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Champion ML, Maier JG, Bushman ET, Barney JB, Casey BM, Sinkey RG. Systematic Review of Lymphangioleiomyomatosis Outcomes in Pregnancy and a Proposed Management Guideline. Am J Perinatol 2024; 41:e1508-e1520. [PMID: 36898409 PMCID: PMC10582203 DOI: 10.1055/a-2051-8395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/12/2023]
Abstract
OBJECTIVE Lymphangioleiomyomatosis (LAM) is a rare, multisystem disease that primarily affects women of reproductive age. Disease progression has been linked to estrogen exposure, and as such many patients are advised to avoid pregnancy. Data are limited regarding the interaction between LAM and pregnancy, and as such we performed a systematic review to summarize available literature reporting outcomes of pregnancies complicated by maternal LAM. STUDY DESIGN This was a systematic review including randomized controlled trials, observational studies, systematic reviews, case reports, clinical practice guidelines, and quality improvement studies with full-text manuscripts or abstracts in the English language with primary data on pregnant or postpartum patients with LAM. The primary outcome was maternal outcomes during pregnancy as well as pregnancy outcomes. Secondary outcomes were neonatal outcomes and long-term maternal outcomes. This search occurred in July 2020 and included MEDLINE, Scopus, clinicaltrials.gov, Embase, and Cochrane Central. Risk of bias was ascertained using the Newcastle-Ottawa Scale. Our systematic review was registered with PROSPERO as protocol number CRD 42020191402. RESULTS A total of 175 publications were identified in our initial search; ultimately 31 studies were included. Six (19%) studies were retrospective cohort studies and 25 (81%) studies were case reports. Patients diagnosed during pregnancy had worse pregnancy outcomes compared to those diagnosed with LAM prior to pregnancy. Multiple studies reported a significant risk of pneumothoraces during pregnancy. Other significant risks included preterm delivery, chylothoraces, and pulmonary function deterioration. A proposed strategy for preconception counseling and antenatal management is provided. CONCLUSION Patients diagnosed with LAM during pregnancy generally experience worse outcomes including recurrent pneumothoraces and preterm delivery as compared to patients with a LAM diagnosis prior to pregnancy. Given that there are limited studies available, and that the majority are low-quality evidence and subject to bias, further investigation of the interaction between LAM and pregnancy is warranted to guide patient care and counseling. KEY POINTS · Data are limited on the effects of lymphangioleiomyomatosis on pregnancy outcomes.. · We performed a systematic review to summarize pregnancy outcomes complicated by LAM.. · Patients diagnosed with LAM during pregnancy experience worse outcomes..
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Affiliation(s)
- Macie L. Champion
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Center for Women’s Reproductive Health at the University of Alabama at Birmingham, Birmingham, Alabama
| | - Julia G. Maier
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Center for Women’s Reproductive Health at the University of Alabama at Birmingham, Birmingham, Alabama
| | - Elisa T. Bushman
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Center for Women’s Reproductive Health at the University of Alabama at Birmingham, Birmingham, Alabama
| | - Joseph B. Barney
- Department of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama
| | - Brian M. Casey
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Center for Women’s Reproductive Health at the University of Alabama at Birmingham, Birmingham, Alabama
| | - Rachel G. Sinkey
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Center for Women’s Reproductive Health at the University of Alabama at Birmingham, Birmingham, Alabama
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Wang-Koehler E, Kern-Goldberger AR, Srinivas SK. Complications of lymphangioleiomyomatosis in pregnancy: a case report and review of the literature. AJOG GLOBAL REPORTS 2024; 4:100309. [PMID: 38327672 PMCID: PMC10848140 DOI: 10.1016/j.xagr.2024.100309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2024] Open
Abstract
Lymphangioleiomyomatosis is a rare cystic lung disease primarily affecting premenopausal females and may be exacerbated by pregnancy. We conducted a literature review of lymphangioleiomyomatosis during pregnancy with a specific focus on related maternal morbidity and obstetrical outcomes. We also report a case of lymphangioleiomyomatosis that presented as an acute spontaneous pneumothorax in the third trimester of pregnancy, followed by significant maternal morbidity. A 37-year-old primigravid woman who presented at 29 weeks 5 days gestation with chest pain was diagnosed with spontaneous pneumothorax. Further imaging demonstrated cystic lung lesions and renal angiomyolipomas. She developed severe abdominal pain concerning for placental abruption that led to an urgent cesarean delivery at 30 weeks 2 days gestation. Her course was complicated by recurrent pneumothorax, superimposed preeclampsia, and significant ileus and bowel dilation complicated by bowel perforation. For patients with a clinical suspicion of lymphangioleiomyomatosis in pregnancy, prompt recognition, diagnosis, and referral to appropriate multidisciplinary subspecialists is critical to mitigate complications and optimize outcomes both during and after pregnancy.
