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Guo P, Cao W. Case report: A pregnant woman with Crohn disease who used ustekinumab to the 3rd trimester developed severe infection. Medicine (Baltimore) 2023; 102:e36253. [PMID: 38050250 PMCID: PMC10695489 DOI: 10.1097/md.0000000000036253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 11/01/2023] [Indexed: 12/06/2023] Open
Abstract
RATIONALE Crohn disease (CD) and pregnancy often impact each other, which poses challenges for women with CD to successfully give birth to a healthy baby. The latest guideline recommends that patients with active inflammatory bowel disease delay pregnancy to induce remission and optimize disease control. Research data has showed that the incidence of infection and severe infection in patients treated with ustekinumab (UST) did not increase compared to those treated with a placebo. PATIENT CONCERNS This report describes the entire process of a pregnant woman with CD who has undergone ileostomy and long-term enteral nutrition and requires biological agents to control the disease, from conception to delivery. This case was pregnant during CD period and regularly treated with UST to the third trimester, with the onset of sepsis and septic shock at 38 weeks gestation. DIAGNOSES The patient was pathologically diagnosed with CD 16 years ago and admitted to our department at 38 weeks gestation. INTERVENTIONS After admission to our department, fetal heart monitoring indicated fetal distress, so we immediately terminated the pregnancy by cesarean section. After the diagnosis of septic shock, the patient was transferred to intensive care unit for active anti-infection and symptomatic supportive treatment. OUTCOMES The mother only experienced an infection in the third trimester, and cured by active treatment. The newborn was delivered at full term and confirmed to be low birth weight. LESSONS Her experience suggests that although pregnant during Crohn active period, a good outcome can be achieved through positively controlling with medication and closely monitoring it. The use of UST during pregnancy appears to be safe for both the mother and fetus but may be associated with severe infections.
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Affiliation(s)
- Peng Guo
- Department of Obstetrics and Gynecology, Zhongshan City People’s Hospital, Zhongshan, China
| | - Wulan Cao
- Department of Obstetrics and Gynecology, Zhongshan City People’s Hospital, Zhongshan, China
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Weiss B, Ben-Horin S, Lev A, Broide E, Yavzori M, Lahat A, Kopylov U, Picard O, Eliakim R, Ron Y, Avni-Biron I, Yerushalmy-Feler A, Assa A, Somech R, Bar-Gil Shitrit A. Immune function in newborns with in-utero exposure to anti-TNFα therapy. Front Pediatr 2022; 10:935034. [PMID: 36120653 PMCID: PMC9470929 DOI: 10.3389/fped.2022.935034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 08/11/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND AND AIM Anti-TNFα is measurable in infants exposed in utero up to 12 months of age. Data about the exposure effect on the infant's adaptive immunity are limited. We aimed to prospectively evaluate the distribution and function of T and B cells, in infants of females with inflammatory bowel disease, in utero exposed to anti-TNFα or azathioprine. METHODS A prospective multi-center study conducted 2014-2017. Anti-TNFα levels were measured in cord blood, and at 3 and 12 months. T-cell repertoire and function were analyzed at 3 and 12 months by flow-cytometry, expression of diverse T cell receptors (TCR) and T-cell receptor excision circles (TREC) quantification assay. Serum immunoglobulins and antibodies for inactivated vaccines were measured at 12 months. Baseline clinical data were retrieved, and 2-monthly telephonic interviews were performed regarding child infections and growth. RESULTS 24 pregnant females, age 30.6 (IQR 26.5-34.5) years were recruited, 20 with anti-TNFα (infliximab 8, adalimumab 12), and 4 with azathioprine treatment. Cord blood anti-TNFα was higher than maternal blood levels [4.3 (IQR 2.3-9.2) vs. 2.5 (IQR 1.3-9.7) mcg/ml], declining at 3 and 12 months. All infants had normal number of B-cells (n = 17), adequate levels of immunoglobulins (n = 14), and protecting antibody levels to Tetanus, Diphtheria, Hemophilus influenza-B and hepatitis B (n = 17). All had normal CD4+, CD8+ T-cells, and TREC numbers. TCR repertoire was polyclonal in 18/20 and slightly skewed in 2/20 infants. No serious infections requiring hospitalization were recorded. CONCLUSION We found that T-cell and B-cell immunity is fully mature and immune function is normal in infants exposed in utero to anti-TNFα, as in those exposed to azathioprine. Untreated controls and large-scale studies are needed to confirm these results.
