Preterm birth is strongly affected by the glucocorticoid dose during pregnancy in women complicated by systemic lupus erythematosus

Stress in utero: prenatal dexamethasone exposure causes greater structural gliovascular alterations in female offspring than in males

From early in life, experiences like prenatal stress profoundly affect long-term health and behavior. Fetal exposure to increased levels of glucocorticoids (GC), via maternal stress or through antenatal corticosteroid therapy (commonly used in women at risk of preterm birth), can disrupt brain development and raise the susceptibility to psychiatric disorders. Previous studies on prenatal exposure to synthetic GCs, such as dexamethasone (DEX), revealed impairments in neurogenesis and dendritic spine development. However, the impact of prenatal stress, specifically antenatal DEX exposure, on the gliovascular interface remains unclear. This interface, involving the relationship between astrocytes and blood vessels, is essential for healthy brain development. Astrocytic endfeet coverage and organization are crucial features of the gliovascular interface, and in this study, we evaluated these aspects through aquaporin-4 (AQ4) expression and organization along the lectin labelled-vasculature. At Postnatal Day 14, no differences in AQ4 expression were observed between males and females. However, prenatal stress induced by DEX exposure (50 μg/kg was administered subcutaneously to pregnant mice through gestational days 16, 17 and 18) significantly impacted this structure in females but not in males. Specifically, in female offspring prenatally exposed to DEX, AQ4 expression was significantly upregulated in the hippocampus, and its rearrangement was observed in the prefrontal cortex. A comparison of vascular density between male and female brains showed no significant sex differences in any analyzed regions, though male cerebellar vessel segments were shorter. Interestingly, prenatal stress caused morphological alterations in female brains, including increased vessel tortuosity, while no such changes were seen in males. In the hippocampus, prenatal DEX exposure reduced vessel segment length in males but did not affect females. In the cerebellum, DEX exposure increased vessel segment length in females. This study highlights sex-specific differences in the impact of prenatal stress on the gliovascular structure across various brain regions, suggesting AQ4 as a potential molecular target relevant to depressive-like behaviors in female offspring. Future studies are needed to correlate the gliovascular structural alterations found with functional disturbances and sex-specific mental health issues.

The conditions that patients with systemic lupus erythematosus should fulfill before pregnancy to optimize outcomes: a large-scale multicenter cohort study from China

BACKGROUND

Systemic lupus erythematosus (SLE) is frequently associated with a lower rate of live birth and a higher incidence of adverse pregnancy outcomes (APOs), and pregnancy can also increase the risk of SLE flares. Comprehensive preconception assessment is critical for improved pregnancy outcomes in patients with SLE. Unfortunately, no global consensus on the conditions that patients with SLE should fulfill prior to pregnancy has yet been formed.

OBJECTIVE

This study aimed to investigate the conditions that patients with SLE should fulfill before pregnancy to optimize outcomes.

STUDY DESIGN

This was a retrospective study utilizing data from a multicenter Chinese SLE cohort. Information on demographics, obstetric history, SLE activity, clinical manifestations, autoantibody profiles, laboratory parameters, therapeutics, and pregnancy outcomes was collected. Logistic regression was used to explore the optimal conditions.

RESULTS

The study comprised 347 singleton pregnancies from 332 patients with SLE in total, with a mean maternal age at conception of 30.3 (SD 4.0) years. The analysis revealed that patients who were stable for at least 6 months, had no active vital organ involvement, were on nonfluorinated corticosteroids no more than the dose equivalent to prednisone 7.5 mg per day, and were on hydroxychloroquine displayed a significantly higher incidence of live birth (86.1% vs. 73.7%, p = 0.004) and a markedly decreased risk of APOs (29.4% vs. 52.1%, p < 0.001). Additionally, flares occurred less frequently during pregnancy (14.7% vs. 27.3%, p = 0.009), particularly for severe flares (5.8% vs. 14.8%, p = 0.011).

CONCLUSION

This study delineated the conditions that patients with SLE should fulfill before pregnancy, which provides better instructions for clinical practice.

Saudi National Clinical Practice Guidelines for Management of Adult Systemic Lupus Erythematosus

OBJECTIVE

To provide evidence-based clinical practice recommendations for managing Systemic Lupus Erythematosus (SLE) in Saudi Arabia.

