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   2016| November  | Volume 11 | Issue 6  
    Online since November 22, 2016

 
 
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REVIEW ARTICLES
Neonatal lupus: An update
Sathish Kumar
November 2016, 11(6):139-144
DOI:10.4103/0973-3698.194548  
Neonatal lupus erythematosus (NLE) is a syndrome that usually presents in the fetus or neonates that is caused by transplacental passage of autoantibodies from the mother. It is a clinical spectrum of cutaneous, cardiac, and systemic abnormalities observed in the newborn or infants whose mothers have autoantibodies against Ro/SSA and/or La/SSB. Congenital complete heart block is the most serious manifestation of NLE that can develop in utero or after birth. Multidisciplinary team involvement is indicated. This article will provide an overview the presentation of NLE and will review the evidence for current therapies.
  8,407 939 1
Fertility and pregnancy in systemic lupus erythematosus
Alexis Jones, Ian Giles
November 2016, 11(6):128-134
DOI:10.4103/0973-3698.194546  
Systemic Lupus Erythematosus (SLE) is a chronic multisystem autoimmune disease with a heterogeneous pattern of clinical and serological manifestations. The predilection for women, particularly of childbearing age, combined with improved survival has led to increasing numbers of women with lupus considering pregnancy. Management of pregnancy in SLE however, requires careful planning and close medical and obstetric monitoring to ensure optimal outcomes. This review, discusses possible causes of subfertility, issues regarding contraception and family planning as well as management of lupus during pregnancy and outcomes in pregnant women with SLE.
  4,580 497 -
Antiphospholipid syndrome in pregnancy
Anisur Rahman
November 2016, 11(6):117-121
DOI:10.4103/0973-3698.194543  
Antiphospholipid syndrome (APS) is an autoimmune condition, in which antiphospholipid antibodies (aPL) cause clinical features including thrombosis, fetal loss, and preterm delivery. Studies in large numbers of patients with APS show that they suffer both early and late fetal loss as well as complications of pregnancy such as preeclampsia. The fetal loss in patients with APS is not caused primarily by thrombosis, but by a number of biological effects of aPL that affect implantation of the embryo. These factors are not yet understood fully but include effects on trophoblast cell viability and migration, inflammation at the fetal-maternal interface, and activation of complement. The established management of pregnancy in patients with known obstetric APS is to give daily low-dose oral aspirin plus daily subcutaneous heparin. This gives a live birth rate of over 70%. The trials that led to this form of management being adopted were small but overall do support the use of the heparin/aspirin combination over aspirin alone. There is no definite evidence supporting the use of heparin plus aspirin in patients who are aPL-positive, but who have never suffered any problems in pregnancy. However, patients taking long-term warfarin for thrombotic APS should have this changed to heparin during pregnancy.
  4,078 541 2
Fertility and pregnancy in systemic sclerosis and other autoimmune rheumatic diseases
Vijay K R Rao
November 2016, 11(6):150-155
DOI:10.4103/0973-3698.194550  
Autoimmune rheumatic diseases usually occur in women of childbearing age. In the past, pregnancy in women with autoimmune rheumatic diseases was not considered safe and was discouraged because gestation could worsen maternal disease and vice versa, and the disease could negatively affect the gestational outcome. However, women with rheumatic diseases often wish to have children even when functional disability is present. The great improvement in the systematic approach to pregnancy over the past few decades has allowed an increasing number of affected women to fulfill their family plan. Women should be informed about potential risks related to their disease and also should be reassured that a good pregnancy outcome is possible if conception occurs when they are in a stable remission state, teratogenic medications have been properly withdrawn, and immunosuppressant drugs that are safe in pregnancy have been maintained to prevent disease flare. The interaction of pregnancy and the rheumatic diseases can vary from spontaneous improvement to flare of disease symptoms. Rheumatic diseases differ in regard to the occurrence of complications during pregnancy and to pregnancy outcome. This review describes the maternal course of systemic sclerosis, ankylosing spondylitis, polymyositis and dermatomyositis during pregnancy, fetal outcome, and therapy during pregnancy and postpartum.
  2,756 281 -
Lupus pregnancies: An Indian perspective
Mithun C Mohan, Vinod Ravindran
November 2016, 11(6):135-138
DOI:10.4103/0973-3698.194547  
There are several challenges to a successful pregnancy outcome in patients with lupus in India including unplanned pregnancies, myths and false beliefs related to lupus pregnancies and poor access to dedicated care. Pregnant lupus patients are best managed by a multidisciplinary team consisting of rheumatologist, obstetrician, and other relevant specialists. In this narrative review, we have appraised available literature on the outcomes of pregnancy among lupus patients in India, highlight the lacunae in the care of such patients, and also present perspective of this issue based on our own experience.
