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Isojima S, Li N, Rowson S, Kandane-Rahtnayake R, Koelmeyer R, Morand EF, Hoi A. Pregnancy outcomes in Australian patients with systemic lupus erythematosus. Intern Med J 2024. [PMID: 39258417 DOI: 10.1111/imj.16524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Accepted: 08/18/2024] [Indexed: 09/12/2024]
Abstract
BACKGROUND Systemic lupus erythematosus (SLE) affects women, with the onset of disease typically around the childbearing years. AIMS This study examines the frequency and risk factors for adverse pregnancy outcomes (APOs) in an Australian cohort, and any disease flares during pregnancy and post partum. METHODS Female patients with SLE enrolled in the Australian Lupus Registry and Biobank (ALRB) between January 2007 and June 2019 were studied. Self-reported pregnancy history, including adverse foetal or maternal outcomes, was collected at the time of enrolment and updated as appropriate. Baseline demographics, clinical parameters, medication exposure and disease activity were collected. Factors associated with APO were examined using univariate and multivariate logistic regression analyses. RESULTS Pregnancy history was available in 278 patients; 30% were nulliparous. Most pregnancies occurred before the diagnosis of SLE. Patients who had pregnancies after SLE diagnosis had an earlier age of diagnosis, and had fewer pregnancies. The APO rate was 44.3% in the overall cohort, with most presenting as prematurity with or without foetal growth restriction. Women with APO were also diagnosed with SLE at a younger age and had a higher prevalence of anti-cardiolipin antibodies and hypocomplementemia. Early age of SLE diagnosis was a significant independent risk factor for APO. No increase in disease flare was observed in those who experienced APO during the observation period of ALRB. CONCLUSION This study shows a considerable incidence of APO in patients with SLE, emphasising the need for pre-pregnancy counselling and collaboration between maternal-foetal medicine specialists and rheumatologists, especially for women diagnosed with SLE at a younger age.
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Affiliation(s)
- Sakiko Isojima
- Department of Medicine, School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
- Division of Rheumatology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Ning Li
- Department of Medicine, School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
| | - Saskia Rowson
- Department of Rheumatology, Austin Health, Melbourne, Victoria, Australia
- Department of Rheumatology, Monash Health, Melbourne, Victoria, Australia
| | - Rangi Kandane-Rahtnayake
- Department of Medicine, School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
| | - Rachel Koelmeyer
- Department of Medicine, School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
| | - Eric F Morand
- Department of Medicine, School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
- Department of Rheumatology, Monash Health, Melbourne, Victoria, Australia
| | - Alberta Hoi
- Department of Medicine, School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
- Department of Rheumatology, Monash Health, Melbourne, Victoria, Australia
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Nossent JC, Inderjeeth C, Keen H. Comparison of pregnancy outcomes between indigenous and non-indigenous lupus patients. Intern Med J 2024; 54:1465-1470. [PMID: 38856175 DOI: 10.1111/imj.16417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 05/08/2024] [Indexed: 06/11/2024]
Abstract
AIM To compare pregnancy outcomes between IA and non IA lupus patients. BACKGROUND Pregnancy in lupus patients confers an increased risk of maternal and fetal morbidity. There are no data on pregnancy outcomes for indigenous Australian (IA) patients with lupus. METHODS Using state-wide longitudinal hospital morbidity data, we studied 702 pregnancies in IA (n = 31) and non-indigenous (NI) patients with lupus (n = 357) in Western Australia and compared rates for live birth (LB), preterm birth (PB) and gestational complications in the period 1985-2015. Results are presented as medians or frequency. RESULTS IA patients had proportionally more pre-existing renal disease (35 vs 13%, P < 0.01) and lower socio-economic status (P = 0.02). Age at first pregnancy was lower in IA patients (27 vs 30 years, P < 0.001), recorded gravidity was similar (2 vs 2, P > 0.6) and elective termination (n = 138) was more frequent in NI than IA pregnancies (21.1 vs 4.8%, P < 0.01). For continued pregnancies (59 in IA and 505 in NI), respective outcomes were as follows: LB 84.7% versus 91.5% (P = 0.15), spontaneous abortion 13.5% versus 6.9% (P = 0.13), (pre-)eclampsia 8% versus 9.9% (P = 0.89), PB 12% versus 13.4% (P = 0.98) and caesarean delivery 30% versus 47.2% (P = 0.02). Gestational diabetes (26% vs 6.1%), renal flares (20% vs 5.6%) and infections (22% vs 6.3%) were all more frequent in IA lupus pregnancies (all P < 0.001). CONCLUSIONS The burden of comorbidities was higher in IA patients with lupus due to renal flares, gestational DM and infections. Although PB rates were overall high, they were, however, similar for IA and NI lupus pregnancies, as were LB rates.
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Affiliation(s)
- Johannes C Nossent
- Medical School, The University of Western Australia, Perth, Western Australia, Australia
- Rheumatology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Charles Inderjeeth
- Medical School, The University of Western Australia, Perth, Western Australia, Australia
- Rheumatology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Helen Keen
- Medical School, The University of Western Australia, Perth, Western Australia, Australia
- Rheumatology, Fiona Stanley Hospital, Perth, Western Australia, Australia
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Ravindran V, Bhadran S, Divakaran M, Reshma VM. Lupus pregnancy outcomes in women with previous adverse outcomes: a prospective cohort study. Clin Rheumatol 2024; 43:2911-2917. [PMID: 39017917 DOI: 10.1007/s10067-024-07069-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2024] [Revised: 07/09/2024] [Accepted: 07/11/2024] [Indexed: 07/18/2024]
Abstract
OBJECTIVES The primary objective of this prospective cohort study was to assess the usefulness of a predefined multidisciplinary care pathway-based management on pregnancy outcome(s) in women with SLE who already had at least one adverse obstetric outcome(s). METHODS Between March 2010 and March 2023, all consecutive, consenting women with SLE who already had at least one previous adverse obstetric outcome (preterm labour, pre-eclampsia, termination of pregnancy, miscarriage, intrauterine growth retardation (IUGR), preterm birth, low birth weight (LBW), intrauterine death (IUD) or stillbirth] were prospectively screened and counselled. The protocol comprised preconception and post-natal drug and disease status review, periodic ante-natal visits for the monitoring of pregnancy and drug and disease status review and post-natal drug and disease status review and contraception advice. Therapeutic changes were made as necessary at each visit. RESULTS A total of 213 women were screened and 197 women (age, 28 ± 6.34 years) were enrolled who had 226 pregnancies. Previous poor obstetric outcomes were miscarriage(s), 186; termination of pregnancy, 4; preterm labour, 51; IUGR, 36; IUD or stillbirth, 16; low birth weight (LBW), 44 and pre-eclampsia, 4. Seventy-seven (39%) women had secondary APS and 37 (19%) had a history of lupus nephritis. There were 194/226 (86%) live births [40 LBW (18%); caesarean section in 101 (45%)]. Thirty pregnancies culminated in miscarriages and 2 in IUDs (14%). Sixty-eight patients (30%) experienced lupus flare during pregnancy (36 mild, 20 moderate and 8 severe). CONCLUSION Our experience underscores the usefulness of a predefined multidisciplinary care pathway-based management for improving pregnancy outcomes in women with SLE who had previous adverse outcomes. Key Points • In women with SLE who had previous adverse obstetric outcome(s) a risk of poor outcome in subsequent pregnancy remains. • Good pregnancy outcomes in these women could be achieved by predefined multidisciplinary care pathways focussed on addressing all relevant issues. • Improved access to rheumatology services and collaboration between rheumatologists and obstetricians is key to improving outcomes in SLE pregnancies.
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Affiliation(s)
- Vinod Ravindran
- Centre for Rheumatology, Calicut, Kerala, India.
- Department of Medicine, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India.
| | - S Bhadran
- Department of Obstetrics, National Hospital, Calicut, Kerala, India
| | - Mini Divakaran
- Department of Obstetrics, PVS Hospital, Calicut, Kerala, India
| | - V M Reshma
- Department of Obstetrics, Indira Gandhi Hospital, Thalassery, Kerala, India
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Huang J, Zhu Q, Wang B, Wang H, Xie Z, Zhu X, Zhao T, Yang Z. Antiphospholipid antibodies and the risk of adverse pregnancy outcomes in patients with systemic lupus erythematosus: a systematic review and meta-analysis. Expert Rev Clin Immunol 2024; 20:793-801. [PMID: 38445835 DOI: 10.1080/1744666x.2024.2324005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 02/12/2024] [Indexed: 03/07/2024]
Abstract
OBJECTIVE This article aims to evaluate the magnitude of adverse pregnancy outcomes (APOs) risks associated with different antiphospholipid antibody (aPL) profiles in women with systemic lupus erythematosus (SLE). METHODS Multiple databases were investigated to identify articles that explored the relationship between aPLs and APOs in SLE patients. A random effects model was used for calculating pooled odds ratios (OR). Stata version 15.0 was utilized to conduct the meta-analysis. RESULTS There were 5234 patients involved in 30 studies. Overall aPL was linked to an increased incidence of any kind of APOs, fetal loss, and preterm birth. Any kind of APOs and preterm delivery were more common in patients with lupus anticoagulant (LA) positive. Anticardiolipin antibody (aCL) was associated with an increased risk of any kind of APOs and fetal loss. The association between aCL-IgM and fetal loss was also significant. Patients with anti-beta2-glycoprotein1 antibody (antiβ2GP1) positivity had an increased risk of fetal loss. CONCLUSIONS Both LA and aCL were risk factors of APOs in patients with SLE. Not only ACL, particularly aCL-IgM, but antiβ2GP1 were associated with an increased risk of fetal loss, while LA appeared to indicate the risk of preterm birth.PROSPERO (CRD42023388122).
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Affiliation(s)
- Jinge Huang
- The First School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, China
| | - Qingmiao Zhu
- School of Basic Medical Sciences, Zhejiang Chinese Medical University, Hangzhou, China
| | - Baizhou Wang
- The First School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, China
| | - Hanzheng Wang
- The First School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, China
| | - Zhijun Xie
- School of Basic Medical Sciences, Zhejiang Chinese Medical University, Hangzhou, China
| | - Xingyu Zhu
- Department of Nephrology, Hangzhou TCM Hospital Affiliated to Zhejiang Chinese Medical University, Hangzhou, China
| | - Ting Zhao
- School of Basic Medical Sciences, Zhejiang Chinese Medical University, Hangzhou, China
| | - Zi Yang
- The Third School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, China
- Teaching Faculty, New Zealand College of Chinese Medicine, Greenlane, New Zealand
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Tsoi A, Nikolopoulos D, Parodis I. Advances in the pharmacological management of systemic lupus erythematosus. Expert Opin Pharmacother 2024; 25:705-716. [PMID: 38756102 DOI: 10.1080/14656566.2024.2354457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2024] [Accepted: 05/08/2024] [Indexed: 05/18/2024]
Abstract
INTRODUCTION Despite setbacks in clinical trials for systemic lupus erythematosus (SLE), three drugs have been approved for SLE and lupus nephritis (LN) treatment in the past decade. Several ongoing clinical trials, some viewed optimistically by the scientific community, underscore the evolving landscape. Emerging clinical data have established specific therapeutic targets in routine clinical practice for treating SLE, aiming to improve long-term outcomes. AREAS COVERED Research related to treatment of SLE and LN is discussed, focusing on randomized clinical trials during the last 5 years and recommendations for the management of SLE published by the European Alliance of Associations for Rheumatology (EULAR), American College of Rheumatology (ACR), Asia Pacific League of Associations for Rheumatology (APLAR), and Pan-American League of Associations of Rheumatology (PANLAR). EXPERT OPINION The landscape of SLE and LN treatments is evolving, as new drugs and combination treatment approaches redefine the traditional concepts of induction and maintenance treatment phases. As the therapeutic armamentarium in SLE continues to expand, the research focus is shifting from the imperative for new therapies to advancing our understanding of optimal treatment selection for individual patients, steering toward precision medicine strategies.
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Affiliation(s)
- Alexander Tsoi
- Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Gastroenterology, Dermatology and Rheumatology, Karolinska University Hospital, Stockholm, Sweden
| | - Dionysis Nikolopoulos
- Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Gastroenterology, Dermatology and Rheumatology, Karolinska University Hospital, Stockholm, Sweden
| | - Ioannis Parodis
- Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Gastroenterology, Dermatology and Rheumatology, Karolinska University Hospital, Stockholm, Sweden
- Department of Rheumatology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
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Isojima S, Yajima N, Yanai R, Miura Y, Fukuma S, Kaneko K, Fujio K, Oku K, Matsushita M, Miyamae T, Wada T, Tanaka Y, Kaneko Y, Nakajima A, Murashima A. Physician approval for pregnancy in patients with systemic lupus erythematosus showing only serological activity: A vignette survey study. Mod Rheumatol 2024; 34:509-514. [PMID: 37243689 DOI: 10.1093/mr/road049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 03/03/2023] [Accepted: 05/24/2023] [Indexed: 05/29/2023]
Abstract
OBJECTIVE The European League Against Rheumatism recommends that the disease activity of systemic lupus erythematosus should be stable before pregnancy because complications and disease flares increase if pregnancy occurs while disease activity is high. However, some patients have ongoing serological activity even after treatment. Herein, we investigated how physicians decide on the acceptability of pregnancy in patients showing only serological activity. METHODS A questionnaire was administered from December 2020 to January 2021. It included the characteristics of physicians, facilities, and the allowance for pregnancies of patients using vignette scenarios. RESULTS The questionnaire was distributed to 4946 physicians, and 9.4% responded. The median age of respondents was 46 years, and 85% were rheumatologists. Pregnancy allowance was significantly affected by the duration of the stable period and status of serological activity [duration: proportion difference 11.8 percentage points (p.p.), P < .001; mild activity: proportion difference -25.8 p.p., P < .001; high activity: proportion difference -65.6 p.p., P < .001]. For patients with high-level serological activity, 20.5% of physicians allowed pregnancy if there were no clinical symptoms for 6 months. CONCLUSIONS Serological activity had a significant effect on the acceptability of pregnancy. However, some physicians allowed patients with serological activity alone to become pregnant. Further observational studies are required to clarify such prognoses.
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Affiliation(s)
- Sakiko Isojima
- Division of Rheumatology, Department of Internal Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Nobuyuki Yajima
- Division of Rheumatology, Department of Internal Medicine, Showa University School of Medicine, Tokyo, Japan
- Department of Healthcare Epidemiology, Kyoto University Graduate School of Medicine and Public Health, Kyoto, Japan
- Center for Innovative Research for Communities and Clinical Excellence, Fukushima Medical University, Fukushima, Japan
| | - Ryo Yanai
- Division of Rheumatology, Department of Internal Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Yoko Miura
- Division of Rheumatology, Department of Internal Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Shingo Fukuma
- Human Health Sciences, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Kayoko Kaneko
- Division of Maternal Medicine, Center of Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Keishi Fujio
- Department of Allergy and Rheumatology, Graduate School of Medicine and Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kenji Oku
- Department of Rheumatology and Infectious Diseases, Kitasato University School of Medicine, Kanagawa, Japan
| | - Masakazu Matsushita
- Department of Internal Medicine and Rheumatology, Juntendo University School of Medicine, Tokyo, Japan
| | - Takako Miyamae
- Department of Pediatric Rheumatology, Institute of Rheumatology, Tokyo Women's Medical University Hospital, Tokyo, Japan
- Division of Rheumatology, Department of Internal Medicine, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Takashi Wada
- Department of Nephrology and Laboratory Medicine, Kanazawa University, Ishikawa, Japan
| | - Yoshiya Tanaka
- The First Department of Internal Medicine, University of Occupational and Environmental Health, Fukuoka, Japan
| | - Yuko Kaneko
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Ayako Nakajima
- Center for Rheumatic Diseases, Mie University Hospital, Tsu, Japan
| | - Atsuko Murashima
- Division of Maternal Medicine, Center of Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
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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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Al Rayes H, AlOudah N, Alsolaimani R, Alharthi A, Attar M, Daghasi H, Albeity A, Afifi AM, AlQahtani A, Alkaff A, Alkhamesi SM, Elnady B. Adverse Impact of Systemic Lupus Erythematosus on Pregnancy Outcomes: A Saudi Arabia Retrospective Multi-Center Study. Open Access Rheumatol 2024; 16:31-41. [PMID: 38322608 PMCID: PMC10844007 DOI: 10.2147/oarrr.s448186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Accepted: 01/26/2024] [Indexed: 02/08/2024] Open
Abstract
Objective The current study aimed to determine the pregnancy outcomes complications in patients with SLE and its association with clinical, laboratory variables, disease activity, and medication use in the Saudi population, as well as pregnancy effect on disease activity. Methods A multicenter study included pregnant female patients with Systemic Lupus Erythematosus (SLE) from three tertiary centers in Saudi Arabia. The demographics, clinical, and laboratory variables, SLE disease activity index (SLEDAI), medication before, during, and after pregnancy, planned pregnancy, pregnancy-related outcomes, and complications in comparison to age-matched healthy female controls were noted. Results A total of 66 pregnant patients with SLE and 93 healthy age-matched pregnant controls were included in the study. A total of 77.3% had SLEDAI-2K ≤ 4 before conception, and 84.85% of pregnancies were planned. Age of conception, cesarean section, miscarriage, and low birth weight were statistically significant (p <0.05) higher in SLE patients than in healthy controls. Among all clinical and laboratory variables, SLEDAI-2K > 4 and active lupus nephritis during pregnancy were statistically associated with adverse outcomes (p <0.05), history of lupus nephritis was not associated with statistically adverse pregnancy outcomes. Higher SLEDAI-2K > 4 was an independent risk at least 4.87 times higher association with adverse pregnancy outcomes. (p <0.05). Conclusion SLE is intricately connected with unfavorable pregnancy outcomes. The preconception of high disease activity stands as a pivotal risk factor for adverse outcomes. Despite the disease remission and meticulous planning, SLE patients frequently grapple with disease exacerbations during pregnancy, culminating in unexpected and unfavorable pregnancy-related outcomes. This underscores the intricate and multifaceted nature of managing SLE during gestation.
