Pregnancy in systemic lupus erythematosus

Maternal Near Miss in Patients with Systemic Lupus Erythematosus

OBJECTIVE

 Systemic lupus erythematosus (SLE) may cause irreversible organ damage. Pregnancy with SLE may have severe life-threatening risks. The present study aimed to determine the prevalence of severe maternal morbidity (SMM) in patients with SLE and analyze the parameters that contributed to cases of greater severity.

METHODS

This is a cross-sectional retrospective study from analysis of data retrieved from medical records of pregnant women with SLE treated at a University Hospital in Brazil. The pregnant women were divided in a control group without complications, a group with potentially life-threatening conditions (PLTC), and a group with maternal near miss (MNM).

RESULTS

 The maternal near miss rate was 112.9 per 1,000 live births. The majority of PLTC (83.9%) and MNM (92.9%) cases had preterm deliveries with statistically significant increased risk compared with the control group (p = 0.0042; odds ratio [OR]: 12.05; 95% confidence interval [CI]: 1.5-96.6 for the MNM group and p = 0.0001; OR: 4.84; 95%CI: 2.2-10.8 for the PLTC group). Severe maternal morbidity increases the risk of longer hospitalization (p < 0.0001; OR: 18.8; 95%CI: 7.0-50.6 and p < 0.0001; OR: 158.17; 95%CI: 17.6-1424,2 for the PLTC and MNM groups, respectively), newborns with low birthweight (p = 0.0006; OR: 3.67; 95%CI: 1.7-7.9 and p = 0.0009; OR: 17.68; 95%CI: 2-153.6) for the PLTC and MNM groups, respectively] as well as renal diseases (PLTC [8.9%; 33/56; p = 0.0069] and MNM [78.6%; 11/14; p = 0.0026]). Maternal near miss cases presented increased risk for neonatal death (p = 0.0128; OR: 38.4; 95%CI: 3.3-440.3]), and stillbirth and miscarriage (p = 0.0011; OR: 7.68; 95%CI: 2.2-26.3]).

CONCLUSION

 Systemic lupus erythematosus was significantly associated with severe maternal morbidity, longer hospitalizations, and increased risk of poor obstetric and neonatal outcomes.

Egyptian recommendations for treating to target of lupus nephritis: an evidence-based consensus on clinical practice recommendations for the management of lupus nephritis and pregnancy

Background

Nephritis is known to be one of the most serious complications of lupus and a strong predictor of poor outcome. This study was carried out aiming at setting up an up-to-date recommendation for the management of women living with lupus nephritis and planning for a family throughout conception, pregnancy, and the postpartum period.

Ten key clinical questions were identified by the scientific committee according to the Patient/Population, Intervention, Comparison, Outcomes and Timing (PICOT) approach. The literature review team performed a systematic review to summarise evidence advocating the benefits and harms of available pharmacologic and nonpharmacologic therapies for women living with lupus nephritis (LN) and planning for a family. Subsequently, recommendations were formulated. The level of evidence was determined for each section using the Oxford Centre for Evidence-Based Medicine (CEBM) system. A 2-round Delphi process was conducted with 24 experts. All rounds were conducted online. A consensus was achieved on the direction and the strength of the recommendations.

Results

An online questionnaire was sent to an expert panel who participated in the two rounds (response rate 100%). At the end of round 2, a total of 20 recommendation items, categorised into 10 domains to address the main LN with pregnancy categories, were obtained. The percentage of those who agreed with the recommendations (rank 7–9) ranged from 88.5 to 100%. On the phrasing of all the clinical standards defined by the scientific committee, a consensus was reached (i.e., 75% of respondents strongly agreed or agreed). An algorithm for the management of LN with pregnancy has been suggested.

Conclusion

These recommendations provide an updated consensus on the pharmacological treatment of LN with pregnancy and strategies to reach optimal outcomes for both the mother and newborn in common clinical scenarios, based on a combination of evidence and expert opinion. Best treatment decisions should be tailored to each individual patient’s situation.

Systemic lupus erythematosus in China: a cross-sectional survey-based study on healthcare-seeking behaviors, disease progression, medication, knowledge of and attitudes toward the disease (Preprint)

BACKGROUND

Systemic lupus erythematosus (SLE) is a systemic autoimmune disease involving multiple organs throughout the body. The health care-seeking behaviors, disease progression of SLE, and patients' knowledge of and attitudes toward SLE have not been characterized in China.

OBJECTIVE

The aim of this study was to depict the health care-seeking behaviors, disease progression, and medications in patients with SLE and to examine the factors associated with their disease flares, knowledge, and attitudes toward SLE in China.

METHODS

We conducted a cross-sectional survey in 27 provinces in China. Descriptive statistical methods were used to depict the demographic characteristics, health care-seeking behaviors, medications, and health status. Multivariable logistic regression models were used to identify the factors associated with disease flares, medication changes, and attitudes toward SLE. An ordinal regression model was used to examine the factors associated with the knowledge of the treatment guidelines.

RESULTS

We recruited 1509 patients with SLE, and 715 had lupus nephritis (LN). Approximately 39.96% (603/1509) of the patients with SLE were primarily diagnosed with LN, and 12.4% (112/906) developed LN (mean time 5.2 years) from non-LN. Patients whose registered permanent residences or workplaces in other cities from the same province and adjacent provinces seeking health care accounted for 66.9% (569/850) and 48.8% (479/981) of the patients with SLE in the provincial capital cities, respectively. Mycophenolate mofetil was the most commonly used immunosuppressive drug in patients without LN (185/794, 23.3%) and patients with LN (307/715, 42.9%). Femoral head necrosis (71/228, 31.1%) and hypertension (99/229, 43.2%) were the most common adverse event (AE) and chronic disease during treatment, respectively. Change of hospitals for medical consultation (odds ratio [OR] 1.90, 95% CI 1.24-2.90) and development of 1 chronic disease (OR 3.60, 95% CI 2.04-6.24) and AE (OR 2.06, 95% CI 1.46-2.92) and more were associated with disease flares. A pregnancy plan (OR 1.58, 95% CI 1.18-2.13) was associated with changes in medication. Only 242 (16.03%) patients with SLE were familiar with the treatment guidelines, and patients with LN tended to be more familiar with the disease (OR 2.20, 95% CI 1.81-2.68). After receiving treatment, 891 (59.04%) patients changed their attitudes toward SLE from fear to acceptance, and patients with college education or higher (OR 2.09, 95% CI 1.10-4.04) were associated with a positive attitude toward SLE.

