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Siegel CH, Sammaritano LR. Safety of Medications Used to Treat Autoimmune Rheumatic Diseases During Pregnancy and Lactation. J Clin Rheumatol 2024; 30:S25-S33. [PMID: 39325122 DOI: 10.1097/rhu.0000000000002123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/27/2024]
Abstract
ABSTRACT Autoimmune rheumatic diseases (ARDs) often affect women during their reproductive years, and early studies of pregnancy in these patients reported high rates of adverse outcomes. Continuation or initiation of safe and effective medications in the preconception period is beneficial for maintaining or achieving disease quiescence throughout pregnancy thereby improving both maternal and pregnancy outcomes. The European Alliance of Associations for Rheumatology, the American College of Rheumatology, and the British Society for Rheumatology have published recommendations and guidelines regarding management of ARDs during pregnancy. The American College of Obstetricians and Gynecologists and the American Gastroenterological Association have also provided guidance statements with relevant recommendations. This review provides an overview of available recommendations for medication use in ARD pregnancy, with discussion of safety considerations for maternal and fetal well-being. Medications considered compatible with pregnancy include hydroxychloroquine, sulfasalazine, azathioprine, cyclosporine, tacrolimus, and TNF inhibitors. Methotrexate, mycophenolate, leflunomide, and cyclophosphamide should be avoided before and during pregnancy. Other medications, most of them newer, are largely discouraged for use in pregnancy due to inadequate data or concerns for neonatal immunosuppression, including non-TNF biologics and small molecule therapies. Further investigation is needed regarding effects of non-TNF biologics, biosimilars, and small molecules in pregnancy. Important efforts for the future will include improved methodologies to gather critical safety data, with consideration of inclusion of pregnant women in clinical trials, a complex and controversial issue. Long-term information on outcomes in offspring of treated women is lacking for many of these medications.
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Abstract
ABSTRACT Systemic lupus erythematosus, antiphospholipid syndrome, and rheumatoid arthritis are chronic autoimmune diseases affecting women of childbearing age. These diseases may impair fertility and fecundity, as well as complicate pregnancy and the puerperium in these patients including disease flare and obstetric complications on both the maternal and fetal side. For each patient, an appropriate preconceptional counseling with risk stratification is required, including assessment of disease activity, organ involvement, serological profile, and comorbidities.In cases of pregnancy, the aims of treatment are to prevent disease activity, to treat disease activity in cases of flare, and to prevent maternal and fetal complications such as preeclampsia or fetal loss. In all patients with these diseases, close clinical monitoring during pregnancy and puerperium is mandatory. This review aims to summarize the fertility issues in patients with systemic lupus erythematosus, antiphospholipid syndrome, and rheumatoid arthritis and to provide an update on pregnancy management and outcomes in these patients.
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Simard JF, Liu EF, Rector A, Cantu M, Chakravarty E, Druzin M, Kuo DZ, Shaw GM, Weisman M, Hedderson M. Hydroxychloroquine and Pre-eclampsia in a Diverse Cohort of Women With Systemic Lupus Erythematosus. Arthritis Care Res (Hoboken) 2024; 76:1390-1395. [PMID: 38926748 PMCID: PMC11424256 DOI: 10.1002/acr.25386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 05/09/2024] [Accepted: 05/29/2024] [Indexed: 06/28/2024]
Abstract
OBJECTIVE Patients with systemic lupus erythematosus (SLE) are at risk for pregnancy complications such as pre-eclampsia and eclampsia. These clinically important complications are associated with maternal morbidity, mortality, and postpartum cardiovascular disease. Some studies suggest that hydroxychloroquine (HCQ) may reduce pre-eclampsia risk in lupus pregnancy. Using a cohort of pregnant patients with prevalent SLE at Kaiser Permanente Northern California (KPNC), we investigated whether HCQ treatment in early pregnancy reduced the risk of pre-eclampsia or eclampsia. METHODS Among pregnant patients with SLE from 2011 to 2020, we assessed HCQ treatment from three months before pregnancy through the first trimester. HCQ exposure was defined multiple ways to account for adherence and duration of treatment. Propensity scores accounted for multiple confounders and modified Poisson models estimated risk ratios (RRs) and 95% confidence intervals of the association between HCQ treatment and pre-eclampsia or eclampsia. Effect modification by pregestational hypertension, history of nephritis, and antiphospholipid antibody (aPL) status was investigated through stratified analysis. RESULTS There were 399 pregnancies among 324 patients with SLE at KPNC between 2011 and 2020. Considering multiple exposure definitions, we consistently found a null association between HCQ and pre-eclampsia or eclampsia. The RRs were consistently lower among nullipara patients, and RRs were consistently protective but not statistically significant among the high-risk subgroup of patients with a history of nephritis, aPL positivity, or pregestational hypertension (for both nullipara and multipara patients). CONCLUSION Although this study found no reduced risk of HCQ on pre-eclampsia or eclampsia, residual confounding may be attenuating the effect despite an integrated health care delivery system setting with detailed clinical data.
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Affiliation(s)
- Julia F Simard
- Stanford University School of Medicine, Stanford, California
| | - Emily F Liu
- Kaiser Permanente Northern California Division of Research, Oakland
| | - Amadeia Rector
- Stanford University School of Medicine, Stanford, California
| | | | | | - Maurice Druzin
- Stanford University School of Medicine, Stanford, California
| | - Daniel Z Kuo
- Kaiser Permanente, Redwood City Medical Center, Redwood City, California
| | - Gary M Shaw
- Stanford University School of Medicine, Stanford, California
| | - Michael Weisman
- Stanford University School of Medicine, Stanford, California
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de Frémont GM, Salmon JE, Costedoat-Chalumeau N. Pregnancy outcome predictors in systemic lupus erythematosus: prospective for brighter perspectives. THE LANCET. RHEUMATOLOGY 2024; 6:e654-e655. [PMID: 39153485 DOI: 10.1016/s2665-9913(24)00184-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2024] [Accepted: 06/17/2024] [Indexed: 08/19/2024]
Affiliation(s)
- Grégoire Martin de Frémont
- National Referral Centre for Rare Autoimmune and Systemic Diseases, Department of Internal Medicine, Hôpital Cochin, AP-HP Centre, Université Paris Cité, F-75014 Paris, France
| | - Jane E Salmon
- Department of Medicine, Hospital for Special Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Nathalie Costedoat-Chalumeau
- National Referral Centre for Rare Autoimmune and Systemic Diseases, Department of Internal Medicine, Hôpital Cochin, AP-HP Centre, Université Paris Cité, F-75014 Paris, France; Centre de Recherche Epidémiologie et Biostatistiques de Sorbonne Paris Cité, Université de Paris, Paris, France.
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Abheiden CNH, Blomjous BS, Slaager C, Landman AJEMC, Ket JCF, Salmon JE, Buyon JP, Heymans MW, de Vries JIP, Bultink IEM, de Boer MA. Systemic lupus erythematosus is associated with an increased frequency of spontaneous preterm births: systematic review and meta-analysis. Am J Obstet Gynecol 2024; 231:408-416.e21. [PMID: 38492714 DOI: 10.1016/j.ajog.2024.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 03/06/2024] [Accepted: 03/06/2024] [Indexed: 03/18/2024]
Abstract
OBJECTIVE Preterm birth is one of the most frequent complications of pregnancy in women with systemic lupus erythematosus. The high indicated preterm birth proportion due to hypertensive disorders of pregnancy and/or fetal growth restriction is well known, and preventive measures and screening for early detection are performed. The risk of spontaneous preterm birth is less well recognized. This study aimed to determine the proportions of spontaneous and indicated preterm birth in pregnancies of women with systemic lupus erythematosus. DATA SOURCES A systematic literature search using Pubmed, Embase, Web of Science, and Google Scholar was performed in June 2021. STUDY ELIGIBILITY CRITERIA Studies in pregnant women with systemic lupus erythematosus reporting spontaneous and indicated preterm birth rates were selected. Original research articles published from 1995 to June 2021 were included. METHODS Quality and risk of bias of the included studies were assessed using the Newcastle-Ottawa quality assessment scale. To estimate the pooled event rates and 95% confidence intervals, meta-analysis of single proportions with a random-effects model was performed. RESULTS We included 21 articles, containing data of 8157 pregnancies in women with systemic lupus erythematosus. On average, 31% (95% prediction interval, 0.14-0.50) of the pregnancies resulted in preterm birth, including 14% (95% prediction interval, 0.04-0.27) spontaneous and 16% (95% prediction interval, 0.03-0.35) indicated preterm birth. CONCLUSION In pregnant women with systemic lupus erythematosus, spontaneous and indicated preterm birth proportions are high. This information should be applied in (prepregnancy) counseling and management in pregnancy. The knowledge obtained by this meta-analysis paves the way for further research of associated risk factors and development of interventions to reduce spontaneous preterm birth in systemic lupus erythematosus pregnancies.
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Affiliation(s)
- Carolien N H Abheiden
- Department of Obstetrics and Gynaecology, Amsterdam University Medical Center, Amsterdam, the Netherlands; Amsterdam Reproduction and Development Research Institute, Amsterdam, the Netherlands.
| | - Birgit S Blomjous
- Department of Rheumatology and Clinical Immunology, Amsterdam Rheumatology and Immunology Center, Amsterdam University Medical Center, Amsterdam, the Netherlands; Amsterdam institute for Immunology and Infectious Diseases, Amsterdam, the Netherlands
| | - Ciska Slaager
- Department of Gynecology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Anadeijda J E M C Landman
- Department of Obstetrics and Gynaecology, Amsterdam University Medical Center, Amsterdam, the Netherlands; Amsterdam Reproduction and Development Research Institute, Amsterdam, the Netherlands
| | - Johannes C F Ket
- Medical Library, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Jane E Salmon
- Hospital for Special Surgery, Weill Cornell Medical College, New York, NY
| | - Jill P Buyon
- NYU Grossman School of Medicine, New York University, New York, NY
| | - Martijn W Heymans
- Department of Epidemiology and Data Science, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Johanna I P de Vries
- Department of Obstetrics and Gynaecology, Amsterdam University Medical Center, Amsterdam, the Netherlands; Amsterdam Reproduction and Development Research Institute, Amsterdam, the Netherlands
| | - Irene E M Bultink
- Department of Rheumatology and Clinical Immunology, Amsterdam Rheumatology and Immunology Center, Amsterdam University Medical Center, Amsterdam, the Netherlands; Amsterdam institute for Immunology and Infectious Diseases, Amsterdam, the Netherlands
| | - Marjon A de Boer
- Department of Obstetrics and Gynaecology, Amsterdam University Medical Center, Amsterdam, the Netherlands; Amsterdam Reproduction and Development Research Institute, Amsterdam, the Netherlands
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Saavedra MÁ, Gracia-Aréchiga TS, Miranda-Hernández D, Sánchez A, Arrucha-Cozaya M, Cruz-Domínguez MDP. Active but not quiescent lupus nephritis during pregnancy is associated with a higher rate of adverse obstetric outcomes: Analysis of a prospective cohort. Int J Gynaecol Obstet 2024; 167:420-426. [PMID: 38736284 DOI: 10.1002/ijgo.15601] [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: 08/06/2023] [Revised: 04/08/2024] [Accepted: 04/28/2024] [Indexed: 05/14/2024]
Abstract
OBJECTIVE To compare the maternal-fetal/neonatal outcome in patients with systemic lupus erythematosus (SLE) with and without lupus nephritis (LN) in remission or with active disease. METHODS A prospective cohort of pregnant patients with SLE (ACR 1997 criteria) was studied from January 2009 to December 2021. Demographic, clinical, biochemical, and immunological variables as well as the usual maternal-fetal/neonatal complications were recorded. We compared four groups according to the status of SLE during pregnancy: patients with quiescent SLE without lupus nephritis, patients with active SLE without lupus nephritis, patients with quiescent lupus nephritis, and patients with active lupus nephritis. Statistical analysis included descriptive statistics, bivariate analysis, and Cox regression analysis. RESULTS A total of 439 pregnancies were studied, with a median age of 28 ± 6, SLE duration of 60 months (interquartile range 36-120). A higher frequency of maternal and fetal/neonatal complications was observed in patients with active SLE with or without lupus nephritis. Multivariate analysis showed that active LN was a risk factor for gestational hypertension (hazard ratios [HR] 1.95; 95% confidence intervals [CI]: 1.01-6.39), premature rupture of membranes (HR 3.56; 95% CI: 1.79-16.05) and more frequent cesarean section (HR 1.82; 95% CI: 1.13-2.94). CONCLUSION LN is associated with a higher frequency of maternal complications, especially in those patients with active disease during pregnancy, and those maternal complications had an impact on poor fetal/neonatal outcomes. Strict control and timely care of LN could improve the obstetric prognosis.
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Affiliation(s)
- Miguel Ángel Saavedra
- División de Investigación en Salud, Hospital de Especialidades Dr. Antonio Fraga Mouret, Centro Médico Nacional La Raza, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - Tayde Sarahí Gracia-Aréchiga
- Departamento de Reumatología, Hospital de Especialidades Dr. Antonio Fraga Mouret, Centro Médico Nacional La Raza, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - Dafhne Miranda-Hernández
- Departamento de Reumatología, Hospital de Especialidades Dr. Antonio Fraga Mouret, Centro Médico Nacional La Raza, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - Antonio Sánchez
- Departamento de Reumatología, Hospital de Especialidades Dr. Antonio Fraga Mouret, Centro Médico Nacional La Raza, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | | | - María Del Pilar Cruz-Domínguez
- Dirección de Educación e Investigación en Salud, Hospital de Especialidades Dr. Antonio Fraga Mouret, Centro Médico Nacional La Raza, México City, Mexico
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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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Isojima S, Li N, Rowson S, Kandane-Rahtnayake R, Koelmeyer R, Morand EF, Hoi A. Pregnancy outcomes in Australian patients with systemic lupus erythematosus. Intern Med J 2024. [PMID: 39258417 DOI: 10.1111/imj.16524] [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: 10/21/2023] [Accepted: 08/18/2024] [Indexed: 09/12/2024]
Abstract
BACKGROUND Systemic lupus erythematosus (SLE) affects women, with the onset of disease typically around the childbearing years. AIMS This study examines the frequency and risk factors for adverse pregnancy outcomes (APOs) in an Australian cohort, and any disease flares during pregnancy and post partum. METHODS Female patients with SLE enrolled in the Australian Lupus Registry and Biobank (ALRB) between January 2007 and June 2019 were studied. Self-reported pregnancy history, including adverse foetal or maternal outcomes, was collected at the time of enrolment and updated as appropriate. Baseline demographics, clinical parameters, medication exposure and disease activity were collected. Factors associated with APO were examined using univariate and multivariate logistic regression analyses. RESULTS Pregnancy history was available in 278 patients; 30% were nulliparous. Most pregnancies occurred before the diagnosis of SLE. Patients who had pregnancies after SLE diagnosis had an earlier age of diagnosis, and had fewer pregnancies. The APO rate was 44.3% in the overall cohort, with most presenting as prematurity with or without foetal growth restriction. Women with APO were also diagnosed with SLE at a younger age and had a higher prevalence of anti-cardiolipin antibodies and hypocomplementemia. Early age of SLE diagnosis was a significant independent risk factor for APO. No increase in disease flare was observed in those who experienced APO during the observation period of ALRB. CONCLUSION This study shows a considerable incidence of APO in patients with SLE, emphasising the need for pre-pregnancy counselling and collaboration between maternal-foetal medicine specialists and rheumatologists, especially for women diagnosed with SLE at a younger age.
