http://www.revistadechimie.ro REV.CHIM.(Bucharest)♦ 69♦ No.8♦ 20182300

* e-mail: anca_musetescu@yahoo.com #Authors with equal contribution to the manuscript and share first authorship.

BIiochemical Markers in Pregnancy Associated withSjogren’s Syndrome and Thrombophilia

ANCA DANIELA BRAILA1#, ADRIAN NEACSU2#, ANCA EMANUELA MUSETESCU3*, ELENA LUMINITA VIRCAN4,ALESANDRA FLORESCU3, ANA MARIA BUMBEA5

1University of Medicine and Pharmacy of Craiova, Department of Obstetrics and Gynecology, 2-4 Petru Rares Str., 200349,Craiova, Romania2 Carol Davila University of Medicine and Pharmacy, Department of Obstetrics-Gynecology and Neonatology, 37 Dionisie LupuStr., 020021, Bucharest, Romania3 University of Medicine and Pharmacy of Craiova, Department of Rheumatology, 2-4 Petru Rares Str., 200349, Craiova, Romania4Department of Allergology and Clinical Immunology, Clinical Institute Fundeni,258 Fundeni Str., Bucharest, Romania5 University of Medicine and Pharmacy of Craiova, Department of Medical Rehabilitation, 2-4 Petru Rares Str., 200349, Craiova,Romania

Sjögren’s syndrome (SS) is a multisystemic disease mainly characterized by the hypofunction of the lachrymaland salivary glands and can be either primary or secondary, when related to other autoimmune pathologies.We present the case of a 35-year-old female admitted in the Department of Obstetrics and Gynecology forpregnancy monitoring. The patient had a personal history of a spontaneous abortion one year prior toadmission at 5 months of gestation and a maternal history of SS. A multidisciplinary approach with solidobstetrical, rheumatological and neonatal monitoring is essential for best outcomes of the mother and fetus.An early detection of maternal and fetal immune-mediated threats and judicious use of medication isessential in women with autoimmune diseases who plan conceiving.

Keywords: Sjögren’s syndrome, thrombophilia, pregnancy, multidisciplinary approach

Sjogren’s syndrome (SS) is a multisystemic diseasemainly characterized by the hypofunction of the lachrymaland salivary glands and can be either primary or secondary,when related to other autoimmune pathologies [1]. Theclinical manifestations are both glandular consisting ofxerostomia, xerophthalmia, swelling of the parotid andsubmandibulary glands and extra-glandular such asarthritis or arthralgias, vasculitis, Raynaud phenomenon,respiratory, gastrointestinal, neurological, hematologicaland renal involvement [2,3].

Mainly a women’s disease, with a female: male ratio of9:1 and a prevalence in the general female population of0.1 – 4.8%, SS is the perfect example of sex hormones’involvement in the disease pathogenesis. Estrogens-deficient individuals provide inefficient protection ofglandular acinar cells against apoptosis and effectiveclearance, leading to failure of self-tolerance andautoimmunity engagement. Several recent studies reportthe probability of pregnancy associated complications inwomen with SS as well as on disease outcome. While SSdoes not influence fertility, the presence of anti-Ro (anti-SS-A) and/or anti-La (anti-SS-B) antibodies asimmunological hallmark of the disease, the disease activityand subsequent treatment may significantly impact fetaland maternal outcome [4, 5].

Anti-Ro and anti-La antibodies are of particularimportance due to the association with congenital heartblock (CHB), neonatal lupus (NL), spontaneous abortions,intrauterine growth restriction (IUGR) and increasedfrequency of cesarean delivery. These antibodies areconsidered to be a model of the transplacentar acquiredautoimmune phenomenon as they start crossing theplacenta around 16 weeks of gestation and are responsibleof the immune –mediated attack of the cardiac conductionsystem and able to induce myocarditis, arrhythmias,endocardial fibroelastosis or cardiomyopathy in the fetus.The presence of anti-Ro/SS-A antibodies in the first

pregnancy determines a 1-2% risk of CHB and substantiallyhigher of 10-20% with subsequent pregnancies if the firstchild is affected, and more strongly associated with thepresence of anti-52kDa Ro/SS-A and anti -La/SS-Bantibodies rather than with anti-60kDa Ro/SS-A antibodies[6].

Experimental partCase report

We present the case of a 35-year-old female admittedin the Department of Obstetrics and Gynecology for aregular medical examination. The patient had a personalhistory of a spontaneous abortion one year prior toadmission at 5 months of gestation and a maternal historyof SS.

The local exam revealed vulva and vagina withpregnancy-specific hormone impregnation, cervix withexternal orifice in the transverse slit with no macroscopiclesions. The vaginal exam combined with abdominalpalpation showed a cervix with closed external orifice,enlarged globular uterus, specific for a 9-week pregnancy,unpainful. The ultrasonographic examination revealed anintrauterine gestational sac with a live, unique 9-week fetus.

