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Wind M, Fierro JJ, Bloemenkamp KWM, de Leeuw K, Lely AT, Limper M, Sueters M, Teng YKO, Walter IJ, Kooiman J. Pregnancy outcome predictors in systemic lupus erythematosus: a systematic review and meta-analysis. THE LANCET. RHEUMATOLOGY 2024; 6:e667-e683. [PMID: 39153486 DOI: 10.1016/s2665-9913(24)00160-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Revised: 06/04/2024] [Accepted: 06/04/2024] [Indexed: 08/19/2024]
Abstract
BACKGROUND To enhance patient-tailored preconception risk assessment for women with systemic lupus erythematosus (SLE), knowledge on risk factors associated with adverse pregnancy outcomes is required. Therefore, we did a systematic review and meta-analysis to identify and provide unambiguous effect sizes of preconception predictors of pregnancy outcomes in women with SLE. METHODS In this systematic review and meta-analysis, we searched PubMed and Embase for studies reporting preconception predictors of pregnancy outcomes in women with SLE, from database inception to Aug 22, 2023. Studies were included if they presented original, quantitative data on pregnant women with SLE and reported on preconception risk factors on at least one of the outcomes as defined in the protocol. Studies were excluded if they had a sample size of less than 20 patients, were restricted to multiple pregnancies, had unclear timing of prognostication, or exclusively reported a composite outcome. Literature screening, data extraction, and risk-of-bias assessment (quality in prognostic studies tool) were done by two reviewers independently, in a blinded, standardised manner. The reported outcomes included livebirth, pre-eclampsia, small for gestational age, preterm birth, pregnancy loss before and after 20 weeks of gestation, and SLE flares. We computed pooled univariate odds ratios (ORs) and 95% CIs using a random effects model. We assessed heterogeneity using the I2 statistic and prediction intervals. This study is registered with PROSPERO, CRD42022344732. FINDINGS Of the 6705 unique articles identified, 72 (1·1%) were included in the meta-analysis, comprising 10 355 pregnancies in 8065 women with SLE. One potentially eligible study was retracted and therefore removed from our analysis. Previous lupus nephritis was associated with decreased livebirth probability (OR 0·62 [95% CI 0·47-0·81]; I2=0%), increased risk of preterm birth (2·00 [1·55-2·57]; I2=17%), and increased risk of pre-eclampsia (3·11 [2·35-4·12]; I2=0%). Chronic hypertension was associated with increased risk of disease flare (2·50 [1·74-3·58]; I2=0%), preterm birth (2·65 [1·87-3·77]; I2=0%), and pre-eclampsia (5·86 [3·41-10·06]; I2=33%). SLE disease activity at conception or preconception was associated with increased risk of preterm birth (2·91 [1·96-4·33]; I2=21%) and pre-eclampsia (2·32 [1·40-3·83]; I2=0%). Secondary antiphospholipid syndrome was associated with decreased livebirth probability (0·40 [0·27-0·58]; I2=0%), increased risk of pregnancy loss after 20 weeks of gestation (2·77 [1·44-5·31]; I2=0%), and increased risk of preterm birth (1·65 [1·29-2·11]; I2=0%). Across studies, risk-of-bias assessment suggested considerable bias in study attrition and confounding. INTERPRETATION We identified previous lupus nephritis, chronic hypertension, SLE disease activity before and at conception, and secondary antiphospholipid syndrome as predictors of adverse pregnancy outcomes in women with SLE. These findings contribute to an optimal patient-tailored risk assessment in preconception counselling. FUNDING None.
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Affiliation(s)
- Merlijn Wind
- Department of Obstetrics, Leiden, Netherlands; Leiden University Medical Centre, Leiden, Netherlands; Department of Obstetrics, Haaglanden Medical Centre, The Hague, Netherlands.
| | - Juan J Fierro
- Department of Rheumatology and Clinical Immunology, University Medical Centre Groningen, Groningen, Netherlands; Grupo Reproducción, Departamento de Microbiología y Parasitología, Universidad de Antioquia UdeA, Medellín, Colombia
| | | | - Karina de Leeuw
- Department of Rheumatology and Clinical Immunology, University Medical Centre Groningen, Groningen, Netherlands
| | - A Titia Lely
- Department of Obstetrics, Utrecht, the Netherlands
| | - Maarten Limper
- Department of Rheumatology and Clinical Immunology, Utrecht, the Netherlands
| | | | | | | | - Judith Kooiman
- Department of Obstetrics, Utrecht, the Netherlands; University Medical Centre Utrecht, Utrecht, the Netherlands; Department of Obstetrics, Erasmus Medical Center, Rotterdam, Netherlands
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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; 43:2911-2917. [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] [MESH Headings] [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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Huang J, Zhu Q, Wang B, Wang H, Xie Z, Zhu X, Zhao T, Yang Z. Antiphospholipid antibodies and the risk of adverse pregnancy outcomes in patients with systemic lupus erythematosus: a systematic review and meta-analysis. Expert Rev Clin Immunol 2024; 20:793-801. [PMID: 38445835 DOI: 10.1080/1744666x.2024.2324005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 02/12/2024] [Indexed: 03/07/2024]
Abstract
OBJECTIVE This article aims to evaluate the magnitude of adverse pregnancy outcomes (APOs) risks associated with different antiphospholipid antibody (aPL) profiles in women with systemic lupus erythematosus (SLE). METHODS Multiple databases were investigated to identify articles that explored the relationship between aPLs and APOs in SLE patients. A random effects model was used for calculating pooled odds ratios (OR). Stata version 15.0 was utilized to conduct the meta-analysis. RESULTS There were 5234 patients involved in 30 studies. Overall aPL was linked to an increased incidence of any kind of APOs, fetal loss, and preterm birth. Any kind of APOs and preterm delivery were more common in patients with lupus anticoagulant (LA) positive. Anticardiolipin antibody (aCL) was associated with an increased risk of any kind of APOs and fetal loss. The association between aCL-IgM and fetal loss was also significant. Patients with anti-beta2-glycoprotein1 antibody (antiβ2GP1) positivity had an increased risk of fetal loss. CONCLUSIONS Both LA and aCL were risk factors of APOs in patients with SLE. Not only ACL, particularly aCL-IgM, but antiβ2GP1 were associated with an increased risk of fetal loss, while LA appeared to indicate the risk of preterm birth.PROSPERO (CRD42023388122).
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Affiliation(s)
- Jinge Huang
- The First School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, China
| | - Qingmiao Zhu
- School of Basic Medical Sciences, Zhejiang Chinese Medical University, Hangzhou, China
| | - Baizhou Wang
- The First School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, China
| | - Hanzheng Wang
- The First School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, China
| | - Zhijun Xie
- School of Basic Medical Sciences, Zhejiang Chinese Medical University, Hangzhou, China
| | - Xingyu Zhu
- Department of Nephrology, Hangzhou TCM Hospital Affiliated to Zhejiang Chinese Medical University, Hangzhou, China
| | - Ting Zhao
- School of Basic Medical Sciences, Zhejiang Chinese Medical University, Hangzhou, China
| | - Zi Yang
- The Third School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, China
- Teaching Faculty, New Zealand College of Chinese Medicine, Greenlane, New Zealand
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Isojima S, Yajima N, Yanai R, Miura Y, Fukuma S, Kaneko K, Fujio K, Oku K, Matsushita M, Miyamae T, Wada T, Tanaka Y, Kaneko Y, Nakajima A, Murashima A. Physician approval for pregnancy in patients with systemic lupus erythematosus showing only serological activity: A vignette survey study. Mod Rheumatol 2024; 34:509-514. [PMID: 37243689 DOI: 10.1093/mr/road049] [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: 01/26/2023] [Revised: 03/03/2023] [Accepted: 05/24/2023] [Indexed: 05/29/2023]
Abstract
OBJECTIVE The European League Against Rheumatism recommends that the disease activity of systemic lupus erythematosus should be stable before pregnancy because complications and disease flares increase if pregnancy occurs while disease activity is high. However, some patients have ongoing serological activity even after treatment. Herein, we investigated how physicians decide on the acceptability of pregnancy in patients showing only serological activity. METHODS A questionnaire was administered from December 2020 to January 2021. It included the characteristics of physicians, facilities, and the allowance for pregnancies of patients using vignette scenarios. RESULTS The questionnaire was distributed to 4946 physicians, and 9.4% responded. The median age of respondents was 46 years, and 85% were rheumatologists. Pregnancy allowance was significantly affected by the duration of the stable period and status of serological activity [duration: proportion difference 11.8 percentage points (p.p.), P < .001; mild activity: proportion difference -25.8 p.p., P < .001; high activity: proportion difference -65.6 p.p., P < .001]. For patients with high-level serological activity, 20.5% of physicians allowed pregnancy if there were no clinical symptoms for 6 months. CONCLUSIONS Serological activity had a significant effect on the acceptability of pregnancy. However, some physicians allowed patients with serological activity alone to become pregnant. Further observational studies are required to clarify such prognoses.
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Affiliation(s)
- Sakiko Isojima
- Division of Rheumatology, Department of Internal Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Nobuyuki Yajima
- Division of Rheumatology, Department of Internal Medicine, Showa University School of Medicine, Tokyo, Japan
- Department of Healthcare Epidemiology, Kyoto University Graduate School of Medicine and Public Health, Kyoto, Japan
- Center for Innovative Research for Communities and Clinical Excellence, Fukushima Medical University, Fukushima, Japan
| | - Ryo Yanai
- Division of Rheumatology, Department of Internal Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Yoko Miura
- Division of Rheumatology, Department of Internal Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Shingo Fukuma
- Human Health Sciences, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Kayoko Kaneko
- Division of Maternal Medicine, Center of Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Keishi Fujio
- Department of Allergy and Rheumatology, Graduate School of Medicine and Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kenji Oku
- Department of Rheumatology and Infectious Diseases, Kitasato University School of Medicine, Kanagawa, Japan
| | - Masakazu Matsushita
- Department of Internal Medicine and Rheumatology, Juntendo University School of Medicine, Tokyo, Japan
| | - Takako Miyamae
- Department of Pediatric Rheumatology, Institute of Rheumatology, Tokyo Women's Medical University Hospital, Tokyo, Japan
- Division of Rheumatology, Department of Internal Medicine, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Takashi Wada
- Department of Nephrology and Laboratory Medicine, Kanazawa University, Ishikawa, Japan
| | - Yoshiya Tanaka
- The First Department of Internal Medicine, University of Occupational and Environmental Health, Fukuoka, Japan
| | - Yuko Kaneko
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Ayako Nakajima
- Center for Rheumatic Diseases, Mie University Hospital, Tsu, Japan
| | - Atsuko Murashima
- Division of Maternal Medicine, Center of Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
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Sangah AB, Jabeen S, Hunde MZ, Devi S, Mumtaz H, Shaikh SS. Maternal and fetal outcomes of SLE in pregnancy: a literature review. J OBSTET GYNAECOL 2023; 43:2205513. [PMID: 37154805 DOI: 10.1080/01443615.2023.2205513] [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: 05/10/2023]
Abstract
Systemic Lupus Erythematosus (SLE) is an auto-immune disease in which the immune system assaults its tissues. We aimed to analyse the maternal and foetal outcomes during pregnancy in SLE mothers. A literature search was conducted by two investigators to assess SLE's outcomes on maternal and foetal during pregnancies. We searched PubMed/Medline, Embase, and Google scholar to collect evidence from different research studies, draw the conclusion, and report it. In our investigation, we found out that SLE could cause a spectrum of complications during pregnancy, not only for the mother but also for the foetus. It could affect fertility and cause difficult pregnancies for the couple as well which includes certain complications such as: preterm labour and delivery, high blood pressure (preeclampsia), placental insufficiency, miscarriage or stillbirth, whereas in the foetus SLE can cause mortality, preterm birth, and neonatal lupus (a temporary condition in the baby caused by SLE-related antibodies) and structural abnormalities. The literature suggests that SLE could prove fatal for the foetus and induce many complications in the mother. However, this could be avoided if pregnancy is planned right from the start and proper management is provided to the mother during pregnancy and delivery.p.
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Affiliation(s)
- Abdul Basit Sangah
- Liaquat National Hospital and Medical College Karachi, Karachi, Pakistan
| | - Sidra Jabeen
- Liaquat National Hospital and Medical College Karachi, Karachi, Pakistan
| | | | - Sunita Devi
- Liaquat National Hospital and Medical College Karachi, Karachi, Pakistan
| | - Hassan Mumtaz
- Senior Clinical Research Associate, Maroof International Hospital, Public Health Scholar, Health Services Academy, Islamabad, Pakistan
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Khogali HI, Al-Bluwi GSM, Guy Pedo V, Al Dhanhani AM. Maternal and fetal health outcomes in systemic lupus erythematosus pregnancies in the Emirati population: A comparative study. Lupus 2023; 32:1453-1461. [PMID: 37786253 DOI: 10.1177/09612033231204650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
OBJECTIVES To evaluate adverse pregnancy outcomes in patients with systemic lupus erythematosus (SLE), compare their maternal and fetal outcomes with those of age-matched pregnant women without SLE, and identify factors linked to increased risks of adverse outcomes. METHODS Medical records from Tawam Hospital were reviewed retrospectively to identify patients with SLE and a history of pregnancy. Demographics, clinical variables, and maternal and fetal outcomes were obtained. A one-to-one age-matched healthy control group was randomly selected. The outcomes and odd ratios of women with and without SLE were compared, and factors associated with adverse pregnancy outcomes were examined. RESULTS The outcomes of 78 SLE pregnancies in 39 women were analyzed. Adverse maternal outcomes, such as gestational diabetes mellitus (GDM), occurred in 32% of pregnancies, whereas adverse fetal outcomes, such as low-birth weight and preterm deliveries, occurred in 51% of pregnancies. Pregnant women with SLE had a 5-fold higher risk of GDM, had higher odds of maternal hypertension, and were more likely to deliver through cesarean section than those without SLE. Preterm deliveries and low-birth weight were also more common in SLE pregnancies. Steroid use during pregnancy was significantly associated with an increased risk of GDM development. Lupus nephritis, maternal hypertension, pre-eclampsia, and GDM were linked to preterm deliveries. CONCLUSION Pregnant women with SLE were at a higher risk for adverse maternal and fetal outcomes than age-matched pregnant women without SLE. These findings can guide clinical management and emphasize the need for close monitoring of SLE pregnancies.