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Affiliation(s)
- Sakiko Isojima
- Department of Medicine, School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
- Division of Rheumatology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Ning Li
- Department of Medicine, School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
| | - Saskia Rowson
- Department of Rheumatology, Austin Health, Melbourne, Victoria, Australia
- Department of Rheumatology, Monash Health, Melbourne, Victoria, Australia
| | - Rangi Kandane-Rahtnayake
- Department of Medicine, School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
| | - Rachel Koelmeyer
- Department of Medicine, School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
| | - Eric F Morand
- Department of Medicine, School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
- Department of Rheumatology, Monash Health, Melbourne, Victoria, Australia
| | - Alberta Hoi
- Department of Medicine, School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
- Department of Rheumatology, Monash Health, Melbourne, Victoria, Australia
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Tan Z, Ding M, Shen J, Huang Y, Li J, Sun A, Hong J, Yang Y, He S, Pei C, Luo R. Causal pathways in preeclampsia: a Mendelian randomization study in European populations. Front Endocrinol (Lausanne) 2024; 15:1453277. [PMID: 39286274 PMCID: PMC11402816 DOI: 10.3389/fendo.2024.1453277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2024] [Accepted: 08/15/2024] [Indexed: 09/19/2024] Open
Abstract
Purpose Our study utilizes Mendelian Randomization (MR) to explore the causal relationships between a range of risk factors and preeclampsia, a major contributor to maternal and perinatal morbidity and mortality. Methods Employing the Inverse Variance Weighting (IVW) approach, we conducted a comprehensive multi-exposure MR study analyzing genetic variants linked to 25 risk factors including metabolic disorders, circulating lipid levels, immune and inflammatory responses, lifestyle choices, and bone metabolism. We applied rigorous statistical techniques such as sensitivity analyses, Cochran's Q test, MR Egger regression, funnel plots, and leave-one-out sensitivity analysis to address potential biases like pleiotropy and population stratification. Results Our analysis included 267,242 individuals, focusing on European ancestries and involving 2,355 patients with preeclampsia. We identified strong genetic associations linking increased preeclampsia risk with factors such as hyperthyroidism, BMI, type 2 diabetes, and elevated serum uric acid levels. Conversely, no significant causal links were found with gestational diabetes, total cholesterol, sleep duration, and bone mineral density, suggesting areas for further investigation. A notable finding was the causal relationship between systemic lupus erythematosus and increased preeclampsia risk, highlighting the significant role of immune and inflammatory responses. Conclusion This extensive MR study sheds light on the complex etiology of preeclampsia, underscoring the causal impact of specific metabolic, lipid, immune, lifestyle, and bone metabolism factors. Our findings advocate for a multidimensional approach to better understand and manage preeclampsia, paving the way for future research to develop targeted preventive and therapeutic strategies.
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Affiliation(s)
- Zilong Tan
- Department of Urology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Mengdi Ding
- Department of Urology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Jianwu Shen
- Department of Urology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- Department of Urology, Qinghai Provincial Hospital of Traditional Chinese Medicine, Xining, China
| | - Yuxiao Huang
- Department of Gynecology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Junru Li
- Department of Internal Medicine, Qinghai Provincial Hospital of Traditional Chinese Medicine, Xining, China
| | - Aochuan Sun
- Department of Geriatrics, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Jing Hong
- Department of Integration of Chinese and Western Medicine, Key Laboratory of Carcinogenesis and Translational Research, Peking University Cancer Hospital and Institute, Beijing, China
| | - Yan Yang
- Department of Critical Care Medicine, Jiangsu Provincial Hospital of Traditional Chinese Medicine, Nanjing, China
| | - Sheng He
- The First Clinical Medical College of Anhui University of Traditional Chinese Medicine, Hefei, China
| | - Chao Pei
- Department of Ophthalmology, China Academy of Traditional Chinese Medicine Hospital of Ophthalmology, Beijing, China
| | - Ran Luo
- Department of Gynecology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
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Rosta K, Heinzl F, Kuczwara V, Schindler S, Falcone V, Catic A, Riedmann M, Leitner H, Simader E, Ritschl V, Stamm T, Szlatinay A, Mandl P, Mazzucato-Puchner A. Pregnancy outcomes in patients with systemic lupus erythematosus compared to a high-risk tertiary cohort and to standard population from the Austrian birth registry. Acta Obstet Gynecol Scand 2024; 103:1820-1828. [PMID: 38943224 PMCID: PMC11324932 DOI: 10.1111/aogs.14880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Revised: 04/24/2024] [Accepted: 05/06/2024] [Indexed: 07/01/2024]
Abstract
INTRODUCTION Women with systemic lupus erythematosus (SLE) have a higher risk for fetal and maternal complications. We aimed to investigate maternal and fetal complications in pregnant women with SLE compared to a high-risk pregnancy cohort (HR) from a tertiary university center and a standard-risk general population (SR) from the Austrian Birth Registry. MATERIAL AND METHODS In this retrospective data analysis, we compared the incidence of fetal/neonatal and maternal complications of pregnancies and deliveries of women with SLE to age, body mass index and delivery date-matched high-risk pregnancies from the same department, a progressive tertiary obstetric center and to a group of women, who represent pregnancies with standard obstetric risk from the Austrian Birth Registry. RESULTS One hundred women with SLE were compared to 300 women with high-risk pregnancies and 207 039 women with standard-risk pregnancies. The incidence of composite maternal complications (preeclampsia, Hemolysis, Elevated Liver enzymes and Low Platelets [HELLP] syndrome, pregnancy-related hypertension, gestational diabetes mellitus, maternal death, thromboembolic events) was significantly higher in the SLE as compared to the SR group (28% vs. 6.28% SLE vs. SR, p = 0.001). There was no difference between the SLE and the HR groups (28% vs. 29.6% SLE vs. HR group, p = 0.80). The incidence of composite fetal complications (preterm birth before 37 weeks of gestation, stillbirths, birthweight less than 2500 g, fetal growth restriction, large for gestational age, admission to neonatal intensive care unit, 5-min Apgar <7) was also higher in the SLE than in the SR group (55% vs. 25.54% SLE vs. SR p < 0.001) while the higher incidence of adverse fetal outcome was detected in the HR than in the SLE group (55% vs. 75% SLE vs. HR group, p = 0.0005). CONCLUSIONS Although composite fetal risk is higher in the SLE group than in the general population, it is still significantly lower as compared to high-risk pregnant women at a tertiary obstetric center. Prepregnancy counseling of women with SLE should put fetal and maternal risk in perspective, not only in relation to healthy, low risk cohorts, but also compared to mixed HR populations.
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Affiliation(s)
- Klara Rosta
- Department of Obstetrics and Gynecology, Clinical Division of Gynecological Endocrinology and Reproductive Medicine, Medical University of Vienna, Vienna, Austria
| | - Florian Heinzl
- Department of Obstetrics and Gynecology, Clinical Division of Gynecological Endocrinology and Reproductive Medicine, Medical University of Vienna, Vienna, Austria
| | - Valerie Kuczwara
- Department of Obstetrics and Gynecology, Clinical Division of Gynecological Endocrinology and Reproductive Medicine, Medical University of Vienna, Vienna, Austria
| | - Stefanie Schindler
- Department of Obstetrics and Gynecology, Clinical Division of Gynecological Endocrinology and Reproductive Medicine, Medical University of Vienna, Vienna, Austria
| | - Veronica Falcone
- Department of Obstetrics and Gynecology, Clinical Division of Gynecological Endocrinology and Reproductive Medicine, Medical University of Vienna, Vienna, Austria
| | - Anja Catic
- Department of Obstetrics and Gynecology, Clinical Division of Gynecological Endocrinology and Reproductive Medicine, Medical University of Vienna, Vienna, Austria
| | - Marina Riedmann
- Department of Clinical Epidemiology, Tyrolean Federal Institute for Integrated Care, Tirol Kliniken GmbH, Innsbruck, Austria
| | - Hermann Leitner
- Department of Clinical Epidemiology, Tyrolean Federal Institute for Integrated Care, Tirol Kliniken GmbH, Innsbruck, Austria
| | - Elisabeth Simader
- Department of Internal Medicine III, Division of Rheumatology, Medical University of Vienna, Vienna, Austria
| | - Valentin Ritschl
- Center for Medical Data Science, Institute for Outcomes Research, Medical University of Vienna, Vienna, Austria
- Ludwig Boltzmann Institute for Arthritis and Rehabilitation, Vienna, Austria
| | - Tanja Stamm
- Center for Medical Data Science, Institute for Outcomes Research, Medical University of Vienna, Vienna, Austria
- Ludwig Boltzmann Institute for Arthritis and Rehabilitation, Vienna, Austria
| | - Alexandra Szlatinay
- Department of Internal Medicine III, Division of Rheumatology, Medical University of Vienna, Vienna, Austria
| | - Peter Mandl
- Department of Internal Medicine III, Division of Rheumatology, Medical University of Vienna, Vienna, Austria
| | - Antonia Mazzucato-Puchner
- Department of Internal Medicine III, Division of Rheumatology, Medical University of Vienna, Vienna, Austria
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Sun W, Jin X, Li Y, Li M, Zhu X. Neonatal lupus erythematosus presenting with effusions: A 13-year retrospective study. Clin Rheumatol 2024; 43:2927-2932. [PMID: 39042213 DOI: 10.1007/s10067-024-07060-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2024] [Revised: 06/11/2024] [Accepted: 07/04/2024] [Indexed: 07/24/2024]
Abstract
OBJECTIVES Neonatal systemic lupus erythematosus (NLE) is an acquired autoimmune disease. The presence of effusions, such as pleural effusion and pericardial effusion, is rare. The present study helped investigate the clinical characteristics and progression of children with NLE combined with effusions. METHODS Clinical data of patients diagnosed with NLE were retrospectively collected and analyzed from January 1, 2011, to December 31, 2023, at the Children's Hospital of Soochow University and Suzhou Municipal Hospital. Patients with NLE were divided into effusion and non-effusion groups based on the presence of effusion. Moreover, the clinical data of the newborns in both groups were compared and investigated. RESULTS Eleven (11/45, 24.44%) NLE patients had effusions, such as pleural effusion, testicular hydrocele, peritoneal effusion, pericardial effusion, and hydrocephalus. Other organs involved in effusion patients were cutaneous, gastrointestinal, hematologic, cardiac, and neurological. Among the patients with effusion, five cases of SLE in pregnant mothers, two cases of Sjogren's syndrome, one case of photoallergic symptoms, and three of pregnant mothers with no history of antenatal autoimmune disease. Pregnant mother' autoimmune disease in remission prior to pregnancy, or stable low disease activity. Seven patients were positive for Anti-SSA, five of which were double positive for Anti-SSA and Anti-SSB. Compared with the non-effusion group, the effusion group patients had significantly higher lactate dehydrogenase, creatine kinase, and fibrinogen, significantly lower platelets, total protein, and albumin. These patients were likelier to have thrombocytopenia and coagulation abnormalities. Logistics regression analysis demonstrated that NLE patients with effusions are more likely to have decreased serum total protein levels. All NLE patients with effusion have self-resorption of the effusion. CONCLUSIONS 24.44% of patients had effusions in our study. NLE patients with effusion are more likely to have hematologic involvement and a more inflammatory response. The effusion in NLE patients is usually self-resorption, severe cases can be treated with nonsteroidal anti-inflammatory drugs/steroids. Key Points • NLE patients combined with effusions and were self-limiting, with pleural effusion being the most common. • NLE patients combined with effusions have a more inflammatory response, significant abnormalities in the blood routine and biochemical-related indexes.
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Affiliation(s)
- Wenqiang Sun
- Department of Neonatology, Children's Hospital of Soochow University, Suzhou, China
| | - Xinyun Jin
- Department of Neonatology, Children's Hospital of Soochow University, Suzhou, China
| | - Yihui Li
- Department of Neonatology, Children's Hospital of Soochow University, Suzhou, China
| | - Mengzhao Li
- Department of Neonatology, Children's Hospital of Soochow University, Suzhou, China
| | - Xueping Zhu
- Department of Neonatology, Children's Hospital of Soochow University, Suzhou, China.
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12
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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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13
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Li M, Zhou R, Yu D, Chen D, Zhao A. A nomogram and risk stratification to predict subsequent pregnancy loss in patients with recurrent pregnancy loss. Hum Reprod 2024:deae181. [PMID: 39178353 DOI: 10.1093/humrep/deae181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Revised: 07/02/2024] [Indexed: 08/25/2024] Open
Abstract
STUDY QUESTION Could the risk of subsequent pregnancy loss be predicted based on the risk factors of recurrent pregnancy loss (RPL) patients? SUMMARY ANSWER A nomogram, constructed from independent risk factors identified through multivariate logistic regression, serves as a reliable tool for predicting the likelihood of subsequent pregnancy loss in RPL patients. WHAT IS KNOWN ALREADY Approximately 1-3% of fertile couples experience RPL, with over half lacking a clear etiological factor. Assessing the subsequent pregnancy loss rate in RPL patients and identifying high-risk groups for early intervention is essential for pregnancy counseling. Previous prediction models have mainly focused on unexplained RPL, incorporating baseline characteristics such as age and the number of previous pregnancy losses, with limited inclusion of laboratory and ultrasound indicators. STUDY DESIGN, SIZE, DURATION The retrospective study involved 3387 RPL patients who initially sought treatment at the Reproductive Immunology Clinic of Renji Hospital, Shanghai Jiao Tong University School of Medicine, between 1 January 2020 and 31 December 2022. Of these, 1153 RPL patients met the inclusion criteria and were included in the analysis. PARTICIPANTS/MATERIALS, SETTING, METHODS RPL was defined as two or more pregnancy losses (including biochemical pregnancy loss) with the same partner before 28 weeks of gestation. Data encompassing basic demographics, laboratory indicators (autoantibodies, peripheral immunity coagulation, and endocrine factors), uterine and endometrial ultrasound results, and subsequent pregnancy outcomes were collected from enrolled patients through initial questionnaires, post-pregnancy visits fortnightly, medical data retrieval, and telephone follow-up for lost patients. R software was utilized for data cleaning, dividing the data into a training cohort (n = 808) and a validation cohort (n = 345) in a 7:3 ratio according to pregnancy success and pregnancy loss. Independent predictors were identified through multivariate logistic regression. A nomogram was developed, evaluated by 10-fold cross-validation, and compared with the model incorporating solely age and the number of previous pregnancy losses. The constructed nomogram was evaluated using the AUC, calibration curve, decision curve analysis (DCA), and clinical impact curve analysis (CICA). Patients were then categorized into low- and high-risk subgroups. MAIN RESULTS AND THE ROLE OF CHANCE We included age, number of previous pregnancy losses, lupus anticoagulant, anticardiolipin IgM, anti-phosphatidylserine/prothrombin complex IgM, anti-double-stranded DNA antibody, arachidonic acid-induced platelet aggregation, thrombin time and the sum of bilateral uterine artery systolic/diastolic ratios in the nomogram. The AUCs of the nomogram were 0.808 (95% CI: 0.770-0.846) in the training cohort and 0.731 (95% CI: 0.660-0.802) in the validation cohort, respectively. The 10-fold cross-validated AUC ranged from 0.714 to 0.925, with a mean AUC of 0.795 (95% CI: 0.750-0.839). The AUC of the nomogram was superior compared to the model incorporating solely age and the number of previous pregnancy losses. Calibration curves, DCAs, and CICAs showed good concordance and clinical applicability. Significant differences in pregnancy loss rates were observed between the low- and high-risk groups (P < 0.001). LIMITATIONS, REASONS FOR CAUTION This study was retrospective and focused on patients from a single reproductive immunology clinic, lacking external validation data. The potential impact of embryonic chromosomal abnormalities on pregnancy loss could not be excluded, and the administration of medication to all cases impacted the investigation of risk factors for pregnancy loss and the model's predictive efficacy. WIDER IMPLICATIONS OF THE FINDINGS This study signifies a pioneering effort in developing and validating a risk prediction nomogram for subsequent pregnancy loss in RPL patients to effectively stratify their risk. We have integrated the nomogram into an online web tool for clinical applications. STUDY FUNDING/COMPETING INTEREST(S) This study was supported by the National Natural Science Foundation of China (82071725). All authors have no competing interests to declare. TRIAL REGISTRATION NUMBER N/A.
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Affiliation(s)
- Mingyang Li
- Department of Obstetrics and Gynecology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, PR China
- Shanghai Key Laboratory of Gynecologic Oncology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, PR China
| | - Renyi Zhou
- Department of Obstetrics and Gynecology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, PR China
- Shanghai Key Laboratory of Gynecologic Oncology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, PR China
| | - Daier Yu
- Department of Obstetrics and Gynecology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, PR China
- Shanghai Key Laboratory of Gynecologic Oncology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, PR China
| | - Dan Chen
- Department of Obstetrics and Gynecology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, PR China
- Shanghai Key Laboratory of Gynecologic Oncology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, PR China
| | - Aimin Zhao
- Department of Obstetrics and Gynecology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, PR China
- Shanghai Key Laboratory of Gynecologic Oncology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, PR China
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Schreiber K, Graversgaard C, Hunt BJ, Wason JMS, Costedoat-Chalumeau N, Aguilera S, Guerra MM, Salmon JE. Challenges of designing and conducting cohort studies and clinical trials in populations of pregnant people. THE LANCET. RHEUMATOLOGY 2024; 6:e560-e572. [PMID: 38876128 DOI: 10.1016/s2665-9913(24)00118-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 04/28/2024] [Accepted: 04/29/2024] [Indexed: 06/16/2024]
Abstract
Rheumatic and musculoskeletal diseases often affect individuals of childbearing age. The incidence and prevalence of rheumatic and musculoskeletal diseases is rising. More pregnancies in patients with rheumatic and musculoskeletal diseases are anticipated and some rheumatic and musculoskeletal diseases are associated with pregnancy complications (eg, miscarriages, fetal deaths, preterm births, and hypertensive disorders in pregnancy). Despite the need to understand the use of drugs to treat rheumatic and musculoskeletal diseases in pregnancy, clinical trials in pregnancy are rare, therapeutics in pregnancy are understudied, and pregnant individuals are routinely excluded as premarketing trial participants. Data on the effectiveness and safety of disease-modifying antirheumatic drugs are most often based on post-marketing observational data. Observational studies assessing the bidirectional relationship between rheumatic and musculoskeletal diseases and pregnancy, as well as interventional studies of treatments during pregnancy, are scarce. Historical reluctance to perform studies in what was deemed an at-risk group persists in pharmaceutical companies, regulatory bodies, and ethics boards. Additionally, patients must be engaged partners, which requires trust that the research respects the needs and interests of the patient and complies with the rules intended to protect the pregnant person and the fetus from harm. In this Series paper, we share challenges we have encountered in conducting prospective cohort studies and interventional trials of postmarketing approved medications, assessing pregnancy specific outcomes in pregnant women with rheumatic and musculoskeletal diseases in the EU, the UK, and the USA. We discuss the changing landscape around trials in pregnancy and present possible solutions to our challenges.
