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Cross-sectional analysis of adverse outcomes in 1,029 pregnancies of Afro-Caribbean women in Trinidad with and without systemic lupus erythematosus
- Mariam Molokhia1Email author,
- Noreen Maconochie1,
- Alan Leslie Patrick2 and
- Pat Doyle1
DOI: 10.1186/ar2332
© Molokhia et al., licensee BioMed Central Ltd. 2007
Received: 16 May 2007
Accepted: 27 November 2007
Published: 27 November 2007
The objective of the study was to examine pregnancy outcomes in women with systemic lupus erythematosus (SLE) and population controls in Trinidad. We performed a cross-sectional analysis of adverse outcomes in pregnancies of Afro-Caribbean women with SLE and without SLE. One hundred and twenty-two female adult cases of SLE and 203 neighbourhood age-matched women without SLE were interviewed concerning details of their reproductive history, and the anticardiolipin antibody (ACL) status was established for women with SLE. A total of 1,029 pregnancies were reported (356 by women with SLE, 673 by women without SLE). In women with ≥ 1 pregnancy the total number of pregnancies was similar in women with a diagnosis of SLE and women without; however, a lower proportion of women with SLE had ever been pregnant compared with women without SLE (80% versus 91%, P = 0.002). In multivariate logistic regression analyses adjusted for maternal age, district of residence, pregnancy order and smoking, SLE pregnancies were more than twice as likely to end in foetal death than non-SLE pregnancies (odds ratio (OR), 2.4; 95% confidence interval (CI), 1.2–4.7). This effect was driven by a large increase in the odds of stillbirth (OR, 8.5; 95% CI, 2.5–28.8). The odds of early miscarriage (OR, 1.4; 95% CI, 0.6–3.1) and of mid-trimester miscarriage (OR, 1.9; 95% CI, 0.4–9.5) were higher, but were not statistically significantly different, in SLE pregnancies than in non-SLE pregnancies. The odds of ectopic pregnancy (OR, 7.5; 95% CI, 0.9–62.5) and of preterm birth (OR, 3.4; 95% CI, 1.2–10.0) were higher in SLE pregnancies conceived after diagnosis than in non-SLE pregnancies. There was no evidence of raised levels of IgG or IgM ACL among the majority (93/97 women, 96%) of SLE cases who reported sporadic mid-trimester miscarriage or stillbirth, although there was evidence of high levels of IgM and IgG ACL among women reporting three or more miscarriages and three consecutive miscarriages, and of raised IgG ACL among those experiencing ectopic pregnancy. In conclusion, we found evidence for a large increase in risk of stillbirth in the pregnancies of Afro-Caribbean Trinidadian women with SLE (not accounted for by high ACL status). There was some evidence of an increased risk of preterm delivery and ectopic pregnancy in pregnancies conceived after a diagnosis of maternal SLE.
Systemic lupus erythematosus (SLE) is a complex autoimmune disease that predominantly affects females of child-bearing age (female:male ratio approximately 9:1), with both genetic and environmental determinants, and is particularly common in Afro-Caribbean populations. SLE has a well-recognised association with second-trimester miscarriage; studies have also examined other adverse pregnancy outcomes including prematurity and pregnancy loss [1–16]. Some of these studies, however, are based on small numbers and/or tertiary referral centres with many high-risk patients, and few studies involved a comparison group [2, 8].
Risk factors that have been previously identified for adverse pregnancy outcome in women with SLE (particularly second-trimester miscarriage) include antibodies to phospholipids (lupus anticoagulant and anticardiolipin antibodies), lupus activity and renal disease [1–3, 5–9, 11, 12, 17, 18]. Many studies may underestimate the rates of early miscarriage, however, as patients may not have been referred after a pregnancy was lost.
Trinidad was selected as an ideal place for study of pregnancy outcomes as large family sizes are common combined with a young age of reproduction. There are no known previous such studies in the Caribbean. There are no national data for Trinidad available on miscarriages, although data are provided on other reproductive outcomes such as live births and stillbirths [19]. At the last census in 2000, the population of Trinidad & Tobago was 1.26 million. Estimating the prevalence of SLE in Northern Trinidad is difficult as we do not have exact denominator data. Typical prevalence rates in Afro-Caribbean women in the United Kingdom, however, are around 200 per 100,000 adult women, which are six to eight times higher than in Europeans [20, 21]. Preliminary work carried out by the authors suggested there may be approximately 373 cases of SLE in Northern Trinidad (see Discussion), with a population denominator of approximately 170,000 adult females [22] – thus giving a crude SLE prevalence of approximately 219 per 100,000 in females in Trinidad.
Health services in Trinidad are mainly public sector with some private hospitals and clinics. Primary healthcare services include 102 nationwide health centres. Secondary healthcare is available at eight district hospitals and three large government hospitals in Port of Spain, San Fernando and Arima. Tertiary healthcare is available in Port of Spain. One of the main facilities is the Mount Hope Medical Complex, which houses a 340-bed general purpose hospital, including a 110-bed maternity hospital. Overall there is reasonable access to healthcare, even in low-income groups.
The aim of the study was to examine adverse pregnancy outcomes (miscarriage, stillbirth, ectopic pregnancy and preterm delivery) in a large group of Trinidadian Afro-Caribbean women with SLE and without SLE.
Patients and methods
Study design
The study was a population-based questionnaire survey of reproductive outcomes of adult Afro-Caribbean women living in Northern Trinidad diagnosed with SLE and without SLE. These women were identified for a case – control study of SLE that was conducted from 1998 to 2002 [23]. We obtained reproductive histories in addition to information on various lifestyle factors and demographic factors, including socioeconomic status, and contraceptive pill use. No women with SLE or without SLE were pregnant at the time of interview. Serum from 122 women with SLE was sent for IgG anticardiolipin antibody (ACL) and IgM ACL assays at a standard UK laboratory. (The laboratory normal range for IgG ACL was 0.0–12.0 U/ml, and that for IgM ACL was 0.0–5.0 U/ml.)
Ascertainment of women with systemic lupus erythematosus
Cases were adult women with SLE, aged 18 years and older, resident in northern Trinidad from 1998 to 2002 who were selected according to the standard revised American Rheumatism Association 1982 criteria [24] through multiple sources. The study was restricted to women of Afro-Caribbean ethnicity (this was because the original study design was examining SLE risk in relation to African ancestry in Afro-Caribbean populations, and other ethnic groups such as Indian or Chinese show epidemiological evidence for increased risk of SLE). In summary, surviving adult women with SLE were ascertained from five sources from both the public sector and the private sector: the lupus register at Port of Spain General Hospital (started in 1992); the rheumatology, renal, and dermatology outpatient departments from the two main hospitals that serve the defined population of Northern Trinidad (Port of Spain General Hospital and Mount Hope Hospital, Arima); a systematic search of outpatient records plus hospital laboratory records of positive tests for antinuclear antibodies at the two main hospitals to identify cases of SLE; Lupus Society meetings and through advertisements in the quarterly newsletter and television; and an immunology register compiled from records for 1992–2000 that included cases diagnosed through high (> 1:256) titres of antinuclear antibodies and antidouble-stranded DNA antibodies and those patients with positive histology from skin biopsies. Details of these registries are described elsewhere [23].
More than 90% of patients with SLE registered with the Lupus Society attended one of the two main hospitals servicing this catchment area. Few patients had been seen exclusively privately (< 5%). We established that case records are available for more than 90% of these patients and that these records include adequate information on the clinical and laboratory findings upon which the patient diagnosis was based. Both hospitals were visited to assess the quality and completeness of the records. When invited for interview, patients were also asked to bring any private case records in their possession, and these were used to validate clinical criteria and medical history.
