Autoimmune hemolytic anemia during pregnancy and puerperium: an international multicenter experience.

Relapsing or occurring de novo autoimmune hemolytic anemia (AIHA) during pregnancy or puerperium is a poorly described condition. Here, we report 45 pregnancies in 33 women evaluated at 12 centers from 1997 to 2022. Among the 20 women diagnosed with AIHA before pregnancy, 10 had a relapse. An additional 13 patients developed de novo AIHA during gestation/puerperium (2 patients had AIHA relapse during a second pregnancy). Among 24 hemolytic events, anemia was uniformly severe (median Hb, 6.4 g/dL; range, 3.1-8.7) and required treatment in all cases (96% steroids ± intravenous immunoglobulin, IVIG, 58% transfusions). Response was achieved in all patients and was complete in 65% of the cases. Antithrombotic prophylaxis was administered to 8 patients (33%). After delivery, rituximab was administered to 4 patients, and cyclosporine was added to 1 patient. The rate of maternal complications, including premature rupture of membranes, placental detachment, and preeclampsia, was 15%. Early miscarriages occurred in 13% of the pregnancies. Fetal adverse events (22% of cases) included respiratory distress, fetal growth restriction, preterm birth, AIHA of the newborn, and 2 perinatal deaths. In conclusion, the occurrence of AIHA does not preclude the ability to carry out a healthy pregnancy, provided close monitoring, prompt therapy, and awareness of potential maternal and fetal complications.

Predictors of preterm birth following emergency and ultrasound-indicated cervical cerclage: A retrospective study on 136 singleton pregnancies.

OBJECTIVE: We aimed to retrospectively evaluate obstetric and neonatal outcomes in patients who underwent ultrasound-indicated and rescue cervical cerclage and to identify predictors for cerclage failure and consequent preterm birth (PTB). MATERIALS AND METHODS: We conducted a retrospective analysis on singleton pregnancies between 16 and 27 weeks of gestation who presented with a transvaginal sonographic cervical length (TVS-CL) <25 mm and a previous PTB/second-trimester miscarriage or prolapsed amniotic membranes and/or a TVS-CL <15 mm and underwent cervical cerclage at Mangiagalli Center, Milan, between September 2011 and December 2021. Univariate and multivariate logistic regression analyses were used to identify possible predictive factors of cerclage failure. RESULTS: During the study period, a total of 136 singletons met the inclusion criteria. Overall, 3 % of pregnancies did not reach fetal viability, mostly due to post-cerclage preterm premature rupture of membranes and/or chorioamnionitis. The mean gestational age at delivery was 35.9 ± 4.5 weeks. Neonates were delivered beyond 37 weeks in 63.2 % of cases, between 28 and 37 weeks in 26.5 %, and less than 28 gestational weeks in 10.3 %. At the multivariate analysis, independent risk factors for miscarriage or PTB were cervical length <10 mm (odds ratio, OR 3.44), advanced cervical dilatation (OR 4.76), and in vitro fertilization (OR 4.66). A history of previous miscarriage, premature delivery, and uterine malformations did not increase the risk of post-cerclage delivery before 37 weeks. In the preterm delivery group, 14 % of patients experienced preterm premature rupture of membranes (pPROM) and 10 % had chorioamnionitis, while no case was registered in the term delivery group. A positive vaginal swab at the time of cervical cerclage was not significantly associated with PTB at the multivariate analysis but it emerged as a significant risk factor for both chorioamnionitis (OR 11.03) and pPROM (OR 5.28). CONCLUSIONS: Ultrasound-indicated and rescue cervical cerclage were effective in prolonging pregnancy, even when placed beyond 24 weeks of gestation. Preoperative cervical length of less than 10 mm, advanced dilatation, and in vitro fertilization are associated with an increased risk of cerclage failure. A positive vaginal swab before cerclage is associated with increased rates of intrauterine infectious-inflammatory processes.

Low-molecular-weight heparin in the prevention of unexplained recurrent miscarriage: a systematic review and meta-analysis.

