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Tingström J, Öst E, Bergman G, Burström Å. Home monitoring of fetal heart rhythm: Lived experiences of women with anti-SSA/Ro52 autoantibodies and their co-parents. Lupus 2024:9612033241244465. [PMID: 38571373 DOI: 10.1177/09612033241244465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2024]
Abstract
OBJECTIVE The aim of this study was to explore the parents' experiences of home monitoring of the fetal heart rhythm. Women with anti-SSA/Ro52 autoantibodies carry a 2%-3% risk of giving birth to a child with congenital heart block (CHB), following transplacental transfer and antibody-mediated inflammation in the fetal conduction system during 18th to 24th gestational week. Early detection and subsequent treatment have been reported to decrease morbidity and mortality. Therefore, home monitoring of the fetal heart rhythm by Doppler has been offered at our fetal cardiology center. This study was undertaken to explore the lived experience of the routine. METHODS Participants were recruited from a single fetal cardiology center. Consecutive sampling was used. The inclusion criteria were women with SSA/Ro52 antibodies who had undergone Doppler examinations within the last two and a half years at the hospital and had monitored the fetal heartbeat at home. A semi-structured questionnaire was created, and the participants were interviewed individually. The interviews were transcribed verbatim and analyzed according to qualitative content analysis. RESULTS The overall theme was defined as "walking on thin ice," with six underlying categories: reality, different strategies, gain and loss, healthcare providers, underlying tension, and conducting the examinations again, all with a focus on how to handle the home monitoring during the risk period. CONCLUSION Both the mother and the co-parent expressed confidence in their own abilities and that the monitoring provided them with the advantage of growing a bond with the expected child. However, all the participants described a feeling of underlying tension during the risk period. The results show that home monitoring is not experienced as complicated or a burden for the parents-to-be and should be considered a vital part of the chain of care for mothers at risk for giving birth to a child with CHB. However, explaining the teamwork between the different caregivers, for the patients involved, their areas of expertise, and how they collaborate with the patient continues to be a pedagogic challenge and should be developed further.
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Affiliation(s)
- Joanna Tingström
- Department of Obstetrics and Gynecology, Department of Clinical Science and Education Karolinska Institutet, Stockholm, Sweden
| | - Elin Öst
- Department of Pediatric Surgery, Karolinska University Hospital, Stockholm, Sweden
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Gunnar Bergman
- Department of Women's and Children's Health, Karolinska Institutet and Department of Pediatric Cardiolgoy, Karolinska University Hospital, Stockholm, Sweden
| | - Åsa Burström
- Neurobiology, Care Science and Society, Karolinska Institutet, Stockholm, Sweden
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Batra AS, Silka MJ, Borquez A, Cuneo B, Dechert B, Jaeggi E, Kannankeril PJ, Tabulov C, Tisdale JE, Wolfe D. Pharmacological Management of Cardiac Arrhythmias in the Fetal and Neonatal Periods: A Scientific Statement From the American Heart Association: Endorsed by the Pediatric & Congenital Electrophysiology Society (PACES). Circulation 2024; 149:e937-e952. [PMID: 38314551 DOI: 10.1161/cir.0000000000001206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2024]
Abstract
Disorders of the cardiac rhythm may occur in both the fetus and neonate. Because of the immature myocardium, the hemodynamic consequences of either bradyarrhythmias or tachyarrhythmias may be far more significant than in mature physiological states. Treatment options are limited in the fetus and neonate because of limited vascular access, patient size, and the significant risk/benefit ratio of any intervention. In addition, exposure of the fetus or neonate to either persistent arrhythmias or antiarrhythmic medications may have yet-to-be-determined long-term developmental consequences. This scientific statement discusses the mechanism of arrhythmias, pharmacological treatment options, and distinct aspects of pharmacokinetics for the fetus and neonate. From the available current data, subjects of apparent consistency/consensus are presented, as well as future directions for research in terms of aspects of care for which evidence has not been established.