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Affiliation(s)
| | - Ghada S M Al-Bluwi
- Internal Medicine Department, College of Medicine & Health Sciences, UAE University, Al Ain, UAE
| | - Virgie Guy Pedo
- Internal Medicine Department, College of Medicine & Health Sciences, UAE University, Al Ain, UAE
| | - Ali M Al Dhanhani
- Internal Medicine Department, College of Medicine & Health Sciences, UAE University, Al Ain, UAE
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Chen X, Di W, Ye L, Hu Y, Jiang M, Wu J, Bu J, Sun J, Bei F. Association of preterm outcome with maternal systemic lupus erythematosus: a retrospective cohort study. Ital J Pediatr 2023; 49:43. [PMID: 37005645 PMCID: PMC10068147 DOI: 10.1186/s13052-023-01436-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 03/02/2023] [Indexed: 04/04/2023] Open
Abstract
BACKGROUND Maternal systemic lupus erythematosus (SLE) is at greater risk of pregnancy complications and is associated with increased risk of preterm delivery. However hardly any study has looked at the influence of SLE on the outcomes of preterm infants. This study aimed to explore the influence of SLE on the outcomes of preterm infants. METHODS In this retrospective cohort study, preterm infants born to mothers with SLE from Shanghai Children's Medical Center during 2012 to 2021 were enrolled. Infants were excluded if they were died during hospitalization or has major congenital anomalies and neonatal lupus. Exposure was defined as mother diagnosed SLE before or during pregnancy. Maternal SLE group was matched with Non-SLE group by gestational age, birth weight and gender. Clinical data has been extracted from patients' records and registered. Major morbidities of premature and biochemical parameters in the two groups were compared using multiple logistic regression. RESULTS One hundred preterm infants born to 95 mothers with SLE were finally enrolled. The mean (standard deviation) of gestational age and birth weight were 33.09 (7.28) weeks and 1768.50 (423.56) g respectively. There was no significant difference in major morbidities between SLE group and non-SLE group. Compared with non-SLE group, SLE off-spring had significantly lower leukocytes, neutrophiles after birth, neutrophils and platlet in one week (mean difference: -2.825, -2.001, -0.842, -45.469, respectively). Among SLE group, lower birth weight and smaller gestational age were observed in SLE mothers with disease active during pregnancy, kidney involved, blood system involved and not taking Aspirin during pregnancy. In the multivariable logistic regression analysis, exposure to aspirin during pregnancy reduced the risk of very preterm birth and increased the incidence of survive without major morbidities among preterm infants born to SLE mothers. CONCLUSION Born to mothers with SLE may not increase the risk of major premature morbidities, but the hematologic profile of SLE preterm infants may be different from preterm infants born to women without SLE. The outcome of SLE preterm infants is associated with maternal SLE status and may benefit from maternal aspirin administration.
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Affiliation(s)
- Xiafang Chen
- Department of Neonatology, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, 1678 DongFang Road, 200127, Shanghai, China
| | - Wen Di
- Department of Obstetrics and Gynecology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Key Laboratory of Gynecologic Oncology, Shanghai, China
- State Key Laboratory of Oncogenes and Related Genes, Ren Ji Hospital, School of Medicine, Shanghai Cancer Institute, Shanghai Jiao Tong University, Shanghai, China
| | - Lili Ye
- Department of Rheumatology, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yabin Hu
- Department of Clinical Epidemiology and Biostatistics, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Meng Jiang
- Department of Obstetrics and Gynecology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Key Laboratory of Gynecologic Oncology, Shanghai, China
| | - Jiayue Wu
- Department of Obstetrics and Gynecology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Key Laboratory of Gynecologic Oncology, Shanghai, China
| | - Jun Bu
- Department of Neonatology, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, 1678 DongFang Road, 200127, Shanghai, China
| | - Jianhua Sun
- Department of Neonatology, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, 1678 DongFang Road, 200127, Shanghai, China
| | - Fei Bei
- Department of Neonatology, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, 1678 DongFang Road, 200127, Shanghai, China.
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Mokbel A, Attia DH, Zayed HS, Eesa Naeem N, Mahmoud G, Riad R, Abou Elewa S, Youssef M, Haggag H, Mohamed SS. Pregnancy outcomes among Egyptian women with systemic lupus erythematosus: A prospective cohort study. Lupus 2023; 32:521-530. [PMID: 36889920 DOI: 10.1177/09612033231159468] [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: 03/10/2023]
Abstract
Pregnant patients with systemic lupus erythematosus (SLE) represent a high-risk group. The aim of this study is to describe the pregnancy outcomes among SLE patients who were followed prospectively at a conjoint high-risk pregnancy/rheumatology clinic from 2007 to 2021 and to identify predictors of adverse maternal and fetal outcomes. This study included 201 singleton pregnancies of 123 women with SLE. Their mean age was 27.16 ± 4.80 years, and their mean disease duration was 7.35 ± 5.46 years. Secondary antiphospholipid syndrome (APS) was diagnosed in 77 (38.3%) pregnancies. The pregnancy was planned in 104 (51.7%) pregnancies. Flares occurred in 83 (41.3%) and pre-eclampsia in 15 (7.5%) pregnancies. Full-term pregnancy occurred in 93 (46.3%), fetal loss (miscarriage and intra-uterine fetal death) in 41 (20.4%), and prematurity in 67 (33.3%) of the pregnancies, respectively. Seven neonates died from complications of prematurity, and another one died from cardiac congenital anomalies. In the multivariate analyses, unplanned pregnancy was associated with eight times higher risk of disease flare OR = 7.92 (p < 0.001), lupus nephritis flare during pregnancy increased the odds of pre-eclampsia occurrence four times OR = 3.98 (p = 0.02), while disease flares during pregnancy predicted prematurity OR = 2.49, p = 0.049. Patients with secondary APS had three times increased risk of fetal loss OR = 2.97, p = 0.049. To conclude, unplanned pregnancy, disease flares, and APS have been identified as predictors for adverse maternal and/or fetal outcomes. Pregnancy planning is necessary to reduce maternal and fetal complications.
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Affiliation(s)
- Abir Mokbel
- Department of Rheumatology and Rehabilitation, 63527Kasr-Alainy School of Medicine, Cairo University, Cairo, Egypt.,Department of Health Research Methods, McMaster University, Hamilton, Canada
| | - Doaa Hs Attia
- Department of Rheumatology and Rehabilitation, 63527Kasr-Alainy School of Medicine, Cairo University, Cairo, Egypt
| | - Hania S Zayed
- Department of Rheumatology and Rehabilitation, 63527Kasr-Alainy School of Medicine, Cairo University, Cairo, Egypt
| | - Nahlaa Eesa Naeem
- Department of Rheumatology and Rehabilitation, 63527Kasr-Alainy School of Medicine, Cairo University, Cairo, Egypt
| | - Geilan Mahmoud
- Department of Rheumatology and Rehabilitation, 63527Kasr-Alainy School of Medicine, Cairo University, Cairo, Egypt
| | - Rafat Riad
- Department of Obstetrics and Gynecology, 63527Kasr-Alainy School of Medicine, Cairo University, Cairo, Egypt
| | - Soumaya Abou Elewa
- Department of Obstetrics and Gynecology, 63527Kasr-Alainy School of Medicine, Cairo University, Cairo, Egypt
| | - Mohamed Youssef
- Department of Obstetrics and Gynecology, 63527Kasr-Alainy School of Medicine, Cairo University, Cairo, Egypt
| | - Hisham Haggag
- Department of Obstetrics and Gynecology, 63527Kasr-Alainy School of Medicine, Cairo University, Cairo, Egypt
| | - Sally S Mohamed
- Department of Rheumatology and Rehabilitation, 63527Kasr-Alainy School of Medicine, Cairo University, Cairo, Egypt
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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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Kaufman KP, Eudy AM, Harris N, Neil L, Clowse MEB. Pregnancy Outcomes in Undifferentiated Connective Tissue Disease Compared to Systemic Lupus Erythematosus: A Single Academic Center's Experience. Arthritis Care Res (Hoboken) 2022; 74:1631-1639. [PMID: 33973409 PMCID: PMC8578567 DOI: 10.1002/acr.24644] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 04/07/2021] [Accepted: 05/04/2021] [Indexed: 11/12/2022]
Abstract
OBJECTIVE Systemic lupus erythematosus (SLE) patients have more pregnancy complications than healthy patients. Data regarding pregnancy outcomes in women with undifferentiated connective tissue disease (UCTD) are more limited, and existing studies are concentrated in Italy and predominantly in patients with a new diagnosis. Our objective was to compare pregnancy outcomes for UCTD and SLE patients with established disease. METHODS Between 2008 and 2017, patients with UCTD and SLE at an academic medical center were recruited to a prospective pregnancy registry. UCTD was defined as a positive autoantibody plus connective tissue disease symptoms not meeting criteria for another rheumatic diagnosis. SLE was defined by American College of Rheumatology or Systemic Lupus International Collaborating Clinics classification criteria or by physician diagnosis. Data were collected throughout pregnancy and postpartum. Comparator groups included UCTD, low-activity SLE, and high-activity SLE. RESULTS A total of 150 SLE and 51 UCTD pregnancies were analyzed. Disease activity was low in most patients, although more patients with SLE had severe activity during pregnancy (12% versus 2%; P = 0.05). The frequencies of prematurity and preeclampsia were significantly lower in UCTD than in high-activity SLE patients (preterm 17% versus 45% [P = 0.004] and preeclampsia 6% versus 34% [P = 0.0008]), although similar to low-activity SLE patients. More infants who were small for gestational age were born to SLE than UCTD patients (33% versus 7% [P = 0.0005]), regardless of disease activity level. CONCLUSION Pregnancies in women with UCTD managed by a rheumatologist have a high rate of pregnancy success and fewer risks than those in women with active SLE.
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Affiliation(s)
| | - Amanda M Eudy
- Duke University Medical Center, Durham, United States
| | | | - Laura Neil
- Duke University Medical Center, Durham, United States
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11
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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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12
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Dos Santos FC, Ignacchiti ML, Rodrigues B, Velarde LG, Levy RA, de Jesús GR, de Jesús NR, de Andrade CAF, Klumb EM. Premature rupture of membranes - A cause of foetal complications among lupus: A cohort study, systematic review and meta-analysis. Lupus 2021; 30:2042-2053. [PMID: 34806483 DOI: 10.1177/09612033211045056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The present study aimed to analyse the frequency of premature rupture of membranes (PROMs) among 190 women with systemic lupus erythematosus (SLE) followed up at the Hospital Universitário Pedro Ernesto from 2011 to 2018 and to review the literature on PROM in patients with SLE. METHODS A cohort study of SLE patients was conducted by analysing the following variables: sociodemographic characteristics, clinical manifestations of lupus, modified disease activity index for pregnancy, drugs used during pregnancy, intercurrent maternal infections and obstetric outcomes. Additionally, seven electronic databases (PubMed, Embase, Cochrane, Scielo, Scielo Brazil, Virtual Health Library Regional Portal and Google Scholar) were systematically searched. The search was updated on 3 February 2020. RESULTS Infections (relative risk (RR): 3.26, 95% confidence interval (CI): 1.5-6.7, p = .001), history of serositis (RR: 2.59, 95% CI: 1.31-5.11, p = .006) and anti-RNP positivity (RR: 3.08, 95% CI: 1.39-6.78, p = .005) were associated risk factors for PROM, while anti-RNP positivity (RR: 3.37, 95% CI: 1.35-8.40; p = .009) were associated with premature PROM (PPROM). The prevalence of PROM and PPROM was 28.7% and 12.9%, respectively. In the systematic review, the prevalence of PROM and PPROM was 2.7%-35% (I2 = 87.62%) and 2.8%-20% (I2 = 79.56%), respectively. CONCLUSIONS PROM, both at term and preterm, occurs more frequently in women with lupus than in the general population. A history of serositis, anti-RN, infections and immunosuppression during pregnancy may increase the susceptibility to PROM. The systematic review did not find any study with the main objective of evaluating PROM/PPROM in women with lupus.
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Affiliation(s)
- Flávia Cunha Dos Santos
- Department of Obstetrics, 28130Universidade do Estado do Rio de Janeiro. Rio de Janeiro, RJ, Brazil
| | | | - Bruna Rodrigues
- Department of Rheumatology, 28130Universidade do Estado Rio de Janeiro. Rio de Janeiro, RJ, Brazil
| | - Luis Guillermo Velarde
- Postgraduate Program in Medical Sciences, 28110Universidade Federal Fluminense, Niterói, RJ, Brazil
| | - Roger Abramino Levy
- Department of Rheumatology, 28130Universidade do Estado Rio de Janeiro. Rio de Janeiro, RJ, Brazil
| | | | - Nilson Ramires de Jesús
- Department of Obstetrics, 28130Universidade do Estado do Rio de Janeiro. Rio de Janeiro, RJ, Brazil
| | - Carlos Augusto Ferreira de Andrade
- Department of Epidemiology, Quantitative Methods in Health, 42499Escola Nacional de Saúde Pública Sérgio Arouca, Fiocruz, Rio de Janeiro, RJ, Brazil
| | - Evandro Mendes Klumb
- Department of Rheumatology, 28130Universidade do Estado Rio de Janeiro. Rio de Janeiro, RJ, Brazil
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Edens C. The Impact of Pediatric Rheumatic Diseases on Sexual Health, Family Planning, and Pregnancy. Rheum Dis Clin North Am 2021; 48:113-140. [PMID: 34798942 DOI: 10.1016/j.rdc.2021.09.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
A comprehensive review of reproductive health subtopics, including sexual intercourse, romantic relationships, contraception, sexually transmitted infections, pregnancy, and infertility, as they pertain to patients with pediatric rheumatic diseases and those who care for them.
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Affiliation(s)
- Cuoghi Edens
- Department of Pediatrics, Section of Pediatric Rheumatology, University of Chicago Medicine, 5841 South Maryland Avenue, C104-A, MC5044, Chicago, IL 60637, USA; Department of Internal Medicine, Section of Rheumatology, University of Chicago Medicine, 5841 South Maryland Avenue, C104-A, MC5044, Chicago, IL 60637, USA.