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Affiliation(s)
- Batia Weiss
- Division of Pediatric Gastroenterology and Nutrition, Edmond and Lily Safra Children's Hospital, Ramat Gan, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shomron Ben-Horin
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Chaim Sheba Medical Center, Institute of Gastroenterology, Ramat Gan, Israel
| | - Atar Lev
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Pediatric Immunology Laboratory, Chaim Sheba Medical Center, Ramat Gan, Israel
| | - Efrat Broide
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Division of Pediatric Gastroenterology, Assaf-Harofe Medical Center, Ramat Gan, Israel
| | - Miri Yavzori
- Chaim Sheba Medical Center, Institute of Gastroenterology, Ramat Gan, Israel
| | - Adi Lahat
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Chaim Sheba Medical Center, Institute of Gastroenterology, Ramat Gan, Israel
| | - Uri Kopylov
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Chaim Sheba Medical Center, Institute of Gastroenterology, Ramat Gan, Israel
| | - Orit Picard
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Chaim Sheba Medical Center, Institute of Gastroenterology, Ramat Gan, Israel
| | - Rami Eliakim
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Chaim Sheba Medical Center, Institute of Gastroenterology, Ramat Gan, Israel
| | - Yulia Ron
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Souraski Medical Center, Institute of Gastroenterology, Tel Aviv, Israel
| | - Irit Avni-Biron
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Division of Gastroenterology, Rabin Medical Center, Petah Tikva, Israel
| | - Anat Yerushalmy-Feler
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Division of Pediatric Gastroenterology, Souraski Medical Center, Dana Duek Children's Hospital, Tel Aviv, Israel
| | - Amit Assa
- Schneider Children's Hospital, Institute of Pediatric Gastroenterology, Hepatology and Nutrition, Petah Tikva, Israel.,The Juliet Keidan Institute of Pediatric Gastroenterology and Nutrition, Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Raz Somech
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Pediatric Immunology Laboratory, Chaim Sheba Medical Center, Ramat Gan, Israel.,Department of Pediatrics A, Edmond and Lily Safra Children's Hospital, Ramat Gan, Israel
| | - Ariella Bar-Gil Shitrit
- The Juliet Keidan Institute of Pediatric Gastroenterology and Nutrition, Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel.,Medical School, The Hebrew University, Jerusalem, Israel
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Fredrickson JS, Kolfenbach JR, Holmes JL, Cathcart JN, Lynch AM, Palestine AG. Therapeutic challenges in the treatment of systemic inflammatory disease in pregnancy. Obstet Med 2019; 12:180-185. [DOI: 10.1177/1753495x18819929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 11/27/2018] [Indexed: 11/17/2022] Open
Abstract
Background Granulomatosis with polyangiitis and Behçet’s disease can occur during pregnancy and may be treated by ophthalmologists, rheumatologists, and obstetricians. We hypothesized that specialty training would affect the way physicians selected therapy. Methods Using an online questionnaire, 209 uveitis specialists, 853 rheumatologists, and 2500 obstetricians were surveyed. Respondents were given clinical vignettes containing a female patient who was contemplating pregnancy or in the first trimester and was diagnosed with granulomatosis with polyangiitis or Behçet’s disease. Results In the patient with granulomatosis with polyangiitis, therapy choice between specialties for biologic versus non-biologic systemic immunosuppressive medications was significantly different for both the non-pregnant and pregnant patient (p < 0.00001, p < 0.00003). In the non-pregnant patient diagnosed with Behçet’s disease, the therapy choice between biologic versus non-biologic medications was also significantly different (p < 0.0003). Conclusions Specialty training affects how physicians manage granulomatosis with polyangiitis and Behçet’s disease. Development of inter-specialty guidelines and treatment plans may improve outcomes, communication, and patient care.
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Affiliation(s)
- Jared S Fredrickson
- Department of Ophthalmology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Jason R Kolfenbach
- Department of Ophthalmology, University of Colorado School of Medicine, Aurora, CO, USA
- Division of Rheumatology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Jennifer L Holmes
- Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Jennifer N Cathcart
- Department of Ophthalmology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Anne M Lynch
- Department of Ophthalmology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Alan G Palestine
- Department of Ophthalmology, University of Colorado School of Medicine, Aurora, CO, USA
- Division of Rheumatology, University of Colorado School of Medicine, Aurora, CO, USA
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Mahadevan U, Vermeire S, Lasch K, Abhyankar B, Bhayat F, Blake A, Dubinsky M. Vedolizumab exposure in pregnancy: outcomes from clinical studies in inflammatory bowel disease. Aliment Pharmacol Ther 2017; 45:941-950. [PMID: 28169436 DOI: 10.1111/apt.13960] [Citation(s) in RCA: 82] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Revised: 10/18/2016] [Accepted: 01/08/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Vedolizumab is a gut-selective immunoglobulin G1 monoclonal antibody to α4 β7 integrin for the treatment of Crohn's disease (CD) and ulcerative colitis (UC). Prospective clinical studies of vedolizumab in pregnancy have not been conducted; therefore, existing safety data of vedolizumab in pregnancy were examined. AIM To assess pregnancy outcomes in females and partners of males who received vedolizumab. METHODS All pregnancy data collected during the clinical programme (from 14 May 2007 to 27 June 2013) and in the post-marketing setting (to 19 November 2015) were analysed. RESULTS Across six studies, there were 27 pregnancies in female participants and 19 pregnancies in partners of male participants. Among 24 vedolizumab-treated females (23 with CD/UC, one healthy volunteer), there were 11 live births, five elective terminations, four spontaneous abortions and four undocumented outcomes. A congenital corpus callosum agenesis anomaly was reported in one live birth from a healthy volunteer with extensive obstetric history exposed to single-dose vedolizumab 79 days before estimated conception. Of 19 pregnancies in partners of male participants, there were 11 live births, two spontaneous abortions, three elective terminations and three undocumented outcomes. Post-marketing reports recorded 81 pregnancies, resulting in four live births, 11 spontaneous abortions and 66 pregnancies that were on-going or reported undocumented outcomes. CONCLUSIONS Initial analysis, limited by sample size and follow-up, identified no new safety concerns for pregnancy outcomes in females directly or indirectly exposed to vedolizumab. However, vedolizumab should be used during pregnancy only if the benefits to the mother outweigh the risks to the mother/unborn child.
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Affiliation(s)
- U Mahadevan
- Center for Colitis and Crohn's Disease, University of California San Francisco, San Francisco, CA, USA
| | - S Vermeire
- University Hospital Gasthuisberg, Leuven, Belgium
| | - K Lasch
- Takeda Pharmaceuticals USA, Inc., Deerfield, IL, USA
| | - B Abhyankar
- Takeda Development Centre Europe Ltd, London, UK
| | - F Bhayat
- Takeda Development Centre Europe Ltd, London, UK
| | - A Blake
- Takeda Development Centre Europe Ltd, London, UK
| | - M Dubinsky
- Department of Pediatrics, Susan and Leonard Feinstein IBD Clinical Center, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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