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Tingström J, Öst E, Bergman G, Burström Å. Home monitoring of fetal heart rhythm: Lived experiences of women with anti-SSA/Ro52 autoantibodies and their co-parents. Lupus 2024:9612033241244465. [PMID: 38571373 DOI: 10.1177/09612033241244465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2024]
Abstract
OBJECTIVE The aim of this study was to explore the parents' experiences of home monitoring of the fetal heart rhythm. Women with anti-SSA/Ro52 autoantibodies carry a 2%-3% risk of giving birth to a child with congenital heart block (CHB), following transplacental transfer and antibody-mediated inflammation in the fetal conduction system during 18th to 24th gestational week. Early detection and subsequent treatment have been reported to decrease morbidity and mortality. Therefore, home monitoring of the fetal heart rhythm by Doppler has been offered at our fetal cardiology center. This study was undertaken to explore the lived experience of the routine. METHODS Participants were recruited from a single fetal cardiology center. Consecutive sampling was used. The inclusion criteria were women with SSA/Ro52 antibodies who had undergone Doppler examinations within the last two and a half years at the hospital and had monitored the fetal heartbeat at home. A semi-structured questionnaire was created, and the participants were interviewed individually. The interviews were transcribed verbatim and analyzed according to qualitative content analysis. RESULTS The overall theme was defined as "walking on thin ice," with six underlying categories: reality, different strategies, gain and loss, healthcare providers, underlying tension, and conducting the examinations again, all with a focus on how to handle the home monitoring during the risk period. CONCLUSION Both the mother and the co-parent expressed confidence in their own abilities and that the monitoring provided them with the advantage of growing a bond with the expected child. However, all the participants described a feeling of underlying tension during the risk period. The results show that home monitoring is not experienced as complicated or a burden for the parents-to-be and should be considered a vital part of the chain of care for mothers at risk for giving birth to a child with CHB. However, explaining the teamwork between the different caregivers, for the patients involved, their areas of expertise, and how they collaborate with the patient continues to be a pedagogic challenge and should be developed further.
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Affiliation(s)
- Joanna Tingström
- Department of Obstetrics and Gynecology, Department of Clinical Science and Education Karolinska Institutet, Stockholm, Sweden
| | - Elin Öst
- Department of Pediatric Surgery, Karolinska University Hospital, Stockholm, Sweden
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Gunnar Bergman
- Department of Women's and Children's Health, Karolinska Institutet and Department of Pediatric Cardiolgoy, Karolinska University Hospital, Stockholm, Sweden
| | - Åsa Burström
- Neurobiology, Care Science and Society, Karolinska Institutet, Stockholm, Sweden
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2
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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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3
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邵 树, 张 懿, 张 晓. [Research progress on the manifestations and prognosis of neonatal lupus erythematosus in various systems]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2024; 26:81-85. [PMID: 38269464 PMCID: PMC10817741 DOI: 10.7499/j.issn.1008-8830.2306125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 11/12/2023] [Indexed: 01/26/2024]
Abstract
Neonatal lupus erythematosus (NLE) is caused by the transmission of maternal anti-Ro/SSA antibodies, anti-La/SSB antibodies, and other autoantibodies to the fetus through the placenta. Usually, with the disappearance of autoantibodies in the children's body, abnormal changes in the mucocutaneous, blood system, and digestive system can spontaneously subside, but the damage to various systems caused by autoantibodies may persist for a long time. This article provides a comprehensive review of the manifestations and prognosis of NLE in various systems, including mucocutaneous, blood system, circulatory system, nervous system, digestive system, respiratory system, aiming to provide reference for clinical work.
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Mosimann B, Amylidi-Mohr S, Surbek D, Förger F, Raio L. Use of Polynomial Reference Ranges for Atrioventricular Intervals Assessed by Fetal Echocardiography in Anti-Ro/SSA Antibody-Positive Pregnancies to Exclude Fetal Heart Blocks: A Pilot Study. Fetal Diagn Ther 2023; 50:422-429. [PMID: 37497922 DOI: 10.1159/000531780] [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: 02/03/2023] [Accepted: 06/21/2023] [Indexed: 07/28/2023]
Abstract
INTRODUCTION Maternal anti-Ro/SSA antibodies can cause fetal atrioventricular blocks (AVB). This pilot study aims to apply previously published echocardiographic reference ranges of the fetal atrioventricular (AV) intervals in the setting of anti-Ro/SSA antibody-positive pregnancies in order to exclude a 1° AVB. MATERIALS AND METHODS Between January 2018 and September 2022, we included all women with known anti-Ro/SSA antibodies followed up at the prenatal ultrasound department of the University Hospital of Bern. AV intervals were serially measured by two previously reported methods and plotted against previously created reference ranges. RESULTS We included 23 pregnancies from 17 anti-Ro/SSA antibody-positive women with connective tissue diseases. 443 AV interval measurements were recorded between 16+3 and 38+4 weeks of gestation. 14 (3.2%) AV-intervals measured >150 ms, none measured >170 ms and 8 (1.8%) were found to be >95th percentile. In none of the pregnancies, serial AV-prolongations were noted. The postnatal electrocardiograms demonstrated normal sinus rhythm without AVB in all children. CONCLUSION AV intervals of pregnancies followed up for anti-Ro/SSA antibodies without neonatal AVB lie within our published polynomial reference ranges. While diagnosing a 1° AVB remains controversial, more data are needed to prove that our reference ranges are helpful exclude a 1° AVB.
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Affiliation(s)
- Beatrice Mosimann
- Department of Obstetrics and Gynaecology, University Hospital, University of Bern, Bern, Switzerland
| | - Sofia Amylidi-Mohr
- Department of Obstetrics and Gynaecology, University Hospital, University of Bern, Bern, Switzerland
| | - Daniel Surbek
- Department of Obstetrics and Gynaecology, University Hospital, University of Bern, Bern, Switzerland
| | - Frauke Förger
- Department of Rheumatology and Immunology, University Hospital, University of Bern, Bern, Switzerland
| | - Luigi Raio
- Department of Obstetrics and Gynaecology, University Hospital, University of Bern, Bern, Switzerland
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5
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Makadia L, Izmirly P, Buyon JP, Phoon CKL. Autoimmune Congenital Complete Heart Block: How Late Can It Occur? AJP Rep 2023; 13:e29-e34. [PMID: 37168107 PMCID: PMC10166639 DOI: 10.1055/s-0043-1768708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 03/14/2023] [Indexed: 05/13/2023] Open
Abstract
Objective Maternal anti-Ro (SSA) and/or anti-La (SSB) antibodies are a risk factor for congenital complete heart block (CHB). Because detailed analysis of the incidence of CHB after 24 weeks of gestational age (GA) is lacking, we aimed to ascertain the risk of "later-onset" CHB among offspring of SSA/SSB-positive mothers in the published literature. Study Design Using search terms "neonatal lupus heart block" and "autoimmune congenital heart block" on PubMed and Ovid, we gathered prospective studies of SSA/SSB-positive mothers with fetal echo surveillance starting from before CHB diagnosis and retrospective cases of fetal CHB diagnosis after 24 weeks of GA (if there was prior normal heart rate) or after birth. Results Ten prospective studies included 1,248 SSA/SSB-positive pregnancies with 24 cases of CHB diagnosed during pregnancy (1.9%). Among these, three (12.5%) were after 24 weeks-at weeks 25, 26, and 28. Our retrospective studies revealed 50 patients with CHB diagnosis in late fetal life and neonatal period and 34 in the nonneonatal childhood period. An additional four cases were diagnosed after age 18 years. Conclusion Later-onset autoimmune CHB in offspring of SSA/SSB-positive mothers does occur. Our analysis suggests that prenatal surveillance should continue beyond 24 weeks of GA but is limited by inconsistent published surveillance data.