CONCLUSIONS

A large proportion of patients seeking health care in the provincial capital cities of China migrated from other cities. Persistent monitoring of potential AEs and chronic diseases during SLE treatment and managing patients who changed hospitals for medical consultation are essential for controlling disease flares. Patients had insufficient knowledge about SLE treatment guidelines and would benefit from health education to maintain a positive attitude toward SLE.

Beyond Systemic Lupus Erythematosus and Anti-Phospholipid Syndrome: The Relevance of Complement From Pathogenesis to Pregnancy Outcome in Other Systemic Rheumatologic Diseases

Evidence about the relevance of the complement system, a highly conserved constituent of the innate immunity response that orchestrates the elimination of pathogens and the inflammatory processes, has been recently accumulated in many different rheumatologic conditions. In rheumatoid arthritis, complement, mainly the classical pathway, contributes to tissue damage especially in seropositive subjects, with complement activation occurring in the joint. Data about complement pathways in psoriatic arthritis are dated and poorly consistent; among patients with Sjögren syndrome, hypocomplementemia exerts a prognostic role, identifying patients at risk of extra-glandular manifestations. Hints about complement involvement in systemic sclerosis have been recently raised, following the evidence of complement deposition in affected skin and in renal samples from patients with scleroderma renal crisis. In vasculitides, complement plays a dual role: on one hand, stimulation of neutrophils with anti-neutrophil cytoplasmic antibodies (ANCA) results in the activation of the alternative pathway, on the other, C5a induces translocation of ANCA antigens, favouring the detrimental role of antibodies. Complement deposition in the kidneys identifies patients with more aggressive renal disease; patients with active disease display low serum levels of C3 and C4. Even though in dermatomyositis sC5b-9 deposits are invariably present in affected muscles, data on C3 and C4 fluctuation during disease course are scarce. C3 and C1q serum levels have been explored as potential markers of disease activity in Takayasu arteritis, whereas data in Behçet disease are limited to in vitro observations. Pregnancies in women with rheumatologic conditions are still burdened by a higher rate of pregnancy complications, thus the early identification of women at risk would be invaluable. A fine-tuning of complement activation is required from a physiological progression of pregnancy, from pre-implantation stages, through placentation to labour. Complement deregulation has been implicated in several pregnancy complications, such as recurrent abortion, eclampsia and premature birth; low complement levels have been shown to reliably identify women at risk of complications. Given its physiologic role in orchestrating pregnancy progression and its involvement as pathogenic effector in several rheumatologic conditions, complement system is an attractive candidate biomarker to stratify the obstetric risk among women with rheumatologic conditions.

Learning from imbalanced fetal outcomes of systemic lupus erythematosus in artificial neural networks

OBJECTIVE

To explore an effective algorithm based on artificial neural network to pick correctly the minority of pregnant women with SLE suffering fetal loss outcomes from the majority with live birth and train a well behaved model as a clinical decision assistant.

METHODS

We integrated the thoughts of comparative and focused study into the artificial neural network and presented an effective algorithm aiming at imbalanced learning in small dataset.

RESULTS

We collected 469 non-trivial pregnant patients with SLE, where 420 had live-birth outcomes and the other 49 patients ended in fetal loss. A well trained imbalanced-learning model had a high sensitivity of 19/21 ([Formula: see text]) for the identification of patients with fetal loss outcomes.

DISCUSSION

The misprediction of the two patients was explainable. Algorithm improvements in artificial neural network framework enhanced the identification in imbalanced learning problems and the external validation increased the reliability of algorithm.

CONCLUSION

The well-trained model was fully qualified to assist healthcare providers to make timely and accurate decisions.

The Complement System in the Pathophysiology of Pregnancy and in Systemic Autoimmune Rheumatic Diseases During Pregnancy

The complement system plays a double role in pregnancy exerting both protective and damaging effects at placental level. Complement activation at fetal-maternal interface participates in protection against infectious agents and helps remove apoptotic and necrotic cells. Locally synthesized C1q contributes to the physiologic vascular remodeling of spiral arteries characterized by loss of smooth muscle cells and transformation into large dilated vessels. Complement activation triggered by the inflammatory process induced by embryo implantation can damage trophoblast and other decidual cells that may lead to pregnancy complications if the cells are not protected by the complement regulators CD55, CD46, and CD59 expressed on cell surface. However, uncontrolled complement activation induces placental alterations resulting in adverse pregnancy outcomes. This may occur in pathological conditions characterized by placental localization of complement fixing antibodies directed against beta2-glycoprotein 1, as in patients with anti-phospholipid syndrome, or circulating immune complexes deposited in placenta, as in patients with systemic lupus erythematosus. In other diseases, such as preeclampsia, the mechanism of complement activation responsible for complement deposits in placenta is unclear. Conflicting results have been reported on the relevance of complement assays as diagnostic and prognostic tools to assess complement involvement in pregnant patients with these disorders.

Prepregnancy Endocrine, Autoimmune Disorders and the Risks of Gestational Hypertension-Preeclampsia in Primiparas: A Nationwide Population-Based Study in Taiwan