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Jiang M, Chang Y, Wang Y, Fu Q, Lin S, Wu J, Di W. High-risk factors for adverse pregnancy outcomes in systemic lupus erythaematosus: a retrospective study of a Chinese population. BMJ Open 2021; 11:e049807. [PMID: 34785549 PMCID: PMC8596043 DOI: 10.1136/bmjopen-2021-049807] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To clarify high-risk factors for adverse pregnancy outcomes (APOs) in systemic lupus erythaematosus (SLE). DESIGN A retrospective chart review study. SETTING Data were collected in a tertiary medical centre, Shanghai, China, from November 2010 to December 2018. PARTICIPANTS A total of 513 pregnancies with SLE were retrospectively analysed. Twenty-seven patients who underwent artificial abortions due to personal reasons were excluded. PRIMARY OUTCOME MEASURES APOs were primary outcomes, including foetal loss, premature birth, small for gestational age (SGA), asphyxia neonatorum, composite foetal APOs and hypertensive disorders of pregnancy (HDP). Multivariable logistic regression and Spearman correlation analysis were performed to determine the risk factors for APOs in SLE. RESULTS Risk factors for foetal loss included prepregnancy hypertension, hypocomplementaemia-C3, anticardiolipin antibodies-IgM positivity and disease flares during pregnancy. Risk factors for premature birth included disease flares, use of immunosuppressive agents and HDP. Moreover, twin pregnancy, disease flares and HDP were risk factors for SGA, and prepregnancy hypertension was an independent risk factor for asphyxia neonatorum. Independent risk factors for composite foetal APOs included twin pregnancy, prepregnancy hypertension, disease flares during pregnancy, HDP, hypocomplementaemia-C3 and the use of immunosuppressive agents. Risk factors for SLE complicated with HDP included prepregnancy hypertension, renal disorders and thrombocytopaenia. Conversely, the use of aspirin was a protective factor against foetal loss and premature birth. The ds-DNA value had a low diagnostic value for APOs, whereas the extent of complement reduction may predict the incidence of composite foetal APOs and foetal loss. Proteinuria occurring in the first 20 gestational weeks may lead to APOs. CONCLUSION Established risk factors for each APO were identified in this study. Indicators with more predictive significance have been screened out from conventional indicators, which may help clinicians predict the pregnancy outcome of patients with SLE more accurately and minimise the incidence of APOs.
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Affiliation(s)
- Meng Jiang
- Department of Obstetrics and Gynecology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Key Laboratory of Gynecologic Oncology, Shanghai, China
| | - Yanling Chang
- Department of Obstetrics and Gynecology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Key Laboratory of Gynecologic Oncology, Shanghai, China
| | - You Wang
- Department of Obstetrics and Gynecology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Key Laboratory of Gynecologic Oncology, Shanghai, China
| | - Qiong Fu
- Department of Rheumatology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Institute of Rheumatology, Shanghai, China
| | - Sihan Lin
- Department of Obstetrics and Gynecology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Key Laboratory of Gynecologic Oncology, Shanghai, China
| | - Jiayue Wu
- Department of Obstetrics and Gynecology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Key Laboratory of Gynecologic Oncology, Shanghai, China
| | - Wen Di
- Department of Obstetrics and Gynecology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Key Laboratory of Gynecologic Oncology, Shanghai, China
- State Key Laboratory of Oncogenes and Related Genes, Shanghai Cancer Institute, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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15
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Obuchowska A, Standyło A, Obuchowska K, Kimber-Trojnar Ż, Leszczyńska-Gorzelak B. Cytokine Storms in the Course of COVID-19 and Haemophagocytic Lymphohistiocytosis in Pregnant and Postpartum Women. Biomolecules 2021; 11:1202. [PMID: 34439868 PMCID: PMC8391528 DOI: 10.3390/biom11081202] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 08/06/2021] [Accepted: 08/11/2021] [Indexed: 12/17/2022] Open
Abstract
The term 'cytokine storm' (CS) applies to a pathological autoimmune reaction when the interactions that lead to cytokine production are destabilised and may even lead to death. CS may be induced by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. In this study, we present our analysis of certain pathological processes that induce a CS in pregnant and postpartum women. We draw our attention to the similarities between the severe course of Coronavirus Disease 2019 (COVID-19) and haemophagocytic lymphohistiocytosis (HLH). It is noteworthy that many of the criteria used to diagnose HLH are described as COVID-19 mortality predictors. Cytokine storms are considered to be an important cause of death in patients with the severe course of SARS-CoV-2 infection. Due to the fact that pregnant women are in an immunosuppressive state, viral pulmonary infections are more perilous for them-possible risks include miscarriage, intrauterine growth restriction or birth before the term; sometimes ventilation support is needed. HLH should be considered in pregnant and puerperal women suffering from moderately severe to severe COVID-19 and presenting with: fever unresponsive to antibiotic therapy, cytopenia, hepatitis and hyperferritinaemia. The HLH disorder is rare and difficult to diagnose; however, its early detection could reduce patient mortality.
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Affiliation(s)
| | - Arkadiusz Standyło
- Department of Obstetrics and Perinatology, Medical University of Lublin, 20-090 Lublin, Poland; (A.O.); (K.O.); (Ż.K.-T.); (B.L.-G.)
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Palma Dos Reis CR, Cardoso G, Carvalho C, Nogueira I, Borges A, Serrano F. Prediction of Adverse Pregnancy Outcomes in Women with Systemic Lupus Erythematosus. Clin Rev Allergy Immunol 2021; 59:287-294. [PMID: 31444781 DOI: 10.1007/s12016-019-08762-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Systemic lupus erythematosus (SLE) is a chronic, autoimmune disease associated with major obstetrical complications such as gestational loss, preterm delivery, fetal growth restriction (FGR) and preeclampsia. Published literature is not consensual regarding the main risk factors for each of these outcomes. Our goal with this study was to determine the most important predictors for each of the main adverse pregnancy outcomes in this population. We conducted a retrospective cohort study of unifetal pregnancies of women with the diagnosis of SLE followed in our unit between January 1994 and December 2016. We excluded elective terminations of pregnancy and cases lost to follow-up and we analyzed 157 pregnancies (128 women). Multiple logistic regression models for the outcomes gestational loss, preterm delivery, fetal growth restriction, and preeclampsia were built. Two-sided p-values of < 0.05 were used to determine statistical significance, and two-sided confidence intervals of 95% are reported. In our cohort, the main risk factors for gestational loss were maternal age and the presence of antiphospholipid antibodies. Lupic nephritis was predictive of a preterm delivery and preeclampsia. Renal involvement and lupus flares during pregnancy were risk factors for FGR. Overall, the main risk factor for an adverse pregnancy outcome were lupus flares during pregnancy. Despite optimal pregnancy monitoring, women with SLE are still at risk for adverse pregnancy outcomes. Risk stratification for each of these outcomes is crucial for an effective counselling and tailored monitoring.
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Affiliation(s)
- Catarina R Palma Dos Reis
- Maternidade Dr. Alfredo da Costa, Centro Hospitalar Universitário Lisboa Central, CHULC, Lisbon, Portugal. .,Department of Obstetrics and Gynecology, Nova Medical School
- Faculdade de Ciências Médicas, Nova University of Lisbon, Lisbon, Portugal.
| | - Gonçalo Cardoso
- Maternidade Dr. Alfredo da Costa, Centro Hospitalar Universitário Lisboa Central, CHULC, Lisbon, Portugal
| | - Carolina Carvalho
- Maternidade Dr. Alfredo da Costa, Centro Hospitalar Universitário Lisboa Central, CHULC, Lisbon, Portugal
| | - Isabel Nogueira
- Maternidade Dr. Alfredo da Costa, Centro Hospitalar Universitário Lisboa Central, CHULC, Lisbon, Portugal
| | - Augusta Borges
- Maternidade Dr. Alfredo da Costa, Centro Hospitalar Universitário Lisboa Central, CHULC, Lisbon, Portugal
| | - Fátima Serrano
- Maternidade Dr. Alfredo da Costa, Centro Hospitalar Universitário Lisboa Central, CHULC, Lisbon, Portugal.,Department of Obstetrics and Gynecology, Nova Medical School
- Faculdade de Ciências Médicas, Nova University of Lisbon, Lisbon, Portugal
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17
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Tani C, Zucchi D, Haase I, Larosa M, Crisafulli F, Strigini FAL, Monacci F, Elefante E, Mucke J, Choi MY, Andreoli L, Iaccarino L, Tincani A, Doria A, Fischer-Betz R, Mosca M. Are remission and low disease activity state ideal targets for pregnancy planning in Systemic Lupus Erythematosus? A multicentre study. Rheumatology (Oxford) 2021; 60:5610-5619. [PMID: 33590843 DOI: 10.1093/rheumatology/keab155] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 02/09/2021] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES To determine whether disease remission or low disease activity state at the beginning of pregnancy in SLE patients is associated with better pregnancy outcome. METHODS pregnancies in SLE patients prospectively monitored by pregnancy clinics at four rheumatology centres were enrolled. Patient demographics and clinical information were collected at baseline (pregnancy visit before 8 weeks of gestation) including whether patients were in remission according to DORIS criteria and and/or Lupus Low Disease Activity State (LLDAS). Univariate and multivariate analysis were performed to determine predictors of disease flare and adverse pregnancy outcomes (APOs) including preeclampsia, preterm delivery, small for gestational age infant, intrauterine growth restriction and intrauterine fetal death. RESULTS 347 pregnancies were observed in 281 SLE patients. Excluding early pregnancy losses, 212 pregnancies (69.7%) occurred in patients who were in remission at baseline, 33 (10.9%) in patients in LLDAS, and the remainder in active patients. 73 flares (24%) were observed during pregnancy or puerperium, and 105 (34.5%) APOs occurred. Multivariate analysis revealed that patients in disease remission or taking hydroxychloroquine were less likely to have disease flare, while a history of lupus nephritis increased the risk. The risk of APOs was increased in patients with shorter disease duration, while being on hydroxychloroquine resulted a protective variable. An almost significant association between complete remission and a decreased risk of APOs was observed. CONCLUSIONS Prenatal planning with a firm treat-to-target goal of disease remission is an important strategy to reduce the risk of disease flares and severe obstetrical complications in SLE pregnancies.
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Affiliation(s)
- Chiara Tani
- Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Italy
| | - Dina Zucchi
- Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Italy
| | - Isabell Haase
- Policlinic and Hiller Research Unit for Rheumatology, Heinrich Heine University Duesseldorf, Duesseldorf, Germany
| | - Maddalena Larosa
- Rheumatology Unit, Department of Medicine (DIMED), University of Padova, Italy
| | | | | | - Francesca Monacci
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Elena Elefante
- Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Italy
| | - Johanna Mucke
- Policlinic and Hiller Research Unit for Rheumatology, Heinrich Heine University Duesseldorf, Duesseldorf, Germany
| | - May Y Choi
- Division of Gynecology and Obstetrics, Department of Clinical and Experimental Medicine, University of Pisa, Italy
| | - Laura Andreoli
- Rheumatology and Clinical Immunology Unit, ASST Spedali Civili, Brescia
| | - Luca Iaccarino
- Rheumatology Unit, Department of Medicine (DIMED), University of Padova, Italy
| | - Angela Tincani
- Rheumatology and Clinical Immunology Unit, ASST Spedali Civili, Brescia
| | - Andrea Doria
- Rheumatology Unit, Department of Medicine (DIMED), University of Padova, Italy
| | - Rebecca Fischer-Betz
- Policlinic and Hiller Research Unit for Rheumatology, Heinrich Heine University Duesseldorf, Duesseldorf, Germany
| | - Marta Mosca
- Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Italy
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Louthrenoo W, Trongkamolthum T, Kasitanon N, Wongthanee A. Predicting factors of adverse pregnancy outcomes in Thai patients with systemic lupus erythematosus: A STROBE-compliant study. Medicine (Baltimore) 2021; 100:e24553. [PMID: 33592909 PMCID: PMC7870266 DOI: 10.1097/md.0000000000024553] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Accepted: 01/13/2021] [Indexed: 01/05/2023] Open
Abstract
Studies on predicting factors for adverse pregnancy outcomes (APOs) in Thai patients with systemic lupus erythematosus (SLE) are limited. This retrospective observation study determined APOs and their predictors in Thai patients with SLE.Medical records of pregnant SLE patients in a lupus cohort, seen from January 1993 to June 2017, were reviewed.Ninety pregnancies (1 twin pregnancy) from 77 patients were identified. The mean age at conception was 26.94 ± 4.80 years. At conception, 33 patients (36.67%) had active disease, 23 (25.56%) hypertension, 20 (22.22%) renal involvement, and 6 of 43 (13.95%) positive anti-cardiolipin antibodies or lupus anti-coagulants, and 37 (41.11%) received hydroxychloroquine. Nineteen patients (21.11%) had pregnancy loss. Of 71 successful pregnancies, 28 (31.11%) infants were full-term, 42 (46.67%) pre-term and 1 (11.11%) post-term; 19 (26.39%) were small for gestational age (SGA), and 38 (52.58%) had low birth weight (LBW). Maternal complications occurred in 21 (23.33%) pregnancies [10 (11.11%) premature rupture of membrane (PROM), 8 (8.89%) pregnancy induced hypertension (PIH), 4 (4.44%) oligohydramnios, 2 (2.22%) post-partum hemorrhage, and 1 (1.11%) eclampsia]. Patients aged ≥ 25 years at pregnancy and those ever having renal involvement had predicted pregnancy loss with adjusted odds ratio (AOR) [95% CI] of 4.15 [1.10-15.72], P = .036 and 9.21 [1.03-82.51], P = .047, respectively. Renal involvement predicted prematurity (6.02 [1.77-20.52, P = .004), SGA (4.46 [1.44-13.78], P = .009), and LBW in infants (10.01 [3.07-32.62], P < .001). Prednisolone (>10 mg/day) and immunosuppressive drugs used at conception protected against prematurity (0.11 [0.02-0.85], P = .034). Flares and hematologic involvement predicted PROM (8.45 [1.58-45.30], P = .013) and PIH (9.24 [1.70-50.24], P = .010), respectively. Cutaneous vasculitis (33.87 [1.05-1,094.65], P = .047), and renal (31.89 [6.66-152.69], P < .001), mucocutaneous (9.17 [1.83-45.90], P = .007) and hematologic involvement (128.00 [4.60-3,564.46], P = .004) during pregnancy predicted flare; while prednisolone (>10 mg/day) and immunosuppressive drug use at conception reduced that risk (0.08 [0.01-0.68, P = .021).APOs remain a problem in Thai pregnant SLE patients. Renal involvement and SLE flares were associated with the risk of APOs.
