and 1-year survival rates of this cohort were 100% and 95%, respectively. At a median age of 3.1 years, 5 of 21 children were paced, and all had normal ventricular function. Conclusions Our findings reveal a low risk of perinatal mortality and postnatal cardiomyopathy in fetuses that received transplacental dexamethasone±other treatment from the time of a new diagnosis of immune-mediated heart disease.
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Affiliation(s)
- Wadi Mawad
- The Hospital for Sick Children Toronto Ontario Canada
| | - Lisa Hornberger
- Stollery Children's Hospital University of Alberta Edmonton Alberta Canada
| | | | | | | | - Jane Lougheed
- Children's Hospital of Eastern Ontario Ottawa Ontario Canada
| | - Karim Diab
- Rush University Medical Center Chicago IL
| | - Julia Parkman
- Stollery Children's Hospital University of Alberta Edmonton Alberta Canada
| | | | - Edgar Jaeggi
- The Hospital for Sick Children Toronto Ontario Canada
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Milazzo R, Ligato E, Laoreti A, Ferri G, Basili L, Serati L, Brucato A, Cetin I. Home fetal heart rate monitoring in anti Ro/SSA positive pregnancies: Literature review and case report. Eur J Obstet Gynecol Reprod Biol 2021; 259:1-6. [PMID: 33556767 DOI: 10.1016/j.ejogrb.2021.01.031] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 01/18/2021] [Indexed: 10/22/2022]
Abstract
Anti-Ro/SSA antibodies are associated with a risk of 1-2 % to develop complete atrioventricular block (AVB) in fetuses of positive mothers. Complete AVB is irreversible, but studies suggest that anti-inflammatory treatment during the transition period from a normal fetal heart rate (FHR) to an AVB might stop this progression and restore sinus rhythm. The most efficient method for diagnostic evaluation of this arrhythmia is the pulsed-Doppler fetal echocardiography. However, weekly or bi-weekly recommended fetal echocardiographic surveillance can rarely identify an AVB in time for treatment success, also because the transition from a normal rhythm to a third degree AVB is very fast. Daily FHR monitoring in a medical facility could increase the chances of identifying the AVB onset but is difficult to realize. For this reason, an alternative method of FHR monitoring, performed directly by mothers in their home context, has been recently proposed. We present a case report utilizing this approach and review the current evidence about this condition.
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Affiliation(s)
- Roberta Milazzo
- Department of Woman, Mother and Neonate, "V. Buzzi" Children Hospital, ASST Fatebenefratelli Sacco, Milan, Italy.
| | - Elisa Ligato
- Department of Woman, Mother and Neonate, "V. Buzzi" Children Hospital, ASST Fatebenefratelli Sacco, Milan, Italy
| | - Arianna Laoreti
- Department of Woman, Mother and Neonate, "V. Buzzi" Children Hospital, ASST Fatebenefratelli Sacco, Milan, Italy
| | - Giulia Ferri
- Department of Woman, Mother and Neonate, "V. Buzzi" Children Hospital, ASST Fatebenefratelli Sacco, Milan, Italy
| | - Ludovica Basili
- Department of Woman, Mother and Neonate, "V. Buzzi" Children Hospital, ASST Fatebenefratelli Sacco, Milan, Italy
| | - Lisa Serati
- Internal Medicine, Fatebenefratelli Hospital, Milan, Italy
| | | | - Irene Cetin
- Department of Woman, Mother and Neonate, "V. Buzzi" Children Hospital, ASST Fatebenefratelli Sacco, Milan, Italy; Department of Biomedical and Clinical Sciences "Luigi Sacco", University of Milan, Milan, Italy
