Search

Objective Little has been published about maternity outcomes from New Zealand’s unique handling of the COVID-19 pandemic. Objectives were to determine obstetric outcomes between the variants, identify risk factors, and whether the changes to healthcare delivery affected pregnancy outcomes. Design This was a case control study comparing singleton pregnancies affected by the Delta and Omicron strains of COVID-19. The COVID 19-free controls were from 2019. Setting & Population The largest tertiary maternity unit in New Zealand providing taxpayer funded healthcare to a multi-ethnic, high deprivation index population with complex health needs. Methods Data were extracted from electronic record systems and further verified by reviewing patient’s notes. The risk of an event was modelled with logistic regression. The multivariate analyses adjusted for known clinical risk factors and other significant differences between the groups. Main Outcome Measures Outcomes of interest included admission for COVID-19, adverse pregnancy outcomes, including placentally-mediated ones. Results In the study population of > 8,000 pregnancies, Delta variant was associated with significantly worse maternal and obstetric outcomes. Fetal anomalies and most placentally-mediated adverse outcomes of pregnancy in the COVID-19 affected cohort did not persist once adjusted for underlying maternal risk factors, except for a 4-fold increased risk of stillbirth. Vaccination was protective against admissions and severe disease (OR 0.19;95%CI 0.11-0.32). Conclusions While the Delta variant has been associated with poorer outcomes, modifications to the delivery of maternity care during the pandemic could have unintended consequences on how patients utilised healthcare; this may have contributed to poorer outcomes.

Invasive Haemophilus influenzae infection during pregnancy can cause preterm birth and fetal loss, but the mechanism is unclear. We investigated 54 cases of pregnancy-associated invasive H. influenzae disease in 52 unique pregnancies in the Auckland region of New Zealand during October 1, 2008‒September 30, 2018. Intraamniotic infection was identified in 36 (66.7%) of 54 cases. Outcome data were available for 48 pregnancies. Adverse pregnancy outcomes, defined as fetal loss, preterm birth, or the birth of an infant requiring intensive/special care unit admission, occurred in 45 (93.8%) of 48 (pregnancies. Fetal loss occurred in 17 (35.4%) of 48 pregnancies, before 24 weeks' gestation in 13 cases, and at24 weeks' gestation in 4 cases. The overall incidence of pregnancy-associated invasive H. influenzae disease was 19.9 cases/100,000 births, which exceeded the reported incidence of pregnancy-associated listeriosis in New Zealand. We also observed higher rates in younger women and women of Māori ethnicity.

In an age where autoimmune rheumatic diseases are successfully managed with biologics, their discontinuation in pregnancy is inadvisable without careful forethought; maternal disease activity is associated with adverse pregnancy outcomes, which has long-term implications for both mother and offspring. We aim to provide clinicians with the necessary tools to facilitate decision-making – when a biologic should be used, when it can be discontinued in pregnancy if appropriate. The pathophysiology of these biologic molecules and their effect on fertility, pregnancy and parturition are discussed. A summary of the 2016 international guidelines (European League Against Rheumatism and British Society in Rheumatology) on biologics in pregnancy has been tabulated; more recent publications are discussed in depth. Data on transplacental-transfer ratios and breastmilk excretion rates are also included. Biologic effects on organogenesis, their implications for the exposed infant in terms of infection risks and vaccination requirements are included, and future directions for research proposed.

Autoimmune diseases affect 5–7% of people, are more common in women of childbearing age, and are frequently encountered in pregnancy. They may remit or improve during pregnancy, but can flare or present in pregnancy. Many women with autoimmune rheumatic diseases have been advised against pregnancy in the past, but this is no longer appropriate with a new generation of pregnancy-friendly disease-modifying antirheumatic drugs and biological agents that afford excellent disease control without compromising fertility. Nevertheless, many women with autoimmune rheumatic diseases are older and have more comorbidities (i.e. hypertension, obesity, diabetes, cardiovascular disease, and so on) when they do attempt pregnancy. This chapter looks at the importance of planned pregnancies with good preconception advice from clinicians knowledgeable in both the disease process and its effects on pregnancy (and lactation), and vice versa.