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Affiliation(s)
- Hanan Al Rayes
- Department of Rheumatology, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Norah AlOudah
- Department of Rheumatology, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Roaa Alsolaimani
- Department of Medicine, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
- Department of Medicine, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | | | - Mohammed Attar
- Department of Rheumatology, Al Hada Armed Forces Hospital, Taif, Saudi Arabia
| | - Hassan Daghasi
- Department of Rheumatology, Al Hada Armed Forces Hospital, Taif, Saudi Arabia
| | - Abdurahman Albeity
- Department of Medicine, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
| | - Afnan M Afifi
- Department of Medicine, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
| | - Abdulelah AlQahtani
- Department of Rheumatology, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Alya Alkaff
- Obstetrics and Gynecology Department, King Faisal Specialist Hospital, and Research Center, Jeddah, Saudi Arabia
| | - Sultan M Alkhamesi
- Department of Medicine, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Basant Elnady
- Department of Rheumatology, Al Hada Armed Forces Hospital, Taif, Saudi Arabia
- Rheumatology and Rehabilitation Department, Faculty of Medicine, Benha University, Benha, Egypt
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Keum H, Bermas B, Patel S, Jacobe HT, Chong BF. Patients with autoimmune skin diseases are at increased risk of adverse pregnancy outcomes. Am J Obstet Gynecol MFM 2024; 6:101226. [PMID: 37972926 DOI: 10.1016/j.ajogmf.2023.101226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 11/06/2023] [Accepted: 11/10/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND Increased rates of adverse pregnancy outcomes have been reported in association with rheumatologic diseases such as systemic lupus erythematosus, rheumatoid arthritis, dermatomyositis. However, little is known about pregnancy outcomes in patients with autoimmune skin diseases. OBJECTIVE This study aimed to determine the frequency of adverse pregnancy outcomes in patients with autoimmune skin diseases. We hypothesized that similar to rheumatic diseases, the rate of adverse pregnancy outcomes in patients with autoimmune skin diseases would be higher than the general population. STUDY DESIGN This is a case control study using the TriNetX US Collaborative Network, which is a database of electronic medical records of >95 million patients seen at 57 healthcare organizations in the United States. All pregnant women between the ages of 15 and 44 years who were seen at a healthcare organization between January 1, 2016 and December 31, 2021 were included. Participants with autoimmune skin disease were matched to healthy controls and controls with systemic rheumatologic conditions (systemic lupus erythematosus or rheumatoid arthritis). For both the autoimmune skin disease and healthy control groups, those with systemic rheumatologic condition or hidradenitis suppurativa were excluded. The primary outcomes were adverse pregnancy outcomes defined as spontaneous abortion, gestational hypertension, preeclampsia or eclampsia, gestational diabetes mellitus, intrauterine growth restriction, preterm premature rupture of membranes, preterm birth, and stillbirth. Patients with autoimmune skin diseases and controls were 1:1 propensity score-matched by age, race, ethnicity, comorbidities, obesity, and substance use. For each outcome, odds ratio with a 95% confidence interval was calculated. RESULTS A total of 2788 patients with autoimmune skin diseases were matched to 2788 healthy controls. Patients with autoimmune skin diseases were at a higher risk of spontaneous abortions than controls (odds ratio, 1.54; 95% confidence interval, 1.36-1.75; P<.001). Compared with patients with systemic lupus erythematosus, patients with autoimmune skin diseases were at lower risk of having infants with intrauterine growth restriction (odds ratio, 0.59; 95% confidence interval, 0.4-0.87; P=.01), preterm birth (odds ratio, 0.68; 95% confidence interval, 0.47-0.98; P=.04), and stillbirth (odds ratio, 0.50; 95% confidence interval, 0.25-0.97; P=.04). The differences in adverse pregnancy outcomes between patients with autoimmune skin diseases and those with rheumatoid arthritis were not statistically significant. CONCLUSION Patients with autoimmune skin diseases are at a higher risk of spontaneous abortions than patients without autoimmune skin diseases. When analyzed by each autoimmune skin disease, patients with cutaneous lupus erythematosus or vitiligo remained at increased risk of spontaneous abortions compared with patients without autoimmune skin diseases. Patients with autoimmune skin diseases have similar risks of adverse pregnancy outcomes as patients with rheumatoid arthritis, but lower risks than patients with systemic lupus erythematosus.
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Affiliation(s)
- Heejo Keum
- Department of Dermatology, The University of Texas Southwestern Medical Center, Dallas, TX (Ms Keum, Drs Jacobe and Chong)
| | - Bonnie Bermas
- Division of Rheumatology, Department of Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, TX (Dr Bermas)
| | - Shivani Patel
- Department of Obstetrics and Gynecology, The University of Texas Southwestern Medical Center, Dallas, TX (Dr Patel)
| | - Heidi T Jacobe
- Department of Dermatology, The University of Texas Southwestern Medical Center, Dallas, TX (Ms Keum, Drs Jacobe and Chong)
| | - Benjamin F Chong
- Department of Dermatology, The University of Texas Southwestern Medical Center, Dallas, TX (Ms Keum, Drs Jacobe and Chong).
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10
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Al-Husban N, Abu-Hassan DW, Saleem RAA, Al-Abdallat L, Alhusban AE, Adwan MH. Therapeutic changes of systemic lupus erythematosus (SLE) patients in pregnancy and feto-maternal outcomes: a retrospective cohort study. J Int Med Res 2024; 52:3000605231225349. [PMID: 38263912 PMCID: PMC10807327 DOI: 10.1177/03000605231225349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 12/20/2023] [Indexed: 01/25/2024] Open
Abstract
OBJECTIVES Patients with systemic lupus erythematosus (SLE) frequently show non-compliance with their medication. We evaluated the compliance of patients with SLE in Jordan with their medication and the relationships with fetal and maternal outcomes. METHODS We performed a retrospective cohort study of patients with SLE who had no co-morbidities or antiphospholipid syndrome; and were taking only prednisolone, hydroxychloroquine, and/or antiplatelet and anticoagulant medication. RESULTS We studied 173 pregnancies. Prednisolone was administered around pregnancy in 50 (28.9%) of these. The compliance with hydroxychloroquine, prednisolone, and anticoagulant and antiplatelet medication was 87.5%, 91.4%, and 97.3%, respectively. Non-compliance with anticoagulant/antiplatelet therapy was significantly associated with pregnancy-related complications. No complications developed in participants who were non-compliant with prednisolone therapy. The mean pre-pregnancy Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) for the pregnancies was 3.7, indicating low disease activity. Pregnancies with high pre-pregnancy SLEDAI scores tended to be more likely to have preterm deliveries, intrauterine growth restriction, and stillbirth. Postpartum relapse tended to be associated with higher pre-pregnancy SLEDAI. CONCLUSIONS In patients with pre-conceptional low SLE activity, changes in therapeutic compliance during pregnancy are not associated with adverse outcomes. In addition, post-partum relapse is not associated with pre-pregnancy SLEDAI score in therapeutically compliant patients.
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Affiliation(s)
- Naser Al-Husban
- Department of Obstetrics and Gynecology, School of Medicine, The University of Jordan, Amman, Jordan
| | - Diala Walid Abu-Hassan
- Department of Physiology and Biochemistry, School of Medicine, The University of Jordan Amman, Jordan
| | | | | | | | - Marwan H Adwan
- Department of Medicine, Division of Rheumatology, The University of Jordan, Amman, Jordan
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11
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Sangah AB, Jabeen S, Hunde MZ, Devi S, Mumtaz H, Shaikh SS. Maternal and fetal outcomes of SLE in pregnancy: a literature review. J OBSTET GYNAECOL 2023; 43:2205513. [PMID: 37154805 DOI: 10.1080/01443615.2023.2205513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
Systemic Lupus Erythematosus (SLE) is an auto-immune disease in which the immune system assaults its tissues. We aimed to analyse the maternal and foetal outcomes during pregnancy in SLE mothers. A literature search was conducted by two investigators to assess SLE's outcomes on maternal and foetal during pregnancies. We searched PubMed/Medline, Embase, and Google scholar to collect evidence from different research studies, draw the conclusion, and report it. In our investigation, we found out that SLE could cause a spectrum of complications during pregnancy, not only for the mother but also for the foetus. It could affect fertility and cause difficult pregnancies for the couple as well which includes certain complications such as: preterm labour and delivery, high blood pressure (preeclampsia), placental insufficiency, miscarriage or stillbirth, whereas in the foetus SLE can cause mortality, preterm birth, and neonatal lupus (a temporary condition in the baby caused by SLE-related antibodies) and structural abnormalities. The literature suggests that SLE could prove fatal for the foetus and induce many complications in the mother. However, this could be avoided if pregnancy is planned right from the start and proper management is provided to the mother during pregnancy and delivery.p.
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Affiliation(s)
- Abdul Basit Sangah
- Liaquat National Hospital and Medical College Karachi, Karachi, Pakistan
| | - Sidra Jabeen
- Liaquat National Hospital and Medical College Karachi, Karachi, Pakistan
| | | | - Sunita Devi
- Liaquat National Hospital and Medical College Karachi, Karachi, Pakistan
| | - Hassan Mumtaz
- Senior Clinical Research Associate, Maroof International Hospital, Public Health Scholar, Health Services Academy, Islamabad, Pakistan
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12
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Crisafulli F, Andreoli L, Zucchi D, Reggia R, Gerardi MC, Lini D, Tani C, Zatti S, Franceschini F, Mosca M, Tincani A. Variations of C3 and C4 Before and During Pregnancy in Systemic Lupus Erythematosus: Association With Disease Flares and Obstetric Outcomes. J Rheumatol 2023; 50:1296-1301. [PMID: 37127323 DOI: 10.3899/jrheum.2022-1135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/08/2023] [Indexed: 05/03/2023]
Abstract
OBJECTIVE To analyze complement level variations in systemic lupus erythematosus (SLE) pregnancies, focusing on disease flares and obstetric complications. METHODS SLE pregnancies prospectively followed by multidisciplinary teams from 1987 to 2018 in 2 Italian rheumatology centers were retrospectively analyzed. As reference, pregnancy-modified ranges of normal levels of C3 and C4 were derived from 175 pregnancies from the general obstetric population (GOP), as previously described by our group. RESULTS Two hundred forty-six pregnancies in 172 patients with SLE were analyzed. Eighty-nine percent were live births. Thirty-five flares were recorded in 30 pregnancies (12.2%) and obstetric complications occurred in 47 pregnancies (19.1%) including 27 pregnancy losses, 11 severely preterm births (2 resulting in perinatal death), and 15 hypertensive disorders. C3 and C4 levels were higher in the GOP than in patients with SLE, at any time point. C3 and C4 levels progressively increased during pregnancy in both GOP and SLE pregnancies without flare and obstetric complications, whereas this physiological increase was not observed in pregnancies with flares or obstetric complications. A significantly higher frequency of low C4 was found in pregnancies with flares (at preconception and in each trimester) and preterm births (at preconception). In multivariate analysis, low C4 at preconception was associated with flares (odds ratio 13.81, 95% CI 3.10-61.43, P < 0.001). CONCLUSION Low C4 at preconception was found to be an independent risk factor for SLE flare during pregnancy. Not only C3 and C4 levels but also their variations should be observed, as their failure to increase can be useful to predict risk of complications and suggest closer monitoring.
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Affiliation(s)
- Francesca Crisafulli
- F. Crisafulli, MD, L. Andreoli, MD, D. Lini, MD, F. Franceschini, MD, A. Tincani, MD, Rheumatology and Clinical Immunology Unit, ASST Spedali Civili, and Department of Clinical and Experimental Sciences, University of Brescia, Brescia;
| | - Laura Andreoli
- F. Crisafulli, MD, L. Andreoli, MD, D. Lini, MD, F. Franceschini, MD, A. Tincani, MD, Rheumatology and Clinical Immunology Unit, ASST Spedali Civili, and Department of Clinical and Experimental Sciences, University of Brescia, Brescia
| | - Dina Zucchi
- D. Zucchi, MD, C. Tani, MD, M. Mosca, MD, Rheumatology Unit, Azienda Ospedaliero Universitaria Pisana, and Department of Clinical and Experimental Medicine, University of Pisa, Pisa
| | - Rossella Reggia
- R. Reggia, MD, Internal Medicine, Casa di Cura San Camillo, Cremona
| | - Maria C Gerardi
- M.C. Gerardi, MD, Rheumatology and Clinical Immunology Unit, ASST Spedali Civili, and Department of Clinical and Experimental Sciences, University of Brescia, Brescia, and Rheumatology Unit, ASST Grande Ospedale Metropolitano Niguarda, Milano
| | - Daniele Lini
- F. Crisafulli, MD, L. Andreoli, MD, D. Lini, MD, F. Franceschini, MD, A. Tincani, MD, Rheumatology and Clinical Immunology Unit, ASST Spedali Civili, and Department of Clinical and Experimental Sciences, University of Brescia, Brescia
| | - Chiara Tani
- D. Zucchi, MD, C. Tani, MD, M. Mosca, MD, Rheumatology Unit, Azienda Ospedaliero Universitaria Pisana, and Department of Clinical and Experimental Medicine, University of Pisa, Pisa
| | - Sonia Zatti
- S. Zatti, MD, Obstetrics and Gynecology Unit, Spedali Civili and University of Brescia, Italy
| | - Franco Franceschini
- F. Crisafulli, MD, L. Andreoli, MD, D. Lini, MD, F. Franceschini, MD, A. Tincani, MD, Rheumatology and Clinical Immunology Unit, ASST Spedali Civili, and Department of Clinical and Experimental Sciences, University of Brescia, Brescia
| | - Marta Mosca
- D. Zucchi, MD, C. Tani, MD, M. Mosca, MD, Rheumatology Unit, Azienda Ospedaliero Universitaria Pisana, and Department of Clinical and Experimental Medicine, University of Pisa, Pisa
| | - Angela Tincani
- F. Crisafulli, MD, L. Andreoli, MD, D. Lini, MD, F. Franceschini, MD, A. Tincani, MD, Rheumatology and Clinical Immunology Unit, ASST Spedali Civili, and Department of Clinical and Experimental Sciences, University of Brescia, Brescia
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13
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Khogali HI, Al-Bluwi GSM, Guy Pedo V, Al Dhanhani AM. Maternal and fetal health outcomes in systemic lupus erythematosus pregnancies in the Emirati population: A comparative study. Lupus 2023; 32:1453-1461. [PMID: 37786253 DOI: 10.1177/09612033231204650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
OBJECTIVES To evaluate adverse pregnancy outcomes in patients with systemic lupus erythematosus (SLE), compare their maternal and fetal outcomes with those of age-matched pregnant women without SLE, and identify factors linked to increased risks of adverse outcomes. METHODS Medical records from Tawam Hospital were reviewed retrospectively to identify patients with SLE and a history of pregnancy. Demographics, clinical variables, and maternal and fetal outcomes were obtained. A one-to-one age-matched healthy control group was randomly selected. The outcomes and odd ratios of women with and without SLE were compared, and factors associated with adverse pregnancy outcomes were examined. RESULTS The outcomes of 78 SLE pregnancies in 39 women were analyzed. Adverse maternal outcomes, such as gestational diabetes mellitus (GDM), occurred in 32% of pregnancies, whereas adverse fetal outcomes, such as low-birth weight and preterm deliveries, occurred in 51% of pregnancies. Pregnant women with SLE had a 5-fold higher risk of GDM, had higher odds of maternal hypertension, and were more likely to deliver through cesarean section than those without SLE. Preterm deliveries and low-birth weight were also more common in SLE pregnancies. Steroid use during pregnancy was significantly associated with an increased risk of GDM development. Lupus nephritis, maternal hypertension, pre-eclampsia, and GDM were linked to preterm deliveries. CONCLUSION Pregnant women with SLE were at a higher risk for adverse maternal and fetal outcomes than age-matched pregnant women without SLE. These findings can guide clinical management and emphasize the need for close monitoring of SLE pregnancies.
