AB0457 IMPROVED PREGNANCY OUTCOMES IN WOMEN WITH SYSTEMIC LUPUS ERYTHEMATOSUS: A RETROSPECTIVE STUDY OF PREGNANCIES FROM A SINGLE CENTER IN DENMARK FROM 2010-2020 COMPARED WITH THE PERIOD 1990-2010

Background

Over the past decades, the approach to follow and treat pregnant SLE patients has changed. Today it is recommended that pregnant patients are monitored closely in a multi-professional team throughout pregnancy (1). The importance of low disease activity before pregnancy and continued treatment during pregnancy has been established (2). Even though many improvements in the management of SLE pregnancies has been made, there is still a high risk of adverse pregnancy outcome (APO).

Objectives

We aimed to evaluate APO in a Danish SLE cohort followed from 2010-2020 and compare the results with a previous study cohort from the same referral area followed from 1990-2010 (3).

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. All patients were followed regularly and fulfilled at least four of the 1997 American College of Rheumatology (ACR) criteria for SLE classification. Data included demographic, clinical, and laboratory data. Demographics included ethnicity, smoking habits, body mass index (BMI), and concomitant APS (recognized before pregnancy). Data were compared with data from a previous study (1990-2010) from the same department.

Results

In total, 66 pregnancies were registered in 41 women. APO occurred in 65 % of pregnancies. Forty-seven pregnancies resulted in a live birth, while 15 ended in miscarriage. Compared to the 1990-2010 cohort, a reduction in preterm deliveries (7.58 % vs. 17.9 %), acute caesarean (6.1 % vs. 15.5 %), and higher average birth weight (3045 g vs. 2870 g) were found (Table 1). Further, we observed more pregnancies and live births per year (Figure 1). A change in the approach to treatment was found, i.e., significantly more patients were treated with hydroxychloroquine (73 %) compared to the 1990-2010 cohort (6 %).

Figure 1.

Pregnancy outcome. Average number of pregnancies and live birth per year in the Aarhus SLE cohort in the period 1990-2010 compared with 2010-2020

Table 1.

Maternal and fetal/neonatal adverse pregnancy outcomes in our study population (2010-2020) compared with previous study at Aarhus University Hospital (1990-2010).

1990-2010 n=842010-2020 n=66p-valuePre-eclampsia/eclampsia, n (%)7 (8.3)8 (12.1)0.59HELLP syndrome, n (%)4 (4.8)0-Gestational hypertension, n (%)20 (23.8)9 (13.6)0.05Preterm deliveries (<37th gestational week), n (%)15 (17.9)5 (7.58)0.07Acute caesarean delivery, n (%)13 (15.5)4 (6.1)0.07Elective caesarean delivery, n (%)11 (13.1)8 (12.1)-Total caesarean delivery, n (%)24 (28.6)12 (18.2)-Total fetal loss, n (%)22 (26.2)19 (28.8)0.72Spontaneous abortion <22 weeks, n (%)18 (21.4)15 (22.7)0.85Therapeutic abortion3 (3.6)4 (6.1)0.47Still birth1 (1.2)0-Fetal death after birth2 (2.4)0-Birth weight, mean ± SD g2870 (SD,NA)3045 ± 611-IUGR10 (11.9)NA-SGANA12 (18.18)-Congenital heart block, n (%)1 (1.2)0-Neonatal Lupus Syndrome, n (%)2 (2.4)0-

Conclusion

Improvements in the frequency of APO were found in 2010-2020 compared with 1990-2010. However, even though a specialized multi-professional team closely follows pregnant women with SLE, pregnancy in SLE still carries a high risk of APO.

References

[1]Andreoli L et al. EULAR recommendations for women’s health and the management of family planning, assisted reproduction, pregnancy and menopause in patients with systemic lupus erythematosus and/or antiphospholipid syndrome. Ann Rheum Dis. 2017;76(3):476–85.

[2]Lateef A, Petri M. Management of pregnancy in systemic lupus erythematosus. Vol. 8, Nature Reviews Rheumatology. Nature Publishing Group; 2012. p. 710–8.

[3]Jakobsen IM et al. Maternal and foetal outcomes in pregnant systemic lupus erythematosus patients: an incident cohort from a stable referral population followed during 1990-2010. Scand J Rheumatol. 2015;44(5):377–84.

Disclosure of Interests

None declared

Cervical occlusion in women with cervical insufficiency: protocol for a randomised, controlled trial with cerclage, with and without cervical occlusion*

OBJECTIVE

To evaluate the effect of double cerclage compared with a single cerclage.

