Pregnancy complicated with Buerger's disease

Management of Buerger's disease during pregnancy

Buerger's disease (BD), also known as thromboangiitis obliterans, is a non-atherosclerotic inflammatory disorder of unknown aetiology that affects small-sized and medium-sized vessels of the extremities. It is usually observed in middle-aged adults, especially those who smoke or use tobacco products. This condition is more frequently observed in men, although recent findings indicate an increasing prevalence among women, potentially due to increased cigarette use. The association between pregnancy and BD is rare, with only a few published cases. Previous reports have indicated that BD may worsen during gestation due to the characteristic hypercoagulable state of pregnancy. In addition, it seems to be associated with intrauterine growth restriction secondary to infarction of placental vessels. Careful obstetric management of maternal and fetal status is mandatory in pregnancies complicated with BD. We report a successful case of a pregnancy in a patient with BD treated with low-molecular-weight heparin.

Thromboangiitis obliterans in pregnancy - Case report and literature review

Thromboangiitis obliterans, also known as Buerger's disease, is rarely reported in young women in pregnancy. It is an occlusive vascular disorder, characterised by episodic non-atherosclerotic thrombosis of small- and medium-sized blood vessels. Thromboangiitis obliterans predominantly occurs in males aged less than 50 years and is almost exclusively diagnosed in smokers. The small number of published cases have frequently reported worsening of thrombotic symptoms, due to the hypercoagulable state of pregnancy, and potential pregnancy complications of intra-uterine growth restriction and pre-term labour. This report provides a summary of the literature and outlines the case of a pregnant 23-year-old female with thromboangiitis obliterans, who was managed with low-dose enoxaparin and aspirin. Her thrombotic symptoms were stable during pregnancy; however, her pregnancy was complicated by placental malperfusion and intra-uterine growth restriction.

Case report of two pregnancies and deliveries by a woman with Buerger disease

Buerger disease is a chronic inflammatory disease that involves blood clot formation in the medium and small arteries, resulting in thrombophlebitis. It is usually observed in middle-aged men who smoke and is very rare in young women. Previous reports have indicated that Buerger disease worsens during pregnancy due to hypercoagulability associated with pregnancy, and newborns' birth weights were often lower than normal. This report describes a young woman with Buerger disease who experienced two pregnancies and deliveries. During the 1st pregnancy, d-dimer and soluble fibrin levels slightly increased, but no treatment was needed. However, during the 2nd pregnancy, d-dimer and soluble fibrin levels abruptly increased at 20 weeks of pregnancy, and heparin was administered subcutaneously. Four days after heparin administration, d-dimer and soluble fibrin levels decreased to normal pregnancy levels. d-dimer and soluble fibrin measurements were useful for evaluating the coagulation tendencies of this pregnant woman with Buerger disease.

Protective effect of Shenfu injection on thromboangiitis obliterans model rats

ETHNOPHARMACOLOGICAL RELEVANCE

Thromboangiitis obliterans (TAO) or Buerger's disease is a non atherosclerotic, segmentar inflammatory vasculitis that is incurable at present. Shenfu injection (SFI), a traditional Chinese formulation, have been confirmed to produce protective influences on several organs and limb during ischemia and reperfusion (IR) injury in rats. However, the effects of SFI on TAO remain unclear.

MATERIALS AND METHODS

Adult male Sprague Dawley rats were randomly divided into sham operated group, TAO model group, SFI 2.5mg/kg (low dose), 5mg/kg (medium dose) and 10mg/kg (high dose) groups (n=8). Rats were intravenously administered SFI 2.5, 5 and 10mg/kg or saline once per day for 15 days. TAO model was prepared by injecting sodium laurate into the femoral artery of rats. Then we examined the changes of pathological signs, pathologic grading of thrombus, the indexes of hematology, the contents of thromboxane B2 (TXB2), 6-keto-prostaglandin F(lα) (6-K-PGF(1α)) in plasma following SFI or saline treatment.

RESULTS

More pathological signs of lesions, higher grades of pathological thrombosis, increased blood platelet counts, the increase in the TXB2 and TXB2/6-K-PGF(1α) ratio, as well as the decrease of 6-K-PGF(1α) in TAO model group were shown in present experiments; SFI treatment significantly improved the pathological signs of lesions induced by sodium laurate injection, reduced the numbers of thrombus formation, blood platelet counts, the TXB2 and TXB2/6-K-PGF(1α) ratio but increased the 6-K-PGF(1α) compared with TAO model group. However, there were no significant alterations in the counts of red blood cell, leucocyte and neutrophil among these groups.

CONCLUSIONS

Our preliminary findings first indicated that SFI can produce significant therapeutic effects on experimental Buerger's disease model rats in a dose independent manner. The underlying mechanisms may be due to its modifying hematology, inhibiting platelet aggregation and enhancing anti-thrombotic function of vessel endothelia.

[Pregnancy and vasculitides]

Systemic vasculitides, like Takayasu's arteritis, polyarteritis nodosa, Wegener's granulomatosis, Churg-Strauss syndrome, Henoch-Schönlein purpura, or Behçet's disease can affect women of child-bearing years. The rarity of these vasculitides, their frequent fatal outcomes until recent years, and the use of toxic immunosuppressants to treat patients, contra-indicating pregnancy and/or potentially inducing hypofertility or sterility, explain the few pregnancies reported in the literature so far. Notably, it does not seem that pregnancy has a major impact on vasculitis outcome, in contrast with systemic lupus erythematosus, but a specialized management of these pregnant patients is mandatory. There are some reported cases of vasculitis revealed during pregnancy. Even though some of these pregnant patients had a severe disease and died, most of them had a favourable outcome, and a living inborn, providing prompt care and adequate treatment. When vasculitis is already known and treated, pregnancy should at best be planned, when the disease is in sustained remission and all toxic immunosuppressants have been stopped for months. Vasculitis sequella, like hypertension, renal insufficiency, or asthma, must also be taken into account, monitored and appropriately managed throughout the pregnancy and a few weeks following delivery. In case of vasculitis' flare during pregnancy, potential treatments include corticosteroids, intravenous immunoglobulins, azathioprine, plasma exchanges, and, for limited skin manifestations or Behçet's disease, hydroxychloroquine or colchicine. Importantly, when the disease is severe, a delay in the prescription of a stronger, immunosuppressant, chiefly intravenous cyclophosphamide, can be more detrimental, although being potentially toxic, for both the mother and the foetus than an ineffective and/or inappropriate regimen with less active drugs. Safety data on biologics, like rituximab, for pregnant women are very sparse to date and their use is therefore not recommended, unless confronted with a severe and refractory disease, and after referring to a specialized center for vasculitides.