METHODS

This EULAR-adapted national guideline in which a multidisciplinary task force utilized the modified Delphi method to develop 31 clinical key questions. A systematic literature review was conducted to update the evidence since the EULAR publication. After reaching a consensus agreement, two rounds of voting and group discussion were conducted to generate consolidated recommendations/ statements.

RESULTS

A significant number of patients in Saudi Arabia experience delays in accessing rheumatologists, highlighting the significance of timely referral to SLE specialists or rheumatologists to ensure accurate diagnosis and prompt treatment. The primary goal of Glucocorticoid (GC) therapy in SLE patients is to establish disease control with a minimum dose and duration. Steroid-sparing agent utilization facilitates steroid-sparing goals. Hydroxychloroquine is recommended for all SLE patients, though physicians must carefully monitor toxicity and prioritize regular medication adherence assessment. SLE management during pregnancy starts from preconception time by assessing disease activity, major organ involvement, hypercoagulability status, and concomitant diseases that may negatively impact maternal and fetal outcomes. Multidisciplinary care with close monitoring may optimize both maternal and fetal outcomes. For patients with antiphospholipid antibodies, low-dose aspirin prophylaxis is recommended. Also, Long-term anticoagulant medications are fundamental to prevent secondary antiphospholipid syndrome due to high thrombosis recurrence.

CONCLUSION

This Saudi National Clinical Practice guidelines for SLE management provide evidence- based recommendations and guidance for healthcare providers in Saudi Arabia who are managing patients with SLE. These guidelines will help to standardize healthcare service, improve provider education, and perhaps lead to better treatment outcomes for SLE patients.

Pregnancy with mixed connective tissue disease: Exploration of factors influencing live birth outcomes

Mixed connective tissue disease (MCTD) predominantly affects women in their reproductive age (30-40 years). This study is aimed to analyze a case series of MCTD-complicated pregnancies. The study design utilized a combined case-series and case-control approach. Pregnant women with MCTD were included and categorized into two groups: the live-birth and non-live birth (encompassing miscarriages at <12 weeks and stillbirths at ≥12 weeks) groups. Primary outcomes included delivery outcomes and factors associated with live births. A total of 57 pregnancies from 34 mothers (median age: 33.0 years) were included. Regarding delivery outcomes, the rates for live birth, miscarriage, and stillbirth were 64.9, 29.8, and 5.3%, respectively. Additionally, the respective rates of preterm delivery, fetal growth restriction (FGR), and small-for-gestational-age (SGA) were 18.9, 18.9, and 27.0%. Higher steroid usage (62.2 vs. 30.0%, p = 0.02) and lower prednisolone dosage in the live birth group (median dose: 7 vs. 10 mg, p = 0.03) were found to be significant factors contributing to live births. MCTD during pregnancy was associated with increased risks of miscarriage, stillbirth, preterm delivery, FGR, and SGA. Notably, low-dose steroid therapy was identified as a contributing factor to successful live births.

Effects of famotidine use during pregnancy: an observational cohort study

BACKGROUND

Famotidine, a histamine2-receptor antagonist (H2Ras), is widely used to treat and prevent gastrointestinal symptoms during pregnancy. Although several studies have reported the use of H2Ras during pregnancy, limited data on famotidine were included in these reports. Therefore, we analyzed pregnancy outcome data to evaluate the effects of famotidine use during pregnancy on the fetus.

METHODS

Pregnancy outcome data were used for females enrolled in two Japanese facilities that provided counseling on drug use during pregnancy between April 1988 and December 2017. For the primary endpoint, the incidence of congenital malformations was calculated from the data of live birth to pregnant women who took famotidine (n = 330) or drugs considered to exert no teratogenic risk (control, n = 1,407) during the first trimester of pregnancy. Considering secondary endpoints, the incidence of obstetric outcomes, including preterm delivery, was calculated from data on the use of famotidine (n = 347) and controls (n = 1,476) during the entire pregnancy. The crude odds ratios (cORs) for the incidence of congenital malformations were calculated using univariate logistic regression analysis, with the control group used as the reference. Adjusted ORs (aORs) were calculated using multivariate logistic regression analysis adjusted for various other factors.

