1
|
Vimercati A, Cazzato G, Lospalluti L, Foligno S, Taliento C, Trojanowska KB, Cicinelli E, Bonamonte D, Caliandro D, Vitagliano A, Nicolì P. Dystrophic Epidermolysis Bullosa (DEB): How Can Pregnancy Alter the Course of This Rare Disease? An Updated Literature Review on Obstetrical Management with an Additional Italian Experience. Diseases 2024; 12:104. [PMID: 38785759 PMCID: PMC11120570 DOI: 10.3390/diseases12050104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2024] [Revised: 05/02/2024] [Accepted: 05/13/2024] [Indexed: 05/25/2024] Open
Abstract
Epidermolysis Bullosa (EB) is an extremely rare and disabling inherited genetic skin disease with a predisposition to develop bullous lesions on the skin and inner mucous membranes, occurring after mild friction or trauma, or even spontaneously. Within the spectrum of EB forms, dystrophic EB (DEB) represents the most intriguing and challenging in terms of clinical management, especially with regard to pregnancy, due to the highly disabling and life-threatening phenotype. Disappointingly, in the literature little focus has been directed towards pregnancy and childbirth in DEB patients, resulting in a lack of sound evidence and guidance for patients themselves and clinicians. The current study aims to contribute to the DEB literature with an updated summary of the existing evidence regarding the obstetrical and anesthesiological management of this rare disease. Furthermore, this literature review sought to answer the question of whether, and if so, in which way, the pregnancy condition may alter the course of the underlying dermatologic skin disease. Having all this information is indispensable when counseling a patient with DEB who desires a child or is expecting one. Finally, we reported own experience with a pregnant woman with a recessive DEB whom we recently managed, with a favorable outcome.
Collapse
Affiliation(s)
- Antonella Vimercati
- Unit of Obstetrics and Gynecology, Department of Interdisciplinary Medicine (DIM), University of Bari “Aldo Moro”, Policlinico of Bari, Piazza Giulio Cesare 11, 70124 Bari, Italy
| | - Gerardo Cazzato
- Department of Emergency and Organ Transplantation (DETO), Section of Pathology, University of Bari “Aldo Moro”, Policlinico of Bari, Piazza Giulio Cesare 11, 70124 Bari, Italy
| | - Lucia Lospalluti
- Department of Biomedical Sciences and Human Oncology (DIMO), Section of Dermatology and Venereology, University of Bari “Aldo Moro”, Policlinico of Bari, Piazza Giulio Cesare 11, 70124 Bari, Italy
| | - Stefania Foligno
- Department of Biomedical Sciences and Human Oncology (DIMO), Section of Dermatology and Venereology, University of Bari “Aldo Moro”, Policlinico of Bari, Piazza Giulio Cesare 11, 70124 Bari, Italy
| | - Cristina Taliento
- Department of Medical Sciences, Obstetrics and Gynecology Unit, University Hospital “Sant’Anna”, 44121 Ferrara, Italy
| | | | - Ettore Cicinelli
- Unit of Obstetrics and Gynecology, Department of Interdisciplinary Medicine (DIM), University of Bari “Aldo Moro”, Policlinico of Bari, Piazza Giulio Cesare 11, 70124 Bari, Italy
| | - Domenico Bonamonte
- Department of Biomedical Sciences and Human Oncology (DIMO), Section of Dermatology and Venereology, University of Bari “Aldo Moro”, Policlinico of Bari, Piazza Giulio Cesare 11, 70124 Bari, Italy
| | - Dario Caliandro
- Pelvic Floor Center, Department of Gynaecology and Obstetrics, Pia Fondazione “Card. G. Panico”, 73039 Tricase, Italy
| | - Amerigo Vitagliano
- Unit of Obstetrics and Gynecology, Department of Interdisciplinary Medicine (DIM), University of Bari “Aldo Moro”, Policlinico of Bari, Piazza Giulio Cesare 11, 70124 Bari, Italy
| | - Pierpaolo Nicolì
- Unit of Obstetrics and Gynecology, Department of Interdisciplinary Medicine (DIM), University of Bari “Aldo Moro”, Policlinico of Bari, Piazza Giulio Cesare 11, 70124 Bari, Italy