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Affiliation(s)
- Worawit Louthrenoo
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai
| | - Thananant Trongkamolthum
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai
- Allergy and Rheumatology Unit, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Songkla
| | - Nuntana Kasitanon
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai
| | - Antika Wongthanee
- Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
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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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20
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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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Karimzadeh P, Shenavandeh S, Asadi N. Maternal and Fetal Outcomes in Iranian Patients with Systemic Lupus Erythematosus: A Five-Year Retrospective Study of 60 Pregnancies. Curr Rheumatol Rev 2020; 15:321-328. [PMID: 30686262 DOI: 10.2174/1573397115666190125162248] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 01/16/2019] [Accepted: 01/17/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND As a multisystem autoimmune disease, Systemic Lupus Erythematosus (SLE) mainly affects women during reproductive age. This retrospective study was designed to investigate the fetal and maternal outcomes of Iranian women with SLE. METHODS Clinical and laboratory records of 60 pregnancies in 55 SLE patients who attended Hafez hospital, a tertiary referral center for high risk pregnancies and SLE patients affiliated with Shiraz University of Medical Science, were reviewed during April 2012 and March 2016. RESULTS The mean age of the patients was 29.28±4.6 years and mean disease duration was 5.09±4.2 years. Live birth rate was 83.3% after exclusion of elective abortions. There were 50 live births, 3 neonatal deaths, 3 spontaneous abortions and 7 stillbirths. 9 (15%) women developed preeclampsia and there was 1 (1.6%) case of HELLP syndrome. Lupus flares occurred in 27 (45%) patients during pregnancy. Preterm delivery occurred in 11.6% of pregnancies. Skin and joints were the most frequently affected organs. Patients with previous lupus nephritis (n=18) were associated with a higher risk of maternal complication, but fetal outcomes were similar in both groups. Cesarean rate was about 66%, mostly related to fetal indications (50%). CONCLUSION Pregnancies in most women with pre-existing SLE can now be managed with successful results although presence of previous lupus nephritis is still a major risk factor for adverse maternal outcomes. In our study, fetal outcome was not different between patients with lupus nephritis compared with the patients without nephritis who were under treatments. Hence, to achieve favorable long-term results, we recommend regular multispecialty treatment approaches and progestational counseling for women with SLE.
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Affiliation(s)
- P Karimzadeh
- Department of Internal Medicine, Division of Rheumatology, Shiraz University of Medical Sciences, Shiraz, Iran
| | - S Shenavandeh
- Department of Internal Medicine, Division of Rheumatology, Shiraz University of Medical Sciences, Shiraz, Iran
| | - N Asadi
- Maternal-fetal medicine Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
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Abstract
PURPOSE OF REVIEW The aim of this study was to describe risks of systemic lupus erythematosus (SLE) in pregnancy and the importance of preconception counselling, medication optimization and close surveillance. RECENT FINDINGS Advances in care for pregnant patients with SLE have led to improved obstetric outcomes, but maternal and foetal risks continue to be elevated. Conception during periods of disease quiescence and continuation of most medications decrease adverse pregnancy outcomes. Hydroxychloroquine (HCQ) appears protective against flares in pregnancy, neonatal congenital heart block and preterm birth. SUMMARY SLE in pregnancy confers increased maternal and foetal risks, including disease flares, preeclampsia, preterm birth, foetal growth restriction, neonatal lupus erythematosus (NLE) and congenital heart block. Disease control on an effective medication regimen mitigates many of these risks, but pregnancy in women with SLE remains a high-risk condition requiring multidisciplinary care and an individualized approach to each patient.
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23
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Kalok A, Abdul Cader R, Indirayani I, Abdul Karim AK, Shah SA, Mohamed Ismail NA, Omar MH, Shafiee MN. Pregnancy outcomes in systemic lupus erythematosus (SLE) women. Horm Mol Biol Clin Investig 2019; 40:/j/hmbci.ahead-of-print/hmbci-2019-0007/hmbci-2019-0007.xml. [PMID: 31553696 DOI: 10.1515/hmbci-2019-0007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 07/11/2019] [Indexed: 01/02/2023]
Abstract
Background Systemic lupus erythematosus (SLE) is a chronic autoimmune inflammatory condition with multi-organ involvement predominantly affecting young women. There are very limited studies in pregnancy in Asian SLE patients and therefore we embarked on this study to identify pregnancy outcomes of Malaysian women with SLE. Materials and methods We performed a retrospective study of pregnancy outcomes in SLE patients in our institution from January 2007 to December 2014. A total of 71 pregnancies from 44 women were analysed. Results The mean age of our cohort was 30.5 ± 3.9 years. The rate of active disease at conception, antiphospholipid syndrome and lupus nephritis were 22.5%, 32.4% and 57.7% respectively. SLE flare occurred in 33 out of 71 pregnancies whereas 19 pregnancies were complicated with preeclampsia. The livebirth rate for our cohort was 78.9%, whilst preterm delivery was 42.9%. On univariate analysis, active disease and flare in pregnancy were both strongly associated with foetal loss and preterm delivery. Lupus nephritis (p = 0.011), SLE flare (p = 0.008) and antiphospholipid syndrome (p = 0.032) significantly increased the risk of preeclampsia. Aspirin and hydroxychloroquine were protective against foetal loss [odds ratio (OR) 0.12] and preeclampsia (OR 0.25), respectively. On multivariate analysis, active disease was a predictor of SLE flare (p = 0.002) and foetal loss (p = 0.018) and SLE flare was the main predictor of preterm delivery (p = 0.006). Conclusions Pregnancies in women with SLE should be planned and aspirin and HCQ use were beneficial in reducing adverse pregnancy outcomes.
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Affiliation(s)
- Aida Kalok
- Faculty of Medicine, Department of Obstetrics and Gynaecology, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Rizna Abdul Cader
- Department of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Ima Indirayani
- Faculty of Medicine, Department of Obstetrics and Gynecology, Syiah Kuala University, Banda Aceh, Indonesia
| | - Abdul Kadir Abdul Karim
- Faculty of Medicine, Department of Obstetrics and Gynaecology, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Shamsul Azhar Shah
- Faculty of Medicine, Department of Community Health, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Nor Azlin Mohamed Ismail
- Faculty of Medicine, Department of Obstetrics and Gynaecology, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Mohd Hashim Omar
- Faculty of Medicine, Department of Obstetrics and Gynaecology, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Mohamad Nasir Shafiee
- Faculty of Medicine, Department of Obstetrics and Gynaecology, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
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Predictors of SLE relapse in pregnancy and post-partum among multi-ethnic patients in Malaysia. PLoS One 2019; 14:e0222343. [PMID: 31539383 PMCID: PMC6754159 DOI: 10.1371/journal.pone.0222343] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 08/27/2019] [Indexed: 01/26/2023] Open
Abstract
Flare of Systemic Lupus Erythematosus (SLE) may occur during pregnancy and puerperium. We studied the prevalence and factors associated with SLE relapse during pregnancy and post-partum period in a multi-ethnic SLE cohort. Consecutive SLE patients who attended the outpatient clinic were reviewed for previous history of pregnancies in our institution. Patients who had a complete antenatal, delivery, and post-partum follow up were included. Their medical records were retrospectively analysed to assess the disease activity at pre-pregnancy/conception, during antenatal, and post-partum period. Presence of flare episodes during pregnancy and puerperium were recorded. The pregnancy outcomes recorded include live birth, foetal loss, prematurity and intra-uterine growth restrictions (IUGR). Univariate and multivariable logistic regression with generalized estimating equations (GEE) analyses were performed to determine the factors associated with disease relapse and the pregnancy outcomes. A total of 120 patients with 196 pregnancies were included, with a live birth rate of 78.6%. Four (2.0%) were diagnosed to have SLE during pregnancy. The flare rate in pregnancy was 40.1% while post-partum 17.4%. Majority of the relapse in pregnancy occurred in haematological system (62.3%) followed by renal (53.2%), musculoskeletal (22.1%), and mucocutaneous (14.3%). In GEE analyses, active disease at conception was the independent predictor of SLE relapse during and after pregnancy, whereas older maternal age and Malay ethnicity were associated with higher flare during post-partum. HCQ use was significantly associated with reduced risk of flare in univariate analysis but it was no longer significant in the GEE analyses. Presence of disease flare in pregnancy was significantly associated with prematurity. In conclusion, pregnancy in SLE need to be planned during quiescent state as pre-pregnant active disease was associated with disease relapse in both during and after pregnancy. Malay patients had an increased risk of post-partum flare but further larger prospective studies are needed to confirm the association between pregnancies in the different ancestral background.
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25
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Stratifying management of rheumatic disease for pregnancy and breastfeeding. Nat Rev Rheumatol 2019; 15:391-402. [DOI: 10.1038/s41584-019-0240-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/14/2019] [Indexed: 12/16/2022]
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Harris N, Eudy A, Clowse M. Patient-Reported Disease Activity and Adverse Pregnancy Outcomes in Systemic Lupus Erythematosus and Rheumatoid Arthritis. Arthritis Care Res (Hoboken) 2019; 71:390-397. [DOI: 10.1002/acr.23621] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Accepted: 06/12/2018] [Indexed: 01/23/2023]
Affiliation(s)
| | - Amanda Eudy
- Duke University Medical Center; Durham North Carolina
| | - Megan Clowse
- Duke University Medical Center; Durham North Carolina
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27
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Normand G, Sens F, Puthet J, Jourde-Chiche N, Lemoine S, Chauveau D, Moranne O, Rémy P, Doret M, Daugas E, Juillard L. Not only disease activity but also chronic hypertension and overweight are determinants of pregnancy outcomes in patients with systemic lupus erythematosus. Lupus 2019; 28:529-537. [PMID: 30799679 DOI: 10.1177/0961203319832097] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
INTRODUCTION Pregnancies in women with lupus nephritis are at high-risk of complications, while scarcity of scientific knowledge on prognostic factors impedes a fair medical counseling. We aimed to identify determinants associated with maternal and fetal complications. MATERIALS We retrospectively reviewed medical charts of pregnancies that lasted more than 22 weeks in 66 patients with pre-existing lupus nephritis between 2004 and 2013 in France. Univariate and multivariate analyses were conducted to identify determinants for maternal complications, lupus renal flare and fetal prematurity or death. RESULTS Eighty-four pregnancies were identified. A maternal complication occurred in 31 pregnancies (36.9%): mostly preeclampsia (17 pregnancies, 20.2%) and renal flares (12 pregnancies, 14.3%). Overall fetal survival was 94.0% (79/84). Maternal pregnancy complications were independently associated with prepregnancy body mass index >25 kg/m2 (OR 3.81, 95% CI 1.03-14.09) and immunological activity (positive anti-dsDNA antibodies or Farr assay lupus) (OR 4.95, 95% CI 1.33-18.43). Renal lupus flares were independently associated with maternal age (OR 1.50, 95% CI 1.12-2.01) and prepregnancy immunological activity (OR 15.99, 95% CI 1.57-162.68) while a remission time >12 months had a protective effect (OR 0.17, 95% CI 0.04-0.68). Three parameters were associated with a higher risk of fetal prematurity or death: a prepregnancy body mass index >25 kg/m2 (HR 3.58, 95% CI 1.45-8.83), hypertension (HR 8.97, 95% CI 3.32-24.25), and immunological activity (HR 3.34, 95% CI 1.30-8.63). CONCLUSION Maternal age, prepregnancy hypertension, body mass index >25 kg/m2 and lupus immunological activity may be considered as the main determinants for fetal and maternal complications. A remission time above 12 months for patients with lupus nephritis could be associated with a reduced risk of renal flare during pregnancy.
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Affiliation(s)
- G Normand
- 1 Department of Nephrology, Hypertension and Dialysis, Hospices Civils de Lyon, Lyon, France.,2 University of Lyon 1, Lyon, France
| | - F Sens
- 1 Department of Nephrology, Hypertension and Dialysis, Hospices Civils de Lyon, Lyon, France
| | - J Puthet
- 1 Department of Nephrology, Hypertension and Dialysis, Hospices Civils de Lyon, Lyon, France
| | - N Jourde-Chiche
- 3 Aix-Marseille University, C2VN, INSERM 1263, INRA 1260, Department of Nephrology, AP-HM, Assistance Publique Hopitaux de Marseille, Marseille, France
| | - S Lemoine
- 1 Department of Nephrology, Hypertension and Dialysis, Hospices Civils de Lyon, Lyon, France.,2 University of Lyon 1, Lyon, France
| | - D Chauveau
- 4 Department of Nephrology and Transplantation, Rangueil Hospital, Toulouse, France
| | - O Moranne
- 5 Department of Nephrology-Dialysis-Apheresis, Carémeau Hospital, Nîmes, France
| | - P Rémy
- 6 Department of Nephrology, Henri Mondor Hospital, Créteil, France
| | - M Doret
- 7 Department of Obstetrics, Hospices Civils de Lyon, Lyon, France
| | - E Daugas
- 8 Department of Nephrology, Bichat Hospital, Paris, France
| | - L Juillard
- 1 Department of Nephrology, Hypertension and Dialysis, Hospices Civils de Lyon, Lyon, France.,2 University of Lyon 1, Lyon, France
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28
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Arese V, Murabito P, Ribero S, Panzone M, Tonella L, Fierro MT, Papini M, Quaglino P. Autoimmune connective tissue diseases and pregnancy. GIORN ITAL DERMAT V 2019; 154:263-276. [PMID: 30650958 DOI: 10.23736/s0392-0488.18.06252-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Autoimmune connective tissue-diseases are more frequent in women and deserve a multidisciplinary approach in which the dermatologist play a major role together with other physicians. Pregnancy in these patients has to be considered a high-risk situation, because of possible worsening of the mother's disease and increased morbility and mortality for the fetus; also, therapies have to be chosen carefully because some drugs cannot be used during pregnancy. For all these reasons, the decision to become pregnant needs to consider the type of disease, stage of disease, age and clinical condition, and requires a multidisciplinary approach. A correct counselling, a close monitoring, a specific approach based on the risks involved and the use of appropriate therapies are the keys to obtain optimal pregnancy outcomes.
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Affiliation(s)
- Veronica Arese
- Department of Medical Sciences, Dermatologic Clinic, University of Turin, Turin, Italy
| | - Pierangela Murabito
- Department of Medical Sciences, Dermatologic Clinic, University of Turin, Turin, Italy
| | - Simone Ribero
- Department of Medical Sciences, Dermatologic Clinic, University of Turin, Turin, Italy
| | - Michele Panzone
- Department of Medical Sciences, Dermatologic Clinic, University of Turin, Turin, Italy
| | - Luca Tonella
- Department of Medical Sciences, Dermatologic Clinic, University of Turin, Turin, Italy
| | - Maria T Fierro
- Department of Medical Sciences, Dermatologic Clinic, University of Turin, Turin, Italy
| | - Manuela Papini
- Department of Surgical and Biomedical Sciences, Dermatologic Clinic of Terni, University of Perugia, Perugia, Italy
| | - Pietro Quaglino
- Department of Medical Sciences, Dermatologic Clinic, University of Turin, Turin, Italy -
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29
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Sammaritano LR, Bermas BL. Management of pregnancy and lactation. Best Pract Res Clin Rheumatol 2018; 32:750-766. [DOI: 10.1016/j.berh.2019.03.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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30
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Teng YKO, Bredewold EOW, Rabelink TJ, Huizinga TWJ, Eikenboom HCJ, Limper M, Fritsch-Stork RDE, Bloemenkamp KWM, Sueters M. An evidence-based approach to pre-pregnancy counselling for patients with systemic lupus erythematosus. Rheumatology (Oxford) 2018; 57:1707-1720. [PMID: 29165607 DOI: 10.1093/rheumatology/kex374] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2016] [Indexed: 12/17/2022] Open
Abstract
Patients with SLE are often young females of childbearing age and a pregnancy wish in this patient group is common. However, SLE patients are at high risk for adverse pregnancy outcomes that require adequate guidance. It is widely acknowledged that pre-pregnancy counselling is the pivotal first step in the management of SLE patients with a wish to become pregnant. Next, management of these patients is usually multidisciplinary and often requires specific expertise from the different physicians involved. Very recently a EULAR recommendation was published emphasizing the need for adequate preconception counselling and risk stratification. Therefore the present review specifically addresses the issue of pre-pregnancy counselling for SLE patients with an evidence-based approach. The review summarizes data retrieved from recently published, high-quality cohort studies that have contributed to a better understanding and estimation of pregnancy-related risks for SLE patients. The present review categorizes risks from a patient-oriented point of view, that is, the influence of pregnancy on SLE, of SLE on pregnancy, of SLE on the foetus/neonate and of SLE-related medication. Lastly, pre-pregnancy counselling of SLE patients with additional secondary APS is reviewed. Collectively these data can guide clinicians to formulate appropriate preventive strategies and patient-tailored monitoring plans during pre-pregnancy counselling of SLE patients.