RESULTS

The incidences of congenital malformations in the famotidine and control groups were 3.9% and 2.8%, respectively. There was no significant difference between the famotidine and control groups (cOR: 1.40 [95% CI:0.68-2.71], aOR: 1.06 [95% CI:0.51-2.16]). Conversely, the preterm delivery rates were 8.1% and 3.8% in the famotidine and control groups, respectively, indicating a significant difference (cOR: 2.00 [95% CI:1.20-3.27]). However, the multivariate analysis eliminated famotidine use as a confounding factor.

CONCLUSIONS

This observational cohort study revealed that exposure to famotidine during the first trimester of pregnancy was not associated with an increased risk of congenital malformations in infants. Although a higher rate of preterm delivery was detected in famotidine users when compared with controls, this could be attributed to confounding factors, such as complications.

Effect of hydroxychloroquine on pregnancy outcome in patients with SLE: a systematic review and meta-analysis

OBJECTIVE

Hydroxychloroquine (HCQ) is an antimalarial drug employed in the treatment of systemic lupus erythematosus (SLE). Prior studies reported inconsistent results regarding the association between HCQ use during pregnancy and adverse pregnancy outcomes. This study aimed to evaluate the impact of HCQ on pregnancy-related outcomes in women with SLE.

METHODS

We conducted a systematic search for studies associating pregnancy outcomes with HCQ use in PubMed, EMBASE, Cochrane Library, Web of Science, CNKI, Wanfang database and VIP from inception to 22 September 2022. Random or fixed effect models were used to estimate the pooled effect based on I2 measurement of heterogeneity.

RESULTS

Twenty-one studies were included, encompassing 929 and 1031 patients in HCQ and non-HCQ groups, respectively. We found that HCQ use was significantly associated with reduced risks of Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) scores (second trimester: mean difference (MD) -1.80, 95% CI -2.46 to -1.13; third trimester: MD -2.30, 95% CI -3.31 to -1.29), flare (OR 0.57, 95% CI 0.33 to 0.97), preterm birth (OR 0.57, 95% CI 0.46 to 0.72), intrauterine growth retardation (IUGR) (OR 0.48, 95% CI 0.31 to 0.72), gestational hypertension (OR 0.19, 95% CI 0.08 to 0.42), pre-eclampsia (OR 0.46, 95% CI 0.29 to 0.72). In contrast, a positive correlation was observed between full-term birth and HCQ use (OR 2.01, 95% CI 1.52 to 2.65). However, the result for disease flare exhibited high heterogeneity (p=0.01, I2=59%). In addition, publication bias was detected in the meta-analysis of full-term birth using the Egger's test.

CONCLUSIONS

This meta-analysis offers a comprehensive assessment of the relationship between disease activity, pregnancy-related outcomes and HCQ use, providing supportive evidence for the therapeutic effectiveness of HCQ in pregnant women with SLE.

PROSPERO REGISTRATION NUMBER

CRD42022374468.

Systemic lupus erythematosus is associated with an increased frequency of spontaneous preterm births: systematic review and meta-analysis

OBJECTIVE

Preterm birth is one of the most frequent complications of pregnancy in women with systemic lupus erythematosus. The high indicated preterm birth proportion due to hypertensive disorders of pregnancy and/or fetal growth restriction is well known, and preventive measures and screening for early detection are performed. The risk of spontaneous preterm birth is less well recognized. This study aimed to determine the proportions of spontaneous and indicated preterm birth in pregnancies of women with systemic lupus erythematosus.

DATA SOURCES

A systematic literature search using Pubmed, Embase, Web of Science, and Google Scholar was performed in June 2021.

STUDY ELIGIBILITY CRITERIA

Studies in pregnant women with systemic lupus erythematosus reporting spontaneous and indicated preterm birth rates were selected. Original research articles published from 1995 to June 2021 were included.

METHODS

Quality and risk of bias of the included studies were assessed using the Newcastle-Ottawa quality assessment scale. To estimate the pooled event rates and 95% confidence intervals, meta-analysis of single proportions with a random-effects model was performed.