(1) Objective: To assess the risks of gestational hypertension/preeclampsia (GH-PE) in women with prepregnancy endocrine and autoimmune disorders such as polycystic ovarian syndrome (PCOS) and systemic lupus erythematosus (SLE). (2) Methods: In a nationwide population-based longitudinal study, data were retrieved from the 1998 to 2012 Taiwan National Health Insurance Research Database. ICD9-CM codes 256.4, 710.0, and 642.X were identified for the corresponding diagnoses of PCOS, SLE, and GH-PE, respectively, which were further confirmed by inspection of medical claims data for ultrasonography findings, laboratory tests, blood pressure measurements and examinations of urine protein to ensure the accuracy of the diagnoses. To clarify the risks of primiparous GH-PE, the study excluded women diagnosed with PCOS or SLE at <15 or >45 years of age, pre-existing chronic hypertension, GH-PE before PCOS and SLE, and abortion or termination before 20 weeks' gestation. For women affected by prepregnancy PCOS or SLE individually, each pregnant woman was age-matched to four pregnant women without PCOS or SLE. Logistic regression analyses were applied to report odds ratios (ORs) for the risks of GH-PE after adjustment for age, occupation, urbanization, economic status, and other co-morbidities. (3) Results: Among 8070 and 2430 women with prepregnancy PCOS and SLE retrieved from a population of 1,000,000 residents, 1953 (24.20%) and 820 (33.74%) had subsequent primiparous pregnancies that were analyzable and compared with 7812 and 3280 pregnancies without prepregnancy PCOS and SLE, respectively. GH-PE occurred more frequently in pregnancies with prepregnancy PCOS (5.79% vs. 2.23%, p < 0.0001) and SLE (3.41% vs. 1.80%, p < 0.01) as compared to those without PCOS and SLE. Further analysis revealed that prepregnancy PCOS (adjusted OR = 2.36; 95%CI: 1.83-3.05) and SLE (adjusted OR = 1.95; 95%CI: 1.23-3.10) were individually associated with GH-PE. The risk of GH-PE was not reduced in women with prepregnancy PCOS receiving metformin treatment (p = 0.22). (4) Conclusions: Prepregnancy PCOS and SLE are independent and significant risk factors for the occurrence of GH-PE. Because the peripartum complications are much higher among pregnancies with GH-PE, the at-risk woman should be informed and well-prepared during her pregnancy and delivery.

Low prevalence of contraceptive use among Brazilian women of reproductive age with systemic lupus erythematosus

This was a cross-sectional study of women of reproductive age with systemic lupus erythematosus (SLE) being treated at Bahiana School Rheumatology Service in Brazil. The study aimed to assess the prevalence of contraceptive counselling and use. An interview was performed, and the results were analysed before and after the SLE diagnosis. Eighty-five women were included; the mean age of the group was 32.98 ± 8.39 years. Before SLE diagnosis, most of the patients had used some contraceptive method; mainly oral contraceptives (54%) or hormone injections (21%). After SLE diagnosis, 53% of patients did not use any contraceptive method. Among the remaining patients who continued using contraceptives, 22% used condoms, 11% used combined oral contraceptives and 7% used hormone injections. Although 62% of the patients regularly visited the gynaecologist, 56% were unaware of which contraceptive method could be used safely. Thus, a better contraceptive counselling of women of a reproductive age should be performed after SLE diagnosis. Impact Statement What is already known on this subject? Women diagnosed with SLE have inadequate counselling about family planning. What the results of this study add? Brazilian women with SLE have a low prevalence of contraceptive use after their diagnosis and are exposed to having high-risk pregnancies. What the implications are of these findings for clinical practice and/or further research? The results we found highlight the importance of continued medical educational programmes and establish questions for further studies in order to investigate the interventions used to improve the contraceptive use for women diagnosed with SLE.

A clinical decision support system for prediction of pregnancy outcome in pregnant women with systemic lupus erythematosus

OBJECTIVE

Pregnancy among systemic lupus erythematosus (SLE)-affected women is highly associated with poor obstetric outcomes. Predicting the risk of foetal outcome is essential for maximizing the success of pregnancy. This study aimed to develop a clinical decision support system (CDSS) to predict pregnancy outcomes among SLE-affected pregnant women.

METHODS

We performed a retrospective analysis of 149 pregnant women with SLE, who were followed at Shariati Hospital (104 pregnancies) and a specialized clinic (45 pregnancies) from 1982 to 2014. We selected significant features (p<0.10) using a binary logistic regression model performed in IBM SPSS (version 20). Afterward, we trained several artificial neural networks (multi-layer perceptron [MLP] and radial basis function [RBF]) to predict the pregnancy outcome. In order to evaluate and select the most effective network, we used the confusion matrix and the receiver operating characteristic (ROC) curve. We finally developed a CDSS based on the most accurate network. MATLAB 2013b software was applied to design the neural networks and develop the CDSS.

RESULTS

Initially, 45 potential variables were analysed by the binary logistic regression and 16 effective features were selected as the inputs of neural networks (P-value<0.1). The accuracy (90.9%), sensitivity (80.0%), and specificity (94.1%) of the test data for the MLP network were achieved. These measures for the RBF network were 71.4%, 53.3%, and 79.4%, respectively. Having applied a 10-fold cross-validation method, the accuracy for the networks showed 75.16% accuracy for RBF and 90.6% accuracy for MLP. Therefore, the MLP network was selected as the most accurate network for prediction of pregnancy outcome.

CONCLUSION

The developed CDSS based on the MLP network can help physicians to predict pregnancy outcomes in women with SLE.

Early resolution of subretinal fluid without high-dose corticosteroids in a pregnant patient with Vogt-Koyanagi-Harada disease: a case report

BACKGROUND

At present, there is no standard of treatment using systemic high-dose corticosteroids in cases of pregnant women with Vogt-Koyanagi-Harada (VKH) disease. Although high-dose systemic corticosteroid treatment is often used for VKH disease during pregnancy, it also poses a risk to the fetus.

FINDINGS

A 29-year-old woman in the 34th week of pregnancy experienced bilateral metamorphopsia. She had been receiving 5 mg of prednisolone daily for the past 8 years as treatment for rheumatoid arthritis. In order to prevent progression of bilateral serous retinal detachment caused by VKH disease, we recommended the use of high-dose systemic corticosteroids but the patient refused. Thus, we administered only topical ophthalmic betamethasone for mild anterior uveitis. Surprisingly, however, the bilateral bullous retinal detachment healed in just 19 days after the onset of symptoms. A healthy baby was born 1 month later, and sunset glow fundus was subsequently observed without any recurrence of uveitis.

CONCLUSIONS

We report a case in which bilateral subretinal fluid caused by VKH disease in a young woman during late pregnancy resolved without high-dose corticosteroid treatment. Pregnancy may have had a beneficial effect on uveitis activity caused by VKH disease. To our knowledge, this report describes the shortest healing period for bilateral bullous retinal detachment in a pregnant woman with VKH disease.

