Pregnancy in women with cystic fibrosis

[Cystic fibrosis and pregnancy: Outcome, prognostic factors and obstetrical management]

As a result of improvements in life expectancy and therapies, increasing numbers of patients with cystic fibrosis become pregnant. The first studies were pessimistic and report adverse outcomes on the fetus and the mother. In the recent publications, long-term outcome for women with cystic fibrosis does not appear to be negatively impacted by pregnancy. Furthermore, the number of women successfully completing pregnancy continues to rise. The aim of this review is to assess the outcome of pregnancy in women with cystic fibrosis and the impact of pregnancy on the disease. It is hoped it will improve the counseling for pregnant women with cystic fibrosis and their obstetrical management.

Amplification of FSH signalling by CFTR and nuclear soluble adenylyl cyclase in the ovary

The cAMP/PKA pathway is one of the most important signalling pathways widely distributed in most eukaryotic cells. The activation of the canonical cAMP/PKA pathway depends on transmembrane adenylyl cyclase (tmAC). Recently, soluble adenylyl cyclase (sAC), which is activated by HCO₃^- or Ca²⁺ , emerges to provide an alternative way to activate cAMP/PKA pathway with the cystic fibrosis transmembrane conductance regulator (CFTR), a cAMP-activated Cl^- /HCO₃^- -conducting anion channel, as a key player. This review summarizes new progress in the investigation of the CFTR/HCO₃^- -dependent sAC signalling and its essential role in various reproductive processes, particularly in ovarian functions. We present the evidence for a CFTR/HCO₃^- -dependent nuclear sAC signalling cascade that amplifies the FSH-stimulated cAMP/PKA pathway, traditionally thought to involve tmAC, in granulosa for the regulation of oestrogen production and granulosa cell proliferation. The implication of the CFTR/HCO₃^- /sAC pathway in amplifying other receptor-activated cAMP/PKA signalling in a wide variety of cell types and pathophysiological processes, including aging, is also discussed.

Medical and obstetric complications among pregnant women with cystic fibrosis

OBJECTIVE

The objective of this study was to estimate the nationwide prevalence of cystic fibrosis (CF) in pregnancy and determine what medical complications exist at delivery among pregnant women with CF.

STUDY DESIGN

The Nationwide Inpatient Sample (NIS) was queried for all delivery-related discharges. Women with CF were identified by International Classification of Diseases, 9th revision, Clinical Modifications codes and compared with women without CF. The prevalence of selected severe medical complications was compared between the 2 groups (NIS years 2008-2010) using multivariable logistic regression and the linear change in prevalence of CF at delivery determined (NIS years 2000-2010).

RESULTS

From 2000 to 2010, there was a significant linear increase in the prevalence of CF at delivery from 3.0 to 9.8 per 100,000 deliveries, in 2000 and 2010, respectively (R(2) = 0.92, P < .0001). From 2008-2010, there were 1119 deliveries to women with CF and 12,627,627 to women without CF. Women with CF were more likely to be white (P < .0001) and have diabetes (odds ratio [OR], 14.0; 95% confidence interval [CI], 11.8-16.7) or asthma (OR, 5.1; 95% CI, 4.3-6.1). Multivariable logistic regression demonstrated that women with CF were more likely to die (adjusted OR [aOR], 76.0; 95% CI, 31.6-183), require mechanical ventilation (aOR, 18.3; 95% CI, 10.8-31.2), or have pneumonia (aOR, 56.5; 95% CI, 43.2-74.1), acute renal failure (aOR, 17.3; 95% CI, 9.1-32.6), preterm labor (aOR, 2.2; 95% CI, 1.9-2.6), or an adverse composite CF outcome (aOR, 28.1; 95% CI, 21.8-36.3).

CONCLUSION

Pregnant women with CF are more likely to die, require mechanical ventilation, and have infectious complications compared with women without CF, although the absolute risks are low and these events are relatively rare.

Adolescents with a chronic condition: challenges living, challenges treating

In this review, we aim to focus attention on the interaction between adolescents with chronic conditions and the health systems that support them. At least 12% of adolescents live with a chronic condition. Some conditions are characterised by increasing incidence (eg, diabetes) or improving survival rates (eg, cystic fibrosis), while others are concerning because of differentially poorer outcomes in adolescents in comparison to both children and adults (eg cancer). Growing evidence suggests that young people with chronic conditions are doubly disadvantaged--engaging in risky behaviours to at least similar if not higher rates as healthy peers, while having the potential for greater adverse health outcomes from these behaviours. In addition to efforts at improving survival, in order to improve their life chances, we need to better understand how the social and emotional outcomes of young people with a chronic disease can be improved, and better support young people's emerging capacity for self-management.

Pregnancy and Chronic Progressive Pulmonary Disease

Progressive pulmonary disease may preclude the option of pregnancy for a number of women in their child-bearing years due to the severity of the disease. For a subset of women with chronic lung disease including cystic fibrosis, pregnancy is possible, but can have a devastating effect both on the prospective mother and fetus. The potential hazards of pregnancy in cystic fibrosis or other progressive pulmonary diseases may trigger a moral conflict between physician and patient. The female patient may argue that her autonomy cannot be circumscribed and that the physician is obliged to assist her reproductive efforts. The physician can counter that his/her participation in potentially harmful interventions is not consistent with professional norms requiring adherence to the principles of beneficence and nonmaleficence. Whenever possible, the ethical conflict between physician and patient should be resolved before initiation of pregnancy. We propose that this best be done through structured negotiations between physician and patient with the goal of constructing an ethical framework for reducing the moral tension between the two. Steps in the negotiating process include defining the therapeutic alliance, information exchange, dialog, and deliberation. As part of the information exchange, it is important to discuss alternatives to pregnancy such as adoption and surrogacy, especially when there are strong contraindications to pregnancy. If negotiations reach a satisfactory conclusion for both sides, there should be a well-delineated consensual agreement to commence the pregnancy with the full support of the medical team.