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Affiliation(s)
| | - Ghada S M Al-Bluwi
- Internal Medicine Department, College of Medicine & Health Sciences, UAE University, Al Ain, UAE
| | - Virgie Guy Pedo
- Internal Medicine Department, College of Medicine & Health Sciences, UAE University, Al Ain, UAE
| | - Ali M Al Dhanhani
- Internal Medicine Department, College of Medicine & Health Sciences, UAE University, Al Ain, UAE
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14
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Alkhodier AA, Alsaif AS, Alqntash NH, Alanazi RB, Alotaibi G, Alrashid A. Pregnancy and Inflammatory Rheumatological Diseases: A Single-Center Retrospective Cohort Study. Cureus 2023; 15:e47277. [PMID: 38021813 PMCID: PMC10659568 DOI: 10.7759/cureus.47277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/14/2023] [Indexed: 12/01/2023] Open
Abstract
Background Rheumatic diseases pose risks to pregnant women, leading to complications like preterm birth, congenital heart block, and pregnancy loss. These diseases are expected to deteriorate during pregnancy and further in the postpartum period. The impact of these diseases on the pregnancy will add further burden on the patient, fetus, physician, and healthcare system. Advances in diagnosis and treatment have improved outcomes making them similar to that of healthy women, but close follow-up in a multidisciplinary clinic is essential. The objective of this study is to study the outcome of pregnancy in women with rheumatological disease and the behavior of the disease during pregnancy. Methods A retrospective cohort study was conducted in King Abdulaziz Medical City (KAMC) in Riyadh, Saudi Arabia, to compare the outcomes of pregnancy across three rheumatological diseases: Sjogren syndrome (SS), systemic lupus erythematosus (SLE), and rheumatoid arthritis (RA) from 2016 to 2021. A total of 128 pregnancies in 107 women with rheumatological diseases were included in this study. Pregnancy measures and outcomes were investigated by assessing maternal health, fetal health, and pregnancy complications, specifically maternal disease activity, medications to control the disease, infection, preterm birth, birth weight, abortions/stillbirths, mode of delivery, bleeding, preeclampsia, congenital heart block, and neonatal lupus. Results There were 55 patients with RA (63 RA pregnancies), 44 with SLE (54 SLE pregnancies), and eight with primary SS (11 SS pregnancies). In most of the pregnancies (n= 108; 95.58%), the patients were in clinical remission before pregnancy. Lupus nephritis, which was in remission before pregnancy, has been reported in nine (16.67%) out of 54 SLE pregnancies. Vaginal delivery was the most common mode of delivery (n=87; 67.97%). On the other hand, there were 38 cesarean sections (29.69%). Rheumatological disease flares occurred in 10 pregnancies (7.87%). One hundred and twenty-two live births were delivered. Preterm infants were born in 25 pregnancies (20.16%), and 16 (13.22%) of the newborns needed neonatal intensive care unit (NICU) care. Interestingly, congenital heart block (CHB) was found in five (12.2%) neonates out of 41 anti-SS-related antigen A (anti-SSA) positive mothers; one of those five died from heart block. Eleven neonates were delivered with positive serology, and five were diagnosed with neonatal lupus. Conclusion The outcome of pregnancy in patients with rheumatological disease is favorable. A multidisciplinary team approach and close clinical follow-up are the cornerstone for such success. A small dose of prednisolone (5 mg or less) is safe and will not have a negative impact on maternal or fetal health. CHB is a concern for pregnant women with positive anti-SSA.
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Affiliation(s)
- Abeer A Alkhodier
- College of Medicine, King Khalid University Hospital, King Saud University, Riyadh, SAU
| | - Abdurhman S Alsaif
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, SAU
| | - Norah H Alqntash
- Clinical Sciences, Princess Nourah bint Abdulrahman University College of Medicine, Riyadh, SAU
| | - Rakan B Alanazi
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, SAU
| | - Ghaida Alotaibi
- Pathology, King Khalid University Hospital, King Saud University, Riyadh, SAU
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15
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Dar S, Koirala S, Khan A, Bellary MD, Patel AV, Mathew B, Singh R, Baigam N, Razzaq W, Abdin ZU, Khawaja UA. A Comprehensive Literature Review on Managing Systemic Lupus Erythematosus: Addressing Cardiovascular Disease Risk in Females and Its Autoimmune Disease Associations. Cureus 2023; 15:e43725. [PMID: 37727166 PMCID: PMC10505685 DOI: 10.7759/cureus.43725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 08/18/2023] [Indexed: 09/21/2023] Open
Abstract
This review aimed to evaluate the mechanism of premature cardiovascular disease (CVD) in systemic lupus erythematosus (SLE) patients, particularly in the female population, and emphasize the need for early management interventions; explore the association between SLE and two autoimmune diseases, myasthenia gravis (MG) and antiphospholipid antibody syndrome (APS), and their management strategies; and evaluate the effectiveness of pharmacological and non-pharmacological interventions in managing SLE, focusing on premenopausal females, females of childbearing age, and pregnant patients. We conducted a comprehensive literature review to achieve these objectives using various databases, including PubMed, Google Scholar, and Cochrane. The collected data were analyzed and synthesized to provide an evidence-based overview of SLE, its management strategies as an independent disease, and some disease associations. The treatment should be focused on remission, preventing organ damage, and improving the overall quality of life (QOL). Extensive emphasis should also be focused on diagnosing SLE and concurrent underlying secondary diseases timely and managing them appropriately.
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Affiliation(s)
- Saleha Dar
- Department of Adult Medicine, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Sabina Koirala
- Department of Medicine, Gandaki Medical College, Pokhara, NPL
| | - Arooba Khan
- Department of Internal Medicine, Khyber Medical College, Peshawar, PAK
| | | | - Arya V Patel
- Department of Internal Medicine, Smt. Nathiba Hargovandas Lakhmichand (NHL) Municipal Medical College, Ahmedabad, IND
| | - Bejoi Mathew
- Department of Internal Medicine, Sri Devaraj Urs Medical College, Kolar, IND
| | - Rahul Singh
- Department of Medicine, Armed Forces Medical College, Pune, IND
| | - Nahida Baigam
- Department of Medicine, Association of Physicians of Pakistani Descent of North America (APPNA), Westmont, USA
| | - Waleed Razzaq
- Department of Internal Medicine, Services Hospital Lahore, Lahore, PAK
| | - Zain U Abdin
- Department of Medicine, District Head Quarter Hospital, Faisalabad, PAK
| | - Uzzam Ahmed Khawaja
- Department of Pulmonary and Critical Care Medicine, Jinnah Medical and Dental College, Karachi, PAK
- Department of Clinical and Translational Research, Dr. Ferrer BioPharma, South Miami, USA
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16
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Attia DH, Mokbel A, Mohamed MF, Haggag HM. Long-term impact of pregnancy on renal function among Egyptian women with lupus nephritis: A case control study. Lupus 2023:9612033231174410. [PMID: 37161972 DOI: 10.1177/09612033231174410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
Few studies tackled the long-term effect of pregnancy on lupus nephritis (LNs); thus, the study aimed to explore the long-term impact of pregnancy on renal outcomes in Egyptian patients with LN. Group I patients included females who had their first pregnancy after LN onset with ≥5 years elapsing after delivery; group II patients included females who had never got pregnant for ≥7 years after LN onset. Data were retrospectively collected at baseline (T0) and the last visit (Tlast). The study included 43 patients in group I and 39 patients in group II. The comparisons between the two groups regarding the characteristics at Tlast showed no significant difference regarding the serum creatinine, estimated glomerular filtration rate (eGFR), renal component of SLICC/ACR Damage Index (SDI) as well as the rate of renal flares, new-onset chronic kidney disease (CKD), progressed CKD and end-stage renal disease. Multivariate regression analysis revealed that systemic hypertension and renal flares were predictors of new-onset/progressed CKD (p = 0.019, OR [95% CI] = 4 [1.3-13]; and 0.022, 13.8 [1.5-128.8], respectively) while pregnancy was not (p = 0.363). Paired comparisons between T0 and Tlast characteristics within each group revealed significant increment of serum creatinine, renal SDI and CKD prevalence; as well as decrement of eGFR in group I (p = 0.004, <0.001, 0.001 and <0.001, respectively) and group II (p = 0.006, <0.001, 0.004 and 0.002, respectively). In conclusion, pregnancy, per se, does not affect the long-term renal outcome in LN patients; however, it is rather dependent on the existence of baseline renal damage and the development of renal flares.
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Affiliation(s)
- Doaa Hs Attia
- Rheumatology and Rehabilitation Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Abir Mokbel
- Rheumatology and Rehabilitation Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Moataz Fatthy Mohamed
- Internal Medicine and Nephrology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Hisham Mamdouh Haggag
- Obstetrics and Gynecology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
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17
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Hu Z, Gao R, Huang W, Wang H, Qin L. Effect of Hydroxychloroquine on Lupus Activity, Preeclampsia and Intrauterine Growth Restriction in Pregnant Women with Systemic Lupus Erythematosus and/or Antiphospholipid Syndrome: A Systematic Review and Meta-Analysis. J Clin Med 2023; 12:jcm12020485. [PMID: 36675415 PMCID: PMC9866542 DOI: 10.3390/jcm12020485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Revised: 12/31/2022] [Accepted: 01/05/2023] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Hydroxychloroquine (HCQ) has been used in the treatment of systematic lupus erythematosus (SLE) and antiphospholipid syndrome (APS), but its effect on lupus activity during pregnancy, preeclampsia and intrauterine growth restriction (IUGR) remains unclear. METHODS PubMed, Embase and Cochrane databases were searched before 11 September 2022 for randomized clinical trials (RCT) or observational studies involving additional HCQ treatment and pregnant women diagnosed as having SLE and/or APS/positive antiphospholipid antibodies (aPLs). Risks of high lupus activity, preeclampsia and IUGR were explored. RESULTS One RCT and 13 cohort studies were included. A total of 1764 pregnancies were included in the pooled meta-analysis (709 in the HCQ group vs. 1055 in the control group). After the additional use of HCQ, the risk of high lupus activity decreased (RR: 0.74, 95% CI: 0.57-0.97, p = 0.03). For preeclampsia, the total incidence decreased (RR: 0.54, 95% CI: 0.37-0.78, p = 0.001). The subgroup analysis showed statistical significance in the SLE subgroup (RR: 0.51, 95% CI: 0.34-0.78, p = 0.002) but not in the APS/aPLs subgroup (RR: 0.66, 95% CI: 0.29-1.54, p = 0.34). For IUGR, the decrease in incidence was not statistically significant (RR: 0.80, 95% CI: 0.47-1.35, p = 0.46), neither in the SLE subgroup (RR: 0.74, 95% CI: 0.40-1.36, p = 0.33) nor in the APS/aPLs subgroup (RR: 1.26, 95% CI: 0.34-4.61, p = 0.73). CONCLUSION The additional use of HCQ may decrease the risk of high lupus activity during pregnancy and the incidence of preeclampsia for SLE patients, but the results do not support that using HCQ decreases the incidence of preeclampsia for APS/aPLs patients or reduces IUGR risk for SLE and/or APS/aPLs patients.
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Affiliation(s)
- Zhengyan Hu
- The Reproductive Medical Center, Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu 610041, China
- Key Laboratory of Birth Defects and Related of Women and Children of Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu 610041, China
- West China School of Medicine, Sichuan University, Chengdu 610041, China
| | - Rui Gao
- The Reproductive Medical Center, Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu 610041, China
- Key Laboratory of Birth Defects and Related of Women and Children of Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu 610041, China
- West China School of Medicine, Sichuan University, Chengdu 610041, China
| | - Wanrong Huang
- Department of Dermatology, The First Hospital of China Medical University, Shenyang 110001, China
| | - Huiqing Wang
- Key Laboratory of Birth Defects and Related of Women and Children of Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu 610041, China
- Medical Simulation Centre, West China Second University Hospital, Sichuan University, Chengdu 610041, China
- Correspondence: (H.W.); (L.Q.)
| | - Lang Qin
- The Reproductive Medical Center, Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu 610041, China
- Key Laboratory of Birth Defects and Related of Women and Children of Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu 610041, China
- Correspondence: (H.W.); (L.Q.)
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Sieiro Santos C, Moriano Morales C, Álvarez Castro C, González Fernández I, Díez Álvarez E. Factors associated with adverse pregnancy outcomes in patients with systemic lupus erythematosus. Musculoskeletal Care 2022; 20:917-925. [PMID: 35615936 DOI: 10.1002/msc.1658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 05/16/2022] [Accepted: 05/17/2022] [Indexed: 01/01/2023]
Abstract
BACKGROUND Pregnancies in Systemic lupus erythematosus (SLE) are considered high risk and associated with maternal and obstetric complications. OBJECTIVES To determine the most important predictors for each of the main adverse pregnancy outcomes in SLE patients. METHODS Patients with SLE were retrospectively analysed from 1990 to 2020. Maternal and fetal complications in pregnant women with SLE were retrieved. We compared clinical and analytical characteristics of SLE patients with adverse pregnancy outcomes to controls with SLE diagnosis without adverse pregnancy outcomes. Qualitative data were analysed by Chi-square test and Fisher's exact test. Continuous variables were analysed by using Student's t test. Multiple logistic regression was performed to determine the predictive factors for adverse pregnancy outcomes with adjustment of confounding factors. RESULTS 135 multiparous women were included (42% with adverse pregnancy outcomes). A total of 57 pregnancies (42%) were linked to adverse outcomes. The occurrence of abortion was correlated with anti-DNAds (β = 0.71, p = 0.04), renal involvement (β = 0.28, p 0.03), antiphospholipid antibodies (APA) (β = 0.29, p 0.03), erythrocyte sedimentation rate (ESR) elevation (β = 0.81, p = 0.02) and C-reactive protein (CPR) elevation (β = 0.91, p = 0.01). Stillbirth was also correlated with renal involvement (β = 0.26, p = 0.04), APA (β = 0.22, p = 0.03) and ESR elevation (β = 0.53, p = 0.02). Preeclampsia was correlated with direct Coombs positivity (β = 0.42, p = 0.01), serositis (β = 0.31, p = 0.02), ESR elevation (β = 0.52, p = 0.03) and CPR elevation (β = 0.32, p = 0.04). Neonatal Lupus was correlated with anti-RNP (β = 0.16, p = 0.03) and anti-Ro/SSA (β = 0.16, p 0.02). CONCLUSIONS The most unfavourable pregnancy outcome in women with SLE was spontaneous abortion. Renal involvement, anti-DNAds positivity, antiphospholipid antibody positivity, anti-Ro/SSA, elevated ESR and a younger age at disease onset increased the risk of pregnancy complications.
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Affiliation(s)
| | | | | | | | - Elvira Díez Álvarez
- Rheumatology Department, Complejo Asistencial Universitario de León, León, Spain
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19
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Mohammed RHA, Mumtaz H, Sangah AB, Shaikh SS, Nasir N, Jabeen S. Pregnancy in lupus: an updated consensus to guide best practice strategies. EGYPTIAN RHEUMATOLOGY AND REHABILITATION 2022. [DOI: 10.1186/s43166-022-00167-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Abstract
Background
Systemic lupus erythematosus is a multifaceted chronic relapsing autoimmune disease of unknown etiology. The disease has always been a serious diagnosis in women being a multisystem pathology that is classically encountered during the childbearing age posing serious systemic comorbidities with a potential impact on the functional performance, psychosocial status, and survival. In this article, we review critical issues related to the decision to conceive in female with lupus highlighting the impact of the diagnosis and disease activity status on the mother and the fetus, attempting to suggest a consensus to guide safe decision making for pregnancy with SLE.