Following the anamnesis and the clinical examinationthe diagnosis of secundiparous, pregnancy of 9 gestationalweeks in evolution, with living, unique fetus is established;spontaneous abortion with fetal mortality at 5 months inthe past. As an attentive anamnesis identified the presenceof oral dryness and the maternal history of connectivetissue disease, in this regard, besides the paraclinicalpregnancy-specific investigations, autoimmune tests anda rheumatologic evaluation were imposed.

Routine hematological investigations showed bloodgroup AB (IV), Rh positive, complete blood count andcoagulogram in normal parameters. Biochemical assayshave revealed minor changes in serum sodium of 135.6mmol / L and the albumin / globulin ratio 1.34 (normal

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range 1.39-2.23). The TORCH profile for toxoplasma,rubella, cytomegalovirus and herpes virus was negative,as well as HIV and hepatitis B and C testing. Double andtriple test for prenatal screening showed a decreased riskfor trisomy 21, trisomy 18 and neural tube defects.

Taking into account the history of pregnancy loss weruled out the possibility of an associated antiphospholipidsyndrome: lupus anticoagulant, anticardiolipin antibodiesand anti-β2GPI were negative.

Thrombophilic profile has been highlighted by factor VLeiden mutation-positive heterozygous mutation ofprothrombin (factor II) -positive, heterozygous MTHFRgene, the mutation-C677T heterozygous genotype, A1298Cmutation-negative, PAI-1 gene heterozygous genotype.Normal values for antithrombin III 128% (normally over80%), protein C 107% (normally 70-130%), protein S 77%(normally 55-140%) were registered.

The clinical rheumatological examination revealedxerostomia and xerophthalmia with a positive Schirmertest and mild arthralgias of the small joints of the hands.

Specific autoimmune laboratory evaluation of the patientis figured in table 1 (table 1).

Ultrasound of the parotid glands was performed andrevealed an aspect of bilateral inhomogeneity of thesalivary parenchyma, through the presence of multiplehypoechoic areas larger than 2mm, of round-ovalar shape,

by diminishing the presence of arthralgias. Baby-aspirin75mg/day was administered for thrombophilia associatedrisk. At 26 weeks, treatment of interphalangeal arthralgiaof the hands associated with marked inflammatorysyndrome is intended by the administration of anti-inflammatory medication, but without a positive result. Inthis case, treatment with dexamethasone is restored aswell as with hydroxychloroquine with a definite beneficialeffect. Clinical and paraclinical monitoring has beensystematically performed, taking into account maternal-fetal prognosis under such circumstances. Fetalantepartum monitoring has as targets fetal biometry, heartrate, fetal movement and respiration, placental appearanceand amniotic fluid production. On the other hand,rheumatological evaluation followed the haemo-leucogram, titer of anti-Ro, La antibodies and RF,complement C3 and C4 values, glandular and extra-glandular involvement.

The case was completed in terms of backgroundpathology and gestation completion at 35 gestationalweeks, through cesarean surgery, with a live fetus, offemale sex, 2330 g, Apgar score of 9. The postoperativeoutcome for both the fetus and the mother was very good.At the patient’s request, we practiced bilateral fallopiantubal ligature with concomitant cesarean surgery.

well-defined, with microcystic or cribriform appearance,normal glandular volume, imprecise posterior margin,corresponding to stage 3 sialadenitis (fig.1).

At 16 weeks of gestation, associated thrombophilia andprimary SS was diagnosed according to 2016 ACR/EULARClasiffication Criteria for Primary Sjögren’s Syndrome.

Being considered at-risk pregnancy, not only for fetalloss but mostly for CHB in a mother anti-SS-A positive,frequent monitoring by serial obstetric sonograms withechocardiograms were performed between 16 to 24 weeksof gestation and thereafter. In order to prevent CHB andmostly to decrease high titer maternal antibodies and theirplacental transfer dexamethasone treatment is instituted,with a beneficial effect for both the fetus and the mother

Table 1SPECIFIC AUTOIMMUNE

LABORATORY EVALUATION

Fig. 1 (A, B, C, D): Right parotid gland -grey scale (A) and power Doppler (B)with marked inhomogeneous patternand hypervascualarity . Left parotid

gland -grey scale (C) and powerDoppler (D) -the same cystic aspectwith grade 2 power Doppler signal

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Fig. 2 (A, B, C, D): A, B, C – Purpuric lesions located on the leftcalf, D -Purpuric lesions located on the right foot

Currently, the baby is clinically healthy, with cardiologicspecific investigations without pathological changes.

