Management of Mastocytosis in Pregnancy: A Review

Effect of Gender and Special Considerations for Women in Mastocytosis and Anaphylaxis

This article reviews the effects of gender on anaphylaxis in general and focuses on mastocytosis-specific issues. Incidence of anaphylaxis is increased in female compared with male patients during the pubertal years through the fifth decade of life, in which these disparities decrease. Estrogen is thought to increase the severity of anaphylaxis through increased endothelial nitric oxide synthase release. Despite this, all-cause fatal anaphylaxis does not appear to show a gender predilection. Systemic mastocytosis incidence is higher in women; however, mortality is increased in men owing to increased molecular and cytogenetic abnormalities.

Mastocytosis in Pregnancy

Mastocytosis is a rare neoplastic disorder of the mast cell lineage resulting in unregulated proliferation and activation of mast cells. Symptoms worsen in about one-third of pregnant patients. Treatment focuses on management of symptoms with antimediator therapy (H1 & H2 antihistamines, glucocorticoids, and epinephrine, if required). Medication selection requires care during labor and delivery. Although it is generally considered safe to use a medication patient tolerated before, some common medications may need to be avoided or used with caution (eg, codeine, morphine, nonsteroidal antiinflammatory drugs, vancomycin) if the patient does not have any history of exposure to them.

How to evaluate the patient with a suspected mast cell disorder and how/when to manage symptoms

Mast cell disorders include mastocytosis and mast cell activation syndromes. Mastocytosis is a rare clonal disorder of the mast cell, driven by KIT D816V mutation in most cases. Mastocytosis is diagnosed and classified according to World Health Organization criteria. Mast cell activation syndromes encompass a diverse group of disorders and may have clonal or nonclonal etiologies. Hematologists may be consulted to assist in the diagnostic workup and/or management of mast cell disorders. A consult to the hematologist for mast cell disorders may provoke anxiety due to the rare nature of these diseases and the management of nonhematologic mast cell activation symptoms. This article presents recommendations on how to approach the diagnosis and management of patients referred for common clinical scenarios.

Diagnosis and treatment of systemic mastocytosis in Brazil: Recommendations of a multidisciplinary expert panel

INTRODUCTION

Systemic Mastocytosis comprises a group of neoplastic diseases characterized by clonal expansion and infiltration of mast cells into several organs. The diagnosis and treatment of this disease may be challenging for non-specialists.

OBJECTIVE

Make suggestions or recommendations in Systemic Mastocytosis based in a panel of Brazilian specialists.

METHOD AND RESULTS

An online expert panel with 18 multidisciplinary specialists was convened to propose recommendations on the diagnosis and treatment of Systemic Mastocytosis in Brazil. Recommendations were based on discussions of topics and multiple-choice questions and were graded using the Oxford Centre for Evidence-Based Medicine 2011 Levels of Evidence Chart.

CONCLUSION

Twenty-two recommendations or suggestions were proposed based on a literature review and graded according to the findings.

Mastocytosis: Fertility and Pregnancy Management in a Rare Disease

Mastocytosis encompasses a subset of rare diseases, characterized by the presence and accumulation of abnormal neoplastic MC in various organ systems, including skin, bone marrow, spleen and gastrointestinal tract. Clinical manifestations are highly heterogeneous, as they result from both MC mediator release and MC organ infiltration. Both pregnancy, a lifetime dominated by huge physiological changes, and labor can provide triggers that could induce worsening of mastocytosis symptoms. On the other hand, mastocytosis has relevant implications in obstetric management and prenatal care during all the pregnancy. In this review article, current knowledge about the impact of mastocytosis on fertility and pregnancy outcome will be reviewed and discussed, with the aim to provide clinical practice guidance for the evaluation and management of pregnancy and delivery in patients with cutaneous and systemic mastocytosis.

ANAPHYLAXIS AND PREGNANCY: A SYSTEMATIC REVIEW AND CALL FOR PUBLIC HEALTH ACTIONS

BACKGROUND

Although rare, anaphylaxis during pregnancy implies a risk to both mothers and newborns.

OBJECTIVE

This systematic review is intended to identify key issues in the diagnosis and management of this condition in order to support prevention strategies and decrease the risk of death related to anaphylaxis during pregnancy.

METHODS

We searched MEDLINE, Cochrane, Lilacs, Scielo and Science Direct databases for manuscripts concerning terms "anaphylaxis during pregnancy" without language restrictions. We screened studies, extracted data, and assessed risk of bias independently in duplicate.

RESULTS

We selected 12 articles. Frequency of anaphylaxis during pregnancy is estimated between 1.5 to 3.8 per 100 000 maternities. Only one study provided anaphylaxis mortality data in pregnant women, and the rate of anaphylaxis-related maternal mortality is estimated at 0.05 per 100 000 live births. No standard definition of anaphylaxis severity has been utilized. Forty-nine percent to 74% of anaphylaxis cases were described during caesarean sections. Beta-lactam antibiotics (58%), latex (25%) and anaesthetic agents (17%) were the main culprits. In 17% of papers, causative agents were proven by allergy testing. Seventy two percent of articles proposed the same management and treatment for a clinical episode of anaphylaxis during pregnancy as in non-pregnant patients, and, use of epinephrine in the patient's care during anaphylaxis in pregnancy.

CONCLUSION

Few studies address anaphylaxis during pregnancy, and the majority have been produced by non-allergy specialists. Collaboration between different specialists involved in the care of pregnant women should be established in order to support preventive strategies and reduce avoidable deaths.

The Journal of Allergy and Clinical Immunology: In Practice 2017 Year in Review

An impressive number of clinically impactful studies and reviews were published in The Journal of Allergy and Clinical Immunology: In Practice in 2017. As a service to our readers, the editors provide this Year in Review article to highlight and contextualize the advances published over the past year. We include information from articles on asthma, allergic rhinitis, rhinosinusitis, immunotherapy, atopic dermatitis, contact dermatitis, food allergy, anaphylaxis, drug hypersensitivity, urticarial/angioedema, eosinophilic disorders, and immunodeficiency. Within each topic, epidemiologic findings are presented, relevant aspects of prevention are described, and diagnostic and therapeutic advances are enumerated. Treatments discussed include behavioral therapy, allergen avoidance therapy, positive and negative effects of pharmacologic therapy, and various forms of immunologic and desensitization management. We hope this review will help readers consolidate and use this extensive and practical knowledge for the benefit of patients.