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Affiliation(s)
- Luv Makadia
- Division of Pediatric Cardiology, Department of Pediatrics, Hassenfeld Children's Hospital at NYU Langone and NYU Grossman School of Medicine, New York, New York
| | - Peter Izmirly
- Division of Rheumatology, Department of Medicine, NYU Langone Health and NYU Grossman School of Medicine, New York, New York
| | - Jill P. Buyon
- Division of Rheumatology, Department of Medicine, NYU Langone Health and NYU Grossman School of Medicine, New York, New York
| | - Colin K. L. Phoon
- Division of Pediatric Cardiology, Department of Pediatrics, Hassenfeld Children's Hospital at NYU Langone and NYU Grossman School of Medicine, New York, New York
- Address for correspondence Colin K. L. Phoon, MPhil, MD Division of Pediatric Cardiology, Department of Pediatrics, Hassenfeld Children's Hospital at NYU Langone and NYU Grossman School of Medicine150-160 East 32nd Street, New York, NY 10016
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6
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Ishii K, Horikoshi T, Kanai M, Ishiguro A, Iwamoto Y, Ishido H, Kikuchi A, Masutani S. Transient Recovery of Complete Atrioventricular Block Due to Maternal Anti-SS-A Antibody Through Antenatal Steroid Administration After 27 Weeks of Gestation. Cureus 2023; 15:e36203. [PMID: 37065348 PMCID: PMC10103817 DOI: 10.7759/cureus.36203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/13/2023] [Indexed: 03/18/2023] Open
Abstract
Maternal anti-SS-A antibodies may cause complete atrioventricular block or myocardial damage in a fetus. Effective treatment for this has not been established. Although antenatal steroids may be a treatment option for anti-SS-A antibody-related myocarditis or atrioventricular block, a complete atrioventricular block is usually considered irreversible once established. Previous reports have indicated that, in cases where antenatal steroids were effective for atrioventricular block, they were administered earlier in the pregnancy. Here we present a case where maternal steroid administration initiated from 27 weeks, which is beyond the recommended optimal treatment period, was effective in altering a complete atrioventricular block to a grade I atrioventricular block.
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Andreoli L, Chighizola CB, Iaccarino L, Botta A, Gerosa M, Ramoni V, Tani C, Bermas B, Brucato A, Buyon J, Cetin I, Chambers CD, Clowse MEB, Costedoat-Chalumeau N, Cutolo M, De Carolis S, Dolhain R, Fazzi EM, Förger F, Giles I, Haase I, Khamashta M, Levy RA, Meroni PL, Mosca M, Nelson-Piercy C, Raio L, Salmon J, Villiger P, Wahren-Herlenius M, Wallenius M, Zanardini C, Shoenfeld Y, Tincani A. Immunology of pregnancy and reproductive health in autoimmune rheumatic diseases. Update from the 11 th International Conference on Reproduction, Pregnancy and Rheumatic Diseases. Autoimmun Rev 2023; 22:103259. [PMID: 36549355 DOI: 10.1016/j.autrev.2022.103259] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 12/18/2022] [Indexed: 12/24/2022]
Abstract
Autoimmune rheumatic diseases (ARD) can affect women and men during fertile age, therefore reproductive health is a priority issue in rheumatology. Many topics need to be considered during preconception counselling: fertility, the impact of disease-related factors on pregnancy outcomes, the influence of pregnancy on disease activity, the compatibility of medications with pregnancy and breastfeeding. Risk stratification and individualized treatment approach elaborated by a multidisciplinary team minimize the risk of adverse pregnancy outcomes (APO). Research has been focused on identifying biomarkers that can be predictive of APO. Specifically, preeclampsia and hypertensive disorders of pregnancy tend to develop more frequently in women with ARD. Placental insufficiency can lead to intrauterine growth restriction and small-for-gestational age newborns. Such APO have been shown to be associated with maternal disease activity in different ARD. Therefore, a key message to be addressed to the woman wishing for a pregnancy and to her family is that treatment with compatible drugs is the best way to ensure maternal and fetal wellbeing. An increasing number of medications have entered the management of ARD, but data about their use in pregnancy and lactation are scarce. More information is needed for most biologic drugs and their biosimilars, and for the so-called small molecules, while there is sufficient evidence to recommend the use of TNF inhibitors if needed for keeping maternal disease under control. Other issues related to the reproductive journey have emerged as "unmet needs", such as sexual dysfunction, contraception, medically assisted reproduction techniques, long-term outcome of children, and they will be addressed in this review paper. Collaborative research has been instrumental to reach current knowledge and the future will bring novel insights thanks to pregnancy registries and prospective studies that have been established in several Countries and to their joint efforts in merging data.
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Affiliation(s)
- Laura Andreoli
- Rheumatology and Clinical Immunology Unit, ASST Spedali Civili, Brescia, Italy; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Cecilia B Chighizola
- Paediatric Rheumatology Unit, ASST G. Pini & CTO, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Luca Iaccarino
- Rheumatology Unit, Department of Medicine-DIMED, University of Padova, Padova, Italy
| | - Angela Botta
- Department of Obstetrics, Gynaecology and Pediatrics, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Maria Gerosa
- Division of Clinical Rheumatology, ASST Gaetano Pini-CTO, Research Center for Adult and Pediatric Rheumatic Diseases, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Véronique Ramoni
- Medicina Generale Lodi, ASST Lodi-Ospedale Maggiore, Lodi, Italy
| | - Chiara Tani
- Rheumatology Unit, Azienda Ospedaliero Universitaria Pisana and Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | | | - Antonio Brucato
- Internal Medicine, Fatebenefratelli Hospital, Milan, Italy; Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
| | - Jill Buyon
- Division of Rheumatology, New York University Grossman School of Medicine, New York, NY, USA
| | - Irene Cetin
- Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy; Department of Woman, Mother and Child, Luigi Sacco and Vittore Buzzi Children Hospitals, ASST Fatebenefratelli-Sacco, Milan, Italy
| | - Christina D Chambers
- Department of Pediatrics, University of California, Herbert Wertheim School of Public Health and Longevity Science, University of California, San Diego, La Jolla, CA, USA
| | - Megan E B Clowse
- Division of Rheumatology & Immunology, Duke University School of Medicine, Durham, NC, USA
| | - Nathalie Costedoat-Chalumeau
- Internal Medicine Department, Cochin Hospital, Referral center for rare autoimmune and systemic diseases, Université de Paris, CRESS, INSERM, INRA, Paris, France
| | - Maurizio Cutolo
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal M edicine, University of Genoa, IRCSS San Martino Polyclinic, Genoa, Italy
| | - Sara De Carolis
- Department of Obstetrics, Gynaecology and Pediatrics, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Radboud Dolhain
- Department of Rheumatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Elisa M Fazzi
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy; Child Neurology and Psychiatry Unit, ASST Spedali Civili, Brescia, Italy
| | - Frauke Förger
- Department of Rheumatology and Immunology, University Hospital (Inselspitaland University of Bern, Bern, Switzerland
| | - Ian Giles
- Centre for Rheumatology, Department of Inflammation, Division of Medicine, University College London, Department of rheumatology, University College London Hospital, London, UK
| | - Isabell Haase
- Department for Rheumatology and Hiller Research Institute, Heinrich-Heine-University, Düsseldorf, Germany
| | - Munther Khamashta
- Women & Children's Health, King's College, London, UK; GlaxoSmithKline Global Medical Expert, Dubai, United Arab Emirates
| | - Roger A Levy
- Universidade do Estado de Rio de Janeiro, Rio de Janeiro, Brazil; GlaxoSmithKline Global Medical Expert, Collegeville, PA, USA
| | - Pier Luigi Meroni
- IRCCS Istituto Auxologico Italiano, Immunorheumatology Research Laboratory, Milan, Italy
| | - Marta Mosca
- Rheumatology Unit, Azienda Ospedaliero Universitaria Pisana and Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | | | - Luigi Raio
- Department of Obstetrics and Gynaecology, University Hospital (Inselspitaland University of Bern, Bern, Switzerland
| | - Jane Salmon
- Division of Rheumatology, Department of Medicine, Hospital for Special Surgery and Weill Cornell Medicine, New York, NY, USA
| | - Peter Villiger
- Rheumatology and Clinical Immunology, Medical Center Monbijou, Bern, Switzerland
| | - Marie Wahren-Herlenius
- Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Marianne Wallenius
- National Advisory Unit on Pregnancy and Rheumatic Diseases, St Olavs Hospital, Trondheim, University Hospital and Institute of Neuromedicine and Movement Science, NTNU, Norwegian University of Science and Technology, Trondheim, Norway
| | - Cristina Zanardini
- Department of Obstetrics and Gynecology, ASST Spedali Civili, Brescia, Italy
| | - Yehuda Shoenfeld
- Sackler Faculty of Medicine, Ariel University, Ariel, Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel
| | - Angela Tincani
- Rheumatology and Clinical Immunology Unit, ASST Spedali Civili, Brescia, Italy; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy.