| |
Collapse
|
2
|
Greenblatt DT, Pillay E, Snelson K, Saad R, Torres Pradilla M, Widhiati S, Diem A, Knight C, Thompson K, Azzopardi N, Werkentoft M, Moore Z, Patton D, Mayre-Chilton KM, Murrell DF, Mellerio JE. Recommendations on pregnancy, childbirth and aftercare in epidermolysis bullosa: a consensus-based guideline. Br J Dermatol 2021; 186:620-632. [PMID: 34687549 PMCID: PMC9298908 DOI: 10.1111/bjd.20809] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/07/2021] [Indexed: 11/29/2022]
Abstract
Linked Comment:A.W. Lucky and E. Pope. Br J Dermatol 2022; 186:602–603. Plain language summary available online
Collapse
Affiliation(s)
- D T Greenblatt
- St John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - E Pillay
- St John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - K Snelson
- St John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - R Saad
- Sydney Children's Hospital, Randwick, Sydney, NSW, Australia
| | - M Torres Pradilla
- Fundacion Universitaria de Ciencias de la Salud and Hospital de San Jose, Bogota, Colombia
| | - S Widhiati
- Pediatric Dermatology Division, Department of Dermatology and Venereology, Faculty of Medicine Universitas Sebelas Maret - Dr. Moewardi General Hospital, Surakarta, Indonesia
| | - A Diem
- EB House Austria, Outpatient Unit, Department of Dermatology and Allergology, University Hospital of the Paracelsus Medical University, Salzburg, Austria
| | - C Knight
- St John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - K Thompson
- Royal Adelaide Hospital, Port Road, Adelaide, SA, Australia
| | | | | | - Z Moore
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | - D Patton
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | - K M Mayre-Chilton
- St John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust, London, UK.,DEBRA International, Vienna, Austria
| | - D F Murrell
- Department of Dermatology at St. George Hospital, University of New South Wales, Sydney, NSW, Australia
| | - J E Mellerio
- St John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| |
Collapse
|
3
|
Abstract
Epidermolysis bullosa (EB) is a group of rare, inherited diseases characterized by skin fragility and multiorgan system involvement that presents many anesthetic challenges. Although the literature regarding anesthetic management focuses primarily on the pediatric population, as life expectancy improves, adult patients with EB are more frequently undergoing anesthesia in nonpediatric hospital settings. Safe anesthetic management of adult patients with EB requires familiarity with the complex and heterogeneous nature of this disease, especially with regard to complications that may worsen during adulthood. General, neuraxial, and regional anesthetics have all been used safely in patients with EB. A thorough preoperative evaluation is essential. Preoperative testing should be guided by EB subtype, clinical manifestations, and extracutaneous complications. Advanced planning and multidisciplinary coordination are necessary with regard to timing and operative plan. Meticulous preparation of the operating room and education of all perioperative staff members is critical. Intraoperatively, utmost care must be taken to avoid all adhesives, shear forces, and friction to the skin and mucosa. Special precautions must be taken with patient positioning, and standard anesthesia monitors must be modified. Airway management is often difficult, and progressive airway deterioration can occur in adults with EB over time. A smooth induction, emergence, and postoperative course are necessary to minimize blister formation from excess patient movement. With careful planning, preparation, and precautions, adult patients with EB can safely undergo anesthesia.