Ascertainment of women without systemic lupus erythematosus
For each case, randomly chosen households in the same neighbourhood were sampled by the field team to obtain two women without SLE, matched with the case patient for sex and for 20-year age group (this was adjusted as the original matching for 10-year age group led to many exclusions for controls). For each case patient the interviewer drew a map, compiled a list of 25 adjacent households and visited these households in random order using random-number tables to interview all eligible individuals in the same age – sex group as the case. Where possible, a listing of the age, sex and ethnicity of all household members was obtained and arranged in descending order of age. The interviewer then selected at random (using printed tables) one suitable individual for interview according to the numbers eligible. This was continued until eligible controls had been obtained from at least two separate households.
Patient interviews
Where possible, all cases identified through the hospital clinics and lupus registers were telephoned and invited to participate in the study. Where telephones were not listed, case records and telephone directories were checked. We established from preliminary studies that 80% of households had a telephone. Where telephones were not available, invitations about the study together with a study information sheet with contact telephone number were sent to the participant's address or were delivered by hand. Nonrespondents were sent reminders or were revisited. All women were offered a choice to be interviewed at home or in the project office using a validated questionnaire that included demographic items, socioeconomic indices in childhood and adult life, birth order, medical history, and reproductive history. Detailed (self-reported) information was collected on all pregnancies, including date of pregnancy end, gestation and outcome of pregnancy. We did not have access to accurate birthweight records so this parameter could not be studied. Pretesting of the questionnaire was used to train research interviewers and to refine ambiguous questions. Participants were paid travel expenses, and were offered a complimentary full blood count, cholesterol measurement, or membership to the Lupus Society for 1 year. All reasons for nonresponse in relation to obtaining the household listing or in relation to selecting suitable control individuals were documented. Crude socioeconomic data on status of nonresponders were compared with those of responders where possible (type of housing, car and telephone ownership). Up to two return visits were made at different times of the day, including weekends and after working hours, in order to interview potential control individuals. Blood was taken for DNA and serum storage prior to analyses at the time of interview.
Ethical approval was granted by the Ethics Committee of the London School of Hygiene & Tropical Medicine and by the Ministry of Health of the Republic of Trinidad & Tobago. All participants provided informed consent for this study.
Pregnancy outcome: statistical analyses
The majority of the analyses described here are pregnancy based. Women were excluded from this analysis if they were aged younger than 18 years at interview (one woman with SLE) or were too ill to participate (four women with SLE). The outcomes of interest were live birth, preterm birth, miscarriage (early and late), ectopic pregnancy, stillbirth, and foetal death as a whole (comprising all miscarriage and stillbirth). The exposure of interest was maternal SLE status. Three categories of foetal death were used according to the reported gestation at the end of the pregnancy: early (first-trimester) miscarriage (≤ 12 completed weeks), late (mid-trimester) miscarriage (13–23 weeks), and stillbirth (≥ 24 weeks gestation). Preterm delivery was defined as a livebirth that ended before 37 weeks of completed gestation.
The denominator for the analyses of early miscarriage was all reported pregnancies; for late miscarriage, the denominator included all pregnancies surviving more than 12 weeks; and the denominator for stillbirth included all live and stillborn babies. For analyses of ectopic pregnancy, the denominator was all pregnancies; and for analyses of preterm delivery, the denominator was all live births. Ectopic pregnancies were excluded from all analyses of foetal death. Information on termination was incomplete as termination for nonmedical reasons is illegal in Trinidad, and was therefore omitted from all analyses. Multiple pregnancies (a total of five twin pregnancies, which could only be identified for those women with gestation over 24 weeks) were excluded from all analyses.
All analyses were carried out using STATA statistical software (release 9.0, 2005; Stata Corporation, College Station, TX, USA). All analyses were adjusted for maternal age at the time of conception, for pregnancy order and for smoking. Although the original design was matched on the neighbourhood of residence, results were similar using matched or unmatched analysis – the latter results are therefore presented. The district of residence, however, was included in all models since in the original design women without SLE were matched to SLE cases in the same neighbourhood as the SLE cases. Analyses were performed using different markers of socioeconomic status, including years of education and district of residence. The unit of analysis was a pregnancy. The association between the relevant pregnancy outcome and SLE status at time of survey or between the relevant pregnancy outcome and SLE status at time of conception was explored using logistic regression analysis – effects on risk being estimated by odds ratios (ORs) with 95% confidence intervals (CIs). Since women could have more than one pregnancy in the analysis, a robust method based on the 'sandwich estimate' [25] was used to compute standard errors, with Wald tests used to test the statistical significance of parameters [26].
The response rate for eligible SLE cases in the case–control study was 122/131 (93%). Two women with SLE refused to participate and seven did not attend for interview. Of eligible women without SLE, the response rate was 70% (203/290). Initial comparison of nonresponders in women without SLE did not show significant differences in age or socioeconomic status. There was no association of district with risk of SLE.
Woman-based analyses
Characteristics of female participants at survey, 1998–2002
Women with SLE (n = 122)
Women without SLE (n = 203)
P valuea
Age at survey
15–24 years
4 (3%)
12 (6%)
25–34 years
21 (17%)
31 (15%)
35–44 years
39 (32%)
77 (38%)
45–54 years
32 (26%)
43 (21%)
≥ 55 years
26 (21%)
40 (20%)
Mean (standard deviation) age at interview (years)
44.4 (11.6)
43.4 (12.1)
Education after 18 years
23 (19%)
29 (14%)
Running water aged 12 years
77 (63%)
149 (73%)
Ever smoked
10 (8%)
27 (13%)
Marital status
Ever married/cohabited
83 (68%)
161 (79%)
39 (32%)
42 (21%)
Hysterectomy reported at survey
15 (12%)
22 (11%)
Ever used contraceptive pillb
66 (55%)
100 (51%)
Ever been pregnant
97 (80%)
184 (91%)
Reported pregnancy histories at the time of survey among women who had ever been pregnant
Ever pregnant women with SLE (n = 97)
Ever pregnant women without SLE (n = 184)
P valuea
Total number of reported pregnancies per woman
13 (13%)
20 (11%)
20 (21%)
36 (20%)
21 (22%)
47 (26%)
19 (20%)
29 (16%)
10 (10%)
23 (13%)
≥ 6
14 (14%)
29 (15%)
Mean (standard deviation) number of pregnancies
3.7 (2.0)
3.7 (2.4)
Mean (standard deviation) age at first pregnancy (years)
22.1 (4.8)
22.5 (4.8)
Ever had a live birth – total number of live births reported per woman
7 (7%)
2 (1%)
20 (21%)
34 (18%)
22 (23%)
40 (22%)
24 (25%)
51 (28%)
11 (11%)
25 (14%)
≥ 5
13 (13%)
32 (17%)
Median (P5–P95)b live births
2.5 (0–5)
3 (1–5)
Ever miscarried – total number of miscarriagesc reported per woman
51 (53%)
125 (68%)
30 (31%)
35 (19%)
11 (11%)
15 (8%)
≥ 3
5 (5%)
9 (5%)
Median (P5–P95)b miscarriagesc
0.5 (0–3)
0 (0–3)
Ever had a stillbirth – total number of stillbirths reported per woman
86 (89%)
175 (95%)
7 (7%)
9 (5%)
≥ 2
4 (4%)
Median (P5–P95)b stillbirths
0 (0–1.25)
0 (0–0.75)
Ever had an ectopic pregnancy
92 (95%)
180 (98%)
5 (5%)
3 (2%)
≥ 2
1 (0.5%)
Median (P5–P95)b ectopic
0 (0–1)
0 (0–0)
Women with a SLE diagnosis only
First pregnancy before SLE diagnosis
78 (80%)
First pregnancy after SLE diagnosis
19 (20%)
Age (years) at first pregnancy
Mean (standard deviation) age at first pregnancy if before SLE diagnosis
22.1 (4.6)
Mean (standard deviation) age at first pregnancy if after SLE diagnosis
26.6 (7.0)
Number of reported pregnancies per woman
Mean (standard deviation) pregnancies whose first conception was before SLE diagnosis
3.7 (2.1)
Mean (standard deviation) pregnancies whose first conception was after SLE diagnosis
3.6 (2.7)
The majority (80%) of women diagnosed with SLE had conceived their first pregnancy prior to their SLE diagnosis – although, on average, the total number of pregnancies reported by those whose first conception was prior to SLE diagnosis was the same as that among women whose first conception was after their SLE diagnosis (Table 2). The average age at first conception was significantly higher among women whose first pregnancy was after their SLE diagnosis (P < 0.001), as might be expected (Table 2).