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Bedei IA, Kniess D, Keil C, Wolter A, Schenk J, Sachs UJ, Axt-Fliedner R. Monitoring of Women with Anti-Ro/SSA and Anti-La/SSB Antibodies in Germany-Status Quo and Intensified Monitoring Concepts. J Clin Med 2024; 13:1142. [PMID: 38398455 PMCID: PMC10889801 DOI: 10.3390/jcm13041142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Revised: 02/10/2024] [Accepted: 02/14/2024] [Indexed: 02/25/2024] Open
Abstract
Background: The fetuses of pregnant women affected by anti-Ro/anti-La antibodies are at risk of developing complete atrioventricular heart block (CAVB) and other potentially life-threatening cardiac affections. CAVB can develop in less than 24 h. Treatment with anti-inflammatory drugs and immunoglobulins (IVIG) can restore the normal rhythm if applied in the transition period. Routine weekly echocardiography, as often recommended, will rarely detect emergent AVB. The surveillance of these pregnancies is controversial. Home-monitoring using a hand-held Doppler is a promising new approach. Methods: To obtain an overview of the current practice in Germany, we developed a web-based survey sent by the DEGUM (German Society of Ultrasound in Medicine) to ultrasound specialists. With the intention to evaluate practicability of home-monitoring, we instructed at-risk pregnant women to use a hand-held Doppler in the vulnerable period between 18 and 26 weeks at our university center. Results: There are trends but no clear consensus on surveillance, prophylaxis, and treatment of anti-Ro/La positive pregnant between specialists in Germany. Currently most experts do not offer home-monitoring but have a positive attitude towards its prospective use. Intensified fetal monitoring using a hand-held Doppler is feasible for pregnant women at risk and does not lead to frequent and unnecessary contact with the center. Conclusion: Evidence-based guidelines are needed to optimize the care of anti-Ro/La-positive pregnant women. Individual risk stratification could help pregnancy care of women at risk and is welcmed by most experts. Hand-held doppler monitoring is accepted by patients and prenatal medicine specialists as an option for intensified monitoring and can be included in an algorithm for surveillance.
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Affiliation(s)
- Ivonne Alexandra Bedei
- Department of Prenatal Diagnosis and Fetal Therapy, Justus-Liebig University Giessen, 35392 Giessen, Germany; (A.W.); (J.S.); (R.A.-F.)
| | - David Kniess
- Department of Prenatal Diagnosis and Fetal Therapy, Philipps-University Marburg, 35041 Marburg, Germany; (D.K.)
| | - Corinna Keil
- Department of Prenatal Diagnosis and Fetal Therapy, Philipps-University Marburg, 35041 Marburg, Germany; (D.K.)
| | - Aline Wolter
- Department of Prenatal Diagnosis and Fetal Therapy, Justus-Liebig University Giessen, 35392 Giessen, Germany; (A.W.); (J.S.); (R.A.-F.)
| | - Johanna Schenk
- Department of Prenatal Diagnosis and Fetal Therapy, Justus-Liebig University Giessen, 35392 Giessen, Germany; (A.W.); (J.S.); (R.A.-F.)
| | - Ulrich J. Sachs
- Institute for Clinical Immunology and Transfusion Medicine, Justus-Liebig University, 35392 Giessen, Germany;
- Center for Transfusion Medicine and Hemotherapy, University Hospital Giessen and Marburg, 35041 Marburg, Germany
- German Center for Fetomaternal Incompatibility (DZFI), University Hospital Giessen and Marburg, 35392 Giessen, Germany
| | - Roland Axt-Fliedner
- Department of Prenatal Diagnosis and Fetal Therapy, Justus-Liebig University Giessen, 35392 Giessen, Germany; (A.W.); (J.S.); (R.A.-F.)
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Nair A, Sklansky M, Satou G, Papneja K. Perivascular Basal Echogenicity in the Fetal Heart: An Unconventional Marker of Maternal Autoimmune Antibodies. Pediatr Cardiol 2024; 45:196-199. [PMID: 37935867 DOI: 10.1007/s00246-023-03325-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 10/10/2023] [Indexed: 11/09/2023]
Abstract
Fetal congenital heart block is a widely recognized complication of pregnancies with anti Ro/La antibodies. Less common presentations, including dilated cardiomyopathy, myocarditis, valvular insufficiency, and endocardial fibroelastosis, have also been described in these fetuses. We present two cases where recognition of isolated basal echogenicity of the fetal heart, an unconventional manifestation of anti-SSA antibodies during pregnancy, led to a suspicion and ultimately diagnosis of antibody positivity in the mother. These cases highlight the importance of being aware of this rare manifestation of anti-SSA antibodies during pregnancy, as early recognition of antibody positivity may lead to improve fetal and maternal outcomes.