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Affiliation(s)
- Karen Schreiber
- Danish Centre for Expertise in Rheumatology (CeViG), Danish Hospital for Rheumatic Diseases, Sønderborg, Denmark; Department of Regional Health Research, University of Southern Denmark, Odense, Denmark; Thrombosis and Haemostasis, Guy's and St Thomas' NHS Foundation Trust, London, UK.
| | - Christine Graversgaard
- Danish Centre for Expertise in Rheumatology (CeViG), Danish Hospital for Rheumatic Diseases, Sønderborg, Denmark; Department of Rheumatology, Århus University Hospital, Århus, Denmark
| | - Beverley J Hunt
- Thrombosis and Haemostasis, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - James M S Wason
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Nathalie Costedoat-Chalumeau
- Centre de référence maladies auto-immunes et systémiques rares de l'île de France, Cochin Hospital, Paris, France; Université Paris Cité, Paris, France; Center Of Research In Epidemiology And Statistics, Inserm University, Paris, France
| | - Silvia Aguilera
- Spanish Association for Antiphospholipid Syndrome, Elche, Spain
| | | | - Jane E Salmon
- Hospital for Special Surgery, New York, NY, USA; Weill Cornell Medicine, New York, NY, USA
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15
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Coenen CS, Hidalgo TN, Lynn T, Jones DM, Salmon JE, Chamley LW, Abrahams VM. Antiphospholipid-exposed trophoblast-derived extracellular vesicles express elevated levels of TLR7/8-activating microRNAs and induce endometrial endothelial activation, in part, through TLR7. J Reprod Immunol 2024; 164:104255. [PMID: 38797133 DOI: 10.1016/j.jri.2024.104255] [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: 03/01/2024] [Revised: 04/11/2024] [Accepted: 05/12/2024] [Indexed: 05/29/2024]
Abstract
Women with antiphospholipid syndrome (APS) are at high risk for miscarriage and preeclampsia. Unlike pro-thrombotic systemic APS, obstetric APS is associated with insufficient placentation, as well as inflammation and vascular dysfunction at the maternal-fetal interface. Antiphospholipid antibodies (aPL) can target the placental trophoblast and induce inflammation. We reported that aPL trigger trophoblast cells to produce elevated levels of IL-8 through activation of Toll-like receptor 4 (TLR4). Downstream of TLR4, we found this IL-8 response is mediated by a TLR8-activating microRNA (miR), miR-146a-3p, which is also released by the trophoblast via extracellular vesicles (EVs). Since endothelial dysfunction is a feature of obstetric APS, we sought to determine if other miRs that can activate the RNA sensors, TLR7 and/or TLR8, are released by the trophoblast via EVs after exposure to aPL, and if these EVs can activate human endometrial endothelial cells (HEECs). Using a human first trimester extravillous trophoblast cell line we found that aPL elevated their release of small EVs (<150 nm). These extracellular vesicles released from trophoblast cells exposed to aPL expressed elevated levels of TLR7/8-activating miR-21a and miR-29a, in addition to the previously reported miR-146a-3p. Extracellular vesicles from aPL-exposed human trophoblast cells triggered human endometrial endothelial cells to generate an inflammatory IL-8 response, in part through TLR7. This study highlights EVs as a mode of communication between the placenta and the maternal vasculature, as well as a potential role for TLR7/8-activating miRs in contributing to inflammation at the maternal-fetal interface in obstetric APS.
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Affiliation(s)
- Carolin S Coenen
- Department of Obstetrics, Gynecology & Reproductive Sciences, Yale University, New Haven, USA; Institute of Molecular Medicine, RWTH Aachen University, Aachen, Germany
| | - Tiffany N Hidalgo
- Department of Obstetrics, Gynecology & Reproductive Sciences, Yale University, New Haven, USA
| | - Tatyana Lynn
- Department of Obstetrics, Gynecology & Reproductive Sciences, Yale University, New Haven, USA
| | - Deidre M Jones
- Department of Obstetrics & Gynecology, University of Auckland, Auckland, New Zealand
| | - Jane E Salmon
- Department of Rheumatology, Weill Cornell Medicine, New York, USA
| | - Lawrence W Chamley
- Department of Obstetrics & Gynecology, University of Auckland, Auckland, New Zealand
| | - Vikki M Abrahams
- Department of Obstetrics, Gynecology & Reproductive Sciences, Yale University, New Haven, USA.
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16
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Reynolds ML, Gibson KL, Manuck TA, Poulton CJ, Blazek L, Stuebe AM, Hogan SL, Falk RJ, Derebail VK. Lupus nephritis kidney biopsy characteristics and preterm birth. FRONTIERS IN NEPHROLOGY 2024; 4:1402597. [PMID: 39139800 PMCID: PMC11319279 DOI: 10.3389/fneph.2024.1402597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2024] [Accepted: 07/09/2024] [Indexed: 08/15/2024]
Abstract
Individuals with lupus nephritis (LN) are at high risk of adverse maternal and fetal outcomes in pregnancy. Outside of pregnancy, proliferative lesions on kidney biopsies are associated with disease progression, but these have not been consistently associated with increased risk in pregnancy. This retrospective, single-center study examines how histologic findings, the timing from kidney biopsy to pregnancy, and the clinical features in the first trimester are associated with preterm birth among individuals with LN. Among 35 deliveries in 31 women, the mean gestational age at delivery was 33.8 weeks. The presence of a urine protein-to-creatinine ratio >0.5 g/g in the first trimester was associated with preterm delivery (81% vs. 36%, p = 0.04). Preterm birth was more common in individuals with glomerular crescents on biopsy (89% in those with >20% crescents vs. 50% in those with <20%, p = 0.06). A pregnancy occurring within 2 years after a kidney biopsy was more likely to result in preterm birth than if the biopsy was performed more than 2 years prior to conception (82% vs. 23%, p = 0.01). The time from diagnostic biopsy may be a surrogate for disease activity, and a 2-year delay from biopsy might allow sufficient time to achieve disease remission. Overall, these data could aid family planning discussions and promote preconception disease optimization for patients and their providers.
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Affiliation(s)
- Monica L. Reynolds
- University of North Carolina (UNC) Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Keisha L. Gibson
- University of North Carolina (UNC) Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Tracy A. Manuck
- University of North Carolina (UNC) Maternal and Fetal Medicine, Division of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Caroline J. Poulton
- University of North Carolina (UNC) Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Lauren Blazek
- University of North Carolina (UNC) Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Alison M. Stuebe
- University of North Carolina (UNC) Maternal and Fetal Medicine, Division of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Susan L. Hogan
- University of North Carolina (UNC) Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Ronald J. Falk
- University of North Carolina (UNC) Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Vimal K. Derebail
- University of North Carolina (UNC) Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
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Chen Y, Chen Y, Li B, Xu W, Lei P, Liu H, Liu D, Hong X. Construction and application of fetal loss risk model in systemic lupus erythematosus patients with mild disease severity. BMC Pregnancy Childbirth 2024; 24:497. [PMID: 39044159 PMCID: PMC11264457 DOI: 10.1186/s12884-024-06679-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 07/04/2024] [Indexed: 07/25/2024] Open
Abstract
BACKGROUND This dynamic nomogram model was developed to predict the probability of fetal loss in pregnant patients with systemic lupus erythematosus (SLE) with mild disease severity before conception. METHODS An analysis was conducted on 314 pregnancy records of patients with SLE who were hospitalized between January 2015 and January 2022 at Shenzhen People's Hospital, and the Longhua Branch of Shenzhen People's Hospital. Data from the Longhua Branch of the Shenzhen People's Hospital were utilized as an independent external validation cohort. The nomogram, a widely used statistical visualization tool to predict disease onset, progression, prognosis, and survival, was created after feature selection using multivariate logistic regression analysis. To evaluate the model prediction performance, we employed the receiver operating characteristic curve, calibration curve, and decision curve analysis. RESULTS Lupus nephritis, complement 3, immunoglobulin G, serum albumin, C-reactive protein, and hydroxychloroquine were all included in the nomogram model. The model demonstrated good calibration and discriminatory power, with an area under the curve of 0.867 (95% confidence interval: 0.787-0.947). According to decision curve analysis, the nomogram model exhibited clinical importance when the probability of fetal loss in patients with SLE ranged between 10 and 70%. The predictive ability of the model was demonstrated through external validation. CONCLUSION The predictive nomogram approach may facilitate precise management of pregnant patients with SLE with mild disease severity before conception.
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Affiliation(s)
- Yanran Chen
- The Second Clinical Medical College, Jinan University (Shenzhen People's Hospital), Shenzhen, China
| | - Yanjuan Chen
- Department of Rheumatology and Immunology, Shenzhen People's Hospital, The Second Clinical Medical College, Jinan University, The First Affiliated Hospital, Southern University of Science and Technology, Shenzhen, China
| | - Bo Li
- Department of Rheumatology and Immunology, Shenzhen Longhua people's Hospital, Shenzhen, China
| | - Wengyi Xu
- Department of Rheumatology and Immunology, Shenzhen People's Hospital, The Second Clinical Medical College, Jinan University, The First Affiliated Hospital, Southern University of Science and Technology, Shenzhen, China
| | - Peipei Lei
- Department of Rheumatology and Immunology, Shenzhen People's Hospital, The Second Clinical Medical College, Jinan University, The First Affiliated Hospital, Southern University of Science and Technology, Shenzhen, China
| | - Hongyang Liu
- Department of Rheumatology and Immunology, Shenzhen People's Hospital, The Second Clinical Medical College, Jinan University, The First Affiliated Hospital, Southern University of Science and Technology, Shenzhen, China
| | - Dongzhou Liu
- The Second Clinical Medical College, Jinan University (Shenzhen People's Hospital), Shenzhen, China.
- Department of Rheumatology and Immunology, Shenzhen People's Hospital, The Second Clinical Medical College, Jinan University, The First Affiliated Hospital, Southern University of Science and Technology, Shenzhen, China.
| | - Xiaoping Hong
- The Second Clinical Medical College, Jinan University (Shenzhen People's Hospital), Shenzhen, China.
- Department of Rheumatology and Immunology, Shenzhen People's Hospital, The Second Clinical Medical College, Jinan University, The First Affiliated Hospital, Southern University of Science and Technology, Shenzhen, China.
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18
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Lu J, Xu D, Wan Q, Chen H. Pregnancy outcomes and risk factors analysis in patients with systemic lupus erythematous. BMC Pregnancy Childbirth 2024; 24:495. [PMID: 39039448 PMCID: PMC11265087 DOI: 10.1186/s12884-024-06701-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 07/15/2024] [Indexed: 07/24/2024] Open
Abstract
BACKGROUND The management of systemic lupus erythematosus (SLE) during pregnancy remains a challenge currently. Identifying early predictors of adverse pregnancy outcomes in SLE patients can help to develop treatment plan and improve prognosis. The aim of this study is to explore the clinical and laboratory variables in the early pregnancy that can predict adverse neonatal and maternal outcomes, thereby facilitating the grading management of SLE. METHODS A retrospective analysis was conducted on 126 pregnant women with SLE who were admitted to Zhongnan Hospital of Wuhan University between January 2017 and December 2022. All enrolled patients were diagnosed (including newly diagnosed and previously diagnosed) during first trimester of pregnancy and their clinical records, laboratory results and pregnancy outcomes were reviewed. The association between the clinical and laboratory characteristics of patients at 12 gestational age and the adverse neonatal (ANOs) as well as maternal outcomes (AMOs) were analyzed. RESULTS A total of 117 live births (92.8%) were recorded in the study. ANOs occurred in 59 (46.8%) cases, including fetal loss in 9 cases (7.1%), preterm birth in 40 cases (31.7%), small for gestational (SGA) in 15 cases (11.9%), and complete heart block in 2 cases (1.5%). Univariate analysis showed that disease activity index (P < 0.0001), lupus nephritis (P = 0.0195), anti-SSB positivity (P = 0.0074) and hypocomplementemia (P = 0.0466) were related to ANOs. However, multivariate analysis showed that only disease activity during early pregnancy was an independent predictor for ANOs (OR = 7.053, 95% CI: 1.882 to 26.291, P = 0.004). In addition, 48 patients experienced AMOs during subsequent trimester, including 24 (19.0%) patients with disease flare and 23 (18.3%) patients with pre-eclampsia. Unplanned pregnancy (P = 0.010), active disease (P = 0.0004), new onset SLE (P = 0.0044) and lupus nephritis (P = 0.0009) were associated with AMOs in univariate analysis, while disease activity was identified as an independent risk factor for AMOs (OR = 2.553, 95% CI: 1.012-6.440, P = 0.047). CONCLUSION Active disease in early pregnancy is associated with adverse pregnancy outcomes. For patients with high risk factor for ANOs and AMOs, more intensive treatment and follow-up should be a wise measure. Especially for those who suffer from active disease, they should be fully informed and given the option to terminate or continue their pregnancy.
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Affiliation(s)
- Jing Lu
- Department of Obstetrics and Gynecology, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
- Clinical Medicine Research Centre of Prenatal Diagnosis and Birth Health in Hubei Province, Wuhan, 430071, China
| | - Dan Xu
- Department of Obstetrics and Gynecology, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
- Clinical Medicine Research Centre of Prenatal Diagnosis and Birth Health in Hubei Province, Wuhan, 430071, China
| | - Qianqian Wan
- Department of Rheumatology and Immunology, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Huijun Chen
- Department of Obstetrics and Gynecology, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China.
- Clinical Medicine Research Centre of Prenatal Diagnosis and Birth Health in Hubei Province, Wuhan, 430071, China.
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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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20
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Ragnarsdóttir IB, Akhter T, Junus K, Lindström L, Lager S, Wikström AK. Does Developing Interpregnancy Hypertension Affect the Recurrence Risk of Preeclampsia? A Population-Based Cohort Study. Am J Hypertens 2024; 37:523-530. [PMID: 38501740 PMCID: PMC11176272 DOI: 10.1093/ajh/hpae034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 01/17/2024] [Accepted: 03/12/2024] [Indexed: 03/20/2024] Open
Abstract
BACKGROUND Preeclampsia in a first pregnancy is a strong risk factor for preeclampsia in a second pregnancy. Whether chronic hypertension developed after a first pregnancy (interpregnancy hypertension) affects the recurrence risk of preeclampsia is unknown. METHODS This is a population-based cohort study of 391,645 women with their first and second singleton births between 2006 and 2017. Exposure groups were women with preeclampsia in their first pregnancy, interpregnancy hypertension, or both risk factors. Women with neither risk factor were used as a reference group. We calculated the adjusted relative risk (aRR) with 95% confidence intervals (CIs) for overall preeclampsia in the second pregnancy as well as preterm (<37 gestational weeks) and term (≥37 gestational weeks) subgroups of the disease. RESULTS Women with preeclampsia in their first pregnancy who did or did not develop interpregnancy hypertension had rates of preeclampsia in their second pregnancy of 21.5% and 13.6%, respectively. In the same population, the corresponding rates of preterm preeclampsia were 5.5% and 2.6%, respectively. After adjusting for maternal factors, women with preeclampsia in their first pregnancy who developed interpregnancy hypertension and those who did not have almost the same risk of overall preeclampsia in their second pregnancy (aRRs with 95% CIs: 14.51; 11.77-17.89 and 12.83; 12.09-13.62, respectively). However, preeclampsia in the first pregnancy and interpregnancy hypertension had a synergistic interaction on the outcome of preterm preeclampsia (aRR with 95% CI 26.66; 17.44-40.80). CONCLUSIONS Women with previous preeclampsia who developed interpregnancy hypertension had a very high rate of preterm preeclampsia in a second pregnancy, and the two risk factors had a synergistic interaction.
