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Ashok A, Russell L, Dey M, Kouranloo K. Incidence, clinical features, management and outcomes of ANCA-associated vasculitis in pregnancy- a systematic literature review. SARCOIDOSIS, VASCULITIS, AND DIFFUSE LUNG DISEASES : OFFICIAL JOURNAL OF WASOG 2023; 40:e2023040. [PMID: 38126499 DOI: 10.36141/svdld.v40i4.15094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 08/28/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND AND AIM Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitides (AAV) are rare multi-system conditions, usually presenting in older age groups. However, younger individuals are also affected. The average increase of childbearing age and lack of studies in pregnancy necessitates this comprehensive review of data to guide the management of AAV in pregnancy. This systematic review (SR) aimed to summarise the incidence, clinical features, management and maternal and foetal outcomes in female patients with AAV. METHODS The protocol was registered on PROSPERO (CRD42023437482). Articles published in Medline, Embase and Cochrane Databases from 1946 until June 2023 were included. Single case reports, reviews and conference abstracts were excluded. Articles meeting inclusion criteria were examined by two authors. Data on demographics, treatment, clinical features, flares during pregnancy and maternal and foetal outcomes were extracted. RESULTS Eight studies were included, detailing 82 pregnancies in 64 women. The most common drugs used for remission induction pre-conception were cyclophosphamide, rituximab, prednisolone and azathioprine. Serious maternal complications in pregnancy included progressive tracheal/subglottic stenosis (n=5), renal disease (n=2), preeclampsia (n=10) and miscarriages (n=5). Foetal anomalies were rare (n=5). The mean birth weight was 3.37kgs and mean gestation age was 38.26 weeks. No maternal deaths or vasculitis in newborns were reported. Conclusions: Patients can have positive maternal and foetal outcomes following strong induction therapy, vigorous monitoring and prompt treatment of flares during pregnancy. Serious complications and flares are not associated with worse outcomes for newborns.
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Affiliation(s)
| | - Laura Russell
- British Medical Association Library, BMA House London.
| | - Mrinalini Dey
- Department of Rheumatology, Queen Elizabeth Hospital London; University if Liverpool, Institute of Life Courses and Medical Sciences .
| | - Koushan Kouranloo
- University of Liverpool, School of Medicine; Liverpool University NHS Foundation Trust .
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Sims CA, Bermas BL, Clowse MEB. Vasculitis and Pregnancy: Disease State and Management. Rheum Dis Clin North Am 2023; 49:679-694. [PMID: 37331740 DOI: 10.1016/j.rdc.2023.03.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2023]
Abstract
Family planning in women with vasculitis requires an interdisciplinary approach. This article summarizes recommendations and guidance for each phase of family planning in persons with vasculitis including preconception counseling, birth control, pregnancy, and breastfeeding. Pregnancy complications are presented by category of vasculitis with accompanying diagnostic and therapeutic recommendations. Birth control and assisted reproductive technology options are reviewed with special considerations for women who are high risk or have a history of blood clots. This article can be used as a clinical reference for reproductive discussions in all patients with vasculitis.
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Affiliation(s)
- Catherine A Sims
- Division of Rheumatology, Duke University, 1021 Red Hat Lane, Durham, NC 27713, USA.