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Kaplinski M, Cuneo BF. Novel approaches to the surveillance and management of fetuses at risk for anti-Ro/SSA mediated atrioventricular block. Semin Perinatol 2022; 46:151585. [PMID: 35410713 DOI: 10.1016/j.semperi.2022.151585] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Approximately one percent of pregnant women will produce anti-Sjogren's syndrome-related antigen A (anti-Ro/SSA) antibodies. Of these pregnancies, one to three percent will have a fetus that develops atrioventricular (AV) block. Earlier stages of AV block (1° or 2°) may respond to anti-inflammatory treatment, but complete (3°) AV block, which can occur within 24 hours of a normal fetal rhythm, is likely irreversible and carries substantial risk for significant morbidity and for mortality. Emerging data has shown that ambulatory fetal heart rhythm monitoring can detect the transition period from normal rhythm to 2° AV block, the time during which treatment with IVIG and dexamethasone can potentially restore normal sinus rhythm. Weekly or biweekly fetal echocardiograms occur too infrequently to detect this transition period but may still be useful in diagnosing extranodal anti-Ro antibody mediated cardiac disease. In this review, we evaluate the most innovative methods for surveillance and treatment of this disease.
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Affiliation(s)
- Michelle Kaplinski
- Division of Cardiology, Department of Pediatrics, Stanford University School of Medicine, Lucile Packard Children's Hospital, Palo Alto, CA, USA.
| | - Bettina F Cuneo
- Division of Cardiology, Departments of Pediatrics and Obstetrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO, USA
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9
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Luo JL, Zhu JF. Complete Congenital Atrioventricular Block Found by Ultrasound in Pregnancy. Ann Emerg Med 2022; 79:568-577. [DOI: 10.1016/j.annemergmed.2021.11.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Indexed: 11/01/2022]
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10
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Meisgen S, Hedlund M, Ambrosi A, Folkersen L, Ottosson V, Forsberg D, Thorlacius GE, Biavati L, Strandberg L, Mofors J, Ramskold D, Ruhrmann S, Meneghel L, Nyberg W, Espinosa A, Hamilton RM, Franco-Cereceda A, Hamsten A, Olsson T, Greene L, Eriksson P, Gemzell-Danielsson K, Salomonsson S, Kuchroo VK, Herlenius E, Kockum I, Sonesson SE, Wahren-Herlenius M. Auxilin is a novel susceptibility gene for congenital heart block which directly impacts fetal heart function. Ann Rheum Dis 2022; 81:1151-1161. [PMID: 35470161 PMCID: PMC9279836 DOI: 10.1136/annrheumdis-2021-221714] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 04/11/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVE Neonatal lupus erythematosus (NLE) may develop after transplacental transfer of maternal autoantibodies with cardiac manifestations (congenital heart block, CHB) including atrioventricular block, atrial and ventricular arrhythmias, and cardiomyopathies. The association with anti-Ro/SSA antibodies is well established, but a recurrence rate of only 12%-16% despite persisting maternal autoantibodies suggests that additional factors are required for CHB development. Here, we identify fetal genetic variants conferring risk of CHB and elucidate their effects on cardiac function. METHODS A genome-wide association study was performed in families with at least one case of CHB. Gene expression was analysed by microarrays, RNA sequencing and PCR and protein expression by western blot, immunohistochemistry, immunofluorescence and flow cytometry. Calcium regulation and connectivity were analysed in primary cardiomyocytes and cells induced from pleuripotent stem cells. Fetal heart performance was analysed by Doppler/echocardiography. RESULTS We identified DNAJC6 as a novel fetal susceptibility gene, with decreased cardiac expression of DNAJC6 associated with the disease risk genotype. We further demonstrate that fetal cardiomyocytes deficient in auxilin, the protein encoded by DNAJC6, have abnormal connectivity and Ca2+ homoeostasis in culture, as well as decreased cell surface expression of the Cav1.3 calcium channel. Doppler echocardiography of auxilin-deficient fetal mice revealed cardiac NLE abnormalities in utero, including abnormal heart rhythm with atrial and ventricular ectopias, as well as a prolonged atrioventricular time intervals. CONCLUSIONS Our study identifies auxilin as the first genetic susceptibility factor in NLE modulating cardiac function, opening new avenues for the development of screening and therapeutic strategies in CHB.
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Affiliation(s)
- Sabrina Meisgen
- Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Malin Hedlund
- Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Aurelie Ambrosi
- Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Lasse Folkersen
- Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.,Technical University of Denmark, Lyngby, Denmark
| | - Vijole Ottosson
- Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - David Forsberg
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Gudny Ella Thorlacius
- Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Luca Biavati
- Department of Physiology and Experimental Medicine, Hospital for Sick Children, Washington, DC, USA
| | - Linn Strandberg
- Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Johannes Mofors
- Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Daniel Ramskold
- Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Sabrina Ruhrmann
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Lauro Meneghel
- Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - William Nyberg
- Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Alexander Espinosa
- Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | | | | | - Anders Hamsten
- Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Tomas Olsson
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Lois Greene
- National Institutes of Health, Bethesda, Maryland, USA
| | - Per Eriksson
- Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | | | - Stina Salomonsson
- Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Vijay K Kuchroo
- Evergrande Center for Immunologic Diseases, Harvard Medical School, Boston, Massachusetts, USA
| | - Eric Herlenius
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Ingrid Kockum
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Sven-Erik Sonesson
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Marie Wahren-Herlenius
- Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden .,Broegelmann Research Laboratory, Department of Clinical Science, University of Bergen, Bergen, Norway
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11
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Merz WM, Fischer-Betz R, Hellwig K, Lamprecht G, Gembruch U. Pregnancy and Autoimmune Disease: Diseases of the Nervous System, Connective Tissue, and the Bowel. DEUTSCHES ARZTEBLATT INTERNATIONAL 2022; 119:145-156. [PMID: 34874264 DOI: 10.3238/arztebl.m2021.0353] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 04/19/2021] [Accepted: 10/01/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Pregnancies in women with chronic disease are on the rise. This pertains to autoimmune diseases in particular since these tend to affect women of childbearing age. The interaction between pregnancy and autoimmune disease may increase the risk of maternal, fetal, and obstetric complications; additional care may be required. METHODS This review is based on a selective literature search in PubMed (2015-2020). RESULTS In women with autoimmune diseases, the course of pregnancy is highly variable. Some autoimmune diseases tend to improve during pregnancy and do not to result in any serious obstetric complications. Others may worsen during pregnancy, with deterioration of the maternal condition as well as obstetric and perinatal complications. In systemic lupus erythematosus and myasthenia gravis, placental transfer of specific autoantibodies may cause fetal or neonatal disease. CONCLUSION The care of pregnant women with chronic diseases requires collaboration between specialists of the pertinent levels of care. A stable course of disease before conception, close interdisciplinary care, and pregnancy-compatible medication contribute to a reduction in maternal and perinatal complications.