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Affiliation(s)
| | - Tansim Akhter
- Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden
| | - Katja Junus
- Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden
| | - Linda Lindström
- Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden
| | - Susanne Lager
- Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden
| | - Anna-Karin Wikström
- Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden
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21
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Gamba A, Zen M, Depascale R, Calligaro A, Gatto M, Iaccarino L, Doria A. Modern Management of Pregnancy in Systemic Lupus Erythematosus: From Prenatal Counseling to Postpartum Support. J Clin Med 2024; 13:3454. [PMID: 38929983 PMCID: PMC11204490 DOI: 10.3390/jcm13123454] [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: 05/12/2024] [Revised: 06/05/2024] [Accepted: 06/12/2024] [Indexed: 06/28/2024] Open
Abstract
Systemic lupus erythematosus (SLE) is a chronic autoimmune disease that predominantly affects women of childbearing age. Pregnancy in SLE patients poses unique challenges due to the potential impact on maternal and fetal outcomes. We provide an overview of the management of SLE during pregnancy, including preconception risk stratification and counseling, treatment, and disease activity monitoring. These assessments are critical to minimize maternal and fetal adverse events in pregnant patients with SLE. Disease flares, preeclampsia, antiphospholipid syndrome complications, and maternal mortality are the major risks for a woman with SLE during gestation. Timely treatment of SLE relapse, differentiation of preeclampsia from lupus nephritis, and tailored management for antiphospholipid syndrome are essential for a successful pregnancy. Fetal outcomes include neonatal lupus (NL), preterm birth, cesarean delivery, fetal growth restriction (FGR), and small-for-gestational-age (SGA) infants. We focused on NL, linked to maternal anti-Ro/SS-A and anti-La/SS-B antibodies, which can lead to various manifestations, particularly cardiac abnormalities, in newborns. While there is a common consensus regarding the preventive effect of hydroxychloroquine, the role of echocardiographic monitoring and fluorinated steroid treatment is still debated. Finally, close postpartum monitoring and counseling for subsequent pregnancies are crucial aspects of care.
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Affiliation(s)
- Anna Gamba
- Rheumatology Unit, Department of Medicine-DIMED, University of Padova, 35128 Padova, Italy
| | - Margherita Zen
- Rheumatology Unit, Department of Medicine-DIMED, University of Padova, 35128 Padova, Italy
| | - Roberto Depascale
- Rheumatology Unit, Department of Medicine-DIMED, University of Padova, 35128 Padova, Italy
| | - Antonia Calligaro
- Rheumatology Unit, Department of Medicine-DIMED, University of Padova, 35128 Padova, Italy
| | - Mariele Gatto
- Academic Rheumatology Centre, Department of Clinical and Biological Sciences, University of Turin, AO Mauriziano di Torino, 10128 Turin, Italy
| | - Luca Iaccarino
- Rheumatology Unit, Department of Medicine-DIMED, University of Padova, 35128 Padova, Italy
| | - Andrea Doria
- Rheumatology Unit, Department of Medicine-DIMED, University of Padova, 35128 Padova, Italy
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22
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Rector A, Marić I, Chaichian Y, Chakravarty E, Cantu M, Weisman MH, Shaw GM, Druzin M, Simard JF. Hydroxychloroquine in Lupus Pregnancy and Risk of Preeclampsia. Arthritis Rheumatol 2024; 76:919-927. [PMID: 38272838 PMCID: PMC11136600 DOI: 10.1002/art.42793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 11/28/2023] [Accepted: 12/26/2023] [Indexed: 01/27/2024]
Abstract
OBJECTIVE Systemic lupus erythematosus (SLE) disproportionately affects women during childbearing years, and hydroxychloroquine (HCQ) is the standard first-line treatment. Preeclampsia complicates up to one-third of pregnancies in lupus patients, although reports vary by parity and multifetal gestation. We investigated whether taking HCQ early in pregnancy may reduce the risk of preeclampsia. METHODS We studied 1,068 live birth singleton pregnancies among 1,020 privately insured patients with SLE (2007-2016). HCQ treatment was defined as three months preconception through the first trimester, and prescription fills were a proxy for taking HCQ. Modified Poisson regression estimated risk ratios (RRs) and 95% confidence intervals (CIs), stratified by parity. Propensity scores accounted for confounders, and stratified analyses examined effect modification. RESULTS Approximately 15% of pregnant patients were diagnosed with preeclampsia. In 52% of pregnancies, patients had one or more HCQ fills. Pregnant patients exposed to HCQ had more comorbidities, SLE activity, and azathioprine treatment. We found no evidence of a statistical association between HCQ and preeclampsia among nulliparous (RR 1.26 [95% CI 0.82-1.93]) and multiparous pregnancies (RR 1.20 [95% CI 0.80-1.70]). Additional controls for confounding decreased the RRs toward the null (nulliparous pregnancy, propensity score-adjusted [PS-adj] RR 1.09 [95% CI 0.68-1.76]; multiparous pregnancy, PS-adj RR 1.01 [95% CI 0.66-1.53]). CONCLUSION Using a large insurance-based database, we did not observe a decreased risk of preeclampsia associated with HCQ treatment in pregnancy, although we cannot rule out residual and unmeasured confounding and misclassification. Further studies leveraging large population-based data and prospective collection could characterize how HCQ influences preeclampsia risk in pregnant patients with SLE and among persons at greater risk of hypertensive disorders of pregnancy.
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Affiliation(s)
- Amadeia Rector
- Department of Epidemiology and Population Health, Stanford University School of Medicine
| | - Ivana Marić
- Department of Pediatrics, Stanford University School of Medicine
| | - Yashaar Chaichian
- Division of Immunology and Rheumatology, Department of Medicine, Stanford University School of Medicine
| | - Eliza Chakravarty
- Arthritis and Clinical Immunology. Oklahoma Medical Research Foundation, Oklahoma City, OK 73104
| | | | - Michael H Weisman
- Division of Immunology and Rheumatology, Department of Medicine, Stanford University School of Medicine
| | - Gary M Shaw
- Department of Pediatrics, Stanford University School of Medicine
| | - Maurice Druzin
- Department of Obstetrics and Gynecology, Stanford University School of Medicine
| | - Julia F Simard
- Department of Epidemiology and Population Health, Stanford University School of Medicine
- Division of Immunology and Rheumatology, Department of Medicine, Stanford University School of Medicine
- Department of Obstetrics and Gynecology, Stanford University School of Medicine
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23
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Shahwar DE, Rehmani D, Raza A. A Comparison of Obstetric Outcomes in Antiphospholipid Syndrome Among Pregnant Women With Systemic Lupus Erythematosus. Cureus 2024; 16:e62126. [PMID: 38993403 PMCID: PMC11238018 DOI: 10.7759/cureus.62126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/11/2024] [Indexed: 07/13/2024] Open
Abstract
Objective The aim of this study was to evaluate the maternal and perinatal outcomes in systemic lupus erythematosus (SLE) women with antiphospholipid syndrome (APS). Methods This retrospective case-control study was conducted among pregnant women with SLE with and without APS. Group A included SLE patients with APS, whereas group B included pregnant SLE women without APS. Data were expressed as mean ± standard deviation (SD). Frequency and percentage were computed for categorical data. The chi-square test was used to analyze the difference between categorical data. Results Out of 125 cases of SLE, APS was found in 72 (57.6%) women. Almost 95.8% of patients were on treatment (aspirin and enoxaparin) in group A. Preterm delivery (31.89±7.36 versus 34.46±4.97; p=0.021) and termination of pregnancy (18.1% [13/72] versus 5.7% [3/53]; p=0.04) were statistically significant in group A. Among these terminations, second-trimester intrauterine death is found to be more in group A (SLE with APS) (16.7% [12/72]) as compared to group B (SLE without APS) (5.7% [3/53]) with a p-value of 0.05. Perinatal outcomes including NICU admissions (39% [23/59] versus 24% [12/50]; p=0.071) and neonatal death (12.3% [7/57]; p=0.015) were also found to be statistically significant between the two groups. Conclusion APS with SLE is associated with adverse pregnancy outcomes such as preterm birth, termination of pregnancy due to second-trimester fetal loss, more NICU admission, and neonatal deaths when compared to the control group. Hence, pregnancies with APS with SLE require vigilant monitoring and frequent follow-ups to ensure a positive pregnancy outcome.
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Affiliation(s)
- Dur E Shahwar
- Obstetrics and Gynecology, Aga Khan University, Karachi, PAK
| | - Duriya Rehmani
- Obstetrics and Gynecology, Aga Khan University, Karachi, PAK
| | - Amir Raza
- Obstetrics and Gynecology, Aga Khan University, Karachi, PAK
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24
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Zhu S, Ren J, Feng L, Jiang Y. Systemic Lupus Erythematosus and Pregnancy Complications and Outcomes: A Mendelian Randomization Study and Retrospective Validation. Int J Womens Health 2024; 16:891-902. [PMID: 38779383 PMCID: PMC11110830 DOI: 10.2147/ijwh.s461640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 05/11/2024] [Indexed: 05/25/2024] Open
Abstract
Introduction Previous studies have shown that pregnant women with systemic lupus erythematosus (SLE) tend to have a higher risk of adverse pregnancy outcomes, but the potential causal role remained unclear. In this study, we aimed to investigate the causal relationship between SLE and some common pregnancy complications and outcomes using two-sample Mendelian randomization (MR). Methods The genetic tools were derived from genome-wide association studies of SLE and pregnancy complications and outcomes. MR analysis was performed using inverse variance weighting as primary method. Sensitivity analyses were performed to evaluate the robustness of the results. A retrospective analysis was conducted on 200 pregnant women with SLE and a control group of pregnant women delivering at Tongji Hospital. Results In the results, we found that genetic susceptibility to SLE was associated with a higher risk of gestational diabetes mellitus (OR = 1.028, 95% CI: 1.006-1.050), premature delivery (OR = 1.039, 95% CI: 1.013-1.066), polyhydramnios (OR = 1.075, 95% CI: 1.004-1.151) and premature rupture of membranes (OR = 1.030, 95% CI: 1.001-1.060). Some of the retrospective analysis results align with the findings from the MR analysis, indicating that pregnant women with SLE have a higher risk of developing gestational diabetes mellitus and preterm birth. Additionally, although MR analysis did not reveal a causal relationship between SLE and preeclampsia/eclampsia, retrospective analysis discovered that SLE pregnant women are more susceptible to developing preeclampsia/eclampsia (OR = 2.935, 95% CI: 1.118-7.620). Conclusion Our study findings suggest a potential causal relationship between SLE and increased risks of gestational diabetes and preterm delivery. Clinical data indicate that pregnant women with SLE are more prone to developing preeclampsia/eclampsia. Clinicians need to be vigilant about the occurrence of these conditions when managing pregnant women with SLE.
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Affiliation(s)
- Shenglan Zhu
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430030, People’s Republic of China
| | - Junlin Ren
- Department of Computer Science, Huazhong University of Science and Technology, Wuhan, 430074, People’s Republic of China
| | - Ling Feng
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430030, People’s Republic of China
| | - Yi Jiang
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430030, People’s Republic of China
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25
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Mitranovici MI, Chiorean DM, Moraru R, Moraru L, Caravia L, Tiron AT, Craina M, Cotoi OS. Understanding the Pathophysiology of Preeclampsia: Exploring the Role of Antiphospholipid Antibodies and Future Directions. J Clin Med 2024; 13:2668. [PMID: 38731197 PMCID: PMC11084819 DOI: 10.3390/jcm13092668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2024] [Revised: 04/26/2024] [Accepted: 04/30/2024] [Indexed: 05/13/2024] Open
Abstract
Preeclampsia (PE) is a hypertensive disorder in pregnancy associated with significant fetal and maternal complications. Antiphospholipid syndrome (APS) is an acquired form of thrombophilia characterized by recurrent venous or arterial thrombosis and obstetric complications that significantly increases morbidity and mortality rates. While preeclampsia may not be the most prevalent obstetric complication in APS, it significantly impacts the long-term health of both mother and child. The treatment of preeclampsia in antiphospholipid syndrome is different from the treatment of preeclampsia as an independent disease. Despite current treatments involving anticoagulants, antiplatelet agents, and antihypertensive drugs, obstetric complications may persist, underscoring the need for cohesive management and effective treatments. The objective of our review is to briefly present knowledge about the physiopathology of preeclampsia and the role of antiphospholipid antibodies in this process. Based on the existing literature, our review aims to identify future directions in molecular pathology toward the discovery of biomarkers and targeted treatments. The application of multidisciplinary approaches and prognostic models, including new biomarkers, could be beneficial in the prediction of PE.
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Affiliation(s)
- Melinda-Ildiko Mitranovici
- Department of Obstetrics and Gynecology, Emergency County Hospital Hunedoara, 14 Victoriei Street, 331057 Hunedoara, Romania
| | - Diana Maria Chiorean
- Department of Pathology, County Clinical Hospital of Targu Mures, 540072 Targu Mures, Romania;
- Department of Pathophysiology, “George Emil Palade” University of Medicine, Pharmacy, Science, and Technology of Targu Mures, 38 Gheorghe Marinescu Street, 540142 Targu Mures, Romania
| | - Raluca Moraru
- Faculty of Medicine, “George Emil Palade” University of Medicine, Pharmacy, Sciences and Technology, 540142 Targu Mures, Romania;
| | - Liviu Moraru
- Department of Anatomy, “George Emil Palade” University of Medicine, Pharmacy, Sciences and Technology, 540142 Targu Mures, Romania;
| | - Laura Caravia
- Division of Cellular and Molecular Biology and Histology, Department of Morphological Sciences, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania;
| | - Andreea Taisia Tiron
- Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania;
| | - Marius Craina
- Department of Obstetrics and Gynecology, University of Medicine and Pharmacy “Victor Babes”, 300001 Timisoara, Romania;
| | - Ovidiu Simion Cotoi
- Department of Pathology, County Clinical Hospital of Targu Mures, 540072 Targu Mures, Romania;
- Department of Pathophysiology, “George Emil Palade” University of Medicine, Pharmacy, Science, and Technology of Targu Mures, 38 Gheorghe Marinescu Street, 540142 Targu Mures, Romania
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26
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Mills BS, Bermas BL. Pregnancy and the Autoimmune Patient. Curr Allergy Asthma Rep 2024; 24:261-267. [PMID: 38563848 DOI: 10.1007/s11882-024-01143-z] [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] [Accepted: 03/15/2024] [Indexed: 04/04/2024]
Abstract
PURPOSE OF REVIEW This article will review the current understanding of the immunologic changes that occur during pregnancy. It will discuss the impact of pregnancy on the disease activity of autoimmune or inflammatory rheumatic diseases (AIRD). Lastly, it will highlight the most recent data on pre-conception and pregnancy management practices that can improve pregnancy outcomes in autoimmune patients. RECENT FINDINGS Pregnancy is an immunologically complex and dynamic state that may affect the activity of AIRDs, with more patients having active disease during pregnancy than previously thought. Uncontrolled inflammatory diseases are associated with poor pregnancy outcomes such as preeclampsia, small for gestational age infants, and prematurity. Pre-conception counseling and early pregnancy planning discussions can help ensure optimal disease control and medication management prior to attempting conception. Adequate control of AIRDs on pregnancy-compatible medications during the pre-conception, pregnancy, and postpartum periods is required for optimal pregnancy outcomes.
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Affiliation(s)
- Brooke S Mills
- University of Texas Southwestern Medical Center, 2001 Inwood Road, Dallas, TX, 75390, USA
| | - Bonnie L Bermas
- University of Texas Southwestern Medical Center, 2001 Inwood Road, Dallas, TX, 75390, USA.