Collapse
|
4
|
King A, Hanley H, Popenhagen M, Perez F, Thompson K, Purvis D, Garcia N, Steinlein I, Werkentoft M, Lightfoot M, Lahat M, Begum K, Tanabe J. Supporting sexuality for people living with epidermolysis bullosa: clinical practice guidelines. Orphanet J Rare Dis 2021; 16:9. [PMID: 33407706 PMCID: PMC7789698 DOI: 10.1186/s13023-020-01640-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 12/09/2020] [Indexed: 12/21/2022] Open
Abstract
This article presents evidence-based Clinical Practice Guidelines (CPG) for the provision of healthcare services to address sexuality for people living with epidermolysis bullosa (EB). Currently, a lack of EB-specific research limits these services to sexual health assessment and intervention strategies designed for the general population. Due to the unique challenges of EB, a rare skin-fragility condition causing blistering responses to minor skin trauma and other systemic and secondary complications, condition-specific strategies are needed to support people with EB in achieving valued sexual lifestyles. This CPG represents the work of an international panel comprised of thirteen members including a medical doctor, nurses, psychologists, a social worker, an occupational therapist, and patient population involvement members living with EB. It describes the development of EB-specific recommendations for two primary domains of assessment and intervention related to sexuality: psychosocial and mechanical. Following a rigorous evidence-based guideline development process, this CPG establishes the first internationally actionable clinical practice recommendations for sexuality-related assessment and intervention for this population. Future research priorities are identified. Supplemental materials included provide additional support to clinicians in developing the necessary understanding and skills to promote equity and efficacy in this care domain.
Collapse
Affiliation(s)
- Alex King
- Department of Rehabilitation, Phoenix Children's Hospital, 1919 East Thomas Rd, Phoenix, AZ, 85016, USA.
| | - Humphrey Hanley
- DEBRA New Zealand, 123 Daniell Street, Newtown, Wellington, 6021, New Zealand
| | - Mark Popenhagen
- Department of Rehabilitation, Phoenix Children's Hospital, 1919 East Thomas Rd, Phoenix, AZ, 85016, USA
| | - Florencia Perez
- DEBRA Chile, Francisco de Villagra 392, 7760099, Ñuñoa, Santiago, Chile
| | - Kerry Thompson
- Royal Adelaide Hospital, Port Road, Adelaide, SA, 5000, Australia
| | - Diana Purvis
- Starship Children's Hospital, Park Road, Grafton, Auckland, 1023, New Zealand
| | - Nora Garcia
- DEBRA Spain, Asociación DEBRA-Piel de Mariopsa, C/ Jacinto Benavente No 12, 29601, Marbella, Málaga, Spain
| | | | | | - Matthew Lightfoot
- DEBRA UK, The Capitol Building, Oldbury, Bracknell, Berkshire, RG12 8FZ, UK
| | - Michelle Lahat
- Children's Hospital of Los Angeles, 4650 Sunset Boulevard, Los Angeles, CA, 90027, USA
| | - Kalsoom Begum
- University Hospitals Birmingham NHS Foundation Trust, Mindelsohn Way, Edgbaston, Birmingham, B15 2GW, UK
| | | |
Collapse
|
5
|
Shah N, Kumaraswami S, Mushi JE. Management of epidermolysis bullosa simplex in pregnancy: A case report. Case Rep Womens Health 2019; 24:e00140. [PMID: 31700804 PMCID: PMC6829095 DOI: 10.1016/j.crwh.2019.e00140] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 08/29/2019] [Accepted: 09/03/2019] [Indexed: 02/07/2023] Open
Abstract
Epidermolysis bullosa (EB) encompasses a group of diseases characterized by extreme fragility of skin and mucous membranes, resulting in blister formation following minimal injury. There are 4 types of EB, with epidermolysis bullosa simplex (EBS) being the most common. We report our experience with the care of a parturient woman diagnosed with EBS. There is little literature on pregnancy in women with this condition. Special precautions are necessary during diagnostic and therapeutic interventions to avoid bullae formation or exacerbation of existing lesions. Frictional or shearing forces are typically more damaging than compressive forces. Multidisciplinary planning was done for our patient to ensure uneventful labor and delivery. Elective induction of labor was started at 40 weeks of gestation. She eventually underwent a cesarean delivery after failed trial of labor. We present this case to highlight the obstetric and anesthetic implications of caring for a parturient with EBS. Blister formation occurs following minimal injury in epidermolysis bullosa. Frictional or shearing forces rather than direct pressure predispose to bullae. Use of adhesive materials should be avoided during patient care. Vaginal delivery without instrumentation is preferred for pregnant women with epidermolysis bullosa. If cesarean delivery is necessary, neuraxial anesthesia is preferred to general anesthesia.