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Anuwutnavin S, Chuenchitkultavorn V, Nitiyarom R, Rekhawasin T, Kanjanauthai S, Sompagdee N. Prenatal predisposing factors associated with neonatal lupus erythematosus. Lupus 2022; 31:77-88. [PMID: 34978218 DOI: 10.1177/09612033211066455] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To identify the prenatal predisposing factors related to neonatal lupus erythematosus (NLE). MATERIALS AND METHODS A retrospective case-control study was made of 131 pregnant women with positive anti-Ro or anti-La autoantibodies and known neonatal outcomes between January 2002 and December 2019 at Siriraj Hospital, Bangkok, Thailand. There were 101 unaffected neonates and 30 NLE cases confirmed postnatally. Demographic and clinical data of the mothers and neonates with and without NLE were statistically compared. RESULTS NLE was diagnosed in 30 out of 131 cases. A multivariate analysis identified the following significant factors for NLE: maternal anti-La antibodies (odds ratio (OR), 3.591; p = 0.030); and maternal treatment with either hydroxychloroquine (OR, 0.082; p = 0.001) or prednisolone (OR, 0.136; p = 0.017). Of the significant variables examined in the multivariate analysis models, high levels of maternal anti-La antibodies were found to be the strongest predictor of noncardiac NLE (OR, 4.558; p = 0.032), while a female baby was significantly higher in pregnancies complicated by cardiac NLE (OR, 5.374; p = 0.046). Hydroxychloroquine still provided a protective effect for both cardiac and noncardiac NLE (p = 0.039 and 0.032, respectively). CONCLUSIONS The maternal anti-La antibodies were a beneficial predictor for NLE, especially as their high titers were influentially associated with noncardiac features. A female fetus seemed to present an increased risk for developing a congenital heart block. Nevertheless, the treatment with hydroxychloroquine during the pregnancies demonstrated a potentially protective factor against both cardiac and noncardiac manifestations.
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Affiliation(s)
- Sanitra Anuwutnavin
- Department of Obstetrics and Gynaecology, Faculty of Medicine Siriraj Hospital, 65106Mahidol University, Bangkok, Thailand
| | - Varisa Chuenchitkultavorn
- Department of Obstetrics and Gynaecology, Faculty of Medicine Siriraj Hospital, 65106Mahidol University, Bangkok, Thailand
| | - Rattanavalai Nitiyarom
- Division of Pediatric Dermatology, Department of Pediatrics, Faculty of Medicine Siriraj Hospital, 65106Mahidol University, Bangkok, Thailand
| | - Thanapa Rekhawasin
- Department of Obstetrics and Gynaecology, Faculty of Medicine Siriraj Hospital, 65106Mahidol University, Bangkok, Thailand
| | - Supaluck Kanjanauthai
- Division of Pediatric Cardiology, Department of Pediatrics, Faculty of Medicine Siriraj Hospital, 65106Mahidol University, Bangkok, Thailand
| | - Nalat Sompagdee
- Department of Obstetrics and Gynaecology, Faculty of Medicine Siriraj Hospital, 65106Mahidol University, Bangkok, Thailand
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13
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Gryka-Marton M, Szukiewicz D, Teliga-Czajkowska J, Olesinska M. An Overview of Neonatal Lupus with Anti-Ro Characteristics. Int J Mol Sci 2021; 22:ijms22179281. [PMID: 34502221 PMCID: PMC8431034 DOI: 10.3390/ijms22179281] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 08/23/2021] [Accepted: 08/23/2021] [Indexed: 01/23/2023] Open
Abstract
Neonatal lupus erythematosus (NLE) is a syndrome of clinical symptoms observed in neonates born to mothers with antibodies to soluble antigens of the cell nucleus. The main factors contributing to the pathogenesis of this disease are anti-Sjögren Syndrome A (anti-SS-A) antibodies, known as anti-Ro, and anti-Sjögren Syndrome B (anti-SS-B) antibodies, known as anti-La. Recent publications have also shown the significant role of anti-ribonucleoprotein antibodies (anti-RNP). Seropositive mothers may have a diagnosed rheumatic disease or they can be asymptomatic without diagnosis at the time of childbirth. These antibodies, after crossing the placenta, may trigger a cascade of inflammatory reactions. The symptoms of NLE can be divided into reversible symptoms, which concern skin, hematological, and hepatological changes, but 2% of children develop irreversible symptoms, which include disturbances of the cardiac stimulatory and conduction system. Preconceptive care and pharmacological prophylaxis of NLE in the case of mothers from the risk group are important, as well as the monitoring of the clinical condition of the mother and fetus throughout pregnancy and the neonatal period. The aim of this manuscript is to summarize the previous literature and current state of knowledge about neonatal lupus and to discuss the role of anti-Ro in the inflammatory process.
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Affiliation(s)
- Malgorzata Gryka-Marton
- Department of Biophysics, Physiology and Pathophysiology, Faculty of Health Sciences, Medical University of Warsaw, 02-004 Warsaw, Poland;
- Department of Systemic Connective Tissue Diseases, National Institute of Geriatrics, Rheumatology and Rehabilitation, 02-637 Warsaw, Poland;
- Correspondence: ; Tel.: +48-663-204-405
| | - Dariusz Szukiewicz
- Department of Biophysics, Physiology and Pathophysiology, Faculty of Health Sciences, Medical University of Warsaw, 02-004 Warsaw, Poland;
| | - Justyna Teliga-Czajkowska
- Department of Obstetrics and Gynecology Didactics, Faculty of Health Sciences, Medical University of Warsaw, 00-315 Warsaw, Poland;
| | - Marzena Olesinska
- Department of Systemic Connective Tissue Diseases, National Institute of Geriatrics, Rheumatology and Rehabilitation, 02-637 Warsaw, Poland;
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14
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Tang C, Yu H, Shao S, Hua Y, Chen M, Zhu Q, Li Y, Zhou K, Wang C. Case Report: Prenatal Diagnosis and Treatment of Fetal Autoimmune-Associated First-Degree Atrioventricular Block: First Report From China. Front Cardiovasc Med 2021; 8:683486. [PMID: 34235189 PMCID: PMC8255611 DOI: 10.3389/fcvm.2021.683486] [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: 03/21/2021] [Accepted: 06/01/2021] [Indexed: 11/16/2022] Open
Abstract
Background: The rapid progression from fetal first-degree atrioventricular block (AVB) to third-degree AVB had been reported. However, how to define fetal first-degree AVB with proper technique and the necessity of the treatment in utero for fetal autoimmune-associated first-degree AVB are still controversial. Purpose: To explore the diagnosis and the effect of treatment for fetal first-degree AVB. Cases Presentation: Four pregnant women with positive autoantibodies anti-SSA/Ro were admitted into our hospital with complaints of rapid prolonged atrioventricular (AV) intervals of their fetuses. Fetal AV intervals were re-measured by tissue Doppler imaging (TDI) from the onset of atrial contraction to ventricular systole (Aa-Sa), which were 170 ms (case 1-twin A), 160 ms (case 1-twin B), 163 ms (case 2) and 172 ms (case 3) and 170 ms (case 4), respectively. The histories of medication usage or infection during gestation were denied. Amniotic fluid genetic screenings and virological tests were negative in all cases. No structural cardiac disorders were found and the cardiovascular profile scores were 10 for each fetus. Oral dexamethasone (initial dose of 4.5 mg daily) and hydroxychloroquine (200 mg bid) plus weekly follow-up surveillance were suggested. The dosage of dexamethasone was adjusted according to the changes of the AV intervals and fetal development of biparietal diameters (BPD) and femur lengths (FL). All fetal AV intervals were controlled well. Maternal and fetal adverse effects were noted as diabetes in 1 mother and growth retardation in all fetuses. All fetuses were delivered via cesarean section at 35+4, 37, 38, and 37+1 gestational weeks, with 10 scores of Apgar score. Postnatally, positive anti-SSA/Ro was found in all neonates. However, there were no clinical or laboratory evidence of neonatal lupus syndrome. No abnormal signs were found on postnatal electrocardiogram and echocardiography for all neonates. With a follow-up of 8–53 months, there was no progression of disease and all infants demonstrated normal physical, mental, and motor development. Conclusion: Prenatal treatment for fetal autoimmune-associated first-degree AVB could be an alternative. Strict surveillance and timely adjustment of the treatment according to the conditions of the mother and the fetus are indicated. Further studies are necessary to prove our concept.