Cardiovascular events (CVEs) are prevalent in patients with systemic lupus erythematosus (SLE), and it is the young women who are disproportionately at risk. The risk factors for accelerated cardiovascular disease remain unclear, with multiple studies producing conflicting results. In this paper, we aim to address both traditional and SLE-specific risk factors postulated to drive the accelerated vascular disease in this cohort. We also discuss the more recent hypothesis that adverse pregnancy outcomes in the form of maternal–placental syndrome and resultant preterm delivery could potentially contribute to the CVEs seen in young women with SLE who have fewer traditional cardiovascular risk factors. The pathophysiology of how placental-mediated vascular insufficiency and hypoxia (with the secretion of placenta-like growth factor (PlGF) and soluble fms-tyrosine-like kinase-1 (sFlt-1), soluble endoglin (sEng) and other placental factors) work synergistically to damage the vascular endothelium is discussed. Adverse pregnancy outcomes ultimately are a small contributing factor to the complex pathophysiological process of cardiovascular disease in patients with SLE. Future collaborative studies between cardiologists, obstetricians, obstetric physicians and rheumatologists may pave the way for a better understanding of a likely multifactorial aetiological process.

For hypertensive women in CHIPS (Control of Hypertension in Pregnancy Study), we assessed whether the maternal benefits of tight control could be achieved, while minimizing any potentially negative effect on fetal growth, by delaying initiation of antihypertensive therapy until later in pregnancy. For the 981 women with nonsevere, chronic or gestational hypertension randomized to less-tight (target diastolic blood pressure, 100 mm Hg), or tight (target, 85 mm Hg) control, we used mixed-effects logistic regression to examine whether the effect of less-tight (versus tight) control on major outcomes was dependent on gestational age at randomization, adjusting for baseline factors as in the primary analysis and including an interaction term between gestational age at randomization and treatment allocation. Gestational age was considered categorically (quartiles) and continuously (linear or quadratic form), and the optimal functional form selected to provide the best fit to the data based on the Akaike information criterion. Randomization before (but not after) 24 weeks to less-tight (versus tight) control was associated with fewer babies with birth weight P interaction =0.005), but more preterm birth ( P interaction =0.043), and no effect on perinatal death or high-level neonatal care >48 hours ( P interaction =0.354). For the mother, less-tight (versus tight) control was associated with more severe hypertension at all gestational ages but particularly so before 28 weeks ( P interaction =0.076). In women with nonsevere, chronic, or gestational hypertension, there seems to be no gestational age at which less-tight (versus tight) control is the preferred management strategy to optimize maternal or perinatal outcomes. Clinical Trial Registration— URL: https://www.isrctn.com . Unique identifier: ISRCTN71416914.

Key content The authors discuss commencing biologics in pregnancy and the potential side effects. Infection is a particular risk, which may be atypical or present atypically. While there is no evidence of teratogenicity, these drugs cross the placenta and neonatal cord drug levels may exceed those of maternal drug levels. If possible, anti-tumour necrosis factor (TNF) agents should be discontinued midtrimester but the gestation to which each drug can be used is slightly different. Neonates exposed in utero to anti-TNF agents beyond the recommended gestation should not be given live attenuated vaccines for the first 6 months of life and any infections promptly treated. Data are lacking on the long-term effects of biologics on children exposed in utero. However, the benefits of controlling active autoimmune disease in the mother often outweigh the small risk to the exposed infants. Learning objectives To know the biologics most commonly used in pregnancy. To understand the literature regarding safety of the common biologics in pregnancy. To be able to counsel a woman taking a biologic about the potential benefits and risks of taking it at different gestations. To be able to counsel a woman receiving biologics in pregnancy about vaccinations for her baby after birth. Ethical issues Biologic agents are relatively new drugs that are being increasingly used in young women because of their perceived ‘fertility sparing’ benefits despite a lack of high quality evidence. Most women who have been prescribed biologics are often refractory to other treatments, and therefore these agents are required for disease control. The decision to continue or discontinue these drugs in pregnancy, especially late pregnancy, is particularly contentious. The long-term effect of biologics on infants exposed in utero is not known and the decision to use these drugs has to be balanced against the risk of severe maternal flares.

