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Lee R, Lebwohl M. Comprehensive Literature Review of Obstetric Outcomes and Fetal Risk during Pregnancy with Pseudoxanthoma Elasticum. J Clin Med 2021; 10:jcm10112532. [PMID: 34200486 PMCID: PMC8201327 DOI: 10.3390/jcm10112532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 05/27/2021] [Accepted: 06/01/2021] [Indexed: 11/24/2022] Open
Abstract
Individuals with pseudoxanthoma elasticum (PXE) have often been advised against becoming pregnant due to a fear of the exacerbation of existing symptoms, likelihood of inheritance of the disease, and possible obstetric risks associated with the mother and child. PXE is a recessive multisystem disorder that leads to calcification of elastic tissues and fibers that can result in arterial rupture and gastrointestinal (GI) bleeding, possibly endangering the fetus and mother. PXE often manifests in skin lesions as well and the risk of exacerbation is a principal concern. To address these complications and to provide transparent understanding to healthcare providers and mothers of the associated risk factors with pregnancy and PXE, we conducted a comprehensive review of the current literature and found that there is no inherent risk for obstetric complications for PXE pregnancies and patients need not be advised against becoming pregnant as previously suggested. PXE-related pregnancies are unremarkable to the mother’s wellbeing and fetal complications are few, if any at all.
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Camacho M, Rengel C, López-Herrero E, Carrillo JL, Eslava AJ, Valdivielso P. Approach to the management of pregnancy in patients with pseudoxanthoma elasticum: a review. J OBSTET GYNAECOL 2016; 36:1061-1066. [PMID: 27623860 DOI: 10.1080/01443615.2016.1196478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Management of pregnancy in patients with rare diseases is often guided by incomplete knowledge because of a lack of high-quality case control studies or single-centre experience. Pseudoxanthoma elasticum (PXE) is an autosomal recessive metabolic disorder that results in calcification of elastic fibres of the skin, retina, and arteries, leading to skin lesions, eventual central visual loss, and potential arterial insufficiency in most patients. It is due to mutations in ABCC6, which encodes the eponymous membrane transport protein. We review the literature on pregnancy in PXE, including the effects of the diseases on pregnancy and its complications, the effect of PXE on the foetus, and the effects of pregnancy on PXE, and conclude that in the majority of pregnancies in women with PXE, the outcome for mother, baby, and the disease is uneventful. We also provide recommendations for managing pregnancy in PXE.
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Affiliation(s)
- Marta Camacho
- a Obstetrics and Gynaecology Unit, 'Virgen de la Victoria' University Hospital , Málaga , Spain
| | - Cristobal Rengel
- a Obstetrics and Gynaecology Unit, 'Virgen de la Victoria' University Hospital , Málaga , Spain
| | - Elisa López-Herrero
- a Obstetrics and Gynaecology Unit, 'Virgen de la Victoria' University Hospital , Málaga , Spain
| | - Juan L Carrillo
- b Internal Medicine Unit, 'Virgen de la Victoria' University Hospital , Málaga , Spain
| | - Agustín J Eslava
- a Obstetrics and Gynaecology Unit, 'Virgen de la Victoria' University Hospital , Málaga , Spain
| | - Pedro Valdivielso
- b Internal Medicine Unit, 'Virgen de la Victoria' University Hospital , Málaga , Spain.,c Department of Medicine and Dermatology , Instituto de Biomedicina de Málaga (IBIMA), University of Malaga , Málaga , Spain
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Tan WC, Rodeck CH. Placental Calcification in Pseudoxanthoma Elasticum. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2008. [DOI: 10.47102/annals-acadmedsg.v37n7p598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Introduction: Pseudoxanthoma elasticum (PXE) is an inherited multisystem disorder of the elastic tissue and the objective of this case report is to correlate ultrasonographic and histological appearances of placental calcification in PXE.
Clinical Picture: We report a case of a 37-year-old white woman with PXE, whose antenatal imaging showed a markedly echogenic placenta due to extensive calcification confirmed on postpartum placental histology.
Outcome: There were no maternal or fetal complications in the antenatal period. A healthy baby of appropriate maturity and weight was delivered via Caesarean section and remained well at 6 months.
Conclusion: The majority of cases of PXE is caused by mutations in the ABCC6 gene. Serious complications in pregnancy can include gastrointestinal haemorrhage, congestive heart failure and cardiac arrhythmia but has not been shown to be associated with markedly increased fetal loss or adverse reproductive outcomes as reported in previous literature. Apart from the cosmetic deterioration of the abdominal skin, there were few serious complications and most have normal pregnancies. Obstetric prognosis is dependent on the vascular damage caused by the illness. There is no basis for advising women with PXE to avoid becoming pregnant, and most pregnancies in PXE are uncomplicated.