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27
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Cozzi GD, Battarbee AN, Sanjanwala AR, Casey BM, Subramaniam A. Association of Maternal Medical Comorbidities with Duration of Expectant Management in Patients with Severe Preeclampsia. Am J Perinatol 2024; 41:e1521-e1530. [PMID: 37072011 PMCID: PMC10582202 DOI: 10.1055/s-0043-1768232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/20/2023]
Abstract
OBJECTIVE This study aimed to estimate the association between number of maternal comorbidities and duration of expectant management and perinatal outcomes in patients with preeclampsia with severe features. STUDY DESIGN Retrospective cohort of patients with preeclampsia with severe features delivering live, nonanomalous singletons at 23 to 342/7 weeks' gestation at a single center from 2016 to 2018. Patients delivered for an indication other than severe preeclampsia were excluded. Patients were categorized based on the number (0, 1, or ≥2) of comorbidities present: chronic hypertension, pregestational diabetes, chronic kidney disease, and systemic lupus erythematosus. The primary outcome was proportion of potential expectant management time achieved, that is, days of expectant management achieved divided by total potential expectant management time (days from severe preeclampsia diagnosis to 340/7 weeks). Secondary outcomes included delivery gestational age, days of expectant management, and perinatal outcomes. Outcomes were compared in bivariable and multivariable analyses. RESULTS Of 337 patients included, 167 (50%) had 0, 151 (45%) had 1, and 19 (5%) had ≥2 comorbidities. Groups differed with respect to age, body mass index, race/ethnicity, insurance, and parity. The median proportion of potential expectant management achieved in this cohort was 1.8% (interquartile range: 0-15.4), and did not differ by number of comorbidities (adjusted β: 5.3 [95% confidence interval [CI]: -2.1 to 12.9] for 1 comorbidity vs. 0 and adjusted β: -2.9 [95% CI: -18.0 to 12.2] for ≥2 comorbidities vs. 0). There was no difference in delivery gestational age or duration of expectant management in days. Patients with ≥2 (vs. 0) comorbidities had higher odds of composite maternal morbidity (adjusted odds ratio: 3.0 [95% CI: 1.1-8.2]). There was no association between number of comorbidities and composite neonatal morbidity. CONCLUSION Among patients with preeclampsia with severe features, the number of comorbidities was not associated with duration of expectant management; however, patients with ≥2 comorbidities had higher odds of adverse maternal outcomes. KEY POINTS · Greater number of medical comorbidities were not associated with expectant management duration.. · Two or more medical comorbidities were associated with higher odds of adverse maternal outcomes.. · Expectant management should be undertaken cautiously in medically complicated patients..
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Affiliation(s)
- Gabriella D. Cozzi
- Division of Maternal Fetal Medicine Center for Women’s Reproductive Health, University of Alabama at Birmingham, Alabama
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Alabama
| | - Ashley N. Battarbee
- Division of Maternal Fetal Medicine Center for Women’s Reproductive Health, University of Alabama at Birmingham, Alabama
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Alabama
| | - Aalok R. Sanjanwala
- Division of Maternal Fetal Medicine Center for Women’s Reproductive Health, University of Alabama at Birmingham, Alabama
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Alabama
| | - Brian M. Casey
- Division of Maternal Fetal Medicine Center for Women’s Reproductive Health, University of Alabama at Birmingham, Alabama
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Alabama
| | - Akila Subramaniam
- Division of Maternal Fetal Medicine Center for Women’s Reproductive Health, University of Alabama at Birmingham, Alabama
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Alabama
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28
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de Assis V, Giugni CS, Ros ST. Evaluation of Recurrent Pregnancy Loss. Obstet Gynecol 2024; 143:645-659. [PMID: 38176012 DOI: 10.1097/aog.0000000000005498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 11/02/2023] [Indexed: 01/06/2024]
Abstract
Recurrent pregnancy loss (RPL) affects approximately 5% of couples. Although RPL definitions vary across professional societies, an evaluation after a second clinically recognized first-trimester pregnancy loss is recommended. Good quality evidence links parental chromosomal rearrangements, uterine anomalies, and antiphospholipid syndrome (APS) to RPL. In contrast, the relationship between RPL and other endocrine, hematologic, and immunologic disorders or environmental exposures is less clear. Anticoagulant therapy and low-dose aspirin are recommended for patients with RPL who have also been diagnosed with APS. Vaginal progesterone supplementation may be considered in patients experiencing vaginal bleeding during the first trimester. Surgical correction may be considered for patients with RPL in whom a uterine anomaly is identified. Evaluation and management of additional comorbidities should be guided by the patient's history rather than solely based on the diagnosis of RPL, with the goal of improving overall health to reduce complications in the event of pregnancy. Most people with RPL, including those without identifiable risk factors, are expected to achieve a live birth within 5 years from the initial evaluation. Nevertheless, clinicians should be sensitive to the psychological needs of individuals with this condition and provide compassionate and supportive care across all stages.
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Affiliation(s)
- Viviana de Assis
- Department of Obstetrics and Gynecology, University of South Florida Morsani College of Medicine, Tampa, Florida
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29
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Rosta K, Binder J, Kuczwara V, Horvath M, Heinzl F, Hörhager C, Mayrhofer D, Mandl P, Fritsch-Stork R, Ott J, Mazzucato-Puchner A. Periconceptional Counselling in Women with Autoimmune Inflammatory Rheumatic Diseases. J Clin Med 2024; 13:2483. [PMID: 38731018 PMCID: PMC11084745 DOI: 10.3390/jcm13092483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Revised: 04/12/2024] [Accepted: 04/17/2024] [Indexed: 05/13/2024] Open
Abstract
Systemic autoimmune rheumatic diseases (SARDs) in pregnancy represent a complex challenge for both patients and healthcare providers. Timely preparation for pregnancy enables adequate disease control, thereby reducing the risk of disease flare and pregnancy complications. Interdisciplinary care starting from the pre-pregnancy period throughout pregnancy and during breastfeeding ensures better fetal and maternal outcomes. This review provides a comprehensive guide to pre-pregnancy counselling in SARDs, an overview of medication management strategies tailored to pregnancy, disease activity and pregnancy monitoring in patients, and the promotion of shared decision making between healthcare providers and patients. Guidelines from international organizations were selected to provide a basis for this review and guidance through the quintessential discussion points of care.
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Affiliation(s)
- Klara Rosta
- Division of Gynecological Endocrinology and Reproductive Medicine, Department of Obstetrics and Gynecology, Medical University of Vienna, 1090 Vienna, Austria
| | - Julia Binder
- Division of Obstetrics and Fetomaternal Medicine, Department of Obstetrics and Gynecology, Medical University of Vienna, 1090 Vienna, Austria
| | - Valerie Kuczwara
- Division of Gynecological Endocrinology and Reproductive Medicine, Department of Obstetrics and Gynecology, Medical University of Vienna, 1090 Vienna, Austria
| | - Mira Horvath
- Division of Gynecological Endocrinology and Reproductive Medicine, Department of Obstetrics and Gynecology, Medical University of Vienna, 1090 Vienna, Austria
| | - Florian Heinzl
- Division of Obstetrics and Fetomaternal Medicine, Department of Obstetrics and Gynecology, Medical University of Vienna, 1090 Vienna, Austria
| | - Christina Hörhager
- Division of Gynecological Endocrinology and Reproductive Medicine, Department of Obstetrics and Gynecology, Medical University of Vienna, 1090 Vienna, Austria
| | - Daniel Mayrhofer
- Division of Gynecological Endocrinology and Reproductive Medicine, Department of Obstetrics and Gynecology, Medical University of Vienna, 1090 Vienna, Austria
| | - Peter Mandl
- Division of Rheumatology, Department of Internal Medicine III, Medical University of Vienna, 1090 Vienna, Austria
| | - Ruth Fritsch-Stork
- Health Care Centre Mariahilf, ÖGK and Rheumatology Department, Sigmund Freud Private University, 1060 Vienna, Austria
| | - Johannes Ott
- Division of Gynecological Endocrinology and Reproductive Medicine, Department of Obstetrics and Gynecology, Medical University of Vienna, 1090 Vienna, Austria
| | - Antonia Mazzucato-Puchner
- Division of Rheumatology, Department of Internal Medicine III, Medical University of Vienna, 1090 Vienna, Austria
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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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Torell A, Stockfelt M, Blennow K, Zetterberg H, Akhter T, Leonard D, Rönnblom L, Pihl S, Saleh M, Sjöwall C, Strevens H, Jönsen A, Bengtsson AA, Trysberg E, Majczuk Sennström M, Zickert A, Svenungsson E, Gunnarsson I, Bylund J, Jacobsson B, Rudin A, Lundell AC. Low CD4 + T cell count is related to specific anti-nuclear antibodies, IFNα protein positivity and disease activity in systemic lupus erythematosus pregnancy. Arthritis Res Ther 2024; 26:65. [PMID: 38459582 PMCID: PMC10924387 DOI: 10.1186/s13075-024-03301-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 03/01/2024] [Indexed: 03/10/2024] Open
Abstract
BACKGROUND Lymphopenia, autoantibodies and activation of the type I interferon (IFN) system are common features in systemic lupus erythematosus (SLE). We speculate whether lymphocyte subset counts are affected by pregnancy and if they relate to autoantibody profiles and/or IFNα protein in SLE pregnancy. METHODS Repeated blood samples were collected during pregnancy from 80 women with SLE and 51 healthy controls (HC). Late postpartum samples were obtained from 19 of the women with SLE. Counts of CD4 + and CD8 + T cells, B cells and NK cells were measured by flow cytometry. Positivity for anti-nuclear antibodies (ANA) fine specificities (double-stranded DNA [dsDNA], Smith [Sm], ribonucleoprotein [RNP], chromatin, Sjögren's syndrome antigen A [SSA] and B [SSB]) and anti-phospholipid antibodies (cardiolipin [CL] and β2 glycoprotein I [β2GPI]) was assessed with multiplexed bead assay. IFNα protein concentration was quantified with Single molecule array (Simoa) immune assay. Clinical data were retrieved from medical records. RESULTS Women with SLE had lower counts of all lymphocyte subsets compared to HC throughout pregnancy, but counts did not differ during pregnancy compared to postpartum. Principal component analysis revealed that low lymphocyte subset counts differentially related to autoantibody profiles, cluster one (anti-dsDNA/anti-Sm/anti-RNP/anti-Sm/RNP/anti-chromatin), cluster two (anti-SSA/anti-SSB) and cluster three (anti-CL/anti-β2GPI), IFNα protein levels and disease activity. CD4 + T cell counts were lower in women positive to all ANA fine specificities in cluster one compared to those who were negative, and B cell numbers were lower in women positive for anti-dsDNA and anti-Sm compared to negative women. Moreover, CD4 + T cell and B cell counts were lower in women with moderate/high compared to no/low disease activity, and CD4 + T cell count was lower in IFNα protein positive relative to negative women. Finally, CD4 + T cell count was unrelated to treatment. CONCLUSION Lymphocyte subset counts are lower in SLE compared to healthy pregnancies, which seems to be a feature of the disease per se and not affected by pregnancy. Our results also indicate that low lymphocyte subset counts relate differentially to autoantibody profiles, IFNα protein levels and disease activity, which could be due to divergent disease pathways.
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Affiliation(s)
- Agnes Torell
- Department of Rheumatology and Inflammation Research, Institute of Medicine, Sahlgrenska Academy at the University of Gothenburg, Guldhedsgatan 10A, 405 30, Gothenburg, Sweden.
| | - Marit Stockfelt
- Department of Rheumatology and Inflammation Research, Institute of Medicine, Sahlgrenska Academy at the University of Gothenburg, Guldhedsgatan 10A, 405 30, Gothenburg, Sweden
- Rheumatology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Kaj Blennow
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
- Paris Brain Institute, ICM, Pitié-Salpêtrière Hospital, Sorbonne University, Paris, France
- Neurodegenerative Disorder Research Center, Division of Life Sciences and Medicine and Department of Neurology, Institute On Aging and Brain Disorders, University of Science and Technology of China and First Affiliated Hospital of USTC, Hefei, People's Republic of China
| | - Henrik Zetterberg
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
- Department of Neurodegenerative Disease, UCL Institute of Neurology, Queen Square, London, UK
- UK Dementia Research Institute at UCL, London, UK
- Hong Kong Center for Neurodegenerative Diseases, Clear Water Bay, Hong Kong, China
- Winsconsin Alzheimer's Disease Research Center, School of Medicine and Public Health, University of Wisconsin, University of Wisconsin-Madison, Madison, WI, USA
| | - Tansim Akhter
- Department of Women's and Children's Health, Section of Obstetrics and Gynecology, Uppsala University, Uppsala, Sweden
| | - Dag Leonard
- Department of Medical Sciences, Rheumatology, Uppsala University, Uppsala, Sweden
| | - Lars Rönnblom
- Department of Medical Sciences, Rheumatology, Uppsala University, Uppsala, Sweden
| | - Sofia Pihl
- Department of Obstetrics and Gynecology, Linköping University Hospital, Linköping, Sweden
- Department of Biomedical and Clinical Sciences, Division of Children's and Women's Health, Linköping University, Linköping, Sweden
| | - Muna Saleh
- Division of Inflammation and Infection, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Christopher Sjöwall
- Division of Inflammation and Infection, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Helena Strevens
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Skåne University Hospital, Lund, Sweden
| | - Andreas Jönsen
- Department of Clinical Sciences Lund, Rheumatology, Lund University, Skåne University Hospital, Lund, Sweden
| | - Anders A Bengtsson
- Department of Clinical Sciences Lund, Rheumatology, Lund University, Skåne University Hospital, Lund, Sweden
| | - Estelle Trysberg
- Rheumatology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Maria Majczuk Sennström
- Department of Womens and Childrens Health, Division for Obstetrics and Gynecology, Karolinska University Hospital, Karolinska Institute, Stockholm, Sweden
| | - Agneta Zickert
- Division of Rheumatology, Department of Medicine Solna, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
| | - Elisabet Svenungsson
- Division of Rheumatology, Department of Medicine Solna, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
| | - Iva Gunnarsson
- Division of Rheumatology, Department of Medicine Solna, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
| | - Johan Bylund
- Department of Oral Microbiology and Immunology, Institute of Odontology, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
| | - Bo Jacobsson
- Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Obstetrics and Gynecology, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
- Department of Genetics and Bioinformatics, Division of Health Data and Digitalisation, Institute of Public Health, Oslo, Norway
| | - Anna Rudin
- Department of Rheumatology and Inflammation Research, Institute of Medicine, Sahlgrenska Academy at the University of Gothenburg, Guldhedsgatan 10A, 405 30, Gothenburg, Sweden
| | - Anna-Carin Lundell
- Department of Rheumatology and Inflammation Research, Institute of Medicine, Sahlgrenska Academy at the University of Gothenburg, Guldhedsgatan 10A, 405 30, Gothenburg, Sweden
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Nakai T, Honda N, Soga E, Fukui S, Kitada A, Yokogawa N, Okada M. Effect of remission, clinical remission with active serology, and glucocorticoid dosage on the pregnancy outcome of pregnant patients with systemic lupus erythematosus. Arthritis Res Ther 2024; 26:63. [PMID: 38459603 PMCID: PMC10924338 DOI: 10.1186/s13075-024-03298-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 02/29/2024] [Indexed: 03/10/2024] Open
Abstract
BACKGROUND Remission is a key treatment target in systemic lupus erythematosus (SLE) management. Given the direct correlation between lupus flares and elevated risks of adverse pregnancy outcomes (APOs), securing remission before conception becomes crucial. However, the association between clinical remission with active serology, and the risk of APOs is not thoroughly understood. Additionally, determining the optimal glucocorticoid dosage during pregnancy to mitigate APO risks remains under-researched. This study investigated the risk of APOs in relation to remission/serological activity status in patients in clinical remission/glucocorticoid dosage. METHODS Pregnant patients with SLE, who were followed up at two Japanese tertiary referral centers, and had their remission status assessed at conception, were included in this study. We categorized the patients into two groups based on whether they achieved Zen/Doria remission at conception and analyzed the APO ratio. We also examined the influence of serological activity in pregnant patients with clinical remission and analyzed the optimal glucocorticoid dosage to minimize the APO ratio. RESULTS Of the 96 pregnancies included, 59 achieved remission at conception. Pregnant patients who achieved remission showed a significant decrease in the APO ratio compared with those who did not. (overall APO: odds ratio (OR) 0.27, 95% confidence interval (CI) 0.11-0.65, p < 0.01, maternal APO: OR 0.34, 95%CI 0.13-0.85, p = 0.021, neonatal APO: OR 0.39, 95%CI 0.17-0.90, p = 0.028). Conversely, no statistical difference was observed in the APO ratio based on serological activity in pregnant patients with clinical remission. (overall APO: OR 0.62, 95%CI 0.21-1.79, p = 0.37, maternal APO: OR 1.25, 95%CI 0.32-4.85, p = 0.75, neonatal APO: OR 0.83, 95%CI 0.29-2.39, p = 0.73). A glucocorticoid dose of prednisolone equivalent ≥ 7.5 mg/day at conception correlated with increased APO. (overall APO: OR 3.01, 95%CI 1.23-7.39, p = 0.016, neonatal APO: OR 2.98, 95% CI:1.23-7.22, p = 0.016). CONCLUSIONS Even with active serology, achieving clinical remission can be a clinical target for reducing APOs in patients who wish to conceive. In addition, if clinically feasible, reducing the glucocorticoid dosage to < 7.5 mg/day before conception could be another predictive factor.
