K Mayer-Pickel

Effect of Additional Treatments Combined with Conventional Therapies in Pregnant Patients with High-Risk Antiphospholipid Syndrome: A Multicentre Study

The effect of additional treatments combined with conventional therapy on pregnancy outcomes was examined in high-risk primary antiphospholipid syndrome (PAPS) patients to identify the most effective treatment strategy. The studys inclusion criteria were (1) positivity to lupus anticoagulant alone or associated with anticardiolipin and/or anti-β2 glycoprotein I antibodies; (2) a history of severe maternal-foetal complications (Group I) or a history of one or more pregnancies refractory to conventional therapy leading to unexplained foetal deaths not associated with severe maternal-foetal complications (Group II). Two different additional treatments were considered: oral-low-dose steroids (10-20 mg prednisone daily) and/or 200 to 400 mg daily doses of hydroxychloroquine and parenteral-intravenous immunoglobulins at 2 g/kg per month and/or plasma exchange. The studys primary outcomes were live birth rates and pregnancy complications. A total of 194 pregnant PAPS patients attending 20 tertiary centres were retrospectively enrolled. Hydroxychloroquine was found to be linked to a significantly higher live birth rate with respect to the other oral treatments in the Group II patients. The high (400 mg) versus low (200 mg) doses of hydroxychloroquine (p = 0.036) and its administration before versus during pregnancy (p = 0.021) were associated with a significantly higher live birth rate. Hydroxychloroquine therapy appeared particularly efficacious in the PAPS patients without previous thrombosis. Parenteral treatments were associated with a significantly higher live birth rate with respect to the oral ones (p = 0.037), particularly in the Group I patients. In conclusion, some additional treatments were found to be safe and efficacious in high-risk PAPS pregnant women.

Has there been a change in peripartal maternal mortality in a tertiary care obstetric European center over the last five decades

OBJECTIVE Maternal mortality still remains a significant problem in obstetrics worldwide. Unchanged or even rising maternal mortality has been reported in several countries. The present study analyzed whether the pattern of maternal mortality has changed over the last five decades at the Department of Obstetrics and Gynecology of the Medical University of Graz. STUDY DESIGN Starting in 1981, a registry of maternal deaths was established and regularly updated at our institution based on retrospective data. Between 1963 and 2012, a total of 187,917 women delivered. Thirty-five consecutive maternal deaths were observed and subdivided into 10 year cohorts. METHODS The registry of maternal deaths included deliveries after 28+0 weeks of gestation. Puerperal deaths were defined as deaths up to day 42 post partum. MAIN OUTCOME MEASURES Clinical data from maternal deaths were extracted from hospital records and autopsy reports. RESULTS Maternal mortality rates declined from 35.0, 29.0, 2.4, 13.1 to 3.6 per 100,000 deliveries in the five subsequent periods, respectively. Sixty-six percent of women who died were 30 years or older. The cesarean section rate was 49%. Ninety-one percent of the 35 maternal deaths occurred in women with no significant medical history or risk factors. Seventy-five percent of deaths occurred after the 37+0 weeks of gestation. During all study periods, the prevalence of infections and hemorrhage was highest. The main causes of bleeding were uterine rupture and placental abruption, respectively. CONCLUSION Even nowadays, peripartal maternal deaths occur mainly due to infections and hemorrhage and also in women with no significant medical history.

Angiogenic factors in pregnancies of women with antiphospholipid syndrome and systemic lupus erythematosus

OBJECTIVES An imbalance of angiogenic placental factors such as endoglin, soluble fms-like tyrosine kinase 1(sFlt-1) and placental growth factor (PlGF) has been implicated in the pathophysiology of preeclampsia. This study aimed to evaluate serum levels of sFlt-1, PlGF and endoglin in women with primary and secondary antiphospholipid Syndrome (APS) and systemic lupus erythematosus (SLE) longitudinally through pregnancy. MATERIAL AND METHODS Serum levels of sFlt-1, PlGF and endoglin were measured prospectively at 4-week intervals (from gestational weeks 12-36) in 17 women with primary APS (PAPS), 18 women with secondary APS (SAPS), and 23 women with SLE. RESULTS 6/17 (35%) of women with PAPS, 3/18 (17%) of women with SAPS, and 2/23 (9%) of women with SLE developed early-onset preeclampsia. Women who developed preeclampsia had significantly higher mean sFlt-1 and endoglin levels, higher sFlt-1/PlGF ratios, and lower mean PlGF-levels than women who did not. These changes became statistically significant at 12 weeks for sFlt-1, PlGF and endoglin. DISCUSSION Endoglin, sFlt-1 and PlGF are potential early screening parameters for the development of preeclampsia in pregnant women with autoimmune diseases like APS and SLE.

Comparison of two-risk assessment algorithms for preeclampsia in first trimester with consecutive intake of low-dose aspirin in the high-risk group – an observational study

Abstract We analyzed outcome of women screened for preeclampsia with two different multifactorial risk algorithms (Predictor®Software by PerkinElmer, PerkinElmer, Waltham, MA; PERK-group: n = 214 and Viewpoint® by GE Healthcare, Dornstadt, Germany; VIEW-group: n = 209) in first trimester. Women at high risk for developing preeclampsia were advised to take low-dose acetylsalicylic acid (LDA). Screening positive rates for early onset preeclampsia differed significantly between the two groups (7.9% versus 26.3%; p = 0.000). According the clinical use of screening test criteria, LDA was prescribed in 63 (29.4%) women in the PE-group and 55 (26.3%) in the VP-group (p = 0.516). There were no differences in onset of preeclampsia [4 (1.9%) versus 6 (2.9%); p = 0.540]. No early or severe preeclampsia occurred in the whole population.

Immunologie und Fertilität

K.Mayer-Pickel. Frauen mit einem aktiven Lupus bzw. bei Einnahme teratogener Medikamente sollten über die Notwendigkeit einer Verhütung aufgeklärt werden. Die Auswahl der kontrazeptiven Maßnahme ist von verschiedenen Faktoren bzw. Risikofaktoren (Adipositas, Nikotinabusus, Hypertonie, positive Eigenbzw. Familienanamnese eines Mamma-/Ovarialkarzinoms) abhängig. So sollten Frauen mit SLE und positiven Antiphospholipidantikörpern sowie Frauen mit einem Antiphospholipidsyndrom aufgrund des erhöhten Thromboserisikos keine Östrogen-GestagenKombinationspräparategegebenwerden. In diesen Fällen wäre der Einsatz von reinen Gestagenpräparaten (Cerazette®, Mirena®) bzw. ein Intrauterinpessar

Orbital hemorrhage as a primary manifestation of disseminated intravascular coagulation (DIC) associated with intrauterine fetal death and placental abruption

Abstract Introduction: Disseminated intravascular coagulation (DIC) is a serious complication of obstetric emergencies, and its clinical manifestation occurs in various organs and tissues. Ocular and orbital involvement has been reported only rarely. Presentation of the case: A 15-year-old primigravida complained about loss of vision in the right eye for 3 days. Magnetic resonance imaging showed a retrobulbar hemorrhage. A first diagnosis of pregnancy (estimated gestational age of 23 weeks) was made, and intrauterine fetal death was diagnosed by ultrasound examination. Laboratory workup revealed the diagnosis of DIC. Due to massive vaginal bleeding a cesarean section was performed, and placental abruption was diagnosed intraoperatively. Discussion: The concomitance of intrauterine fetal death and other obstetric complications such as placental abruption might induce a fulminant coagulopathy with severe consequences even with uncommon organ localization.