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Affiliation(s)
- Changqing Tang
- Department of Paediatric Cardiology, West China Second University Hospital, Sichuan University, Chengdu, China.,The Cardiac Development and Early Intervention Unit, West China Institute of Women and Children's Health, West China Second University Hospital, Sichuan University, Chengdu, China.,West China Medical School, Sichuan University, Chengdu, China
| | - Haiyan Yu
- The Cardiac Development and Early Intervention Unit, West China Institute of Women and Children's Health, West China Second University Hospital, Sichuan University, Chengdu, China.,Department of Obstetrics, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Shuran Shao
- Department of Paediatric Cardiology, West China Second University Hospital, Sichuan University, Chengdu, China.,The Cardiac Development and Early Intervention Unit, West China Institute of Women and Children's Health, West China Second University Hospital, Sichuan University, Chengdu, China.,West China Medical School, Sichuan University, Chengdu, China
| | - Yimin Hua
- Department of Paediatric Cardiology, West China Second University Hospital, Sichuan University, Chengdu, China.,The Cardiac Development and Early Intervention Unit, West China Institute of Women and Children's Health, West China Second University Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China.,Key Laboratory of Development and Diseases of Women and Children of Sichuan Province, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Maoli Chen
- The People's Hospital of Yaan, Yaan, China
| | - Qi Zhu
- Department of Ultrasonaography, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Yifei Li
- Department of Paediatric Cardiology, West China Second University Hospital, Sichuan University, Chengdu, China.,The Cardiac Development and Early Intervention Unit, West China Institute of Women and Children's Health, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Kaiyu Zhou
- Department of Paediatric Cardiology, West China Second University Hospital, Sichuan University, Chengdu, China.,The Cardiac Development and Early Intervention Unit, West China Institute of Women and Children's Health, West China Second University Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China.,Key Laboratory of Development and Diseases of Women and Children of Sichuan Province, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Chuan Wang
- Department of Paediatric Cardiology, West China Second University Hospital, Sichuan University, Chengdu, China.,The Cardiac Development and Early Intervention Unit, West China Institute of Women and Children's Health, West China Second University Hospital, Sichuan University, Chengdu, China
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Abstract
Systemic lupus erythematosus (SLE) is an autoimmune disease that primarily affects women of childbearing age. Pregnancy-related morbidity and mortality are well described in SLE; however, better management of disease activity throughout the disease course have minimized periods of disease activity and damage accrual, making pregnancy more feasible and desirable. A growing body of literature has defined risk factors for adverse pregnancy outcomes in patients with SLE, and coordinated medical and obstetric management has allowed most patients with SLE to safely achieve full-term pregnancies by timing pregnancy to maximal disease quiescence and use of pregnancy-compatible medications from preconception through lactation.
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Affiliation(s)
- Amanda Moyer
- Deapartments of Medicine and Pediatrics, University of Oklahoma School of Medicine, Oklahoma City, OK, USA
| | - Eliza F Chakravarty
- Arthritis and Clinical Immunology, Oklahoma Medical Research Foundation, Oklahoma City, OK, USA.
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16
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Hou M, Zhao Y, Liu XW, He YH. Treatment and follow-up of fetuses that developed congenital heart block due to autoantibody in two cases. J Int Med Res 2021; 48:300060520925596. [PMID: 32588691 PMCID: PMC7436825 DOI: 10.1177/0300060520925596] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective Autoantibody-related congenital heart block (ACHB) is a passively acquired autoimmune disease. This study aimed to examine the pathogenesis, clinical manifestations, and treatment of ACHB. Method The clinical data of two fetuses with first-degree ACHB were retrospectively analyzed. Results Two pregnant women were strongly positive for anti-Sjögren’s syndrome-related antigen A (SSA) antibody. Among these two cases, one had a prolonged atrioventricular (AV) interval at 28+3 weeks in utero, while the other had a prolonged AV interval at 24+6 weeks in utero. After prenatal intervention, one patient recovered to normal, while one fetus continued to have ACHB after treatment with dexamethasone and intravenous immunoglobulin. Furthermore, the two neonates were positive for anti-SSA antibody and were diagnosed with ACHB. Conclusion The pathogenesis of ACHB is closely correlated with anti-SSA/Ro antibody and anti-SSB/La antibody from the mother, and is affected by fetal susceptibility. Early screening and early intervention for ACHB are important.
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Affiliation(s)
- Min Hou
- Department of Echocardiography, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,Department of Ultrasonography, Affiliated Hospital of Hebei University, Baoding, China
| | - Ying Zhao
- Department of Echocardiography, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xiao-Wei Liu
- Department of Echocardiography, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yi-Hua He
- Department of Echocardiography, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
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17
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Liao H, Tang C, Qiao L, Zhou K, Hua Y, Wang C, Li Y. Prenatal Management Strategy for Immune-Associated Congenital Heart Block in Fetuses. Front Cardiovasc Med 2021; 8:644122. [PMID: 33996939 PMCID: PMC8113399 DOI: 10.3389/fcvm.2021.644122] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Accepted: 03/30/2021] [Indexed: 12/13/2022] Open
Abstract
Fetal congenital heart block (CHB) is the most commonly observed type of fetal bradycardia, and is potentially life-threatening. More than 50% of cases of bradycardia are associated with maternal autoimmunity, and these are collectively termed immune-associated bradycardia. Several methods have been used to achieve reliable prenatal diagnoses of CHB. Emerging data and opinions on pathogenesis, prenatal diagnosis, fetal intervention, and the prognosis of fetal immune-associated CHB provide clues for generating a practical protocol for clinical management. The prognosis of fetal immune-associated bradycardia is based on the severity of heart blocks. Morbidity and mortality can occur in severe cases, thus hieratical management is essential in such cases. In this review, we mainly focus on optimal strategies pertaining to autoimmune antibodies related to CHB, although the approaches for managing autoimmune-mediated CHB are still controversial, particularly with regard to whether fetuses benefit from transplacental medication administration. To date there is still no accessible clinical strategy for autoimmune-mediated CHB. This review first discusses integrated prenatal management strategies for the condition. It then provides some advice for clinicians involved in management of fetal cardiovascular disorder.
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Affiliation(s)
- Hongyu Liao
- Key Laboratory of Birth Defects and Related Diseases of Women and Children of Ministry of Education (MOE), Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Changqing Tang
- Key Laboratory of Birth Defects and Related Diseases of Women and Children of Ministry of Education (MOE), Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Lina Qiao
- Key Laboratory of Birth Defects and Related Diseases of Women and Children of Ministry of Education (MOE), Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Kaiyu Zhou
- Key Laboratory of Birth Defects and Related Diseases of Women and Children of Ministry of Education (MOE), Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Yimin Hua
- Key Laboratory of Birth Defects and Related Diseases of Women and Children of Ministry of Education (MOE), Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Chuan Wang
- Key Laboratory of Birth Defects and Related Diseases of Women and Children of Ministry of Education (MOE), Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Yifei Li
- Key Laboratory of Birth Defects and Related Diseases of Women and Children of Ministry of Education (MOE), Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
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18
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Reference ranges and Z-scores of atrioventricular and ventriculoatrial time intervals in normal fetuses. Int J Cardiovasc Imaging 2021; 37:2419-2428. [PMID: 33723733 DOI: 10.1007/s10554-021-02217-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 03/03/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To establish a reference range and compare differences among three methods, and then to construct Z-score reference ranges in normal fetuses from the three methods to provide an extra tool for fetal conduction time assessment. METHODS A total of 227 echocardiographic examinations were finally included. Fetal atrioventricular (AV) time and ventriculoatrial (VA) time intervals were measured by three methods: superior vena cava/ascending aorta (SVC/AAO), pulmonary artery/pulmonary vein (PA/PV) and tissue Doppler imaging (TDI). Regression analysis of the mean and standard deviation was performed to establish Z-scores. RESULTS With the three methods, positive correlations of intervals with gestational age (GA) and fetal heart rate (FHA) were observed, while intervals were negatively correlated with fetal heart rate (FHR). Correlations between VA/AV and GA, FHA and FHR were weak. The general trend of all intervals was towards an increase. In AV intervals, PA/PV revealed the longest mean AV time interval and SVC/AAO showed the shortest interval. In addition, PA/PV revealed the shortest VA interval. CONCLUSION This study presents not only the reference range of AV and VA intervals with the three methods but also the Z-score reference ranges for these indices against GA and FHA in normal fetuses. Each method has a different reference range, and appropriate application can facilitate diagnosis and treatment.
