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Kline M, Fuller K, Gray K. Myasthenia Gravis in Pregnancy and the Newborn. Neoreviews 2024; 25:e228-e231. [PMID: 38556492 DOI: 10.1542/neo.25-3-e228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Affiliation(s)
- Meagan Kline
- Department of Obstetrics and Gynecology, University of Arizona Phoenix College of Medicine, Banner University Medical Center, Phoenix, AZ
| | - Kisti Fuller
- Department of Obstetrics and Gynecology, University of Arizona Phoenix College of Medicine, Banner University Medical Center, Phoenix, AZ
| | - Kendra Gray
- Department of Obstetrics and Gynecology, University of Arizona Phoenix College of Medicine, Banner University Medical Center, Phoenix, AZ
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Kline M, Fuller K, Gray K. Myasthenia Gravis in Pregnancy and the Newborn. Neoreviews 2024; 25:e228-e231. [PMID: 38556501 DOI: 10.1542/neo.25-4-e228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Affiliation(s)
- Meagan Kline
- Department of Obstetrics and Gynecology, University of Arizona Phoenix College of Medicine, Banner University Medical Center, Phoenix, AZ
| | - Kisti Fuller
- Department of Obstetrics and Gynecology, University of Arizona Phoenix College of Medicine, Banner University Medical Center, Phoenix, AZ
| | - Kendra Gray
- Department of Obstetrics and Gynecology, University of Arizona Phoenix College of Medicine, Banner University Medical Center, Phoenix, AZ
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Kumar L, Kachhadia MP, Kaur J, Patel H, Noor K, Gohel RG, Kaur P, Raiyani S, Gohel VA, Vasavada AM. Choices and Challenges With Treatment of Myasthenia Gravis in Pregnancy: A Systematic Review. Cureus 2023; 15:e42772. [PMID: 37663985 PMCID: PMC10469352 DOI: 10.7759/cureus.42772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/31/2023] [Indexed: 09/05/2023] Open
Abstract
Myasthenia gravis (MG) is an autoimmune disease affecting young women in their second and third decades, coinciding with their reproductive years. We aim to explore the choices and challenges in the treatment of MG in pregnancy. Cochrane, PubMed, Google Scholar, and Embase were the four databases systematically searched for studies with patients reporting pregnancy outcomes for women with MG during pregnancy using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) technique. Quality assessment was done using the Joanna Briggs Institute critical tool (JBI, Adelaide, Australia) for methodological quality. From 2000 to 2023, 40 studies from database search results were considered. There is a substantial risk of complications with MG, especially if it appears during pregnancy. In particular, widespread weakness is a cause of severe, life-threatening disorders, but several treatment options are available.
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Affiliation(s)
- Lakshya Kumar
- Internal Medicine, Pandit Dindayal Upadhyay (PDU) Medical College, Rajkot, IND
| | | | - Jashanpreet Kaur
- Internal Medicine, Mata Gujri Memorial Medical College, Kishanganj, IND
| | - Harshkumar Patel
- Internal Medicine, Pandit Dindayal Upadhyay (PDU) Medical College, Rajkot, IND
| | - Khutaija Noor
- Internal Medicine, Shadan Institute of Medical Sciences, Hyderabad, IND
| | - Rushi G Gohel
- Internal Medicine, Pandit Dindayal Upadhyay (PDU) Medical College, Rajkot, IND
| | - Paramjeet Kaur
- Internal Medicine, Guru Gobind Singh Medical College, Faridkot, IND
| | - Siddharth Raiyani
- Internal Medicine, Pandit Dindayal Upadhyay (PDU) Medical College, Rajkot, IND
| | - Vatsal A Gohel
- Internal Medicine, Karaganda Medical University, Karaganda, KAZ
| | - Advait M Vasavada
- Internal Medicine, M. P. Shah Medical College, Jamnagar, IND
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
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Harada Y, Bettin M, Juel VC, Hobson-Webb LD, Raja SM, Sanders DB, Massey JM. Pregnancy in MuSK-positive myasthenia gravis: A single-center case series. Muscle Nerve 2023. [PMID: 37150596 DOI: 10.1002/mus.27839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 04/18/2023] [Accepted: 04/18/2023] [Indexed: 05/09/2023]
