Pregnancy in vasculitis

Pregnancy Outcomes in Systemic Vasculitides

Purpose of Review

In recent years, improvements in the recognition of primary vasculitides and increased treatment options have led to greater survival rates and a better quality of life for patients. Therefore, pregnancy in women with vasculitis has become a more frequent consideration or event. Literature on pregnancy outcomes in this population has grown and allowed us, in this article, to review the effects of pregnancy on disease activity, as well as maternal and fetal outcomes for each type of vasculitides.

Recent Findings

Successful pregnancies in patients with vasculitides are possible, especially when conception is planned, and the disease is in remission. The risk of vasculitis flare is highly dependent on the type of vasculitis, but overall limited. The most frequent complication associated with large-vessel vasculitis (mainly Takayasu arteritis) is hypertension and preeclampsia. Preterm deliveries and intrauterine growth restriction occur more frequently with small- and medium-vessel vasculitis.

Summary

Pregnancies in patients with vasculitis should be considered high risk and followed by a multidisciplinary team with expertise in the field. Flares should be managed as in the non-pregnant population, while avoiding medications with unknown safety in pregnancy or known teratogens. Although commonly prescribed for the prevention of preeclampsia, there is limited evidence supporting the use of low-dose aspirin for pregnant women with vasculitis. Prospective registries or studies are needed, to better assess the value of aspirin, the place and long-term impact of new biologics and, to identify predictors of pregnancy outcomes other than disease status at conception.

CanVasc Recommendations for the Management of Antineutrophil Cytoplasm Antibody-associated Vasculitides

Objective.

The Canadian Vasculitis research network (CanVasc) is composed of physicians from different medical specialties and researchers with expertise in vasculitis. One of its aims is to develop recommendations for the diagnosis and management of antineutrophil cytoplasm antibody (ANCA)-associated vasculitides (AAV) in Canada.

Methods.

Diagnostic and therapeutic questions were developed based on the results of a national needs assessment survey. A systematic review of existing non-Canadian recommendations and guidelines for the diagnosis and management of AAV and studies of AAV published after the 2009 European League Against Rheumatism/European Vasculitis Society recommendations (publication date: January 2009) until November 2014 was performed in the Medline database, Cochrane library, and main vasculitis conference proceedings. Quality of supporting evidence for each therapeutic recommendation was graded. The full working group as well as additional reviewers, including patients, reviewed the developed therapeutic recommendations and nontherapeutic statements using a modified 2-step Delphi technique and through discussion to reach consensus.

Results.

Nineteen recommendations and 17 statements addressing general AAV diagnosis and management were developed, as well as appendices for practical use, for rheumatologists, nephrologists, respirologists, general internists, and all other healthcare professionals more occasionally involved in the management of patients with AAV in community and academic practice settings.

Conclusion.

These recommendations were developed based on a synthesis of existing international guidelines, other published supporting evidence, and expert consensus considering the Canadian healthcare context, with the intention of promoting best practices and improving healthcare delivery for patients with AAV.

What matters for patients with vasculitis?

Advances in clinical care for patients with vasculitis have improved survival rates and created new challenges related to the ongoing management of chronic disease. Lack of curative therapies, burden of disease, treatment-related side effects, and fear of relapse contribute to patient-perceived reduction in quality of life. Patient-held beliefs about disease and priorities may differ substantially from the beliefs of their health care providers, and research paradigms are shifting to reflect more emphasis on understanding vasculitis from the patient's perspective. Efforts are ongoing to develop disease outcome measures in vasculitis that better represent the patient experience. Health care providers who care for patients with vasculitis should be sensitive to the substantial burdens of disease commonly experienced by patients living with the disease and should strive to provide comprehensive care directed towards the medical and biopsychological needs of these patients.

Takayasu Arteritis in Southern Sweden

Objective.

To study the epidemiology and clinical characteristics of Takayasu arteritis (TA) in southern Sweden.

Methods.

The study area is situated in Skåne, the southernmost county in Sweden (total population December 2011: 983,419, 50.5% women). Patients were identified using clinical registries in all the 5 hospitals and private rheumatology clinics within the study area between the years 1997 and 2011. The diagnosis of TA was confirmed by medical records review. Only patients fulfilling the 1990 American College of Rheumatology classification criteria were included.