Pregnancy-based analyses
Characteristics of all reported singleton pregnanciesa
Mother ever diagnosed with SLE
Mother never diagnosed with SLE
Pregnancies conceived before mother's SLE diagnosis
Pregnancies conceived after mother's SLE diagnosis
All pregnancies conceived by mothers ever diagnosed with SLE
Total number of pregnancies
274 (100%)
78 (100%)
352 (100%)
667 (100%)
Mean (standard deviation) maternal age at conception
25.0 (5.5)
30.1 (5.6)
25.6 (5.8)
26.3 (6.1)
Pregnancy type
Live birth
224/274 (81.8%)
33/78 (42.3%)
257/352 (73.0%)
553/667 (82.9)
Foetal death
47/274 (17.2%)
43/78 (55.1%)
90/352 (25.6%)
109/667 (16.3%)
First-trimester miscarriage (0–12 weeks)b
28/274 (10.2%)
34/78 (43.6%)
62/352 (17.6%)
90/667 (13.4%)
Mid-trimester miscarriage (13–23 weeks)b
3/259 (1.2%)
4/49 (8.2%)
7/315 (2.2%)
9/605 (1.5%)
Miscarriage missing gestation
3/274 (1.1%)
1/78 (1.3%)
4/352 (1.1%)
1/667 (0.1%)
Stillbirth (≥ 24 weeks)c
13/237 (5.5%)
4/37 (10.8%)
17/274 (6.2%)
9/562 (1.6%)
Ectopic pregnancy
3/274 (1.1%)
2/78 (2.6%)
5/352 (1.4%)
5/667 (0.7%)
Reported gestation of live births (completed weeks)
All pregnancies ending in live birth
224 (100%)
33 (100%)
257 (100%)
553 (100%)
< 24 weeks
5 (2.2%)
3 (9.1%)
8 (3.1%)
20 (3.6%)
24–31 weeks
2 (0.9%)
3 (9.1%)
5 (2.0%)
2 (0.4%)
32–36 weeks
5 (2.2%)
1 (3.0%)
6 (2.3%)
4 (0.7%)
All preterm (< 37 weeks)
12 (5.4%)
7 (21.2%)
19 (7.4%)
26 (4.7%)
37–42 weeks
212 (94.6%)
26 (78.8%)
238 (92.6%)
526 (95.1%)
42–46 weeks
0 (0%)
0 (0%)
1 (0.2%)
Reported gestation of foetal deaths (completed weeks)
All pregnancies ending in foetal deathb
47 (100%)
43 (100%)
90 (100%)
109 (100%)
< 8 weeks
17 (36.2%)
25 (58.1%)
42 (46.7%)
63 (57.8%)
8–12 weeks
11 (23.4%)
9 (20.9%)
20 (22.2%)
28 (25.7%)
13–15 weeks
2 (4.3%)
0 (0%)
2 (2.2%)
4 (3.7%)
16–23 weeks
1 (2.1%)
4 (9.3%)
5 (5.6%)
5 (4.6%)
24–36 weeks
6 (12.7%)
4 (9.3%)
10 (11.1%)
4 (3.7%)
≥ 37 weeks
7 (14.9%)
0 (0%)
7 (7.7%)
3 (2.8%)
Missing gestation category
3 (6.4%)
1 (2.3%)
4 (4.4%)
2 (1.8%)
Foetal deatha among pregnanciesb reported by Trinidadian women by systemic lupus erythematosus (SLE) status
Early miscarriagea,c (0–12 weeks)
Late miscarriagea,d (13–23 weeks)
All miscarriagea,e (0–23 weeks)
Stillbirthf (≥ 24 weeks)
All foetal deathg
n (%)
Adjusted ORh (95% CI)
n (%)
Adjusted ORh (95% CI)
n (%)
Adjusted ORh (95% CI)
n (%)
Adjusted ORh (95% CI)
n (%)
Adjusted ORh (95% CI)
Mother not diagnosed with SLE
90 (13.5%)
1.0 (-)
9 (1.8%)
1.0 (-)
100i (15.0%)
1.0 (-)
9 (16.0%)
1.0 (-)
109 (16.3%)
1.0 (-)
Mother diagnosed with SLE
62 (17.6%)
1.4 (0.6–3.1)
7 (2.2%)
1.9 (0.4–9.5)
73j (20.7%)
1.6 (0.8–3.5)
17 (6.2%)
8.5 (2.5–28.8)
90j (25.6%)
2.4 (1.2–4.7)
Pregnancy conceived prior to SLE diagnosis
28 (8.0%)
1.6 (0.7–3.7)
3 (1.0%)
2.2 (0.4–10.9)
34k (9.7%)
1.9 (0.8–4.2)
13 (4.7%)
8.3 (2.3–29.2)
47k (13.3%)
2.6 (1.3–5.4)
Pregnancy conceived after SLE diagnosis
34 (9.7%)
0.4 (0.1–2.6)
4 (1.2%)
39m (11.1%)
0.3 (0.0–2.5)
4 (1.4%)
9.8 (1.7–58.0)
43m (12.2%)
1.1 (0.3–3.3)
Table 4 presents multivariate logistic regression analyses of foetal death, adjusted for district of residence, maternal age, pregnancy order and smoking.
Overall foetal death was over twice as likely among pregnancies conceived by women with SLE than women without SLE (OR, 2.4; 95% CI, 1.2–4.7). There was, however, no strong evidence of an effect of SLE on risk of early miscarriage (OR, 1.4; 95% CI, 0.6–3.1, regardless of time of diagnosis). Odds of late miscarriage were almost doubled among pregnancies conceived by women with SLE than those of women without SLE (OR, 1.9; 95% CI, 0.4–9.5), although the numbers of cases were extremely small and this result was not statistically significant. There was strong evidence of an effect of SLE on stillbirth: the odds of stillbirth were over eight times higher among pregnancies conceived by women diagnosed with SLE compared with that among pregnancies conceived by women never diagnosed with SLE (OR, 8.5; 95% CI, 2.5–28.8).
Once adjusted for maternal age, which acted as a strong confounder, there was no strong evidence to suggest a difference in risk of foetal death between pregnancies conceived before and after SLE diagnosis (Table 4), although the numbers of cases among pregnancies conceived after SLE diagnosis were really too small to draw meaningful conclusions.
Ectopic pregnancy and live-born preterm delivery among all pregnancies reported by Trinidadian women by systemic lupus erythematosus (SLE) status
Ectopic pregnancya
Preterm delivery among live-born infantsb
n (prevalence %)
Adjusted odds ratio (95% confidence interval)
n (prevalence %)
Adjusted odds ratio (95% confidence interval)
Mother not diagnosed with SLE
5 (0.7%)
1.0 (-)
26 (4.7%)
1.0 (-)
Mother diagnosed with SLE
5 (1.4%)
3.6 (0.7–18.7)
19 (7.3%)
1.5 (0.7–3.2)
Pregnancy conceived prior to SLE diagnosis
3 (0.8%)
12 (4.7%)
Pregnancy conceived after SLE diagnosis
2 (0.6%)
7.5 (0.9–62.5)
7 (2.7%)
3.4 (1.2–10.0)
After adjustment for district of residence, maternal age, pregnancy order and smoking, the odds of preterm delivery were also raised – pregnancies conceived by women with SLE being an estimated 50% more likely to be preterm than those conceived by women without SLE (OR, 1.5; 95% CI, 0.7–3.2) (Table 5). This effect again appeared much stronger among pregnancies conceived after SLE diagnosis (OR, 3.4; 95% CI, 1.2–10.0).