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Affiliation(s)
- Anupama Nair
- Division of Fetal Cardiology, David Geffen School of Medicine, UCLA, Los Angeles, USA.
| | - Mark Sklansky
- Division of Fetal Cardiology, David Geffen School of Medicine, UCLA, Los Angeles, USA
| | - Gary Satou
- Division of Fetal Cardiology, David Geffen School of Medicine, UCLA, Los Angeles, USA
| | - Koyelle Papneja
- Division of Fetal Cardiology, David Geffen School of Medicine, UCLA, Los Angeles, USA
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Jaeggi E, Kulasingam V, Chen J, Fan CPS, Laskin C, Hamilton RM, Hiraki LT, Silverman ED, Sepiashvili L. Maternal Anti-Ro Antibody Titers Obtained With Commercially Available Immunoassays Are Strongly Associated With Immune-Mediated Fetal Heart Disease. Arthritis Rheumatol 2023; 75:1556-1565. [PMID: 36996277 DOI: 10.1002/art.42513] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 03/04/2023] [Accepted: 03/10/2023] [Indexed: 04/01/2023]
Abstract
OBJECTIVE Anti-Ro antibody-positive mothers are frequently referred for serial echocardiography due to the fetal risk of developing heart block and endocardial fibroelastosis. Little is known why only some and not all offspring develop these cardiac manifestations of neonatal lupus (CNL). This prospective study examined associations between anti-Ro antibody titers and fetal CNL. METHODS Antibody-positive mothers referred since 2018 for fetal echocardiography at risk of CNL (group 1; n = 240) or with CNL (group 2; n = 18) were included. Maternal antibody titers were measured with a chemiluminescent immunoassay (CIA). Additional testing on diluted serum samples was used to quantify anti-Ro 60 antibody titers above the analytical measuring range (AMR) of the standard CIA (≥1,375 chemiluminescent units [CU]). RESULTS Among 27 total mothers with a fetal diagnosis of CNL, all displayed anti-Ro 60 antibody titers that exceeded the AMR of the CIA at least 10-fold. Of 122 mothers in group 1 who underwent additional anti-Ro 60 antibody testing, event rates of CNL (n = 9) were 0% (0 of 45) among mothers with anti-Ro 60 antibody titers from 1,375-10,000 CU, 5% (3 of 56) among mothers with titers from 10,000-50,000 CU, but 29% (6 of 21) among mothers with titers >50,000 CU (odds ratio 13.1, P = 0.0008). Of mothers in group 2 with a primary diagnosis of CNL, 0% (0 of 18 mothers) had anti-Ro 60 antibody titers <10,000 CU, 44% (8 of 18 mothers) had titers from 10,000-50,000 CU, and 56% (10 of 18 mothers) had titers >50,000 CU. CONCLUSION CNL is associated with substantially higher anti-Ro antibody titers than are obtained using a standard CIA. Enhancing the assay measuring range allows an improved specificity of identifying pregnancies at risk of CNL.