Objective To determine if maternal placental syndromes (MPS) are associated with an increased risk of death from cardiovascular causes in women with systemic lupus erythematosus (SLE). Methods Between 1973 and 2011, women with SLE and a history of pregnancy were identified using linked Swedish population registries. The outcome was death from primarily cardiovascular causes, defined as death from acute coronary syndrome or coronary artery disease, stroke, or peripheral vascular disease. The exposure was MPS, defined as any hypertensive disorders in pregnancy, stillbirth, placental abruption, or delivery of a small-for-gestational-age infant. The association of preterm delivery (delivery at

Background and aims Women with SLE are at greater risk of premature cardiovascular disease and adverse pregnancy outcomes including preterm delivery. In the general population, preterm delivery is associated with an increased risk of maternal cardiovascular events (CVE). Therefore, we sought to determine if preterm delivery was a surrogate marker for accelerated CVE in women with SLE. Methods Utilising linked population-based registries from Sweden between 1973–2011, women with SLE born between 1951 – 1971 were included. Preterm delivery was defined as delivery Results There were 3224 women, median age 49 years (IQR 44–54); 72% had a previous pregnancy and 6% had delivered Those with Conclusions The women with preterm deliveries

Most published cases of cytomegalovirus infection in pregnancy relate to congenital abnormalities in neonates infected in early pregnancy, while the mother remains asymptomatic. We describe a diagnostically challenging case of an immunosuppressed woman with scleroderma who developed deranged liver function tests attributed to intrahepatic cholestasis of pregnancy and haemolysis, elevated liver enzymes and low platelets syndrome but was ultimately found to have disseminated cytomegalovirus. Cytomegalovirus can present in a myriad of ways. Clinicians caring for immunocompromised pregnant women should consider cytomegalovirus as a possible differential diagnosis when reviewing abnormal liver function tests.

OBJECTIVES Women with SLE are at increased risk of cardiovascular events (CVEs), but a relationship with traditional cardiovascular and SLE-specific risk factors has not been established. In unselected populations, adverse pregnancy outcomes linked to maternal-placental syndrome (MPS) are associated with an increased risk of CVEs. However, the effect of MPS on CVEs is unknown in women with SLE. The aim of this study was to determine if MPS increased the risk and accelerated the development of CVEs in women with SLE. METHODS Utilizing Swedish population registries, parous women with SLE were identified. Exposures were the following: MPS defined as hypertensive disorders of pregnancy; small-for-gestational-age; placental abruption and stillbirth; and preterm delivery

As the maternal age increases, and with the emergence of more effective therapies, clinicians are seeing more women with rheumatoid arthritis (RA) contemplating pregnancy. Newer evidence shows that RA remains active in pregnancy; active RA correlates well with adverse obstetric outcomes. Preeclampsia is common, as are operative and preterm deliveries in women with RA. Women with active RA are also more likely to have babies of lower birthweight. This article discusses the latest findings on population-based studies of women with RA and the various drugs used to manage RA. Controversies regarding biological agents are addressed, and guidance on prepregnancy counseling, antenatal care, delivery and breastfeeding based on our experience are detailed here. With appropriate prepregnancy counseling and planning, most women with RA can safely fall pregnant and continue to enjoy good disease control in pregnancy and the postpartum interval.

AIMS The role of CYP pharmacogenetics in the bioactivation of cyclophosphamide is still controversial. Recent clinical studies have suggested a role for either CYP2C19 or CYP2B6. The aim of this study was to clarify the role of these pharmacogenes.

Antiphospholipid syndrome is a heterogenous disorder with many pregnancy-related complications. Despite the refinement of laboratory testing and classification criteria, controversy continues regarding the management of women with antiphospholipid antibodies (aPLs) in pregnancy. This is compounded by the lack of large randomized placebo-controlled trials in pregnancy. This article attempts to address some of the controversies and suggest management guidelines. The issues discussed include: pathogenesis and clinical relevance of aPLs, clinical implications of aPLs for the mother and fetus, management of the different clinical phenotypes of antiphospholipid syndrome and its overlap with systemic lupus erythematosus, treatment options in pregnancy and breast feeding. We review controversies regarding the appropriateness of anticoagulant use in women with recurrent pregnancy losses and aPLs, and issues surrounding heparin dosing regimens. We have also included suggestions for the directions of future studies.