Collapse
Affiliation(s)
- Nidhi Shah
- Department of Obstetrics & Gynecology, New York Medical College, Westchester Medical Center, 100, Woods Road, Valhalla, New York 10595, USA
| | - Sangeeta Kumaraswami
- Department of Anesthesiology, New York Medical College, Westchester Medical Center, 100, Woods Road, Valhalla, New York 10595, USA
- Corresponding author at: Department of Anesthesiology, Westchester Medical Center, 100, Woods Road, Valhalla, New York 10595, USA.
| | - Juliet E. Mushi
- Department of Obstetrics & Gynecology, New York Medical College, Westchester Medical Center, 100, Woods Road, Valhalla, New York 10595, USA
| |
Collapse
|
6
|
Boria F, Maseda R, Martín-Cameán M, De la Calle M, de Lucas R. Recessive Dystrophic Epidermolysis Bullosa and Pregnancy. ACTAS DERMO-SIFILIOGRAFICAS 2019. [DOI: 10.1016/j.adengl.2018.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
|
7
|
Epidermólisis bullosa distrófica recesiva y embarazo. ACTAS DERMO-SIFILIOGRAFICAS 2019; 110:50-52. [DOI: 10.1016/j.ad.2017.06.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Revised: 06/05/2017] [Accepted: 06/25/2017] [Indexed: 11/20/2022] Open
|
8
|
Intong LRA, Choi SD, Shipman A, Kho YC, Hwang SJE, Rhodes LM, Walton JR, Chapman MG, Murrell DF. Retrospective evidence on outcomes and experiences of pregnancy and childbirth in epidermolysis bullosa in Australia and New Zealand. Int J Womens Dermatol 2017; 3:S1-S5. [PMID: 28492031 PMCID: PMC5418959 DOI: 10.1016/j.ijwd.2017.02.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Revised: 12/14/2014] [Accepted: 12/15/2014] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Pregnancy in epidermolysis bullosa (EB) has not been comprehensively studied. OBJECTIVE We aimed to develop a foundational database, which could provide peri-obstetric advice in EB. METHODS Survey questionnaires were sent to obstetricians, unaffected mothers of EB babies, and mothers with EB. Results were analyzed using chi-square, Fisher exact, and t-tests. RESULTS Out of 1346 obstetricians surveyed, 195 responded, and only 14 had encountered EB. All recommended normal vaginal delivery (NVD), except for one elective Caesarean section (CS). We received responses from 75 unaffected mothers who had delivered EB babies. They had significantly more complications in their EB pregnancies compared to their non-EB pregnancies. A further 44 women with various types of EB who had given birth responded. Most delivered via NVD and had no significant increase in complications in both their EB and non-EB pregnancies. In both groups, there were no significant differences in blistering at birth in babies delivered via NVD and CS. CONCLUSION In conclusion, most patients with EB who are capable of giving birth do not have an increased risk for pregnancy-related complications and NVD appears to be safe. Awareness of this data amongst obstetricians and dermatologists should lead to improved quality of care for mothers and babies affected with EB.