At 2 weeks postpartum the patient developed rightparietal ictus with remitted left hemiparesis andconvulsions. The patient was admitted to the Departmentof Neurology. The angiography revealed signs of fluxturbulences through the right parietal cortical veins andminimal bleeding at the level of the right parietal girus. Thepatient was started on methylprednisolone 16 mg per day,hydroxychloroquine 400 mg per day and enoxaparin 40mg per day.

Six months later the patient developed purpura locatedat the lower limbs and other smaller eruptions on the armsand abdomen. The laboratory tests showedcryoglobulinemia, high ESR, low C3 and C4 complement,high titers of anti- Ro and La antibodies, negative lupusanticoagulant and anticardiolipin antibodies, as figured intable 1. The patient was started on high doseglucocorticoids, azathioprine 100 mg per day,hydroxychloroquine 400mg per day and plasmapheresiswith disappearance of purpuric lesions and favorableresponse of Sjögren syndrome (fig. 2).

thyroiditis [8]. The stimulation of T helper 2 cells leads tothe increased secretion of interleukins 4, 6 and 13.Pregnancy hormones alter the immune cell response,estrogens increase the response of T cells, androgensdecrease it, while progesterone has an immunosuppressiveeffect [9].

Some immune-mediated diseases may be activated asa result of anterior pregnancies. The fetal cells and DNAare detectable in the maternal blood since the beginningof the pregnancy. Fetal cells can persist in the maternalblood and organs even after birth and can stimulate theautoantibodies or can become grafted into maternaltissues, thus emphasizing on the fact that fetal cells maybe related to the predilection for autoimmune diseases.Grafted fetal stem cells have been found in maternaltissues of women with autoimmune thyroiditis, systemicsclerosis, systemic lupus erythematosus and rheumatoidarthritis.

Autoimmune conditions, mostly systemic lupuserythematosus and SS are likely to severely impact theevolution of a pregnancy [10]. Hereby, we took intoconsideration a case with maternal background of SS,asymptomatic before pregnancy. While most studies reportprimary SS onset before or after pregnancy, in our case thediagnosis was established upon the appearance ofsymptoms during pregnancy. The real onset was mostprobably before, but as cited, SS is a disease with adiagnosis frequently delayed for years, due to somecommon symptoms which may also be encountered inthe general population (dryness, asthenia, diffuse/localizedpain).

SS in pregnancy can either complicate the gestation oraggravate the autoimmune disease in the intra or mostlypostpartum period. In our case, among pregnancy outcomecomplications we mention early delivery at 35 weeks ofgestation, through cesarean section as well as a lowerbirth weight. Although the risk of CHB was consideredincreased in our patient due to the high titer of anti-SS-A/Ro antibodies in the mother, as well as low complementC3, probably the administration of dexamethasonedecreased significantly the transplacentar passage andlowered the titer so their pathogenic influence was notrecorded upon the conduction system. The presence ofanti-Ro and La antibodies in the maternal serum isresponsible for the development of postpartumcomplications such as neonatal lupus and CHB butadministration of fluorinated glucocorticoids that are notinactivated by the placentar hydroxylase significantlyreduce the immune-mediated effect on the nodal tissue,even though the treatment is not routinely recommendeddue to frequent side effects. In this case, we did not recordany maternal or fetal adverse effects related todexamethasone administration [11].

Maternal antibodies can be transported through theplacenta as early as 11 weeks of gestation leading to thedevelopment of cardiac abnormalities, rash, liver andhematological abnormalities. Only the cardiacmanifestations persist after 6-8 weeks post-natal whilethe rest of the features disappear due to the clearance ofantibodies [12].

Several hypotheses of the molecular mechanism leadingto CHB have been proposed, one of the theories acceptedbeing that anti-Ro52 antibody produces disturbances insignal conduction due to the direct impact on the calciumhomeostasis in the fetal heart [13].

Administration of hydroxychloroquine was effective interms of joint involvement, sicca syndrome andconstitutional symptoms. More recently, it is reported to

Results and discussionsPregnancy is associated with the suppression of the

humoral and cellular immunological function in order toallow the implantation of the paternal semiallogenic fetalgraft, non-self to the maternal organism. The pregnancy isboth a pro-inflammatory and an anti-inflammatory state,depending on the trimester. The beginning of the pregnancyis considered pro-inflammatory due to implantation andplacentation processes. The second trimester,characterized by rapid growth and development of thefetus is anti-inflammatory. The birth is defined by an influxof immune cell in the myometrium in order to trigger ananti-inflammatory process [7].

An anti-inflammatory component of the pregnancy isthe suppression of helper 1 and cytotoxic T cells whichdecreases the production of interleukin 2, interferon â andtumor necrosis factor. Pregnancy induces thepredominance of T helper 2 cells to the detriment of Thelper 1 cells, explaining the remission of certainautoimmune diseases during pregnancy such asrheumatoid arthritis, multiple sclerosis and Hashimoto

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decrease inflammatory and immune biomarkers such asESR, CRP, RF and anti-Ro and La antibodies and consideredsafe during pregnancy [14].