RESULTS

We included 21 articles, containing data of 8157 pregnancies in women with systemic lupus erythematosus. On average, 31% (95% prediction interval, 0.14-0.50) of the pregnancies resulted in preterm birth, including 14% (95% prediction interval, 0.04-0.27) spontaneous and 16% (95% prediction interval, 0.03-0.35) indicated preterm birth.

CONCLUSION

In pregnant women with systemic lupus erythematosus, spontaneous and indicated preterm birth proportions are high. This information should be applied in (prepregnancy) counseling and management in pregnancy. The knowledge obtained by this meta-analysis paves the way for further research of associated risk factors and development of interventions to reduce spontaneous preterm birth in systemic lupus erythematosus pregnancies.

Lupus nephritis: management challenges during pregnancy

Lupus nephritis (LN), a severe complication of systemic lupus erythematosus (SLE), leads to significant kidney inflammation and damage and drastically increases mortality risk. Predominantly impacting women in their reproductive years, LN poses specific risks during pregnancy, including pre-eclampsia, growth restrictions, stillbirth, and preterm delivery, exacerbated by lupus activity, specific antibodies, and pre-existing conditions like hypertension. Effective management of LN during pregnancy is crucial and involves carefully balancing disease control with the safety of the fetus. This includes pre-conception counseling and a multidisciplinary approach among specialists to navigate the complexities LN patients face during pregnancy, such as distinguishing LN flare-ups from pregnancy-induced conditions. This review focuses on exploring the complex dynamics between pregnancy and LN, emphasizing the management difficulties and the heightened risks pregnant women with LN encounter.

A retrospective analysis of the safety of tacrolimus use and its optimal cut-off concentration during pregnancy in women with systemic lupus erythematosus: study from two Japanese tertiary referral centers

BACKGROUND

Tacrolimus is one of the major treatment options for systemic lupus erythematosus (SLE) and is considered to be a pregnancy-compatible medication. Since little is known about tacrolimus safety during pregnancy complicated by SLE, this study was designed.

METHODS

We included SLE pregnant patients who were followed up at two Japanese tertiary referral centers. We performed multivariate logistic regression analysis to assess each adverse pregnancy outcome (APO) risk. Moreover, we assessed the influence of tacrolimus on the APO ratio in pregnant patients with lupus nephritis, and the impact of combined tacrolimus-aspirin therapy on the APO ratio relative to patients exclusively administered tacrolimus.

RESULTS

Of the 124 pregnancies, 29 were exposed to tacrolimus. Multivariate analysis showed no statistical difference in APO ratio. (overall APO: adjusted odds ratio [aOR], 0.69; 95% confidence interval [CI], 0.23-2.03; p = 0.50; maternal APO: aOR, 1.17; 95% CI, 0.36-3.83; p = 0.80; neonatal APO: aOR, 1.10; 95% CI, 0.38-3.21; p = 0.86; PROMISSE APO: aOR, 0.50; 95% CI, 0.14-1.74; p = 0.27). Blood pressure and estimated glomerular filtration rate (eGFR) during pregnancy and after delivery did not differ between the two groups. Receiver operating characteristic (ROC) curve showed that tacrolimus concentration > 2.6 ng/ml was related to reduced preterm birth rate. (AUC = 0.85, 95% CI: 0.61-1.00, sensitivity: 93% and specificity: 75%). Regarding effect of tacrolimus on lupus nephritis during pregnancy, tacrolimus showed no increased risk of APO, blood pressure or eGFR during pregnancy and after delivery. (overall APO: OR, 1.00; 95% CI, 0.25-4.08; p = 0.98; maternal APO: OR 1.60, 95% CI, 0.39-6.64; p = 0.51; neonatal APO: OR, 0.71; 95% CI, 0.17-3.03; p = 0.65, PROMISSE APO: OR, 0.50; 95% CI, 0.08-3.22; p = 0.47). Tacrolimus-aspirin combination therapy showed a protective tendency against hypertensive disorders during pregnancy, preeclampsia and low birth weight.

CONCLUSIONS

Tacrolimus use during pregnancy with SLE and lupus nephritis showed no significant influence on APO, blood pressure, or renal function; therefore tacrolimus may be suitable for controlling lupus activity during pregnancy. In addition, when using tacrolimus during pregnancy, we should aim its trough concentration ≥ 2.6 ng/ml while paying careful attention to possible maternal side effects of tacrolimus.