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Affiliation(s)
- Takehiro Nakai
- Immuno-Rheumatology Center, St. Luke's International Hospital, 9-1 Akashi-cho, Chuo-ku, Tokyo, Japan.
| | - Nanase Honda
- Department of Rheumatic Diseases, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Eri Soga
- Department of Obstetrics and Gynecology, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Sho Fukui
- Immuno-Rheumatology Center, St. Luke's International Hospital, 9-1 Akashi-cho, Chuo-ku, Tokyo, Japan
- Department of General Medicine, Kyorin University School of Medicine, Tokyo, Japan
- Division of Rheumatology, Inflammation, and Immunity, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Ayako Kitada
- Immuno-Rheumatology Center, St. Luke's International Hospital, 9-1 Akashi-cho, Chuo-ku, Tokyo, Japan
- Department of Rheumatology, Institute of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Naoto Yokogawa
- Department of Rheumatic Diseases, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Masato Okada
- Immuno-Rheumatology Center, St. Luke's International Hospital, 9-1 Akashi-cho, Chuo-ku, Tokyo, Japan
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Le Guern V, Guettrot-Imbert G, Dupré A, Perol S, Pannier E, Morel N, Costedoat-Chalumeau N. Issues with pregnancy in systemic lupus. Joint Bone Spine 2024; 91:105713. [PMID: 38447695 DOI: 10.1016/j.jbspin.2024.105713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 02/15/2024] [Accepted: 02/20/2024] [Indexed: 03/08/2024]
Abstract
Systemic lupus erythematosus is a disease that affects a large number of young women of childbearing age. Today, pregnancy is considered safe in almost all women with lupus, especially when the disease is under control. However, pregnancies in this population have a higher risk of maternal complications than in the general population. It is therefore important to plan pregnancies as effectively as possible, using effective contraception and pre-pregnancy counselling. In fact, effective, well-tolerated contraception is essential for patients for whom pregnancy cannot be safely envisaged, particularly in the setting of teratogenic treatment or significant disease activity. Preconception counselling is essential and helps to anticipate several aspects of a future pregnancy. Several recent prospective studies have clearly identified risk factors for obstetric complications and disease flare. High level of lupus activity, low complement, primigravida and a history of lupus nephritis are predictive factors of disease flare when antiphospholipid syndrome or antiphospholipid antibodies (specifically for lupus anticoagulant), damage, activity of lupus are predictive for obstetric events. Appropriate therapeutic management is essential, based primarily on the continuation of hydroxychloroquine, although some recent warnings about its use in pregnancy have been discussed controversially. Corticosteroid therapy can be continued at the lowest possible dose, as can certain immunosuppressive drugs. In the case of a history of lupus nephritis, low-dose aspirin is also prescribed. Although still exceptional, the risk of neonatal lupus is also higher, in patients with anti-SSA and anti-SSB antibodies. The aim of this review is to summarise the risk factors for adverse obstetric outcomes and to improve medical and obstetric management in this population of pregnant women with lupus.
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Affiliation(s)
- Véronique Le Guern
- Service de médecine interne, Centre de références maladies auto-immunes et systémiques rares d'Île-de-France, Cochin, AP-HP, Paris, France.
| | - Gaelle Guettrot-Imbert
- Service de médecine interne, Centre de références maladies auto-immunes et systémiques rares d'Île-de-France, Cochin, AP-HP, Paris, France; Université Paris Cité, Paris, France
| | - Anastasia Dupré
- Service de médecine interne, Centre de références maladies auto-immunes et systémiques rares d'Île-de-France, Cochin, AP-HP, Paris, France
| | - Sandrine Perol
- Service de gynécologie médicale, Port-Royal, Cochin, AP-HP, Paris, France
| | | | - Nathalie Morel
- Service de médecine interne, Centre de références maladies auto-immunes et systémiques rares d'Île-de-France, Cochin, AP-HP, Paris, France
| | - Nathalie Costedoat-Chalumeau
- Service de médecine interne, Centre de références maladies auto-immunes et systémiques rares d'Île-de-France, Cochin, AP-HP, Paris, France; Université Paris Cité, Paris, France; Centre de recherche en épidémiologie et statistiques, université Paris Cité (CRESS), équipe Épidémiologie clinique appliquée aux maladies rhumatismales et musculosquelettiques (ECAMO), Inserm U1153, Paris, France
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Tarter L, Bermas BL. Expert Perspective on a Clinical Challenge: Lupus and Pregnancy. Arthritis Rheumatol 2024; 76:321-331. [PMID: 37975160 DOI: 10.1002/art.42756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 10/10/2023] [Accepted: 11/13/2023] [Indexed: 11/19/2023]
Abstract
Systemic lupus erythematosus (SLE), a multiorgan systemic inflammatory disorder, predominantly affects women during their reproductive years. In this review, we summarize the state of knowledge about preconception planning and management of SLE during pregnancy. Achieving remission or low disease activity for several months on medications compatible with pregnancy prior to conception is essential to decreasing the risk of disease flare and improving pregnancy outcomes, including pre-eclampsia, preterm birth, and intrauterine growth restriction. With close management and well-controlled disease before and during pregnancy, <10% of patients flare. All patients with SLE should remain on hydroxychloroquine unless contraindicated. Expectant mothers with a history of antiphospholipid syndrome should be treated with anticoagulant therapy during pregnancy. Women with anti-Ro/SSA or anti-La/SSB antibodies require additional monitoring because their offspring are at increased risk for congenital heart block. Patients with SLE should be offered low-dose aspirin starting at the end of the first trimester to reduce the risk of pre-eclampsia. Flares of SLE during pregnancy require escalation of therapy. The immunosuppressives azathioprine, tacrolimus, and cyclosporine are compatible with pregnancy, and biologic agents can also be considered. Glucocorticoid use in pregnancy should be limited to the lowest effective dose. Mycophenolate mofetil/mycophenolic acid, methotrexate, leflunomide, and cyclophosphamide are known to be teratogenic and are contraindicated in pregnancy. Distinguishing a flare of lupus nephritis during pregnancy from pre-eclampsia can be particularly challenging. Overall, outcomes in pregnancy for women with lupus are improving, but gaps in knowledge about optimal management strategies persist.
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Affiliation(s)
- Laura Tarter
- Brigham and Women's Hospital, Boston, Massachusetts
| | - Bonnie L Bermas
- University of Texas Southwestern Medical Center, Dallas, Texas
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35
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Jiang Y, Tao M, Chen J, Luo L, You Q, Wu H, Zhang N. Calcineurin inhibitors in the treatment of systemic lupus erythematosus during pregnancy: A narrative review with emphasis on efficacy and safety. Eur J Obstet Gynecol Reprod Biol 2024; 294:148-155. [PMID: 38245953 DOI: 10.1016/j.ejogrb.2023.12.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Revised: 11/21/2023] [Accepted: 12/31/2023] [Indexed: 01/23/2024]
Abstract
Systemic lupus erythematosus (SLE) predominantly affects child-bearing women, leading to an elevated risk of maternal and fetal complications and adverse pregnancy outcomes. Since some medications can cross the placental barrier that persist a threat to both mother and fetus, the risk-benefit ratio of SLE medications should be taken into consideration during pregnancy. Calcineurin inhibitor (CNI), mainly including cyclosporin A, tacrolimus, and voclosporin, is a category of immunosuppressive agents that inhibit calcium/calmodulin-dependent phosphatase calcineurin to block T cell activation. Based on the current clinical evidence, CNI is an alternative in pregnant SLE patients with persistent disease activity (especially lupus nephritis patients) and non-responders to azathioprine. However, there is no comprehensive review that summarizes the efficacy and safety profile of CNI for SLE management during pregnancy. This review presents a summary on the utilization of CNI for SLE management during pregnancy, including the mechanism of action, gestational amelioration of lupus flare, and the balance of maternal benefit-fetal risk, which may provide more references for the management of SLE pregnancies.
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Affiliation(s)
- Yi Jiang
- Department of Rheumatology and Immunology, The First Hospital Affiliated to Army Medical University, Chongqing 400038, China
| | - Min Tao
- Department of Pediatrics, The First Hospital Affiliated to Army Medical University, Chongqing 400038, China
| | - Jingjing Chen
- Department of Rheumatology and Immunology, The First Hospital Affiliated to Army Medical University, Chongqing 400038, China
| | - Lihua Luo
- Department of Rheumatology and Immunology, The First Hospital Affiliated to Army Medical University, Chongqing 400038, China
| | - Qingxia You
- Department of Rheumatology and Immunology, The First Hospital Affiliated to Army Medical University, Chongqing 400038, China
| | - Hong Wu
- Department of Rheumatology and Immunology, The First Hospital Affiliated to Army Medical University, Chongqing 400038, China
| | - Nian Zhang
- Department of Traditional Chinese Medicine, The Second Hospital Affiliated to Army Medical University, Chongqing 400037, China.
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Delgado M, Rodman J, Xepoleas M, Weisman M, Wise LM. Differences in reproductive health discussions in an urban Hispanic population with SLE: lessons from the field. Lupus Sci Med 2024; 11:e001095. [PMID: 38382933 PMCID: PMC10882303 DOI: 10.1136/lupus-2023-001095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 02/03/2024] [Indexed: 02/23/2024]
Abstract
OBJECTIVE Management of reproductive health-related issues is crucial for patients with SLE, given this is a disease that primarily affects women of childbearing age. Little is known as to how the 2020 American College of Rheumatology (ACR) Reproductive Health in Rheumatic Disease Guideline is experienced by an underserved, primarily Hispanic population and their physicians as it relates to pregnancy planning and contraception conversations. Given this population experiences high rates of unplanned pregnancies and worse SLE outcomes compared with the non-Hispanic white population, it is crucial to understand how reproductive health is discussed in this setting. METHODS A survey based on the 2020 ACR Reproductive Health Guideline was created and distributed in English and Spanish in the outpatient setting to 151 patients with SLE to determine patients' beliefs, experiences and limitations with reproductive health discussions. Associations between categorical variables were evaluated using Pearson's χ2 or Fisher's exact test, as appropriate, and differences in continuous variables were assessed using Wilcoxon rank-sum test. RESULTS English language survey respondents were significantly more likely to report having conversations regarding contraception, pregnancy planning and peripartum medication use than the Spanish survey respondents. Two-thirds of all respondents relied on the rheumatologist as a top source of reproductive health information. CONCLUSION Disparities exist regarding reproductive health conversations on multiple topics between English-speaking and Spanish-speaking populations with SLE. Further understanding is needed to clarify why reproductive health conversations occur at lower frequencies in Spanish-speaking SLE populations.
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Affiliation(s)
- Martha Delgado
- Keck School of Medicine, Department of Medicine Residency Program, University of Southern California, Los Angeles, California, USA
| | - Jack Rodman
- Southern California Clinical and Translational Science Institute, University of Southern California, Los Angeles, California, USA
| | - Meredith Xepoleas
- Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | | | - Leanna Marderian Wise
- Department of Medicine, Division of Rheumatology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
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Yelnik CM, Xie X, Guerra MM, Costedoat-Chalumeau N, Khosroshahi A, Kamen DL, Schwartz N, Katz P, Minett M, Amoss RT, Fu A, Guettrot-Imbert G, Lazaro E, Le Guern V, Oates J, Dall'Era M, Yazdany J, Molto A, Kim MY, Salmon JE. Prevalence of clinically meaningful antiphospholipid antibodies in patients with systemic lupus erythematosus varies by race and ethnicity. Ann Rheum Dis 2024; 83:404-406. [PMID: 37875285 PMCID: PMC10922457 DOI: 10.1136/ard-2023-224952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 10/03/2023] [Indexed: 10/26/2023]
Affiliation(s)
- Cécile M Yelnik
- Département de Médecine Interne et d'Immunologie Clinique, Universite de Lille, Lille, France
| | - Xianhong Xie
- Department of Epidemiology & Population Health, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Marta M Guerra
- Department of Medicine/Rheumatology, Hospital for Special Surgery, New York, New York, USA
| | - Nathalie Costedoat-Chalumeau
- Department of Internal Medicine, Cochin Hospital, Paris, France
- ECAMO Team (INSERM U-1153), CRESS - Université Paris Cité, Paris, France
| | - Arezou Khosroshahi
- Lowance Center for Human Immunology, Emory University, Atlanta, Georgia, USA
| | - Diane L Kamen
- Division of Rheumatology and Immunology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Noa Schwartz
- Department of Medicine, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Patricia Katz
- Department of Medicine/Rheumatology, University of California San Francisco, San Francisco, California, USA
| | - Margaret Minett
- Department of Medicine/Rheumatology, Hospital for Special Surgery, New York, New York, USA
| | - R Toby Amoss
- Lowance Center for Human Immunology, Emory University, Atlanta, Georgia, USA
| | - April Fu
- Department of Medicine, Albert Einstein College of Medicine, Bronx, New York, USA
| | | | - Estibaliz Lazaro
- Department of Internal Medicine, Haut Lévêque Hospital, Bordeaux, France
- ImmunoconcEpT Lab, Bordeaux University, Bordeaux, France
| | | | - Jim Oates
- Division of Rheumatology and Immunology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Maria Dall'Era
- Department of Medicine/Rheumatology, University of California San Francisco, San Francisco, California, USA
| | - Jinoos Yazdany
- Department of Medicine/Rheumatology, University of California San Francisco, San Francisco, California, USA
| | - Anna Molto
- ECAMO Team (INSERM U-1153), CRESS - Université Paris Cité, Paris, France
- Department of Rheumatology, Cochin Hospital, Paris, France
| | - Mimi Y Kim
- Department of Epidemiology & Population Health, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Jane E Salmon
- Department of Medicine/Rheumatology, Hospital for Special Surgery, New York, New York, USA
- Department of Medicine, Weill Cornell Medicine, New York, New York, USA
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Venturelli V, Abrantes AM, Rahman A, Isenberg DA. The impact of antiphospholipid antibodies/antiphospholipid syndrome on systemic lupus erythematosus. Rheumatology (Oxford) 2024; 63:SI72-SI85. [PMID: 38320586 DOI: 10.1093/rheumatology/kead618] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 10/31/2023] [Indexed: 02/08/2024] Open
Abstract
aPLs are a major determinant of the increased cardiovascular risk in patients with SLE. They adversely affect clinical manifestations, damage accrual and prognosis. Apart from the antibodies included in the 2006 revised classification criteria for APS, other non-classical aPLs might help in identifying SLE patients at increased risk of thrombotic events. The best studied are IgA anti-β2-glycoprotein I, anti-domain I β2-glycoprotein I and aPS-PT. Major organ involvement includes kidney and neuropsychiatric systems. aPL/APS severely impacts pregnancy outcomes. Due to increased thrombotic risk, these patients require aggressive cardiovascular risk factor control. Primary prophylaxis is based on low-dose aspirin in high-risk patients. Warfarin is the gold-standard drug for secondary prophylaxis.
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Affiliation(s)
- Veronica Venturelli
- Rheumatology Unit, Department of Medical Sciences, Università degli Studi di Ferrara, Azienda Ospedaliero-Universitaria S. Anna, Cona, Italy
| | - Ana Mafalda Abrantes
- Division of Internal Medicine II, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
- Instituto de Semiótica Clínica, Faculty of Medicine, University of Lisbon, Lisbon, Portugal
| | - Anisur Rahman
- Centre for Rheumatology, Department of Medicine, University College London, London, UK
| | - David A Isenberg
- Centre for Rheumatology, Department of Medicine, University College London, London, UK
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Danieli MG, Brunetto S, Gammeri L, Palmeri D, Claudi I, Shoenfeld Y, Gangemi S. Machine learning application in autoimmune diseases: State of art and future prospectives. Autoimmun Rev 2024; 23:103496. [PMID: 38081493 DOI: 10.1016/j.autrev.2023.103496] [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: 11/12/2023] [Accepted: 11/29/2023] [Indexed: 04/30/2024]
Abstract
Autoimmune diseases are a group of disorders resulting from an alteration of immune tolerance, characterized by the formation of autoantibodies and the consequent development of heterogeneous clinical manifestations. Diagnosing autoimmune diseases is often complicated, and the available prognostic tools are limited. Machine learning allows us to analyze large amounts of data and carry out complex calculations quickly and with minimal effort. In this work, we examine the literature focusing on the use of machine learning in the field of the main systemic (systemic lupus erythematosus and rheumatoid arthritis) and organ-specific autoimmune diseases (type 1 diabetes mellitus, autoimmune thyroid, gastrointestinal, and skin diseases). From our analysis, interesting applications of machine learning emerged for developing algorithms useful in the early diagnosis of disease or prognostic models (risk of complications, therapeutic response). Subsequent studies and the creation of increasingly rich databases to be supplied to the algorithms will eventually guide the clinician in the diagnosis, allowing intervention when the pathology is still in an early stage and immediately directing towards a correct therapeutic approach.