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5
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Huo HH, Wei YJ, Qi YH, Liu BM. Isolated anti-Ro/La antibody-negative fetal complete atrioventricular block: a case report. Chin Med J (Engl) 2020; 133:97-98. [PMID: 31923112 PMCID: PMC7028199 DOI: 10.1097/cm9.0000000000000581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Indexed: 11/26/2022] Open
Affiliation(s)
- Huan-Huan Huo
- Department of Ultrasound, the Second Affiliated Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi 710004, China
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Fredi M, Andreoli L, Bacco B, Bertero T, Bortoluzzi A, Breda S, Cappa V, Ceccarelli F, Cimaz R, De Vita S, Di Poi E, Elefante E, Franceschini F, Gerosa M, Govoni M, Hoxha A, Lojacono A, Marozio L, Mathieu A, Meroni PL, Minniti A, Mosca M, Muscarà M, Padovan M, Piga M, Priori R, Ramoni V, Ruffatti A, Tani C, Tonello M, Trespidi L, Zatti S, Calza S, Tincani A, Brucato A. First Report of the Italian Registry on Immune-Mediated Congenital Heart Block (Lu.Ne Registry). Front Cardiovasc Med 2019; 6:11. [PMID: 30873413 PMCID: PMC6404544 DOI: 10.3389/fcvm.2019.00011] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 01/31/2019] [Indexed: 12/12/2022] Open
Abstract
Objective: Neonatal Lupus (NL) is a rare syndrome caused by placental transfer of maternal anti-SSA/Ro and anti-La/SSB autoantibodies to the fetus. The rarity of this condition requires the establishment of multidisciplinary registries in order to improve our knowledge. Method: Inclusion criteria in this retrospective study were the maternal confirmed positivity for anti-SSA/Ro and/or anti-SSB/La antibodies, and the presence of II or III degree congenital heart block (CHB) in utero or neonatal period (up to 27 days after birth). Result: Eighty-nine cases of CHB were observed in 85 women with 88 pregnancies that occurred between 1969 and 2017. CHB was mostly detected in utero (84 cases, 94.2%), while five cases were observed in the neonatal period. A permanent pacemaker was implanted in 51 of 73 children born alive (69.8), whereas global mortality rate was 25.8% (23 cases): 16 in utero, five perinatal, and two during childhood. By univariate analysis, factors associated with fetal death were pleural effusion (p = 0.005, OR > 100; CI 95% 2.88->100 and hydrops (p = 0.003, OR = 14.09; CI 95% 2.01–122). Fluorinated steroids (FS) were administered in 71.4% pregnancies, and its use was not associated with better survival. Some centers treated all cases with fluorinated steroids and some centers did not treat any case. CHB was initially incomplete in 24 fetuses, and of them five cases of II degree block reverted to a lower degree block after treatments. Recurrence rate in subsequent pregnancies was 17.6% (3 out of 17). A prophylactic treatment was introduced in 10 of these 16 subsequent (58.8%) pregnancies, mostly with FS or high dose intravenous immunoglobulins. Conclusion: This is the first report from the Italian Registry of neonatal lupus/CHB. The live birth rate was nearly 80%, with nearly two thirds of the children requiring the implantation of a pacemaker. The management of fetuses diagnosed with CHB was heterogeneous across Italian Centers. The registry at present is mainly rheumatological, but involvement of pediatric cardiologists and gynecologists is planned.