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19
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Ambrosi A, Thorlacius GE, Sonesson SE, Wahren-Herlenius M. Interferons and innate immune activation in autoimmune congenital heart block. Scand J Immunol 2021; 93:e12995. [PMID: 33188653 DOI: 10.1111/sji.12995] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 10/26/2020] [Accepted: 11/06/2020] [Indexed: 12/12/2022]
Abstract
Autoimmune congenital heart block (CHB) may develop in foetuses of women carrying anti-Ro/SSA and La/SSB autoantibodies and is characterized by disruption of signal conduction at the atrioventricular (AV) node, resulting in partial or complete AV block. If not fatal in utero, complete CHB typically requires lifelong cardiac pacing. No treatment has so far been unequivocally demonstrated to prevent or treat autoimmune CHB, and the relatively low incidence (1%-5%) and recurrence (12%-16%) rates of second/third-degree AV block add to the complexity of managing pregnancies in women with anti-Ro/La antibodies. Altogether, a better understanding of events leading to development of autoimmune CHB is needed to improve surveillance and treatment strategies. In the past decade, studies have started to look beyond the role of maternal autoantibodies in disease pathogenesis to assess other contributing factors such as foetal genetics and, more recently, immune responses in foetuses and neonates of anti-Ro/La antibody-positive women. In this review, we provide an update on the epidemiology, clinical presentation and current treatment approaches of autoimmune CHB, summarize the previously proposed pathogenic mechanisms implicating maternal autoantibodies, and discuss the recent findings of type I interferon (IFN) and innate immune activation in foetuses with autoimmune CHB and in neonates of anti-Ro/La antibody-positive mothers, and how these may contribute to autoimmune CHB pathogenesis.
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Affiliation(s)
- Aurelie Ambrosi
- Division of Rheumatology, Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Gudny Ella Thorlacius
- Division of Rheumatology, Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Sven-Erik Sonesson
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Marie Wahren-Herlenius
- Division of Rheumatology, Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.,Broegelmann Research Laboratory, Department of Clinical Science, University of Bergen, Bergen, Norway
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20
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Ivanchenko M, Thorlacius GE, Hedlund M, Ottosson V, Meneghel L, Björkander S, Ossoinak A, Tingström J, Bremme K, Sverremark-Ekström E, Gemzell-Danielsson K, Sonesson SE, Chemin K, Wahren-Herlenius M. Natural killer cells and type II interferon in Ro/SSA and La/SSB autoantibody-exposed newborns at risk of congenital heart block. Ann Rheum Dis 2020; 80:194-202. [PMID: 33004330 DOI: 10.1136/annrheumdis-2019-216786] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Revised: 08/17/2020] [Accepted: 08/18/2020] [Indexed: 11/04/2022]
Abstract
OBJECTIVE Congenital heart block (CHB) with immune cell infiltration develops in the fetus after exposure to maternal Ro/La autoantibodies. CHB-related serology has been extensively studied, but reports on immune-cell profiles of anti-Ro/La-exposed neonates are lacking. In the current study, we characterised circulating immune-cell populations in anti-Ro/La+mothers and newborns, and explored potential downstream effects of skewed neonatal cell populations. METHODS In total, blood from mothers (n=43) and neonates (n=66) was sampled at birth from anti-Ro/La+ (n=36) and control (n=30) pregnancies with or without rheumatic disease and CHB. Flow cytometry, microarrays and ELISA were used for characterising cells and plasma. RESULTS Similar to non-pregnant systemic lupus erythematosus and Sjögren-patients, anti-Ro/La+mothers had altered B-cell subset frequencies, relative T-cell lymphopenia and lower natural killer (NK)-cell frequencies. Surprisingly, their anti-Ro/La exposed neonates presented higher frequencies of CD56dimCD16hi NK cells (p<0.01), but no other cell frequency differences compared with controls. Type I and II interferon (IFN) gene-signatures were revealed in neonates of anti-Ro/La+ pregnancy, and exposure of fetal cardiomyocytes to type I IFN induced upregulation of several NK-cell chemoattractants and activating ligands. Intracellular flow cytometry revealed IFNγ production by NK cells, CD8+ and CD4+ T cells in anti-Ro/La exposed neonates. IFNγ was also detectable in their plasma. CONCLUSION Our study demonstrates an increased frequency of NK cells in anti-Ro/La exposed neonates, footprints of type I and II IFN and an upregulation of ligands activating NK cells in fetal cardiac cells after type I IFN exposure. These novel observations demonstrate innate immune activation in neonates of anti-Ro/La+pregnancy, which could contribute to the risk of CHB.
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Affiliation(s)
- Margarita Ivanchenko
- Division of Rheumatology, Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Gudny Ella Thorlacius
- Division of Rheumatology, Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Malin Hedlund
- Division of Rheumatology, Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Vijole Ottosson
- Division of Rheumatology, Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Lauro Meneghel
- Division of Rheumatology, Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Sophia Björkander
- Department of Molecular Biosciences, The Wenner-Gren Institute, Stockholm University, Stockholm, Sweden
| | - Amina Ossoinak
- Division of Rheumatology, Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Joanna Tingström
- Division of Rheumatology, Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Katarina Bremme
- Division of Obstetrics and Gynecology, Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Eva Sverremark-Ekström
- Department of Molecular Biosciences, The Wenner-Gren Institute, Stockholm University, Stockholm, Sweden
| | - Kristina Gemzell-Danielsson
- Division of Obstetrics and Gynecology, Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Sven-Erik Sonesson
- Division of Pediatric Cardiology, Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Karine Chemin
- Division of Rheumatology, Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Marie Wahren-Herlenius
- Division of Rheumatology, Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden .,Broegelmann Research Laboratory, Department of Clinical Science, University of Bergen, Bergen, Hordaland, Norway
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21
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Sonesson SE, Wahren-Herlenius M. Mortality in congenital heart block. THE LANCET. RHEUMATOLOGY 2020; 2:e588-e589. [PMID: 38273622 DOI: 10.1016/s2665-9913(20)30281-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 07/28/2020] [Indexed: 12/17/2022]
Affiliation(s)
- Sven-Erik Sonesson
- Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital, Stockholm 17176, Sweden
| | - Marie Wahren-Herlenius
- Division of Rheumatology, Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm 17176, Sweden.
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Hansahiranwadee W. Diagnosis and Management of Fetal Autoimmune Atrioventricular Block. Int J Womens Health 2020; 12:633-639. [PMID: 32884363 PMCID: PMC7434531 DOI: 10.2147/ijwh.s257407] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 07/17/2020] [Indexed: 11/23/2022] Open
Abstract
Autoimmune congenital atrioventricular block (CAVB) has been extensively studied in recent decades. The American Heart Association published guidelines for monitoring pregnant women with anti-Ro/Sjögren’s syndrome antigen A (SSA) or anti-La/Sjögren’s syndrome antigen B (SSB) autoantibodies, which are considered to increase the risk of CAVB. Information about the natural history of the disease in utero has contributed to the detection of fetuses with CAVB in the treatable stage. Hydroxychloroquine (HCQ) may be used to prevent CAVB. The lack of large randomized control trials is a major drawback to fully confirm the benefits of fluorinated steroids such as dexamethasone. Although, when combined with a β-sympathomimetic agent, the outcome of administering a fluorinated steroid in complete CAVB is still controversial. Novel treatments targeting the immunological process might prevent the recurrence of CAVB in pregnant women with previously affected children.