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Affiliation(s)
- Maria Giovanna Danieli
- SOS Immunologia delle Malattie Rare e dei Trapianti. AOU delle Marche & Dipartimento di Scienze Cliniche e Molecolari, Università Politecnica delle Marche, via Tronto 10/A, 60126 Torrette di Ancona, Italy; Postgraduate School of Allergy and Clinical Immunology, Università Politecnica delle Marche, via Tronto 10/A, 60126 Ancona, Italy.
| | - Silvia Brunetto
- Operative Unit of Allergy and Clinical Immunology, Department of Clinical and Experimental Medicine, University of Messina, Via Consolare Valeria 1, 98125 Messina, Italy
| | - Luca Gammeri
- Operative Unit of Allergy and Clinical Immunology, Department of Clinical and Experimental Medicine, University of Messina, Via Consolare Valeria 1, 98125 Messina, Italy
| | - Davide Palmeri
- Postgraduate School of Allergy and Clinical Immunology, Università Politecnica delle Marche, via Tronto 10/A, 60126 Ancona, Italy
| | - Ilaria Claudi
- Postgraduate School of Allergy and Clinical Immunology, Università Politecnica delle Marche, via Tronto 10/A, 60126 Ancona, Italy
| | - Yehuda Shoenfeld
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, and Reichman University Herzliya, Israel.
| | - Sebastiano Gangemi
- Operative Unit of Allergy and Clinical Immunology, Department of Clinical and Experimental Medicine, University of Messina, Via Consolare Valeria 1, 98125 Messina, Italy.
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Yan P, Yao J, Ke B, Fang X. Mendelian randomization reveals systemic lupus erythematosus and rheumatoid arthritis and risk of adverse pregnancy outcomes. Eur J Obstet Gynecol Reprod Biol 2024; 293:78-83. [PMID: 38128388 DOI: 10.1016/j.ejogrb.2023.12.020] [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: 09/25/2023] [Revised: 11/16/2023] [Accepted: 12/13/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND The effect of systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA) on adverse pregnancy outcomes is a controversial topic. This study aimed to use Mendelian randomization (MR) analysis to assess the causal relationship between SLE, RA and adverse pregnancy outcomes. METHODS Genetic variants for SLE and RA, as well as adverse pregnancy outcomes, were derived from pooled statistics from large public genome-wide association studies. Several methods, such as inverse variance weighting (IVW), MR-Egger, weighted median and MR-Pleiotropic Residuals Sum and Outliers, were employed to estimate two-sample causality. RESULTS Genetic prediction of SLE was associated with higher odds of preterm labour [odds ratio (OR) 1.03, 95 % confidence interval (CI) 1.01-1.05; p = 0.008]. RA was associated with higher odds of preterm labour (OR 1.03, 95 % CI 1.01-1.06; p = 0.009), pre-eclampsia or eclampsia (OR 1.04, 95 % CI 1.01-1.07; p = 0.005), and poor fetal growth (OR 1.08, 95 % CI 1.04-1.12; p = 2.91 × 10-5). The results of bidirectional MR analysis did not indicate that SLE was associated with spontaneous abortion, pre-eclampsia or eclampsia, preterm rupture of membranes, or poor fetal growth (p-value for IVW 0.13-0.97). CONCLUSIONS This study found a genetic association between SLE and the risk of preterm labour, and highlights the importance of perinatal care and monitoring for patients with SLE. Furthermore, RA was found to be associated with a wide range of adverse outcomes, including preterm labour, pre-eclampsia or eclampsia, and poor fetal growth; as such, there is a need for more intensive therapeutic interventions and prenatal monitoring.
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Affiliation(s)
- Peng Yan
- Department of Nephrology, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nangchang 330000, China
| | - Jiahuizi Yao
- Department of Nephrology, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nangchang 330000, China
| | - Ben Ke
- Department of Nephrology, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nangchang 330000, China.
| | - Xiangdong Fang
- Department of Nephrology, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nangchang 330000, China.
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Nakai T, Honda N, Soga E, Fukui S, Kitada A, Yokogawa N, Okada M. A retrospective analysis of the safety of tacrolimus use and its optimal cut-off concentration during pregnancy in women with systemic lupus erythematosus: study from two Japanese tertiary referral centers. Arthritis Res Ther 2024; 26:15. [PMID: 38178242 PMCID: PMC10765865 DOI: 10.1186/s13075-023-03256-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 12/27/2023] [Indexed: 01/06/2024] Open
Abstract
BACKGROUND Tacrolimus is one of the major treatment options for systemic lupus erythematosus (SLE) and is considered to be a pregnancy-compatible medication. Since little is known about tacrolimus safety during pregnancy complicated by SLE, this study was designed. METHODS We included SLE pregnant patients who were followed up at two Japanese tertiary referral centers. We performed multivariate logistic regression analysis to assess each adverse pregnancy outcome (APO) risk. Moreover, we assessed the influence of tacrolimus on the APO ratio in pregnant patients with lupus nephritis, and the impact of combined tacrolimus-aspirin therapy on the APO ratio relative to patients exclusively administered tacrolimus. RESULTS Of the 124 pregnancies, 29 were exposed to tacrolimus. Multivariate analysis showed no statistical difference in APO ratio. (overall APO: adjusted odds ratio [aOR], 0.69; 95% confidence interval [CI], 0.23-2.03; p = 0.50; maternal APO: aOR, 1.17; 95% CI, 0.36-3.83; p = 0.80; neonatal APO: aOR, 1.10; 95% CI, 0.38-3.21; p = 0.86; PROMISSE APO: aOR, 0.50; 95% CI, 0.14-1.74; p = 0.27). Blood pressure and estimated glomerular filtration rate (eGFR) during pregnancy and after delivery did not differ between the two groups. Receiver operating characteristic (ROC) curve showed that tacrolimus concentration > 2.6 ng/ml was related to reduced preterm birth rate. (AUC = 0.85, 95% CI: 0.61-1.00, sensitivity: 93% and specificity: 75%). Regarding effect of tacrolimus on lupus nephritis during pregnancy, tacrolimus showed no increased risk of APO, blood pressure or eGFR during pregnancy and after delivery. (overall APO: OR, 1.00; 95% CI, 0.25-4.08; p = 0.98; maternal APO: OR 1.60, 95% CI, 0.39-6.64; p = 0.51; neonatal APO: OR, 0.71; 95% CI, 0.17-3.03; p = 0.65, PROMISSE APO: OR, 0.50; 95% CI, 0.08-3.22; p = 0.47). Tacrolimus-aspirin combination therapy showed a protective tendency against hypertensive disorders during pregnancy, preeclampsia and low birth weight. CONCLUSIONS Tacrolimus use during pregnancy with SLE and lupus nephritis showed no significant influence on APO, blood pressure, or renal function; therefore tacrolimus may be suitable for controlling lupus activity during pregnancy. In addition, when using tacrolimus during pregnancy, we should aim its trough concentration ≥ 2.6 ng/ml while paying careful attention to possible maternal side effects of tacrolimus. TRIAL REGISTRATION Retrospectively registered.
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Affiliation(s)
- Takehiro Nakai
- Immuno-Rheumatology Center, St. Luke's International Hospital, 9-1 Akashi-Cho, Chuo-Ku, Tokyo, Japan.
| | - Nanase Honda
- Department of Rheumatic Diseases, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Eri Soga
- Department of Obstetrics and Gynecology, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Sho Fukui
- Immuno-Rheumatology Center, St. Luke's International Hospital, 9-1 Akashi-Cho, Chuo-Ku, Tokyo, Japan
- Department of General Medicine, Kyorin University School of Medicine, Tokyo, Japan
- Division of Rheumatology, Inflammation, and Immunity, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Ayako Kitada
- Immuno-Rheumatology Center, St. Luke's International Hospital, 9-1 Akashi-Cho, Chuo-Ku, Tokyo, Japan
- Department of Rheumatology, Institute of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Naoto Yokogawa
- Department of Rheumatic Diseases, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Masato Okada
- Immuno-Rheumatology Center, St. Luke's International Hospital, 9-1 Akashi-Cho, Chuo-Ku, Tokyo, Japan
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Clowse MEB, Oates J, Barnado A, Kirchoff K, Blaske A, Sheikh SZ, Crofford LJ, Eudy AM. Implications of the accuracy of diagnostic algorithms for systemic lupus on our understanding of racial disparities in pregnancy outcomes. Rheumatology (Oxford) 2024; 63:119-126. [PMID: 37225388 PMCID: PMC10765149 DOI: 10.1093/rheumatology/kead178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 03/24/2023] [Accepted: 04/04/2023] [Indexed: 05/26/2023] Open
Abstract
OBJECTIVE Disparities in pregnancy outcomes among women with SLE remain understudied, with few available racially diverse datasets. We sought to identify disparities between Black and White women in pregnancy outcomes within academic institutions in the United States. METHODS Using the Common Data Model electronic medical record (EMR)-based datasets within the Carolinas Collaborative, we identified women with pregnancy delivery data (2014-2019) and ≥1 SLE International Classification of Diseases 9 or 10 code (ICD9/10) code. From this dataset, we identified four cohorts of SLE pregnancies, three based on EMR-based algorithms and one confirmed with chart review. We compared the pregnancy outcomes identified in each of these cohorts for Black and White women. RESULTS Of 172 pregnancies in women with ≥1 SLE ICD9/10 code, 49% had confirmed SLE. Adverse pregnancy outcomes occurred in 40% of pregnancies in women with ≥1 ICD9/10 SLE code and 52% of pregnancies with confirmed SLE. SLE was frequently over-diagnosed in women who were White, resulting in 40-75% lower rates of adverse pregnancy outcomes in EMR-derived vs confirmed SLE cohorts. Over-diagnosis was less common for Black women with pregnancy outcomes 12-20% lower in EMR-derived vs confirmed SLE cohorts. Black women had higher rates of adverse pregnancy outcomes than White women in the EMR-derived, but not the confirmed cohorts. CONCLUSION EMR-derived cohorts of pregnancies in women who are Black, but not White, provided accurate estimations of pregnancy outcomes. The data from the confirmed SLE pregnancies suggest that all women with SLE, regardless of race, referred to academic centres remain at very high risk for adverse pregnancy outcome.
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Affiliation(s)
- Megan E B Clowse
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - James Oates
- Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - April Barnado
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Katie Kirchoff
- Biomedical Informatics Center, Medical University of South Carolina, Charleston, SC, USA
| | - Ashley Blaske
- Department of Internal Medicine, East Tennessee State University College of Medicine, Johnson City, TN, USA
| | - Saira Z Sheikh
- Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Leslie J Crofford
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Amanda M Eudy
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
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Keum H, Bermas B, Patel S, Jacobe HT, Chong BF. Patients with autoimmune skin diseases are at increased risk of adverse pregnancy outcomes. Am J Obstet Gynecol MFM 2024; 6:101226. [PMID: 37972926 DOI: 10.1016/j.ajogmf.2023.101226] [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: 08/22/2023] [Revised: 11/06/2023] [Accepted: 11/10/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND Increased rates of adverse pregnancy outcomes have been reported in association with rheumatologic diseases such as systemic lupus erythematosus, rheumatoid arthritis, dermatomyositis. However, little is known about pregnancy outcomes in patients with autoimmune skin diseases. OBJECTIVE This study aimed to determine the frequency of adverse pregnancy outcomes in patients with autoimmune skin diseases. We hypothesized that similar to rheumatic diseases, the rate of adverse pregnancy outcomes in patients with autoimmune skin diseases would be higher than the general population. STUDY DESIGN This is a case control study using the TriNetX US Collaborative Network, which is a database of electronic medical records of >95 million patients seen at 57 healthcare organizations in the United States. All pregnant women between the ages of 15 and 44 years who were seen at a healthcare organization between January 1, 2016 and December 31, 2021 were included. Participants with autoimmune skin disease were matched to healthy controls and controls with systemic rheumatologic conditions (systemic lupus erythematosus or rheumatoid arthritis). For both the autoimmune skin disease and healthy control groups, those with systemic rheumatologic condition or hidradenitis suppurativa were excluded. The primary outcomes were adverse pregnancy outcomes defined as spontaneous abortion, gestational hypertension, preeclampsia or eclampsia, gestational diabetes mellitus, intrauterine growth restriction, preterm premature rupture of membranes, preterm birth, and stillbirth. Patients with autoimmune skin diseases and controls were 1:1 propensity score-matched by age, race, ethnicity, comorbidities, obesity, and substance use. For each outcome, odds ratio with a 95% confidence interval was calculated. RESULTS A total of 2788 patients with autoimmune skin diseases were matched to 2788 healthy controls. Patients with autoimmune skin diseases were at a higher risk of spontaneous abortions than controls (odds ratio, 1.54; 95% confidence interval, 1.36-1.75; P<.001). Compared with patients with systemic lupus erythematosus, patients with autoimmune skin diseases were at lower risk of having infants with intrauterine growth restriction (odds ratio, 0.59; 95% confidence interval, 0.4-0.87; P=.01), preterm birth (odds ratio, 0.68; 95% confidence interval, 0.47-0.98; P=.04), and stillbirth (odds ratio, 0.50; 95% confidence interval, 0.25-0.97; P=.04). The differences in adverse pregnancy outcomes between patients with autoimmune skin diseases and those with rheumatoid arthritis were not statistically significant. CONCLUSION Patients with autoimmune skin diseases are at a higher risk of spontaneous abortions than patients without autoimmune skin diseases. When analyzed by each autoimmune skin disease, patients with cutaneous lupus erythematosus or vitiligo remained at increased risk of spontaneous abortions compared with patients without autoimmune skin diseases. Patients with autoimmune skin diseases have similar risks of adverse pregnancy outcomes as patients with rheumatoid arthritis, but lower risks than patients with systemic lupus erythematosus.
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Affiliation(s)
- Heejo Keum
- Department of Dermatology, The University of Texas Southwestern Medical Center, Dallas, TX (Ms Keum, Drs Jacobe and Chong)
| | - Bonnie Bermas
- Division of Rheumatology, Department of Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, TX (Dr Bermas)
| | - Shivani Patel
- Department of Obstetrics and Gynecology, The University of Texas Southwestern Medical Center, Dallas, TX (Dr Patel)
| | - Heidi T Jacobe
- Department of Dermatology, The University of Texas Southwestern Medical Center, Dallas, TX (Ms Keum, Drs Jacobe and Chong)
| | - Benjamin F Chong
- Department of Dermatology, The University of Texas Southwestern Medical Center, Dallas, TX (Ms Keum, Drs Jacobe and Chong).
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Al-Husban N, Abu-Hassan DW, Saleem RAA, Al-Abdallat L, Alhusban AE, Adwan MH. Therapeutic changes of systemic lupus erythematosus (SLE) patients in pregnancy and feto-maternal outcomes: a retrospective cohort study. J Int Med Res 2024; 52:3000605231225349. [PMID: 38263912 PMCID: PMC10807327 DOI: 10.1177/03000605231225349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 12/20/2023] [Indexed: 01/25/2024] Open
Abstract
OBJECTIVES Patients with systemic lupus erythematosus (SLE) frequently show non-compliance with their medication. We evaluated the compliance of patients with SLE in Jordan with their medication and the relationships with fetal and maternal outcomes. METHODS We performed a retrospective cohort study of patients with SLE who had no co-morbidities or antiphospholipid syndrome; and were taking only prednisolone, hydroxychloroquine, and/or antiplatelet and anticoagulant medication. RESULTS We studied 173 pregnancies. Prednisolone was administered around pregnancy in 50 (28.9%) of these. The compliance with hydroxychloroquine, prednisolone, and anticoagulant and antiplatelet medication was 87.5%, 91.4%, and 97.3%, respectively. Non-compliance with anticoagulant/antiplatelet therapy was significantly associated with pregnancy-related complications. No complications developed in participants who were non-compliant with prednisolone therapy. The mean pre-pregnancy Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) for the pregnancies was 3.7, indicating low disease activity. Pregnancies with high pre-pregnancy SLEDAI scores tended to be more likely to have preterm deliveries, intrauterine growth restriction, and stillbirth. Postpartum relapse tended to be associated with higher pre-pregnancy SLEDAI. CONCLUSIONS In patients with pre-conceptional low SLE activity, changes in therapeutic compliance during pregnancy are not associated with adverse outcomes. In addition, post-partum relapse is not associated with pre-pregnancy SLEDAI score in therapeutically compliant patients.