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Affiliation(s)
- Micaela Fredi
- Rheumatology and Clinical Immunology Unit, Department of Clinical and Experimental Science, ASST Spedali Civili, University of Brescia, Brescia, Italy
| | - Laura Andreoli
- Rheumatology and Clinical Immunology Unit, Department of Clinical and Experimental Science, ASST Spedali Civili, University of Brescia, Brescia, Italy
| | - Beatrice Bacco
- S.S.d.D.U. Immunologia, Allergologia, A.O. Ordine Maurziano di Torino, Torino, Italy
| | - Tiziana Bertero
- S.S.d.D.U. Immunologia, Allergologia, A.O. Ordine Maurziano di Torino, Torino, Italy
| | - Alessandra Bortoluzzi
- UO e Sezione di Reumatologia, Dipartimento di Scienze Mediche, Universita' degli Studi di Ferrara, Cona, Italy
| | - Silvia Breda
- Struttura Complessa Medicina Interna, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Veronica Cappa
- Unit of Biostatistics, Biomathematics, and Bioinformatics, Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | - Fulvia Ceccarelli
- UO Complessa Reumatologia, Policlinico Umberto I- University La Sapienza, Rome, Italy
| | - Rolando Cimaz
- Anna Meyer Children's Hospital, University of Firenze, Firenze, Italy
| | - Salvatore De Vita
- Clinica di Reumatologia, Azienda Sanitaria Universitaria Integrata di Udine, Udine, Italy
| | - Emma Di Poi
- Clinica di Reumatologia, Azienda Sanitaria Universitaria Integrata di Udine, Udine, Italy
| | - Elena Elefante
- UO Reumatologia, Dipartimento di Medicina Clinica e Sperimentale, Universita' di Pisa, Pisa, Italy
| | - Franco Franceschini
- Rheumatology and Clinical Immunology Unit, Department of Clinical and Experimental Science, ASST Spedali Civili, University of Brescia, Brescia, Italy
| | - Maria Gerosa
- Istituto Ortopedico Gaetano Pini, University of Milan, Milan, Italy
| | - Marcello Govoni
- UO e Sezione di Reumatologia, Dipartimento di Scienze Mediche, Universita' degli Studi di Ferrara, Cona, Italy
| | - Ariela Hoxha
- Unità di Reumatologia, Dipartimento di Medicina, Università di Padova, Padova, Italy
| | - Andrea Lojacono
- Department of Obstetrics and Gynecology, ASST Spedali Civili and University, Brescia, Italy
| | - Luca Marozio
- Ginecologia e Ostetricia 1, Dipartimento di Scienze Chirurgiche, Università di Torino, Turin, Italy
| | - Alessandro Mathieu
- Cattedra e Struttura Complessa di Reumatologia, Universita' degli Studi e AOU di Cagliari, Cagliari, Italy
| | - Pier Luigi Meroni
- Immunorheumatology Research Laboratory, Istituto Auxologico Italiano, Milan, Italy
| | - Antonina Minniti
- UO Complessa Reumatologia, Policlinico Umberto I- University La Sapienza, Rome, Italy
| | - Marta Mosca
- UO Reumatologia, Dipartimento di Medicina Clinica e Sperimentale, Universita' di Pisa, Pisa, Italy
| | | | - Melissa Padovan
- UO e Sezione di Reumatologia, Dipartimento di Scienze Mediche, Universita' degli Studi di Ferrara, Cona, Italy
| | - Matteo Piga
- Cattedra e Struttura Complessa di Reumatologia, Universita' degli Studi e AOU di Cagliari, Cagliari, Italy
| | - Roberta Priori
- UO Complessa Reumatologia, Policlinico Umberto I- University La Sapienza, Rome, Italy
| | - Véronique Ramoni
- Rheumatology, IRCCS Policlinico San Matteo Foundation, University of Pavia, Padova, Italy
| | - Amelia Ruffatti
- Unità di Reumatologia, Dipartimento di Medicina, Università di Padova, Padova, Italy
| | - Chiara Tani
- UO Reumatologia, Dipartimento di Medicina Clinica e Sperimentale, Universita' di Pisa, Pisa, Italy
| | - Marta Tonello
- Unità di Reumatologia, Dipartimento di Medicina, Università di Padova, Padova, Italy
| | - Laura Trespidi
- Dipartimento per la Salute della Donna, Bambino e Neonato, Fondazione Ospedale Maggiore, Milan, Italy
| | - Sonia Zatti
- Department of Obstetrics and Gynecology, ASST Spedali Civili and University, Brescia, Italy
| | - Stefano Calza
- Unit of Biostatistics, Biomathematics, and Bioinformatics, Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | - Angela Tincani