Healthcare costs of pregnancy in systemic lupus erythematosus: retrospective observational analysis from a US health claims database

OBJECTIVE

Systemic lupus erythematosus is a complex autoimmune disease, most frequently affecting women of childbearing age. Women with lupus are at increased risk of pregnancy complications that are exacerbated by active disease. Despite this, their use of medications and hospital resources has not been extensively studied.

METHODS

Retrospective analyses of the Truven Health MarketScan database (2006-2012) aimed to quantify drug and resource utilization in pregnant women with lupus, as well as the incidence of pregnancy complications in these patients. Records of women aged 12-54 were reviewed and both lupus patients and pregnancies identified. Pregnant women with lupus were matched 1:5 with either pregnant women without lupus, or non-pregnant women with lupus.

RESULTS

Pregnancies with lupus were associated with increased complications when compared to pregnancies without lupus. During pregnancy, the use of immunosuppressants decreased in pregnant women with lupus, as did rheumatologist visits, while the number of women not treated with any immunosuppressant increased. Pregnant women with lupus showed higher overall treatment costs than controls. However, compared to non-pregnant women with lupus, medication costs actually dropped, possibly due to the withdrawal of medications from these patients or women becoming pregnant while disease activity was low.

CONCLUSIONS

The large database analyses reported here revealed that pregnancies in women with lupus were associated with a higher risk of complications, higher healthcare costs, and fewer prescribed medications, including immunosuppressants, than the control groups. The increased risk of complications and decreased immunosuppressant use suggest that patients require additional guidance from physicians to give them the best chance of experiencing a safe pregnancy. Indeed, despite the recognized role active lupus plays in increasing pregnancy complications, women with lupus had fewer rheumatology visits during pregnancy, although their visits to their general practitioner/primary healthcare provider increased, highlighting the need for team-based co-ordination care between OBGYN physicians and rheumatologists.

Bone status of children born from mothers with autoimmune diseases treated during pregnancy with prednisone and/or low molecular weight heparin

BACKGROUND

To evaluate bone status in children born from mothers followed for autoimmune diseases and treated during pregnancy with low molecular weight heparin (LMVH) and/or prednisone.

FINDINGS

History, physical examination, laboratory tests and phalangeal ultrasonography were performed. Demographic, clinical, and laboratory data were entered into a customized database, and results were analyzed with SPSS software. In children whose mothers were treated with LMWH, we retrieved dried blood spots taken for newborn screening, and analyzed the presence of heparin with tandem mass spectrometry. We enrolled 27 females and 14 males born from 31 mothers with SLE or connective tissue diseases. These women were continuously treated during pregnancy with LMWH (n = 10), prednisone (n = 16), or both (n = 15). Bone ultrasound revealed low values (≤ 3 centile for age) in ten patients. In a multistep regression analysis, age at examination resulted the single predictor of low ultrasound values (p < 0.004). Tandem mass spectroscopy failed to determine traces of heparin in newborn blood.

CONCLUSIONS

Children born from mothers with autoimmune diseases are at risk to develop reduced bone mass. The administration of LMWH and of prednisone seems to be safe with regard to children's bone health.

Risk of congenital malformations for asthmatic pregnant women using a long-acting β₂-agonist and inhaled corticosteroid combination versus higher-dose inhaled corticosteroid monotherapy

BACKGROUND

Current recommendations for managing persistent asthma during pregnancy when low-dose inhaled corticosteroids (ICSs) are insufficient include adding a long-acting β₂-agonist (LABA) or increasing the ICS dose. However, there are no data to help clinicians evaluate the safest regimen during pregnancy.

OBJECTIVE

We sought to compare the risk of major congenital malformations in asthmatic women exposed to a LABA plus ICS combination and those exposed to ICS monotherapy at higher doses during the first trimester.

METHODS

A cohort of asthmatic pregnant women exposed to ICSs during the first trimester who delivered between January 1990 and March 2009 was established. The primary outcome was major malformation recorded at birth or during the first year of life. Two subcohorts were established as follows: (1) users of a LABA plus low-dose ICS combination or users of a medium-dose ICS and (2) users of a LABA plus medium-dose ICS combination or users of a high-dose ICS. Generalized estimating equations were used to compare the risk of major malformations between the groups.

RESULTS

In one subcohort there were 643 women who used a LABA plus low-dose ICS and 305 who used a medium-dose ICS; the other subcohort included 198 users of a LABA plus medium-dose ICS and 156 users of a high-dose ICS. The prevalence of major malformations was 6.9% and 7.2%, respectively. The adjusted odds ratio for major malformations was 1.1 (95% CI, 0.6-1.9) when a LABA plus low-dose ICS was used compared with a medium-dose ICS and 1.2 (95% CI, 0.5-2.7) when a LABA plus medium-dose ICS was used compared with a high-dose ICS.

CONCLUSION

The risk of major malformations was similar with a LABA plus ICS combination and ICS monotherapy at higher doses, suggesting that both therapeutic options can be considered during pregnancy.

Relaxin: a missing link in the pathomechanisms of Systemic Lupus Erythematosus?

Systemic Lupus Erythematosus (SLE) is an autoimmune rheumatic disease which predominantly affects women of reproductive age. Despite significant progress in recent years to elucidate many potential mechanisms involved in the generation of autoimmunity the factors behind the high incidence among women, the relapsing-remitting clinical course and pregnancy-related complications in SLE remain unclear. In this review, we hypothesize a potential role for uterine endometrium through its production of relaxin, a peptide hormone, as a "missing-link" to explain this female predominance, variable clinical course and obstetric complications operating in SLE.