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Affiliation(s)
- Y K Onno Teng
- Department of Nephrology, Leiden University Medical Center, Leiden, The Netherlands
| | - Edwin O W Bredewold
- Department of Nephrology, Leiden University Medical Center, Leiden, The Netherlands
| | - Ton J Rabelink
- Department of Nephrology, Leiden University Medical Center, Leiden, The Netherlands
| | - Tom W J Huizinga
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - H C Jeroen Eikenboom
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Maarten Limper
- Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Ruth D E Fritsch-Stork
- Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht, Utrecht, The Netherlands.,1st Medical Department & Ludwig Boltzmann Institute of Osteology at the Hanusch Hospital of WGKK and AUVA Trauma Centre Meidling, Hanusch Hospital.,Sigmund Freud University, Vienna, Austria
| | - Kitty W M Bloemenkamp
- Department of Obstetrics, Wilhelmina's Children Hospital, Division Woman and Baby, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marieke Sueters
- Department of Gynaecology and Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
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31
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Nahal SK, Selmi C, Gershwin ME. Safety issues and recommendations for successful pregnancy outcome in systemic lupus erythematosus. J Autoimmun 2018; 93:16-23. [PMID: 30056945 DOI: 10.1016/j.jaut.2018.07.016] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2018] [Revised: 07/19/2018] [Accepted: 07/19/2018] [Indexed: 02/07/2023]
Abstract
Systemic lupus erythematosus (SLE) primarily affects women of childbearing age. One of the major changes in SLE focuses on the timing of a successful pregnancy. In the past, pregnancy was strongly discouraged in SLE, especially in the presence of risk factors such as nephritis, use of immunosuppressive therapies, or positivity of specific autoantibodies such as anti-phospholipids and anti-Ro/SSA, La/SSBA. Thanks to our better knowledge on the disease and management, pregnancy success rates in SLE patients have significantly improved care by the a multidisciplinary team which fosters a successful pregnancy with minimal complications for the mother and fetus when the disease is inactive or in remission. This approach is based on a counseling phase before pregnancy, to assess SLE activity phase, specific medications, risk factors, and continues through pregnancy and lactation with significantly improved pregnancy outcomes. Further, we can now better define the risk of disease flares during pregnancy based on a better understanding of the changes in maternal immunity and its relationship with SLE-associated autoimmunity and chronic inflammation. There is wide consensus that women with SLE can have successful pregnancies as long as conception is planned in a phase of inactive disease, and when the patient is closely managed by a rheumatologist, high-risk OB/GYN, neonatologist, and other medical specialists as indicated. Preconception counseling is essential to assess the risk of both fetal and maternal complications as well as identify life-threatening contraindications. Particular attention should be used in those SLE cases that have nephritis, APS or positivity for aPL, pulmonary hypertension, and positive anti-Ro/SSA or anti-La/SSB antibodies. In conclusion, the use of specific guidelines on the management of SLE before and during pregnancy and lactation, and a better understanding of the use of immunosuppressive therapies have significantly increased pregnancy success.
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Affiliation(s)
- Simran Kaur Nahal
- Division of Rheumatology, Allergy, and Clinical Immunology, University of California, Davis, CA, USA
| | - Carlo Selmi
- Division of Rheumatology and Clinical Immunology, Humanitas Research Hospital, Rozzano, Milan, Italy; Department of Biomedical Science and Translational Medicine, University of Milan, Italy.
| | - M Eric Gershwin
- Division of Rheumatology, Allergy, and Clinical Immunology, University of California, Davis, CA, USA.
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32
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McDonald EG, Bissonette L, Ensworth S, Dayan N, Clarke AE, Keeling S, Bernatsky S, Vinet E. Monitoring of Systemic Lupus Erythematosus Pregnancies: A Systematic Literature Review. J Rheumatol 2018; 45:1477-1490. [PMID: 30008450 DOI: 10.3899/jrheum.171023] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/25/2018] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Few data exist to guide the frequency and type of monitoring in systemic lupus erythematosus (SLE) pregnancies. A systematic literature review was performed to address this gap in the literature. METHODS A systematic review of original articles (1975-2015) was performed using Medline, Embase, and Cochrane Library. We included search terms for SLE, pregnancy, and monitoring. We also hand-searched reference lists, review articles, and grey literature for additional relevant articles. RESULTS The search yielded a total of 1106 articles. After removing 117 duplicates, 929 articles that were evidently unrelated to our topic based on title and/or abstract, and 7 that were in a language other than English or French, 53 articles were included for full-text review. Following a more in-depth review, 15 were excluded: 6 did not use any measure of SLE activity and 6 did not specifically address SLE monitoring in pregnancy; 1 case series, 1 review, and 1 metaanalysis were removed. Among the 38 included studies, presence of active disease, antiphospholipid (aPL) antibodies positivity, and abnormal uterine and umbilical artery Doppler studies predicted poor pregnancy outcomes. No studies evaluated an evidence-based approach to the frequency of monitoring. CONCLUSION Few existing studies address monitoring for optimal care during SLE pregnancies. The available data imply roles for aPL antibodies measurement (prior to pregnancy and/or during the first trimester), uterine and umbilical artery Doppler studies in the second trimester, and following disease activity. Optimal frequency of monitoring is not addressed in the existing literature.
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Affiliation(s)
- Emily G McDonald
- From the Division of General Internal Medicine, and the Division of Rheumatology, Department of Medicine, McGill University Health Centre, Montréal; Division of Rheumatology, Department of Medicine, University of Sherbrooke, Sherbrooke, Québec; Division of Rheumatology, Mary Pack Arthritis Center, University of British Columbia, Vancouver, British Columbia; Division of Rheumatology, Department of Medicine, University of Alberta, Edmonton; Division of Rheumatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada.,E.G. McDonald, MD, MSc, Division of General Internal Medicine, Department of Medicine, McGill University Health Centre; L. Bissonette, MD, Division of Rheumatology, Department of Medicine, University of Sherbrooke; S. Ensworth, MD, Assistant Professor, Division of Rheumatology, University of British Columbia; N. Dayan, MD, MSc, Division of General Internal Medicine, Department of Medicine, McGill University Health Centre; A.E. Clarke, MD, MSc, Division of Rheumatology, Department of Medicine, University of Calgary; S. Keeling, MD, MSc, Division of Rheumatology, Department of Medicine, University of Alberta; S. Bernatsky, MD, PhD, Division of Rheumatology, Department of Medicine, McGill University Health Centre; E. Vinet, MD, PhD, Division of Rheumatology, Department of Medicine, McGill University Health Centre
| | - Lyne Bissonette
- From the Division of General Internal Medicine, and the Division of Rheumatology, Department of Medicine, McGill University Health Centre, Montréal; Division of Rheumatology, Department of Medicine, University of Sherbrooke, Sherbrooke, Québec; Division of Rheumatology, Mary Pack Arthritis Center, University of British Columbia, Vancouver, British Columbia; Division of Rheumatology, Department of Medicine, University of Alberta, Edmonton; Division of Rheumatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada.,E.G. McDonald, MD, MSc, Division of General Internal Medicine, Department of Medicine, McGill University Health Centre; L. Bissonette, MD, Division of Rheumatology, Department of Medicine, University of Sherbrooke; S. Ensworth, MD, Assistant Professor, Division of Rheumatology, University of British Columbia; N. Dayan, MD, MSc, Division of General Internal Medicine, Department of Medicine, McGill University Health Centre; A.E. Clarke, MD, MSc, Division of Rheumatology, Department of Medicine, University of Calgary; S. Keeling, MD, MSc, Division of Rheumatology, Department of Medicine, University of Alberta; S. Bernatsky, MD, PhD, Division of Rheumatology, Department of Medicine, McGill University Health Centre; E. Vinet, MD, PhD, Division of Rheumatology, Department of Medicine, McGill University Health Centre
| | - Stephanie Ensworth
- From the Division of General Internal Medicine, and the Division of Rheumatology, Department of Medicine, McGill University Health Centre, Montréal; Division of Rheumatology, Department of Medicine, University of Sherbrooke, Sherbrooke, Québec; Division of Rheumatology, Mary Pack Arthritis Center, University of British Columbia, Vancouver, British Columbia; Division of Rheumatology, Department of Medicine, University of Alberta, Edmonton; Division of Rheumatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada.,E.G. McDonald, MD, MSc, Division of General Internal Medicine, Department of Medicine, McGill University Health Centre; L. Bissonette, MD, Division of Rheumatology, Department of Medicine, University of Sherbrooke; S. Ensworth, MD, Assistant Professor, Division of Rheumatology, University of British Columbia; N. Dayan, MD, MSc, Division of General Internal Medicine, Department of Medicine, McGill University Health Centre; A.E. Clarke, MD, MSc, Division of Rheumatology, Department of Medicine, University of Calgary; S. Keeling, MD, MSc, Division of Rheumatology, Department of Medicine, University of Alberta; S. Bernatsky, MD, PhD, Division of Rheumatology, Department of Medicine, McGill University Health Centre; E. Vinet, MD, PhD, Division of Rheumatology, Department of Medicine, McGill University Health Centre
| | - Natalie Dayan
- From the Division of General Internal Medicine, and the Division of Rheumatology, Department of Medicine, McGill University Health Centre, Montréal; Division of Rheumatology, Department of Medicine, University of Sherbrooke, Sherbrooke, Québec; Division of Rheumatology, Mary Pack Arthritis Center, University of British Columbia, Vancouver, British Columbia; Division of Rheumatology, Department of Medicine, University of Alberta, Edmonton; Division of Rheumatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada.,E.G. McDonald, MD, MSc, Division of General Internal Medicine, Department of Medicine, McGill University Health Centre; L. Bissonette, MD, Division of Rheumatology, Department of Medicine, University of Sherbrooke; S. Ensworth, MD, Assistant Professor, Division of Rheumatology, University of British Columbia; N. Dayan, MD, MSc, Division of General Internal Medicine, Department of Medicine, McGill University Health Centre; A.E. Clarke, MD, MSc, Division of Rheumatology, Department of Medicine, University of Calgary; S. Keeling, MD, MSc, Division of Rheumatology, Department of Medicine, University of Alberta; S. Bernatsky, MD, PhD, Division of Rheumatology, Department of Medicine, McGill University Health Centre; E. Vinet, MD, PhD, Division of Rheumatology, Department of Medicine, McGill University Health Centre
| | - Ann E Clarke
- From the Division of General Internal Medicine, and the Division of Rheumatology, Department of Medicine, McGill University Health Centre, Montréal; Division of Rheumatology, Department of Medicine, University of Sherbrooke, Sherbrooke, Québec; Division of Rheumatology, Mary Pack Arthritis Center, University of British Columbia, Vancouver, British Columbia; Division of Rheumatology, Department of Medicine, University of Alberta, Edmonton; Division of Rheumatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada.,E.G. McDonald, MD, MSc, Division of General Internal Medicine, Department of Medicine, McGill University Health Centre; L. Bissonette, MD, Division of Rheumatology, Department of Medicine, University of Sherbrooke; S. Ensworth, MD, Assistant Professor, Division of Rheumatology, University of British Columbia; N. Dayan, MD, MSc, Division of General Internal Medicine, Department of Medicine, McGill University Health Centre; A.E. Clarke, MD, MSc, Division of Rheumatology, Department of Medicine, University of Calgary; S. Keeling, MD, MSc, Division of Rheumatology, Department of Medicine, University of Alberta; S. Bernatsky, MD, PhD, Division of Rheumatology, Department of Medicine, McGill University Health Centre; E. Vinet, MD, PhD, Division of Rheumatology, Department of Medicine, McGill University Health Centre
| | - Stephanie Keeling
- From the Division of General Internal Medicine, and the Division of Rheumatology, Department of Medicine, McGill University Health Centre, Montréal; Division of Rheumatology, Department of Medicine, University of Sherbrooke, Sherbrooke, Québec; Division of Rheumatology, Mary Pack Arthritis Center, University of British Columbia, Vancouver, British Columbia; Division of Rheumatology, Department of Medicine, University of Alberta, Edmonton; Division of Rheumatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada.,E.G. McDonald, MD, MSc, Division of General Internal Medicine, Department of Medicine, McGill University Health Centre; L. Bissonette, MD, Division of Rheumatology, Department of Medicine, University of Sherbrooke; S. Ensworth, MD, Assistant Professor, Division of Rheumatology, University of British Columbia; N. Dayan, MD, MSc, Division of General Internal Medicine, Department of Medicine, McGill University Health Centre; A.E. Clarke, MD, MSc, Division of Rheumatology, Department of Medicine, University of Calgary; S. Keeling, MD, MSc, Division of Rheumatology, Department of Medicine, University of Alberta; S. Bernatsky, MD, PhD, Division of Rheumatology, Department of Medicine, McGill University Health Centre; E. Vinet, MD, PhD, Division of Rheumatology, Department of Medicine, McGill University Health Centre
| | - Sasha Bernatsky
- From the Division of General Internal Medicine, and the Division of Rheumatology, Department of Medicine, McGill University Health Centre, Montréal; Division of Rheumatology, Department of Medicine, University of Sherbrooke, Sherbrooke, Québec; Division of Rheumatology, Mary Pack Arthritis Center, University of British Columbia, Vancouver, British Columbia; Division of Rheumatology, Department of Medicine, University of Alberta, Edmonton; Division of Rheumatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada.,E.G. McDonald, MD, MSc, Division of General Internal Medicine, Department of Medicine, McGill University Health Centre; L. Bissonette, MD, Division of Rheumatology, Department of Medicine, University of Sherbrooke; S. Ensworth, MD, Assistant Professor, Division of Rheumatology, University of British Columbia; N. Dayan, MD, MSc, Division of General Internal Medicine, Department of Medicine, McGill University Health Centre; A.E. Clarke, MD, MSc, Division of Rheumatology, Department of Medicine, University of Calgary; S. Keeling, MD, MSc, Division of Rheumatology, Department of Medicine, University of Alberta; S. Bernatsky, MD, PhD, Division of Rheumatology, Department of Medicine, McGill University Health Centre; E. Vinet, MD, PhD, Division of Rheumatology, Department of Medicine, McGill University Health Centre
| | - Evelyne Vinet
- From the Division of General Internal Medicine, and the Division of Rheumatology, Department of Medicine, McGill University Health Centre, Montréal; Division of Rheumatology, Department of Medicine, University of Sherbrooke, Sherbrooke, Québec; Division of Rheumatology, Mary Pack Arthritis Center, University of British Columbia, Vancouver, British Columbia; Division of Rheumatology, Department of Medicine, University of Alberta, Edmonton; Division of Rheumatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada. .,E.G. McDonald, MD, MSc, Division of General Internal Medicine, Department of Medicine, McGill University Health Centre; L. Bissonette, MD, Division of Rheumatology, Department of Medicine, University of Sherbrooke; S. Ensworth, MD, Assistant Professor, Division of Rheumatology, University of British Columbia; N. Dayan, MD, MSc, Division of General Internal Medicine, Department of Medicine, McGill University Health Centre; A.E. Clarke, MD, MSc, Division of Rheumatology, Department of Medicine, University of Calgary; S. Keeling, MD, MSc, Division of Rheumatology, Department of Medicine, University of Alberta; S. Bernatsky, MD, PhD, Division of Rheumatology, Department of Medicine, McGill University Health Centre; E. Vinet, MD, PhD, Division of Rheumatology, Department of Medicine, McGill University Health Centre.