Key words: Angioid streaks, Echogenic placenta, Gastrointestinal haemorrhage
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Bercovitch L, Leroux T, Terry S, Weinstock MA. Pregnancy and obstetrical outcomes in pseudoxanthoma elasticum. Br J Dermatol 2005; 151:1011-8. [PMID: 15541079 DOI: 10.1111/j.1365-2133.2004.06183.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Pseudoxanthoma elasticum (PXE) is a genetic multisystem disorder characterized by calcified dystrophic elastic fibres in skin, retina and arteries. Much of the earlier literature on pregnancy in PXE contained reports of severe complications, leading some healthcare providers to advise women with PXE against becoming pregnant and some women with PXE to avoid pregnancy. OBJECTIVES To evaluate the obstetrical outcomes and the incidence of pregnancy complications in women with PXE and to determine if pregnancy is associated with an adverse effect on the course of the disease. METHODS Women with PXE (n = 407) answered detailed questionnaires regarding reproductive history and pregnancy as well as the course of their disease. The frequency of reported pregnancy outcomes and complications was determined. Severity indices for the major clinical manifestations of PXE were developed and correlated with gravidity of affected women aged 40 years or over. RESULTS Among the 306 respondents with PXE who had ever been pregnant, there were 795 pregnancies. Of these, 83% ended in live births and 1% in stillbirth. The median birth weight was within the normal range and the incidence of low birth weight for gestation was low. Hypertension occurred in 10% of pregnancies, gastric bleeding and retinal complications in < 1%, and 12% of pregnancies were associated with worsening of skin manifestations. There was no effect of gravidity and clinical severity on cutaneous (P = 0.07), ocular (P = 0.59) or cardiac (P = 0.42) manifestations of PXE in women aged 40+ years, nor did ever having been pregnant adversely affect these clinical severity indices. Of the 101 women who had never been pregnant, 17% made the decision because they were advised against becoming pregnant by a healthcare professional and 11% did not become pregnant because they feared an adverse outcome either in their pregnancy or disease. CONCLUSIONS PXE is not associated with markedly increased fetal loss or adverse reproductive outcomes. The incidence of gastric bleeding, although probably higher than in the unaffected population, is much lower than previously reported, and retinal complications are uncommon. Although a few pregnancies were associated with worsening of skin manifestations, there was no correlation of either gravidity or ever having been pregnant with ultimate severity of skin, ocular or cardiovascular manifestations. There is no basis for advising women with PXE to avoid becoming pregnant, and most pregnancies in PXE are uncomplicated.
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Affiliation(s)
- L Bercovitch
- Department of Dermatology, Brown Medical School, Providence, RI, USA.
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Douglas MJ, Gunka VB, von Dadelszen P. Anesthesia for the parturient with pseudoxanthoma elasticum. Int J Obstet Anesth 2003; 12:45-7. [PMID: 15676320 DOI: 10.1016/s0959-289x(02)00161-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/01/2002] [Indexed: 10/27/2022]
Abstract
We present our experience in the anesthetic management of two parturients with pseudoxanthoma elasticum. The first had an epidural catheter inserted for labor analgesia and ultimately had a forceps delivery. The second had a cesarean section under epidural anesthesia and had a complicated postoperative course. There were no untoward effects of regional anesthesia in either of these two women. The anesthetic implications for parturients with pseudoxanthoma elasticum are discussed.
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Affiliation(s)
- M J Douglas
- Department of Anaesthesia, University of British Columbia and British Columbia's Women's Hospital and Health Centre, Vancouver, BC, Canada.