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Affiliation(s)
- Edgar Jaeggi
- Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Vathany Kulasingam
- Division of Clinical Biochemistry, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Jack Chen
- Department of Laboratory Medicine & Pathobiology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Chun-Po Steve Fan
- Rogers Computational Program, Ted Rogers Centre for Heart Research, University Health Network, Toronto, Ontario, Canada
| | - Carl Laskin
- Department of Medicine, Mount Sinai Hospital, New York, New York
| | - Robert M Hamilton
- Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Linda T Hiraki
- Division of Rheumatology, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Earl D Silverman
- Division of Rheumatology, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Lusia Sepiashvili
- Department of Laboratory Medicine & Pathobiology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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Sapantzoglou I, Fasoulakis Z, Daskalakis G, Theodora M, Antsaklis P. Congenital Heart Block and Its Association With Anti-Ro and Anti-La Antibodies in Pregnancy: A Case Report of a Rare Entity and a Review of the Current Evidence. Cureus 2023; 15:e45832. [PMID: 37881400 PMCID: PMC10593915 DOI: 10.7759/cureus.45832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/23/2023] [Indexed: 10/27/2023] Open
Abstract
Systemic lupus erythematosus (SLE) is a heterogeneous chronic, multisystem, inflammatory autoimmune disorder with variable clinical features, with its manifestations being attributed to the presence of multiple autoantibodies and their subsequent autoimmune reactions. Multiple organs may be involved, with the kidneys, the joints, and the skin being the most common, increasing maternal and fetal morbidity and mortality. Our current article describes the case of a 32-year-old primigravida who was referred to our department after the detection of fetal bradycardia and the strong suspicion of an underlying cardiac abnormality. After a detailed fetal and maternal assessment, the diagnosis of SLE-associated fetal congenital heart block was established, and the appropriate management and treatment were provided, factors that led to the uncomplicated delivery and prompt successful management of an otherwise severely affected fetus. Our work, also, includes a detailed review of the accumulated evidence regarding the association between autoantibodies and congenital heart block, the available screening modalities of the condition, and its potential therapeutic interventions.
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Affiliation(s)
- Ioakeim Sapantzoglou
- Obstetrics and Gynecology, Alexandra Hospital, University of Athens, Athens, GRC
| | | | - George Daskalakis
- First Department of Obstetrics and Gynecology, National and Kapodistrian University of Athens, Athens, GRC
| | - Marianna Theodora
- First Department of Obstetrics and Gynecology, National and Kapodistrian University of Athens School of Medicine, Athens, GRC
| | - Panagiotis Antsaklis
- Obstetrics and Gynecology, National and Kapodistrian University of Athens, Athens, GRC
- Obstetrics and Gynecology, National and Kapodistrian University of Athens, Athens, GRC
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Kotecha MK, Merchant K, Chan CJ, Choo JTL, Gopagondanahalli KR, Zhang DZ, Tan TH, Sundararaghavan S. Endocardial Fibroelastosis as an Independent Predictor of Atrioventricular Valve Rupture in Maternal Autoimmune Antibody Exposed Fetus: A Systematic Review with Clinicopathologic Analysis. Diagnostics (Basel) 2023; 13:diagnostics13081481. [PMID: 37189582 DOI: 10.3390/diagnostics13081481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 04/12/2023] [Accepted: 04/13/2023] [Indexed: 05/17/2023] Open
Abstract
BACKGROUND Neonatal lupus (NL) is a clinical syndrome that develops in the fetus as a result of maternal autoimmune antibodies. Congenital complete heart block (CHB) is the most common manifestation, while extranodal cardiac manifestations of NL, such as endocardial fibroelastosis (EFE) and myocarditis, are rare but more serious. Less is known about this atrioventricular valve rupture due to valvulitis as a consequence of maternal autoantibodies. We have described a case of cardiac neonatal lupus with an antenatally detected CHB patient who developed mitral and tricuspid valve chordal rupture at 45 days of age. We compared the cardiac histopathology and the fetal cardiac echocardiographic findings of this case with another fetus that was aborted after being antenatally diagnosed with CHB but without valvar rupture. A narrative analysis after a systematic review of the literature regarding atrioventricular valve apparatus rupture due to autoimmune etiology along with maternal characteristics, presentation, treatment, and outcome have been discussed in this article. OBJECTIVES To describe published data on atrioventricular valve rupture in neonatal lupus, including clinical presentation, diagnostic evaluation, management, and outcomes. METHODS We conducted a PRISMA-compliant descriptive systematic examination of case reports that included accounts of lupus during pregnancy or in the newborn period that resulted in an atrioventricular valve rupture. We gathered information on the patient's demographics, the details of the valve rupture and other comorbidities, the maternal therapy, the clinical course, and the results. We also used a standardized method to evaluate the cases' quality. A total of 12 cases were investigated, with 11 cases drawn from 10 case reports or case series and 1 from our own experience. RESULTS Tricuspid valve rupture (50%) is more common than mitral valve rupture (17%). Unlike mitral valve rupture, which occurs postnatally, the timing of tricuspid valve rupture is perinatal. A total of 33% of the patients had concomitant complete heart block, while 75% of the patients had endocardial fibroelastosis on an antenatal ultrasound. Antenatal changes pertaining to endocardial fibroelastosis can be seen as early as 19 weeks of gestation. Patients with both valve ruptures generally have a poor prognosis, especially if they occur at close intervals. CONCLUSION Atrioventricular valve rupture in neonatal lupus is rare. A majority of patients with valve rupture had antenatally detected endocardial fibroelastosis in the valvar apparatus. Appropriate and expedited surgical repair of ruptured atrioventricular valves is feasible and has a low mortality risk. Rupture of both atrioventricular valves occurring at close intervals carries a high mortality risk.