Among women who reported three or more pregnancies, there was no apparent difference in risk of three or more miscarriages (any gestation) between women with SLE and without SLE (6/64 (9.4%) versus 9/128 (7.0%), respectively; P = 0.6). Nor was there evidence of a difference in risk of three consecutive miscarriages in this group (4/64 (6.3%) among women with SLE versus 7/128 (5.5%) among women without SLE, P = 0.8). The numbers, however, were too small to draw firm conclusions.
Our analyses of IgG ACL levels or IgM ACL levels among women with SLE did not show evidence of high IgG ACL or IgM ACL associated with sporadic mid-trimester miscarriage. There was evidence, however, of an association of high titres of IgG ACL and IgM ACL among the small number (n = 5, 5%) of women with SLE reporting three or more miscarriages (P = 0.001 and P = 0.009, respectively, when compared with (normal) expectation), and among women with SLE reporting three consecutive miscarriages (P = 0.03 and P = 0.05, respectively). Of those women with SLE who experienced a stillbirth, 1/17 (6%) had high IgM ACL and 3/17 (18%) had high IgG ACL. We also found an association of high titres of IgM ACL with preterm delivery (P = 0.013) and with ectopic pregnancy (0.05), although this was based on small numbers. Elevated IgG ACL levels were also associated with increased risk of ectopic pregnancy (P = 0.03).
Regression analyses adjusting for other socioeconomic indicators such as years of education or previous foetal death made little difference to the overall results reported above. Furthermore, the results were largely unchanged when we used the Sydney antiphospholipid syndrome criterion of loss at > 10 weeks gestation to define the reported foetal losses in this study.
The present study is the first to examine pregnancy outcome in women with SLE in Trinidad, where large family sizes and early age of reproduction make it an ideal environment to study the relationship between SLE and foetal outcomes. Access to healthcare was equal for women with SLE and for women in the comparison group, even in low-income groups.
We found that pregnancies conceived by Afro-Caribbean Trinidadian women with SLE were more likely to end in foetal death (OR, 2.4; 95% CI, 1.2–4.7). The strongest effect was on risk of stillbirth, where pregnancies conceived by women with SLE were greater than eight times more likely to end in this way (OR, 8.5; 95% CI, 2.5–28.8). There was also some evidence of an increased risk of ectopic pregnancy among pregnancies conceived by women with SLE. Finally, we found that pregnancies conceived by women with SLE also appeared more likely to end in preterm delivery. This effect was strongest among those conceived after SLE diagnosis, which were greater than three times more likely to end in preterm delivery than those conceived by women without SLE (OR, 3.4; 95% CI, 1.2–10.0).
Details regarding pregnancy outcomes in general within Trinidad are unavailable, but recent national data suggest that the overall crude live birth rate of 18,490 per 629,315 (2.9%) total female population [19] is approximately twice as high as in North America [27]. At the time of writing there were no national data available on miscarriage in Trinidad, although the national stillbirth rate was estimated as 1.2% total births, which is slightly higher than European figures (approximately 0.5% of total births around the time of this study) [28].
The live birth rate (42%) among women conceiving after a diagnosis of SLE is lower than that reported in other studies (84–87%) [1, 3, 5]; however, this may reflect higher disease activity and comorbidity in Trinidad. Furthermore, termination of pregnancy is currently illegal in Trinidad and therefore is likely to have been misreported as miscarriage – combined with the fact that most foetal deaths were reported as first-trimester miscarriage (17.6%), this misreporting might suggest that the higher pregnancy loss rate in our study could be explained by a higher proportion of induced abortion in this age group. Our findings for foetal death overall (24% in women diagnosed with SLE and 16% in women without SLE) is slightly higher than those in other studies (7–16%) [1, 3, 5, 8]. Early foetal loss may not, however, have been counted in these studies. Few other studies have reported on ectopic pregnancy in relation to SLE (or it is not clear whether ectopic was included as 'foetal loss') – but an increased risk of ectopic pregnancy was found in SLE patients in one study that did, based on a study of only 17 women (42 pregnancies) with SLE [29]. The increased risk of ectopic pregnancy is possibly explained by reduced tubal motility.
First-trimester miscarriage rates are reported as 18% in women with SLE and 13% in women without SLE, although these may be overestimated values owing to the inclusion of induced abortions, as discussed above. North American studies report first-trimester miscarriage as between 7% and 10% based on moderate numbers of pregnancies in women with SLE (63–267 pregnancies) [1, 3, 5]. Other European studies have reported similar proportions to those found here. Evidence of first-trimester miscarriage has been reported as 5% in a cohort of 46 women with SLE (60 pregnancies); however, this was in a tertiary centre with intensive management protocol for these high-risk pregnancies [6]. A study in France also estimated a spontaneous miscarriage rate of 16% in European women with SLE in 62 pregnancies (38 women) [12], although this included cases with SLE nephropathy. Spontaneous (first and second) miscarriage rates in pregnant women from Saudi Arabia with lupus nephropathy (inactive and active) are reported as between 25% and 32%, with higher rates in patients with antibodies to phospholipids, although this study included only 24 patients [10].
High stillbirth rates in women with SLE have been reported in a number of other studies, with particular high risk in patients with lupus nephritis and/or altered immunological profiles including antiphospholipid syndrome [5, 10, 12, 16, 17]. Some studies include a definition of stillbirth as spontaneous abortion at gestation ≥ 20 weeks [12, 17], however, which will inflate the estimates. In a study that defined stillbirth as spontaneous abortion at > 24 weeks (as used here), the prevalence is estimated as 3/19 (16%) pregnancies in women with lupus nephritis. Risk of stillbirth also appears to be increased in women who became pregnant after SLE was diagnosed (3/44 (6.8%) compared with one out of 10 pregnancies before SLE was diagnosed) [7]. In general these figures are difficult to interpret as estimates are based on very low numbers studied, but the general finding of an increased risk of stillbirth is similar to that reported here.
Other studies have identified risk of preterm birth in women with SLE [6–9, 12], although in some cases prematurity can be medically induced due to complications such as maternal preeclampsia [14]. We did not analyse cause of preterm birth separately in this study.
Although the present study showed an important relationship between SLE and both foetal death and preterm birth, the study does have limitations, which need to be considered.
First, we were only studying women with SLE who had survived, and it is unknown what the reproductive outcomes of those (more severe cases) who died before survey might have been, and whether this might have impacted onto the results.
Next, there was a differential response rate in cases (93%) and control individuals (70%) in the case – control study from which these data came; however, analyses of socioeconomic status such as car and home ownership did not differ between control individuals who agreed to participate and those that refused. It is possible that there may be bias from residual differences between controls who responded and those that did not; however, after obtaining a household listing of all inhabitants, a strict protocol was followed to identify a possible control. Every attempt was made to ensure that selection included working cases (up to three calls were made to identify eligible control individuals at different times of the day and weekends). No SLE cases or controls were excluded because they were pregnant at the time of the survey.
In epidemiological studies, the capture – recapture technique examines the degree of overlap between two (or more) methods of ascertainment and uses a simple formula to estimate the predicted total size of the population. From capture – recapture methods, we estimate a total of 373 cases of SLE are resident in Northern Trinidad; this includes both sexes. In reality, this is likely to be an underestimate as the probability of being on the dermatology register and on the books of the Lupus Society is associated with one another. Assuming 90% of SLE cases are female, we estimate a total of 335 female adult cases in Northern Trinidad. Allowing for incorrect addresses, exclusions on nonAfro-Caribbean individuals and deaths, the total estimated number of eligible SLE cases in Northern Trinidad is 167, of whom we have ascertained 122 (73%).
