Chapters authored
The Impact of Nailfold Capillaroscopy in the Approach of Microcirculation
Nailfold capillaroscopy (NFC) is a simple, validated, and noninvasive method to assess the microcirculation, through direct visualization of the capillaries. Main patterns are classified, according to Cutolo et al., as scleroderma, further divided into early, active, or late patterns, or nonscleroderma. NFC findings include dilated loops, tortuosities, meandering or bushy capillaries, hemorrhage, or architectural distortion. NFC use has been indicated for the evaluation of Raynaud’s phenomenon (RP), once it permits the distinction between primary and secondary RP. NFC results accounts for diagnostic criteria of systemic sclerosis, but they can also be useful in staging other connective tissue autoimmune diseases, like systemic lupus erythematosus, inflammatory myositis, or vasculitis. The CSURI index uses NFC for prediction of digital ulcer relapse. Recent evidence revealed NFC can also be applied in systemic disorders with vascular involvement.
Part of the book: Vascular Biology
Systemic Lupus Erythematosus Pregnancy
Systemic Lupus Erythematosus (SLE) is an autoimmune disease of unknown etiology that often affects women during childbearing age. Pregnant women with SLE are considered high-risk patients, with pregnancy outcomes being complicated by high maternal and fetal mortality and morbidity. Obstetric morbidity includes preterm birth, fetal growth restriction (FGR), and neonatal lupus syndromes. Active SLE during conception is a strong predictor of adverse pregnancy outcomes and exacerbations of disease can occur more frequently during gestation. Therefore, management of maternal SLE should include preventive strategies to minimize disease activity and to reduce adverse pregnancy outcomes. Patients with active disease at time of conception have increased risk of flares, like lupus nephritis, imposing a careful differential diagnosis of pre-eclampsia, keeping in mind that physiological changes of pregnancy may mimic a lupus flare. Major complications arise when anti-phospholipid antibodies are present, like recurrent pregnancy loss, stillbirth, FGR, and thrombosis in the mother. A multidisciplinary approach is hence crucial and should be initiated to all women with SLE at childbearing age with an adequate preconception counseling with assessment of risk factors for adverse maternal and fetal outcomes with a tight pregnancy monitoring plan. Although treatment choices are limited during pregnancy, prophylactic anti-aggregation and anticoagulation agents have proven beneficial in reducing thrombotic events and pre-eclampsia related morbidity. Pharmacological therapy should be tailored, allowing better outcomes for both the mother and the baby. Immunosuppressive and immunomodulators, must be effective in controlling disease activity and safe during pregnancy. Hydroxychloroquine is the main therapy for SLE due to its anti-inflammatory and immunomodulatory effects recommended before and during pregnancy and other immunosuppressive drugs (e.g. azathioprine and calcineurin inhibitors) are used to control disease activity in order to improve obstetrical outcomes. Managing a maternal SLE is a challenging task, but an early approach with multidisciplinary team with close monitoring is essential and can improve maternal and fetal outcomes.
Part of the book: Lupus