SLE, APS, Pregnancy in 1win, Cantonment

N. Dharsshini ¹, S. Booma ²

¹Group Clinical Pharmacist, 1win, Trichy

²Assistant Nursing Superintendent, MAA 1win, Trichy

Abstract

Background: Antiphospholipid antibodies are associated with adverse pregnancy outcomes and particularly with systemic lupus erythematosus (SLE). However, data on pregnancy outcomes in patients with both APS and SLE are limited. This retrospective study evaluates and relates the association of APS, SLE and pregnancy with their outcomes.

Methods: Medical records of ten pregnant patients who were managed in Kauvery hospital Cantonment, Trichy with previous or newly positive APS from the year 2022-2023 were reviewed. Data on maternal demographics, obstetric history, lupus activity, primary or secondary APS during pregnancy, anticoagulation therapy and pregnancy outcomes were collected and analysed.

Results: Among the patients included in the study 20% population had APS positive from 20-25 age category, 40% had APS positive from 25-30 category 20% from 30-35 category and 10% with both APS, SLE from the year 2022-2023. The obstetric history states that 12.5% of pregnant patients had miscarriage 8.33% had preterm labor and preeclampsia 45.8 % had termination and 25% had LSCS. 30% patients with positive APS had miscarriage within 10-24 weeks and 10% with positive APS had miscarriage after 24 weeks in previous pregnancy. 30% of APS positive patients were managed with LMWH and Enoxaparin. 20% with aspirin.10% of SLE and both were treated with Methylprednisolone.

Conclusion: This retrospective study highlights the outcomes and association of pregnant patients with positive APS and SLE. Despite optimal management with anticoagulant therapy and immunosuppressive agents, adverse pregnancy outcomes including recurrent pregnancy loss, miscarriage, preeclampsia remains prevalent. The findings relate the outcomes and the need to further research to identify effective strategies for improving pregnancy in this high-risk patient group.

Background

Antiphospholipid antibodies are associated with adverse pregnancy outcomes and particularly when associated with systemic lupus erythematosus (SLE). However, data on pregnancy outcomes in patients with both APS and SLE are limited.
The association of thromboembolic complications and miscarriages with anticardiolipin antibodies (aCL) were first reported in SLE patients and later without SLE. The latter condition has been classified as primary APS.
The fertility of women with APS is not compromised by antiphospholipid antibodies (APLA), nor is it linked to infertility. But can lead to fewer live births and a greater incidence of miscarriages leading to smaller families.1
APS, SLE and pregnancy pathogenesis involves autoantibodies targeting phospholipid binding proteins (Glycoprotein I and Prothrombin) leading to hypercoagulability, placental insufficiency and adverse maternal outcomes.
One to five percent of healthy women who are of reproductive age have antiphospholipid antibodies. The most common treated acquired thrombophilia during pregnancy is aPL/APS and in recent years, its prevalence has significantly increased. 10–29% of women who experience poor obstetric outcomes are aPL carriers.

Pathogenesis of APS, SLE and Pregnancy

Direct Placental Damage: APS, SLE both can directly damage placental tissues. In SLE autoantibodies and immune complexes can target placental cells and impair functions
Inflammatory Responses: Inflammatory mediators released in SLE & APS, such as cytokines and complement proteins, can contribute to placental inflammation and dysfunction
Thrombotic Microangiopathy: It is more commonly associated with APS; it can lead to placental infarction and foetal compromise.
Endothelial Dysfunction: Both can cause immune mediated endothelial damage, which can occur systemically and within placental insufficiency and adverse pregnancy outcomes.
Angiogenic Imbalance: Dysregulation of antigenic factors, such as vascular growth factor (VEGF). In SLE, abnormal angiogenesis and vascular remodelling can occur in placenta leading to impaired perfusion and foetal growth restriction.

Materials and Methods

A retrospective observational study which evaluates and relates the association of APS, SLE and Pregnancy with their outcomes.
Medical records of ten pregnant patients who were managed in Kauvery hospital Cantonment, Trichy with previous or newly positive APS from the year 2022-2023 were reviewed.
Data on maternal demographics, obstetric history, lupus activity, primary or secondary APS during pregnancy, anticoagulation therapy and pregnancy outcomes were collected and analysed.
All patients positive from the year 2022-2023 were included.
Patients who delivered a baby were only included.