Abstract
INTRODUCTION/AIMS Myasthenia gravis (MG) with muscle-specific tyrosine kinase (MuSK) antibodies (MMG) is predominantly seen in women of childbearing age. Our objective in this study was to describe the course of MMG during pregnancy and within 6 months postpartum, and to document any effect on fetal health. METHODS A retrospective review was performed of medical records of patients with MMG seen in the Duke Myasthenia Gravis Clinic from 2003 to 2022. MMG patients with onset of MMG symptoms before or during pregnancy as well as within 6 months postpartum were reviewed. RESULTS A total of 14 pregnancies in 10 patients were included in our study cohort. Initial MG symptoms developed during pregnancy or within 6 months postpartum in six patients. Four patients had two pregnancies, three of whom developed MG during their first pregnancy. In the patients diagnosed before pregnancy, MG symptoms increased in five of eight patients during pregnancy or postpartum. Four patients required rescue therapy with plasma exchange or intravenous immunoglobulin during pregnancy or postpartum. One patient had a cesarean section after prolonged labor due to failure of progression. There were no other complications of pregnancy or delivery, and all infants were healthy at delivery. DISCUSSION As in non-MuSK MG, women with MMG may also have worsening or may develop initial MG symptoms during pregnancy or within 6 months postpartum. More aggressive medical therapy may be required for pregnant patients with MMG. Further study is needed to identify the mechanism and risk of worsening of MMG during pregnancy or postpartum.
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Affiliation(s)
- Yohei Harada
- Department of Neurology, Duke University Medical Center, Durham, North Carolina, USA
| | - Margaret Bettin
- Division of Neurology, Centra Neurology, Lynchburg, Virginia, USA
| | - Vern C Juel
- Department of Neurology, Duke University Medical Center, Durham, North Carolina, USA
| | - Lisa D Hobson-Webb
- Department of Neurology, Duke University Medical Center, Durham, North Carolina, USA
| | - Shruti M Raja
- Department of Neurology, Duke University Medical Center, Durham, North Carolina, USA
| | - Donald B Sanders
- Department of Neurology, Duke University Medical Center, Durham, North Carolina, USA
| | - Janice M Massey
- Department of Neurology, Duke University Medical Center, Durham, North Carolina, USA
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Abstract
INTRODUCTION Myasthenia gravis (MG) is an autoimmune disease where muscle antibodies form against the acetylcholine receptor (AChR), MuSK, or LRP4 at the neuromuscular junction leading to weakness. Patients worry about consequences for pregnancy, giving birth, nursing, and child outcome. AREAS COVERED This review lists the pharmacological treatments for MG in the reproductive age and gives recommendations. Consequences for pregnancy, giving birth, breastfeeding, and child outcome are discussed. EXPERT OPINION Pyridostigmine, corticosteroids in low doses, and azathioprine are regarded as safe during pregnancy and should be continued. Mycophenolate mofetil, methotrexate, and cyclophosphamide should not be used in reproductive age. Rituximab should not be given during pregnancy. Other monoclonal IgG antibodies such as eculizumab and efgartigimod should be given only when regarded strictly necessary to avoid long-term and severe incapacity. Intravenous and subcutaneous immunoglobulin and plasma exchange are safe treatments during pregnancy and are recommended for exacerbations with moderate or severe generalized weakness. Most MG women have spontaneous vaginal deliveries. Indications for Cesarean section are obstetrical and similar to non-MG women. Neonatal myasthenia manifests as a transient weakness caused by the mother's IgG muscle antibodies and affects 10% of the babies. MG women should be supported in their wish to have children.