Main body
The pleomorphic dysregulated immune nature of lupus in the presence of uncontrolled disease carries a higher risk of complicated pregnancy. Therefore, SLE pregnancies should be well planned and are usually encouraged if the disease is inactive (at least 6 months prior to conception) to ensure immune quiescence towards a safer outcome.
Conclusion
With the proper implementation of preconception counseling strategy, choice of the correct timing of conception, close monitoring of SLE flares with tight control, and the appreciation of the value of multidisciplinary management to best practice most young women with SLE can carry on successful pregnancies with favorable outcome.
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Gohr M, Jakobsen IM, Helmig RB, Stengaard-Pedersen K, Laurberg TB, Troldborg A. Improved pregnancy outcomes in systemic lupus erythematosus: A retrospective study of pregnancies from a single centre in Denmark from 2010-2020 compared with the period 1990-2010. Lupus 2022; 31:1202-1210. [PMID: 35676102 DOI: 10.1177/09612033221107538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Over the past decades new international guidelines recommend that pregnant Systemic lupus erythematosus (SLE) patients are monitored closely in a multi-professional team throughout pregnancy. The importance of low disease activity before pregnancy and continued treatment during pregnancy has been established. However, there is still a high risk of adverse pregnancy outcome (APO).The APO in a Danish SLE cohort was evaluated and compared with the results in a previous study cohort from the same centre and referral area. METHODS This retrospective cohort study used the local patient registry to identify pregnancies in SLE patients followed at the Department of Rheumatology, Aarhus University Hospital, Denmark, from January 2010 to October 2020. In total, 66 pregnancies were registered in 41 women. Data were compared with a previous retrospective study (1990-2010) from the same hospital. RESULTS Adverse pregnancy outcome occurred in 65% of pregnancies. Forty-seven pregnancies resulted in a live birth, while 15 ended in miscarriages. Compared to the 1990-2010 cohort, a numerical reduction in preterm deliveries (7.58% vs. 17.9%) and emergent caesarean (6.1% vs. 15.5%) was observed, although not reaching statistical significance (p = .07 in both cases). Further, a higher average birth weight (3045 g vs. 2870 g) as well as a higher number of pregnancies and live births per year were observed. Gestational hypertension was significantly reduced from 23.8% to 13.6% (p = .05). Significantly more patients were treated with prednisolone (66.7% vs 35.7%, p = .0002), hydroxychloroquine (6% vs. 73.4%, p < .0001) and acetylsalicylic acid (39.3% vs. 73.1%, p = .0001) in 2010-2020 compared to the 1990-2010. CONCLUSION We observed significant improvements in the frequency of some APOs in the recent 2010-2020 cohort compared with the previous cohort followed from 1990 to 2010. However, even though a specialized multi-professional team closely follows SLE patients through their pregnancies, pregnancy in SLE still carries a high risk of APO.
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Affiliation(s)
- Mette Gohr
- Department of Rheumatology, 11297Aarhus University Hospital, Aarhus, Denmark
| | - Iris Marie Jakobsen
- Department of Rheumatology, 53141Aalborg University Hospital, Aalborg, Denmark
| | - Rikke Bek Helmig
- Department of Gynecology and Obstetrics, 11297Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, 1006Aarhus University, Aarhus, Denmark
| | | | - Trine Bay Laurberg
- Department of Rheumatology, 11297Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, 1006Aarhus University, Aarhus, Denmark
| | - Anne Troldborg
- Department of Rheumatology, 11297Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, 1006Aarhus University, Aarhus, Denmark.,Department of Biomedicine, 1006Aarhus University, Aarhus, Denmark
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21
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Barnado A, Hubbard J, Green S, Camai A, Wheless L, Osmundson S. Systemic Lupus Erythematosus Delivery Outcomes Are Unchanged Across Three Decades. ACR Open Rheumatol 2022; 4:711-720. [PMID: 35670028 PMCID: PMC9374054 DOI: 10.1002/acr2.11447] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 03/08/2022] [Accepted: 04/13/2022] [Indexed: 12/14/2022] Open
Abstract
Objective Using a large, de‐identified electronic health record database with over 3.2 million patients, we aimed to identify trends of systemic lupus erythematosus (SLE) medication use during pregnancy and birth outcomes from 1989 to 2020. Methods Using a previously validated algorithm for SLE deliveries, we identified 255 pregnancies in patients with SLE and 604 pregnancies in controls with no known autoimmune diseases. We examined demographics, medications, SLE comorbidities, and maternal and fetal outcomes in SLE and control deliveries. Results Compared with control deliveries, SLE deliveries were more likely to be complicated by preterm delivery (odds ratio [OR]: 6.71; 95% confidence interval [CI]: 4.31‐10.55; P < 0.001) and preeclampsia (OR: 3.22; 95% CI: 1.83‐5.66; P < 0.001) after adjusting for age at delivery, race, and parity. In a longitudinal analysis, medication use during SLE pregnancies remained relatively stable, with some increased use of hydroxychloroquine over time but no increase in aspirin use. For SLE deliveries, preterm delivery and preeclampsia rates remained stable. Conclusion We observed rates of preeclampsia and preterm delivery in SLE that were five times higher than the general population and higher compared with other prospective SLE cohorts. Furthermore, we did not observe improved outcomes over time with preeclampsia and preterm delivery. Despite increasing evidence for universal use of hydroxychloroquine and aspirin, we did not observe substantially higher use of these medications over time, particularly for aspirin. Our results demonstrate the continued need to prioritize educational and implementation efforts to improve adverse pregnancy outcomes in SLE.
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Affiliation(s)
- April Barnado
- Vanderbilt University Medical CenterNashvilleTennessee
| | - Janie Hubbard
- Vanderbilt University Medical CenterNashvilleTennessee
| | - Sarah Green
- Vanderbilt University Medical CenterNashvilleTennessee
| | - Alex Camai
- Vanderbilt University Medical CenterNashvilleTennessee
| | - Lee Wheless
- Vanderbilt University Medical CenterNashvilleTennessee
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22
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Moroni G, Calatroni M, Ponticelli C. The Impact of Preeclampsia in Lupus Nephritis. Expert Rev Clin Immunol 2022; 18:1-13. [PMID: 35510378 DOI: 10.1080/1744666x.2022.2074399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 05/03/2022] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Women with systemic lupus erythematosus (SLE), particularly those with lupus nephritis (LN), remain at high risk for adverse pregnancy outcome. Although in the last decades maternal and fetal outcomes have improved dramatically, preeclampsia remains a major cause of maternal and perinatal morbidity and mortality. AREAS COVERED A narrative review of literature was conducted, underlying the importance of pre-conception counseling, and focusing on the correlation between preeclampsia and LN. The clinical characteristics of preeclampsia were described, with emphasis on risk factors in LN and the differential diagnosis between preeclampsia and lupus flares. Additionally, the prevention and treatment of preeclampsia were discussed, as well as the management of short-term and long-term consequences of preeclampsia. We highlight the importance of a pre-pregnancy counseling from a multidisciplinary team to plan pregnancy during inactive SLE and LN. EXPERT OPINION Further studies are needed to evaluate the long-term consequences of pregnancy in LN. Considering that preeclamptic patients can be at high risk for long-term renal failure, we suggest renal checkup for at least 6-12 months after delivery in all patients.
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Affiliation(s)
- Gabriella Moroni
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Nephrology and Dialysis Division, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Marta Calatroni
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Nephrology and Dialysis Division, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Claudio Ponticelli
- Independent Researcher, Past Director Nephrology Policlinico, Milan, Italy
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23
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Dao KH, Bermas BL. Systemic Lupus Erythematosus Management in Pregnancy. Int J Womens Health 2022; 14:199-211. [PMID: 35210867 PMCID: PMC8859727 DOI: 10.2147/ijwh.s282604] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 01/19/2022] [Indexed: 01/08/2023] Open
Abstract
Systemic lupus erythematosus (SLE) affects reproductive aged women. Issues regarding family planning are an important part of SLE patient care. Women with SLE can flare during pregnancy, in particular those who have active disease at conception or prior history of renal disease. These flares can lead to increased adverse pregnancy outcomes including fetal loss, pre-eclampsia, preterm birth and small for gestational aged infants. In addition, women with antiphospholipid antibodies can have thrombosis during pregnancy or higher rates of fetal loss. Women who have anti-Ro/SSA and anti-La/SSB antibodies need special monitoring as their offspring are at risk for congenital complete heart block and neonatal lupus. Ideally, SLE patients should have their disease under good control on medications compatible with pregnancy prior to conception. All patients with SLE should remain on hydroxychloroquine unless contraindicated. We recommend the addition of 81mg/d of aspirin at the end of the first trimester to reduce the risk of pre-eclampsia. The immunosuppressive azathioprine, tacrolimus and cyclosporine are compatible with pregnancy and lactation, mycophenolate mofetil (MMF)/mycophenolic acid are not. Providers should use glucocorticoids at the lowest possible dose. Methotrexate, leflunomide and cyclophosphamide are contraindicated in pregnancy and lactation. SLE patients on the biologics rituximab, belimumab and abatacept can continue these medications until conception and resume during lactation.
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Affiliation(s)
- Kathryn H Dao
- Division of Rheumatic Diseases, UTSouthwestern Medical Center, Dallas, TX, USA
| | - Bonnie L Bermas
- Division of Rheumatic Diseases, UTSouthwestern Medical Center, Dallas, TX, USA
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24
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Chung YY, Rahim MN, Heneghan MA. Autoimmune hepatitis and pregnancy: considerations for the clinician. Expert Rev Clin Immunol 2022; 18:325-333. [PMID: 35179437 DOI: 10.1080/1744666x.2022.2044307] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Autoimmune hepatitis (AIH) is an immune mediated inflammatory disease of the liver which affects females of reproductive age. AIH poses unique challenges in pregnancy and historically was associated with adverse pregnancy outcomes. AREAS COVERED This report aims to review the current evidence for AIH pregnancy outcomes and the use of medical therapies in pregnancy. The disease course of AIH in pregnancy including loss of biochemical response (LOBR) and hepatic decompensation is also reviewed. The importance of preconception counselling and continued monitoring into the post-partum phase are reinforced. EXPERT OPINION The lack of prognostic markers and targeted immunosuppression are some of the areas for future development, as this will aid the move towards individualised risk stratification and personalised care.
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Affiliation(s)
- Y Y Chung
- Institute of Liver Studies, King's College Hospital, London, SE5 9RS, UK
| | - M N Rahim
- Institute of Liver Studies, King's College Hospital, London, SE5 9RS, UK.,School of Transplantation, Immunology and Mucosal Biology, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - M A Heneghan
- Institute of Liver Studies, King's College Hospital, London, SE5 9RS, UK.,School of Transplantation, Immunology and Mucosal Biology, Faculty of Life Sciences and Medicine, King's College London, London, UK
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25
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Dima A, Jurcut C, Chasset F, Felten R, Arnaud L. Hydroxychloroquine in systemic lupus erythematosus: overview of current knowledge. Ther Adv Musculoskelet Dis 2022; 14:1759720X211073001. [PMID: 35186126 PMCID: PMC8848057 DOI: 10.1177/1759720x211073001] [Citation(s) in RCA: 54] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 12/17/2021] [Indexed: 12/22/2022] Open
Abstract
The antimalarial hydroxychloroquine (HCQ) has demonstrated several crucial properties for the treatment of systemic lupus erythematosus (SLE). Herein, we reviewed the main HCQ pharmacologic features, detailed its mechanism of action, and summarized the existing guidelines and recommendations for HCQ use in rheumatology with a systematic literature search for the randomized controlled trials focused on lupus. HCQ has been shown to decrease SLE activity, especially in mild and moderate disease, to prevent disease flare and to lower the long-term glucocorticoid need. The numerous benefits of HCQ are extended to pregnancy and breastfeeding period. Based on cohort studies, antithrombotic and metabolic HCQ’s effects were shown, including lipid-lowering properties, which might contribute to an improved cardiovascular risk. Moreover, early HCQ use in antinuclear antibodies positive individuals might delay the progression to SLE. Finally, HCQ has a significant favorable impact on long-term outcomes such as damage accrual and mortality in SLE. Based on these multiple benefits, HCQ is now the mainstay long-term treatment in SLE, recommended by current guidelines in all patients unless contraindications or side effects. The daily dose associated with the best compromise between efficacy and safety is matter of debate. The concern regarding retinal toxicity rather than proper efficacy data is the one that dictated the daily dosage of ⩽5 mg/kg/day actual body weight currently agreed upon.
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Affiliation(s)
- Alina Dima
- Department of Rheumatology, Colentina Clinical Hospital, Bucharest, Romania
| | - Ciprian Jurcut
- Department of Internal Medicine, Dr. Carol Davila Central Military Emergency University Hospital, Bucharest, Romania
| | - François Chasset
- Department of Dermatology and Allergology, Hôpital Tenon, Paris, France; Faculté de Médecine, Sorbonne Université, Paris, France
| | - Renaud Felten
- National Reference Center for Rare Auto-immune and Systemic Diseases Est Sud-Est (RESO), Strasbourg, France
- Department of Rheumatology, Les Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Laurent Arnaud
- National Reference Center for Rare Auto-immune and Systemic Diseases Est Sud-Est (RESO), Strasbourg, France
- Department of Rheumatology, Les Hôpitaux Universitaires de Strasbourg, Strasbourg, France
- Université de Strasbourg, Inserm UMR-S 1109, Strasbourg, France
- Service de Rhumatologie, Hôpital de Hautepierre, 1, avenue Molière BP 83049, 67098 Strasbourg Cedex, France
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26
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Tarplin S, Hubbard J, Green S, Whitney R, Wheless L, Barnado A. Women with Rheumatoid Arthritis have similar rates of postpartum maternal outcomes compared to women without autoimmune disease. Semin Arthritis Rheum 2022; 53:151975. [PMID: 35152084 PMCID: PMC8960024 DOI: 10.1016/j.semarthrit.2022.151975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 01/07/2022] [Accepted: 01/31/2022] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Limited data exist on the effect of rheumatoid arthritis (RA) on maternal postpartum outcomes. Using a real-world, electronic health record (EHR) cohort, we assessed maternal postpartum outcomes in RA. METHODS In a large, de-identified EHR, we identified possible RA deliveries using ≥1 delivery ICD-9 or ICD-10-CM codes and a validated RA algorithm. RA cases were required to be diagnosed by a rheumatologist on chart review. Maternal postpartum outcomes included rates of blood transfusion, rates of infection up to 6 weeks postpartum defined by a clinician, and length of hospital stay. We also identified deliveries to women without autoimmune diseases. RESULTS We identified 202 deliveries occurring after RA diagnosis and 596 deliveries to controls without autoimmune diseases. Postpartum infection rates were similar among RA patients and controls (8% vs. 4%, p = 0.10), as were red blood cell transfusion rates (2% vs. 2%, p = 1.00). RA case status was not significantly associated with postpartum infection (OR = 2.10, 95% CI 0.88 - 4.98, p = 0.09) but was significantly associated with preterm birth (OR = 2.11, 95% CI 1.38 - 3.23, p = 0.001). Corticosteroid use during pregnancy was common at 41%, while tumor necrosis factor inhibitor use was 13%. After adjusting for age at delivery and race, corticosteroid use at delivery was not associated with postpartum maternal infections but was associated with a significantly lower birthweight in RA cases. CONCLUSION Women with RA have an increased risk of adverse pregnancy outcomes, particularly preterm birth. Our study highlights, however, that maternal postpartum outcomes such as postpartum infection and blood transfusion are not significantly increased in RA patients.