- Rheumatology and Clinical Immunology Unit, Department of Clinical and Experimental Science, ASST Spedali Civili, University of Brescia, Brescia, Italy
| | - Antonio Brucato
- Struttura Complessa Medicina Interna, ASST Papa Giovanni XXIII, Bergamo, Italy.,Dipartimento di Scienze Biomediche e Cliniche "Sacco", Università degli Studi di Milano, Milan, Italy
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Kasar T, Saygı M, Özyılmaz İ, Ergül Y. Spontaneous Remission of Congenital Complete Atrioventricular Block in Anti-Ro/La Antibody-Negative Monozygotic Twins: Case Report. Balkan Med J 2017; 34:71-73. [PMID: 28251027 PMCID: PMC5322508 DOI: 10.4274/balkanmedj.2015.0535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Accepted: 12/30/2015] [Indexed: 12/01/2022] Open
Abstract
Background: Congenital complete atrioventricular block without any structural heart disease and anti-Ro/La negativity is very rare. Discordant complete atrioventricular block, which is more frequently defined in the literature as an autoimmune mechanism, is much more rare in monozygotic twins. Case Report: The 26-year-old healthy mother had given birth in her first spontaneous, uneventful pregnancy to monozygotic twins at week 35. While the first twin’s physical examination proved her to be normal with a pulse rate consistent with her age, the second twin had a pulse rate of approximately 40 beats/minute.The patient was confirmed to have congenital complete atrioventricular block. Conclusion: Despite this case appears to be an isolated one, a discordant complete atrioventricular block regression without any autoimmune evidence should be included in the differential diagnosis of bradycardia in infants.
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Affiliation(s)
- Taner Kasar
- Department of Pediatric Cardiology, İstanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Center and Research Hospital, İstanbul, Turkey
| | - Murat Saygı
- Department of Pediatric Cardiology, İstanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Center and Research Hospital, İstanbul, Turkey
| | - İsa Özyılmaz
- Department of Pediatric Cardiology, İstanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Center and Research Hospital, İstanbul, Turkey
| | - Yakup Ergül
- Department of Pediatric Cardiology, İstanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Center and Research Hospital, İstanbul, Turkey
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8
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Brito-Zerón P, Izmirly PM, Ramos-Casals M, Buyon JP, Khamashta MA. Autoimmune congenital heart block: complex and unusual situations. Lupus 2016; 25:116-28. [PMID: 26762645 DOI: 10.1177/0961203315624024] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Autoimmune congenital heart block (ACHB) is an immune-mediated cardiac disease included among the manifestations collectively referred to as neonatal lupus. The placental transference of maternal Ro/La autoantibodies may damage the conduction tissues during fetal development leading to blocking of signal conduction at the atrioventricular (AV) node in an otherwise structurally normal heart. Irreversible complete AV block is the main cardiac manifestation of ACHB, but some babies may develop endocardial fibroelastosis, valvular insufficiency, and/or frank cardiomyopathies with significantly reduced cardiac function requiring transplant. The severity of ACHB is illustrated by a global mortality rate of 20% and pacemaker rates of at least 64%, often within the first year of life. This review analyses the main complex and/or unusual clinical situations associated with ACHB, including unusual maternal immunological profiles, infrequent maternal autoimmune diseases, cardiac damage unrelated to AV block, fetal invasive management, late complications after birth, risk of congenital heart block (CHB) in ovodonation and in vitro fertilization techniques, the role of maternal features other than autoimmunity, the influence of the birth order or the risk of CHB in twins and triplets.