Results.

Thirteen patients (all women) were identified. The median age at diagnosis was 23 years [interquartile range (IQR) 16–38]. Ten patients were diagnosed between 1997 and 2011. The annual incidence rate was estimated to 0.7/million inhabitants (95% CI 0.3–1.2) and 1.5/million among women (95% CI 0.6–2.4). Patients were followed for a median of 9 years (IQR 4–17.5). As of January 1, 2012, all 13 patients were alive and living within the study area. The point prevalence per million inhabitants was 13.2 (95% CI 6.0–20.4), and 26.2 among women (95% CI 11.9–40.4). Subclavian arteries were the most commonly affected vessels. Organ damage was common, affecting all patients. Seven pregnancies resulting in 5 live births and 2 abortions were registered after the diagnosis of TA.

Conclusion.

The incidence of TA in Sweden is comparable to recently reported rates from other European studies, while the prevalence is higher than previously reported. The prognosis of TA is good, but the rate of damage is high.

Fertility and pregnancy in vasculitis

Despite the rarity of vasculitides, fertility and pregnancy outcome in the setting of vasculitis have become a major topic of interest within the past decade. The potential impact of vasculitis therapies, particularly cyclophosphamide, has been examined to some extent, but data are limited on the possible impact of the disease itself on fertility. Ideally, pregnancy should be planned when the vasculitis is in remission. The outcome for mothers and newborns is usually good when vasculitis is known before the pregnancy and is in remission, but every pregnant woman must be monitored by a specialised health-care team consisting of obstetricians specialised in high-risk births and internists/rheumatologists with expertise in managing these rare conditions. Most maternal complications during pregnancy are indeed due to vasculitis damage: hypertension in Takayasu arteritis (TAK) or granulomatosis with polyangiitis (GPA)/microscopic polyangiitis (MPA) with renal insufficiency, asthma or cardiac damage in eosinophilic granulomatosis with polyangiitis (EGPA) and subglottic and/or bronchial stenosis(es) in GPA. Pregnancy loss can occur in about 10% of cases in GPA, up to 20% in EGPA, 20-30% in Behçet's disease and up to 25% in TAK, and several studies found high rates of preterm births, at least with some vasculitides. Vasculitis manifestations in newborns from mothers with known vasculitis are very rare and usually transient.

Pregnancies in systemic necrotizing vasculitides: report on 12 women and their 20 pregnancies

OBJECTIVES

To describe pregnancies of women with systemic necrotizing vasculitides (SNVs), i.e. PAN, WG, Churg-Strauss syndrome (CSS) or microscopic polyangiitis (MPA), followed over the past 15 years at four French centres.

METHODS

Retrospective analysis of women whose SNV appeared during pregnancy or who became pregnant after SNV diagnosis.

RESULTS

Among the 12 women identified, one experienced rupture of pancreatic artery microaneurysms at 27 weeks revealing PAN, leading to surgical haemostasis and caesarean delivery. Eleven others started 19 pregnancies after SNV diagnosis (8 in four WG, 6 in three CSS, 1 each in three PAN and 2 in one MPA); 14 conceived during vasculitis remission. Two ended in first-trimester abortions, four miscarried; the remaining 13 pregnancies yielded 14 live newborns (1 twin pregnancy), with 7 pre-term births. Life-threatening complications occurred during 3 of these latter 13 pregnancies and required caesarean delivery. The twin pregnancy (in a CSS patient with initial vasculitis-related cardiac involvement, but in remission at conception) was complicated by transient maternal cardiac failure at 32 weeks. One WG patient with vasculitis-related renal damage developed thrombotic microangiopathy-associated renal impairment at 32 weeks, and another WG patient had severe pneumonia at 37 weeks. Other pregnancies were uneventful or with minor vasculitis manifestations.

CONCLUSION

Pregnant SNV patients should be monitored closely, because miscarriages and pre-term births are not uncommon. Pregnancy does not seem to have a major impact on vasculitis activity. However, life-threatening manifestations can occur, especially in patients with vasculitis-related cardiac or renal damage.