| | - Bonnie L Bermas
- University of Texas Southwestern, 2001 Inwood Road, Dallas, TX 75235, USA
| | - Megan E B Clowse
- Division of Rheumatology & Immunology, Duke University, 40 Duke Medicine Circle Clinic 1J, Durham, NC 27713, USA
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3
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Mettler C, Beeker N, Collier M, Guern VL, Terrier B, Chouchana L. Patterns of immunosuppressive drug use during pregnancy in women with systemic vasculitis: A nationwide population-based cohort study. Eur J Intern Med 2023; 109:33-41. [PMID: 36702739 DOI: 10.1016/j.ejim.2023.01.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 01/10/2023] [Accepted: 01/12/2023] [Indexed: 01/26/2023]
Abstract
OBJECTIVE Systemic vasculitis (SV) rarely affects women of childbearing age and only small series have been reported to date in pregnant patients. The discovery of an unplanned pregnancy can be an urgent cause for modifying treatments. This study aimed to describe immunosuppressive drugs use before, during and after pregnancy in women with SV. METHODS We conducted a cohort study using the French nationwide claims database. We included all women with SV being pregnant between 2013 and 2018. Exposure of interest was defined as exposure to oral systemic or injectable immunosuppressive drug identified using out-hospital reimbursement data and in-hospital reimbursement for expensive drugs. RESULTS Of 3,246,454 pregnancies, 649 pregnancies were observed in 606 women with SV. Immunosuppressant and glucocorticoids use decreased before pregnancy and then increased after pregnancy (48.4%, 40.7%, 50.4%, respectively before, during, after). Prevalence of glucocorticoids use was broadly stable during pregnancy from 27.9% to 27.6% and 23.7% in the 1st, 2nd and 3rd trimesters, respectively, with a daily dose of about 5 mg. The number of patients treated with non-recommended immunosuppressant during pregnancy gradually decreased before pregnancy and then increased after delivery, whereas proportion of systemic vasculitis flare, estimated from the glucocorticoids daily dose, did not increase significantly during pregnancy. CONCLUSION Immunosuppressants and glucocorticoids use decreased before pregnancy and remained stable throughout, suggesting a vasculitis control during this period. Our findings support the importance of pre-conceptional consultations to review medications, and switch not-recommended and teratogenic medications to drugs considered being safe during pregnancy.
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Affiliation(s)
- Camille Mettler
- Département de Médecine Interne, Centre de Référence National pour les maladies auto-immunes systémiques rares, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Paris, France; Unité de Recherche Clinique, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Nathanael Beeker
- Unité de Recherche Clinique, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Mathis Collier
- Unité de Recherche Clinique, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Véronique Le Guern
- Département de Médecine Interne, Centre de Référence National pour les maladies auto-immunes systémiques rares, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Benjamin Terrier
- Département de Médecine Interne, Centre de Référence National pour les maladies auto-immunes systémiques rares, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Paris, France; Université Paris Cité, Paris, France
| | - Laurent Chouchana
- Unité de Recherche Clinique, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Paris, France; Département de Pharmacologie, Centre Régional de Pharmacovigilance, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Paris, France.
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Colquhoun M, Thanopoulou V, Quick V, Mouyis M. Rituximab Administration during the 2nd Trimester of Pregnancy for Systemic Lupus Erythematosus: Case Report and Review of the Literature in Rheumatic Disease. Mod Rheumatol Case Rep 2021; 6:173-177. [PMID: 34850082 DOI: 10.1093/mrcr/rxab051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 10/01/2021] [Accepted: 10/27/2021] [Indexed: 11/12/2022]
Abstract
Rituximab is an anti-CD20 monoclonal antibody that is used in the treatment of many rheumatic diseases, for both licensed and unlicensed indications. Due to concerns regarding foetal B cell depletion and possible infection, there is conflicting advice about whether the drug should be administered during pregnancy, with some organizations advising administration if the potential benefit to the mother outweighs the risk to the foetus and some advising stopping rituximab six months prior to conception. Caution in particular is advised about administering rituximab in later trimesters when maternal IgG is transported across the placenta. There has been little literature thus far examining the safety of administering rituximab from the second trimester onwards in rheumatic diseases. We present a case where rituximab was used during the second trimester for the treatment of refractory systemic lupus erythematosus, without adverse effect on the neonate.
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Affiliation(s)
- Matthew Colquhoun
- Department of Rheumatology, Northwick Park Hospital, Harrow, United Kingdom
| | | | - Vanessa Quick
- Department of Rheumatology, Luton and Dunstable Hospital, Luton, United Kingdom
| | - Maria Mouyis
- Department of Rheumatology, Luton and Dunstable Hospital, Luton, United Kingdom
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5
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Alves P, Navarro D, Góis M, Mendes M, Nolasco F. A Pregnant Woman With Gross Hematuria and Acute Kidney Injury. Am J Kidney Dis 2021; 78:A11-A12. [PMID: 34560910 DOI: 10.1053/j.ajkd.2021.05.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 05/02/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Patrícia Alves
- Nephrology Department, Centro Hospitalar Lisboa Central, Lisboa, Portugal.