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Affiliation(s)
- Nils Erik Gilhus
- Department of Neurology, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
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Dobson R, Rog D, Ovadia C, Murray K, Hughes S, Ford HL, Pearson OR, White S, Bonham N, Mathews J, Nelson-Piercy C, Brex P. Anti-CD20 therapies in pregnancy and breast feeding: a review and ABN guidelines. Pract Neurol 2023; 23:6-14. [PMID: 35803727 DOI: 10.1136/pn-2022-003426] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/13/2022] [Indexed: 02/02/2023]
Abstract
Neurologists increasingly use anti-CD20 therapies, including for women of childbearing age, despite these medications being unlicensed for use in pregnancy. Current evidence suggests that women can safely conceive while taking anti-CD20 therapy. Women should not be denied treatment during pregnancy when it is clinically indicated, although they should be counselled regarding live vaccinations for their infant. Women receiving regular ocrelizumab for multiple sclerosis should preferably wait 3 months before trying to conceive. There are few data around ofatumumab in pregnancy, and while there is probably a class effect across all anti-CD20 therapies, ofatumumab may need to be continued during pregnancy to maintain efficacy. We recommend that anti-CD20 therapies can be safely given while breast feeding. It is important to make time to discuss treatments with women of childbearing age to help them choose their most suitable treatment. Outcomes should be monitored in pregnancy registries.
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Affiliation(s)
- Ruth Dobson
- Preventive Neurology Unit, Wolfson Institute of Population Health, Queen Mary University, London, UK .,Department of Neurology, The Royal London Hospital, London, UK
| | - David Rog
- Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Salford, UK
| | - Caroline Ovadia
- Department of Women and Children's Health, King's College London, London, UK
| | - Katy Murray
- Anne Rowling Regenerative Neurology Clinic, The University of Edinburgh, Edinburgh, UK.,Department of Neurology, Forth Valley Royal Hospital, Larbert, UK
| | - Stella Hughes
- Department of Neurology, Belfast Health and Social Care Trust, Belfast, UK
| | - Helen L Ford
- Department of Neurology, Leeds Teaching Hospitals NHS Trust, Leeds, UK.,Department of Neurosciences, University of Leeds Faculty of Medicine and Health, Leeds, UK
| | - Owen R Pearson
- Department of Neurology, Morriston Hospital, Swansea, UK
| | - Sarah White
- Department of Neurology, St George's Hospitals NHS Trust, London, UK
| | - Nicola Bonham
- Department of Neurology, Forth Valley Royal Hospital, Larbert, UK
| | - Joela Mathews
- Department of Neurology, The Royal London Hospital, London, UK
| | - Catherine Nelson-Piercy
- Department of Obstetrics, Guy's and St Thomas' Hospitals NHS Trust, London, UK.,Department of Obstetrics, King's College Hospital NHS Foundation Trust, London, UK
| | - Peter Brex
- Department of Neurology, King's College Hospital NHS Foundation Trust, London, UK
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Alcantara M, Barnett C, Katzberg H, Bril V. An update on the use of immunoglobulins as treatment for myasthenia gravis. Expert Rev Clin Immunol 2022; 18:703-715. [PMID: 35639497 DOI: 10.1080/1744666x.2022.2084074] [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: 11/04/2022]
Abstract
INTRODUCTION Myasthenia gravis (MG) is an antibody mediated disease where pathogenic antibodies interact with the acetylcholine receptor or other proteins at the post-synaptic neuromuscular junction. There is growing evidence that immunoglobulin infusions are beneficial for clinical exacerbations and chronic refractory disease and may be an option for patients unresponsive to conventional immunosuppressive therapies. AREAS COVERED We performed an extensive literature review, looking for evidence on the use of immunoglobulins for the treatment of MG, by conducting a search in MEDLINE (1946 to present), EMBASE (1947 to present) and Clinicaltrials.gov. We have included studies on the use of intravenous immunoglobulins (IVIG) and subcutaneous immunoglobulins (SCIG) for acute deterioration and chronic disease. EXPERT OPINION The use of IVIG in MG provides an option for rapid improvement in critical deterioration, being preferred over more invasive and less available therapies such as plasmapheresis. For refractory MG, the addition of IVIG can improve a patient's status and reduce the dosage of immunosuppressive medications. The alternative of SCIG is also effective and has advantages of infusion time flexibility, fewer side-effects, and patient independence. The safety and efficacy of both interventions, patient preferences and quality of life may direct therapeutic choices in the future.