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Ernst LM, Parkash V. Placental pathology in fetal bartter syndrome. Pediatr Dev Pathol 2002; 5:76-9. [PMID: 11815871 DOI: 10.1007/s10024-001-0092-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2001] [Accepted: 08/15/2001] [Indexed: 10/26/2022]
Abstract
Bartter syndrome, which presents clinically with polyuria, urinary potassium loss, hypokalemia, hypercalciuria, and alkalosis, is an autosomal recessive disorder with mutations in genes encoding the Na-K-2Cl cotransporter, the chloride channel CLC-NKB, and the potassium channel ROMK. Prenatal diagnosis of Bartter syndrome is now possible; however, there are no reports of the placental pathology associated with fetal Bartter syndrome. We present the placental pathologic findings in two siblings with fetal Bartter syndrome. Both pregnancies were complicated by polyhydramnios and preterm delivery. The first pregnancy delivered at 30 weeks, and Bartter syndrome was diagnosed in the perinatal period. The subsequent pregnancy required periodic therapeutic amniocentesis secondary to massive polyhydramnios and delivered at 32 weeks gestation. The suspicion of fetal Bartter syndrome was very high in this second pregnancy, and the infant was confirmed to have Bartter syndrome subsequently. Both placentas were large for gestational age, weighing greater than the 95th percentile. Microscopic examination showed extensive subtrophoblastic basement membrane mineralization (special stains positive for iron and calcium) in the chorionic villi. This striking finding was present in both placentas. Subtrophoblastic mineralization has been described in the literature in placentas of fetuses with abnormalities including anencephaly, trisomy 21, and other congenital abnormalities; however, it has also been described in normal pregnancies. Mechanisms of calcification in the placenta are not well understood, but these striking cases suggest that defects in fetal renal excretion of ions can lead to dystrophic calcification within the placenta, particularly in a subtrophoblastic pattern.
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Affiliation(s)
- Linda M Ernst
- Department of Anatomic Pathology, Yale University School of Medicine, PO Box 208070, New Haven, CT 06520, USA
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Aessopos A, Farmakis D, Loukopoulos D. Elastic tissue abnormalities resembling pseudoxanthoma elasticum in beta thalassemia and the sickling syndromes. Blood 2002; 99:30-5. [PMID: 11756149 DOI: 10.1182/blood.v99.1.30] [Citation(s) in RCA: 112] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
The development of clinical and histopathologic manifestations of a diffuse elastic tissue defect, resembling inherited pseudoxanthoma elasticum (PXE), has been encountered with a notable frequency in patients with beta thalassemia, sickle cell disease, and sickle thalassemia. The PXE-like clinical syndrome, consisting of skin, ocular, and vascular manifestations, has a variable severity in these hemoglobinopathies and it is age-dependent, with a generally late onset, after the second decade of life. The defect is believed to be acquired rather than inherited and related to the consequences of the primary disease. The high prevalence of the findings implicates the elastic tissue injury as one of the main comorbid abnormalities encountered in beta thalassemia and the sickling syndromes. In these patients a number of complications, sometimes serious, has been recognized to be related to ocular and vascular elastic tissue defects. Because several organ systems are involved, each medical specialty should be aware of the phenomenon. This coexistence, on the other hand, introduces a novel pathogenetic aspect of PXE and an important research challenge.
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Affiliation(s)
- Athanasios Aessopos
- First Department of Internal Medicine, University of Athens, School of Medicine, Laiko General Hospital, Athens, Greece.
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Gheduzzi D, Taparelli F, Quaglino D, Di Rico C, Bercovitch L, Terry S, Singer DB, Pasquali-Ronchetti I. The placenta in pseudoxanthoma elasticum: clinical, structural and immunochemical study. Placenta 2001; 22:580-90. [PMID: 11440547 DOI: 10.1053/plac.2001.0687] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Pseudoxanthoma elasticum (PXE) is a rare genetic disorder clinically characterized by skin, cardiovascular and eye manifestations, mainly due to calcification and fragmentation of elastic fibres. Although infrequent, complications during pregnancy in women affected by PXE have been reported. The aim of the present study was to compare structural features of placentae at term from 14 control and 15 PXE-affected women, in order to better understand if and how abnormal mineral and/or matrix accumulation might affect placental function in PXE. In all cases, pregnancy, fetus growth and delivery were normal. Both gross and light microscopy examination did not reveal dramatic differences between placentae of PXE patients and controls, with regard to weight, dimensions, infarcts, thrombi, inflammatory lesions or vessels. However, necrotic changes and mineralization appeared statistically more pronounced in PXE. By electron microscopy the most remarkable differences between PXE and control placentae were observed in the localization and morphology of mineral precipitates; a significant higher deposition of mineral precipitates was observed associated with the "matrix"-type fibrinoid and among collagen fibrils, especially on the maternal side. Immunocytochemistry revealed the presence of vitronectin and fibronectin associated with the PXE-specific mineralizations and the absence of mineralization on the small and scarce elastic fibres in either controls or in PXE.
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Affiliation(s)
- D Gheduzzi
- Department of Biomedical Sciences, University of Modena and Reggio Emilia, Via Campi 287, 41100-Modena, Italy
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Abstract
The dermatoses of pregnancy can be classified into the following 3 groups: physiologic skin changes in pregnancy, dermatoses and cutaneous tumors affected by pregnancy, and specific dermatoses of pregnancy. Correct diagnosis and classification are essential for the treatment of these disorders, when necessary. Laboratory investigations are required when the diagnosis remains in question despite a careful history and thorough physical examination. A discussion with the pregnant woman about the nature of her skin condition, and the possible fetal risks associated with it, is imperative.