| | - David Navarro
- Nephrology Department, Centro Hospitalar Lisboa Central, Lisboa, Portugal
| | - Mário Góis
- Nephrology Department, Centro Hospitalar Lisboa Central, Lisboa, Portugal
| | - Marco Mendes
- Nephrology Department, Centro Hospitalar Lisboa Central, Lisboa, Portugal
| | - Fernando Nolasco
- Nephrology Department, Centro Hospitalar Lisboa Central, Lisboa, Portugal
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Nguyen H, Ahmed K, Luo W, Flint J, Giles I. A Systematic Review of the safety of non-TNF inhibitor biologic and targeted synthetic drugs in rheumatic disease in pregnancy. Semin Arthritis Rheum 2021; 51:1205-1217. [PMID: 34689007 DOI: 10.1016/j.semarthrit.2021.09.004] [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: 07/06/2021] [Revised: 08/07/2021] [Accepted: 09/13/2021] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Despite increasing evidence to support safe use of tumour necrosis factor inhibitors (TNFi) and other biologic disease modifying anti-rheumatic drugs (bDMARDs) during pre-conception/pregnancy, there remains a paucity of evidence regarding the safety and compatibility of other non-TNFi and novel targeted synthetic (ts)DMARDs during pre-conception/pregnancy. Therefore, we conducted a systematic review to determine the compatibility of these drugs in pre-conception, during pregnancy and post-partum period. METHOD Databases including; EMBASE, Pubmed (MEDLINE), and Cochrane were searched up to 23rd October 2020 to find relevant peer-reviewed papers, using keywords including; rheumatic disease, pregnancy, conception/pre-conception, lactation/breastfeeding, childhood and vaccination/infection, and commonly prescribed non-TNFi drugs and tsDMARDs. RESULTS Our search yielded 1483 papers that were screened independently by two authors, and 109 full-text papers were eligible for final analysis. These studies reported 1291 maternal pregnancies exposed to non-TNFi bDMARDs and tsDMARDs with known outcomes, including 721 live births, 219 spontaneous miscarriages and 27 congenital abnormalities. Paternal exposures in 174 pregnancies had reassuring outcomes. A total of 48 breast-fed infants were exposed to non-TNFi bDMARDs and no adverse events reported upon long-term follow-up. Fifteen infants exposed to bDMARDs received normal vaccination regimes, including live vaccines, and had normal developmental outcomes, without any complications or infections. CONCLUSION Overall, the findings are reassuring and do not suggest a cause for any major concerns or an increased risk of adverse pregnancy outcomes for maternal or paternal exposures to non-TNFi bDMARDs or tsDMARDs. There were no major concerns for breastfeeding exposures to non-TNFi bDMARDs.
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Affiliation(s)
- Hanh Nguyen
- Centre for Rheumatology Research, Rayne Institute, University College London (UCL), London, UK
| | | | - Weike Luo
- University College London (UCL), London, UK
| | | | - Ian Giles
- Centre for Rheumatology Research, Rayne Institute, University College London (UCL), London, UK; Department of Rheumatology, University College London Hospital, London, UK.
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Galstyan GM, Maschan AA, Klebanova EE, Kalinina II. [Treatment of thrombotic thrombocytopenic purpura]. TERAPEVT ARKH 2021; 93:736-745. [PMID: 36286842 DOI: 10.26442/00403660.2021.06.200894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Accepted: 07/10/2021] [Indexed: 11/22/2022]
Abstract
The review discusses approaches to treatment of acquired thrombotic thrombocytopenic purpuгa (aTTP). In patients with aTTP plasma exchanges, glucocorticosteroids allow to stop an acute attack of TTP, and use of rituximab allows to achieve remission. In recent years, caplacizumab has been used. Treatment options such as cyclosporin A, bortezomib, splenectomy, N-acetylcysteine, recombinant ADAMTS13 are also described. Separately discussed issues of management of patients with TTP during pregnancy, and pediatric patients with TTP.