DESIGN

Randomised, controlled multicentre trial.

SETTING

Ten different countries are participating with both secondary and tertiary centres. The countries participating are Denmark, Sweden, Germany, United Kingdom, Spain, South Africa, Australia and India. This gives both a broad spectrum of diversity global and local. We expect a total of 242 women enrolled per year.

POPULATION

Prophylactic study: 1. History of cervical incompetence/insufficiency. (Delivery 15 to <36 weeks.) 2. Congenital short cervix (secondary to maternal administration of diethyl stilbestrol) or traumatic/surgical damage rendering the vaginal approach difficult (e.g. conisation). 3. Cervical suture applied in previous pregnancy, successful outcome. 4. Previous failed cerclage. Therapeutic study: 5. Secondary cerclage: Short cervix, without the membranes being exposed to the vagina. 6. Tertiary cerclage: Short cervix, membranes exposed to the vagina. Observational study: Eligible women who refuse to be randomised will participate in an observational study. 7. Repeat/requested cervical occlusion.

METHODS

The women will be randomised between a single (vaginal or abdominal) and a double cerclage. The cervical cerclage (McDonald or Shirodkar) as well as the abdominal suture will be performed with the same material and technique normally used by the participating department. Those randomised to the double cerclage will have their external os closed with a continuous nylon 2-0/3-0 suture, in addition to the standard single cerclage. Local guidelines concerning antibiotics, Heparin, bed rest, tocolytics etc. are followed and recorded in the follow-up form.

MAIN OUTCOME MEASURES

Primary endpoint is take home baby rate. The secondary endpoints are gestational age at delivery, incidence of preterm birth (<34+0 days) and number of days in neonatal unit.

Could a cervical occlusion suture be effective at improving perinatal outcome?

Cervical weakness and infection have long been regarded as major causes of preterm birth. Cervical cerclage has been used extensively to reduce the risk of preterm birth arising as a result of cervical weakness, but increasing evidence suggests that the cervix plays more than just a mechanical role. Immunological function of the cervix and mucus plug is thought to be important in minimising the ingress of microbes, which can lead to chorioamnionitis and rupture of the amniotic membranes. In this review, we examine the background of traditional cervical cerclage and introduce the concept of the occlusion suture and its potential benefit in reducing the risk of recurrent preterm prelabour rupture of membranes.

An in vitro study of antibacterial properties of the cervical mucus plug in pregnancy

OBJECTIVE

To evaluate whether cervical mucus plugs are antibacterial in vitro.

STUDY DESIGN

Cervical mucus plugs from 56 healthy women in labor were studied by 2 different antimicrobial assays: (1) analysis of the inhibition by the cervical mucus plug of several gram-positive and gram-negative bacteria by overlaying the cervical mucus plug onto an agar plate with imbedded bacteria, and (2) determination of the antibacterial property of the cervical mucus plug material by radial diffusion assay with group B Streptococcus and Escherichia coli.

RESULTS

In the agar overlay assay, there was complete inhibition of clinical isolates of Staphylococcus saprophyticus, E coli, and Pseudomonas aeruginosa and patient-variable partial-to-complete inhibition of Enterococcus faecium, Staphylococcus aureus, Streptococcus pyogenes, and Streptococcus agalactiae. In the radial diffusion assay, cervical mucus plugs had activity toward group B Streptococcus equivalent to 0.075 microg/mL of gentamicin and toward E coli equivalent to 0.5 microg/mL of gentamicin.

CONCLUSION

A low-molecular substance with antibacterial activity in the cervical mucus plug may protect the fetus against ascending infections.

[The value of vaginal swabs]

INTRODUCTION

The use of culture of vaginal secretions by physicians and their use of microscopy of vaginal secretions were assessed.

METHODS

The study was conducted partly as a registration of all microbiological requests and reports from the Department of Clinical Microbiology in a selected period, and partly as a questionnaire sent to all general practitioners (GPs) and specialists in obstetrics and gynaecology in the county of Arhus.

RESULTS

In only 19% of 1,354 vaginal swabs received in a month could the findings lead to a specific antimicrobial treatment; 48% of these cases could be diagnosed by microscopy of vaginal secretions alone. Sixty-four per cent of the physicians returned the questionnaire. Half of the specialists and 60% of the GPs performed microscopy. Twenty-five per cent of the physicians treated patients solely on the basis of clinical symptoms.