Collapse
Affiliation(s)
- Lizbeth R A Intong
- Department of Dermatology, St. George Hospital, Sydney, Australia.,The University of New South Wales, Sydney, Australia
| | - S Deanne Choi
- Department of Dermatology, St. George Hospital, Sydney, Australia
| | - Alexa Shipman
- Department of Dermatology, St. George Hospital, Sydney, Australia
| | - Yong C Kho
- Department of Dermatology, St. George Hospital, Sydney, Australia.,The University of New South Wales, Sydney, Australia
| | - Shelley J E Hwang
- Department of Dermatology, St. George Hospital, Sydney, Australia.,The University of New South Wales, Sydney, Australia
| | - Lesley M Rhodes
- Department of Dermatology, St. George Hospital, Sydney, Australia.,The University of New South Wales, Sydney, Australia
| | - Judie R Walton
- Department of Orthopedic Surgery, St. George Hospital, Sydney, Australia.,The University of New South Wales, Sydney, Australia
| | - Michael G Chapman
- Department of Women's Health, St. George Hospital, Sydney, Australia.,The University of New South Wales, Sydney, Australia
| | - Dédée F Murrell
- Department of Dermatology, St. George Hospital, Sydney, Australia.,The University of New South Wales, Sydney, Australia
| |
Collapse
|
9
|
Retrospective evidence on outcomes and experiences of pregnancy and childbirth in epidermolysis bullosa in Australia and New Zealand. Int J Womens Dermatol 2015; 1:26-30. [PMID: 28491951 PMCID: PMC5418753 DOI: 10.1016/j.ijwd.2014.12.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Revised: 12/14/2014] [Accepted: 12/15/2014] [Indexed: 11/24/2022] Open
Abstract
Background Pregnancy in epidermolysis bullosa (EB) has not been comprehensively studied. Objective We aimed to develop a foundational database, which could provide peri-obstetric advice in EB. Methods Survey questionnaires were sent to obstetricians, unaffected mothers of EB babies, and mothers with EB. Results were analyzed using chi-square, Fisher exact, and t-tests. Results Out of 1346 obstetricians surveyed, 195 responded, and only 14 had encountered EB. All recommended normal vaginal delivery (NVD), except for one elective Caesarean section (CS). We received responses from 75 unaffected mothers who had delivered EB babies. They had significantly more complications in their EB pregnancies compared to their non-EB pregnancies. A further 44 women with various types of EB who had given birth responded. Most delivered via NVD and had no significant increase in complications in both their EB and non-EB pregnancies. In both groups, there were no significant differences in blistering at birth in babies delivered via NVD and CS. Conclusion In conclusion, most patients with EB who are capable of giving birth do not have an increased risk for pregnancy-related complications and NVD appears to be safe. Awareness of this data amongst obstetricians and dermatologists should lead to improved quality of care for mothers and babies affected with EB. There is limited information on pregnancy in EB. This is the first comprehensive study in the world on pregnancy experiences of a large group of mothers with EB, unaffected mothers of EB babies and an obstetrician survey. We have recommendations for mothers expecting EB babies and expectant mothers with EB.
Collapse
|
10
|
Dystrophic epidermolysis bullosa in pregnancy: a case report of the autosomal dominant subtype and review of the literature. Case Rep Med 2014; 2014:242046. [PMID: 24864146 PMCID: PMC4017779 DOI: 10.1155/2014/242046] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2013] [Revised: 04/03/2014] [Accepted: 04/03/2014] [Indexed: 11/24/2022] Open
Abstract
Epidermolysis bullosa (EB) is a group of inherited blistering skin diseases that vary widely in their pathogenesis and severity. There are three main categories of EB: simplex, junctional, and dystrophic. This classification is based on the level of tissue separation within the basement membrane zone and this is attributed to abnormalities of individual or several anchoring proteins that form the interlocking network spanning from the epidermis to the dermis underneath. Dystrophic EB results from mutations in COL7A1 gene coding for type VII collagen leading to blister formation within the dermis. Diagnosis ultimately depends on the patient's specific genetic mutation, but initial diagnosis can be made from careful examination and history taking. We present a pregnant patient known to have autosomal dominant dystrophic EB and discuss the obstetrical and neonatal outcome. The paper also reviews the current English literature on this rare skin disorder.
Collapse
|