TRIAL REGISTRATION

Retrospectively registered.

Azathioprine metabolite levels and outcomes during pregnancies with rheumatic disease

OBJECTIVE

Despite widespread use of azathioprine (AZA) during pregnancy, no studies evaluated the impact of pregnancy on AZA metabolites 6-thioguanine nucleotide (6-TGN) and 6-methylmercaptopurine nucleotide (6-MMPN) disposition in rheumatic diseases. This study characterises changes in AZA metabolite concentrations throughout pregnancy in women with rheumatic disease and explores relationships between metabolite concentrations, maternal disease activity, and neonatal outcomes.

METHODS

Patients with rheumatic disease from a single centre prescribed AZA prior to pregnancy and ≥1 blood sample during pregnancy (5/2016 to 4/2022) were included. Commercial laboratories quantified AZA metabolite concentrations. The upper safety limit for 6-MMPN was >5700 pmol/8×108 RBC. The therapeutic target for 6-TGN was ≥159 pmol/8×108 RBC. Repeated correlation measures were used to evaluate the relationship between metabolite concentrations and pregnancy duration, and the relationship between 6-TGN concentration and SLE Physician Global Assessment (PGA). The relationship between pregnancy average 6-TGN and neonatal gestational age at birth was analysed using linear regression.

RESULTS

Thirty-seven pregnancies in 35 women with 108 serum samples were included. There was no significant difference in dose-adjusted 6-TGN concentrations across pregnancy and peripartum, whereas 6-MMPN concentrations appeared higher during pregnancy. No elevated transaminases or cholestasis were observed concurrently with 6-MMPN above 5700 pmol/8×108 RBC. Metabolite concentrations were related to total AZA dosage, weight-based dosage and TPMT phenotype. In pregnant women with SLE achieving average 6-TGN in the therapeutic range, we observed a non-significant reduction in PGA and increase in neonatal gestational age at birth.

CONCLUSIONS

In this exploratory study, we did not observe systematic changes in 6-TGN concentrations throughout pregnancy and peripartum, whereas 6-MMPN concentrations were higher during pregnancy. Monitoring AZA metabolite concentrations in pregnancy is a potential tool to identify medication non-adherence as well as patients with high 6-MMPN in whom dosage adjustment or close laboratory monitoring may optimise safety.

Pregnancy in systemic lupus erythematosus

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease which frequently affects women of childbearing age. Nowadays, pregnancy is not contraindicated in cases of well-controlled disease activity, but pregnancies are still at higher risk of maternal and fetal complications compared to the general population. During pregnancy and puerperium patients are at risk of disease flare, and obstetric complications are more frequent in cases of active disease at conception/beginning of pregnancy, a history of lupus nephritis, and concomitant presence of antiphospholipid syndrome. To improve pregnancy outcomes in SLE patients, appropriate preconception counseling with changes in medication, if necessary, and close rheumatological and obstetrical monitoring are fundamental. This review aims to summarize the risk factors for adverse pregnancy outcomes and provide an update on developments in medical care for pregnancy in SLE patients.

Immunological disease activity parameters at conception are risk factors for preterm birth and low birth weight in patients with systemic lupus erythematosus

OBJECTIVE

This study aimed to identify which disease activity parameters may be risk factors for preterm birth (PB) and low birth weight (LBW) in patients with systemic lupus erythematosus (SLE). We also analyzed the extent to which these parameters affected PB and LBW.

METHODS

We collected the SLE Disease Activity Index (SLEDAI), the rate of lupus low disease activity state (LLDAS) attainment, complement levels, and the titer of anti-double stranded DNA (dsDNA) antibody as disease activity parameters. We retrospectively analyzed the associations of these parameters with PB and LBW.

RESULTS

Sixty pregnancies were included in this study. C3 levels and anti-dsDNA antibody titers at conception were strongly associated with PB (p = 0.03 and p = 0.01, respectively), whereas C3 and CH50 levels were associated with LBW (p = 0.02 and p = 0.03, respectively). A logistic regression analysis showed that the cutoff values of C3 and anti-dsDNA antibody for PB were 62.0 mg/dl and 5.4 IU/ml, respectively. The cutoff values of C3 and CH50 for LBW were 87.0 mg/dl and 41.8 U/ml, respectively. The risk of PB or LBW was increased when divided by the cutoff value, and the combination of these cutoff values showed a significantly higher risk of PB and LBW (p = 0.01 and p < 0.01, respectively).