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Affiliation(s)
- Monika Kantilal Kotecha
- Department of Paediatric Subspecialties, Cardiology Service, KK Women's and Children's Hospital, Singapore 229899, Singapore
| | - Khurshid Merchant
- Department of Pathology and Laboratory Medicine, KK Women's and Children's Hospital, Singapore 229899, Singapore
| | - Charmaine Jiahui Chan
- Department of Paediatric Subspecialties, Cardiology Service, KK Women's and Children's Hospital, Singapore 229899, Singapore
| | - Jonathan Tze Liang Choo
- Department of Paediatric Subspecialties, Cardiology Service, KK Women's and Children's Hospital, Singapore 229899, Singapore
| | | | - Dyan Zhewei Zhang
- Department of Paediatric Subspecialties, Cardiology Service, KK Women's and Children's Hospital, Singapore 229899, Singapore
| | - Teng Hong Tan
- Department of Paediatric Subspecialties, Cardiology Service, KK Women's and Children's Hospital, Singapore 229899, Singapore
| | - Sreekanthan Sundararaghavan
- Department of Paediatric Subspecialties, Cardiology Service, KK Women's and Children's Hospital, Singapore 229899, Singapore
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Silver R, Craigo S, Porter F, Osmundson SS, Kuller JA, Norton ME. Society for Maternal-Fetal Medicine Consult Series #64: Systemic lupus erythematosus in pregnancy. Am J Obstet Gynecol 2023; 228:B41-B60. [PMID: 36084704 DOI: 10.1016/j.ajog.2022.09.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Systemic lupus erythematosus (SLE) is a chronic, multisystem, inflammatory autoimmune disease characterized by relapses (commonly called "flares") and remission. Many organs may be involved, and although the manifestations are highly variable, the kidneys, joints, and skin are commonly affected. Immunologic abnormalities, including the production of antinuclear antibodies, are also characteristic of the disease. Maternal morbidity and mortality are substantially increased in patients with systemic lupus erythematosus, and an initial diagnosis of systemic lupus erythematosus during pregnancy is associated with increased morbidity. Common complications of systemic lupus erythematosus include nephritis, hematologic complications such as thrombocytopenia, and a variety of neurologic abnormalities. The purpose of this document is to examine potential pregnancy complications and to provide recommendations on treatment and management of systemic lupus erythematosus during pregnancy. The following are the Society for Maternal-Fetal Medicine recommendations: (1) we recommend low-dose aspirin beginning at 12 weeks of gestation until delivery in patients with systemic lupus erythematosus to decrease the occurrence of preeclampsia (GRADE 1B); (2) we recommend that all patients with systemic lupus erythematosus, other than those with quiescent disease, either continue or initiate hydroxychloroquine (HCQ) in pregnancy (GRADE 1B); (3) we suggest that for all other patients with quiescent disease activity who are not taking HCQ or other medications, it is reasonable to engage in shared decision-making regarding whether to initiate new therapy with this medication in consultation with the patient's rheumatologist (GRADE 2B); (4) we recommend that prolonged use (>48 hours) of nonsteroidal antiinflammatory drugs (NSAIDs) generally be avoided during pregnancy (GRADE 1A); (5) we recommend that COX-2 inhibitors and full-dose aspirin be avoided during pregnancy (GRADE 1B); (6) we recommend discontinuing methotrexate 1-3 months and mycophenolate mofetil/mycophenolic acid at least 6 weeks before attempting pregnancy (GRADE 1A); (7) we