Although there is potential over-reporting of 'miscarriage', as termination for nonmedical reasons is illegal, this is unlikely to be differential between women with SLE and women without SLE. We are aware that this misclassification is likely to inflate estimates of foetal loss, particularly first-trimester miscarriage.
Our analyses did not show evidence of either high titres of IgG ACL or IgM ACL with sporadic mid-trimester miscarriage, foetal loss, or stillbirth among SLE cases. There was evidence of an association of high titres of IgG ACL and IgM ACL among women reporting three or more miscarriages, and among women with three consecutive miscarriages, but this was experienced by just five of the 97 women with SLE who reported ever being pregnant. We also found an association of high IgM ACL and IgG ACL with ectopic pregnancy, although this was based on small numbers, and an association of high IgM ACL with preterm delivery. Treatment of women with SLE during pregnancy with aspirin and/or heparin is not, however, standard clinical practice in Trinidad. These findings suggest that raised ACL antibodies cannot explain the results for foetal death reported in the present paper, although the investigation of the role of ACL antibodies in preterm and ectopic pregnancies warrants further attention.
Only 27/122 (22%) women who had ever been pregnant had ever had a history of nephritis; however, specific information at time of pregnancy was not available. No women without SLE had documented renal involvement. In any case, adjusting for history of renal involvement in the analyses made little difference. The percentage of immunosuppressive medication in women with SLE treated with corticosteroids, treated with other immunosuppressive medication, and treated with nonsteroidal antiinflammatory drugs was 96%, 84% and 52%, respectively – compared with values for control individuals of 4%, 16% and 48%, respectively. The prevalence of diagnosed hypertension was higher in control individuals than in cases (56% versus 44%), although this was not significant.
This well-conducted large population-based case-control study of SLE provided data on 1,029 pregnancies, which allowed us to examine adverse pregnancy outcomes in a systematic way. In women with SLE, we found a significantly increased risk for still birth and all foetal death (not accounted for by raised titres of ACL). We also found evidence for increased (nonsignificant) risk of all miscarriage, and ectopic pregnancies. Risk of preterm birth was significantly increased among pregnancies conceived after SLE diagnosis.
Further studies may help clarify whether ectopic pregnancy risk is raised in women with SLE, and the role of ACL in preterm and ectopic pregnancies. Women with SLE known to have APL syndrome which is associated with recurrent fetal loss and preterm delivery may benefit from antithrombotic treatment including low dose aspirin [31], where early identification of patients of particular risk (e.g. APL syndrome) for closer patient management between rheumatologist and obstetrician may help improve outcomes further. We suggest further work could be carried out in monitoring of high obstetric risk in women with SLE.
= anticardiolipin antibody (subtypes IgM and IgG)
- Anti-ds DNA:
= Anti-double stranded DNA
= Anti-Phospholipid Syndrome
= 95% confidence interval
= odds ratio
= systemic lupus erythematosus.
The study was supported by the UK Arthritis Research Campaign (M0600). The authors thank those who participated in this research, Gloria Chan, Odette Mason, Martha Greenidge and Sylvia Liverpool for help with the data collection, Paul McKeigue and Alan Silman for help with the original study design, Wayne LaBastide for help with programming, and Dr Marilyn Suite, Dr Kim Basdeo Maharaj, Dr Leslie Roberts, Dr Deepak Mahabir, Dr Rajiv Serrano, Prof Hylton McFarlane, Dr Zinora Asgaralli, Ms Arlene Damanie, Dr Peter Poon King, Dr Richard Poon King, Dr Dianne Sandy, Mr Curtis Wilson and others at the Lupus Society of Trinidad & Tobago for help with case ascertainment.
Authors' Affiliations
- Chakravarty EF, Colon I, Langen ES, Nix DA, El-Sayed YY, Genovese MC, Druzin ML: Factors that predict prematurity and preeclampsia in pregnancies that are complicated by systemic lupus erythematosus. Am J Obstet Gynecol. 2005, 192: 1897-1904. 10.1016/j.ajog.2005.02.063.View ArticlePubMedGoogle Scholar
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- Clowse ME, Magder LS, Witter F, Petri M: The impact of increased lupus activity on obstetric outcomes. Arthritis Rheum. 2005, 52: 514-521. 10.1002/art.20864.View ArticlePubMedGoogle Scholar
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- Clowse ME, Magder LS, Witter F, Petri M: Early risk factors for pregnancy loss in lupus. Obstet Gynecol. 2006, 107: 293-299.View ArticlePubMedGoogle Scholar
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- Johns KR, Morand EF, Littlejohn GO: Pregnancy outcome in systemic lupus erythematosus (SLE): a review of 54 cases. Aust N Z J Med. 1998, 28: 18-22.View ArticlePubMedGoogle Scholar
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This article is published under license to BioMed Central Ltd. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.


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The Pentagon last night said that the US advanced ballistic missile defence system would be deployed in the Pacific in a direct response to increased threats from North Korea.
The Terminal High Altitude Area Defence System (Thaad) will be stationed on the Pacific island of Guam within weeks, in what appears to be a direct response to heightened rhetoric from North Korea last night.
Shortly before the Pentagon announcement, the North Korean Army said it had ratified a "merciless" attack against the US – potentially involving a "cutting-edge" nuclear strike.
"The moment of explosion is approaching fast," warned the military in a statement on the state news agency KCNA. With war ready to break out "today or tomorrow," Pyongyang said the US had "better ponder over the prevailing grave situation".
US authorities claimed the deployment of the nuclear missile defence system would "strengthen our regional defence posture against the North Korean regional ballistic missile threat".
Both developments came after North Korea yesterday barred South Korean workers from entering the Kaesong joint industrial zone, north of their demilitarised border. The move, which will only deepen tensions on the peninsula, came 24 hours after the North announced it was restarting the mothballed plutonium reactor at its Yongbyon facility, thereby signalling its intention to step up its nuclear weapons programme.
The interruption at Kaesong is seen by some experts as an especially ominous development, given that – with the exception of three days in 2009 – the complex had remained open through the string of previous crises since it opened in 2004 and is a rare enduring instance of co-operation between the two Koreas.
The closure "is something that was less expected, and is less directly in North Korea's interests," Patrick Cronin, a senior analyst with the Centre for a New American Security in Washington, said. "Is this a short-term demonstration of dissatisfaction with US-South Korean policy, or a portent of something more drastic at Kaesong?"
For the South, the world's 15th largest economy, Kaesong is of relatively minor significance, producing annually some $470m worth of goods which are shipped back to South Korea and then exported. But for the North it is a precious source of hard currency and jobs – but one that for now at least seems in jeopardy.
The move is thus being generally seen as yet another act of brinkmanship in the North's confrontation with South Korea and its protector, the US.
As Pyongyang has stepped up its provocations, so the US and North Korea have continued, more ostentatiously than ever, the military exercises that they conduct each spring.
After despatching nuclear-capable B-2 stealth bombers from their base in the US to take part, Washington has positioned a second missile-defence destroyer off the Korean peninsula – in reaction to Pyongyang's recent threats to target US bases in South Korea, where 28,500 American troops are stationed, and in the Pacific.
"Let me be perfectly clear," Secretary of State John Kerry said this week after talks with his South Korean counterpart Yun Byung-se, "the United States will defend and protect ourselves and our treaty ally, the Republic of Korea [South Korea]."
The Defence Secretary Chuck Hagel, went further yesterday, claiming North Korea's actions represented a "real and clear danger" to the US and its allies.
Although Pyongyang's current rhetoric is of a violence without precedent, some US analysts still believe the North is playing a familiar game – doing everything in its power to secure concessions from the West.
They would come both in the shape of economic assistance and diplomatically, in a resumption of the long-suspended six-nation talks over its nuclear programme.