Rheumatologists are increasingly involved in the care of young women who, in the age of biologic therapy, are now gaining control of their rheumatic diseases and attempting pregnancy. With careful planning, most women with rheumatic diseases have successful pregnancies. This article focuses specifically on the highest-risk pregnancies and controversial areas. We discuss the women at risk of complications, the types of maternal and fetal complications, the treatments that can be used in pregnancy (and breastfeeding) and longer-term outcomes that could affect the mother. SLE, RA, ANCA-associated vasculitides, large vessel vasculitis (e.g. Takayasu's) and other CTDs (e.g. scleroderma) are among the conditions covered. The evidence and controversies regarding the recommendations for the use of biologics in pregnancy are discussed. The role of the rheumatologist in pregnancy planning and caring for the pregnant and post-partum woman as part of the multidisciplinary team is discussed.

To determine if maternal placental syndromes (MPS) are associated with an increased risk of death from cardiovascular causes in women with systemic lupus erythematosus (SLE).Between 1973 and 2011, women with SLE and a history of pregnancy were identified using linked Swedish population registries. The outcome was death from primarily cardiovascular causes, defined as death from acute coronary syndrome or coronary artery disease, stroke, or peripheral vascular disease. The exposure was MPS, defined as any hypertensive disorders in pregnancy, stillbirth, placental abruption, or delivery of a small-for-gestational-age infant. The association of preterm delivery (delivery at34 weeks of gestation) with death from cardiovascular causes was also explored. Risk of death from cardiovascular causes was determined using logistic regression, adjusting for the year of first delivery, duration of SLE, number of inpatient admissions, and cardiovascular risk factors.A total of 3,977 women with SLE had 7,410 pregnancies during the study interval. Death from primarily cardiovascular causes occurred in 44 of the 325 women who died (13.5%). The median age at death from cardiovascular causes was 54 years (interquartile range 48-58 years), and these women were more likely to have had hypertension and renal disease. MPS was associated with an increased risk of death from primarily cardiovascular causes (adjusted odds ratio [OR] 2.19 [95% confidence interval (95% CI) 1.14-4.22]), specifically, a history of placental abruption (adjusted OR 5.78 [95% CI 1.61-20.72]). Delivery at34 weeks of gestation, particularly when combined with MPS, was also associated with an increased risk of death from primarily cardiovascular causes (adjusted OR 2.49 [95% CI 1.06-5.85]).MPS in pregnancy is associated with a higher risk of death from primarily cardiovascular causes in women with SLE.

To determine whether women with persistent aPL (12 weeks apart on at least two separate occasions) without a history of thrombosis or adverse pregnancy outcome had the same adverse pregnancy outcomes as those with obstetric APS or unmatched controls.This was a case-control study between 2005 and 2011 where we identified 73 women with persistent aPL and coincidentally the same number with obstetric APS. Unmatched controls were identified from low-risk clinics (ratio 1:4). Women with multiple pregnancies, fetal anomalies, SLE, thrombotic APS and other thrombophilias were excluded.Cases and controls were demographically similar, with the exception of younger controls with fewer medical comorbidities. aPL profiles were similar between aPL and APS. In women with aPL, risk of APS-type complications (odds ratio 1.3; 95% CI 0.6, 2.9) and birthweight distribution (median birthweight on a customized centile was 50.8, interquartile range 26.4-68.9; P0.05) were similar to controls. These findings persisted even after adjustment for maternal age and medical comorbidities.Women with persistent aPL on aspirin had pregnancy outcomes that were similar to controls. These data suggest that in the absence of other risk factors, women with aPL do not need intense antenatal surveillance or modified management in pregnancy.