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Affiliation(s)
- G Kroumpouzos
- Department of Dermatology, Boston Medical Center, Boston University School of Medicine, Massachusetts, USA
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Abstract
INTRODUCTION Systemic elastorrhexis or Grönblad-Strandberg-Touraine syndrome is a rare inherited disease characterized by a generalized elastic tissue dysplasia and polymorphic clinical features, with the main tissues affected being cutaneous, ocular and arterial. CURRENT KNOWLEDGE AND KEY POINTS Usual cardiovascular complications of this entity include ischemic heart disease, renovascular hypertension and atherosclerotic peripheral vascular disease. Some cases of restrictive cardiomyopathies and valvular disease have been reported. Coronary artery disease, often with early onset, is seen in approximately 20% of cases. FUTURE PROSPECTS AND PROJECTS This review of the literature concerning a rare cause of cardiopathy underlines the need to search for underlying elastorrhexis in the clinical setting of early onset and severe coronary artery disease or arteriopathy, especially in the absence of vascular risk factors. This hereditary disease has been traced to chromosome 16p13.1 and may in the future be easily diagnosed, bypassing the need for cutaneous biopsy.
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Affiliation(s)
- K Bendjelid
- Division des soins intensifs chirurgicaux, département APSIC, hôpital cantonal universitaire de Genève, 1211 Genève 14, Suisse.
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Abstract
During pregnancy, immunologic, endocrine, metabolic, and vascular changes occur that make the pregnant woman susceptible to aggravation of certain skin diseases. These diseases can be organized into five broad categories: infections, diseases of altered immunity, metabolic diseases, connective tissue disorders, and miscellaneous conditions. A discussion of how each of these diseases is altered by pregnancy and how treatment may differ during gestation is presented.
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Affiliation(s)
- G B Winton
- Department of Medicine, Walter Reed Army Medical Center, Washington, DC 20307-5001
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Viljoen DL, Beatty S, Beighton P. The obstetric and gynaecological implications of pseudoxanthoma elasticum. BRITISH JOURNAL OF OBSTETRICS AND GYNAECOLOGY 1987; 94:884-8. [PMID: 3663550 DOI: 10.1111/j.1471-0528.1987.tb03760.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
The obstetric aspects of 54 pregnancies in 20 women with pseudoxanthoma elasticum (PXE) have been reviewed. Forty live births were delivered vaginally, three of them were preterm. Twelve pregnancies miscarried at between 6 and 14 weeks gestation and two were terminated in the 8th week for psychiatric reasons. Fetal losses in two instances were attributed to cervical incompetence. One baby died at 4 days of age from a complex congenital cardiac anomaly. No abnormal maternal genital or gastrointestinal bleeding was recorded. Hypertension complicated seven pregnancies. Abdominal striae developed in all patients, the severity of which correlated with weight gain and the number of pregnancies. All the women had normal gynaecological histories, none had excessive menstrual bleeding or increased episodes of menorrhagia. The eye, blood vessels and other organ systems involved in PXE were unaffected by pregnancy. Apart from the increased risk of first trimester miscarriage and the cosmetic deterioration of the abdominal skin, there are few serious complications in pregnancy in patients with PXE.
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Affiliation(s)
- D L Viljoen
- Department of Human Genetics, Medical School, University of Cape Town, Republic of South Africa
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Elejalde BR, de Elejalde MM. The prenatal growth of the human body determined by the measurement of bones and organs by ultrasonography. AMERICAN JOURNAL OF MEDICAL GENETICS 1986; 24:575-98. [PMID: 3526890 DOI: 10.1002/ajmg.1320240402] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
This paper presents the ultrasonographic analysis of the growth of two groups of human fetuses, one longitudinal and the other cross-sectional. Measurements of all the long bones were taken, as well as measurements of the following diameters: Biparietal, occipitofrontal, thoracic and abdominal anterior/posterior and transverse, spinal canal width, arm, forearm, thigh and leg transverse. The bladder and the stomach were also measured. The pregnancies analyzed covered the period between the 8th and 38th week of gestation. Centiles (3rd-97th) were calculated for each structure and week. All pregnancies known or suspected to be abnormal were removed from the study. The values obtained were tested in 102 pregnancies (test group); the expected values (from the graphs) did not deviate from the values obtained from this group of fetuses, demonstrating the reliability of the values presented in these graphs. All structures measured showed linear growth. There was no significant difference between the longitudinal and cross-sectional groups.
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