Objective To analyze the impact of different classes of lupus nephritis as risk variables for maternal and fetal adverse outcomes in a cohort of pregnant lupus patients. Methods This is a cohort study with retrospective and prospective data collection, conducted at the University Hospital of State University of Rio de Janeiro, Brazil, from 2011 to 2016. A total of 147 pregnancies of 137 systemic lupus erythematosus patients of whom 66 had lupus nephritis were included. Demographic and clinical features, as well as maternal and fetal outcomes were observed for each nephritis histological class among systemic lupus erythematosus patients and compared with those without nephritis. Categorical variables were expressed as absolute and relative frequencies and numerical variables as means and standard deviation. The chi-square test with Fisher's correction and Student's t-test were used for statistical analysis. A pvalue < 0.05 was considered statistically significant. Results Systemic lupus erythematosus patients with proliferative nephritis (classes III/IV, n = 54) presented more frequent disease flares ( p = 0.02), continuous active disease during pregnancy and puerperium ( p = 0.006), hospitalization due to systemic lupus erythematosus ( p < 0.001), hospitalization not directly associated to systemic lupus erythematosus ( p = 0.04), higher frequency of cesarean delivery ( p = 0.03) and preeclampsia ( p = 0.01) than patients without nephritis. Permanent damage measured by Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index was more frequent in classes III/IV than among the other patients. The frequency of adverse fetal outcomes such as prematurity and admission to neonatal intensive care unit were not different among systemic lupus erythematosus patients with or without nephritis. However, perinatal deaths were more frequent in patients with all classes of nephritis ( p = 0.003). Conclusion Systemic lupus erythematosus patients with proliferative nephritis (classes III/IV) have a higher frequency of adverse maternal outcomes. This is probably due to the major impact of proliferative forms of nephritis on women's global heath, which is corroborated by the higher Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index findings, although we cannot exclude the negative influence of disease activity for the maternal adverse events. The findings indicate a need for further lupus nephritis classification beyond the nonspecific term nephritis in the context of lupus pregnancy as the impact on maternal and fetal outcomes varies according to histological class.

Objective To evaluate mean serum levels of vascular endothelial growth factor (VEGF), placental growth factor (PlGF), and soluble Flt‐1 (sFlt‐1) in pregnant patients with systemic lupus erythematosus (SLE) with inactive disease, active lupus nephritis, and preeclampsia for differential diagnosis between these conditions. Methods Pregnant women with SLE, with singleton pregnancies and no other autoimmune diseases, were classified according to disease activity (inactive SLE and active lupus nephritis) and the presence of preeclampsia. Serum samples were collected within 3 weeks of delivery and frozen for subsequent blinded analysis through the enzyme‐linked immunosorbent assay method. Results A total of 71 women were included, with 41 classified as having inactive SLE (group 1; Systemic Lupus Erythematosus Pregnancy Disease Activity Index [SLEPDAI] score <4), 15 with a diagnosis of active lupus nephritis (group 2, SLEPDAI score ≥4, including renal criteria), and 15 with a diagnosis of preeclampsia (group 3). Patients in group 3 had higher mean levels of sFlt‐1 and lower mean levels of PlGF compared to groups 1 and 2, both findings with statistical significance. The sFlt‐1:PlGF ratio was also significantly higher in patients with preeclampsia, while mean VEGF levels were higher in pregnant woman with active lupus nephritis compared to patients with preeclampsia or inactive SLE. Conclusion Evaluation of serum VEGF, PlGF, and sFlt‐1 levels can differentiate between preeclampsia, inactive SLE, and active lupus nephritis during pregnancy.

This article describes three complicated cases in rheumatology and pregnancy. The first case elucidates the challenges in treating SLE in conjunction with pulmonary arterial hypertension, while the second case features an SLE-affected pregnancy with development of portal hypertension secondary to portal vein thrombosis related to APS. The third case is a pregnant woman with stable SLE who developed thrombotic microangiopathy caused by atypical haemolytic uraemic syndrome, and failed to improve despite multiple measures including biopsy and elective preterm delivery. There are grave and unique challenges for women with autoimmune disease, but adverse outcomes can sometimes be avoided with careful and multidisciplinary medical management. Pre-conception counselling with regard to medications and disease treatment should also include discussion of the advisability of pregnancy, which may be difficult for a patient, but present the best course for optimizing health outcomes.

This study analyzed maternal and fetal outcomes of pregnancies of neuropsychiatric systemic lupus erythematosus patients followed in a reference unit. This retrospective cohort study included 26 pregnancies of patients seen between 2011 and 2015 included with history and/or active neuropsychiatric systemic lupus erythematosus among 135 pregnancies. Three patients had active neuropsychiatric systemic lupus erythematosus at conception, but only one remained with neurological activity during gestation, characteristically related to the inadvertent suspension of medications. Twenty six percent of the newborns were small for gestational age and 40% of live births were premature, with no neonatal death or early complications of prematurity. Preeclampsia was diagnosed in nine pregnancies, with two cases of early severe form that resulted in intrauterine fetal death. Patients with neuropsychiatric systemic lupus erythematosus had more prematurity and preeclampsia compared to patients without neuropsychiatric disease. However, when concomitant lupus nephritis was excluded, the gestational results of neuropsychiatric systemic lupus erythematosus patients were more favorable.