Systemic lupus erythematosis (SLE) commonly affects women of child bearing-age, and advances in treatment have resulted in an increasing number of women with renal involvement becoming pregnant. Knowledge of the relationship of the condition with respect to fertility and pregnancy is important for all clinicians involved in the care of women with lupus nephritis because they have complicated pregnancies. Presentation of lupus nephritis can range from mild asymptomatic proteinuria to rapidly progressive renal failure and may occur before, during, or after pregnancy. The timing of diagnosis may influence pregnancy outcome. Pregnancy may also affect the course of lupus nephritis. All pregnancies in women with lupus nephritis should be planned, preferably after more than six-months of quiescent disease. Predictors of poor obstetric outcome include active disease at conception or early pregnancy, baseline poor renal function with Creatinine >100 μmol/L, proteinuria >0.5 g/24 hours, presence of concurrent antiphospholipid syndrome and hypertension. In this review the most recent studies of pregnancies in women with lupus nephritis are discussed and a practical approach to managing women prepregnancy, during pregnancy and post-partum is described

The role of CYP pharmacogenetics in the bioactivation of cyclophosphamide is still controversial. Recent clinical studies have suggested a role for either CYP2C19 or CYP2B6. The aim of this study was to clarify the role of these pharmacogenes.We used a combined in vitro-in vivo approach to determine the role of these pharmacogenes in the bioactivation of the prodrug to 4-hydroxy cyclophosphamide (4-OHCP). Cyclophosphamide metabolism was determined in a human liver biobank (n= 14) and in patients receiving the drug for treatment of lupus nephritis (n= 16)In livers of known CYP2C19 and CYP2B6 genotype and protein expression we observed that there was a combined role for both CYP2C19 and CYP2B6 in the bioactivation of cyclophosphamide in vitro. The presence of at least one loss of function (LoF) allele at either CYP2C19 or CYP2B6 resulted in a significant decrease in both V(max) (P= 0.028) and CL(int) (P= 0.0017) compared with livers with no LoF alleles. This dual genotype relationship was also observed in a preliminary clinical study, with patients who had ≥1 LoF allele at either CYP2C19 or CYP2B6 also displaying significantly (P= 0.0316) lower bioactivation of cyclophosphamide. The mean 4-OHCP : CP bioactivation ratio was 0.0014 (95% CI 0.0007, 0.002) compared with 0.0071 (95% CI 0.0001, 0.014) in patients with no LoF alleles at either of these genes.The presence of ≥1 LoF allele(s) at either CYP2B6 or CYP2C19 appeared to result in decreased bioactivation of cyclophosphamide both in vitro and in patients. Further clinical studies to confirm this relationship are warranted.

Pregnancy associated with Wegener's granulomatosis is rare. Therapeutic options are limited. There is a paucity of published literature to guide clinical decision-making in these complex patients. Two cases are presented. Firstly, a 33-year-old woman with generalized Wegener's in remission and off all medications presented with a flare in the third trimester with haemoptysis, raised C-reactive protein and c-anti-neutrophilic cytoplasmic antibody (c-ANCA) levels. Her care was complicated by florid steroid-induced psychosis. With deteriorating disease control, she was treated with pulsed-intravenous cyclophosphamide with a good response. She delivered a healthy baby at 38 weeks. She had a severe postpartum flare. Secondly, a 37-year-old woman with limited Wegener's in remission for the last two years and off all treatment became pregnant after pre-conception counselling. A normal baby was delivered at term. An exhaustive review of all published literature on Wegener's activity in pregnancy is presented along with therapeutic options and recommendations.