Postpartum Churg-Strauss syndrome with severe cardiac involvement: description of a case and review of the literature

Churg-Strauss syndrome (CSS) is a rare small- or intermediate-vessel necrotizing vasculitis typically characterized by asthma, lung infiltrates, necrotizing granulomas, and hypereosinophilia. In this report, we describe the case of a 35-year-old woman who, during her third trimester of pregnancy, developed dyspnea and, after delivery, severe cardiac failure which required heart transplantation. Diagnosis of CSS was made after performing a myocardial biopsy. We have also undertaken a review of the English-language literature regarding previously reported cases of pregnancies in women suffering from Churg-Strauss syndrome with particular attention to those patients with cardiovascular involvement.

[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.

Subglottic stenosis in pregnancy

Subglottic stenosis (SGS) in pregnancy is rare but may cause a potentially life-threatening delivery and is a challenge to the anaesthetist and the obstetrician. Clinical signs of SGS may not be obvious and the diagnosis can be difficult. Patients usually present with shortness of breath rather than stridor. Many patients have been wrongly diagnosed with asthma and recurrent bronchitis before subsequent discovery of a SGS. Early diagnosis of SGS and multidisciplinary input is important in managing these patients. We present a case of a pregnant woman with a history of Wegener's granulomatosis and the successful multidisciplinary management of her SGS.

Pregnancy and vasculitis

Until recently, the prognosis associated with many forms of systemic vasculitis was quite grim. Advances in this field have allowed us to begin to focus on issues related to quality of life such as fertility, conception, and pregnancy among women with vasculitis. Because the systemic vasculitides are rare diagnoses, many important questions remain unanswered. Overall, it seems that women who have inactive vasculitis may not be subject to unusual complications during pregnancy, but our understanding of the interaction between pregnancy and specific forms of vasculitis continues to evolve.

Ritodrine-induced leukocytoclastic vasculitis in pregnancy

OBJECTIVE

To report 2 cases of pregnant women who presented with leukocytoclastic vasculitis (LV) associated with the administration of ritodrine hydrochloride after undergoing genetic amniocentesis and to review the literature on LV. case summaries: Case 1. A 40-year-old pregnant woman was diagnosed with autoimmune hypothyroidism at week 12 of her third gestation. At week 14, she underwent a genetic amniocentesis and received oral prophylactic treatment with ritodrine for 10 days. At week 16, she presented with fever, epigastric abdominal pain, polyarthritis, microhematuria, and purpura. Skin biopsy showed LV. Case 2. A 34-year-old pregnant woman had developed polyarthralgias and polyarthritis after receiving ritodrine following genetic amniocentesis in her second gestation. She also underwent a genetic amniocentesis in her third gestation and received ritodrine. Five days later, she presented with fever, polyarthritis, and purpura. A skin biopsy demonstrated LV. The rest of her gestation was normal until week 33, when she developed oligohydramnios and a delay of intrauterine fetal growth. A cesarean section was then performed. After birth, the baby developed tachypnea, anemia, splenomegaly, edema, and renal failure; she died on her 15th day of life.

DISCUSSION

Ritodrine hydrochloride is a beta(2)-adrenergic agonist that is used in pregnant women as a tocolytic agent. In our 2 patients, there was a time relationship between the administration of ritodrine and the appearance of LV. In both cases, other causes of vasculitis were excluded in a reasonable way. As of November 4, 2003, only one other case has been found in the literature. An objective causality assessment revealed that the reactions to ritodrine were probable and possible, respectively, in our 2 cases.

CONCLUSIONS

In pregnant women with autoimmune disease, ritodrine should be used with caution because of its ability to induce vasculitis.

Abdominal pain during pregnancy

Numerous medical, surgical, psychiatric, gynecologic, and obstetric disorders can cause abdominal pain during pregnancy. The patient history, physical examination, laboratory data, and radiologic findings usually provide the diagnosis. The pregnant woman has physiologic alterations that affect the clinical presentation, including atypical normative laboratory values. Abdominal ultrasound is generally the recommended radiologic imaging modality; roentgenograms are generally contraindicated during pregnancy because of radiation teratogenicity. Concerns about the fetus limit the pharmacotherapy. Maternal and fetal survival have recently increased in many life-threatening conditions, such as ectopic pregnancy, appendicitis, and eclampsia, because of improved diagnostic technology, better maternal and fetal monitoring, improved laparoscopic technology, and earlier therapy.