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Affiliation(s)
- Naser Al-Husban
- Department of Obstetrics and Gynecology, School of Medicine, The University of Jordan, Amman, Jordan
| | - Diala Walid Abu-Hassan
- Department of Physiology and Biochemistry, School of Medicine, The University of Jordan Amman, Jordan
| | | | | | | | - Marwan H Adwan
- Department of Medicine, Division of Rheumatology, The University of Jordan, Amman, Jordan
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Robert M, Scherlinger M. Platelets are a major player and represent a therapeutic opportunity in systemic lupus erythematosus. Joint Bone Spine 2024; 91:105622. [PMID: 37495075 DOI: 10.1016/j.jbspin.2023.105622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 07/04/2023] [Accepted: 07/12/2023] [Indexed: 07/28/2023]
Abstract
Systemic lupus erythematosus (SLE) is an autoimmune disease characterized by immune dysregulation and organ injury with a premature mortality due to cardiovascular diseases. Platelets, that are primarily known for their role in hemostasis, have been shown to play an active role in the pathogenesis and in the progression of immune-mediated inflammatory diseases. Here we summarize the evidence of their roles in SLE pathogenesis which supports the development of targeted treatments. Platelets and their precursors, the megakaryocytes, are intrinsically different in SLE patients compared with healthy controls. Different triggers related to innate and adaptive immunity activate platelets which release extracellular vesicles, soluble factors and interact with immune cells, thereby perpetuating inflammation. Platelets are involved in organ damage in SLE, especially in lupus nephritis and participate in the heightened cardiovascular mortality. They also play a clear role in antiphospholipid syndrome which can be associated with both thrombocytopenia and thrombosis. To tackle platelet activation and their interactions with immune cells now constitute promising therapeutic strategies in SLE.
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Affiliation(s)
- Marie Robert
- Service de médecine interne et immunologie clinique, centre hospitalier universitaire Édouard-Herriot, hospices civils de Lyon, Lyon, France
| | - Marc Scherlinger
- Service de rhumatologie, centre hospitalier universitaire de Strasbourg, 1, avenue Molière, 67098 Strasbourg, France; Laboratoire d'immuno-rhumatologie moléculaire, Institut national de la santé et de la recherche médicale (Inserm) UMR S 1109, Strasbourg, France; Centre national de référence des maladies auto-immunes et systémiques rares, Est/Sud-Ouest (RESO), France.
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Hou Y, Jin J, Luo L, Zhong Y, Peng Z, Song Z, Li C, Zhang X. Menstrual irregularity, pregnancy outcomes, and birth outcomes in patients with systemic lupus erythematosus of childbearing age in China: a multicenter cross-sectional study. Chin Med J (Engl) 2023; 136:2886-2888. [PMID: 37185157 PMCID: PMC10686584 DOI: 10.1097/cm9.0000000000002559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Indexed: 05/17/2023] Open
Affiliation(s)
- Yuke Hou
- Department of Rheumatology and Immunology, Peking University People's Hospital, Beijing 100044, China
| | - Jiayang Jin
- Department of Rheumatology and Immunology, Peking University People's Hospital, Beijing 100044, China
| | - Liang Luo
- Department of Rheumatology and Immunology, Peking University People's Hospital, Beijing 100044, China
- Department of Chinese Medicine, Chongqing Yubei People's Hospital, Chongqing 401120, China
| | - Yuchao Zhong
- Department of Rheumatology and Immunology, Peking University People's Hospital, Beijing 100044, China
- Department of Rheumatology and Immunology, Peking University Shenzhen Hospital, Shenzhen, Guangdong 518036, China
| | - Zhe Peng
- Department of Rheumatology and Immunology, Peking University People's Hospital, Beijing 100044, China
| | - Ziyi Song
- Center of Reproductive Medicine, Peking University People's Hospital, Beijing 100044, China
| | - Chun Li
- Department of Rheumatology and Immunology, Peking University People's Hospital, Beijing 100044, China
| | - Xuewu Zhang
- Department of Rheumatology and Immunology, Peking University People's Hospital, Beijing 100044, China
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Zucchi D, Fischer-Betz R, Tani C. Pregnancy in systemic lupus erythematosus. Best Pract Res Clin Rheumatol 2023; 37:101860. [PMID: 37596173 DOI: 10.1016/j.berh.2023.101860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 07/25/2023] [Indexed: 08/20/2023]
Abstract
Systemic lupus erythematosus (SLE) is a chronic autoimmune disease which frequently affects women of childbearing age. Nowadays, pregnancy is not contraindicated in cases of well-controlled disease activity, but pregnancies are still at higher risk of maternal and fetal complications compared to the general population. During pregnancy and puerperium patients are at risk of disease flare, and obstetric complications are more frequent in cases of active disease at conception/beginning of pregnancy, a history of lupus nephritis, and concomitant presence of antiphospholipid syndrome. To improve pregnancy outcomes in SLE patients, appropriate preconception counseling with changes in medication, if necessary, and close rheumatological and obstetrical monitoring are fundamental. This review aims to summarize the risk factors for adverse pregnancy outcomes and provide an update on developments in medical care for pregnancy in SLE patients.
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Affiliation(s)
- Dina Zucchi
- Rheumatology Unit, Azienda Ospedaliero Universitaria Pisana and Department of Clinical and Experimental Medicine, University of Pisa, Italy; Department of Medical Biotechnologies, University of Siena, Italy
| | - Rebecca Fischer-Betz
- Medical Faculty, Department Rheumatology & Hiller-Research Unit Rheumatology, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Chiara Tani
- Rheumatology Unit, Azienda Ospedaliero Universitaria Pisana and Department of Clinical and Experimental Medicine, University of Pisa, Italy.
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Radin M, Cecchi I, Crisafulli F, Klumb EM, de Jesús GR, Lacerda MI, Saavedra MÁ, Reyes-Navarro GV, Iaccarino L, Larosa M, Moroni G, Tamborini F, Roccatello D, Andreoli L, Sciascia S, Chighizola CB. Complement levels during the first trimester predict disease flare and adverse pregnancy outcomes in systemic lupus erythematosus: A network meta-analysis on 532 pregnancies. Autoimmun Rev 2023; 22:103467. [PMID: 37852515 DOI: 10.1016/j.autrev.2023.103467] [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: 09/28/2023] [Accepted: 10/15/2023] [Indexed: 10/20/2023]
Abstract
BACKGROUND Complement levels have been proposed as candidate biomarkers of disease activity and obstetric risk in systemic lupus erythematosus (SLE) pregnancies, but their reliability has been questioned due to the physiologic fluctuations of complement during gestation. Thus, this network meta-analysis aimed at assessing the clinical significance of complement fluctuations in lupus pregnant women. METHODS Corresponding authors of 19 studies meeting inclusion criteria were invited to contribute with additional data including C3 and C4 levels [before pregnancy, at conception, in every trimester (T) and 3 months after delivery]; data were pooled together in a network meta-analysis. RESULTS A total of 532 lupus women from four studies were included in the analysis. In SLE women, C3 and C4 increased progressively during gestation: levels remained stable during T1 and peaked in T2 to decrease in T3. Patients with previous lupus nephritis (LN) and those who experienced flares during pregnancy had significantly lower mean levels of C3 and C4 at all timepoints. The lowest levels of complement were observed, particularly during T1, in patients with LN and gestational flare. Both reduction and the lack of increase of C3 and C4 levels at T1 versus conception were associated with gestational flares, particularly in LN patients. Pregnancies with flare had a statistically significant higher rate of maternal and fetal complications(60% versus 50.3%; p = 0.03). CONCLUSIONS Low complement levels, particularly in T1, were associated with a higher frequency of gestational flare. Either reduction or smaller increase of C3 and/or C4 levels, even within normal range, might predict flares especially in early gestation.
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Affiliation(s)
- Massimo Radin
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-Net, ERN-Reconnect and RITA-ERN Member) with Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hub Hospital, Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Irene Cecchi
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-Net, ERN-Reconnect and RITA-ERN Member) with Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hub Hospital, Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Francesca Crisafulli
- Rheumatology and Clinical Immunology Unit, Department of Clinical and Experimental Sciences, ASST SpedaliCivili of Brescia, University of Brescia, Brescia, Italy
| | - Evandro Mendes Klumb
- Department of Rheumatology, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil
| | | | | | - Miguel Ángel Saavedra
- RheumatologyDepartment, Hospital de Especialidades Dr. Antonio Fraga Mouret, Centro Médico Nacional La Raza, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | | | - Luca Iaccarino
- Rheumatology Unit, Department of Medicine, University of Padova, Padova, Italy
| | - Maddalena Larosa
- Rheumatology Unit, Department of Medicine, University of Padova, Padova, Italy; Division of Rheumatology, Department of Locomotor System, ASL3, Genoa, Italy
| | - Gabriella Moroni
- Department of Biomedical Sciences, Humanitas University, 20089 Rozzano, Italy; IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy
| | | | - Dario Roccatello
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-Net, ERN-Reconnect and RITA-ERN Member) with Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hub Hospital, Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Laura Andreoli
- Rheumatology and Clinical Immunology Unit, Department of Clinical and Experimental Sciences, ASST SpedaliCivili of Brescia, University of Brescia, Brescia, Italy
| | - Savino Sciascia
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-Net, ERN-Reconnect and RITA-ERN Member) with Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hub Hospital, Department of Clinical and Biological Sciences, University of Turin, Turin, Italy.
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Long Y, Huang C, Cui Y, Xie Z, Zhou Y, Shi X, Song Y, Tian X, Li M, Liu J, Liu X, Zeng X, Zhao J. Cluster analysis of antiphospholipid antibodies-associated adverse pregnancy outcome patients: based on a 13-years cohort study. Clin Exp Med 2023; 23:5377-5388. [PMID: 37821708 DOI: 10.1007/s10238-023-01195-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Accepted: 09/12/2023] [Indexed: 10/13/2023]
Abstract
Antiphospholipid antibodies (aPLs) are the leading causes of adverse pregnancy outcomes (APOs). We conducted cluster analysis to identify distinct phenotypes among aPLs-associated APOs patients. This approach aims to facilitate risk stratification and improve pregnancy outcomes for obstetric APS. This was a retrospective study of persistent aPLs positive women cohort in Peking Union Medical College Hospital. Baseline demographic characteristics, clinical manifestation, previous APOs and antibodies profiles were included for hierarchical cluster analysis. Placentae from portions of patients were collected and performed the histopathologic diagnoses. Four clusters among 209 patients with 477 pregnancies were identified. Cluster 1 comprised patients with triple aPLs positivity and demonstrates a high incidence of gestational hypertension (34.92%, P < 0.05) and preterm delivery (20.63%, P < 0.05). Patients in cluster 2 were characterized by lupus anticoagulant (LA) positivity, with high risk of whole gestational APOs. Cluster 3 included patients with isolated aPLs-IgM isotype combined with early miscarriage (60.92%, P = 0.016). Patients in cluster 4 majorly presented aPLs-IgG isotype combined with placenta insufficiency (22.73%). During the follow-up, the live birth rate in cluster 1 and 2 was only 69.20%. Placenta pathology revealed the most severe impairment within cluster 1, whereas clusters 3 and 4 exhibited relatively milder damage. By cluster analysis, we identified four clinical subtypes of aPLs-associated APOs patients. Patients with triple antibodies or high-risk lupus characteristics were prone to occurred gestational hypertension and premature delivery. Isolated LA or aCL/aβ2GPI positivity were found to be more frequently associated with early-stage fetal loss.
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Affiliation(s)
- Yin Long
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 1 Shuai Fu Yuan, Wangfu Jing Street, Beijing, 100730, China
| | - Can Huang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 1 Shuai Fu Yuan, Wangfu Jing Street, Beijing, 100730, China
- National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), No. 1 Shuai Fu Yuan, Wangfu Jing Street, Beijing, 100730, China
- Ministry of Science and Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), No. 1 Shuai Fu Yuan, Wangfu Jing Street, Beijing, 100730, China
- Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, No. 1 Shuai Fu Yuan, Wangfu Jing Street, Beijing, 100730, China
| | - Yixin Cui
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 1 Shuai Fu Yuan, Wangfu Jing Street, Beijing, 100730, China
| | - Zhijuan Xie
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 1 Shuai Fu Yuan, Wangfu Jing Street, Beijing, 100730, China
| | - Yangzhong Zhou
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 1 Shuai Fu Yuan, Wangfu Jing Street, Beijing, 100730, China
- National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), No. 1 Shuai Fu Yuan, Wangfu Jing Street, Beijing, 100730, China
- Ministry of Science and Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), No. 1 Shuai Fu Yuan, Wangfu Jing Street, Beijing, 100730, China
- Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, No. 1 Shuai Fu Yuan, Wangfu Jing Street, Beijing, 100730, China
| | - Xiaohua Shi
- Department of Pathology, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Yijun Song
- Department of Obstetrics, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 1 Shuai Fu Yuan, Wangfu Jing Street, Beijing, 100730, China
| | - Xinping Tian
- National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), No. 1 Shuai Fu Yuan, Wangfu Jing Street, Beijing, 100730, China
- Ministry of Science and Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), No. 1 Shuai Fu Yuan, Wangfu Jing Street, Beijing, 100730, China
- Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, No. 1 Shuai Fu Yuan, Wangfu Jing Street, Beijing, 100730, China
| | - Mengtao Li
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 1 Shuai Fu Yuan, Wangfu Jing Street, Beijing, 100730, China
- National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), No. 1 Shuai Fu Yuan, Wangfu Jing Street, Beijing, 100730, China
- Ministry of Science and Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), No. 1 Shuai Fu Yuan, Wangfu Jing Street, Beijing, 100730, China
- Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, No. 1 Shuai Fu Yuan, Wangfu Jing Street, Beijing, 100730, China
| | - Juntao Liu
- Department of Obstetrics, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 1 Shuai Fu Yuan, Wangfu Jing Street, Beijing, 100730, China
| | - Xinyan Liu
- Department of Obstetrics, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 1 Shuai Fu Yuan, Wangfu Jing Street, Beijing, 100730, China.
| | - Xiaofeng Zeng
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 1 Shuai Fu Yuan, Wangfu Jing Street, Beijing, 100730, China.
- National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), No. 1 Shuai Fu Yuan, Wangfu Jing Street, Beijing, 100730, China.
- Ministry of Science and Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), No. 1 Shuai Fu Yuan, Wangfu Jing Street, Beijing, 100730, China.
- Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, No. 1 Shuai Fu Yuan, Wangfu Jing Street, Beijing, 100730, China.
| | - Jiuliang Zhao
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 1 Shuai Fu Yuan, Wangfu Jing Street, Beijing, 100730, China.
- National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), No. 1 Shuai Fu Yuan, Wangfu Jing Street, Beijing, 100730, China.
- Ministry of Science and Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), No. 1 Shuai Fu Yuan, Wangfu Jing Street, Beijing, 100730, China.
- Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, No. 1 Shuai Fu Yuan, Wangfu Jing Street, Beijing, 100730, China.
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David M, Singh S, Naicker T. Is the central complement component C3 altered in the synergy of HIV infection and preeclampsia? Eur J Obstet Gynecol Reprod Biol X 2023; 20:100257. [PMID: 37885814 PMCID: PMC10598405 DOI: 10.1016/j.eurox.2023.100257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 09/26/2023] [Accepted: 10/17/2023] [Indexed: 10/28/2023] Open
Abstract
Objective In light of complement activation in preeclampsia and HIV infection, this study evaluates the concentration of complement component 3 (C3) in HIV-associated preeclampsia. Method The study population (n = 76) was equally stratified by pregnancy type (normotensive pregnant and preeclampsia) and by HIV status (HIV positive and HIV negative). The plasma concentration of C3 was determined using a Bioplex immunoassay procedure. Results We report a significant increase in C3 concentration in the HIV-negative versus the HIV-positive groups (p < 0.05), regardless of pregnancy type. However, based on pregnancy type and irrespective of HIV status, C3 concentration was similar between normotensive versus preeclampsia. Concentration of C3 was significantly increased in the HIV-positive preeclamptic compared HIV-negative preeclamptic groups (p = 0.04). The correlation of C3 with all study groups was non-significant. Conclusion This study demonstrates that C3 was upregulated in HIV-associated PE compared to HIV- associated normotensive pregnancies. The dysregulation of C3 expression by HIV infection may be attributed to antiretroviral therapy.
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Affiliation(s)
- Mikyle David
- Optics and Imaging Centre, Doris Duke Medical Research Institute, Nelson R. Mandela School of Medicine, College of Health Sciences, University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa
| | - Shoohana Singh
- Optics and Imaging Centre, Doris Duke Medical Research Institute, Nelson R. Mandela School of Medicine, College of Health Sciences, University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa
| | - Thajasvarie Naicker
- Optics and Imaging Centre, Doris Duke Medical Research Institute, Nelson R. Mandela School of Medicine, College of Health Sciences, University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa
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