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27
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Javinani A, Radmard F, Razavinia FS, Masoumi M. Preconception Obstetrics and Rheumatology Consultation: A Protective Factor Against Spontaneous Abortion in Women With Autoimmune Rheumatic Disorders. J Clin Rheumatol 2022; 28:e166-e170. [PMID: 33323753 DOI: 10.1097/rhu.0000000000001667] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Autoimmune rheumatic disorders are a group of illnesses that significantly affect pregnancy outcomes. AIM The aim of this study was to evaluate the incidence and risk factors of spontaneous abortion and its association with maternal medical care in women with autoimmune rheumatic diseases. METHODS In this medical record review study, we recruited patients who were referred to our clinic from September 2014 to September 2019. All confirmed pregnancies (based on a positive pregnancy test and sonogram) were included. Binary logistic regression was applied to construct the statistical model. FINDINGS The present study involved 97 women (215 total confirmed pregnancies) who were diagnosed with 7 different autoimmune rheumatic disorders. The rate of spontaneous abortion was 28.8%. In the univariate analysis, the preconception obstetrics and rheumatology consultation were negatively associated with spontaneous abortion (p < 0.001; odds ratio [OR], 0.255; 95% confidence interval [CI], 0.136-0.480; and p < 0.001; OR, 0.042; 95% CI, 0.015-0.122, respectively). Perinatal obstetric care had a significant protective effect (p < 0.001; OR, 0.260; 95% CI, 0.139-0.486). The multivariate analysis showed that the preconception rheumatology consultation (p = 0.003; OR, 0.062; 95% CI, 0.010-0.393) was negatively associated with spontaneous abortions. The presence of active diseases before pregnancy (p = 0.005; OR, 9.978; 95% CI, 2.023-49.223), anti-SSA/Ro (p < 0.001; OR, 22.927; 95% CI, 4.921-106.818), and anticardiolipin IgM (p = 0.004; OR, 298.207; 95% CI, 6.209-14,323.037) were associated with a heightened risk of spontaneous abortion. CONCLUSIONS A collaborative work carried out by maternal-fetal medicine specialists and rheumatologists could remarkably improve pregnancy outcomes.
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Affiliation(s)
- Ali Javinani
- From the Rheumatology Research Center, Tehran University of Medical Sciences, Tehran
| | | | | | - Maryam Masoumi
- Clinical Research Development Center, Shahid Beheshti Hospital, Qom University of Medical Sciences, Qom, Iran
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28
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Angley M, Drews-Botsch C, Lewis TT, Badell M, Lim SS, Howards PP. Adverse Perinatal Outcomes Before and After Diagnosis with Systemic Lupus Erythematosus Among African American Women. Arthritis Care Res (Hoboken) 2021; 74:904-911. [PMID: 34931482 DOI: 10.1002/acr.24848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 12/01/2021] [Accepted: 12/16/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Women with systemic lupus erythematosus (SLE) may experience adverse perinatal outcomes in the years before an SLE diagnosis. Overall, there is limited research on perinatal outcomes among African American women with SLE. METHODS Women with SLE identified from the Georgia Lupus Registry and the Georgians Organized Against Lupus Cohort were linked with birth certificates by the Georgia Department of Public Health. Births were categorized into occurring more than 3 years before SLE diagnosis, 0-3 years before SLE diagnosis, 0-3 years after SLE diagnosis or more than 3 years after SLE diagnosis. Comparison births certificates to African American women in the same geographic area were obtained from the National Center for Health Statistics. We used log-risk models to compare the risk of preterm birth or small-for-gestational age among SLE births in each diagnosis timing category to the general population, adjusting for maternal age and education and parity. RESULTS Births to women with SLE were more likely to occur preterm 0-3 years before SLE diagnosis (risk ratio [RR]: 1.71, 95% confidence interval [CI]: 1.24, 2.35), 0-3 years after SLE diagnosis (RR: 2.29, 95% CI: 1.70, 3.09) and 3 or more years after diagnosis (RR: 2.83, 95% CI: 2.36, 3.38), but not 3 or more years before SLE diagnosis compared to the general population (RR: 1.03, 95% CI: 0.77, 1.38). Similar results were observed for small-for-gestational age births. CONCLUSION Our analysis, conducted among African American women, demonstrates an increased risk of adverse perinatal outcomes even before a clinical diagnosis of SLE.
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Affiliation(s)
- Meghan Angley
- Department of Epidemiology, Rollins School of Public Health, Emory University
| | | | - Tené T Lewis
- Department of Epidemiology, Rollins School of Public Health, Emory University
| | - Martina Badell
- Division of Maternal-Fetal Medicine, Department of Gynecology and Obstetrics, Emory University School of Medicine
| | - S Sam Lim
- Department of Epidemiology, Rollins School of Public Health, Emory University.,Department of Medicine, Division of Rheumatology, Emory University School of Medicine
| | - Penelope P Howards
- Department of Epidemiology, Rollins School of Public Health, Emory University
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29
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Lu Q, Long H, Chow S, Hidayat S, Danarti R, Listiawan Y, Deng D, Guo Q, Fang H, Tao J, Zhao M, Xiang L, Che N, Li F, Zhao H, Lau CS, Ip FC, Ho KM, Paliza AC, Vicheth C, Godse K, Cho S, Seow CS, Miyachi Y, Khang TH, Ungpakorn R, Galadari H, Shah R, Yang K, Zhou Y, Selmi C, Sawalha AH, Zhang X, Chen Y, Lin CS. Guideline for the diagnosis, treatment and long-term management of cutaneous lupus erythematosus. J Autoimmun 2021; 123:102707. [PMID: 34364171 DOI: 10.1016/j.jaut.2021.102707] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 07/13/2021] [Indexed: 12/20/2022]
Abstract
Cutaneous lupus erythematosus (CLE) is an inflammatory, autoimmune disease encompassing a broad spectrum of subtypes including acute, subacute, chronic and intermittent CLE. Among these, chronic CLE can be further classified into several subclasses of lupus erythematosus (LE) such as discoid LE, verrucous LE, LE profundus, chilblain LE and Blaschko linear LE. To provide all dermatologists and rheumatologists with a practical guideline for the diagnosis, treatment and long-term management of CLE, this evidence- and consensus-based guideline was developed following the checklist established by the international Reporting Items for Practice Guidelines in Healthcare (RIGHT) Working Group and was registered at the International Practice Guideline Registry Platform. With the joint efforts of the Asian Dermatological Association (ADA), the Asian Academy of Dermatology and Venereology (AADV) and the Lupus Erythematosus Research Center of Chinese Society of Dermatology (CSD), a total of 25 dermatologists, 7 rheumatologists, one research scientist on lupus and 2 methodologists, from 16 countries/regions in Asia, America and Europe, participated in the development of this guideline. All recommendations were agreed on by at least 80% of the 32 voting physicians. As a consensus, diagnosis of CLE is mainly based on the evaluation of clinical and histopathological manifestations, with an exclusion of SLE by assessment of systemic involvement. For localized CLE lesions, topical corticosteroids and topical calcineurin inhibitors are first-line treatment. For widespread or severe CLE lesions and (or) cases resistant to topical treatment, systemic treatment including antimalarials and (or) short-term corticosteroids can be added. Notably, antimalarials are the first-line systemic treatment for all types of CLE, and can also be used in pregnant patients and pediatric patients. Second-line choices include thalidomide, retinoids, dapsone and MTX, whereas MMF is third-line treatment. Finally, pulsed-dye laser or surgery can be added as fourth-line treatment for localized, refractory lesions of CCLE in cosmetically unacceptable areas, whereas belimumab may be used as fourth-line treatment for widespread CLE lesions in patients with active SLE, or recurrence of ACLE during tapering of corticosteroids. As for management of the disease, patient education and a long-term follow-up are necessary. Disease activity, damage of skin and other organs, quality of life, comorbidities and possible adverse events are suggested to be assessed in every follow-up visit, when appropriate.
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Affiliation(s)
- Qianjin Lu
- Institute of Dermatology, Chinese Academy of Medical Sciences and Peking Union Medical College, Nanjing, China; Key Laboratory of Basic and Translational Research on Immune-Mediated Skin Diseases, Chinese Academy of Medical Sciences, Nanjing, China.
| | - Hai Long
- Department of Dermatology, The Second Xiangya Hospital, Central South University, Changsha, China.
| | | | - Syarief Hidayat
- League of ASEAN Dermatologic Societies, Kuala Lumpur, Malaysia
| | - Retno Danarti
- Department of Dermatology and Venereology, Gadjah Mada University, Yogyakarta, Indonesia
| | - Yulianto Listiawan
- Department of Dermatology and Venereology, Airlangga University, Surabaya, Indonesia
| | - Danqi Deng
- Department of Dermatology, The Second Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Qing Guo
- Department of Dermatology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Hong Fang
- Department of Dermatology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Juan Tao
- Department of Dermatology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ming Zhao
- Department of Dermatology, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Leihong Xiang
- Department of Dermatology, Huashan Hospital, Fudan University, Shanghai, China
| | - Nan Che
- Department of Rheumatology and Immunology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Fen Li
- Department of Rheumatology and Immunology, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Hongjun Zhao
- Department of Rheumatology and Immunology, Xiangya Hospital, Central South University, Changsha, China
| | - Chak Sing Lau
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, Hong Kong, China
| | - Fong Cheng Ip
- Department of Dermatology, Yung Fung Shee Dermatological Clinic, Hong Kong, China
| | - King Man Ho
- Social Hygiene Service, Department of Health, Hong Kong Government, Hong Kong, China
| | - Arnelfa C Paliza
- Department of Dermatology, Faculty of Medicine and Surgery, University of Santo Tomas, Manila, Philippines
| | - Chan Vicheth
- Department of Dermatology, Khmer Soviet Friendship Hospital, Phnom Penh, Cambodia
| | - Kiran Godse
- D. Y. Patil University School of Medicine, Nerul, Navi Mumbai, India
| | - Soyun Cho
- Department of Dermatology, Seoul National University Boramae Medical Center, Seoul, South Korea
| | | | | | - Tran Hau Khang
- National Hospital of Dermatology, Vietnamese Society of Dermatology and Venereology, Hanoi, Viet Nam
| | - Rataporn Ungpakorn
- Skin and Aesthetic Lasers Clinic, Bumrungrad International Hospital, Bangkok, Thailand
| | - Hassan Galadari
- College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates
| | | | - Kehu Yang
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China; Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province, Lanzhou, China
| | - Youwen Zhou
- Department of Dermatology and Skin Science, University of British Columbia, Vancouver, BC, Canada
| | - Carlo Selmi
- Rheumatology and Clinical Immunology, Humanitas Clinical and Research Center- IRCCS, Rozzano, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Amr H Sawalha
- Divisions of Rheumatology, Departments of Pediatrics and Medicine & Lupus Center of Excellence, University of Pittsburgh, Pittsburgh, PA, USA
| | - Xuan Zhang
- Department of Rheumatology, Beijing Hospital, National Center of Gerontology, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; Clinical Immunology Center, Medical Epigenetics Research Center, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yaolong Chen
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China; Chinese GRADE Center, Lanzhou University, Lanzhou, China.
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30
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Irino K, Arinobu Y, Ayano M, Kawano S, Kimoto Y, Mitoma H, Akahoshi M, Akashi K, Horiuchi T, Niiro H. Predictive factors of fetal and maternal pregnancy outcomes in Japanese patients with systemic lupus erythematosus. Lupus 2021; 30:1637-1643. [PMID: 34266321 DOI: 10.1177/09612033211031989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The number of pregnant and delivery cases in systemic lupus erythematosus (SLE) patients are increasing due to the advances in therapies. However, there are many problems such as the exacerbation of SLE during pregnancy and the risk of fetal complications. We investigated the impact of both pregnancy on lupus and lupus on pregnancy in Japanese patients. METHODS We retrospectively analyzed 64 pregnancies in 39 cases of lupus patients at Kyushu University Hospital, Japan, from October 2002 to July 2018 and then assessed the clinical profiles and maternal and fetal outcomes. RESULTS In terms of the impact of pregnancy on SLE, 29.7% of patients had lupus flare during pregnancy. Multivariate analysis showed that flare rates were significantly higher in patients who discontinued the immunosuppressants when pregnancy was detected or before pregnancy. Pregnancy results were 25.0% for preterm birth, 39.1% for low birth weight infants, and 31.3% for small-for-gestational-age infants. Regarding the effect of SLE on fetal death, the rates of stillbirth were significantly higher in cases whose C3 value at 12 weeks of gestation was lower than before conception. Preterm birth was associated with disease duration and lupus flare during pregnancy. CONCLUSIONS Discontinuation of immunosuppressive drugs was a predictive factor for lupus flare during pregnancy. Further, the decrease of C3 levels at 12 weeks of gestation from baseline was a predictive factor for fetal loss. It is essential for lupus pregnant patients to prevent flares, even with the use of immunosuppressive medications.
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Affiliation(s)
- Kensuke Irino
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Yojiro Arinobu
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Masahiro Ayano
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Shotaro Kawano
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Yasutaka Kimoto
- Faculty of Medical Sciences Medical Education, Kyushu University, Fukuoka, Japan
| | - Hiroki Mitoma
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Mitsuteru Akahoshi
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Koichi Akashi
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Takahiko Horiuchi
- Department of Internal Medicine, 73912Kyushu University Beppu Hospital, Kyushu University Beppu Hospital, Beppu, Japan
| | - Hiroaki Niiro
- Faculty of Medical Sciences Medical Education, Kyushu University, Fukuoka, Japan
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Eisfeld H, Glimm AM, Burmester GR, Ohrndorf S, Backhaus M. Pregnancy outcome in women with different rheumatic diseases: a retrospective analysis. Scand J Rheumatol 2021; 50:299-306. [PMID: 33622159 DOI: 10.1080/03009742.2020.1849788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2020] [Indexed: 10/22/2022]
Abstract
Objective: Pregnancy may influence the course of inflammatory rheumatic diseases and, conversely, rheumatic and musculoskeletal diseases (RMDs) can affect the outcome of pregnancy. This study aimed to retrospectively analyse the outcome of pregnancy and disease in women with RMDs.Method: Subjects were patients with high-risk pregnancy and connective tissue diseases (CTDs) or inflammatory joint diseases (IJDs) managed at a specialized rheumatology outpatient clinic from 2007 to 2014. Data from conception to 6 months postpartum were collected from medical records and a questionnaire, and analysed regarding clinical symptoms, medications, pregnancy complications, birth outcomes, and infant development. Generalized estimating equations were used to compare the groups (CTD vs IJD).Results: The eligible 66 pregnancies in 57 RMD patients were divided into two groups by RMD type: CTD (n = 48) or IJD (n = 18). The live birth rate was 97% overall. Pregnancy complications (excluding two twin pregnancies) were incurred in 39.1%: miscarriage (n = 2), premature delivery (n = 12), small-for-gestational-age infants (n = 5), and/or pregnancy-related diseases (n = 14). Three children born to women with CTDs had affected development (autism spectrum disorder, congenital heart disease, bronchopulmonary dysplasia). CTD infants had a significantly lower mean gestational age (in weeks) (p = 0.042), weight (p = 0.009), and length (p = 0.016) at birth than IJD infants.Conclusion: Although the live birth rate was high, complications occurred in 39.1% of pregnancies in this cohort. Therefore, interdisciplinary management of pregnant women with RMDs at specialized clinics is strongly recommended.
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Affiliation(s)
- H Eisfeld
- Department of Rheumatology and Clinical Immunology, Charité University Hospital, Berlin, Germany
| | - A M Glimm
- Department of Rheumatology and Clinical Immunology, Charité University Hospital, Berlin, Germany
| | - G R Burmester
- Department of Rheumatology and Clinical Immunology, Charité University Hospital, Berlin, Germany
| | - S Ohrndorf
- Department of Rheumatology and Clinical Immunology, Charité University Hospital, Berlin, Germany
| | - M Backhaus
- Department of Rheumatology and Clinical Immunology, Charité University Hospital, Berlin, Germany
- Department of Internal Medicine, Rheumatology and Clinical Immunology, Parkklinik Weißensee, Berlin, Germany
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Palmsten K, Bredesen D, JaKa MM, Kumar PC, Ziegenfuss JY, Kharbanda EO. "I know my body better than you:" patient focus groups to inform a decision aid on oral corticosteroid use during pregnancy. Pharmacoepidemiol Drug Saf 2021; 30:451-461. [PMID: 33314542 PMCID: PMC8686489 DOI: 10.1002/pds.5183] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Accepted: 12/07/2020] [Indexed: 01/03/2023]
Abstract
PURPOSE There is unmet need for decision support regarding medication use during pregnancy. We aimed to inform the development of a decision aid on oral corticosteroid (OCS) use during pregnancy through focus groups. METHODS We invited patients from one health system who had a recent live birth and a condition for which OCSs may be prescribed (ie, asthma or other autoimmune disease) to participate in focus groups. We conducted conventional qualitative content analysis of verbatim transcripts of the focus groups using inductive coding. RESULTS There were 30 participants across five focus groups from May to June 2019. Women endorsed the need for patient-provider discussions about OCS use during pregnancy in which the provider shares risks and benefits and the patient makes her decision. Furthermore, women generally expressed support for patient-centered handouts about OCS use during pregnancy that the provider discusses with the patient. When considering whether to take OCSs in pregnancy, women had concerns about: the medication's impact on their baby (eg, miscarriage, birth defects, long-term effects), themselves (eg, effects on mood, sleep, weight gain), pregnancy complications (eg, preterm birth, increased blood pressure), and lactation. Women wanted information on OCSs (eg, indications, length of treatment, and cost), alternative treatments, and risks of not taking OCSs. CONCLUSIONS We established patient need for a decision aid on OCS use during pregnancy that providers can discuss with patients. To address patient concerns, the aid should at a minimum describe the medication's impact on baby, including long-term effects, maternal health, pregnancy complications, and lactation.