Background Young women with SLE are at greater risk for cardiovascular events (CVE) even in the relative absence of cardiovascular risk factors.1 They also have more pregnancy complications.2 We have previously demonstrated that pregnancy complications related to maternal-placental syndrome (MPS) are associated with an increased risk and accelerated development of CVE in parous women with SLE.3 However, it is still unknown if pregnancy and its complications – in the form of MPS - accelerate CVE in women with SLE or if SLE-related morbidity plays a more significant role. Objectives To determine if parity and pregnancy complications were associated with accelerated development of CV events in women with SLE. Methods Utilizing linked Swedish population registries, women with SLE born between 1951-71 were included. MPS was defined as hypertensive disorders of pregnancy, small-for-gestational-age, stillbirth and placental abruption. SLE-related morbidity was defined as inpatient admissions, renal disease, malignancies and infections. Outcome was any CVE, this included coronary artery disease, stroke, peripheral vascular disease and death from these causes. Hazard was determined using Cox proportional-hazards adjusting for cardiovascular risk factors and SLE-related morbidity. Survival was assessed using Kaplan-Meier9s methods. Results Of 3232 women with SLE identified, 2317 (72%) were parous. Median age was 49 years. Compared to the parous women, the non-parous women had more SLE-related morbidity [LM1], cardiovascular risk factors and CVE (15.1 vs. 8.5 [LM2] %). Amongst the parous women 23.3% (n=539) had a history of MPS. The incidence of CV events was highest amongst the non-parous group at 3.4 per 1,000 person-years (95%CI 2.91-4.07) followed by those who had pregnancies complicated by MPS (2.8 per 1,000 person-years (95% CI 2.2-3.6)). Hazard of a CVE was 2.2-fold higher in the non-parous group (HR 2.2; 95%CI 1.7-2.8) compared to 1.8-fold increase in those with MPS (HR 1.8; 95%CI 1.3-2.4). This hazard persisted after adjustment. The probability of a CVE-free survival was lowest in the non-parous group even when compared to those with MPS (p Conclusions Pregnancy and its complications do not accelerate CVE to the same extent as SLE-related morbidity – which is more prevalent in the non-parous group. Non-parous women with SLE had the highest incidence and hazard of CVE; they developed accelerated CVE even when compared with women who have had a history of MPS complicating their pregnancies. It is possible that the more severe SLE that accelerates the development of CVE may also reduce fertility and the chances of successful pregnancy. References Manzi S, et al. Am J Epidemiol 1997;145:408-15. Chakravarty EF, et al. Arth Rheum 2006;54:899-907. Soh MC, et al. Ann Rheum Dis 2014;73:137. Acknowledgements We would like to thank the Rose-Hellaby Medical Scholarship, BMFMS Bursary and APLAR Research Grant for the support of Dr. MC Soh. Disclosure of Interest None declared

Background Young women with systemic lupus erythematosus (SLE) have a higher risk of cardiovascular disease (CVD). In unselected populations, maternal-placental syndrome (MPS) increases the risk of CVD. Aims To determine if the history of MPS increases the risk of CVD in this high risk population. Methods Using linked population-registries from Sweden, parous women with SLE were identified between 1973–2011. The outcome of interest was CVD, which encompassed coronary artery disease (CAD), stroke and peripheral vascular disease (PVD). MPS was defined as pre-eclampsia, small-for-gestational-age (SGA), placental abruption or intrauterine death (IUD). Multivariate analysis was performed adjusting for duration of SLE and maternal co-morbidities Results There were 7,410 pregnancies in 3,977 women. The prevalence of CVD was 9% (n = 359), of which CAD accounted for 51.8% (n = 186), stroke 43.5% (n = 156) and PVD 18.9% (n = 68). MPS was not associated with CVD in multivariate analysis (adjusted OR1.2; 95% CI 0.9–1.5). The only features of MPS that were associated with CVD were IUD (adjusted OR1.8; 95% CI 1.0–3.3) and SGA (adjusted OR 1.4; 95% CI 1.0–1.9). Conclusion Risk of CVD was not increased in women with SLE who had a history of MPS unless IUD or SGA occurred.