So far though the US has given not the slightest public indication it is ready to go along.Reuse content

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Home >
Posts Tagged ' Venky's '
Venky's Acquires Stake In Online Music Site Hitlab.comWednesday, April 6, 2011 | Preethi J | More »
The London based subsidiary of Pune-based poultry major Venkateshwara Hatcheries Group (called Venky's) has bought a stake in Hitlab ULC, which runs the music site Hitlab.com. The size of the stake and its value are not disclosed. However, according to a PTI report in IBNLive.in, Venky's India ...


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Culture / Slices
Illusionist Dan White recently stopped by The Tonight Show, and performed an "illusion" that is so perplexing, it appeared to actually freak out host Jimmy Fallon.
Seriously guys, how did he do this. Discuss
Current / Slices
The Johnson Family of San Antonio will make you want to step up your Christmas light game. The homeowners—that were once featured on ABC's The Great Christmas Light Fight TV show—have turned their house into a tribute to dubstep, with this 11-minute audio/visual masterpiece. And, the best part is, it's all for a great cause. Visitors are encouraged to text donations to Living Water International, an organization that provides clean water to communities in need around the world. Discuss
If you watched Saturday Night Live this weekend, than you were lucky enough to see Larry David hilariously impersonate democratic presidential hopeful Bernie Sanders. But before David took the SNL stage, the site Death and Taxes showed just how much the Seinfeld co-creator sounded like the Vermont Senator. They created several clips last week, mashing up Bernie Sanders debate soundbites with scenes of Larry David impersonating Yankees owner George Steinbrenner on Seinfeld. At this point, we aren't convinced they aren't actually the same person. Discuss
This is truly a sick joke. In honor of the 30th anniversary of the film Back to the Future—a franchise which predicted we would all be flying around on sweet hover boards in the year 2015—Universal Pictures has released this fake commercial, showing just how high they had gotten all of our hopes up. Discuss


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kangna ranaut krrish News
Can you handle two Kangna Ranauts in the sequel of 'Tanu Weds Manu'?
Did you like watching the curly-haired actor's onscreen dramatics? If you did, then gear up for double the fun in the sequel of Anand Rai's wedding caper Tanu Weds Manu
We have an official confirmation from Kangna Ranaut, the leading lady of Anand Rai's last film Tanu Weds Manu that a sequel of the shaadi flick is very much in the pipeline. That's reason enough for the curly-haired lady to dance and be merry, 'coz TWM's success was largely attributed to her sprightly and spunky performance. Click here to read more


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Join us this afternoon for a liveblog of WilSon and Gack from Days of Our Lives with our very own snicks.
Also, be sure to join me on Twitter Sunday night for all the goings on at the Grammy Awards. It might be interesting, even with all the wardrobe rules that CBS rolled out at the last minute.
James Wolk will pit his furry chest against Robin Williams' furry back in Crazy Ones, the new CBS comedy pilot.
Out power producer/director/writer Bryan Singer has donated $5 million to the USC School of Film and had one of their six programs named after him.
Indiana lawmakers have postponed a vote to place a constitutional amendment against marriage equality on the ballot until next year, citing the pending Supreme Court decisions.
Chace Crawford says that while he hasn't read Fifty Shades of Grey, he'd be up for playing the title role. When asked if he'd be up for all the S&M sex involved, he jokingly (we assume) said "I am only comfortable with S&M sex scenes! The other ones are just too simple and boring for me."
Sex.com has offered NFL player Rob Gronkowski $3.75 million to film a sex scene for them. He's already posed naked for ESPN magazine, so why not?
The manhunt continues for former LAPD officer Christopher Dorner. Dorner left a vicious manifesto online, saying that lesbian police officers were high value targets, while expressing his love for Ellen DeGeneres. He also sent a package to Anderson Cooper with a coin with three bullet holes in it.
Justin Timberlake has been named the creative director of Bud Light Platinum, whatever that means. Based on "Suit & Tie" alone, I'm now hoping he focuses on that and forgets music for a while again.
Rumor has it that the entire script for Justice League has been scrapped, and they'll start over from scratch if Man of Steel is a success.
I just want to be the first at
AfterElton.com TheBackLot.com to say "Not It" if this gets made and needs recapped.
I would have normally skipped over any press release about a new show on TLC, especially one set in a trailer park in Myrtle Beach, but it does mention that among the colorful residents of Welcome to Myrtle Manor are drag queens.
Tony Perkins seems to be claiming he met with the management of Wal-Mart and got them to agree to cease funding any pro-gay groups. There are some problems with that idea, because 1) To my knowledge, Wal-Mart doesn't like the gays; 2) Wal-Mart would never agree to allow him to talk publicly about such a deal, it's terrible business, even from a company with low gay appeal.
President Obama has nominated Todd Hughes of the Justice Department to the Federal Court of Appeals, which if confirmed, would make him the first openly gay judge to sit on the Appeals bench.
Michigan has begun cross referencing HIV infections with previous partners, which could lead to legal problems if they can find a "patient zero" who didn't disclose their status.
In the UK, 16-year-old Anthony Stubb, a bisexual teenage father has hung himself in the woods after years of bullying. We have got to stop losing kids.
Ryan Gosling and Matt Smith are going to costar in How To Catch a Monster, a movie about a young mother drawn into a dark fantasy world after her son discovers a road into an underwater town. The internet may not survive. Certainly Tumblr is doomed. Do we ship it? Of course we do!
Andy Kelso models the shirts for the first day of rehearsals for Kinky Boots in NYC
Steve Aoki prepares to DJ for the opening of Ollie's club on Arrow
Jake Shears' husbro caught him in bed with the other man
Jeopardy gets a little clever with the categories for their teen tournament
Nolan Funk hits up the premiere of Beautiful Creatures
Oh, and last night during Glee, Adam Lambert RT'd me
Sacha Sacket grew up in Iran. He was bullied and isolated. But he was touched by the story of Jamey Rodemeyer, who took his own life after being bullied. Sacket wrote "Song for Jamey" in a single sitting, and it's part of the Gay Men's Chorus of Los Angeles tour right now, and it's stunning. h/t Towleroad.
Del Marquis isn't taking his time off from Scissor Sisters and catching a tan, he's recorded a mixtape, and the first video from it is called "Let me Tickle Your Fancy," and boy does it ever. A very 80s feel to the video, with a hot go-go boy, it's NSFW, but so fun to watch.
Al Jazeera English takes a look at the changing face of GLBT rights in Asia, and some of the advances that are being made in marriage and transgender rights in particular. The good news is that things are changing. The bad news is that there is still a long way to go in many countries.
Li Hongbo is a Chinese artist who does absolutely stunning things with paper. I seriously can't even begin to describe this, you'll just have to watch for yourself. This is Neil Patrick Harris endorsed stuff.
The history of condoms is a little longer than I perhaps imagined, and even goes through a phase in which they were as thick as bicycle tires, which honestly sounds like a major boner killer to me. Still, it's fascinating to see how things have evolved over the years for something we depend on so much these days.
I'm not entirely sure that these bar tricks designed to impress the ladies would be that effective in a gay bar, where more emphasis is placed on your abs and your biceps. But I can see pulling a few of them off to impress my bros.


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Results 1 to 5 of 12
Thread: Need a character name.
July 2nd, 2013 08:01 PM #1Junior Member
- Join Date
- Jul 2013
- Posts
- 2
Need a character name.
So I an notoriously bad at naming my main character.
I want a name like Lucy, but not Lucy. Her best friend's name happens to be Lily (unchangeable at this point), and it's just too close.
This character is reserved, fiercely loyal, and extremely strong. Think warrior, but feminine. She's a teenager sometime in the seventies. I'm looking for something a little tragic.
I really really need some help. I've considered names like Audrey, Elizabeth, and Hazel, but they just don't fit her or the story at all well.
July 2nd, 2013 09:17 PM #3
I feel ya... All the names I pick for characters don't seem right. I usually over-think it so I use the first name that comes to mind when I see my character.