[Cystic fibrosis and pregnancy: report of a twin pregnancy and review of the literature]

We report here the first published case of twin pregnancy in a woman with cystic fibrosis. This situation will become more and more common because the increased life expectancy of patients with cystic fibrosis and the development of medically assisted procreation. Conception of this twin pregnancy was medically assisted in a cystic fibrosis woman with moderate pulmonary disease. This observation is in accordance with several recent reports dealing with single pregnancies: morbidity, mortality and degradation of lung function have not been found to increase. The only effect of cystic fibrosis on pregnancy is an increased risk of preterm delivery. There is thus no systematic contraindication to pregnancy among women with cystic fibrosis provided that they are given attentive care by a multidisciplinary team. Genetic counselling and prenatal diagnosis also have an important role to play.

Exacerbation of underlying pulmonary disease in pregnancy

OBJECTIVE

The presence of underlying pulmonary disease in women of childbearing potential can present a significant challenge during pregnancy and the postpartum period. Management of the underlying disease, recognizing and preventing disease progression, and, most important, managing and minimizing toxic side effects of various therapies require the expertise of an interdisciplinary team. This team must involve close collaboration between intensive care physicians, pulmonary physicians, and high-risk obstetricians familiar with these disease states in an effort to minimize fetal and maternal morbidity and mortality. We will review the impact of the pregnant state in lung transplant recipients, patients with pulmonary arterial hypertension, and patients with underlying cystic fibrosis.

DESIGN

Review of the literature in regards to pregnancy outcomes and issues for patients with cystic fibrosis, pulmonary hypertension, and lung transplants.

METHODS

A review of the epidemiology, pathophysiology, risk factors, classification, clinical features, and outcomes for pregnant patients with underlying pulmonary diseases.

CONCLUSIONS

Safety of pregnancy in the female lung transplant recipient concerns three outcomes: maternal outcome, fetal outcome, and transplanted graft outcome.

Fertility and pregnancy outcomes in men and women with cystic fibrosis in the United Kingdom

BACKGROUND

The survival of patients with cystic fibrosis (CF) now occurs into the fourth decade of life. Our aim was to evaluate the fertility and pregnancy outcomes of men and women with cystic fibrosis within a large British cohort.

METHODS

A population based cohort study of 4659 males and females registered with the UK Cystic Fibrosis Database in 2001.

RESULTS

Poor respiratory health (forced expiratory volume in 1 s FEV1 <50%) and CF-related diabetes increased significantly post-puberty compared with childhood. Few individuals with CF sought fertility treatment (1% men, 0.5% women) or achieved pregnancies (1.3% of partners of men, 5.7% women). However, the majority of pregnancies had a good outcome (67% live term birth among male partners, 74% among women). Women who achieved a pregnancy were less likely to suffer from poor respiratory health (FEV1 <50%), age adjusted Odds Ratio 0.6 (95% CI 0.3-0.9), less likely to be homozygous for the DF508 genotype OR 0.5 (95% CI 0.3-0.9) and had a significantly earlier median age at diagnosis (0 years vs 2 years, P=0.001).

CONCLUSIONS

Increasing numbers of males and females with cystic fibrosis are reaching reproductive age but currently very few have a child. Optimal adult health should improve the reproductive prognosis for both men and women.

Exacerbation of underlying pulmonary disease in pregnancy

This article examines the management and outcomes of pregnant women with cystic fibrosis, primary pulmonary hypertension, and sarcoidosis. Pregnancy and the puerperium are associated with important cardiopulmonary changes that can adversely affect the clinical condition. Management of pregnant women with CF should be done with careful attention to complications of altered body weight, diabetes, and liver disease. Primary pulmonary hypertension is characterized by a progressive increase in pulmonary pressure and resistance in the absence of an identified cardiac or pulmonary cause. A multidisciplinary approach to the management of patients with primary pulmonary hypertension is of great importance for a successful maternal and fetal outcome. Good maternal and fetal outcomes are possible in women with restrictive lung disease in general and sarcoidosis in particular. The management of pregnancy, labor, and delivery are not altered by the presence of sarcoidosis.

Respiratory disease in pregnancy

A variety of respiratory complications can be encountered in pregnancy. An understanding of the pathophysiology of pregnancy is important in the management of such complications. Despite the changes in immunity, the incidence of respiratory infections is not higher in pregnancy. Asthma is the most common preexisting medical disorder encountered in pregnancy, and its prevalence in women of childbearing age is increasing. There is a slight increase in the risk to the pregnancy, but suboptimal therapy is the most common reason for poor control. X-rays should be obtained whenever clinically indicated, and most drugs used in the management of asthma have a long track record of safety. For women with poor control in pregnancy, there should be good liaison between the respiratory physician and the obstetrician. Tuberculosis is increasingly important and may complicate human immunodeficiency virus infection. First-line antituberculous drugs can safely be administered in pregnancy and lactation.