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Affiliation(s)
- Eileen Wang-Koehler
- Department of Obstetrics and Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA (Drs Wang-Koehler and Srinivas)
| | - Adina R. Kern-Goldberger
- Division of Maternal-Fetal Medicine, Women's Health Institute, Cleveland Clinic Foundation, Cleveland, OH (Dr Kern-Goldberger)
| | - Sindhu K. Srinivas
- Department of Obstetrics and Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA (Drs Wang-Koehler and Srinivas)
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA (Dr Srinivas)
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Pais F, Fayed M, Evans T. Lymphangioleiomyomatosis: an explosive presentation of a rare disease. Oxf Med Case Reports 2017; 2017:omx023. [PMID: 28616248 PMCID: PMC5461433 DOI: 10.1093/omcr/omx023] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Revised: 02/17/2017] [Accepted: 03/04/2017] [Indexed: 11/14/2022] Open
Abstract
Lymphangioleiomyomatosis (LAM) is a rare cystic lung disease, commonly affecting women in the reproductive age group. Exacerbation of pre-existing disease is common during pregnancy likely due to the up-regulation of estrogen and progesterone receptors present within the proliferating smooth muscle cells. This case highlights a dramatic presentation of LAM for the first time in pregnancy, its rapid progression during gestation, and a partial resolution with delivery. The unusual radiographic imaging in this patient, lacked the characteristic cystic lesions commonly associated with LAM, but instead demonstrated a dense interstitial pattern with micronodular expansion of the interlobular septa suggesting severe lymphatic obstruction.
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Affiliation(s)
- Faye Pais
- Pulmonary and Critical Care Medicine, University of California San Francisco Fresno, 155 N Fresno Street, Fresno, CA 93701, USA
| | - Mohamed Fayed
- Pulmonary and Critical Care Medicine, University of California San Francisco Fresno, 155 N Fresno Street, Fresno, CA 93701, USA
| | - Timothy Evans
- Pulmonary and Critical Care Medicine, University of California San Francisco Fresno, 155 N Fresno Street, Fresno, CA 93701, USA
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WU KAI, LU HUIYU. Sporadic lymphangioleiomyomatosis with bloody sputum as an initial symptom: A case report and review of the literature. Exp Ther Med 2015; 9:2159-2164. [DOI: 10.3892/etm.2015.2397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2014] [Accepted: 03/20/2015] [Indexed: 11/06/2022] Open
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Abstract
Lymphangioleiomyomatosis (LAM), a multisystem disease affecting almost exclusively women, is characterized by cystic lung destruction and presents with dyspnea, recurrent pneumothoraxes, chylous effusions, lymphangioleiomyomas, and angiomyolipomas. It is caused by the proliferation of a cancer-like LAM cell that possesses a mutation in either the tuberous sclerosis complex (TSC)1 or TSC2 genes. This article reviews current therapies and new potential treatments that are currently undergoing investigation. The major development in the treatment of LAM is the discovery of two mammalian target of rapamycin (mTOR) inhibitors, sirolimus and everolimus, as effective drugs. However, inhibition of mTOR increases autophagy, which may lead to enhanced LAM cell survival. Use of autophagy inhibitors, for example, hydroxychloroquine, in combination with sirolimus is now the subject of an ongoing drug trial (SAIL trial). Another consequence of mTOR inhibition by sirolimus is an increase in Rho activity, resulting in reduced programmed cell death. From these data, the concept evolved that a combination of sirolimus with disruption of Rho activity with statins (e.g. simvastatin) may increase TSC-null cell death and reduce LAM cell survival. A combined trial of sirolimus with simvastatin is under investigation (SOS trial). Since LAM occurs primarily in women and TSC-null cell survival and tumor growth is promoted by estrogens, the inhibition of aromatase to block estrogen synthesis is currently undergoing study (TRAIL trial). Other targets, for example, estrogen receptors, mitogen-activated protein kinase inhibitors, vascular endothelial growth factor-D signaling pathway, and Src kinase, are also being studied in experimental model systems. As in the case of cancer, combination therapy may become the treatment of choice for LAM.