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Bundhun PK, Soogund MZS, Huang F. Arterial/venous thrombosis, fetal loss and stillbirth in pregnant women with systemic lupus erythematosus versus primary and secondary antiphospholipid syndrome: a systematic review and meta-analysis. BMC Pregnancy Childbirth 2018; 18:212. [PMID: 29879927 PMCID: PMC5992885 DOI: 10.1186/s12884-018-1850-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 05/25/2018] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND We aimed to systematically compare arterial/venous thrombosis, fetal loss and stillbirth in pregnant women with systemic lupus erythematosus (SLE), primary anti-phospholipid syndrome (PAPS) and secondary anti-phospholipid syndrome (SAPS). METHODS Online databases were carefully searched for relevant publications comparing SLE with PAPS and/or SAPS in pregnancy. Studies were included if: they compared SLE with APS [SLE versus PAPS or SLE versus SAPS or SLE versus PAPS and SAPS respectively] in pregnant women; and they reported specific adverse outcomes as their clinical endpoints including arterial/venous thrombosis, fetal loss and stillbirth. Risk ratios (RR) with 95% confidence intervals (CIs) were used as statistical parameters and the analysis was carried out by the RevMan 5.3 software. RESULTS A total number of 941 pregnant women were included: 556 were candidates of SLE; 200 were candidates of PAPS; and 185 were candidates of SAPS. APS was associated with a significantly higher risk of fetal loss (RR: 4.49, 95% CI: 2.09-9.64; P = 0.0001). In addition, stillbirth and arterial/venous thrombosis were also significantly increased with APS (RR: 6.65, 95% CI: 2.14-20.60; P = 0.001) and (RR: 3.95, 95% CI: 1.28-12.16; P = 0.02) respectively. When patients with PAPS were compared with patients who suffered from SLE alone, fetal loss and arterial/venous thrombosis were still significantly higher with the former. When SAPS were compared with SLE (without anti-phospholipid antibodies), arterial/venous thrombosis, stillbirth and fetal loss were still significantly higher with SAPS. However, no significant difference was observed in arterial/venous thrombosis and fetal loss between PAPS and SAPS. CONCLUSIONS PAPS and SAPS were associated with significantly higher arterial/venous thrombosis, fetal loss and stillbirth in comparison to SLE. However, no significant difference was observed when PAPS was compared to SAPS.
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Affiliation(s)
- Pravesh Kumar Bundhun
- Department of Internal Medicine, the First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi 530021 People’s Republic of China
| | | | - Feng Huang
- Institute of Cardiovascular Diseases and Guangxi Key Laboratory Base of Precision Medicine in Cardio-cerebrovascular Diseases Control and Prevention, the First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi 530021 People’s Republic of China
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Wu J, Ma J, Zhang WH, Di W. Management and outcomes of pregnancy with or without lupus nephritis: a systematic review and meta-analysis. Ther Clin Risk Manag 2018; 14:885-901. [PMID: 29785115 PMCID: PMC5955382 DOI: 10.2147/tcrm.s160760] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Background Although it is well established that systemic lupus erythematosus (SLE) negatively affects pregnancy outcomes, there is insufficient evidence on the effect of lupus nephritis (LN) on antenatal management and pregnancy outcomes. We performed a systematic review and meta-analysis to determine the association of LN with management and pregnancy outcomes in SLE patients. Methods Embase, Medline, Cochrane, and ClinicalTrials.gov were carefully searched for relevant English and Chinese language studies. A total of 2,987 articles were reviewed. Data were extracted that compared management and pregnancy outcomes in SLE pregnant women with LN vs without LN. Risk of bias was assessed by a modified version of the Newcastle-Ottawa Scale and the STROBE checklist. Combined odds ratios (OR) and 95% confidence intervals (CI) were obtained and sensitivity analysis was performed using RevMan 5.3 software. Results Sixteen studies, including 1,760 pregnant patients with SLE, were included. Gestational hypertension (OR=5.65, 95% CI=2.94–10.84), preeclampsia (OR=2.84, 95% CI=1.87–4.30), SLE flare (OR=2.66, 95% CI=1.51–4.70), renal flare (OR=15.18, 95% CI=5.89–39.14), proteinuria (OR=8.86, 95% CI=4.75–16.52), and hypocomplementemia (OR=2.86, 95% CI=1.68–4.87) were significantly affected in pregnant women with LN. Anti-Sjögren’s syndrome-related antigen A/Ro autoantibodies were negatively associated with pregnant women with LN (OR=0.57, 95% CI=0.33–0.98). Pregnant women with LN presented a significant decrease in live births (OR=0.62, 95% CI=0.49–0.80) and a significant increase in preterm births (OR=1.92, 95% CI=1.49–2.49) and fetal growth restriction (OR=1.43, 95% CI=1.08–1.91). Regarding antenatal management, steroids (OR=2.48, 95% CI=1.59–3.87) and immunosuppressant treatment (OR=6.77, 95% CI=3.30–13.89) were more frequently used in women with LN. Conclusion This review identified a significant association between the aforementioned outcomes and SLE pregnant patients with LN. In patients with SLE, LN increased the risks for adverse pregnancy outcomes and the use of medication. Therefore, special treatment and close monitoring should be allocated to pregnant women with LN.
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Affiliation(s)
- Jiayue Wu
- Department of Obstetrics and Gynecology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, People's Republic of China.,Shanghai Key Laboratory of Gynecologic Oncology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, People's Republic of China.,International Centre for Reproductive Health (ICRH), Ghent University, Ghent, Belgium
| | - Jinghang Ma
- Department of Obstetrics and Gynecology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, People's Republic of China.,Shanghai Key Laboratory of Gynecologic Oncology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, People's Republic of China
| | - Wei-Hong Zhang
- International Centre for Reproductive Health (ICRH), Ghent University, Ghent, Belgium
| | - Wen Di
- Department of Obstetrics and Gynecology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, People's Republic of China.,Shanghai Key Laboratory of Gynecologic Oncology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, People's Republic of China
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Ling N, Lawson E, von Scheven E. Adverse pregnancy outcomes in adolescents and young women with systemic lupus erythematosus: a national estimate. Pediatr Rheumatol Online J 2018; 16:26. [PMID: 29661199 PMCID: PMC5902884 DOI: 10.1186/s12969-018-0242-0] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 04/04/2018] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Pregnant women with systemic lupus erythematosus (SLE) have increased risk of adverse outcomes including disease flare, spontaneous abortion, preeclampsia/eclampsia, premature birth and maternal death. However, pregnancy outcomes among adolescents and young women with SLE have not been well-explored. Our objective was to compare risk of adverse pregnancy outcomes in adolescents and young women with SLE to risk among peers without SLE. METHODS We studied the 2000-2011 Nationwide Inpatient Sample (NIS) of the Healthcare Cost and Utilization Project (HCUP) to estimate the prevalence of adverse pregnancy outcomes in women with SLE aged ≤ 21 years at time of delivery. Outcomes were compared to peers without SLE by using multivariate logistic regression to calculate odds ratios and risk differences. Additionally, differences in length of stay and total charges per hospitalization were described. RESULTS There were 8,791,391 unique pregnancies, of which 4002 occurred in young women with SLE. After adjustment for age, race, insurance type and quartile of median income based on patient ZIP code individuals with SLE had increased odds of pre-eclampsia/eclampsia (OR 3.2, 95% CI 2.3-4.6), maternal death (OR 80, 95% CI 10-604), preterm birth (OR 2.7, 95% CI 2-3.7), spontaneous abortion (OR 5.1, 95% CI 2.8-9.6), and induced abortion (OR 30, 95% CI 14-63). The increase in risk among women with SLE was greatest for preterm birth (RD 11%, 95% CI 6-16), pre-eclampsia/eclampsia (RD 9%, 95% CI 5-13), and spontaneous abortion (RD 4%, 95% CI 0.9-6). Risk difference for induced abortion was 2% with 95% CI 0.6-4, while the difference in risk for maternal death did not reach statistical significance (RD 0.4, 95% CI -0.4-1). CONCLUSIONS Adolescents and young women with SLE experience increased risk of adverse, pregnancy-specific outcomes as compared to their peers, including pre-eclampsia/eclampsia, maternal death, preterm birth, spontaneous abortion, and induced abortion. Additionally, length of stay and total charges for hospitalization are increased.
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Affiliation(s)
- Nicole Ling
- University of California San Francisco, 550 16th Street, 5th Floor, Box 0632, San Francisco, CA, 94143, USA.
| | - Erica Lawson
- 0000 0001 2297 6811grid.266102.1University of California San Francisco, 550 16th Street, 5th Floor, Box 0632, San Francisco, CA 94143 USA
| | - Emily von Scheven
- 0000 0001 2297 6811grid.266102.1University of California San Francisco, 550 16th Street, 5th Floor, Box 0632, San Francisco, CA 94143 USA
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Maternal and Perinatal Outcome in Women with Systemic Lupus Erythematosus: A Retrospective Bicenter Cohort Study. J Immunol Res 2017; 2017:8245879. [PMID: 29094052 PMCID: PMC5637847 DOI: 10.1155/2017/8245879] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Revised: 07/28/2017] [Accepted: 08/08/2017] [Indexed: 01/19/2023] Open
Abstract
Objective To investigate disease activity around and during pregnancy and pregnancy outcome in women with systemic lupus erythematosus (SLE) considering antiphospholipid antibody status. Moreover, differences between first and consecutive pregnancies were examined. Methods Pregnancies > 16 weeks gestation of SLE patients receiving joint care from rheumatologists and gynecologists in two tertiary centers in the Netherlands between 2000 and 2015 were included. Disease activity, flare rate, and pregnancy outcomes and complications were assessed. Results Ninety-six women (84% Caucasian) with 144 pregnancies were included. The median SLE(P)DAI score was 2 before, during, and after pregnancy. Flare rates were 6.3%, 20.1%, and 15.3%, respectively. Severe hypertensive disorder of pregnancy, intrauterine fetal death, preterm birth, and small-for-gestational age infants occurred in 18.1%, 4.1%, 32.7%, and 14.8%, respectively. Complication rates were similar in the first and consecutive pregnancies. Half of the women did not experience any pregnancy complication whereas 42.7% developed a complication during all pregnancies. Mean number of pregnancies was 2.4 and live births 1.7. Conclusion In this SLE population with low disease activity, pregnancy complications were present irrespective of antiphospholipid antibody status. Furthermore, there were no differences in complication rates between the first and consecutive pregnancies as seen in healthy mothers. This information is useful for patient counseling.
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Wei S, Lai K, Yang Z, Zeng K. Systemic lupus erythematosus and risk of preterm birth: a systematic review and meta-analysis of observational studies. Lupus 2017; 26:563-571. [PMID: 28121241 DOI: 10.1177/0961203316686704] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We performed a meta-analysis to identify the association between systemic lupus erythematosus (SLE) and preterm birth. In this study, we studied the effects of SLE, SLE disease activity, a history of nephritis and active nephritis on preterm birth. Searches were conducted before 20 May 2016 of PubMed, Embase, Medline and Cochrane Library of literature and article reference lists. Eleven observational case-control studies and thirteen cohort studies met the inclusion criteria. The pooled relative risk (RR) for the risk of preterm birth in SLE patients versus controls was 2.05 (95% confidence interval (CI): 1.72-3.32); for active SLE patients versus inactive was 2.98 (95% CI: 2.32-3.83); for SLE patients with a history of lupus nephritis versus those without nephritis it was 1.62 (95% CI: 1.35-1.95); and for SLE patients with active nephritis versus those with quiescent nephritis it was 1.78 (95% CI: 1.17-2.70). In summary, this study identified a significant association in the above results. This association was more significant in active SLE patients versus inactive. With respect to SLE itself, active inflammation (such as disease activity) may be more hazardous for the management of the pregnancy. This suggests that it is essential to control disease activity in order to achieve a better outcome of SLE pregnancy.