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Rezaieyazdi Z, Mohammadi M, Yousefi Z, Jafari H, Khodashahi M. Outcomes of planned pregnancy in patients with systemic lupus erythematosus and their neonates. THE EGYPTIAN RHEUMATOLOGIST 2021. [DOI: 10.1016/j.ejr.2021.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Hashimoto Y, Michihata N, Yamana H, Shigemi D, Morita K, Matsui H, Yasunaga H, Aihara M. Ophthalmic Corticosteroids in Pregnant Women with Allergic Conjunctivitis and Adverse Neonatal Outcomes: Propensity Score Analyses. Am J Ophthalmol 2020; 220:91-101. [PMID: 32681904 DOI: 10.1016/j.ajo.2020.07.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 06/03/2020] [Accepted: 07/08/2020] [Indexed: 12/23/2022]
Abstract
PURPOSE The risks of topical ophthalmic corticosteroids during pregnancy remain unclear. This study investigated the association between exposure to topical ophthalmic corticosteroids during pregnancy and adverse neonatal outcomes. DESIGN Retrospective, cohort, database study. METHODS Pregnant women with allergic conjunctivitis in the JMDC claims database (JMDC, Tokyo, Japan) between 2005 and 2018 were included. Adverse neonatal outcomes (congenital anomalies [CA], preterm birth [PB], low birthweight [LB], and the composite of these 3 outcomes) were compared between mothers who did and did not receive topical ophthalmic corticosteroids during the first trimester. Controls were women who were not prescribed topical ophthalmic corticosteroids during the first trimester. First, propensity scores were calculated with known confounders, including disorders during pregnancy, other chronic comorbidities, and use of antihistamines. Logistic regression was then conducted with propensity score adjustment. RESULTS A total of 6,847 eligible women were identified of whom 898 (13%) had received topical ophthalmic corticosteroids. CA occurred in 5.5% and 4.9%, respectively; PB in 3.4% and 3.9%, respectively; LB in 5.9% and 7.0%, respectively; and the composite outcome in 11.7% and 11.7% of unexposed and exposed mothers, respectively. Corticosteroid eye drops were not significantly associated with an increase in CA (adjusted odds ratio [aOR], 0.78; 95% confidence interval [CI], 0.54-1.14; P = .20); PB (aOR, 1.23; 95% CI, 0.80-1.88; P = .35); LB (aOR, 1.17; 95% CI, 0.84-1.61; P = .35), or composite outcome (aOR, 0.95; 95% CI, 0.73-1.22; P = .68). CONCLUSIONS The use of topical ophthalmic corticosteroids in pregnant women with allergic conjunctivitis was not associated with any increase in CA, PB, or LB.
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Affiliation(s)
- Yohei Hashimoto
- Department of Ophthalmology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan; Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan.
| | - Nobuaki Michihata
- Department of Health Services Research, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hayato Yamana
- Department of Health Services Research, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Daisuke Shigemi
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Kojiro Morita
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Makoto Aihara
- Department of Ophthalmology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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Holden F, Bramham K, Clark K. Rituximab for the maintenance of minimal change nephropathy - A report of two pregnancies. Obstet Med 2020; 13:145-147. [PMID: 33093868 DOI: 10.1177/1753495x18813739] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 10/28/2018] [Indexed: 01/09/2023] Open
Abstract
Rituximab targets the CD20 antigen expressed on B-lymphocytes and is used to treat recurrent minimal change disease, but experience of its use in pregnancy is limited. We describe a 28-year-old Caucasian female, with recurrent nephrotic syndrome secondary to minimal change disease. She had failed to respond to non-teratogenic alternative therapies. The patient was successfully maintained in remission with rituximab during two consecutive pregnancies. Rituximab (1 g) was administered at 14+6 weeks 14 weeks and 6 days during Pregnancy 1 and 500 mg administered at 23+4 weeks 23 weeks and 4 days of Pregnancy 2. Rituximab had no apparent effect on infant B-cell development in either pregnancy, as neonatal lymphocyte titres were within normal range. There were no maternal complications in either pregnancy. Neither infant encountered infection-related complications. Although rituximab administration during pregnancy appeared safe, evidence of placental transfer is reported with neonatal B-cell depletion, thus alternatives with known safety profiles in pregnancy should be considered before rituximab administration.
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Affiliation(s)
- Francesca Holden
- Department of Nephrology and Obstetrics, King's College Hospital NHS Foundation Trust, London, UK
| | - Kate Bramham
- Department of Nephrology and Obstetrics, King's College Hospital NHS Foundation Trust, London, UK
| | - Katherine Clark
- Department of Nephrology and Obstetrics, King's College Hospital NHS Foundation Trust, London, UK
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Clinical features of new-onset systemic lupus erythematosus during pregnancy in Central China: a retrospective study of 68 pregnancies. Clin Rheumatol 2020; 40:2121-2131. [PMID: 33064224 DOI: 10.1007/s10067-020-05452-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 09/30/2020] [Accepted: 10/06/2020] [Indexed: 01/01/2023]
Abstract
The aim of this study is to explore the clinical features and pregnancy outcomes of Chinese patients with new-onset systemic lupus erythematosus (SLE) during pregnancy or puerperium. We retrospectively evaluated the data of all pregnant women with SLE managed at the First Affiliated Hospital of Zhengzhou University between April 2013 and March 2017. Clinical characteristics, laboratory features, medication use, and pregnancy outcomes were compared between pregnant women with new-onset SLE and pregnant women with pre-existing SLE. Risk factors for adverse pregnancy outcomes were determined using binary regression analyses. Overall, 223 pregnancies in 216 patients were included; 148 (69.6%) patients had a history of SLE, and 68 (30.4%) were diagnosed with SLE during pregnancy or puerperium. Most cases of new-onset SLE (72.1%) occurred during the first and second trimesters. Thrombocytopaenia (especially severe thrombocytopaenia) (76.5% vs 54.2%, P = 0.008; 39.7% vs 15.5%, P = 0.001) and anaemia (especially moderate anaemia) (73.5% vs 56.9%, P = 0.007; 52.9% vs 35.2%, P = 0.035) were more common in women with new-onset SLE than in women with pre-existing SLE and active disease during pregnancy. Additionally, patients with new-onset SLE experienced higher rates of moderate-to-severe disease activity than patients with pre-existing SLE (P < 0.01); disease activity occurred mostly during the first and second trimesters (75.4%). Compared with pre-existing SLE patients, disease activity in new-onset SLE patients occurred mostly in the first trimester (33.3% vs 15.3%, P = 0.043) and less in the third trimester (21.1% vs 47.2%, P < 0.001). Pregnancy loss was significantly higher in patients with new-onset SLE than in patients with pre-existing SLE (62.4% vs 27.1%, P < 0.001), with most cases occurring during the first and second trimesters (95.3%). However, there were no significant differences in neonatal outcomes between new-onset and pre-existing SLE patients with active disease. Within the new-onset SLE group, active disease was an independent risk factor for pregnancy loss (odds ratio [OR] = 16.185, confidence interval [CI] = 1.895-138.232, P = 0.011), whereas disease onset at late gestation was a protective factor against pregnancy loss (OR = 0.589, CI = 0.435-0.796, P = 0.013). Patients with new-onset SLE suffered greater haematological involvement (mainly thrombocytopaenia and anaemia) and higher rates of moderate-to-severe disease activity and pregnancy loss than patients with pre-existing SLE. Controlling disease activity and extending gestational age may improve pregnancy outcomes in women with new-onset SLE. Key Points • The clinical features of new-onset SLE during pregnancy and its impact on pregnancy outcomes have rarely been reported, especially in Chinese patients. • New-onset SLE during pregnancy in Chinese women occurred primarily during the first and second trimesters and was characterised by haematological disorders, including thrombocytopaenia and anaemia. • Women with new-onset SLE during pregnancy had significantly higher disease activity scores and pregnancy loss rates than women with pre-existing SLE, especially during the first and second trimesters; controlling disease activity and prolonging gestational age may improve pregnancy outcomes in this setting.
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Chighizola CB, Lonati PA, Trespidi L, Meroni PL, Tedesco F. The Complement System in the Pathophysiology of Pregnancy and in Systemic Autoimmune Rheumatic Diseases During Pregnancy. Front Immunol 2020; 11:2084. [PMID: 32973817 PMCID: PMC7481445 DOI: 10.3389/fimmu.2020.02084] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 07/30/2020] [Indexed: 12/16/2022] Open
Abstract
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.
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Affiliation(s)
- Cecilia Beatrice Chighizola
- Experimental Laboratory of Immunological and Rheumatologic Researches, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Paola Adele Lonati
- Experimental Laboratory of Immunological and Rheumatologic Researches, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Laura Trespidi
- Department of Obstetrics and Gynaecology, Fondazione Cà Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Pier Luigi Meroni
- Experimental Laboratory of Immunological and Rheumatologic Researches, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Francesco Tedesco
- Experimental Laboratory of Immunological and Rheumatologic Researches, Istituto Auxologico Italiano, IRCCS, Milan, Italy
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Palmsten K, Bandoli G, Vazquez-Benitez G, Xi M, Johnson DL, Xu R, Chambers CD. Oral corticosteroid use during pregnancy and risk of preterm birth. Rheumatology (Oxford) 2020; 59:1262-1271. [PMID: 31566229 DOI: 10.1093/rheumatology/kez405] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 07/30/2019] [Indexed: 01/23/2023] Open
Abstract
OBJECTIVE To evaluate the associations between oral corticosteroid (OCS) dose early and late in pregnancy and preterm birth (PTB) among women with RA. METHODS Pregnant women in the MotherToBaby Pregnancy Studies (2003-2014) with RA (n = 528) were included in the primary analysis. Information was collected by phone interview and from medical records. We estimated risk ratios (RR) for OCS dose trajectories and other disease-related medications before gestational day 140 and hazard ratios (HR) for time-varying exposures after gestational day 139. RESULTS PTB risk was 15.5% overall. Compared with no OCS, PTB risk was increased in high (adjusted (a)RR: 4.77 (95% CI: 2.76, 8.26)) and medium (aRR: 1.81 (95% CI: 1.10, 2.97)) cumulative OCS dose trajectories during the first 139 gestational days. The low cumulative trajectory group was associated with an increased risk of PTB that was not statistically significant (aRR: 1.38 (95% CI: 0.79, 2.38)), and DMARDs were not associated with PTB (biologic DMARDs aHR: 1.08 (95% CI: 0.70, 1.66); non-biologic DMARDs aHR: 0.87 (95% CI: 0.55, 1.38)). OCS exposure to ⩾10 mg of prednisone equivalent daily dose after gestational day 139 vs none was associated with increased PTB rate (aHR: 2.45 (95% CI: 1.32, 4.56)), whereas <10 mg was associated with a modestly increased rate of PTB that was not statistically significant (aHR: 1.18 (95% CI: 0.60, 2.30)). CONCLUSION Higher OCS doses vs no OCS use, both earlier and later in pregnancy, were associated with an increase in PTB among women with RA.
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Affiliation(s)
- Kristin Palmsten
- HealthPartners Institute, Minneapolis, MN.,Department of Pediatrics, University of California, CA, USA
| | - Gretchen Bandoli
- Department of Pediatrics, University of California, CA, USA.,Department of Family Medicine and Public Health, University of California, CA, USA
| | | | - Min Xi
- HealthPartners Institute, Minneapolis, MN
| | | | - Ronghui Xu
- Department of Family Medicine and Public Health, University of California, CA, USA.,Department of Mathematics, University of California, CA, USA
| | - Christina D Chambers
- Department of Pediatrics, University of California, CA, USA.,Department of Family Medicine and Public Health, University of California, CA, USA
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Palmsten K, Bandoli G, Watkins J, Vazquez-Benitez G, Gilmer TP, Chambers CD. Oral Corticosteroids and Risk of Preterm Birth in the California Medicaid Program. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 9:375-384.e5. [PMID: 32791247 DOI: 10.1016/j.jaip.2020.07.047] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 07/03/2020] [Accepted: 07/27/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND There is limited information regarding the impact of dose and gestational timing of oral corticosteroid (OCS) use on preterm birth (PTB), especially among women with asthma. OBJECTIVES To evaluate OCS dose and timing on PTB for asthma and, as a comparison, systemic lupus erythematosus (SLE). METHODS We used health care data from California Medicaid enrollees linked to birth certificates (2007-2013), identifying women with asthma (n = 22,084) and SLE (n = 1174). We estimated risk ratios (RR) for OCS cumulative dose trajectories and other disease-related medications before gestational day 140 and hazard ratios (HR) for time-varying exposures after day 139. RESULTS For asthma, PTB risk was 14.0% for no OCS exposure and 14.3%, 16.8%, 20.5%, and 32.7% in low, medium, medium-high, and high cumulative dose trajectory groups, respectively, during the first 139 days. The high-dose group remained associated with PTB after adjustment (adjusted RR [aRR]: 1.46; 95% confidence interval [CI]: 1.00, 2.15). OCS dose after day 139 was not clearly associated with PTB, nor were controller medications. For SLE, PTB risk for no OCS exposure was 24.9%, and it was 39.1% in low- and 61.2% in high-dose trajectory groups. aRR were 1.80 (95% CI: 1.34, 2.40) for high and 1.24 (95% CI: 0.97, 1.58) for low groups. Only prednisone equivalent dose >20 mg/day after day 139 was associated with increased PTB (adjusted HR: 2.54; 95% CI: 1.60, 4.03). CONCLUSIONS For asthma, higher OCS doses early in pregnancy, but not later, were associated with increased PTB. For SLE, higher doses early and later in pregnancy were associated with PTB.
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Affiliation(s)
- Kristin Palmsten
- Research Division, HealthPartners Institute, Minneapolis, Minn; Department of Pediatrics, University of California, San Diego, Calif.
| | - Gretchen Bandoli
- Department of Pediatrics, University of California, San Diego, Calif; Department of Family Medicine and Public Health, University of California, San Diego, Calif
| | - Jim Watkins
- Research and Analytic Studies Division, California Department of Health Services, Sacramento, Calif
| | | | - Todd P Gilmer
- Department of Family Medicine and Public Health, University of California, San Diego, Calif
| | - Christina D Chambers
- Department of Pediatrics, University of California, San Diego, Calif; Department of Family Medicine and Public Health, University of California, San Diego, Calif
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Al-Rifai RH, Ali N, Barigye ET, Al Haddad AHI, Al-Maskari F, Loney T, Ahmed LA. Maternal and birth cohort studies in the Gulf Cooperation Council countries: a systematic review and meta-analysis. Syst Rev 2020; 9:14. [PMID: 31948468 PMCID: PMC6964097 DOI: 10.1186/s13643-020-1277-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Accepted: 01/10/2020] [Indexed: 02/11/2023] Open
Abstract
BACKGROUND We systematically reviewed and chronicled exposures and outcomes measured in the maternal and birth cohort studies in the Gulf Cooperation Council (GCC) countries and quantitatively summarized the weighted effect estimates between maternal obesity and (1) cesarean section (CS) and (2) fetal macrosomia. METHODS We searched MEDLINE-PubMed, Embase, Cochrane Library, Scopus, and Web of Science electronic databases up to 30 June 2019. We considered all maternal and birth cohort studies conducted in the six GCC countries (Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and United Arab Emirates (UAE)). We categorized cohort studies on the basis of the exposure(s) (anthropometric, environmental, medical, maternal/reproductive, perinatal, or socioeconomic) and outcome(s) (maternal or birth) being measured. Adjusted weighted effect estimates, in the form of relative risks, between maternal obesity and CS and fetal macrosomia were generated using a random-effects model. RESULTS Of 3502 citations, 81 published cohort studies were included. One cohort study was in Bahrain, eight in Kuwait, seven in Qatar, six in Oman, 52 in Saudi Arabia, and seven in the UAE. Majority of the exposures studied were maternal/reproductive (65.2%) or medical (39.5%). Birth and maternal outcomes were reported in 82.7% and in 74.1% of the cohort studies, respectively. In Saudi Arabia, babies born to obese women were at a higher risk of macrosomia (adjusted relative risk (aRR), 1.15; 95% confidence interval (CI), 1.10-1.20; I2 = 50%) or cesarean section (aRR, 1.21; 95% CI, 1.15-1.26; I2 = 62.0%). Several cohort studies were only descriptive without reporting the magnitude of the effect estimate between the assessed exposures and outcomes. CONCLUSIONS Cohort studies in the GCC have predominantly focused on reproductive and medical exposures. Obese pregnant women are at an increased risk of undergoing CS delivery or macrosomic births. Longer-term studies that explore a wider range of environmental and biological exposures and outcomes relevant to the GCC region are needed. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42017068910.
