Prospective Evaluation of High Titer Autoantibodies and Fetal Home Monitoring in the Detection of Atrioventricular Block Among Anti-SSA/Ro Pregnancies

Jill P. Buyon, NYU Langone Health, New York City, New York.
Mala Masson, NYU Langone Health, New York City, New York.
Caroline G. Izmirly, NYU Langone Health, New York City, New York.
Colin Phoon, NYU Langone Health, New York City, New York.
Ruben Acherman, Children's Heart Center, Las Vegas, Nevada.
Elena Sinkovskaya, East Virginia Medical School, Norfolk, Virginia.
Alfred Abuhamad, East Virginia Medical School, Norfolk, Virginia.
Majd Makhoul, University of Kentucky, Lexington, Kentucky.
Gary Satou, University of California, Los Angeles, California.
Whitnee Hogan, University of Utah, Salt Lake City, Utah.
Nelangi Pinto, University of Utah, Salt Lake City, Utah.
Anita Moon-Grady, University of California San Francisco, California.
Lisa Howley, Midwest Fetal Care Center, Children's Minnesota/Allina Health, Minneapolis, Minnesota.
Mary Donofrio, Children's National Hospital, Washington, DC.
Anita Krishnan, Children's National Hospital, Washington, DC.
Homa Ahmadzia, George Washington University, Washington, DC.
Stephanie Levasseur, Columbia University, New York City, New York.
Erin Paul, Mount Sinai Hospital, New York City, New York.
Sonal Owens, University of Michigan, Ann Arbor, Michigan.
Kristopher Cumbermack, University of Kentucky, Lexington, Kentucky.
Jyothi Matta, University of Louisville, Louisville, Kentucky.
Gary Joffe, Perinatal Associates of New Mexico, Rio Rancho, New Mexico.
Christopher Lindblade, Phoenix Children's Hospital, Phoenix, Arizona.
Caitlin Haxel, University of Vermont Children's Hospital, Burlington, Vermont.
Katherine Kohari, Yale University, New Haven, Connecticut.
Joshua Copel, Yale University, New Haven, Connecticut.
James Strainic, UH Rainbow Babies & Children's Hospital, Cleveland, Ohio.
Tam Doan, Baylor School of Medicine, Baylor College of Medicine, Houston, Texas.
Karla Bermudez-Wagner, Baylor School of Medicine, Baylor College of Medicine, Houston, Texas.
Conisha Holloman, Baylor School of Medicine, Baylor College of Medicine, Houston, Texas.
Shreya S. Sheth, Baylor School of Medicine, Baylor College of Medicine, Houston, Texas.
Stacy Killen, Vanderbilt University, Nashville.

Document Type

Journal Article

Publication Date

11-10-2023

Journal

Arthritis & rheumatology (Hoboken, N.J.)

DOI

10.1002/art.42733

Abstract

OBJECTIVE: This prospective study of pregnant patients, Surveillance To Prevent AV Block Likely to Occur Quickly (STOP BLOQ), addresses the impact of anti-SSA/Ro titers and utility of ambulatory monitoring in the detection of fetal second-degree atrioventricular block (AVB). METHODS: Women with anti-SSA/Ro autoantibodies by commercial testing were stratified into high and low anti-52-kD and/or 60-kD SSA/Ro titers applying at-risk thresholds defined by previous evaluation of AVB pregnancies. The high-titer group performed fetal heart rate and rhythm monitoring (FHRM) thrice daily and weekly/biweekly echocardiography from 17-26 weeks. Abnormal FHRM prompted urgent echocardiography to identify AVB. RESULTS: Anti-52-kD and/or 60-kD SSA/Ro met thresholds for monitoring in 261 of 413 participants (63%); for those, AVB frequency was 3.8%. No cases occurred with low titers. The incidence of AVB increased with higher levels, reaching 7.7% for those in the top quartile for anti-60-kD SSA/Ro, which increased to 27.3% in those with a previous child who had AVB. Based on levels from 15 participants with paired samples from both an AVB and a non-AVB pregnancy, healthy pregnancies were not explained by decreased titers. FHRM was considered abnormal in 45 of 30,920 recordings, 10 confirmed AVB by urgent echocardiogram, 7 being second-degree AVB, all <12 hours from normal FHRM and within another 0.75 to 4 hours to echocardiogram. The one participant with second/third-degree and two participants with third-degree AVB were diagnosed by urgent echocardiogram >17 to 72 hours from an FHRM. Surveillance echocardiograms detected no AVB when the preceding interval FHRM recordings were normal. CONCLUSION: High-titer antibodies are associated with an increased incidence of AVB. Anti-SSA/Ro titers remain stable over time and do not explain the discordant recurrence rates, suggesting that other factors are required. Fetal heart rate and rhythm (FHRM) with results confirmed by a pediatric cardiologist reliably detects conduction abnormalities, which may reduce the need for serial echocardiograms.

Department

Pediatrics

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