Background Young women with systemic lupus erythematosus (SLE) have a higher risk of cardiovascular disease and death from cardiovascular causes (CVDD) even in the absence cardiovascular risk factors. 1 Women with SLE are at greater risk of pregnancy complications from placental insufficiency as a result of vasculopathy that manifests clinically as maternal-placental syndrome (MPS). 2,3 In unselected populations, the risk of CVDD is increased two-fold in women with previous history of MPS. 4 This could be shared pathophysiological processes between MPS and future CVDD that have been unmasked by the stress of pregnancy, or pre-existing cardiac risk factors for more generalised vascular disease that are present in women who develop MPS. 5 However, it is not known if MPS increases the risk of future CVDD in the young women with SLE. Objectives To determine the future risk of CVDD in women with SLE who have had pregnancies complicated by MPS. Methods Using linked population registries from Sweden, parous women with SLE were identified between 1973-2011. The outcomes of interest were CVDD, this encompassed main cause of death or disease from coronary artery disease (CAD), stroke and peripheral vascular disease (PVD). MPS was defined as pre-eclampsia, small for gestational age (SGA), placental abruption or intrauterine death. Multivariate analysis was performed adjusting for duration of SLE and co-morbidities that were renal disease, hypertension and diabetes. Results There were 7,410 pregnancies in 3,977 women. Prevalence of cardiovascular disease was 9.0% (n=359) of which CAD accounted for 51.8% (n=186), stroke 43.5% (n=156) and PVD 18.9% (n=68). The median age of onset of cardiovascular disease was 50 years (IQR 41-57). There were 47 women with cardiovascular pathology documented as the main cause of death; CAD accounted for 66.5% (n=31), stroke 23.4% (n=11) and PVD 4.3% (n=2). Median age of death from cardiovascular causes was 53 years (IQR 46-58). Overall, the median age of CVDD was 50 years (IQR 41-57). The risk of CVDD was not significantly increased in those with a history of MPS (Adjusted OR 1.2; 95%CI 0.9-1.5), but there was a two-fold increase risk of CVDD in women with history of intrauterine deaths (Adjusted OR 1.9; 95%CI 1.1-3.3). These associations were independent of SLE disease status at the time of pregnancy (p>0.05). Conclusions Unlike reports from the general population, the risk of CVDD in women with SLE was not affected by MPS in pregnancy unless intrauterine death was present. References Urowitz M, et al. J Rheumatol 2007;34:70-75. Clowse M, et al. Am J Obstet Gynecol. 2008;199:127e1.6. Magid MS, et al. Am J OG179: 226-34. Bellamy, L, et al. BMJ 2007;335:974. Magnussen EB, et al. BMJ 2007;335:978. Acknowledgements The Rose-Hellaby Medical Trust Scholarship and the APLAR Fellowship grant for the support of Dr. May Ching Soh. Ms. Alexandra Gillett for data linkage of the databases. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.3286

Background In the absence of a defining history, aPLs are of uncertain clinical significance. Aim To compare obstetric outcomes between women with aPL and APS. Study design Retrospective cohort study of women with known aPL attending the Obstetric Medicine Clinic, 2005-2011. Women were classified as aPL or obstetric APS (by 2006 classification criteria). Multiple pregnancies, APS diagnosed post-partum, thrombotic APS and secondary APS were excluded. Results Of 161 pregnancies in 112 women, 80 (48.5%) were aPL and 81 (51.5%) were obstetric APS. There were no significant differences in baseline characteristics. The incidence of pre-eclampsia (PET) was 6.2% (n=10), early PET 3.7% (n=6) and abruption 3.1% (n=5). Low molecular weight heparin (LMWH) was not protective against SGA (OR 0.92; 95% CI 0.34-2.70), early PET (OR 0.45; 0.09-2.33) or abruption (OR 0.69; 0.11-4.28). In women with aPL the risk of SGA (OR 0.20; 0.06-0.62) was lower compared to APS. There were similar trends in the risk of early PET (OR 0.19; 0.02-1.69) and abruption (OR 0.24; 0.03-2.23). These associations persisted following adjustment. Conclusion Women with aPL have infants with higher birthweight and better obstetric outcomes that were not improved by LMWH. LMWH is not indicated in aPL pregnancies.

A 28-year-old man with a bicuspid aortic valve presented with facial droop and slurred speech with several months of constitutional symptoms of night sweats, weight loss and productive cough. Examination confirmed aortic regurgitation, palpable spleen and left facial droop. Multiple peripheral blood cultures were negative. Inflammatory markers, cytoplasmic staining antineutrophil cytoplasmic antibodies (cANCA) and anti-PR3 antibody were all elevated. MRI of the brain and CT of the chest and abdomen confirmed embolic infarcts to brain, kidney and spleen. Transoesophageal echocardiogram (ECG) showed valve vegetations and severe aortic regurgitation. Endocardial Wegener's granulomatosis was considered. Aortic valve replacement was performed. Grindings from aortic valve leaflets were analysed for rpoB gene, which confirmed the presence of Bartonella henselae. Serological assays demonstrated B henselae IgM 20 (normal 2048 (normal < 64). The patient completely recovered after prolonged antibiotic treatment. Culture-negative infective endocarditis may mimic vasculitis and be associated with positive cANCA. Serology and molecular techniques may aid diagnosis.

β blockers may precipitate circulatory collapse in thyrotoxic patients with low output heart failure