suggest the decision to initiate, continue, or discontinue biologics in pregnancy be made in collaboration with a rheumatologist and be individualized to the patient (GRADE 2C); (8) we suggest treatment with a combination of prophylactic unfractionated or low-molecular-weight heparin and low-dose aspirin for patients without a previous thrombotic event who meet obstetrical criteria for antiphospholipid syndrome (APS) (GRADE 2B); (9) we recommend therapeutic unfractionated or low-molecular-weight heparin for patients with a history of thrombosis and antiphospholipid (aPL) antibodies (GRADE 1B); (10) we suggest treatment with low-dose aspirin alone in patients with systemic lupus erythematosus and antiphospholipid antibodies without clinical events meeting criteria for antiphospholipid syndrome (GRADE 2C); (11) we recommend that steroids not be routinely used for the treatment of fetal heart block due to anti-Sjögren's-syndrome-related antigen A or B (anti-SSA/SSB) antibodies given their unproven benefit and the known risks for both the pregnant patient and fetus (GRADE 1C); (12) we recommend that serial fetal echocardiograms for assessment of the PR interval not be routinely performed in patients with anti-SSA/SSB antibodies outside of a clinical trial setting (GRADE 1B); (13) we recommend that patients with systemic lupus erythematosus undergo prepregnancy counseling with both maternal-fetal medicine and rheumatology specialists that includes a discussion regarding maternal and fetal risks (GRADE 1C); (14) we recommend that pregnancy be generally discouraged in patients with severe maternal risk, including patients with active nephritis; severe pulmonary, cardiac, renal, or neurologic disease; recent stroke; or pulmonary hypertension (GRADE 1C); (15) we recommend antenatal testing and serial growth scans in pregnant patients with systemic lupus erythematosus because of the increased risk of fetal growth restriction (FGR) and stillbirth (GRADE 1B); and (16) we recommend adherence to the Centers for Disease Control and Prevention medical eligibility criteria for contraceptive use in patients with systemic lupus erythematosus (GRADE 1B).
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10
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Hoda M, Scott W, Sharma K, Duryea E, Ikemba C. Reversal of Fetal Heart Block in Antibody-Positive Mother After Hydroxychloroquine and Dexamethasone. Pediatr Cardiol 2023; 44:727-31. [PMID: 35699754 DOI: 10.1007/s00246-022-02945-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Accepted: 05/31/2022] [Indexed: 10/18/2022]
Abstract
Maternal autoantibody-related complete heart block in the fetus is considered irreversible. During prenatal care for a 25-year-old nulliparous Hispanic woman with newly diagnosed nephrotic-range proteinuria and positive anti-nuclear antigen antibody, complete fetal heart block with a ventricular rate of 60 beats per minute was detected on a fetal echocardiogram at 28-week gestation. A small pericardial effusion and ascites were noted consistent with fetal hydrops. Dexamethasone and hydroxychloroquine were initiated. Fetal rhythm improved to Mobitz type 1 second-degree heart block, with a ventricular rate of 91 beats per minute. The fetus was born prematurely at 34-week gestation with second-degree heart block which improved to first-degree heart block prior to hospital discharge. First-degree heart block persisted at 2 years of age with a P-R interval of 185 ms. Transplacental treatment with dexamethasone and hydroxychloroquine was associated with sustained reversal of complete heart block to sinus rhythm.