Here's the link for the 200 most popular names for females in the 70's:
Not much help. SorryAlexis
teen berry
excuse my username
Isla Juno - Elodie Clover - Genevieve Aisling- Juliet Sparrow
Wolfgang Pascal - Evander Hugo - Jasper Fox - Theodore Blaise - Lucian Atlas
July 2nd, 2013 09:33 PM #5~ Catholic. College. Communicative Disorders. ~~(updated 11/3/15)
Saints, Classics, & Norwegian Boyfriend's Influence
~♀ ~ Alice Georgina ~ Aurora Seraphina ~ Elizabeth "Elska" Cecilia ~ Genevieve Astrid ~ Juliet Sunniva ~
♂ ~ Caspian Alexander ~ Declan Raphael ~ Ronan Oliver ~ Sebastian Anthony ~
Musings: ~ Charlotte Francesca ~
(I'm using the soo-NEE-va pronunciation of Sunniva)
July 2nd, 2013 11:20 PM #7Member
- Join Date
- Jun 2013
- Posts
- 55
July 2nd, 2013 11:28 PM #9robin | intj | ravenclaw | sci-fi writer | extended list
Esther Andromeda Pearl | Phoebe Winifred Briar | Delilah November Eve
Guinevere Dove | Posey Imogen | Adelina Opal | Sybil Magdalene | Rosemary Eluned | Ingrid Lavender
Leopold Elias Wolfgang | Callum Alasdair Rhys | Benedict Eamon Prosper
Lincoln Sage | Jupiter Samson | Desmond Fox | George Etienne | Patrick Frey | Orion Ramsey


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Defense theme raised early in Zumba paid-sex case
Credit: The Associated Press
ALFRED, Maine — A key defense claim that an insurance agent charged with helping a Zumba instructor run a prostitution business was unfairly targeted because he was investigating Kennebunk police was raised by the man's brother on the same day a search warrant was served, an official testified Friday.
The brother of defendant Mark Strong Sr., who is a private investigator in addition to an insurance agent, warned state police investigators not to let any electronic evidence fall into the hands of Kennebunk police, yet a hard drive ended up with the lead investigator, a Kennebunk officer, for about 36 hours, Sgt. Mark Holmquist acknowledged.
Holmquist said he didn't see a problem that former Officer Audra Presby ended up with the hard drive because it remained in the hands of law enforcement, ensuring the chain of custody.
But the defense contends the hard drive contained details about alleged unprofessional conduct by Presby, who was reprimanded for having an affair with her boss and was accused of abusing a 5-year-old boy. The police chief says the abuse claim was determined to be unfounded.
"My client was investigating the Kennebunk police, which had a lot of skeletons in their closet, and he got singled out in this particular case for a criminal charge in order to have him back off. We can't find any other motive," Strong's lawyer, Daniel Lilley, told reporters after court.
Strong, 57, of Thomaston, is accused of helping Alexis Wright run a prostitution business out of her Zumba dance studio in the coastal town of Kennebunk. He faces 13 misdemeanor counts related to promotion of prostitution. Wright will be tried later.
Strong was having an affair with Wright and signed on as guarantor for her Zumba studio, but he didn't know about the accusations of prostitution centered on the business, the defense contends.
Strong contends he began taking a look at the conduct of Kennebunk police after Wright told him that she was being harassed.
And his brother, attorney James Strong, backed up the notion, telling evidence technicians in July that Mark Strong had obtained "revealing evidence" about Kennebunk police, Holmquist said.
All hard drives and computers seized went to a state police computer crimes lab except one that ended up with Presby, who later delivered it to state police, he testified. "We simply overlooked that one piece of evidence," he said.
Also Friday, an attorney for the town of Kennebunk turned over some personnel records to defense lawyers who intend to attack Presby's credibility.
Lilley clashed with prosecutors and the town's attorney after being told that municipal workers' personnel records were confidential under state law and that disciplinary actions against officers were purged because of union rules.
Minutes later, Kennebunk police Chief Robert MacKenzie testified under cross-examination that the records still exist, even after being removed from an officer's personnel file. He also confirmed that a Presby reprimand was once considered a public record.
The matter of records will be revisited next week before Presby testifies. Lilley contends his client's rights in a criminal matter trump state civil law that makes personnel records confidential.
Still pending was a motion by Lilley to dismiss the remaining 13 counts because of discovery violations by prosecutors. "This is about the third or fourth time that we've complained about the state not furnishing documents. So at this point, we think the sanction should be extreme," Lilley said.
Follow David Sharp at http://twitter.com/David_Sharp_AP [1]


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Number: 0679
Aetna considers high-voltage pulsed electrogalvanic stimulation medically necessary for members with refractory levator syndrome (also known as proctalgia fugax, chronic anal pain syndrome) when all the following criteria are met:
Note: More than 3 60-min sessions, administered over a 10-day period, are not considered medically necessary. Electrogalvanic stimulators for home use are considered experimental and investigational because they have not been proven to be safe and effective for home use.
Aetna considers high-voltage pulsed electrogalvanic stimulation for levator syndrome experimental and investigational when criteria are not met.
Aetna considers biofeedback medically necessary for members with refractory levator syndrome when criteria listed above are met. (See CPB 0132 - Biofeedback).
Aetna considers the following interventions (not an all-inclusive list) experimental and investigational for the treatment of levator syndrome because their effectiveness for this indication has not been established:
Levator syndrome (LS), also known as proctalgia fugax and chronic anal pain syndrome, is a benign disorder characterized by brief, episodic attacks of rectal discomfort and pain of varying severity. Although the term levator syndrome suggests that spasm of the levator ani muscles is the cause of symptoms, it is still unclear that this mechanism is responsible for all cases of functional rectal discomfort/pain. Attacks often occur suddenly at night, waking patients from sleep. In some cases, attacks may occur when the patient is straining at stool or after a bowel movement. The pain usually lasts for seconds to minutes, and then disappears completely. Most patients have less than 6 episodes a year, however, some patients experience attacks very frequently. The condition generally does not appear until after puberty and the frequency and severity of attacks decrease after age 60. The site of pain is located in the upper anal canal, just above the anal sphincter. Precipitating factors for this disorder include anxiety, stress, heat, cold, or fatigue (Thompson and Heaton, 1980).
Treatments of patients with LS include high-fiber diet, withdrawal of drugs which have gut effects (e.g., drugs that provoke or worsen constipation including narcotics and calcium channel blockers; drugs that provoke or worsen diarrhea including quinidine, theophylline, and antibiotics), warm baths, rectal massage, perineal strengthening exercises, anti-cholinergic agents, non-narcotic analgesics, sedatives or muscle relaxants. High-voltage pulsed galvanic stimulation (HVPGS) has also been used in the treatment of this condition, and is not associated with any adverse side effects. It should be noted that HVPGS is generally not employed to treat patients while they are experiencing symptoms since the attacks usually last only for seconds to minutes. Instead, this technology is often used as a prophylactic means to reduce the incidence of attacks. The patient is usually placed in the left lateral decubitus position and a sterile probe is inserted into the anus. The negative electrode is used and the stimulator is set with a pulse frequency of 80 to 120 cycles per second. The voltage (intensity) is started at 0, progressively raised to a threshold of patient discomfort, and then is decreased to a level that the patient finds comfortable. As the patient's tolerance increases, the voltage can be gradually increased to 250 to 350 Volts. Each treatment session usually lasts between 15 to 60 mins (Oliver et al, 1985; Morris and Newton, 1987). Several studies have reported short-term success rates that ranged from 65 to 91 % (Sohn et al, 1982; Nicosia and Abcarian, 1985; Oliver et al, 1985; Morris and Newton, 1987; Billingham et al, 1987).