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Affiliation(s)
- P Brito-Zerón
- Josep Font Laboratory of Autoimmune Diseases, Department of Autoimmune Diseases, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - P M Izmirly
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York, USA
| | - M Ramos-Casals
- Josep Font Laboratory of Autoimmune Diseases, Department of Autoimmune Diseases, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - J P Buyon
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York, USA
| | - M A Khamashta
- Graham Hughes Lupus Research Laboratory, The Rayne Institute, Division of Women's Health, Kings College London St Thomas Hospital, United Kingdom
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9
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Madhusudan D, Raju A, Vijaya N. Correlation of Maternal Autoantibodies with Fetal Congenital Heart Block. J Obstet Gynaecol India 2015; 66:112-6. [PMID: 27651588 DOI: 10.1007/s13224-015-0813-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Accepted: 10/29/2015] [Indexed: 10/22/2022] Open
Abstract
BACKGROUND Autoimmune fetal congenital heart block (CHB) is the most severe manifestation of neonatal lupus, and it is seen when maternal autoimmune antibodies cross the placenta and damage the AV node of the fetus. CHB is mainly associated with maternal SLE with anti-Ro/SSA- and anti-La/SSB-positive status, and incidence of CHB increases when both the antibodies are present. This study was conducted to know the incidence of fetal CHB in patients of SLE who had ANA, anti-Ro/SSA and anti-La/SSB positivity. METHODS A prospective study was conducted in a tertiary-care teaching hospital of Indian Armed Forces between Jan 2012 to Sep 2014 where 13 cases of SLE were studied. All these patients were tested for ANA, anti-Ro/SSA and anti-La/SSB antibodies and fetal heart abnormalities. Fetuses with CHB were treated with steroids. RESULTS Incidence of SLE was 0.14 %, 92 % of SLE patients were positive for ANA, and 46 % had anti-Ro/SSA- and anti-La/SSB-positive status. Two fetuses had congenital heart block, and one fetus required pacemaker placement 5 months after delivery. CONCLUSION All the fetal congenital heart blocks are associated with maternal anti-Ro/SSA and anti-La/SSB and ANA antibodies. Treatment by steroids may improve the outcome in early stages of fetal CHB, and delivery with follow-up should be planned in a tertiary-care center where pacemaker placement facility is available.
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Affiliation(s)
- Dey Madhusudan
- Department of Obstetrics and Gynecology, Armed Forces Medical College, Pune, 411040 India
| | - Agarwal Raju
- Department of Obstetrics and Gynecology, Armed Forces Medical College, Pune, 411040 India
| | - Nambula Vijaya
- Department of Obstetrics and Gynecology, Armed Forces Medical College, Pune, 411040 India
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Ruffatti A, Favaro M, Brucato A, Ramoni V, Facchinetti M, Tonello M, Del Ross T, Calligaro A, Hoxha A, Grava C, De Silvestro G. Apheresis in high risk antiphospholipid syndrome pregnancy and autoimmune congenital heart block. Transfus Apher Sci 2015; 53:269-78. [DOI: 10.1016/j.transci.2015.11.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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11
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Abstract
Autoimmune congenital heart block (CHB) is an immune-mediated acquired disease that is associated with the placental transference of maternal antibodies specific for Ro and La autoantigens. The disease develops in a fetal heart without anatomical abnormalities that could otherwise explain the block, and which is usually diagnosed in utero, but also at birth or within the neonatal period. Autoantibody-mediated damage of fetal conduction tissues causes inflammation and fibrosis and leads to blockage of signal conduction at the atrioventricular (AV) node. Irreversible complete AV block is the principal cardiac manifestation of CHB, although some babies might develop other severe cardiac complications, such as endocardial fibroelastosis or valvular insufficiency, even in the absence of cardiac block. In this Review, we discuss the epidemiology, classification and management of women whose pregnancies are affected by autoimmune CHB, with a particular focus on the autoantibodies associated with autoimmune CHB and how we should test for these antibodies and diagnose this disease. Without confirmed effective preventive or therapeutic strategies and further research on the aetiopathogenic mechanisms, autoimmune CHB will remain a severe life-threatening disorder.