  2,361 263 1
Pregnancy and systemic vasculitis
Himanshu Pathak, Chetan Mukhtyar
November 2016, 11(6):145-149
DOI:10.4103/0973-3698.194549  
The systemic vasculitides are rare diseases of vessel wall inflammation. They are classified according to the vessel wall size. Systemic vasculitis is usually diagnosed after the fifth decade of life, except Takayasu arteritis and Bechet's disease which can manifest earlier. The increase in understanding of etiopathogenesis and effective treatment strategies have significantly improved outcomes associated with vasculitis, and more patients are living longer than ever. Primary systemic vasculitis in women of reproductive age group poses a special challenge. The diseases as well as the drugs used in their treatment affect fertility. Vasculitis increases maternal and fetal complications during pregnancy. However, there is some immunological rationale to suggest that normal hormonal and immunological changes in the maternal body may improve the tolerance to certain Th1-modulated syndromes. The successful outcome of pregnancy depends on vasculitis activity status, type of immunosuppressive medications, and maternal comorbidities. The inherent risks and ethical dilemmas of conducting clinical trials in this group of patients remain an obstacle in collecting high-quality evidence. The pregnancy should be monitored closely by a specialist team comprising a rheumatologist, an obstetrician, and other specialties as per organ involvement to ensure a successful outcome.
  2,136 212 -
Nonbiologic disease-modifying antirheumatic drugs in pregnancy
Durga Prasanna Misra, Jignesh Babulal Usdadiya, Vir Singh Negi
November 2016, 11(6):156-162
DOI:10.4103/0973-3698.194551  
Rheumatic disease often affects young females and males in the reproductive age group. Management of these diseases with immunosuppressive disease-modifying antirheumatic drugs (DMARDs) is fraught with potential risks for the developing fetus as well as adverse pregnancy outcomes. In developing countries like India, most patients are treated with conventional DMARDs. We reviewed recent literature on safety during pregnancy for conventional disease-modifying agents, in view of the recently published landmark guidelines of the British Society for Rheumatology and the European League against Rheumatism. Exposure to leflunomide and cyclophosphamide is contraindicated in mothers during pregnancy and preconception phase, and fathers during conception due to risks for the developing fetus. Maternal exposure to methotrexate (MTX) during pregnancy or preconception confers higher risk of adverse pregnancy and fetal outcomes although paternal exposure may not be harmful. Sulfasalazine is safe during pregnancy; however, paternal exposure may reduce fertility, but this is reversible with cessation of the drug. Hydroxychloroquine, azathioprine, cyclosporine, and tacrolimus are compatible with maternal and paternal exposures without evidence for increased risk to the developing fetus. Insufficient data exist regarding safety profile of tofacitinib and apremilast during pregnancy. Rheumatologists should be cautious while starting these drugs in women and men of reproductive age group, and counsel patients accordingly to minimize the risk of adverse fetomaternal outcomes.
  1,975 253 -
PREFACE
Fertility and pregnancy in autoimmune rheumatic diseases
Caroline Gordon, Molly Thabah
November 2016, 11(6):115-116
DOI:10.4103/0973-3698.194539  
  1,459 252 -
CONFERENCE REPORT
International scleroderma symposium: July 16-17, 2016, Bengaluru
Rajkiran Dudam, Balebail G Dharmanand
November 2016, 11(6):163-164
DOI:10.4103/0973-3698.194552  
  1,191 146 -
REVIEW ARTICLES
Fertility and pregnancy in rheumatoid arthritis
Monika Østensen, Marianne Wallenius
November 2016, 11(6):122-127
DOI:10.4103/0973-3698.194544  
Although the peak onset of rheumatoid arthritis (RA) is after 35 years of age, the disease also occurs during the childbearing years and may interfere with reproduction. Several studies have shown that women with RA need a longer time to conceive and have fewer children than expected. The prolonged time to conceive may be related to very active disease and its treatment which requires postponing a pregnancy. A major proportion of patients experience improvement of symptoms during pregnancy; however, patients positive for rheumatoid factor and/or citrullinated protein antibodies have less chance to ameliorate during pregnancy. About 20% of RA patients will remain active during pregnancy and need drug therapy. Pregnancy outcome is, in general, uncomplicated when the patient was in remission at conception and remained quiescent during pregnancy. By contrast, high disease activity and treatment with >10 mg of prednisone/day increase adverse outcomes, particularly premature delivery. Several studies found birth weight within normal range but lower than in children of healthy women. Pregnancy complications are more frequently encountered in a first pregnancy than in subsequent pregnancies. Disease activity relapses in 50%-65% of pregnancies within 3 months after birth necessitating drug therapy during lactation. The management of a patient with a desire of children should include preconception counseling, adjustment of therapy to medications compatible with pregnancy and lactation, and monitoring disease activity throughout. The best condition for a successful outcome is a planned pregnancy in a period of remission or at low disease activity.
  1,076 96 -