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Affiliation(s)
- S Wei
- Department of Dermatology, Nanfang Hospital, Southern Medical University, Guangzhou, PR China
| | - K Lai
- Department of Dermatology, Nanfang Hospital, Southern Medical University, Guangzhou, PR China
| | - Z Yang
- Department of Dermatology, Nanfang Hospital, Southern Medical University, Guangzhou, PR China
| | - K Zeng
- Department of Dermatology, Nanfang Hospital, Southern Medical University, Guangzhou, PR China
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Paydar K, Niakan Kalhori SR, Akbarian M, Sheikhtaheri A. A clinical decision support system for prediction of pregnancy outcome in pregnant women with systemic lupus erythematosus. Int J Med Inform 2016; 97:239-246. [PMID: 27919382 DOI: 10.1016/j.ijmedinf.2016.10.018] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2015] [Revised: 10/14/2016] [Accepted: 10/29/2016] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Pregnancy among systemic lupus erythematosus (SLE)-affected women is highly associated with poor obstetric outcomes. Predicting the risk of foetal outcome is essential for maximizing the success of pregnancy. This study aimed to develop a clinical decision support system (CDSS) to predict pregnancy outcomes among SLE-affected pregnant women. METHODS We performed a retrospective analysis of 149 pregnant women with SLE, who were followed at Shariati Hospital (104 pregnancies) and a specialized clinic (45 pregnancies) from 1982 to 2014. We selected significant features (p<0.10) using a binary logistic regression model performed in IBM SPSS (version 20). Afterward, we trained several artificial neural networks (multi-layer perceptron [MLP] and radial basis function [RBF]) to predict the pregnancy outcome. In order to evaluate and select the most effective network, we used the confusion matrix and the receiver operating characteristic (ROC) curve. We finally developed a CDSS based on the most accurate network. MATLAB 2013b software was applied to design the neural networks and develop the CDSS. RESULTS Initially, 45 potential variables were analysed by the binary logistic regression and 16 effective features were selected as the inputs of neural networks (P-value<0.1). The accuracy (90.9%), sensitivity (80.0%), and specificity (94.1%) of the test data for the MLP network were achieved. These measures for the RBF network were 71.4%, 53.3%, and 79.4%, respectively. Having applied a 10-fold cross-validation method, the accuracy for the networks showed 75.16% accuracy for RBF and 90.6% accuracy for MLP. Therefore, the MLP network was selected as the most accurate network for prediction of pregnancy outcome. CONCLUSION The developed CDSS based on the MLP network can help physicians to predict pregnancy outcomes in women with SLE.
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Affiliation(s)
- Khadijeh Paydar
- Department of Health Information Management, School of Allied Medical Sciences, Tehran University of Medical Sciences, Tehran, Islamic Republic of Iran.
| | - Sharareh R Niakan Kalhori
- Department of Health Information Management, School of Allied Medical Sciences, Tehran University of Medical Sciences, Tehran, Islamic Republic of Iran.
| | - Mahmoud Akbarian
- Rheumatology Research Center, Tehran University of Medical Sciences, Tehran, Islamic Republic of Iran.
| | - Abbas Sheikhtaheri
- Department of Health Information Management, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Islamic Republic of Iran.
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Lazzaroni MG, Dall’Ara F, Fredi M, Nalli C, Reggia R, Lojacono A, Ramazzotto F, Zatti S, Andreoli L, Tincani A. A comprehensive review of the clinical approach to pregnancy and systemic lupus erythematosus. J Autoimmun 2016; 74:106-117. [DOI: 10.1016/j.jaut.2016.06.016] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Accepted: 06/27/2016] [Indexed: 01/23/2023]
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Rezk M, Ellakwa H, Al-Halaby A, Shaheen A, Zahran A, Badr H. Predictors of poor obstetric outcome in women with systemic lupus erythematosus: a 10-year experience of a university hospital. J Matern Fetal Neonatal Med 2016; 30:2031-2035. [PMID: 27628505 DOI: 10.1080/14767058.2016.1236244] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To compare the maternal and fetal outcome in patients with systemic lupus erythematosus (SLE) by a retrospective analysis from 2005 to 2010, and a prospective follow-up of pregnant SLE patients from 2010 to 2015 to find out predictors of poor obstetric outcome. METHODS The study included 236 SLE pregnant females (retrospective group) whose data were viewed retrospectively from their medical records, and 214 SLE pregnant females (prospective group) who were followed prospectively to record their maternal and fetal outcome. RESULTS There was a highly significant difference between the two groups regarding abortion, venous thromboembolism, prematurity, and intrauterine fetal death (p < 0.001) with more occurrence in retrospective group. Also, the frequency of lupus flares, worsening of renal functions, blood transfusion, maternal mortality, admission to NICU, and neonatal death was higher in the retrospective group (p < 0.05). Predictors of poor obstetric outcome included Last flare before pregnancy <6 months, number of antenatal hospital admissions ≥ 6, use of immunosuppressive therapy, the presence of anti-SSA/Ro and anti-SSB/La, and SLE with nephritis (p < 0.05). CONCLUSION Improved maternal and fetal outcome in women with SLE has occurred following integrated multidisciplinary approach. This emphasizes the importance of postponing pregnancy when predictors of poor outcome are encountered.
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Affiliation(s)
| | | | | | | | | | - Hassan Badr
- c Department of Pediatrics , Faculty of Medicine, Menoufia University , Menoufia , Egypt
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Abstract
Reproductive issues including contraception, fertility, and pregnancy are important components of the comprehensive care of women with systemic lupus erythematosus (SLE). SLE pregnancies are complicated due to risk for maternal disease exacerbation and potential for fetal and neonatal complications. Pre-pregnancy assessment is important to identify patients with severe disease-related damage who should avoid pregnancy, counsel patients to conceive when disease has been stable and inactive on appropriate medications, and assess relevant risk factors including renal disease, antiphospholipid antibody, and anti-Ro/SS-A and anti-La/SS-B antibodies. With careful planning, monitoring, and care, most women with SLE can anticipate a successful pregnancy.
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Affiliation(s)
- Lisa R Sammaritano
- Hospital for Special Surgery, Weill Cornell Medicine, New York, NY 10021;
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Abstract
The management of lupus nephritis in pregnancy presents a diagnostic and therapeutic challenge for providers. Pregnancy creates a series of physiologic changes in the immune system and kidney that may result in an increased risk of disease flare and adverse maternal and fetal outcomes, such as preeclampsia, fetal loss, and preterm delivery. Conception should be delayed until disease is in remission to ensure the best pregnancy outcomes. Maternal disease activity and fetal well-being should be monitored closely by an interdisciplinary team, including obstetricians, rheumatologists, and nephrologists throughout pregnancy. Careful attention must be paid to the dosing and potential teratogenicity of medications.
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Affiliation(s)
- Andrea G Kattah
- Department of General Internal Medicine, Mayo Clinic, Rochester, MN
| | - Vesna D Garovic
- Division of Nephrology and Hypertension, Department of General Internal Medicine, Mayo Clinic, Rochester, MN
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Ku M, Guo S, Shang W, Li Q, Zeng R, Han M, Ge S, Xu G. Pregnancy Outcomes in Chinese Patients with Systemic Lupus Erythematosus (SLE): A Retrospective Study of 109 Pregnancies. PLoS One 2016; 11:e0159364. [PMID: 27442513 PMCID: PMC4956200 DOI: 10.1371/journal.pone.0159364] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2015] [Accepted: 07/01/2016] [Indexed: 11/18/2022] Open
Abstract
Systemic lupus erythematosus (SLE) is a multisystem autoimmune disease that primarily affects women during their reproductive years. The interaction between SLE and pregnancy remains debated. The objective of this study was to analyze the fetal and maternal outcomes of Chinese women with SLE. A total of 109 pregnancies in 83 SLE patients from June 2004 to June 2014 at a tertiary university hospital were reviewed retrospectively. Patients' characteristics, clinical and laboratory data during pregnancy were obtained from electronic medical records. After exclusion of elective abortions, the live birth rate was 61.5%. Significantly, APS (antiphospholipid syndrome), disease activity, hypertension, hypocomplementemia, thrombocytopenia, and anemia during pregnancy were more commonly observed in fetal loss pregnancies than in live birth pregnancies. Compared to the 64 women with a history of SLE, 19 women with new-onset lupus during pregnancy had worse pregnancy outcome. Furthermore, the 64 patients with a history of SLE were divided into lupus nephritis group and SLE group (non-renal involvement). We found that the lupus nephritis group had worse maternal outcome than the SLE group. We conclude that new-onset lupus during pregnancy predicts both adverse maternal and fetal outcomes, while a history of lupus nephritis predicts adverse maternal outcomes. It is essential to provide SLE women with progestational counseling and regular multispecialty care during pregnancy.
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Affiliation(s)
- Ming Ku
- Division of Nephrology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Shuiming Guo
- Division of Nephrology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Weifeng Shang
- Division of Nephrology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Qing Li
- Division of Nephrology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Rui Zeng
- Division of Nephrology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Min Han
- Division of Nephrology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Shuwang Ge
- Division of Nephrology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
- * E-mail: (SWG); (GX)
| | - Gang Xu
- Division of Nephrology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
- * E-mail: (SWG); (GX)
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Yamamoto Y, Aoki S. Systemic lupus erythematosus: strategies to improve pregnancy outcomes. Int J Womens Health 2016; 8:265-72. [PMID: 27468250 PMCID: PMC4944915 DOI: 10.2147/ijwh.s90157] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Systemic lupus erythematosus (SLE) is a chronic autoimmune inflammatory disease with a high prevalence in females of childbearing age. Thus, reproduction in SLE patients is a major concern for clinicians. In the past, SLE patients were advised to defer pregnancy because of poor pregnancy outcomes and fear of SLE flares during pregnancy. Investigations to date show that maternal and fetal risks are higher in females with SLE than in the general population. However, with appropriate management of the disease, sufferers may have a relatively uncomplicated pregnancy course. Factors such as appropriate preconception counseling and medication adjustment, strict disease control prior to pregnancy, intensive surveillance during and after pregnancy by both the obstetrician and rheumatologist, and appropriate interventions when necessary play a key role. This review describes the strategies to improve pregnancy outcomes in SLE patients at different time points in the reproduction cycle (preconception, during pregnancy, and postpartum period) and also details the neonatal concerns.
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Affiliation(s)
- Yuriko Yamamoto
- Perinatal Center for Maternity and Neonate, Yokohama City University Medical Center, Yokohama, Kanagawa Prefecture, Japan
| | - Shigeru Aoki
- Perinatal Center for Maternity and Neonate, Yokohama City University Medical Center, Yokohama, Kanagawa Prefecture, Japan
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Tedeschi SK, Guan H, Fine A, Costenbader KH, Bermas B. Organ-specific systemic lupus erythematosus activity during pregnancy is associated with adverse pregnancy outcomes. Clin Rheumatol 2016; 35:1725-32. [PMID: 27166627 DOI: 10.1007/s10067-016-3270-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Revised: 04/08/2016] [Accepted: 04/08/2016] [Indexed: 11/28/2022]
Abstract
Systemic lupus erythematosus (SLE) is a disease of reproductive-age women, and thus questions regarding how disease influences pregnancy outcomes arise. We investigated whether five specific types of SLE activity during the 6 months before conception or during pregnancy (nephritis, cytopenias, skin disease, arthritis, serositis) were associated with adverse pregnancy outcomes. We performed a retrospective cohort study of pregnancy outcomes among women with SLE at the Brigham and Women's Hospital Lupus Center. Adverse pregnancy outcomes included pre-eclampsia, pre-term delivery, elective termination due to SLE, spontaneous miscarriage at weeks 12-20, and stillbirth. SLE and obstetric history, laboratories, and medications were obtained from electronic medical records. Generalized linear mixed models adjusting for potential confounders were used to identify predictors of any adverse pregnancy outcome. Most pregnancies resulted in a live term delivery (76.5 %). After adjustment for Hispanic ethnicity, prior adverse pregnancy outcome and medication use 6 months before conception, nephritis during pregnancy (odds ratio (OR) 3.6, 95 % confidence interval (CI) 1.0-12.8), cytopenias during pregnancy (OR 3.9, 95 % CI 1.3-11.4), and serositis during pregnancy (OR 5.9, 95 % CI 1.0-34.0) were significantly associated with adverse pregnancy outcome. Specific types of SLE disease activity during pregnancy were related to adverse pregnancy outcome. Nephritis, cytopenias, and serositis carried a higher risk of adverse pregnancy outcome, suggesting that these abnormalities should be carefully monitored during pregnancy.
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Affiliation(s)
- Sara K Tedeschi
- Department of Medicine, Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA.
| | - Hongshu Guan
- Department of Medicine, Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Alexander Fine
- Department of Medicine, Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Karen H Costenbader
- Department of Medicine, Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Bonnie Bermas
- Department of Medicine, Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
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46
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Kim IJ, Kim HA, Suh CH, Park YW, Lee HS, Bang SY, Bae SC, Kang YM, Lee WK, Park H, Lee J. Impact of Childbearing Decisions on Family Size of Korean Women with Systemic Lupus Erythematosus. J Korean Med Sci 2016; 31:729-34. [PMID: 27134494 PMCID: PMC4835598 DOI: 10.3346/jkms.2016.31.5.729] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Accepted: 01/21/2016] [Indexed: 11/20/2022] Open
Abstract
Systemic lupus erythematosus (SLE) predominantly affects women in their reproductive years and has a significant impact on childbearing. We investigated the influence of personal decision on family size among Korean women with SLE and factors that affect the decisions. A case-control study comparing childbearing history and decisions of 112 SLE patients and 135 controls was performed. Women with SLE participating in the Network for Lupus Clinical Research in South Korea and matching controls between ages of 18-45, who are/were married or living with a partner were included. Data regarding socio-demographics, reproductive history, and childbearing decisions were collected through a survey using a standardized questionnaire and medical record review. More women with SLE reported at least one pregnancy (85.7% vs. 71.9%, P = 0.009) or at least one live birth (85.7% vs. 71.9%, P = 0.003) compared with controls. Mean number of pregnancies was significantly higher (2.4 ± 1.6 vs. 1.4 ± 1.3, P < 0.001), and mean number of live births was significantly lower in women with SLE (1.2 ± 0.8 vs. 1.6 ± 0.8, P < 0.001). Significantly more women with SLE made the decision not to have children compared with controls (54.5% vs. 40.7%, P = 0.031), and health-related concerns were the major cause of the decision. Other socio-demographic factors did not influence the decision to limit childbearing in SLE women. The disease-related concerns had significant impact on family size and childbearing decisions among Korean women with SLE.