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12
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Johnson B. Overview of neonatal lupus. J Pediatr Health Care 2014; 28:331-41. [PMID: 24100008 DOI: 10.1016/j.pedhc.2013.07.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2012] [Revised: 07/02/2013] [Accepted: 07/17/2013] [Indexed: 11/26/2022]
Abstract
Neonatal lupus (NL) is defined by the presentation of the fetus and the newborn who possess autoantibodies received from the mother. It is the dysfunction of the maternal immune system that leads to the production of autoantibodies to anti-Sjögren syndrome-A, anti-Sjögren syndrome-B, and anti-ribonuclear protein antigens. These antibodies are shared through the placenta and produce bodily changes in the fetal skin and heart, as well as potential changes in other body systems. Congenital complete heart block is the most dangerous manifestation of NL that can occur in utero or after birth. This article will provide an overview the presentation of NL and current therapies. Prenatal steroids have been the mainstay of therapy to try to reverse first- and second-degree congenital heart block and to prevent progression to a more advanced stage. New therapies are combining steroids with intravenous immunoglobulin and plasmapheresis. This article will provide guidelines for practitioners so they can consider NL as a differential diagnosis when presented with cutaneous lesions, congenital heart block, or abnormal findings in the hematologic, hepatobiliary, neurologic, and musculoskeletal systems.
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Abstract
Pregnancy poses an important challenge for doctors looking after women with systemic lupus erythematosus. Knowledge about safety of medications, the effect of pregnancy on such disease, and vice versa, together with multidisciplinary team care, are basic cornerstones needed to provide the best obstetric and medical care to these women. Pre-conceptional counselling constitutes the ideal scenario where a patient's previous obstetric history, organ damage, disease activity, serological profile and additional medical history can be summarized. Important issues regarding medication adjustment, planned scans and visits, and main risks discussion should also be raised at this stage. Planned pregnancies lead to better outcomes for both mothers and babies. Close surveillance throughout pregnancy and the puerperium, and tailored management approach guarantee the highest rates of successful pregnancies in these women.
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Affiliation(s)
- O Ateka-Barrutia
- Lupus Research Unit, Women's Health Division, King's College London, UK
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14
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Roy KK, Subbaiah M, Kumar S, Sharma JB, Singh N. Feto-maternal outcome in pregnancies complicated by isolated fetal congenital complete heart block. J OBSTET GYNAECOL 2014; 34:492-4. [PMID: 24830484 DOI: 10.3109/01443615.2014.914480] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
A retrospective analysis of eleven pregnancies complicated by isolated fetal congenital complete heart block (CCHB) in anti-SSA/Ro antibody positive women was carried out at a tertiary hospital in India to study the perinatal outcome. The mean gestational age at the time of detection of fetal CCHB was 24.5 ± 3.1weeks. Six mothers were asymptomatic; two had Sjögren's syndrome and three had systemic lupus erythematosus. Oral dexamethasone was given to all the patients after the diagnosis was made. There was one case of intrauterine death. Seven (63.6%) neonates needed a permanent pacemaker. There was no significant difference in the perinatal outcome in asymptomatic women with fetal CCHB and in women with connective tissue disorder and fetal CCHB. To conclude, fetal CCHB is associated with high morbidity but the presence of underlying connective disorder in the mother does not worsen the prognosis of the affected neonate.
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Affiliation(s)
- K K Roy
- Department of Obstetrics and Gynecology, All India Institute of Medical Sciences (AIIMS) , New Delhi , India
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15
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Mitra S, Saha AK, Sardar SK, Singh AK. Remission of congenital complete heart block without anti-Ro/La antibodies: A case report. Ann Pediatr Cardiol 2014; 6:182-4. [PMID: 24688242 PMCID: PMC3957454 DOI: 10.4103/0974-2069.115278] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Anti-Ro/La negative congenital heart block (CHB) is uncommon. We report one such case of CHB, with no associated structural heart disease or maternal autoantibodies. The heart block reverted to sinus rhythm spontaneously at two weeks of age, and the patient remains in sinus rhythm at a one year followup. Whether patients with antibody negative complete heart block have a different clinical course is conjectural.
