Pregnancy complications in women with the antiphospholipid syndrome (APS) and/or SLE include recurrent miscarriage, preeclampsia, placental insufficiency, and intrauterine growth restriction (IUGR). The mechanisms leading to placental and fetal injury in vivo are incompletely understood and treatment remains sub-optimal. We have identified complement as an early effector in pregnancy loss and/or IUGR associated with placental inflammation in a mouse model of APS and shown that complement activation causes the release of anti- angiogenic factors and abnormal placental development. The PROMISSE Study (Predictors of pRegnancy Outcome: bioMarkers In antiphospholipid antibody Syndrome and Systemic lupus Erythematosus) is a first-time effort to translate our novel findings in mice to humans and determine if elevations of complement split products predict pregnancy complications in patients with antiphospholipid (aPL) antibodies and/or SLE. In the first 4 years of this prospective, observational study of pregnant patients grouped and analyzed according to the presence or absence of aPL antibodies and preexisting SLE, we have enrolled 342 pregnant patients in 7 centers, obtained detailed medical and obstetrical information monthly, and serially collected plasma, serum, DNA, RNA, and urine. Preliminary data suggest that elevated levels of complement activation products antecede and predict poor fetal outcome, consistent with our hypothesis that complement is a proximal mediator of fetal loss and IUGR. We propose to increase our target sample size from 400 to 700 pregnant patients to maintain study power given lower than expected outcome rates, and to leverage the infrastructure and rich collection of patient data and samples by expanding the array of biomarkers and scope of adverse pregnancy outcomes. Specifically, in Aim 1 we will determine whether elevations of split products generated by activation of complement pathways predict poor fetal and/or maternal outcome in patients with aPL antibodies and/or SLE and, in Aim 2, whether the balance of circulating angiogenic and antiangiogenic factors predicts preeclampsia or delivery of IUGR infants.
In Aim 3, a new direction, we will use the PROMISSE cohort to affirm in humans our recent findings in mice, that certain anti-DNA antibodies cross-react with N-methyl D- aspartate receptors (NMDAR) and cause neuronal death with ensuing cognitive and behavioral impairment. We propose to quantitate anti-NMDAR antibody levels throughout pregnancy in PROMISSE SLE patients and test the hypothesis that in utero exposure to maternal anti-NMDAR antibodies alters behavior and cognitive development in offspring by evaluating cortical function tasks in 12 month and 3.5 year old children. This competitive renewal and extension of the PROMISSE Study provides an outstanding opportunity to translate knowledge from mouse models to patients, define pathogenic mechanisms, identify predictors of poor pregnancy outcome in APL and/or SLE, and define novel therapeutic targets to prevent such outcomes.Patients with systemic lupus erythematosus (SLE) and/or antiphospholipid (aPL) antibodies are at increased risk for miscarriage, preeclampsia and fetal growth restriction - major causes of maternal, fetal, and neonatal morbidity and mortality in the US and worldwide - whose etiology and mechanism remain unknown and for which therapy is limited. In addition to causing placental dysfunction, maternal autoantibodies may also directly impair fetal brain development. Identification of biomarkers that predict poor pregnancy outcome in these patients will elucidate mechanisms of disease, define targets for treating patients, and generate clinically applicable indicators to permit initiation of interventional trials in patients at greatest risk for pregnancy complications.

National Institute of Health (NIH)
National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS)
Research Project (R01)
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Special Emphasis Panel (ZAR1-KM-H (J1))
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Wang, Yan Z
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Hospital for Special Surgery
New York
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Kim, Mimi Y; Guerra, Marta M; Kaplowitz, Elianna et al. (2018) Complement activation predicts adverse pregnancy outcome in patients with systemic lupus erythematosus and/or antiphospholipid antibodies. Ann Rheum Dis 77:549-555
Mulla, Melissa J; Weel, Ingrid C; Potter, Julie A et al. (2018) Antiphospholipid Antibodies Inhibit Trophoblast Toll-Like Receptor and Inflammasome Negative Regulators. Arthritis Rheumatol 70:891-902
Abrahams, Vikki M; Chamley, Lawrence W; Salmon, Jane E (2017) Emerging Treatment Models in Rheumatology: Antiphospholipid Syndrome and Pregnancy: Pathogenesis to Translation. Arthritis Rheumatol 69:1710-1721
Buyon, Jill P; Kim, Mimi Y; Guerra, Marta M et al. (2017) Kidney Outcomes and Risk Factors for Nephritis (Flare/De Novo) in a Multiethnic Cohort of Pregnant Patients with Lupus. Clin J Am Soc Nephrol 12:940-946
Simard, Julia F; Arkema, Elizabeth V; Nguyen, Cathina et al. (2017) Early-onset Preeclampsia in Lupus Pregnancy. Paediatr Perinat Epidemiol 31:29-36
Yelnik, Cecile M; Porter, T Flint; Branch, D Ware et al. (2016) Brief Report: Changes in Antiphospholipid Antibody Titers During Pregnancy: Effects on Pregnancy Outcomes. Arthritis Rheumatol 68:1964-9
Kim, Mimi Y; Buyon, Jill P; Guerra, Marta M et al. (2016) Angiogenic factor imbalance early in pregnancy predicts adverse outcomes in patients with lupus and antiphospholipid antibodies: results of the PROMISSE study. Am J Obstet Gynecol 214:108.e1-108.e14
Buyon, Jill P; Kim, Mimi Y; Salmon, Jane E (2016) Predictors of Pregnancy Outcomes in Patients With Lupus. Ann Intern Med 164:131
Yelnik, Cecile M; Laskin, Carl A; Porter, T Flint et al. (2016) Lupus anticoagulant is the main predictor of adverse pregnancy outcomes in aPL-positive patients: validation of PROMISSE study results. Lupus Sci Med 3:e000131
Buyon, Jill P; Kim, Mimi Y; Guerra, Marta M et al. (2015) Predictors of Pregnancy Outcomes in Patients With Lupus: A Cohort Study. Ann Intern Med 163:153-63

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