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Affiliation(s)
- In Je Kim
- Department of Rheumatology, Ewha Womans University School of Medicine, Seoul, Korea
| | - Hyoun-Ah Kim
- Department of Rheumatology, Ajou University School of Medicine, Suwon, Korea
| | - Chang-Hee Suh
- Department of Rheumatology, Ajou University School of Medicine, Suwon, Korea
| | - Yong-Wook Park
- Department of Rheumatology, Chonnam National University Hospital and Medical School, Gwangju, Korea
| | - Hye-Soon Lee
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul, Korea
| | - So-Young Bang
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul, Korea
| | - Sang-Cheol Bae
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul, Korea
| | - Young Mo Kang
- Department of Rheumatology, Kyungpook National University School of Medicine, Daegu, Korea
| | - Won Kyung Lee
- Department of Social and Preventive Medicine, Inha University School of Medicine, Incheon, Korea
| | - Hyesook Park
- Department of Preventive Medicine, Ewha Womans University School of Medicine, Seoul, Korea
| | - Jisoo Lee
- Department of Rheumatology, Ewha Womans University School of Medicine, Seoul, Korea
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Saavedra Salinas MÁ, Barrera Cruz A, Cabral Castañeda AR, Jara Quezada LJ, Arce-Salinas CA, Álvarez Nemegyei J, Fraga Mouret A, Orozco Alcalá J, Salazar Páramo M, Cruz Reyes CV, Andrade Ortega L, Vera Lastra OL, Mendoza Pinto C, Sánchez González A, Cruz Cruz PDR, Morales Hernández S, Portela Hernández M, Pérez Cristóbal M, Medina García G, Hernández Romero N, Velarde Ochoa MDC, Navarro Zarza JE, Portillo Díaz V, Vargas Guerrero A, Goycochea Robles MV, García Figueroa JL, Barreira Mercado E, Amigo Castañeda MC. Guías de práctica clínica para la atención del embarazo en mujeres con enfermedades reumáticas autoinmunes del Colegio Mexicano de Reumatología. Parte I. ACTA ACUST UNITED AC 2015; 11:295-304. [DOI: 10.1016/j.reuma.2014.11.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2014] [Revised: 10/07/2014] [Accepted: 11/08/2014] [Indexed: 10/24/2022]
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48
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Chen S, Sun X, Wu B, Lian X. Pregnancy in Women with Systemic Lupus Erythematosus: A Retrospective Study of 83 Pregnancies at a Single Centre. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2015; 12:9876-88. [PMID: 26295404 PMCID: PMC4555317 DOI: 10.3390/ijerph120809876] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Revised: 08/13/2015] [Accepted: 08/13/2015] [Indexed: 01/03/2023]
Abstract
Objective: To evaluate the outcome of 80 pregnant women with systemic lupus erythematosus (SLE) and explore the risk factors for lupus flare, obstetric complications and fetal loss. Methods: 83 pregnancies in 80 women were divided into three groups. Group A: patients in remission for > 6 months before pregnancy, proteinuria < 0.5 g per day, without renal failure and discontinuation of cytotoxic drugs for > one year; Group B: patients with SLE disease activity in the six months before pregnancy; Group C: patients with new onset SLE during pregnancy. Results: In group A, 76.47% pregnancies achieved full-term deliveries and 80.39% achieved live born infants. In group B and C, the outcome was poor. Among 62 patients (64 pregnancies) diagnosed as SLE before pregnancy, SLE flares occurred in 27 (42.19%) pregnancies. SLE disease activity in the six months before pregnancy was significantly associated with lupus flare (OR 5.00, 95% CI 1.14–21.87, p = 0.03) and fetal loss. New onset lupus during pregnancy was independently associated with obstetric complications (OR 7.22, 95% CI 2.14–24.38, p = 0.001). Conclusions: The current study confirmed the previous report that SLE should be considered a high risk of pregnancy. If pregnancy is planned after remission for > 6 months, the favorable outcome can be achieved.
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Affiliation(s)
- Shanying Chen
- Department of Nephrology, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou 363000, China.
| | - Xuejuan Sun
- Department of Nephrology, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou 363000, China.
| | - Bide Wu
- Department of Nephrology, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou 363000, China.
| | - Xuejian Lian
- Department of Nephrology, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou 363000, China.
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49
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Buyon JP, Kim MY, Guerra MM, Laskin CA, Petri M, Lockshin MD, Sammaritano L, Branch DW, Porter TF, Sawitzke A, Merrill JT, Stephenson MD, Cohn E, Garabet L, Salmon JE. Predictors of Pregnancy Outcomes in Patients With Lupus: A Cohort Study. Ann Intern Med 2015; 163:153-63. [PMID: 26098843 PMCID: PMC5113288 DOI: 10.7326/m14-2235] [Citation(s) in RCA: 345] [Impact Index Per Article: 38.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Because systemic lupus erythematosus (SLE) affects women of reproductive age, pregnancy is a major concern. OBJECTIVE To identify predictors of adverse pregnancy outcomes (APOs) in patients with inactive or stable active SLE. DESIGN Prospective cohort. SETTING Multicenter. PATIENTS 385 patients (49% non-Hispanic white; 31% with prior nephritis) with SLE in the PROMISSE (Predictors of Pregnancy Outcome: Biomarkers in Antiphospholipid Antibody Syndrome and Systemic Lupus Erythematosus) study. Exclusion criteria were urinary protein-creatinine ratio greater than 1000 mg/g, creatinine level greater than 1.2 mg/dL, prednisone use greater than 20 mg/d, and multifetal pregnancy. MEASUREMENTS APOs included fetal or neonatal death; birth before 36 weeks due to placental insufficiency, hypertension, or preeclampsia; and small-for-gestational-age (SGA) neonate (birthweight below the fifth percentile). Disease activity was assessed with the Systemic Lupus Erythematosus Pregnancy Disease Activity Index and the Physician's Global Assessment (PGA). RESULTS APOs occurred in 19.0% (95% CI, 15.2% to 23.2%) of pregnancies; fetal death occurred in 4%, neonatal death occurred in 1%, preterm delivery occurred in 9%, and SGA neonate occurred in 10%. Severe flares in the second and third trimesters occurred in 2.5% and 3.0%, respectively. Baseline predictors of APOs included presence of lupus anticoagulant (LAC) (odds ratio [OR], 8.32 [CI, 3.59 to 19.26]), antihypertensive use (OR, 7.05 [CI, 3.05 to 16.31]), PGA score greater than 1 (OR, 4.02 [CI, 1.84 to 8.82]), and low platelet count (OR, 1.33 [CI, 1.09 to 1.63] per decrease of 50 × 109 cells/L). Non-Hispanic white race was protective (OR, 0.45 [CI, 0.24 to 0.84]). Maternal flares, higher disease activity, and smaller increases in C3 level later in pregnancy also predicted APOs. Among women without baseline risk factors, the APO rate was 7.8%. For those who either were LAC-positive or were LAC-negative but nonwhite or Hispanic and using antihypertensives, the APO rate was 58.0% and fetal or neonatal mortality was 22.0%. LIMITATION Patients with high disease activity were excluded. CONCLUSION In pregnant patients with inactive or stable mild/moderate SLE, severe flares are infrequent and, absent specific risk factors, outcomes are favorable. PRIMARY FUNDING SOURCE National Institutes of Health.
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Affiliation(s)
- Jill P. Buyon
- From New York University School of Medicine, Hospital for Special Surgery, Albert Einstein College of Medicine, and Weill Cornell Medical College, New York, New York; University of Utah Health Sciences Center and Intermountain Healthcare, Salt Lake City, Utah; Oestfold Hospital Trust, Fredrikstad, Norway; University of Toronto, Toronto, Ontario, Canada; Oklahoma Medical Research Foundation and the University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
- Johns Hopkins University School of Medicine, Baltimore, Maryland; and University of Illinois at Chicago, Chicago, Illinois
| | - Mimi Y. Kim
- From New York University School of Medicine, Hospital for Special Surgery, Albert Einstein College of Medicine, and Weill Cornell Medical College, New York, New York; University of Utah Health Sciences Center and Intermountain Healthcare, Salt Lake City, Utah; Oestfold Hospital Trust, Fredrikstad, Norway; University of Toronto, Toronto, Ontario, Canada; Oklahoma Medical Research Foundation and the University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
- Johns Hopkins University School of Medicine, Baltimore, Maryland; and University of Illinois at Chicago, Chicago, Illinois
| | - Marta M. Guerra
- From New York University School of Medicine, Hospital for Special Surgery, Albert Einstein College of Medicine, and Weill Cornell Medical College, New York, New York; University of Utah Health Sciences Center and Intermountain Healthcare, Salt Lake City, Utah; Oestfold Hospital Trust, Fredrikstad, Norway; University of Toronto, Toronto, Ontario, Canada; Oklahoma Medical Research Foundation and the University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
- Johns Hopkins University School of Medicine, Baltimore, Maryland; and University of Illinois at Chicago, Chicago, Illinois
| | - Carl A. Laskin
- From New York University School of Medicine, Hospital for Special Surgery, Albert Einstein College of Medicine, and Weill Cornell Medical College, New York, New York; University of Utah Health Sciences Center and Intermountain Healthcare, Salt Lake City, Utah; Oestfold Hospital Trust, Fredrikstad, Norway; University of Toronto, Toronto, Ontario, Canada; Oklahoma Medical Research Foundation and the University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
- Johns Hopkins University School of Medicine, Baltimore, Maryland; and University of Illinois at Chicago, Chicago, Illinois
| | - Michelle Petri
- From New York University School of Medicine, Hospital for Special Surgery, Albert Einstein College of Medicine, and Weill Cornell Medical College, New York, New York; University of Utah Health Sciences Center and Intermountain Healthcare, Salt Lake City, Utah; Oestfold Hospital Trust, Fredrikstad, Norway; University of Toronto, Toronto, Ontario, Canada; Oklahoma Medical Research Foundation and the University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
- Johns Hopkins University School of Medicine, Baltimore, Maryland; and University of Illinois at Chicago, Chicago, Illinois
| | - Michael D. Lockshin
- From New York University School of Medicine, Hospital for Special Surgery, Albert Einstein College of Medicine, and Weill Cornell Medical College, New York, New York; University of Utah Health Sciences Center and Intermountain Healthcare, Salt Lake City, Utah; Oestfold Hospital Trust, Fredrikstad, Norway; University of Toronto, Toronto, Ontario, Canada; Oklahoma Medical Research Foundation and the University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
- Johns Hopkins University School of Medicine, Baltimore, Maryland; and University of Illinois at Chicago, Chicago, Illinois
| | - Lisa Sammaritano
- From New York University School of Medicine, Hospital for Special Surgery, Albert Einstein College of Medicine, and Weill Cornell Medical College, New York, New York; University of Utah Health Sciences Center and Intermountain Healthcare, Salt Lake City, Utah; Oestfold Hospital Trust, Fredrikstad, Norway; University of Toronto, Toronto, Ontario, Canada; Oklahoma Medical Research Foundation and the University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
- Johns Hopkins University School of Medicine, Baltimore, Maryland; and University of Illinois at Chicago, Chicago, Illinois
| | - D. Ware Branch
- From New York University School of Medicine, Hospital for Special Surgery, Albert Einstein College of Medicine, and Weill Cornell Medical College, New York, New York; University of Utah Health Sciences Center and Intermountain Healthcare, Salt Lake City, Utah; Oestfold Hospital Trust, Fredrikstad, Norway; University of Toronto, Toronto, Ontario, Canada; Oklahoma Medical Research Foundation and the University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
- Johns Hopkins University School of Medicine, Baltimore, Maryland; and University of Illinois at Chicago, Chicago, Illinois
| | - T. Flint Porter
- From New York University School of Medicine, Hospital for Special Surgery, Albert Einstein College of Medicine, and Weill Cornell Medical College, New York, New York; University of Utah Health Sciences Center and Intermountain Healthcare, Salt Lake City, Utah; Oestfold Hospital Trust, Fredrikstad, Norway; University of Toronto, Toronto, Ontario, Canada; Oklahoma Medical Research Foundation and the University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
- Johns Hopkins University School of Medicine, Baltimore, Maryland; and University of Illinois at Chicago, Chicago, Illinois
| | - Allen Sawitzke
- From New York University School of Medicine, Hospital for Special Surgery, Albert Einstein College of Medicine, and Weill Cornell Medical College, New York, New York; University of Utah Health Sciences Center and Intermountain Healthcare, Salt Lake City, Utah; Oestfold Hospital Trust, Fredrikstad, Norway; University of Toronto, Toronto, Ontario, Canada; Oklahoma Medical Research Foundation and the University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
- Johns Hopkins University School of Medicine, Baltimore, Maryland; and University of Illinois at Chicago, Chicago, Illinois
| | - Joan T. Merrill
- From New York University School of Medicine, Hospital for Special Surgery, Albert Einstein College of Medicine, and Weill Cornell Medical College, New York, New York; University of Utah Health Sciences Center and Intermountain Healthcare, Salt Lake City, Utah; Oestfold Hospital Trust, Fredrikstad, Norway; University of Toronto, Toronto, Ontario, Canada; Oklahoma Medical Research Foundation and the University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
- Johns Hopkins University School of Medicine, Baltimore, Maryland; and University of Illinois at Chicago, Chicago, Illinois
| | - Mary D. Stephenson
- From New York University School of Medicine, Hospital for Special Surgery, Albert Einstein College of Medicine, and Weill Cornell Medical College, New York, New York; University of Utah Health Sciences Center and Intermountain Healthcare, Salt Lake City, Utah; Oestfold Hospital Trust, Fredrikstad, Norway; University of Toronto, Toronto, Ontario, Canada; Oklahoma Medical Research Foundation and the University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
- Johns Hopkins University School of Medicine, Baltimore, Maryland; and University of Illinois at Chicago, Chicago, Illinois
| | - Elisabeth Cohn
- From New York University School of Medicine, Hospital for Special Surgery, Albert Einstein College of Medicine, and Weill Cornell Medical College, New York, New York; University of Utah Health Sciences Center and Intermountain Healthcare, Salt Lake City, Utah; Oestfold Hospital Trust, Fredrikstad, Norway; University of Toronto, Toronto, Ontario, Canada; Oklahoma Medical Research Foundation and the University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
- Johns Hopkins University School of Medicine, Baltimore, Maryland; and University of Illinois at Chicago, Chicago, Illinois
| | - Lamya Garabet
- From New York University School of Medicine, Hospital for Special Surgery, Albert Einstein College of Medicine, and Weill Cornell Medical College, New York, New York; University of Utah Health Sciences Center and Intermountain Healthcare, Salt Lake City, Utah; Oestfold Hospital Trust, Fredrikstad, Norway; University of Toronto, Toronto, Ontario, Canada; Oklahoma Medical Research Foundation and the University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
- Johns Hopkins University School of Medicine, Baltimore, Maryland; and University of Illinois at Chicago, Chicago, Illinois
| | - Jane E. Salmon
- From New York University School of Medicine, Hospital for Special Surgery, Albert Einstein College of Medicine, and Weill Cornell Medical College, New York, New York; University of Utah Health Sciences Center and Intermountain Healthcare, Salt Lake City, Utah; Oestfold Hospital Trust, Fredrikstad, Norway; University of Toronto, Toronto, Ontario, Canada; Oklahoma Medical Research Foundation and the University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
- Johns Hopkins University School of Medicine, Baltimore, Maryland; and University of Illinois at Chicago, Chicago, Illinois
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50
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Clinical outcomes and predictors of fetal and maternal consequences of pregnancy in lupus nephritis patients. Int Urol Nephrol 2015; 47:1379-85. [DOI: 10.1007/s11255-015-1032-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Accepted: 06/07/2015] [Indexed: 01/16/2023]
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