Chinese SLE Treatment and Research group (CSTAR) registry: I. Major clinical characteristics of Chinese patients with systemic lupus erythematosus

The Chinese systemic lupus erythematosus (SLE) treatment and research group (CSTAR) provides major clinical characteristics of SLE in China and establishes a platform to provide resources for future basic and clinical studies. CSTAR originated as a multicentre, consecutive, and prospective design. The data were collected online from 104 rheumatology centers, which covered 30 provinces in China. The registered patients were required to meet four or more of the American College of Rheumatology (ACR) criteria for the classification of SLE. All CSTAR centers use the same protocol-directed methods to provide uniform evaluations, which included demographic data, clinical features, laboratory examinations, and disease activity evaluations. The patient samples, including DNA samples and sera, were also collected for further quality controls and additional studies. Preliminary analysis from 2104 baseline evaluations was available for this analysis. Of 1914 female and 190 male patients (F:M=10.1), the mean age at onset was 29.2 y with confirmed diagnosis one year later at the age of 30.3 y. Eighty four (4.2%) of 2002 patients had a family history of rheumatic diseases, including 34 (1.7%) cases with SLE. In addition, one hundred and seven (5.2%) abnormal pregnancies were recorded among 2026 experiences. The characteristics of the CSTAR cohort were compared to similarly sized cohorts from other studies. We found that 56.1% of patients presented with concurrent hematological disorders compared to only 18.2% of European patients. Moreover, 47.4% of patients presented with nephropathy compared to 27.9% of European patients. Conversely, neurological manifestations were only seen in 4.8% of Chinese SLE patients compared to 19.4% of European patients, 12.1% of U.S. patients, 22.8% of Malaysian patients and 26.4% of Latin Americans. Pulmonary arterial hypertension and interstitial lung diseases were complications identified in 3.8% and 4.2% of Chinese lupus patients, respectively. The CSTAR registry has provided epidemiological data and phenotypes of Chinese patients with SLE, and has demonstrated several differences between ethnicities. Clinical data and biologic samples would be valuable resources for future translational studies with national and international collaboration.

Obstetric outcomes and prognostic factors of lupus pregnancies

PURPOSE

To determine maternal and fetal outcomes in pregnancies with Systemic Lupus Erythematosus (SLE), and to evaluate the prognostic factors that may affect obstetrical outcomes.

METHODS

Sixty-five consecutive cases of SLE and pregnancy were included in this retrospective clinical study, performed in a university hospital which is also a reference center for SLE. Lupus pregnancies followed and delivered during the period from 2002 to 2011 in our department are evaluated. Obstetric outcomes and prognostic factors were main outcome measures.

RESULTS

The mean patient age was 28.8 years and the nulliparity rate was 43.1%. Disease flare-up occurred in 7.7% of patients. Lupus anticoagulants, anticardiolipin IgG and IgM antibodies were positive in 27.6, 15.3 and 13.8% of patients, respectively. Mean gestational age at delivery was 36.6 ± 4.2 and mean birth weight was 2,706 ± 927 g. Stillbirth, fetal growth restriction, preeclampsia and preterm delivery rates were 4.6, 18.5, 9.2 and 27.6%, respectively. Cases with uterine artery Doppler abnormalities had significantly poorer obstetric outcomes.

CONCLUSIONS

Multidisciplinary approach to the care of pregnant women with SLE is mandatory for good maternal and fetal outcomes. Uterine artery Doppler seems to be a good prognostic factor for adverse obstetric outcomes.

Susac syndrome and multifocal motor neuropathy first manifesting in pregnancy

Susac Syndrome (SS) and multifocal motor neuropathy (MMN) are rare autoimmune neurological conditions which can affect women of childbearing years. The effect of pregnancy on these disorders is poorly characterised. We report a case of SS first manifesting in pregnancy with challenges in diagnosis and management and a poor clinical outcome, and a case of MMN manifesting in pregnancy then relapsing in a subsequent pregnancy. A summary of other cases in the literature and the postulated underlying immune mechanisms is presented.

Risk factors for blood transfusion in singleton pregnancy deliveries in Taiwan

OBJECTIVE

To investigate risk factors for blood transfusion in pregnancy.

METHODS

In a population-based study, data from all women with singleton pregnancies (n=225 304) admitted for delivery in Taiwanese hospitals in 2002 were obtained from the National Health Insurance claims database. To identify risk factors for blood transfusion, a logistic regression model with generalized estimating equation was used to calculate the adjusted odds ratio (OR) and 95% confidence intervals (CI) for characteristics of the pregnant women, hospitals, clinics, and obstetricians.

RESULTS

The incidence of blood transfusion was 1.43%. Cesarean delivery, vaginal birth after cesarean (VBAC), and repeat cesarean delivery had higher rates of blood transfusion than vaginal delivery, with an OR of 7.2 (95% CI, 6.38-8.02), 4.2 (95% CI, 2.52-6.87), and 5.9 (95% CI, 5.06-6.80), respectively. Other risk factors included extremes of age; pregnancies complicated by prepartum hemorrhage, placenta previa, pre-eclampsia, eclampsia, anemia, or systemic lupus erythematosus; and obstetricians with low or mid-to-low numbers of deliveries.

CONCLUSION

The study has identified risk factors for blood transfusion in pregnancy on the basis of a nationwide database and provides useful information for obstetric practice. For women with a history of cesarean delivery, vaginal delivery might be considered owing to its lower incidence of transfusion.

Nonmalignant diseases and treatments associated with primary ovarian failure: an expanded role for fertility preservation

Cancer treatments can be detrimental to fertility; recent literature has focused on the efforts of fertility preservation for this patient population. It should be recognized, however, that several nonmalignant medical conditions and therapeutic interventions could be similarly hazardous to fertility. Some of these nonmalignant diseases and their treatments that can adversely impact the reproductive axis are gastrointestinal diseases, rheumatologic disorders, nonmalignant hematologic conditions, neurologic disorders, renal disorders, gynecologic conditions, and metabolic diseases. Their negative effects on reproductive function are only now being appreciated and include impaired ovarian function, endocrine function, or sexual function and inability to carry a pregnancy to term. Complications and comorbidities associated with certain diseases may limit the success of established fertility preservation options. Recent advances in fertility preservation techniques may provide these patients with new options for childbearing. Here, we review several fertility-threatening conditions and treatments, describe current established and experimental fertility preservation options, and present three initiatives that may help minimize the adverse reproductive effects of these medical conditions and treatments by raising awareness of the issues and options: (1) increase awareness among practitioners about the reproductive consequences of specific diseases and treatments, (2) facilitate referral of patients to fertility-sparing or restorative programs, and (3) provide patient education about the risk of infertility at the time of diagnosis before initiation of treatment.