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Affiliation(s)
- Wirada Hansahiranwadee
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynaecology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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23
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Mofors J, Sonesson SE, Wahren-Herlenius M. Effects of maternal medication on long-term outcome in congenital heart block remain to be established. Response to: 'Comorbidity and long-term outcome in patients with congenital heart block and their siblings exposed to Ro/SSA autoantibodies in utero' by Satis et al. Ann Rheum Dis 2020; 79:e95. [PMID: 31272943 DOI: 10.1136/annrheumdis-2019-215677] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 06/15/2019] [Indexed: 11/04/2022]
Affiliation(s)
- Johannes Mofors
- Division of Rheumatology, Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Sven-Erik Sonesson
- Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hopsital, Stockholm, Sweden
| | - Marie Wahren-Herlenius
- Division of Rheumatology, Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
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24
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Limaye MA, Buyon JP, Cuneo BF, Mehta-Lee SS. A review of fetal and neonatal consequences of maternal systemic lupus erythematosus. Prenat Diagn 2020; 40:1066-1076. [PMID: 32282083 DOI: 10.1002/pd.5709] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 03/20/2020] [Accepted: 04/06/2020] [Indexed: 12/14/2022]
Abstract
Systemic lupus erythematosus (SLE) primarily affects women of childbearing age and is commonly seen in pregnancy. The physiologic and immunologic changes of pregnancy may alter the course of SLE and impact maternal, fetal, and neonatal health. Multidisciplinary counseling before and during pregnancy from rheumatology, maternal fetal medicine, obstetrics, and pediatric cardiology is critical. Transplacental passage of autoantibodies, present in about 40% of women with SLE, can result in neonatal lupus (NL). NL can consist of usually permanent cardiac manifestations, including conduction system and myocardial disease, as well as transient cutaneous, hematologic, and hepatic manifestations. Additionally, women with SLE are more likely to develop adverse pregnancy outcomes such as preeclampsia, fetal growth restriction, and preterm birth, perhaps due to an underlying effect on placentation. This review describes the impact of SLE on maternal and fetal health by trimester, beginning with prepregnancy optimization of maternal health. This is followed by a discussion of NL and the current understanding of the epidemiology and pathophysiology of anti-Ro/La mediated cardiac disease, as well as screening, treatment, and methods for prevention. Finally discussed is the known increase in preeclampsia and fetal growth issues in women with SLE that can lead to iatrogenic preterm delivery.
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Affiliation(s)
- Meghana A Limaye
- Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, NYU Langone Medical Center, New York, New York, USA
| | - Jill P Buyon
- Division of Rheumatology, Department of Medicine, NYU Langone Medical Center, New York, New York, USA
| | - Bettina F Cuneo
- Division of Cardiology, Department of Pediatrics, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Shilpi S Mehta-Lee
- Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, NYU Langone Medical Center, New York, New York, USA
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25
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Sonesson SE, Wahren-Herlenius M. Surveillance of congenital heart block in highly specialised care. THE LANCET. RHEUMATOLOGY 2020; 2:e203-e204. [PMID: 38268151 DOI: 10.1016/s2665-9913(20)30028-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 01/23/2020] [Accepted: 01/24/2020] [Indexed: 10/24/2022]
Affiliation(s)
- Sven-Erik Sonesson
- Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Marie Wahren-Herlenius
- Division of Rheumatology, Department of Medicine, Karolinska Institutet, Karolinska University Hospital 171 76, Stockholm, Sweden.
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26
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Erden A, Fanouriakis A, Kiliç L, Sari A, Armağan B, Bilgin E, Şener YZ, Hymabaccus B, Gürler F, Ceylan S, Kiraz S, Karadağ Ö, Boumpas D. Geoepidemiology and clinical characteristics of neonatal lupus erythematosus: a systematic literature review of individual patients’ data. Turk J Med Sci 2020; 50:281-290. [PMID: 31905489 PMCID: PMC7164747 DOI: 10.3906/sag-1910-39] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 01/01/2020] [Indexed: 01/05/2023] Open
Abstract
Background/aim Neonatal lupus erythematosus (NLE) is an autoimmune syndrome caused by transplacental transmission of maternal autoantibodies, often with devastating consequences. The objective of this systematic literature review was to analyze the demographic data, geoepidemiology, clinical, and serological characteristics associated with NLE. Materials and methods We performed a systematic literature search of the Pubmed database covering the period from 1976 to August 2015, using the MeSH terms “neonatal lupus” or “congenital heart block”. To be included in the study, articles of any type (original articles, case series, and case reports) had to report on infants with NLE on an individualized (i.e. patient-by-patient) basis. Results A total of 198 studies were included in the review, reporting on a total of 755 NLE patients. The most frequently reported clinical manifestations of NLE were congenital heart block (CHB, 65.2%), cutaneous lupus (33.1%), and cytopenias (15.5%). We found differences in NLE characteristics based on study geographical origin, with CHB being much more frequent in patients of European or American descent (49.4% and 35%, respectively), while reports originating from Asia reported a higher prevalence of skin involvement (45.2%). Most CHB cases (72.9%) were diagnosed between the 18th and 26th week of gestation. Conclusions Phenotypic differences of NLE depending on race and country may reflect true pathophysiologic differences or methodologic discrepancies. While maternal autoimmune disease is not a prerequisite for the development of NLE, the existence of a truly “immunonegative” CHB is questionable.
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Affiliation(s)
- Abdulsamet Erden
- Division of Rheumatology, Department of Internal Medicine, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Antonis Fanouriakis
- Rheumatology and Clinical Immunology, 4th Department of Internal Medicine, “Attikon” University Hospital, Athens, Greece
| | - Levent Kiliç
- Division of Rheumatology, Department of Internal Medicine, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Alper Sari
- Division of Rheumatology, Department of Internal Medicine, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Berkan Armağan
- Division of Rheumatology, Department of Internal Medicine, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Emre Bilgin
- Division of Rheumatology, Department of Internal Medicine, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Yusuf Ziya Şener
- Department of Internal Medicine, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Benazir Hymabaccus
- Department of Internal Medicine, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Fatih Gürler
- Department of Internal Medicine, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Serdar Ceylan
- Department of Internal Medicine, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Sedat Kiraz
- Division of Rheumatology, Department of Internal Medicine, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Ömer Karadağ
- Division of Rheumatology, Department of Internal Medicine, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Dimitrious Boumpas
- Division of Rheumatology, Department of Internal Medicine, Hacettepe University Faculty of Medicine, Ankara, Turkey
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27
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De Carolis S, Garufi C, Garufi E, De Carolis MP, Botta A, Tabacco S, Salvi S. Autoimmune Congenital Heart Block: A Review of Biomarkers and Management of Pregnancy. Front Pediatr 2020; 8:607515. [PMID: 33415090 PMCID: PMC7784711 DOI: 10.3389/fped.2020.607515] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 11/30/2020] [Indexed: 11/13/2022] Open
Abstract
Autoimmune Congenital Heart Block (CHB) is an immune-mediated disease due to transplacental passage of circulating anti-Ro/SSA and anti-La/SSB autoantibodies. It occurs in 2% of anti-Ro/SSA-exposed pregnancies, and recurrence rate is nine times higher in subsequent pregnancies. Aim of this review is to identify biomarkers of CHB and treatment strategies. The Ro-system is constituted by two polypeptides targeted by the anti-Ro52 and anti-Ro60 autoantibodies. The central portion of Ro52 (p200), more than the full amino-acid sequence of Ro-52, is recognized to be the fine specificity of anti-Ro associated to the highest risk of cardiac damage. If anti-p200 antibody should be tested, as biomarker of CHB, over standard commercial ELISAs is still debated. Recent studies indicate that type I-Interferon (IFN) can activate fibroblasts in fetal heart. In the mother the anti-Ro/La antibodies activate the type I IFN-signature, and maternal IFN-regulated genes correlate with a similar neonatal IFN-gene expression. Evaluation of maternal IFN-signature could be used as novel biomarker of CHB. The measurement of "mechanical" PR interval with weekly fetal echocardiogram (ECHO) from 16 to at least 24 weeks of gestation is strongly recommended for CHB prenatal diagnosis. However, ECHO screening presents some limitations due to difficult identification of first-degree block and possible occurrence of a complete block from a normal rhythm in few days. Maternal administration of Hydroxychloroquine from the tenth week of gestation, modulating toll-like receptor and autoantibody-dependent type I IFN activation on the fetus, has an important role in preventing CHB in pregnant women with high risk for recurrent CHB.