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Affiliation(s)
- Souvik Mitra
- Department of Neonatology, Institute of Postgraduate Medical Education and Research, SSKM Hospital, Kolkata, West Bengal, India
| | - Anindya Kumar Saha
- Department of Neonatology, Institute of Postgraduate Medical Education and Research, SSKM Hospital, Kolkata, West Bengal, India
| | - Syamal Kumar Sardar
- Department of Neonatology, Institute of Postgraduate Medical Education and Research, SSKM Hospital, Kolkata, West Bengal, India
| | - Arun Kumarendu Singh
- Department of Neonatology, Institute of Postgraduate Medical Education and Research, SSKM Hospital, Kolkata, West Bengal, India
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16
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Costedoat-Chalumeau N, Izmirly P, Clancy R, Saxena A, Wahren-Herlenius M, Silverman E, Brucato A, Boutjdir M, Khamashta M, Llanos C, Pisoni CN, Friedman DM, Phoon CKL, Buyon JP. Letter to the Editor in response to the article "Preventing congenital neonatal heart block in offspring of mothers with anti-SSA/Ro and SSB/La antibodies: a review of published literature and registered clinical trials." by Gleicher N, Elkayam U, Autoimmun Rev. 2013 Sep;12(11):1039-45. Autoimmun Rev 2013; 13:70-2. [PMID: 24008147 DOI: 10.1016/j.autrev.2013.08.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2013] [Accepted: 08/02/2013] [Indexed: 12/29/2022]
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18
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Miyoshi T, Maeno Y, Sago H, Inamura N, Yasukohchi S, Kawataki M, Horigome H, Yoda H, Taketazu M, Shozu M, Nii M, Kato H, Hayashi S, Hagiwara A, Omoto A, Shimizu W, Shiraishi I, Sakaguchi H, Nishimura K, Ueda K, Katsuragi S, Ikeda T. Evaluation of Transplacental Treatment for Fetal Congenital Bradyarrhythmia. Circ J 2012; 76:469-76. [DOI: 10.1253/circj.cj-11-1020] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
| | | | | | - Noboru Inamura
- Osaka Medical Center and Research Institute for Maternal and Child Health
| | | | | | | | | | - Mio Taketazu
- Saitama Medical University International Medical Center
| | | | | | - Hitoshi Kato
- National Center for Child Health and Development
| | | | | | | | | | | | | | | | - Keiko Ueda
- National Cerebral and Cardiovascular Center
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19
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Brucato A, Cimaz R, Caporali R, Ramoni V, Buyon J. Pregnancy outcomes in patients with autoimmune diseases and anti-Ro/SSA antibodies. Clin Rev Allergy Immunol 2011; 40:27-41. [PMID: 20012231 DOI: 10.1007/s12016-009-8190-6] [Citation(s) in RCA: 114] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Anti-Ro/SSA antibodies are associated with neonatal lupus (congenital heart block (CHB), neonatal transient skin rash, hematological and hepatic abnormalities), but do not negatively affects other gestational outcomes, and the general outcome of these pregnancies is now good, when followed by experienced multidisciplinary teams. The prevalence of CHB, defined as an atrioventricular block diagnosed in utero, at birth, or within the neonatal period (0-27 days after birth), in the offspring of an anti-Ro/SSA-positive women is 1-2%, of neonatal lupus rash around 10-20%, while laboratory abnormalities in asymptomatic babies can be detected in up to 27% of cases. The risk of recurrence of CHB is ten times higher. Most of the mothers are asymptomatic at delivery and are identified only by the birth of an affected child. Half of these asymptomatic women develop symptoms of a rheumatic disease, most commonly arthralgias and xerophtalmia, but few develop lupus nephritis. A standard therapy for CHB is still matter of investigation, although fluorinated corticosteroids have been reported to be effective for associated cardiomyopathy. Serial echocardiograms and obstetric sonograms, performed at least every 1-2 weeks starting from the 16th week of gestational age, are recommended in anti-Ro/SSA-positive pregnant women to detect early fetal abnormalities that might be a target of preventive therapy.