The impact of the EUSCLE core set questionnaire for the assessment of cutaneous lupus erythematosus

Epidemiological data and standard European guidelines for the diagnosis and treatment of cutaneous lupus erythematosus (CLE) are lacking in the current literature. In order to provide a standardized tool for an extensive consistent data collection, a study group of the European Society of Cutaneous Lupus Erythematosus (EUSCLE) recently developed a Core Set Questionnaire for the assessment of patients with different subtypes of CLE. The EUSCLE Core Set Questionnaire includes six sections on patient data, diagnosis, skin involvement, activity and damage of disease, laboratory analysis, and treatment. An instrument like the EUSCLE Core Set Questionnaire is essential to gain a broad and comparable data collection of patients with CLE from different European centres and to achieve consensus concerning clinical standards for the disease. The data will also be important for further characterization of the different CLE subtypes and the evaluation of therapeutic strategies; moreover, the EUSCLE Core Set Questionnaire might also be useful for the comparison of data in clinical trials. In this review, the impact of the EUSCLE Core Set Questionnaire is discussed in detail with regard to clinical and serological features as well as therapeutic modalities in CLE. Lupus (2010) 19, 1144—1152.

Pregnancy outcome in systemic lupus erythematosus: Asia's largest single centre study

AIM

To evaluate pregnancy outcome in women with systemic lupus erythematosus (SLE).

METHODS

A total of 71 pregnancies in 35 women with SLE were evaluated for maternal and perinatal outcomes in a tertiary centre of Northern India. Thirty-five pregnancies were evaluated prospectively while details of previous 36 pregnancies in the same women were studied retrospectively.

RESULTS

The Mean age of pregnant women with SLE was 26.89 ± 2.7 years and 14.57% were nulliparous. The presenting event was arthritis in 60% of the patients; others presented with febrile illness, renal manifestation and cutaneous manifestation. One woman was lupus anticoagulant positive. All women conceived while on disease quiescence period and were continued on the same pre-pregnancy dose of pharmacological agents. Hypertensive disorders of pregnancy were seen in 28.5% while chronic hypertension was seen in 5.6%. The incidence of abortion, preterm deliveries and perinatal loss was 33.8, 29.57 and 12.67%, respectively. Vaginal delivery rate was 47.88 and 18.3% underwent caesarean section. There was no case of neonatal lupus and none had disease flare-up in the postpartum period.

CONCLUSION

A better pregnancy outcome can be expected if clinical remission is achieved and disease activity is adequately controlled prior to pregnancy.

Systemic lupus erythematosus and pregnancy

We present a retrospective study of 42 consecutive cases of systemic lupus erythematosus (SLE) and pregnancy followed and delivered during the period 2002-2007 in our department. The mean patient age was 28.6 years and the nulliparity rate was 45.2%. Disease flare up occurred in 9.5% of patients. Lupus anticoagulants, anticardiolipin IgG and IgM antibodies were positive in 33%, 16.6% and 19% of patients, respectively. Mean gestational age at delivery was 36.9 +/- 4.2 and mean birth weight was 2,750 +/- 844 g. Stillbirth, fetal growth restriction, pre-eclampsia and pre-term delivery rates were 7.1%, 14.3%, 2.4% and 23.1%, respectively. Cases with uterine artery Doppler abnormalities had significantly poorer obstetric outcomes. Antiphospholipid antibodies, renal involvement and lupus activation did not have any significant influence on poor obstetric outcome. Multidisciplinary approach to the care of pregnant women with SLE is mandatory for good maternal and fetal outcomes. Uterine artery Doppler seems to be a good prognostic factor for adverse obstetric outcomes.

Contraception for adolescents with lupus

Sexually active adolescents, including young women with lupus, are at high risk for unplanned pregnancy. Unplanned pregnancy among teens with lupus is associated with an elevated risk of poor maternal and fetal outcomes. The provision of effective contraception is a crucial element of care for a sexually-active young woman with lupus. Unfortunately, providers may be hesitant to prescribe contraception to this group due to concerns about increasing the risk of lupus complications. This article reviews the risks and benefits of currently-available contraceptives for young women with lupus. Providers are encouraged to consider long-term, highly-effective contraception, such as implantables and intrauterine devices, for appropriately selected adolescents with lupus.

Reproductive health in women with systemic lupus erythematosus compared to population controls

OBJECTIVE

To study the reproductive health history in women with systemic lupus erythematosus (SLE) compared to population controls.

METHODS

A total of 206 female SLE patients were interviewed regarding demographic and disease data, menstruation, use of contraception and hormone replacement therapy (HRT), infertility, and pregnancies. The control group consisted of 1037 women from the general population of similar age and socioeconomic status living in the same region.

RESULTS

In SLE women compared to population controls, mean age at menarche (13.3 vs. 13.2 years) and frequency of infertility (16% vs. 16%) were similar but menopause occurred earlier (44.9 vs. 46.8 years, p = 0.01). Current use of oral contraceptives (OCs) was less common than in controls [18% vs. 28%, odds ratio (OR) 0.55, 95% CI 0.3-1.0] while previous use of progesterone-containing intrauterine devices (IUDs) was more common (13% vs. 5%, OR 3.2, 95% CI 1.9-5.4). Current use of HRT was similar (22% vs. 21%) but SLE patients had started the use earlier (43.2 vs. 47.1 years, p = 0.003). Mean number of pregnancies was lower in SLE patients compared to controls (2.3 vs. 2.5, p = 0.046) and in lupus nephritis patients compared to SLE patients without nephritis (1.9 vs. 2.5, p = 0.01). No difference was found in the occurrence of spontaneous and induced abortions compared to controls, but pregnancy-associated complications were more common in SLE women.

CONCLUSION

When compared to population controls women with SLE are normally fertile, use less OCs and more IUDs, have earlier menopause and use HRT as frequently. Family size is reduced, especially in lupus nephritis patients, and pregnancy-associated complications are more common.

The clinical content of preconception care: women with chronic medical conditions

This article reviews the medical conditions that are associated with adverse pregnancy outcomes for women and their offspring. We also present the degree to which specific preconception interventions and treatments can impact the effects of the condition on birth outcomes. Because avoiding, delaying, or achieving optimal timing of a pregnancy is often an important component of the preconception care of women with medical conditions, contraceptive considerations particular to the medical conditions are also presented.