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Affiliation(s)
- Rami H. Al-Rifai
- Institute of Public Health, College of Medicine and Health Sciences, United Arab Emirates University, P.O. Box 15551, Al Ain, United Arab Emirates
| | - Nasloon Ali
- Institute of Public Health, College of Medicine and Health Sciences, United Arab Emirates University, P.O. Box 15551, Al Ain, United Arab Emirates
| | - Esther T. Barigye
- Institute of Public Health, College of Medicine and Health Sciences, United Arab Emirates University, P.O. Box 15551, Al Ain, United Arab Emirates
| | - Amal H. I. Al Haddad
- Institute of Public Health, College of Medicine and Health Sciences, United Arab Emirates University, P.O. Box 15551, Al Ain, United Arab Emirates
| | - Fatima Al-Maskari
- Institute of Public Health, College of Medicine and Health Sciences, United Arab Emirates University, P.O. Box 15551, Al Ain, United Arab Emirates
| | - Tom Loney
- College of Medicine, Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, United Arab Emirates
| | - Luai A. Ahmed
- Institute of Public Health, College of Medicine and Health Sciences, United Arab Emirates University, P.O. Box 15551, Al Ain, United Arab Emirates
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Phuti A, Hodkinson B, Tikly M, Schneider M. 'The feeling of not being entitled to something': fertility, pregnancy, and sexuality among women with systemic lupus erythematosus in South Africa. Scand J Rheumatol 2019; 49:214-220. [PMID: 31583923 DOI: 10.1080/03009742.2019.1657492] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Objective: Fertility, pregnancy, and the postpartum period can pose many challenges for patients with systemic lupus erythematosus (SLE) in sub-Saharan Africa. We explored the perceptions and experiences of South African women relating to fertility and pregnancy.Method: In-depth interviews were conducted with 25 consenting women with SLE. We explored their perceptions and experiences on conception, pregnancy, and sexuality. Data were analysed using Nvivo software.Results: Participants had a mean age of 30.9 years (range 22-45 years) and mean disease duration of 4.5 years (range 1-5 years). The majority were black Africans, and the remainder were of mixed racial ancestry. Unemployment, low educational level, and singlehood status were the most predominant sociodemographic features. Most participants had been pregnant and a few reported being sexually inactive. Participants described many negative pregnancy outcomes including lupus flares, miscarriages, premature deliveries, prolonged hospitalization, and unexpected caesarean sections. Conflicting medical advice on conception, together with conflicting personal, cultural, and societal pressures to procreate, resulted in emotional turmoil and pessimism. Participants frequently described intimacy problems, loss of libido, and infidelity by partners leading to sexually transmitted infections. Aesthetic and physical concerns were perceived as the main causes of infidelity. Most participants felt confined to these relationships as they were financially dependent on their partners, which added to their stress.Conclusion: A combination of patient-centred care focusing on safe, effective contraception and medication targeting remission state, constant counselling, consistent information, and a pregnancy managed jointly by an obstetrics and rheumatology team could achieve optimum results.
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Affiliation(s)
- A Phuti
- Rheumatic Disease Unit, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - B Hodkinson
- Rheumatic Disease Unit, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa.,Division of Rheumatology, Department of Medicine, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - M Tikly
- Division of Rheumatology, Department of Medicine, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - M Schneider
- Alan J Flisher Centre for Public Mental Health, University of Cape Town, Cape Town, South Africa
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Ocampo-Ramírez SM, Hoyos-Patiño S, Lambertino-Montaño JR, Gutiérrez-Marín JH, Campo-Campo MN, Sanín-Blair JE, García-Posada RA, Rodríguez-Padilla LM, Velásquez-Franco CJ, Mesa-Navas MA. Caracterización de mujeres embarazadas con lupus eritematoso sistémico y resultados materno-fetales en el noroeste de Colombia. Estudio descriptivo. IATREIA 2019. [DOI: 10.17533/udea.iatreia.25] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Objetivo: evaluar las características epidemiológicas, clínicas y de tratamiento de las mujeres embarazadas con lupus eritematoso sistémico, así como sus resultados obstétricos, en dos centros de referencia en el noroeste de Colombia.Métodos: serie de casos retrospectiva que evaluó las gestantes atendidas en la Unidad de Medicina Materno Fetal y en el servicio de Reumatología entre 2010 y 2015.Resultados: se incluyeron 40 pacientes y 43 embarazos. Edad promedio al diagnóstico: 24 ± 7 años; 22 (55 %) fueron primigestantes. La afectación clínica más frecuente fue articular (n = 32; 80 %). Ocho de 43 embarazos (18,6 %) presentaron actividad lúpica al inicio de éste. La complicación obstétrica más frecuente fue preeclampsia en 11/43 (25,6 %) embarazos. La complicación fetal más común fue el parto prematuro (8/43; 18,6 %). Los anticuerpos anticardiolipinas y anti-DNA fueron positivos en 10/43 (23,3 %) y en 15/38 (39,5 %) embarazos, respectivamente. En 13 gestaciones (31,7 %) hubo recaídas durante el tercer trimestre, y de éstas, en seis casos (46,1 %) fue grave, especialmente nefritis. Al ingreso, en 29/43 (65 %) embarazos se utilizó prednisona y en 32/43 (74,4 %) antimaláricos. En el puerperio dos pacientes presentaron recaída moderada y dos madres tuvieron preeclampsia. No se encontraron muertes maternas y la supervivencia perinatal fue 86 % (37/43 gestaciones).Discusión: en esta cohorte de pacientes con LES y embarazo, la nefritis y los anticuerpos antifosfolípidos estaban presentes en gran parte de las pacientes con complicaciones obstétricas, aunque un bajo porcentaje de pacientes estuvo activa antes de la gestación; las complicaciones maternas y fetales fueron frecuentes.
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43
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Kalok A, Abdul Cader R, Indirayani I, Abdul Karim AK, Shah SA, Mohamed Ismail NA, Omar MH, Shafiee MN. Pregnancy outcomes in systemic lupus erythematosus (SLE) women. Horm Mol Biol Clin Investig 2019; 40:/j/hmbci.ahead-of-print/hmbci-2019-0007/hmbci-2019-0007.xml. [PMID: 31553696 DOI: 10.1515/hmbci-2019-0007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 07/11/2019] [Indexed: 01/02/2023]
Abstract
Background Systemic lupus erythematosus (SLE) is a chronic autoimmune inflammatory condition with multi-organ involvement predominantly affecting young women. There are very limited studies in pregnancy in Asian SLE patients and therefore we embarked on this study to identify pregnancy outcomes of Malaysian women with SLE. Materials and methods We performed a retrospective study of pregnancy outcomes in SLE patients in our institution from January 2007 to December 2014. A total of 71 pregnancies from 44 women were analysed. Results The mean age of our cohort was 30.5 ± 3.9 years. The rate of active disease at conception, antiphospholipid syndrome and lupus nephritis were 22.5%, 32.4% and 57.7% respectively. SLE flare occurred in 33 out of 71 pregnancies whereas 19 pregnancies were complicated with preeclampsia. The livebirth rate for our cohort was 78.9%, whilst preterm delivery was 42.9%. On univariate analysis, active disease and flare in pregnancy were both strongly associated with foetal loss and preterm delivery. Lupus nephritis (p = 0.011), SLE flare (p = 0.008) and antiphospholipid syndrome (p = 0.032) significantly increased the risk of preeclampsia. Aspirin and hydroxychloroquine were protective against foetal loss [odds ratio (OR) 0.12] and preeclampsia (OR 0.25), respectively. On multivariate analysis, active disease was a predictor of SLE flare (p = 0.002) and foetal loss (p = 0.018) and SLE flare was the main predictor of preterm delivery (p = 0.006). Conclusions Pregnancies in women with SLE should be planned and aspirin and HCQ use were beneficial in reducing adverse pregnancy outcomes.
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Affiliation(s)
- Aida Kalok
- Faculty of Medicine, Department of Obstetrics and Gynaecology, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Rizna Abdul Cader
- Department of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Ima Indirayani
- Faculty of Medicine, Department of Obstetrics and Gynecology, Syiah Kuala University, Banda Aceh, Indonesia
| | - Abdul Kadir Abdul Karim
- Faculty of Medicine, Department of Obstetrics and Gynaecology, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Shamsul Azhar Shah
- Faculty of Medicine, Department of Community Health, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Nor Azlin Mohamed Ismail
- Faculty of Medicine, Department of Obstetrics and Gynaecology, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Mohd Hashim Omar
- Faculty of Medicine, Department of Obstetrics and Gynaecology, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Mohamad Nasir Shafiee
- Faculty of Medicine, Department of Obstetrics and Gynaecology, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
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44
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Motaharinezhad M, Torklalebaq F, Moradi M. New-Onset Systemic Lupus Erythematosus in a Pregnant Woman: A Case Report. JOURNAL OF CLINICAL AND BASIC RESEARCH 2019. [DOI: 10.29252/jcbr.3.3.33] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
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45
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Stratifying management of rheumatic disease for pregnancy and breastfeeding. Nat Rev Rheumatol 2019; 15:391-402. [DOI: 10.1038/s41584-019-0240-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/14/2019] [Indexed: 12/16/2022]
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Abstract
Pregnancy presents challenges for women with autoimmune diseases. It is associated with significant physiological, hormonal and immunomodulatory changes which are complex and vary according to the stage of pregnancy Pregnancy planning and counselling should be offered Autoimmune diseases such as rheumatoid arthritis tend to improve in pregnancy while systemic lupus erythematosus may increase in activity During pregnancy the chosen regimen should control or prevent underlying disease activity and minimise risk to the fetus. Ideally, women should be on a stable regimen before conception Poorly controlled disease is associated with poor outcomes for both mother and fetus, such as higher risks of pre-eclampsia, early delivery and growth restriction of the fetus Postpartum, there is a sudden fall in hormone concentrations, and a switch to a pro-inflammatory state. This increases the risk of relapse of many autoimmune diseases in particular rheumatoid arthritis, Crohn’s disease and autoimmune hepatitis Many drugs are compatible with breastfeeding, but there are limited data on many of the new drugs
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Affiliation(s)
- Kathy Paizis
- Mercy Hospital for Women, Western Health Sunshine, Austin Health, Melbourne
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47
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Normand G, Sens F, Puthet J, Jourde-Chiche N, Lemoine S, Chauveau D, Moranne O, Rémy P, Doret M, Daugas E, Juillard L. Not only disease activity but also chronic hypertension and overweight are determinants of pregnancy outcomes in patients with systemic lupus erythematosus. Lupus 2019; 28:529-537. [PMID: 30799679 DOI: 10.1177/0961203319832097] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
INTRODUCTION Pregnancies in women with lupus nephritis are at high-risk of complications, while scarcity of scientific knowledge on prognostic factors impedes a fair medical counseling. We aimed to identify determinants associated with maternal and fetal complications. MATERIALS We retrospectively reviewed medical charts of pregnancies that lasted more than 22 weeks in 66 patients with pre-existing lupus nephritis between 2004 and 2013 in France. Univariate and multivariate analyses were conducted to identify determinants for maternal complications, lupus renal flare and fetal prematurity or death. RESULTS Eighty-four pregnancies were identified. A maternal complication occurred in 31 pregnancies (36.9%): mostly preeclampsia (17 pregnancies, 20.2%) and renal flares (12 pregnancies, 14.3%). Overall fetal survival was 94.0% (79/84). Maternal pregnancy complications were independently associated with prepregnancy body mass index >25 kg/m2 (OR 3.81, 95% CI 1.03-14.09) and immunological activity (positive anti-dsDNA antibodies or Farr assay lupus) (OR 4.95, 95% CI 1.33-18.43). Renal lupus flares were independently associated with maternal age (OR 1.50, 95% CI 1.12-2.01) and prepregnancy immunological activity (OR 15.99, 95% CI 1.57-162.68) while a remission time >12 months had a protective effect (OR 0.17, 95% CI 0.04-0.68). Three parameters were associated with a higher risk of fetal prematurity or death: a prepregnancy body mass index >25 kg/m2 (HR 3.58, 95% CI 1.45-8.83), hypertension (HR 8.97, 95% CI 3.32-24.25), and immunological activity (HR 3.34, 95% CI 1.30-8.63). CONCLUSION Maternal age, prepregnancy hypertension, body mass index >25 kg/m2 and lupus immunological activity may be considered as the main determinants for fetal and maternal complications. A remission time above 12 months for patients with lupus nephritis could be associated with a reduced risk of renal flare during pregnancy.
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Affiliation(s)
- G Normand
- 1 Department of Nephrology, Hypertension and Dialysis, Hospices Civils de Lyon, Lyon, France.,2 University of Lyon 1, Lyon, France
| | - F Sens
- 1 Department of Nephrology, Hypertension and Dialysis, Hospices Civils de Lyon, Lyon, France
| | - J Puthet
- 1 Department of Nephrology, Hypertension and Dialysis, Hospices Civils de Lyon, Lyon, France
| | - N Jourde-Chiche
- 3 Aix-Marseille University, C2VN, INSERM 1263, INRA 1260, Department of Nephrology, AP-HM, Assistance Publique Hopitaux de Marseille, Marseille, France
| | - S Lemoine
- 1 Department of Nephrology, Hypertension and Dialysis, Hospices Civils de Lyon, Lyon, France.,2 University of Lyon 1, Lyon, France
| | - D Chauveau
- 4 Department of Nephrology and Transplantation, Rangueil Hospital, Toulouse, France
| | - O Moranne
- 5 Department of Nephrology-Dialysis-Apheresis, Carémeau Hospital, Nîmes, France
| | - P Rémy
- 6 Department of Nephrology, Henri Mondor Hospital, Créteil, France
| | - M Doret
- 7 Department of Obstetrics, Hospices Civils de Lyon, Lyon, France
| | - E Daugas
- 8 Department of Nephrology, Bichat Hospital, Paris, France
| | - L Juillard
- 1 Department of Nephrology, Hypertension and Dialysis, Hospices Civils de Lyon, Lyon, France.,2 University of Lyon 1, Lyon, France
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Wu J, Zhang WH, Ma J, Bao C, Liu J, Di W. Prediction of fetal loss in Chinese pregnant patients with systemic lupus erythematosus: a retrospective cohort study. BMJ Open 2019; 9:e023849. [PMID: 30755448 PMCID: PMC6377554 DOI: 10.1136/bmjopen-2018-023849] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE To develop a predictive model for fetal loss in women with systemic lupus erythematosus (SLE). DESIGN A retrospective cohort study. SETTING Data were collected in a tertiary medical centre, located in Shanghai, China, from September 2011 to May 2017. PARTICIPANTS 338 pregnancies with SLE were analysed retrospectively. Cases of multiple pregnancy and those in which artificial abortion was performed for personal reasons were excluded. PRIMARY OUTCOME MEASURES Fetal loss was the primary outcome. A stepwise regression to identify the predictors related to the fetal loss and coefficient B of each variable was used to develop a predictive model and make a corresponding risk classification. The Hosmer-Lemeshow test, Omnibus test and area under the receiver-operating characteristic curve (AUC) were used to assess the goodness-of-fit and discrimination of the predictive model. A 10-fold cross validation was used to assess the model for overfitting. RESULTS Unplanned pregnancies (OR 2.84, 95% CI 1.12 to 7.22), C3 hypocomplementemia (OR 5.46, 95% CI 2.30 to 12.97) and 24 hour-urinary protein level (0.3≤protein<1.0 g/24 hours: OR 2.10, 95% CI 0.63 to 6.95; protein≥1.0 g/24 hours: OR 5.89, 95% CI 2.30 to 15.06) were selected by the stepwise regression. The Hosmer-Lemeshow test resulted in p=0.325; the Omnibus test resulted in p<0.001 and the AUC was 0.829 (95% CI 0.744 to 0.91) in the regression model. The corresponding risk score classification was divided into low risk (0-3) and high risk groups (>3), with a sensitivity of 60.5%, a specificity of 93.3%, positive likelihood ratio of 9.03 and negative likelihood ratio of 0.42. CONCLUSIONS A predictive model for fetal loss in women with SLE was developed using the timing of conception, C3 complement and 24 hour-urinary protein level. This model may help clinicians in identifying women with high risk pregnancies, thereby carrying out monitoring or/and interventions for improving fetal outcomes.