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Affiliation(s)
- Monica Alcantara
- Ellen & Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
| | - Carolina Barnett
- Ellen & Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada.,Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto
| | - Hans Katzberg
- Ellen & Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
| | - Vera Bril
- Ellen & Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
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Maria Merz W, Fischer-Betz R, Hellwig K, Lamprecht G, Gembruch U. Pregnancy and Autoimmune Disease. DEUTSCHES ARZTEBLATT INTERNATIONAL 2022; 119:145-156. [PMID: 34874264 PMCID: PMC9201458 DOI: 10.3238/arztebl.m2021.0353] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 04/19/2021] [Accepted: 10/01/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Pregnancies in women with chronic disease are on the rise. This pertains to autoimmune diseases in particular since these tend to affect women of childbearing age. The interaction between pregnancy and autoimmune disease may increase the risk of maternal, fetal, and obstetric complications; additional care may be required. METHODS This review is based on a selective literature search in PubMed (2015-2020). RESULTS In women with autoimmune diseases, the course of pregnancy is highly variable. Some autoimmune diseases tend to improve during pregnancy and do not to result in any serious obstetric complications. Others may worsen during pregnancy, with deterioration of the maternal condition as well as obstetric and perinatal complications. In systemic lupus erythematosus and myasthenia gravis, placental transfer of specific autoantibodies may cause fetal or neonatal disease. CONCLUSION The care of pregnant women with chronic diseases requires collaboration between specialists of the pertinent levels of care. A stable course of disease before conception, close interdisciplinary care, and pregnancy-compatible medication contribute to a reduction in maternal and perinatal complications.
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Affiliation(s)
- Waltraut Maria Merz
- Department of Obstetrics and Prenatal Medicine, Center for Obstetrics and Gynecology, University Hospital Bonn
| | - Rebecca Fischer-Betz
- Department of Rheumatology and Hiller, Forschungszentrum University Hospital Düsseldorf
| | - Kerstin Hellwig
- Katholisches Klinikum Bochum, Neurology Clinic,Clinic of Ruhr-Universität Bochum
| | - Georg Lamprecht
- Department of Medicine II, Division of Gastroenterology and Endocrinology, University Medical Center Rostock
| | - Ulrich Gembruch
- Department of Obstetrics and Prenatal Medicine, Center for Obstetrics and Gynecology, University Hospital Bonn
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Siriratnam P, Zhang W, Faragher M. Trauma-induced myasthenia gravis: coincidence or causal relationship? BMJ Case Rep 2021; 14:14/4/e238415. [PMID: 33811091 PMCID: PMC8023623 DOI: 10.1136/bcr-2020-238415] [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: 11/03/2022] Open
Abstract
We report a case of a 55-year-old man presenting with diplopia, masticatory weakness and dysarthria several weeks post multitrauma. The clinical suspicion of myasthenia gravis (MG) was supported with positive acetylcholine receptor antibodies and abnormal repetitive stimulation study. He responded well to pyridostigmine, intravenous immunoglobulin and oral prednisolone. In this report, we describe the timing and progression of MG in our patient, and review the literature pertaining to the relationship between trauma and MG. The search for definitive evidence of causation may be impractical, but should not delay the recognition and management of a treatable condition.
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Affiliation(s)
| | - Wenwen Zhang
- Neuroscience, Alfred Health, Melbourne, Victoria, Australia
| | - Mark Faragher
- Neuroscience, Alfred Health, Melbourne, Victoria, Australia.,Department of Internal Medicine, Peter MacCallum Cancer Institute, Melbourne, Victoria, Australia
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Willekens B, Kleffner I. Susac syndrome and pregnancy: a review of published cases and considerations for patient management. Ther Adv Neurol Disord 2021; 14:1756286420981352. [PMID: 33796140 PMCID: PMC7970706 DOI: 10.1177/1756286420981352] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 11/24/2020] [Indexed: 12/31/2022] Open
Abstract
Susac syndrome (SuS) is a rare autoimmune endotheliopathy leading to hearing loss, branch retinal artery occlusions and encephalopathy. Young females are more frequently affected than males, making counselling for family planning an important issue. We reviewed published cases on SuS during pregnancy or in the postpartum period, and selected 27 reports describing the details of 33 patients with SuS. Treatment options and implications for pregnancy and breastfeeding are discussed. We propose new areas for research and suggest a management strategy.
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Affiliation(s)
- Barbara Willekens
- Department of Neurology, Antwerp University Hospital, Drie Eikenstraat 655, Edegem, 2650, Belgium
| | - Ilka Kleffner
- University Hospital Knappschaftskrankenhaus Bochum, Ruhr University Bochum, Bochum, Germany
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