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11
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Strasburger JF, Eckstein G, Butler M, Noffke P, Wacker-Gussmann A. Fetal Arrhythmia Diagnosis and Pharmacologic Management. J Clin Pharmacol 2022; 62 Suppl 1:S53-S66. [PMID: 36106782 PMCID: PMC9543141 DOI: 10.1002/jcph.2129] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 07/25/2022] [Indexed: 11/24/2022]
Abstract
One of the most successful achievements of fetal intervention is the pharmacologic management of fetal arrhythmias. This management usually takes place during the second or third trimester. While most arrhythmias in the fetus are benign, both tachy‐ and bradyarrhythmias can lead to fetal hydrops or cardiac dysfunction and require treatment under certain conditions. This review will highlight precise diagnosis by fetal echocardiography and magnetocardiography, the 2 primary means of diagnosing fetuses with arrhythmia. Additionally, transient or hidden arrhythmias such as bundle branch block, QT prolongation, and torsades de pointes, which can lead to cardiomyopathy and sudden unexplained death in the fetus, may also need pharmacologic treatment. The review will address the types of drug therapies; current knowledge of drug usage, efficacy, and precautions; and the transition to neonatal treatments when indicated. Finally, we will highlight new assessments, including the role of the nurse in the care of fetal arrhythmias. The prognosis for the human fetus with arrhythmias continues to improve as we expand our ability to provide intensive care unit–like monitoring, to better understand drug treatments, to optimize subsequent pregnancy monitoring, to effectively predict timing for delivery, and to follow up these conditions into the neonatal period and into childhood. Coordinated initiatives that facilitate clinical fetal research are needed to address gaps in knowledge and to facilitate fetal drug and device development.
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Affiliation(s)
- Janette F Strasburger
- Division of Cardiology, Departments of Pediatrics and Biomedical Engineering, Children's Wisconsin, Herma Heart Institute, and Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Gretchen Eckstein
- Division of Cardiology, Departments of Pediatrics and Biomedical Engineering, Children's Wisconsin, Herma Heart Institute, and Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Mary Butler
- College of Nursing, University of Wisconsin-Oshkosh, Oshkosh, Wisconsin, USA
| | - Patrick Noffke
- Division of Cardiology, Departments of Pediatrics and Biomedical Engineering, Children's Wisconsin, Herma Heart Institute, and Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Annette Wacker-Gussmann
- German Heart Center, Department of Congenital Heart Disease and Pediatric Cardiology Munich, Munchen, Bavaria, Germany
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Buyon J, Saxena A, Friedman D, Izmirly P. To Be or Not to Be Treated: That Is the Question in Managing a Fetus With Cardiac Injury Exposed to Anti-SSA/Ro. J Am Heart Assoc 2022; 11:e025580. [PMID: 35730612 PMCID: PMC9333387 DOI: 10.1161/jaha.122.025580] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Jill Buyon
- Division of Rheumatology Department of Medicine New York University Grossman School of Medicine New York NY
| | - Amit Saxena
- Division of Rheumatology Department of Medicine New York University Grossman School of Medicine New York NY
| | | | - Peter Izmirly
- Division of Rheumatology Department of Medicine New York University Grossman School of Medicine New York NY
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13
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Jaeggi E, Hornberger L, Cuneo B, Moon-Grady AJ, Raboisson MJ, Lougheed J, Diab K, Mawad W, Silverman E. To Be or Not to Be: Surviving Immune-Mediated Fetal Heart Disease. J Am Heart Assoc 2022; 11:e026241. [PMID: 35730606 PMCID: PMC9333378 DOI: 10.1161/jaha.122.026241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Edgar Jaeggi
- Labatt Family Heart Centre The Hospital for Sick Children Toronto Ontario Canada
| | - Lisa Hornberger
- Labatt Family Heart Centre Stollery Children's Hospital University of Alberta Edmonton Alberta Canada
| | - Bettina Cuneo
- Labatt Family Heart Centre Children's Hospital Colorado Denver CO
| | - Anita J Moon-Grady
- Labatt Family Heart Centre UCSF Benioff Children's Hospital San Francisco CA
| | - Marie-Josée Raboisson
- Labatt Family Heart Centre Centre Hospitalier Universitaire Sainte Justine Montréal Quebec Canada
| | - Jane Lougheed
- Labatt Family Heart Centre Children's Hospital of Eastern Ontario Ottawa Ontario Canada
| | - Karim Diab
- Labatt Family Heart Centre Rush University Medical Center Chicago IL
| | - Wadi Mawad
- Labatt Family Heart Centre The Hospital for Sick Children Toronto Ontario Canada
| | - Earl Silverman
- Labatt Family Heart Centre The Hospital for Sick Children Toronto Ontario Canada
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