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Affiliation(s)
- Jiayue Wu
- Department of Obstetrics and Gynecology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Key Laboratory of Gynecologic Oncology, Shanghai, China
- International Centre for Reproductive Health (ICRH), Ghent University, Gent, Belgium
| | - Wei-Hong Zhang
- International Centre for Reproductive Health (ICRH), Ghent University, Gent, Belgium
- Research Laboratory for Human Reproduction, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Jinghang Ma
- Department of Obstetrics and Gynecology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Key Laboratory of Gynecologic Oncology, Shanghai, China
| | - Chunde Bao
- Department of Rheumatology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Institute of Rheumatology, Shanghai, China
| | - Jinlin Liu
- School of Public Policy and Administration, Xi’an Jiaotong University, Xi’an, China
| | - Wen Di
- Department of Obstetrics and Gynecology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Key Laboratory of Gynecologic Oncology, Shanghai, China
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Teng YKO, Bredewold EOW, Rabelink TJ, Huizinga TWJ, Eikenboom HCJ, Limper M, Fritsch-Stork RDE, Bloemenkamp KWM, Sueters M. An evidence-based approach to pre-pregnancy counselling for patients with systemic lupus erythematosus. Rheumatology (Oxford) 2018; 57:1707-1720. [PMID: 29165607 DOI: 10.1093/rheumatology/kex374] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2016] [Indexed: 12/17/2022] Open
Abstract
Patients with SLE are often young females of childbearing age and a pregnancy wish in this patient group is common. However, SLE patients are at high risk for adverse pregnancy outcomes that require adequate guidance. It is widely acknowledged that pre-pregnancy counselling is the pivotal first step in the management of SLE patients with a wish to become pregnant. Next, management of these patients is usually multidisciplinary and often requires specific expertise from the different physicians involved. Very recently a EULAR recommendation was published emphasizing the need for adequate preconception counselling and risk stratification. Therefore the present review specifically addresses the issue of pre-pregnancy counselling for SLE patients with an evidence-based approach. The review summarizes data retrieved from recently published, high-quality cohort studies that have contributed to a better understanding and estimation of pregnancy-related risks for SLE patients. The present review categorizes risks from a patient-oriented point of view, that is, the influence of pregnancy on SLE, of SLE on pregnancy, of SLE on the foetus/neonate and of SLE-related medication. Lastly, pre-pregnancy counselling of SLE patients with additional secondary APS is reviewed. Collectively these data can guide clinicians to formulate appropriate preventive strategies and patient-tailored monitoring plans during pre-pregnancy counselling of SLE patients.
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Affiliation(s)
- Y K Onno Teng
- Department of Nephrology, Leiden University Medical Center, Leiden, The Netherlands
| | - Edwin O W Bredewold
- Department of Nephrology, Leiden University Medical Center, Leiden, The Netherlands
| | - Ton J Rabelink
- Department of Nephrology, Leiden University Medical Center, Leiden, The Netherlands
| | - Tom W J Huizinga
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - H C Jeroen Eikenboom
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Maarten Limper
- Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Ruth D E Fritsch-Stork
- Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht, Utrecht, The Netherlands.,1st Medical Department & Ludwig Boltzmann Institute of Osteology at the Hanusch Hospital of WGKK and AUVA Trauma Centre Meidling, Hanusch Hospital.,Sigmund Freud University, Vienna, Austria
| | - Kitty W M Bloemenkamp
- Department of Obstetrics, Wilhelmina's Children Hospital, Division Woman and Baby, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marieke Sueters
- Department of Gynaecology and Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
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50
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McDonald EG, Bissonette L, Ensworth S, Dayan N, Clarke AE, Keeling S, Bernatsky S, Vinet E. Monitoring of Systemic Lupus Erythematosus Pregnancies: A Systematic Literature Review. J Rheumatol 2018; 45:1477-1490. [PMID: 30008450 DOI: 10.3899/jrheum.171023] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/25/2018] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Few data exist to guide the frequency and type of monitoring in systemic lupus erythematosus (SLE) pregnancies. A systematic literature review was performed to address this gap in the literature. METHODS A systematic review of original articles (1975-2015) was performed using Medline, Embase, and Cochrane Library. We included search terms for SLE, pregnancy, and monitoring. We also hand-searched reference lists, review articles, and grey literature for additional relevant articles. RESULTS The search yielded a total of 1106 articles. After removing 117 duplicates, 929 articles that were evidently unrelated to our topic based on title and/or abstract, and 7 that were in a language other than English or French, 53 articles were included for full-text review. Following a more in-depth review, 15 were excluded: 6 did not use any measure of SLE activity and 6 did not specifically address SLE monitoring in pregnancy; 1 case series, 1 review, and 1 metaanalysis were removed. Among the 38 included studies, presence of active disease, antiphospholipid (aPL) antibodies positivity, and abnormal uterine and umbilical artery Doppler studies predicted poor pregnancy outcomes. No studies evaluated an evidence-based approach to the frequency of monitoring. CONCLUSION Few existing studies address monitoring for optimal care during SLE pregnancies. The available data imply roles for aPL antibodies measurement (prior to pregnancy and/or during the first trimester), uterine and umbilical artery Doppler studies in the second trimester, and following disease activity. Optimal frequency of monitoring is not addressed in the existing literature.
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Affiliation(s)
- Emily G McDonald
- From the Division of General Internal Medicine, and the Division of Rheumatology, Department of Medicine, McGill University Health Centre, Montréal; Division of Rheumatology, Department of Medicine, University of Sherbrooke, Sherbrooke, Québec; Division of Rheumatology, Mary Pack Arthritis Center, University of British Columbia, Vancouver, British Columbia; Division of Rheumatology, Department of Medicine, University of Alberta, Edmonton; Division of Rheumatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada.,E.G. McDonald, MD, MSc, Division of General Internal Medicine, Department of Medicine, McGill University Health Centre; L. Bissonette, MD, Division of Rheumatology, Department of Medicine, University of Sherbrooke; S. Ensworth, MD, Assistant Professor, Division of Rheumatology, University of British Columbia; N. Dayan, MD, MSc, Division of General Internal Medicine, Department of Medicine, McGill University Health Centre; A.E. Clarke, MD, MSc, Division of Rheumatology, Department of Medicine, University of Calgary; S. Keeling, MD, MSc, Division of Rheumatology, Department of Medicine, University of Alberta; S. Bernatsky, MD, PhD, Division of Rheumatology, Department of Medicine, McGill University Health Centre; E. Vinet, MD, PhD, Division of Rheumatology, Department of Medicine, McGill University Health Centre
| | - Lyne Bissonette
- From the Division of General Internal Medicine, and the Division of Rheumatology, Department of Medicine, McGill University Health Centre, Montréal; Division of Rheumatology, Department of Medicine, University of Sherbrooke, Sherbrooke, Québec; Division of Rheumatology, Mary Pack Arthritis Center, University of British Columbia, Vancouver, British Columbia; Division of Rheumatology, Department of Medicine, University of Alberta, Edmonton; Division of Rheumatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada.,E.G. McDonald, MD, MSc, Division of General Internal Medicine, Department of Medicine, McGill University Health Centre; L. Bissonette, MD, Division of Rheumatology, Department of Medicine, University of Sherbrooke; S. Ensworth, MD, Assistant Professor, Division of Rheumatology, University of British Columbia; N. Dayan, MD, MSc, Division of General Internal Medicine, Department of Medicine, McGill University Health Centre; A.E. Clarke, MD, MSc, Division of Rheumatology, Department of Medicine, University of Calgary; S. Keeling, MD, MSc, Division of Rheumatology, Department of Medicine, University of Alberta; S. Bernatsky, MD, PhD, Division of Rheumatology, Department of Medicine, McGill University Health Centre; E. Vinet, MD, PhD, Division of Rheumatology, Department of Medicine, McGill University Health Centre
| | - Stephanie Ensworth
- From the Division of General Internal Medicine, and the Division of Rheumatology, Department of Medicine, McGill University Health Centre, Montréal; Division of Rheumatology, Department of Medicine, University of Sherbrooke, Sherbrooke, Québec; Division of Rheumatology, Mary Pack Arthritis Center, University of British Columbia, Vancouver, British Columbia; Division of Rheumatology, Department of Medicine, University of Alberta, Edmonton; Division of Rheumatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada.,E.G. McDonald, MD, MSc, Division of General Internal Medicine, Department of Medicine, McGill University Health Centre; L. Bissonette, MD, Division of Rheumatology, Department of Medicine, University of Sherbrooke; S. Ensworth, MD, Assistant Professor, Division of Rheumatology, University of British Columbia; N. Dayan, MD, MSc, Division of General Internal Medicine, Department of Medicine, McGill University Health Centre; A.E. Clarke, MD, MSc, Division of Rheumatology, Department of Medicine, University of Calgary; S. Keeling, MD, MSc, Division of Rheumatology, Department of Medicine, University of Alberta; S. Bernatsky, MD, PhD, Division of Rheumatology, Department of Medicine, McGill University Health Centre; E. Vinet, MD, PhD, Division of Rheumatology, Department of Medicine, McGill University Health Centre
| | - Natalie Dayan
- From the Division of General Internal Medicine, and the Division of Rheumatology, Department of Medicine, McGill University Health Centre, Montréal; Division of Rheumatology, Department of Medicine, University of Sherbrooke, Sherbrooke, Québec; Division of Rheumatology, Mary Pack Arthritis Center, University of British Columbia, Vancouver, British Columbia; Division of Rheumatology, Department of Medicine, University of Alberta, Edmonton; Division of Rheumatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada.,E.G. McDonald, MD, MSc, Division of General Internal Medicine, Department of Medicine, McGill University Health Centre; L. Bissonette, MD, Division of Rheumatology, Department of Medicine, University of Sherbrooke; S. Ensworth, MD, Assistant Professor, Division of Rheumatology, University of British Columbia; N. Dayan, MD, MSc, Division of General Internal Medicine, Department of Medicine, McGill University Health Centre; A.E. Clarke, MD, MSc, Division of Rheumatology, Department of Medicine, University of Calgary; S. Keeling, MD, MSc, Division of Rheumatology, Department of Medicine, University of Alberta; S. Bernatsky, MD, PhD, Division of Rheumatology, Department of Medicine, McGill University Health Centre; E. Vinet, MD, PhD, Division of Rheumatology, Department of Medicine, McGill University Health Centre
| | - Ann E Clarke
- From the Division of General Internal Medicine, and the Division of Rheumatology, Department of Medicine, McGill University Health Centre, Montréal; Division of Rheumatology, Department of Medicine, University of Sherbrooke, Sherbrooke, Québec; Division of Rheumatology, Mary Pack Arthritis Center, University of British Columbia, Vancouver, British Columbia; Division of Rheumatology, Department of Medicine, University of Alberta, Edmonton; Division of Rheumatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada.,E.G. McDonald, MD, MSc, Division of General Internal Medicine, Department of Medicine, McGill University Health Centre; L. Bissonette, MD, Division of Rheumatology, Department of Medicine, University of Sherbrooke; S. Ensworth, MD, Assistant Professor, Division of Rheumatology, University of British Columbia; N. Dayan, MD, MSc, Division of General Internal Medicine, Department of Medicine, McGill University Health Centre; A.E. Clarke, MD, MSc, Division of Rheumatology, Department of Medicine, University of Calgary; S. Keeling, MD, MSc, Division of Rheumatology, Department of Medicine, University of Alberta; S. Bernatsky, MD, PhD, Division of Rheumatology, Department of Medicine, McGill University Health Centre; E. Vinet, MD, PhD, Division of Rheumatology, Department of Medicine, McGill University Health Centre
| | - Stephanie Keeling
- From the Division of General Internal Medicine, and the Division of Rheumatology, Department of Medicine, McGill University Health Centre, Montréal; Division of Rheumatology, Department of Medicine, University of Sherbrooke, Sherbrooke, Québec; Division of Rheumatology, Mary Pack Arthritis Center, University of British Columbia, Vancouver, British Columbia; Division of Rheumatology, Department of Medicine, University of Alberta, Edmonton; Division of Rheumatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada.,E.G. McDonald, MD, MSc, Division of General Internal Medicine, Department of Medicine, McGill University Health Centre; L. Bissonette, MD, Division of Rheumatology, Department of Medicine, University of Sherbrooke; S. Ensworth, MD, Assistant Professor, Division of Rheumatology, University of British Columbia; N. Dayan, MD, MSc, Division of General Internal Medicine, Department of Medicine, McGill University Health Centre; A.E. Clarke, MD, MSc, Division of Rheumatology, Department of Medicine, University of Calgary; S. Keeling, MD, MSc, Division of Rheumatology, Department of Medicine, University of Alberta; S. Bernatsky, MD, PhD, Division of Rheumatology, Department of Medicine, McGill University Health Centre; E. Vinet, MD, PhD, Division of Rheumatology, Department of Medicine, McGill University Health Centre
| | - Sasha Bernatsky
- From the Division of General Internal Medicine, and the Division of Rheumatology, Department of Medicine, McGill University Health Centre, Montréal; Division of Rheumatology, Department of Medicine, University of Sherbrooke, Sherbrooke, Québec; Division of Rheumatology, Mary Pack Arthritis Center, University of British Columbia, Vancouver, British Columbia; Division of Rheumatology, Department of Medicine, University of Alberta, Edmonton; Division of Rheumatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada.,E.G. McDonald, MD, MSc, Division of General Internal Medicine, Department of Medicine, McGill University Health Centre; L. Bissonette, MD, Division of Rheumatology, Department of Medicine, University of Sherbrooke; S. Ensworth, MD, Assistant Professor, Division of Rheumatology, University of British Columbia; N. Dayan, MD, MSc, Division of General Internal Medicine, Department of Medicine, McGill University Health Centre; A.E. Clarke, MD, MSc, Division of Rheumatology, Department of Medicine, University of Calgary; S. Keeling, MD, MSc, Division of Rheumatology, Department of Medicine, University of Alberta; S. Bernatsky, MD, PhD, Division of Rheumatology, Department of Medicine, McGill University Health Centre; E. Vinet, MD, PhD, Division of Rheumatology, Department of Medicine, McGill University Health Centre
| | - Evelyne Vinet
- From the Division of General Internal Medicine, and the Division of Rheumatology, Department of Medicine, McGill University Health Centre, Montréal; Division of Rheumatology, Department of Medicine, University of Sherbrooke, Sherbrooke, Québec; Division of Rheumatology, Mary Pack Arthritis Center, University of British Columbia, Vancouver, British Columbia; Division of Rheumatology, Department of Medicine, University of Alberta, Edmonton; Division of Rheumatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada. .,E.G. McDonald, MD, MSc, Division of General Internal Medicine, Department of Medicine, McGill University Health Centre; L. Bissonette, MD, Division of Rheumatology, Department of Medicine, University of Sherbrooke; S. Ensworth, MD, Assistant Professor, Division of Rheumatology, University of British Columbia; N. Dayan, MD, MSc, Division of General Internal Medicine, Department of Medicine, McGill University Health Centre; A.E. Clarke, MD, MSc, Division of Rheumatology, Department of Medicine, University of Calgary; S. Keeling, MD, MSc, Division of Rheumatology, Department of Medicine, University of Alberta; S. Bernatsky, MD, PhD, Division of Rheumatology, Department of Medicine, McGill University Health Centre; E. Vinet, MD, PhD, Division of Rheumatology, Department of Medicine, McGill University Health Centre.
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