Sohn et al (1982) reported that HVPGS is effective in treating patients with LS. Eighty patients participated in the study. Treatment duration was 1 hour per day, 3 times over a period of 3 to 10 days. Of the 72 patients evaluated, 90 % had excellent (total relief of pain and no recurrence of levator spasm during the course of follow up) or good (with complete resolution of pain but with recurrence of levator spasm at a markedly reduced frequency during the course of follow-up) results. Nicosia and Abcarian (1985) treated 45 patients with LS using HVPGS. Treatment time was 15 to 30 mins administered every other day for an average of 5 treatments. Excellent (complete pain relief) or good (relief was followed by recurrence of pain that responded completely to additional treatment) results were observed in 91 % of patients.
Oliver et al (1985) also employed HVPGS to treat 102 patients with LS. Patients had tried and failed conservative treatments before being included in this study. All treatments were 60 mins in duration, and a total of 3 treatments were provided within a 10-day period. Follow-ups consisted of 1 post-treatment office visit to the attending surgeon or by telephone interviews if the patient failed to return for follow-up examination. Of the 90 patients with correct diagnoses, 77 % were relieved or improved after treatment. Morris and Newton (1987) reported their findings of 28 patients with LS treated with HVPGS. The number of treatments ranged from 3 to 10 with each session lasting for 60 mins. Overall, 75 % patients reported complete or partial relief of pain/symptoms following HVPGS treatment.
In the study by Billingham et al (1987) 20 patients received an average of 5.6 treatment sessions of HVPGS treatment. Immediately after the first course of treatment, 65 % of patients achieved excellent or good results. Several months after completion of therapy, results were classified as excellent in 4 (20 %) patients, good in 4 (20 %), fair in 6 (30 %), and poor in 6 (30 %). The authors concluded that although the long-term results of HVPGS are not as successful as the short-term results, this modality is still a valuable adjunct in the management of patients with LS.
In a randomized, placebo-controlled, cross-over study, Rao et al (2009) examined the safety and effectiveness of botulinum toxin in patients with LS. A total of 12 patients with LS (greater than or equal to 1 year) received anal intra-sphincteric injections of 100 units of botulinum toxin A and placebo at 90-day intervals using electromyographical guidance. Daily frequency, severity, duration and intensity of pain (by means of visual analog scale [VAS]) were recorded. Anorectal manometry, balloon expulsion and pudendal nerve latency tests were performed to examine the physiological changes and adverse effects. Seven patients (male/female = 4/3) completed the study and 3 had incomplete data, but all 10 underwent in an intention-to-treat analysis; 2 others dropped out. After administration of botulinum toxin, the mean frequency, intensity and duration of pain were unchanged (p = 0.31) compared with baseline. The 90-day mean VAS pain score was 6.79 +/- 0.27 versus baseline score of 7.08 +/- 0.29 (p = 0.25). Anal sphincter pressures, rectal sensory thresholds, pudendal nerve latency and balloon expulsion times were unchanged after drug or placebo administration. The authors concluded that injection of botulinum toxin into anal sphincter is safe, but it does not improve anorectal pain in LS.
Dudding and colleagues (2013) state that a small number of published case reports suggested that sacral nerve stimulation (SNS) could treat chronic idiopathic anal pain. In a pilot study, these researchers examined the effectiveness of SNS for the treatment of chronic anal pain. A total of 10 patients with chronic idiopathic anal pain were recruited. All had failed to respond to conservative treatments. Clinical and psychological evaluation was performed in all patients prior to SNS. Temporary stimulation of the S3 foramina was performed for 3 weeks and outcome assessed by comparison of a pain score diary and VAS obtained during stimulation and at baseline. Primary outcome was defined as a greater than 50 % reduction in pain score. Of the 10 patients recruited, 5 were found to have clinical depression; 4 patients withdrew from the study prior to testing and 6 underwent peripheral nerve evaluation (PNE). Three patients had greater than 50 % reduction in pain score and progressed to permanent SNS. Of these, only 1 had good pain control at latest follow-up of 5 years; the remaining 2 patients obtained no benefit and had their devices removed or de-activated. These 2 patients both had depression that was also not improved by SNS. The authors concluded that the findings of this pilot study suggested that SNS is not an effective treatment for chronic anal pain in the majority of patients. Furthermore, PNE is not an effective means of identifying which of these patients are likely to respond to permanent SNS.
|CPT Codes / HCPCS Codes / ICD-10 Codes
|Information in the [brackets] below has been added for clarification purposes.  Codes requiring a 7th character are represented by "+":
|CPT codes covered if selection criteria are met:
|Application of a modality to one or more areas; electrical stimulation (unattended)
|Application of a modality to one or more areas; electrical stimulation, (manual), each 15 minutes
|CPT codes not covered for indications listed in the CPB:
|Percutaneous implantation of neurostimulator electrode array; sacral nerve (transforaminal placement) including image guidance, if performed
|Incision for implantation of neurostimulator electrode array; sacral nerve (transforaminal placement)
|Other CPT codes related to the CPB:
|Anoscopy; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)
|Application of surface (transcutaneous) neurostimulator
|Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry
|95970 - 95972
|Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements)
|HCPCS codes covered if selection criteria are met:
|Electromyography (EMG), biofeedback device
|HCPCS codes not covered for indications listed in the CPB:
|Sacral nerve stimulation test lead, each
|Botulinum toxin type A, per unit
|Injection, Abobotulinumtoxina, 5 units
|Botulinum toxin type B, per 100 units
|Injection, Incobotulinumtoxin A, 1 unit
|Injection, betamethasone acetate 3 mg and betamethasone sodium phosphate 3 mg
|Injection, cosyntropin, not otherwise specified, 0.25 mg
|Injection, cosyntropin (Cortrosyn), 0.25 mg
|Injection, methylprednisolone acetate, 20 mg
|Injection, methylprednisolone acetate, 40 mg
|Injection, methylprednisolone acetate, 80 mg
|Injection, dexamethasone acetate, 1 mg
|Injection, dexamethasone sodium phosphate, 1 mg
|Injection, hydrocortisone acetate, up to 25 mg
|Injection, hydrocortisone sodium phosphate, up to 50 mg
|Injection, hydrocortisone sodium succinate, up to 100 mg
|Injection, prednisolone acetate, up to 1 ml
|Injection, methylprednisolone sodium succinate, up to 40 mg
|Injection, methylprednisolone sodium succinate, up to 125 mg
|Injection, triamcinolone acetonide, preservative free, 1 mg
|Injection, triamcinolone acetonide, not otherwise specified, 10 mg
|Injection, triamcinolone diacetate, per 5 mg
|Injection, triamcinolone hexacetonide, per 5 mg
|Radiofrequency transmitter (external) for use with implantable sacral root neurostimulator receiver for bowel and bladder management, replacement
|Other HCPCS codes related to the CPB:
|Neuromuscular stimulator, electronic shock unit
|Non-thermal pulsed high frequency radiowaves, high peak power electromagnetic energy treatment device
|Electrical stimulation (unattended), to one or more areas for indication(s) other than wound care, as part of a therapy plan of care
|Implantable neurostimulator electrode, each
|Patient programmer (external) for use with implantable programmable implantable neurostimulator pulse generator
|Implantable neurostimulator radiofrequency receiver
|Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver
|Implantable neurostimulator pulse generator, single array, rechargeable, includes extension
|Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension
|Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension
|Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension
|External recharging system for battery (internal) for use with implantable neurostimulator
|ICD-10 codes covered if selection criteria are met:
|Anal spasm [proctalgia fugax]
|Other specified diseases of anus and rectum [chronic anal pain syndrome] [levator syndrome or chronic anal pain syndrome]


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text: Barca Complete The SexfectaBarry Petchesky12/20/09 11:30amFiled to: SoccerFC Barcelona5EditPromoteShare to KinjaToggle Conversation toolsGo to permalink Barcelona go seis por seis, winning every single club title this year. That's like the Steelers winning the Super Bowl, other countries actually playing football, and then Pittsburgh beating all of them. [CNN]Reply5 repliesLeave a reply