Prognosis of neonates in pregnant women with systemic lupus erythematosus

PURPOSE

The effects of maternal systemic lupus erythematosus (SLE) on neonatal prognosis were examined by comparing clinical features of full-term babies born to lupus mothers and age- and parity-matched controls.

PATIENTS AND METHODS

From January 2000 to December 2005, 39 singletons were born to 37 SLE women. Excluding 11 cases of prematurity and preeclampsia, 28 full-term neonates formed the lupus group. The control group included 66 full-term babies. The retrospective study examined medical records and compared gestational age, birth weight, days of hospital stay, small for gestational age (SGA) frequency, Apgar scores < 7, and parity. Lupus neonates were tested for anti-nuclear antibody (ANA) and platelet count, and electrocardiogram was performed.

RESULTS

Average gestational age (38 vs. 39 weeks, p < 0.05) and birth weight (2,775 vs. 3,263g, p < 0.05) were significantly different between the SLE and control groups. SGA frequency was higher in the SLE group (25% vs. 4.5%, p < 0.05). No significant difference was observed in Apgar score, birth weight, gestational age, SGA frequency, and platelet count between lupus subgroups formed based on anti-dsDNA antibody levels and antiphospholipid antibody status.

CONCLUSION

The association of maternal ANAs, antiphospholipid antibodies, and drug history with neonatal prognosis could not be elucidated. However, even in uncomplicated pregnancies, maternal lupus is disadvantageous for gestational age, birth weight, and SGA frequency.

[Myasthenia gravis and pregnancy: clinical course and management of delivery and the postpartum phase]

OBJECTIVES

To study influences of pregnancy on the time-course of myasthenia gravis (MG) and of MG on pregnancy, delivery, postpartum and newborn.

METHODS

We retrospectively collected data from 100 women affected with MG, hospitalized between 1994 and 2003 in departments of Neurology of Lille University Hospital.

RESULTS

Eighteen patients had a total of 36 pregnancies, occurring 7.2 years on average after MG onset. MG exacerbation occurred in 7 patients (26 percent) during pregnancy and in 4 (14.8 percent) during postpartum. One patient died of acute respiratory failure during postpartum. Delay between the onset of MG and pregnancy was the only variable significantly associated with MG exacerbation: 5.8 years when exacerbation and 9.5 years when no exacerbation (p=0.03). Seven miscarriages, two therapeutic abortions and no death at birth were reported. Levels of anti-acetylcholine receptor antibodies were abnormal in 3 of 27 newborns (11 percent), but only one (3.7 percent) developed seronegative transient neonatal myasthenia gravis.

DISCUSSION

During pregnancy, the clinical course of MG is variable but exacerbations were associated with a shorter delay between MG diagnosis and pregnancy. The risk of transient neonatal myasthenia gravis is relatively small but exists even when the parturient has stable MG without elevated levels of anti-acetylcholine receptor antibodies.

CONCLUSION

Our study confirms pregnancy is more difficult to manage at the beginning of MG. Given the unpredictable course of MG during pregnancy, we recommend women affected with MG to begin a pregnancy when the disease is stable.

Cyclophosphamide for lupus during pregnancy

Severe systemic lupus erythematosus often requires the use of cyclophosphamide in women of reproductive age. As cyclophosphamide is generally avoided during pregnancy because of its teratogenic risk, its impact on fetal survival is poorly understood. This is a case series of lupus patients exposed to cyclophosphamide during pregnancy. We reviewed pregnancies in patients with lupus seen at a large university hospital between October 1986 and September 2003. The pregnancies were evaluated prospectively for cyclophosphamide exposure, lupus activity, and fetal outcome. Comparison was made between pregnancies with severe lupus requiring cyclophosphamide and those that did not. We identified four pregnancies with cyclophosphamide exposure. Two pregnancies were inadvertently exposed to cyclophosphamide early in the first trimester; both resulted in first trimester miscarriages. Two patients were administered cyclophosphamide for severe lupus nephritis and thrombocytopenia during the second trimester. Soon after the administration of cyclophosphamide, both pregnancies ended with fetal demise. Pregnancies exposed to cyclophosphamide for severe lupus flare resulted in a higher rate of fetal losses than pregnancies with severe lupus but not requiring the drug (100% versus 31.25%). In conclusion we present four pregnancies exposed to cyclphosphamide, each ending with pregnancy loss. Based on our experience, the survival of the fetus is strongly in doubt when cyclophosphamide is required to treat lupus in the mother.

The consequences for human reproduction of a robust inflammatory response

Innate and adaptive immune responsiveness is variable within the population. Since robust immune reactions are critical to the survival of humans, the existence of immune variability in the population suggests the existence of competing, alternative phenotypes. Although women with powerful immune responsiveness may be more likely to survive to reproduce, their reproductive experiences may be less successful than women who are not as responsive. Normal pregnancy elicits a maternal inflammatory reaction. This can be understood on the basis of maternal-fetal conflict theory: inflammation is a component of the maternal attempt to limit excessive fetal demands. However, an overly aggressive inflammatory reaction has been shown to relate to a variety of adverse reproductive outcomes. Reviewed here are several examples, including the fallopian tube damage that results from pelvic inflammatory disease, the upregulated inflammatory response among women who develop preeclampsia, an association between immune hyperresponsiveness and premature delivery, and the relationship between autoimmune diseases and multiple adverse pregnancy outcomes. The hypothesis that immune hyperresponsiveness limits reproductive capacity suggests many avenues for research.

The effect of pregnancy on lupus nephritis

OBJECTIVE

To evaluate the effect of pregnancy on lupus nephritis with respect to renal activity and renal deterioration.

METHODS

Seventy-eight pregnancies occurred in 53 women with systemic lupus erythematosus (SLE) and renal disease. Seventy-eight nonpregnant SLE patients with evidence of renal disease were matched to the study population by age at the time of each pregnancy and by the presence of a renal manifestation at the beginning of the study. The nonpregnant controls were seen within 2 years of the assessment dates of the pregnant patients with whom they were matched. Renal activity was defined as the presence of active urine sediment or proteinuria, and changes in these parameters were monitored throughout the study period in both study populations. Renal deterioration was defined as an increase in the serum creatinine level that was >20% above the baseline value or an increase to >120 mmoles/liter.