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Affiliation(s)
- Antonio Brucato
- Internal Medicine, Ospedali Riuniti, Largo Barozzi, Bergamo, Italy.
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20
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Acherman RJ, Friedman DM, Buyon JP, Schwartz J, Castillo WJ, Rollins RC, Evans WN. Doppler fetal mechanical PR interval prolongation with positive maternal anti-RNP but negative SSA/Ro and SSB/La auto-antibodies. Prenat Diagn 2010; 30:797-9. [PMID: 20582918 DOI: 10.1002/pd.2544] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
MESH Headings
- Adult
- Antibodies, Antinuclear/blood
- Antibodies, Antinuclear/immunology
- Female
- Fetal Heart/diagnostic imaging
- Fetus
- Humans
- Infant, Newborn
- Lupus Erythematosus, Systemic/blood
- Lupus Erythematosus, Systemic/diagnostic imaging
- Lupus Erythematosus, Systemic/immunology
- Pregnancy
- Pregnancy Complications, Cardiovascular/blood
- Pregnancy Complications, Cardiovascular/diagnostic imaging
- Pregnancy Complications, Cardiovascular/immunology
- Ribonucleoproteins/blood
- Ribonucleoproteins/immunology
- Ultrasonography, Doppler
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21
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Abstract
Perfusion of human foetal heart with anti-Ro/SSA antibodies induces transient heart block. Anti-Ro/SSA antibodies may cross-react with T- and L-type calcium channels, and anti-p200 antibodies may cause calcium to accumulate in rat heart cells. These actions may explain a direct electrophysiological effect of these antibodies. Congenital complete heart block is the more severe manifestation of so-called "Neonatal Lupus". In clinical practice, it is important to distinguish in utero complete versus incomplete atrioventricular (AV) block, as complete AV block to date is irreversible, while incomplete AV block has been shown to be potentially reversible after fluorinated steroid therapy. Another issue is the definition of congenital AV block, as cardiologists have considered congenital blocks detected months or years after birth. We propose as congenital blocks detected in utero or within the neonatal period (0-27 days after birth). The possible detection of first degree AV block in utero, with different techniques, might be a promising tool to assess the effects of these antibodies. Other arrhythmias have been described in NL or have been linked to anti-Ro/SSA antibodies: first degree AV block, in utero and after birth, second degree (i.e. incomplete block), sinus bradycardia and QT prolongation, both in infants and in adults, ventricular arrhythmias (in adults). Overall, these arrhythmias have not a clinical relevance, but are important for research purposes.
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Affiliation(s)
- A Brucato
- Internal Medicine, Ospedali Riuniti, Bergamo, Italy.
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22
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Tunaoglu FS, Yildirim A, Vurali D. Isolated congenital heart block. Tex Heart Inst J 2010; 37:579-583. [PMID: 20978575 PMCID: PMC2953227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Isolated congenital heart block, frequently seen in mothers who have connective-tissue disease, can be transmitted to the fetus through transplacental passage of anti-Ro/SSA and anti-La/SSB autoantibodies. Even if the antibodies appear transiently in the fetal circulation, the block is permanent and can require pacemaker implantation. Complete congenital heart block is seen in 1% to 5% of neonates born to mothers who carry these autoantibodies. Herein, we report the case of a baby-born to a 31-year-old asymptomatic woman-who manifested congenital heart block in utero, at 30 weeks of gestation. During gestation and following birth, no further problems were detected. At her last follow-up appointment, 8 years later, the girl still had no clinical symptoms, and exercise increased her heart rate despite complete heart block. We report this case for its unique presentation, and we discuss isolated congenital heart block within the context of the inadequate literature on its pathogenesis and treatment.
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Affiliation(s)
- F Sedef Tunaoglu
- Department of Pediatric Cardiology, Gazi University Medical Faculty, 1060 Ankara, Turkey
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