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Affiliation(s)
- Sara De Carolis
- Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Department of Obstetrics, Gynaecology and Pediatrics, Rome, Italy
| | - Cristina Garufi
- Dipartimento di Scienze Cliniche, Internistiche, Anestesiologiche e Cardiovascolari, UOC Reumatologia, Sapienza University of Rome, Rome, Italy
| | - Ester Garufi
- Medical School, University of Florence, Florence, Italy
| | - Maria Pia De Carolis
- Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Department of Obstetrics, Gynaecology and Pediatrics, Rome, Italy
| | - Angela Botta
- Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Department of Obstetrics, Gynaecology and Pediatrics, Rome, Italy
| | - Sara Tabacco
- Department of Gynecological Sciences, Sapienza University of Rome, Rome, Italy
| | - Silvia Salvi
- Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Department of Obstetrics, Gynaecology and Pediatrics, Rome, Italy
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28
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Costedoat-Chalumeau N, Morel N, Fischer-Betz R, Levesque K, Maltret A, Khamashta M, Brucato A. Routine repeated echocardiographic monitoring of fetuses exposed to maternal anti-SSA antibodies: time to question the dogma. THE LANCET. RHEUMATOLOGY 2019; 1:e187-e193. [PMID: 38229394 DOI: 10.1016/s2665-9913(19)30069-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 09/06/2019] [Accepted: 09/09/2019] [Indexed: 11/21/2022]
Abstract
In around 1% of exposed pregnancies, anti-Ro/SSA and anti-La/SSB antibodies lead to congenital heart block, the main feature of neonatal lupus syndrome. As such, echocardiographic screening to detect congenital heart block, done every other week from 16 weeks to at least 24 weeks gestation, is widely recommended for anti-SSA-positive pregnant women. Such screening is now routinely done in many centres worldwide. In this Viewpoint, we call this dogma into question for several reasons. Even if congenital heart block is discovered (which is rare), the usefulness of treatment with fluorinated steroids has not been shown, whereas the associated side-effects are well known. The discovery of congenital heart block very early in the pregnancy does not modify obstetric management, and at least 500 ultrasounds are needed to find one case of congenital heart block, which would ultimately be found by other means. Finally, this screening strategy misses most cases of congenital heart block because most affected women are not known to have anti-SSA antibodies, and thus are not screened. Accordingly, except in the context of research protocols, which are certainly needed and are outside the scope of this Viewpoint, overturning the dogma of routine repeated screenings for congenital heart block could save money and health-care staff time and prevent maternal stress without substantial clinical consequences.
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Affiliation(s)
- Nathalie Costedoat-Chalumeau
- Assistance Publique - Hôpitaux de Paris, Cochin Hospital, Internal Medicine Department, Referral Center for Rare Autoimmune and Systemic Diseases, Paris, France; Centre of Research in Epidemiology and Statistics, Institut National de la Santé et de la Recherche Médicale, Institut National de la Recherche Agronomique, Université de Paris, Paris, France.
| | - Nathalie Morel
- Assistance Publique - Hôpitaux de Paris, Cochin Hospital, Internal Medicine Department, Referral Center for Rare Autoimmune and Systemic Diseases, Paris, France
| | - Rebecca Fischer-Betz
- Policlinic of Rheumatology and Hiller Research Unit Rheumatology, Medical Faculty, Heinrich-Heine-University, Dusseldorf, Germany
| | - Kateri Levesque
- Service Médecine Interne Gynéco-obstétricale, Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Canada
| | - Alice Maltret
- Assistance Publique - Hôpitaux de Paris, Service de Cardiologie, Hôpital Necker, Paris, France
| | - Munther Khamashta
- Lupus Clinic Rheumatology Department, Dubai Hospital, Dubai, United Arab Emirates
| | - Antonio Brucato
- Dipartimento di Scienze Biomediche e Cliniche, Università degli Studi di Milano, Ospedale Fatebenefratelli, Milano, Italy
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29
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Cuneo BF, Buyon JP. Keeping upbeat to prevent the heartbreak of anti-Ro/SSA pregnancy. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2019; 54:7-9. [PMID: 31313868 DOI: 10.1002/uog.20361] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Linked Comment: Ultrasound Obstet Gynecol 2019; 54: 87-95.
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Affiliation(s)
- B F Cuneo
- Division of Cardiology, Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO, USA
| | - J P Buyon
- Division of Rheumatology, Department of Internal Medicine, New York University Langone School of Medicine, NYU Langone Health, New York, NY, USA
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30
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Congenital heart block: Pace earlier (Childhood) than later (Adulthood). Trends Cardiovasc Med 2019; 30:275-286. [PMID: 31262557 DOI: 10.1016/j.tcm.2019.06.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Revised: 06/16/2019] [Accepted: 06/17/2019] [Indexed: 12/22/2022]
Abstract
Congenital complete heart block (CCHB) occurs in 2-5% of pregnancies with positive anti-Ro/SSA and/or anti-La/SSB antibodies, and has a recurrence rate of 12-25% in a subsequent pregnancy. After trans-placental passage, these autoantibodies attack and destroy the atrioventricular (AV) node in susceptible fetuses with the highest-risk period observed between 16 and 28 weeks' gestational age. Many mothers are asymptomatic carriers, while <1/3 have a preexisting diagnosis of a rheumatic disease. The mortality of CCHB is predominant in utero and in the first months of life, reaching 15-30%. The diagnosis of CCHB can be confirmed by fetal echocardiography before birth and by electrocardiography after birth. Whether early in-utero detection and treatment might prevent or reverse this condition remains controversial. In addition to autoantibody-associated CCHB, there is also an isolated (absent structural heart disease) nonimmune early- or late-onset heart block detected later in childhood that may be associated with specific genetic markers or other pathogenic mechanisms. In isolated immune or non-immune CCHB, cardiac pacemakers are implanted in symptomatic patients, however, data on the natural history of CCHB in the adult life indicate that all patients, even if asymptomatic, should receive a pacemaker when first diagnosed. However, important issues have emerged in these patients wherein life-long conventional right ventricular apical pacing may produce left ventricular dysfunction (pacing-induced cardiomyopathy) necessitating a priori alternate site pacing or subsequent upgrading to biventricular pacing. All these issues are herein reviewed and two algorithms are proposed for diagnosis and management of CCHB in the fetus and in the older individual.
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31
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Gardiner HM. In utero intervention for severe congenital heart disease. Best Pract Res Clin Obstet Gynaecol 2019; 58:42-54. [PMID: 30772145 DOI: 10.1016/j.bpobgyn.2019.01.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 01/11/2019] [Indexed: 10/27/2022]
Abstract
The aim of foetal cardiac therapy is to treat an abnormality at the developmental stage so that the process of cardiac growth, which is complex and relies on the volume and direction of circulating blood as well as genetic determinants, can continue. In reality, most cardiac interventions are palliative; hence, major abnormalities are still present at birth. Nevertheless, tangible benefits following successful foetal intervention include improved haemodynamics and reduction in secondary damage leading to better postnatal outcomes. In cases of semilunar valve stenosis, or atresia, foetal valvuloplasty aims to achieve a biventricular, rather than univentricular, circulation. Opening and stenting a restrictive atrial foramen may preserve the pulmonary function in cases of hypoplastic left heart syndrome, thereby increasing the chances of successful postnatal surgery. More recent endeavours include percutaneous implantation of a miniaturised pacemaker to treat complete heart block and the promotion of left-sided heart growth by chronic maternal hyperoxygenation. The true clinical benefit of these interventions over natural history remains uncertain because of the paucity of appropriate randomised controlled trials (RCTs). Foetal cardiac therapy must now move from a pioneering approach to one that is supported by evidence, as has been done successfully for other foetal therapies.
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Affiliation(s)
- Helena M Gardiner
- The Fetal Center, Children's Memorial Hermann Hospital and the Department of Obstetrics and Gynecology, McGovern Medical School, UTHealth, Houston, TX, USA.
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