DISCUSSION

General culture of vaginal secretions has a limited clinical value. The diagnosis in patients complaining of vaginal discharge can often be made by microscopy. There is, however, a need for training GPs in microscopy, as well as specialists.

Proteoglycans and hyaluronan in human fetal membranes

OBJECTIVE

The aim of this study was to describe the distributions of major extracellular matrix components, such as proteoglycans, collagen and hyaluronan, in the fetal membranes at term.

STUDY DESIGN

Fetal membranes were obtained from elective cesarean deliveries at term. Guanidinium extracts were analyzed for proteoglycans with alcian blue precipitation, sodium dodecyl sulfate- polyacrylamide gel electrophoresis, and Western blotting and for hyaluronan with a radioimmunoassay. Collagen was measured by estimating hydroxyproline content. Tissue sections were immunostained for decorin and biglycan and stained for hyaluronan with a biotin-labeled hyaluronan-binding protein.

RESULTS

The fetal membranes contained predominantly smaller proteoglycans, such as biglycan and decorin. The amnion consisted of typical fibrous connective tissue with a high concentration of collagen. The amnion was dominated by decorin located in close connection with the collagen fibrils. The chorion was composed of a fibroblastic part containing collagen and decorin and a trophoblastic part mainly containing biglycan. In addition, large amounts of hyaluronan were found, especially in the amnion and in the decidual cell layers.

CONCLUSION

The distributions of proteoglycans, collagen, and hyaluronan in human fetal membranes may explain the biomechanical properties of this tissue. We suggest that changes in the relative proportions of these extracellular molecules are crucial for the proposed maturation process in the fetal membranes during the last weeks of pregnancy.

Antibacterial properties of human amnion and chorion in vitro

OBJECTIVE

The purpose of the present study was to explore the direct effects of amnion and chorion on bacterial growth in vitro including the antibacterial spectrum. Chorioamniotic membranes were obtained under sterile conditions from 13 healthy women undergoing elective cesarean section at term. Likewise, chorioamniotic membranes were obtained from 10 healthy women with spontaneous vaginal delivery at term. Five strains of Hemolytic streptococci group B (GBS) were tested and one clinical isolate of the following species or bacterial groups: Hemolytic streptococcus group A, Staphylococcus aureus, Staphylococcus saprophyticus, Enterococcus faecalis, Escherichia coli, Pseudomonas aeruginosa, Acinetobacter calcoaceticus and Lactobacillus species. Bacteriological media included (1) blood-agar medium; (2) a transparent agar medium for submerged cultures; and (3) a nutrient broth medium.

RESULTS

An inhibitory effect of fetal membranes against a range of bacteria was found. Consistent results were obtained in experiments with cultures on agar and cultures suspended in agar (membranes from eight women in both studies). In experiments with liquid cultures (seven women) only chorion showed a marginal inhibitory effect. All strains were inhibited, but the most pronounced inhibition was obtained for streptococcus group A, S. aureus and S. saprophyticus by both chorion and amnion.

CONCLUSION

This study demonstrated an inhibitory effect of the fetal membranes on a diverse panel of bacteria

[Life-threatening puerperal sepsis caused by group A streptococci]

A case of postpartum streptococcal toxic shock syndrome due to group A streptococci is described. The patient suffered multiorgan failure, was critically ill and stayed in the intensive care unit for 18 days before recovering. The patient received massive antibiotic treatment as well as intravenous immunoglobulin therapy. The case is described to draw attention to the reoccurrence of serious group A streptococcal infections.

Chorioamniotic membranes constitute a competent barrier to group b streptococcus in vitro

OBJECTIVE

To study the penetration of group B streptococcus (GBS) through human chorioamniotic membranes in vitro.

STUDY DESIGN

Chorioamniotic membranes from seventeen healthy women were mounted onto glass cylinders and placed in tissue culture trays constituting a two-compartment system with a maternal compartment internally and a fetal compartment externally. GBS from healthy pregnant women and from newborn babies with sepsis were added to the maternal compartment at densities from 10(7) to 10(9) colony forming units (cfu) per ml.

RESULTS

Irrespective of inoculum density, GBS was not recovered from the fetal compartment within a 20 h incubation period. By histology, micro-colonies of GBS were found on the maternal surface after 8 h, but invasion of the morphologically intact membranes was not observed. A five log reduction in cfu occurred in the maternal compartment with amnion when GBS were suspended in saline.

CONCLUSION

In this in vitro model the membranes appear to constitute an effective barrier against ascending infection.