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Iruloh C, Keriakos R, Smith DJ, Cleveland T. Renal angiomyolipoma and lymphangioleiomyomatosis in pregnancy. J OBSTET GYNAECOL 2014; 33:542-6. [PMID: 23919845 DOI: 10.3109/01443615.2013.812622] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
This is a literature review for management of angiomyolipoma (AML), lymphangioleiomyomatosis (LAM) and tuberous sclerosis (TS) during pregnancy, prompted by a case of a 23-year-old woman who presented with generalised itching at 31 weeks' gestation and was found to have a large vascular retroperitoneal mass in the lower pole of the left kidney. Magnetic resonance imaging (MRI) was suggestive of angiomyolipoma with multiple large aneurysms and haemorrhage within the tumour. She was delivered at 38 weeks by elective caesarean section, to avoid the risk of rupture and bleeding from the aneurysms during labour. Further imaging, with MR angiogram, computed tomography (CT) of the abdomen and pelvis and high resolution CT (HRCT) of the chest, confirmed lymphangioleiomyomatosis with left AML. She had embolisation of the AML performed twice, 8 weeks apart after delivery and subsequently had a left nephrectomy.
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Affiliation(s)
- C Iruloh
- Jessop Wing and 2 Royal Hallamshire Hospital, Sheffi eld Teaching Hospitals, Sheffi eld, UK
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Kim D, Lee SN, Lee SK, Lee J. Lymphangiomyomatosis discovered by massive hemoptysis during general anesthesia -A case report-. Korean J Anesthesiol 2012; 62:371-4. [PMID: 22558505 PMCID: PMC3337385 DOI: 10.4097/kjae.2012.62.4.371] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2011] [Revised: 05/12/2011] [Accepted: 05/19/2011] [Indexed: 11/10/2022] Open
Abstract
Lymphangiomyomatosis (LAM) is a rare lung disease that is characterized by the progressive proliferation of atypical smooth muscle-like cells, which leads to severe respiratory impairment and death. Dyspnea, cough, recurrent pneumothorax, and hemoptysis are the most common clinical symptoms of LAM. We report a 29-year-old female patient with massive hemoptysis during laparoscopic gynecologic surgery under general anesthesia, who was diagnosed with pulmonary LAM.
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Affiliation(s)
- Deokkyu Kim
- Department of Anesthesiology and Pain Medicine, Chonbuk National University Medical School, Jeonju, Korea
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Yamashita S, Nakamura K, Shinozaki H, Minegishi T. Lymphangioleiomyomatosis suspected to be a gynecologic disease. J Obstet Gynaecol Res 2011; 37:267-9. [PMID: 21314806 DOI: 10.1111/j.1447-0756.2010.01368.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Lymphangioleiomyomatosis (LAM) is a rare, systemic disorder that predominantly affects women. Although patients with LAM mostly present with pulmonary symptoms, some patients may present initially with extrapulmonary symptoms. We present a case of a 30-year-old Japanese female with abdominal pain during menstrual periods was suspected of having ovarian cancer due to exaggerated ascites observed at a local clinic. Subsequently, she was transferred to our hospital for further investigations, and was diagnosed with LAM. Three years after diagnosis, she had a girl by cesarean section to avoid the progression of pulmonary LAM by vaginal delivery. The patient is undergoing follow-up treatment with the administration of gonadotropin-releasing hormone-analog. Though LAM is rare, gynecologists should know about it because it may occur with gynecological symptoms in young women.
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Affiliation(s)
- Soichi Yamashita
- Department of Gynecology and Reproductive Medicine, Gunma University Graduate School of Medicine, Gunma, Japan.