The etiology of recurrent pregnancy loss (RPL) is complex and multifactorial and in half of patients it remains unexplained (U-RPL). Recently, low-molecular-weight heparin (LMWH) has gained increasing relevance for its therapeutic potential. On this regard, the aim of this systematic review and meta-analysis is to analyze the efficacy of low molecular weight heparin (LMWH) from the beginning of pregnancy in terms of live birth rates (LBR) in U-RPL. Registered randomized controlled trials (RCTs) were included. We stratified findings based on relevant clinical factors including number of previous miscarriages, treatment type and control type. Intervention or exposure was defined as the administration of LMWH alone or in combination with low-dose aspirin (LDA). A total of 6 studies involving 1016 patients were included. The meta-analysis results showed that LMWH used in the treatment of U-RPL was not associated with an increase in LBR with a pooled OR of 1.01, a medium heterogeneity (26.42%) and no publication bias. Results of other sub-analyses according to country, treatment type, and control type showed no significant effect of LMWH on LBR in all subgroups, with a high heterogeneity. The results highlight a non-significant effect of LMWH in U-RPL on LBR based on moderate quality evidence.Registration number: PROSPERO: ( https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022326433 ).

Treating unexplained recurrent pregnancy loss based on lessons learned from obstetric antiphospholipid syndrome and inherited thrombophilia: A propensity-score adjusted retrospective study.

The efficacy of low molecular weight heparin (LMWH) is well-established in patients with obstetric antiphospholipid syndrome (O-APS). Their role in women with unexplained recurrent pregnancy loss (U-RPL) and late obstetrical complications (intrauterine growth restriction, IUGR and preeclampsia) is controversial. Here we compared rates of miscarriage and late obstetrical complications in RPL patients diagnosed with O-APS (n = 57) or hereditary thrombophilia (n = 25) (both assuming LMWH from the beginning of pregnancy) and in patients with a history of U-RPL (n = 118), assuming or not LMWH, followed at the 'Pregnancy at risk' and 'Recurrent pregnancy loss' outpatient clinics at the San Raffaele Hospital from April 2010 to April 2020. Patients with systemic autoimmune diseases other than primary O-APS were excluded. We tested for bivariate or multivariate associations among adverse pregnancy outcomes, the presence of thrombophilia and LMWH use by using chi-square test, Anova, propensity score adjusted univariate logistic regression and multivariate analysis as appropriate. U-RPL patients assuming LMWH from the beginning of pregnancy (group A) had a significantly lower rate of miscarriage compared to U-RPL patients who were not treated with LMWH (group B) (13 % vs. 41 % respectively, p 0.001) and similar pregnancy rates compared to both O-APS patients with a history of RPL taking LMWH (group C, 18 %) and RPL patients with thrombophilia and treated with LMWH (group D, 16 %). Our data highlight a protective effect of LMWH on miscarriage in patients with a history of U-RPL. In these patients, LMWH seems as effective as in O-APS and hereditary thrombophilia in reducing RPL.

Low incidence of intrauterine growth restriction in pregnant patients with systemic lupus erythematosus taking hydroxychloroquine.

Systemic lupus erythematosus (SLE) preferentially affects women of childbearing age. Miscarriages or fetal death, intrauterine growth restriction (IUGR), preterm delivery, preeclampsia and disease flares complicate pregnancy in SLE patients. Treatment is challenging due to the need to prevent disease exacerbations and limit obstetrical complications, while showing an acceptable safety profile for both the mother and the fetus. We collected data from 74 pregnancies in 53 SLE patients prospectively followed in a dedicated 'Pregnancy at risk' outpatient clinic from 2003 to 2019. Out of 74, 45 pregnancies patients were treated with hydroxychloroquine (HCQ). Mothers under HCQ therapy (HCQ+ patients) and those who did not receive HCQ (HCQ-) were homogeneous in terms of age and comorbidities. Disease activity prior to conception was slightly higher in HCQ+ patients. No significant difference was observed in terms of obstetrical history. In patients achieving a viable pregnancy, the rate of IUGR (4/39, 10% in HCQ+ vs 8/25, 32%, in HCQ- patients, p < .05) was significantly lower in HCQ+ patients. Conversely, HCQ+ patients displayed a significantly longer time to delivery (37.8 ± 1.72 vs. 36.3 ± 4.11 in HCQ- patients, p < .05). HCQ is safe in pregnant patients with SLE and protects against obstetrical complications.