RESULTS

Renal disease activity patterns were available for 74 pairs of pregnancies and controls. Renal disease became active during the study period in 33 pregnancies (44.6%) and 31 controls (41.9%). Serial serum creatinine levels were available for 75 study pairs, among which 62 pregnancies (82.7%) and 57 controls (76.0%) showed no deterioration. Comparison of the treatments received by both the pregnant and the nonpregnant patients showed no significant difference in the amount of steroids taken. A significantly lower amount of immunosuppressive and antimalarial agents were taken during the pregnancies.

CONCLUSION

During pregnancy in patients with SLE and renal disease, changes in renal disease activity and deterioration in renal function are similar to those which occur in nonpregnant patients with lupus nephritis.

Pregnancy outcome after first trimester exposure to corticosteroids: a prospective controlled study

OBJECTIVE

To evaluate the safety of glucocorticosteroids (GCS) in pregnancy.

STUDY DESIGN

The Israeli Teratogen Information Service (TIS) prospectively collected and followed 311 pregnancies counseled regarding systemic use of different GCS in the first trimester. The rate of major congenital anomalies was compared to that of 790 controls who were counseled for non-teratogenic exposure.

RESULTS

The rate of major anomalies did not significantly differ between the groups [12/262 = 4.6% (GCS), 19/728 = 2.6% (control), [P = 0.116 ]. There was no case of oral cleft and no pattern of anomalies among the GCS exposed group. Higher rates of miscarriages (11.5% versus 7.0%, P = 0.013) and preterm births (22.7% versus 10.8%, P < 0.001 ) were observed among the GCS exposed group compared to the controls. GCS exposed infants had a lower median birth weight [3080 g versus 3290 g, P < 0.001 ] and were born at an earlier median gestational age [39 weeks versus 40, P < 0.001 ] compared to the control.

CONCLUSIONS

The present study supports that GCS do not represent a major teratogenic risk in humans. The study was powered to find a 2.5-fold increase in the overall rate of major anomalies.

Using corticosteroids during pregnancy. Are topical, inhaled, or systemic agents associated with risk?

QUESTION

I am concerned about use of corticosteroids during pregnancy. Some of my women patients of reproductive age are using topical, inhaled, or oral preparations, and I am not sure what to advise.

ANSWER

Both topical and systemic corticosteroids are used for a variety of autoimmune and inflammatory conditions. Results of first-trimester studies were inconclusive and underpowered. Recent meta-analyses suggest a small but significant association between use of systemic corticosteroids during the first trimester and oral clefts. This is consistent with results of animal studies. No similar evidence exists for topical or inhaled corticosteroids, probably because of much lower systemic exposure.

[So-called antiphospholipid antibodies and infertility: biological data]

Recurrent early and late foetal losses are common problems found in women with antiphospholipid syndrome, with therapeutic implication and improvement of the prognosis for the next pregnancies with antithrombotic therapy. After these results, some groups propose to extend the antiphospholipid investigations to infertility and failure of in vitro fertilization embryo transfer, but actually without demonstration of a real utility in the management of these women.

Pathogenesis of systemic lupus erythematosus

The exact patho-aetiology of systemic lupus erythematosus (SLE) remains elusive. An extremely complicated and multifactorial interaction among various genetic and environmental factors is probably involved. Multiple genes contribute to disease susceptibility. The interaction of sex, hormonal milieu, and the hypothalamo-pituitary-adrenal axis modifies this susceptibility and the clinical expression of the disease. Defective immune regulatory mechanisms, such as the clearance of apoptotic cells and immune complexes, are important contributors to the development of SLE. The loss of immune tolerance, increased antigenic load, excess T cell help, defective B cell suppression, and the shifting of T helper 1 (Th1) to Th2 immune responses leads to B cell hyperactivity and the production of pathogenic autoantibodies. Finally, certain environmental factors are probably required to trigger the disease.

Current concepts for the management of systemic lupus erythematosus in adults: a therapeutic challenge

Systemic lupus erythematosus (SLE) is a chronic, autoimmune rheumatic disease with many clinical presentations typically affecting women of childbearing age. The successful therapy of SLE depends upon treating both symptoms and the underlying inflammation. Both non-pharmacological as well as pharmacological therapies are invariably required. Non-pharmacological therapy includes avoiding over-exposure to sunlight with the use of adequate sunscreen protection, avoiding "live" vaccination if on immunosuppressive agents, adherence to a diet low in saturated fat and high in fish oil, stress avoidance, and smoking cessation. Pharmacological measures revolve around four main classes of drugs: non-steroidal anti-inflammatory drugs, antimalarials, corticosteroids, and cytotoxic agents. Cyclophosphamide and azathioprine are the two most commonly used cytotoxic agents and these in combination with corticosteroids need to be employed early if there is major organ involvement to prevent or minimise irreversible damage. The potential side effects of corticosteroids and cytotoxic agents need constant consideration. The rapid developments in biotechnology of recent years may soon lead to new and more specific therapies for patients with SLE.

Autoimmune rheumatic diseases in women

OBJECTIVE

To review the presenting symptoms, possible complications, treatment options, and reproductive considerations for rheumatoid arthritis, systemic lupus erythematosus, systemic sclerosis, and Sjogren's syndrome.

DATA SOURCES

Articles retrieved from MEDLINE and OVID using the search terms women and female in combination with autoimmune disease, rheumatoid arthritis, systemic lupus erythematosus, systemic sclerosis, and Sjogren's syndrome. References identified from citations in these articles were also reviewed.

DATA SYNTHESIS

Autoimmune rheumatic diseases are more common in women than in men and are most likely to manifest during the reproductive years. The reasons for this incidence pattern remain unclear but appear to be related to sex hormones and microchimerism. These diseases have varied clinical presentations that may be local or systemic and range from mild to severe. There is no cure for these autoimmune rheumatic diseases; treatments focus on managing symptoms. Many of the agents used for treating these diseases are contraindicated in pregnancy, posing special considerations for women who develop these diseases during their childbearing years.

CONCLUSION

Knowledge of the presenting symptoms of, treatment options for, and reproductive considerations with these diseases is important for pharmacists who counsel women with them.