Hepatic encephalopathy (HE) encompasses a variety of neuropsychiatric symptoms, including anxiety and psychomotor dysfunction. Although HE is a frequent complication of liver cirrhosis, the neurobiological substrates responsible for its clinical manifestations are largely unclear. In the present study, male Wistar rats were bile duct-ligated (BDL), a procedure which induces liver cirrhosis, and on the 21 st day after surgery tested in the elevated plus-maze (EPM) and in an open field for anxiety and locomotor activity measurements. Analysis of Fos protein immunoreactivity (Fos-ir) was used to better understand the neurobiological alterations present in BDL animals. Plasma levels of ammonia were quantified and histopathological analysis of the livers was performed. BDL rats showed a significant decrease in the percentage of entries and time spent in the open arms of the EPM, an anxiogenic effect. These animals also presented significant decreases in Fos-ir in the lateral septal nucleus and medial amygdalar nucleus. Their ammonia plasma levels were significantly higher when compared to the sham group and the diagnosis of cirrhosis was confirmed by histopathological analysis. These results indicate that the BDL model induces anxiogenic results, possibly related to changes in the activation of anxiety-mediating circuitries and to increases in ammonia plasma levels.

Implantation of bone substitutes is the treatment of choice for bone defects exceeding a critical size, when self-healing becomes impossible. The use of 3D printing techniques allows the construction of scaffolds with customized properties. However, there is a lack of suitable materials for bone replacement. In this study, maleic anhydride-grafted poly (lactic acid) (MAPLA) was investigated as a potential compatibilizer agent for 3D-printed polylactic acid (PLA)/hydroxyapatite (HA) composites, in order to enhance the physicochemical and biological properties of the scaffolds. The grafting process was performed by reactive processing in a torque rheometer, with the evaluation of the use of different concentrations of maleic anhydride (MA). The success of the grafting reaction was confirmed by titration of acid groups and spectroscopic analyses, indicating the presence of succinic anhydride groups on the PLA chain. Morphological analysis of the PLA/HA 3D scaffolds, using SEM, revealed that the use of the compatibilizer resulted in a structure free from voids and holes. The compatibilization also increased the degradation process. On the other hand, TGA and DSC analyses revealed that the use of a compatibilizer had little effect on the thermal properties of the composite. Most importantly, the samples with compatibilizer were demonstrated to have a minimal cytotoxic effect on human mesenchymal stem cells (MSCs), promoting the osteogenic differentiation of these cells in a medium without the addition of classical osteogenic factors. Therefore, the grafting of PLA/HA composites improved their physicochemical and biological properties, especially the induction of MSC osteogenic differentiation, demonstrating the potential of these scaffolds for bone tissue replacement.

Injured bone tissues can be healed with bone grafts, but this procedure may cause intense pain to the patient. A slow and localized delivery of nonsteroidal anti-inflammatory drugs (NSAIDs) could help to reduce the pain without affecting bone regeneration. The objective of the present study was to use [Mg-Al]-layered double hydroxide (LDH) as a matrix for controlled release of sodium naproxen (NAP). This system could be applied in biomaterial formulations (such as bone grafts) to achieve a local delivery of naproxen. [Mg-Al]-LDH successfully incorporated up to 80% (w/w) of naproxen by the structural reconstruction route, with the [Mg-Al]-LDH interlayer space increasing by 0.55 nm, corresponding to the drug molecule size. The evaluation of the naproxen release kinetics showed that 40% of the drug was delivered over 48 h in aqueous medium (pH 7.4 ± 0.1), indicating the potential of [Mg-Al]-LDH/NAP for local release of naproxen at adequate concentrations. Kinetic modeling showed that the naproxen release process was closely related to the Higuchi model, which considers the drug release as a diffusional process based on Fick’s law. The chemical stability of NAP after the release tests was verified by 1H NMR. The [Mg-Al]-LDH/NAP also exhibited low cytotoxicity toward fibroblast cells (L929 cell line), without modifications in their morphology and adhesion capacity. These results describe a suitable approach for preparing efficient systems for local delivery of nonsteroidal anti-inflammatory drugs for biomedical applications.

Objective The present study aimed to analyse the frequency of premature rupture of membranes (PROMs) among 190 women with systemic lupus erythematosus (SLE) followed up at the Hospital Universitário Pedro Ernesto from 2011 to 2018 and to review the literature on PROM in patients with SLE. Methods A cohort study of SLE patients was conducted by analysing the following variables: sociodemographic characteristics, clinical manifestations of lupus, modified disease activity index for pregnancy, drugs used during pregnancy, intercurrent maternal infections and obstetric outcomes. Additionally, seven electronic databases (PubMed, Embase, Cochrane, Scielo, Scielo Brazil, Virtual Health Library Regional Portal and Google Scholar) were systematically searched. The search was updated on 3 February 2020. Results Infections (relative risk (RR): 3.26, 95% confidence interval (CI): 1.5–6.7, p = .001), history of serositis (RR: 2.59, 95% CI: 1.31–5.11, p = .006) and anti-RNP positivity (RR: 3.08, 95% CI: 1.39–6.78, p = .005) were associated risk factors for PROM, while anti-RNP positivity (RR: 3.37, 95% CI: 1.35–8.40; p = .009) were associated with premature PROM (PPROM). The prevalence of PROM and PPROM was 28.7% and 12.9%, respectively. In the systematic review, the prevalence of PROM and PPROM was 2.7%–35% (I2 = 87.62%) and 2.8%–20% (I2 = 79.56%), respectively. Conclusions PROM, both at term and preterm, occurs more frequently in women with lupus than in the general population. A history of serositis, anti-RN, infections and immunosuppression during pregnancy may increase the susceptibility to PROM. The systematic review did not find any study with the main objective of evaluating PROM/PPROM in women with lupus.