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Kim MS, Lee SH, Hwang JY, Kang SS. Anesthetic management for a cesarean section under regional anesthesia in a parturient with tuberous sclerosis - A case report -. Korean J Anesthesiol 2009; 57:123-126. [DOI: 10.4097/kjae.2009.57.1.123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Min Soo Kim
- Department of Anesthesiology and Pain Medicine, Kangwon National University Medical School, Chuncheon, Korea
| | - Sang Hyun Lee
- Department of Anesthesiology and Pain Medicine, Kangwon National University Medical School, Chuncheon, Korea
| | - Jong Yun Hwang
- Department of Obstetrics and Gynecology, Kangwon National University Medical School, Chuncheon, Korea
| | - Seong Sik Kang
- Department of Anesthesiology and Pain Medicine, Kangwon National University Medical School, Chuncheon, Korea
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Causse-Mariscal A, Palot M, Visseaux H, Daigremont-Botmans C, Malinovsky JM. Labor analgesia and cesarean section in women affected by tuberous sclerosis: report of two cases. Int J Obstet Anesth 2007; 16:277-80. [PMID: 17337175 DOI: 10.1016/j.ijoa.2006.10.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2005] [Revised: 07/01/2005] [Accepted: 10/01/2006] [Indexed: 10/23/2022]
Abstract
Tuberous sclerosis is a multi-system disease characterized by the presence of benign growths in many tissues, mostly localized in skin, brain, kidney and lungs. Epileptic seizures and renal hemorrhage are frequent in such patients. Apart from life-threatening hemorrhage after rupture of angiomyolipomatoma, few data are available about anesthetic considerations during pregnancy. We report two cases of pregnant patients with tuberous sclerosis, one scheduled for medical termination of pregnancy at 27 weeks of gestational, the other a cesarean section for breech presentation under general anesthesia. We review and discuss the ability to perform regional anesthesia in each case.
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Toyoda K, Matsumoto K, Inoue H, Komori M, Fujita M, Hashimoto S, Kuwano K, Nakanishi Y. A pregnant woman with complications of lymphangioleiomyomatosis and idiopathic thrombocytopenic purpura. Intern Med 2006; 45:1097-100. [PMID: 17077573 DOI: 10.2169/internalmedicine.45.1678] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A pregnant 26-year-old woman developed hemosputum, dyspnea and pneumothorax. Lymphangioleiomyomatosis was suspected based on multiple cystic lesions on chest computed tomography. Additionally, moderate thrombocytopenia occurred during the last trimester. Hyperplasia of megakaryocytes in a bone marrow specimen and a high serum titer of platelet-associated IgG led to a diagnosis of idiopathic thrombocytopenic purpura. High-dose intravenous gammaglobulin promptly restored her platelet count, and the patient successfully gave birth to a healthy baby by cesarean section. After delivery, lymphangioleiomyomatosis was diagnosed by lung biopsy that was obtained during a video-assisted thoracoscopic abscission for recurrent pneumothorax. Underlying lymphangioleiomyomatosis and idiopathic thrombocytopenic purpura may be obviated by pregnancy.
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Affiliation(s)
- Kazuhiro Toyoda
- The Research Institute for Diseases of the Chest, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
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Johnson SR, Whale CI, Hubbard RB, Lewis SA, Tattersfield AE. Survival and disease progression in UK patients with lymphangioleiomyomatosis. Thorax 2004; 59:800-3. [PMID: 15333859 PMCID: PMC1747117 DOI: 10.1136/thx.2004.023283] [Citation(s) in RCA: 88] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Lymphangioleiomyomatosis (LAM) is a rare and progressive disease of young women with no effective treatment. Previous estimates of 10 year survival, based mostly on case series or patients from tertiary centres, have ranged from 40% to 79%; no data are available on the progression of respiratory disability. In order to provide data for patients and for planning intervention studies, we have looked at the time course of LAM using a national cohort. METHODS Time to death, time to MRC dyspnoea grades 2-5, and need for oxygen in patients on the UK LAM database were analysed using Kaplan-Meier analysis and Cox regression. RESULTS Fifty seven of 72 patients responded with a median duration of follow up of 12.6 years (range 2.3-37) from the onset of symptoms. Ten year survival was 91% from onset of symptoms but varied widely with 11 patients alive after 20 years. Median time to MRC grade 3 dyspnoea (breathless walking on the flat) was 9.3 years (95% CI 5.1 to 13.4) from onset of symptoms. CONCLUSIONS Survival from LAM appears to be better than that reported in early studies. These data should be helpful for patients and for planning clinical trials.
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Affiliation(s)
- S R Johnson
- Division of Therapeutics and Molecular Medicine, Queens Medical Centre, University of Nottingham, Nottingham, UK.
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