As central nervous system involvement is a matter ofconsiderable debate, but with several cases of stroke,transverse myelitis or multiple sclerosis-like diseasedescribed in literature in SS, we interpret the neurologicalevent that occurred 2 weeks postpartum as associated tothe existing thrombophilia, only after the exclusion ofantiphospholipid syndrome [15].

Postpartum outcome of the patient 6 months afterdelivery with increased autoimmune activation, additionof cryoglobulinemic vasculitis in the presence of high titersof RF and low complement was consistent with severalcase reports found in literature that note Sjögren syndromeaggravation following pregnancy [16].

ConclusionsAnti-Ro (SS-A) and anti-La (SS-B) antibodies play an

important role in the diagnosis and monitoring ofautoimmune diseases associated with pregnancy.Dexamethasone treatment was beneficial for both thefetus in preventing CHB and its maturation, as well as forthe mother in alleviating glandular and extra-glandularsymptoms of Sjögren’s disease.

With all the diagnostic and treatment impairments thatthis case has raised during gestation and despite theworsening of the autoimmune disease following delivery,the general condition of the patient and the intrauterinecondition of the fetus was controlled. The fetus wasextracted through cesarean section, with grade Iprematurity and did not require neonatal resuscitation,being adaptable to the very good external environment.

A multidisciplinary approach with tight obstetrical,rheumatological, and neonatal monitoring is essential forbest outcomes of the mother and fetus. An early detectionof maternal and fetal immune-mediated threats and

judicious use of medication is essential in women withautoimmune diseases who plan conceiving.

References1.DINESCU, S. C., FORÞOFOIU, M.C., ANA-MARIA BUMBEA, A.M.,CIUREA, P.L., BUSUIOC, C.J., MUSETESCU, A.M., Rom J MorpholEmbryol, 58, no. 2, 2017, p. 409-4172.ANCUTA, C., GHIORGHE, C.A., CHIRIEAC, R., PENDEFUNDA, A.A.,IORDACHE, C., Rev. Chim. (Bucharest), 68, no.9, 2017, p. 2135-21383.MACOVEI, L.M., CRISTESCU, V., DEBITA, M., DINU, C.A., Rev. Chim.(Bucharest), 68, no.10, 2017, p. 2440-24424.SARWEN, Z.H., S , LENNART, T.H.H., LINDQUIST, P.G., THEANDER,E., Rheumatology, 50, 2011, p. 1612-16175.TINCANI, ANDREOLI, L. , CAVAZZANA, I. , DORIA, A., FAVERO, M.,FENINI, M.G. , FRANCESCHINI, F., LOJACONO , A., NASCIMBENI, G.,SANTORO, A., SEMERARO, F., TONIATI, P., SHOENFELD, Y., BMCMedicine, 11, 2013 p. 936.DE CAROLIS, S., SALVI, S. , BOTTA, A. , GAROFALO, S. , GARUFI, C.,FERRAZZANI, S., DE CAROLIS, M.P., Autoimmunity Reviews, 13, 2014,p. 103–1077.MOR, G., CARDENAS, I., Am J ReprodImmunol, 63, 2010, p. 425–4338.KUMRU, S., GODEKMERDAN, A., KUTLU, S., OZCAN, Z., EuropeanJournal of Obstetrics & Gynecology and Reproductive Biology, 124,2006, p. 164–1679.MICHIMATA, T., SAKAI, M., MIYAZAKI, S., OGASAWARA, M.S.,SUZUMORI, K., AOKI, K., NAGATA, K., SAITO, S., Human Reproduction,18, no. 7, 2013, p. 1523–152810.HERBERTS, C., BARBRO MELGERT, B., VAN DER LAAN, J.W.,FAAS, M., Expert Rev Vaccines., 9, no. 12,2010, p. 1411-142211.SCOFIELD, R.H., Curr Rheumatol Rep., 13, no. 6, p. 482–48812.CHRISTINE CAPONE, C., BUYON, J.P., FRIEDMAN, D.M., FRISHMANW.H., Cardiol Rev., 20, no. 2, 2012, p. 72–7613.ZHOU, K.H., HUA, Y.M., Chin Med J (Engl), 130, no. 23, 2017, p.2863–287114.GUPTA,S., GUPTA, N., Perm J, 21, no. 16, 2017, p. 4715.JISHA, J., NAIR, TEJAS, P., J Clin Exp Dent, 9, no.4, 2017, p. 584-58916.KHALELE, B.A.E.O., Future Dental Journal, 2, no. 2, 2016, p. 94-98

Manuscript received: 07.01.2018