Results

The sample size for the retrospective study of Kauvery hospital Cantonment, from the year 2022-2023, is of n=10. All the data are interpreted and the study reveals the correlation between APLA positive with pregnancy, SLE positive with pregnancy and APLA with SLE. The significance of findings was tested and data interpreted.

1) Age of pregnant patient with APLA

40% patients where within the age category of 25-30 and 30% of population were within 30-35

Age	Frequency(n=10)	Percentage (%)
20–25	3	30
25–30	4	40
30–35	3	30
Above 30	0	0

2) Percentage of APLA patients with obstetric history

Patients with positive APLA and obstetric history were categorized. 12.5% of pregnant patients had miscarriage, 8.33% had preterm labor and preeclampsia. 45.8 % had termination and 25% had LSCS.

3) Population of pregnant patients with APLA, SLE and both in 1win Cantonment in 2023 & 2022

The chart below shows the population of pregnant women who had positive APLA only, SLE only and both from year 2022 to 2023.

20% population had APLA positive from 20-25 age category, 40% had APLA positive from 25-30 category and 20% from 30-35 category.

4) Distribution of patients according to early or late miscarriages in previous pregnancy

	APLA
	Positive	Negative
Less than 10 weeks	10	10
10-24 weeks	30	10
Above 24 weeks	10	0

5) Distribution of patients according to Primary and Secondary Autoimmune aetiology

APLA	Frequency(n=10)	Percentage (%)
APLA, Primary	7	70
APLA Secondary	3	30

6) Distribution of Patients with positive APS, SLE and Management

Discussion

This audit highlights many important points that are commonly encountered in clinical practice around APS, SLE and pregnancy. Our retrospective study describes the percentage of pregnant patients who were positive to APS, SLE and delivered a baby.
APS is a complex disorder and our understanding of its diagnosis and management is continuously evolving. Moreover, the decisions around patient care are influenced by many factors including the patient’s history, clinical presentation, and many other variables in addition to the laboratory results, and the results of this study.²
From the two-year retrospective analysis, there were 20% APS negative who also had early or late miscarriage. But most common reasons were being APS positive. Miscarriage can have many different causes, and although it is closely linked to APS, recurrent miscarriage can also occur for other reasons.^3,4,5
One to five percent of healthy women who are of reproductive age have antiphospholipid antibodies. The most common acquired thrombophilia during pregnancy is APL/APS in recent years, and its prevalence has significantly increased. As a matter of fact, 10–29% of women who experience poor obstetric outcomes are aPL carriers.

Conclusion

This study, highlights the association of patients with positive APS, SLE and their outcomes in kauvery hospital.
The interference with and disruption of trophoblast cells, responsible for implantation and development of the placenta, may have contributed to the miscarriage and adverse outcomes in the study population.
Despite optimal management adverse pregnancy outcomes including recurrent pregnancy loss, miscarriage and preeclampsia remain prevalent.
From this study, we conclude that there were significant obstetric events, APS and SLE that impacted pregnancy outcomes.
These findings state the outcomes. There is need for further research to identify the effective strategies for improving the safety of pregnancy in this high-risk patient group.

Reference

Costedoat-Chalumeau, Z. Amoura, D. Le Thi Huong, B. Wechsler, J.-C. Piette,Plaidoyer pour le maintien de l’hydroxychloroquine dans les grossesses lupiques,La Revue de Médecine Interne, Volume 26, Issue 6. https://doi.org/10.1016/j.revmed.2005.02.012
Branch W. Report of the Obstetric APS Task Force: 13th International Congress on Antiphospholipid Antibodies, 13th April 2010. 2011;20:158–164. doi: 10.1177/0961203310395054.
Regan L, Rai R. Epidemiology and the medical causes of miscarriage.BaillieresBest Pract Res Clin Obstet Gynaecol2000;14: 839–54.
Rai R, Regan L. Recurrent miscarriage.Lancet2006;368: 601–11.
Kaandorp SP, Goddijn M,van der Post JA, Hutten BA,Verhoeve HR, Hamulyák Ket al. Aspirinplus heparin or aspirin alone in women.

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SLE, APS, Pregnancy in 1win, Cantonment