CONCLUSIONS

PB and LBW are strongly associated with disease activity parameters in patients with SLE. Therefore, strictly monitoring and controlling these disease activity parameters, with or without clinical manifestation, is important for women who want to become mothers.

[Update on pregnancy in inflammatory rheumatic diseases]

Women with rheumatic diseases should receive pre-pregnancy counselling to plan their pregnancy based on their individual risk profile. Low-dose aspirin is highly valued in the prevention of pre-eclampsia and is recommended for any lupus patient. In women with rheumatoid arthritis treated with bDMARDs, continuation during pregnancy should be considered to reduce the risk of disease relapse and adverse pregnancy outcomes. NSAIDs should be discontinued after the 20th week of pregnancy if possible. In SLE pregnancies, a lower glucocorticoid dose (6.5-10 mg/day) than previously thought is associated with preterm birth. HCQ therapy in pregnancy offers a benefit that clearly goes beyond mere disease control and should be emphasized accordingly in counselling. The use of HCQ is recommended for all SS-A-positive women from the 10th week of pregnancy at the latest, especially in the case of previous cAVB. Continuation of belimumab during pregnancy should be decided on an individual basis.Stable disease under pregnancy-compatible medication is one of the most important predictive factors for a good pregnancy outcome. Current recommendations should be considered in individual counselling.

Preterm rat survival is enhanced by gestational environmental enrichment

Throughout the last decade, the estimated global human preterm birth rate was 10.6 %, with higher rates in Asia, South America, and Africa. Preterm individuals, even in adulthood, are more likely to develop cardiorespiratory, renal, and metabolic disorders. On the other hand, when experimental animals are housed in an enriched environment during gestation, the development of the progeny in utero is accelerated, compared to standard housing conditions. By terminating gestation one and a half days before parturition, we investigated whether environmental enrichment restricted to gestation may have an impact on progeny survival. Our results demonstrate that the gestational enriched environment tripled the rat´s offspring survival, which was associated with decreased expression of anxiety-like behaviors in the pregnant mother. Sex of the offspring was not a factor in determining survival. We discuss the effect of increased secretion of various trophic factors and hormones induced by the enriched environment on progeny survival.

Systemic lupus erythematosus dysregulates the expression of long noncoding RNAs in placentas

Background

Systemic lupus erythematosus (SLE) can cause placental dysfunctions, which may result in pregnancy complications. Long noncoding RNAs (lncRNAs) are actively involved in the regulation of immune responses during pregnancy. The present study aimed to determine the lncRNA expression profiles in placentas from women with SLE to gain new insights into the underlying molecular mechanisms in SLE pregnancies.

Methods

RNA sequencing (RNA-seq) analysis was performed to identify SLE-dysregulated lncRNAs and mRNAs in placentas from women with SLE and normal full-term (NT) pregnancies. Bioinformatics analysis was conducted to predict the biological functions of these SLE-dysregulated lncRNAs and mRNAs.

Results

RNA-seq analysis identified 52 dysregulated lncRNAs in SLE placentas, including 37 that were upregulated and 15 downregulated. Additional 130 SLE-dysregulated mRNAs were discovered, including 122 upregulated and 8 downregulated. Bioinformatics analysis revealed that SLE-dysregulated genes were associated with biological functions and gene networks, such as regulation of type I interferon-mediated signaling pathway, response to hypoxia, regulation of MAPK (mitogen-activated protein kinase) cascade, response to steroid hormone, complement and coagulation cascades, and Th1 and Th2 cell differentiation.

Conclusions

This is the first report of the lncRNA profiles in placentas from SLE pregnancies. These results suggest that the aberrant expression and the potential regulatory function of lncRNAs in placentas may play comprehensive roles in the pathogenesis of SLE pregnancies. SLE-dysregulated lncRNAs may potentially serve as biomarkers for SLE.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13075-022-02825-7.