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Affiliation(s)
| | - A A Maschan
- Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology
| | | | - I I Kalinina
- Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology
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8
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Mormile I, Granata F, Punziano A, de Paulis A, Rossi FW. Immunosuppressive Treatment in Antiphospholipid Syndrome: Is It Worth It? Biomedicines 2021; 9:biomedicines9020132. [PMID: 33535377 PMCID: PMC7911562 DOI: 10.3390/biomedicines9020132] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Revised: 01/18/2021] [Accepted: 01/26/2021] [Indexed: 11/16/2022] Open
Abstract
The antiphospholipid syndrome (APS) is characterized by the development of venous and/or arterial thrombosis and pregnancy morbidity in patients with persistent antiphospholipid antibodies (aPL). Catastrophic antiphospholipid syndrome (CAPS) is a life-threatening form of APS occurring in about 1% of cases. Lifelong anticoagulation with vitamin K antagonists remains the cornerstone of the therapy for thrombotic APS, but frequently the use of anticoagulation may be problematic due to the increased risk of bleeding, drug interactions, or comorbidities. Immunosuppressant drugs are widely used to treat several autoimmune conditions, in which their safety and effectiveness have been largely demonstrated. Similar evidence in the treatment of primary APS is limited to case reports or case series, and studies on a large scale lack. Immunomodulatory drugs may be an emerging tool in managing such particular situations, like refractory obstetrical complications, CAPS, or so-called APS non-criteria manifestations. In addition, immunomodulatory drugs may be useful in patients experiencing recurrent thromboembolic events despite optimized anticoagulant therapy. We did a comprehensive review of literature analyzing the possible role of immunomodulation in primary APS to provide a broad overview of potentially safe and effective target treatments for managing this devastating disease.
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Affiliation(s)
- Ilaria Mormile
- Department of Translational Medical Sciences, University of Naples Federico II, Via S. Pansini 5, 80131 Naples, Italy; (I.M.); (F.G.); (A.P.); (A.d.P.)
| | - Francescopaolo Granata
- Department of Translational Medical Sciences, University of Naples Federico II, Via S. Pansini 5, 80131 Naples, Italy; (I.M.); (F.G.); (A.P.); (A.d.P.)
| | - Alessandra Punziano
- Department of Translational Medical Sciences, University of Naples Federico II, Via S. Pansini 5, 80131 Naples, Italy; (I.M.); (F.G.); (A.P.); (A.d.P.)
| | - Amato de Paulis
- Department of Translational Medical Sciences, University of Naples Federico II, Via S. Pansini 5, 80131 Naples, Italy; (I.M.); (F.G.); (A.P.); (A.d.P.)
- Center for Basic and Clinical Immunology Research (CISI), WAO Center of Excellence, University of Naples Federico II, 80131 Naples, Italy
| | - Francesca Wanda Rossi
- Department of Translational Medical Sciences, University of Naples Federico II, Via S. Pansini 5, 80131 Naples, Italy; (I.M.); (F.G.); (A.P.); (A.d.P.)
- Center for Basic and Clinical Immunology Research (CISI), WAO Center of Excellence, University of Naples Federico II, 80131 Naples, Italy
- Correspondence: ; Tel.: +39-81-7464513
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9
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Gleeson S, Lightstone L. Glomerular Disease and Pregnancy. Adv Chronic Kidney Dis 2020; 27:469-476. [PMID: 33328063 DOI: 10.1053/j.ackd.2020.08.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 08/04/2020] [Accepted: 08/04/2020] [Indexed: 12/28/2022]
Abstract
Nephrologists are routinely involved in the care of pregnant women with glomerulonephritis. Prepregnancy counseling is vital to inform women of the potential risks of pregnancy and to reduce those risks by optimizing clinical status and medications. In general, for all glomerulonephritides, the best pregnancy outcomes are achieved when the disease is in remission and the woman has preserved renal function with no proteinuria or hypertension. Each glomerulonephritis has specific considerations, for example in lupus nephritis, mycophenolate is teratogenic and must be stopped at least 6 weeks before conception, hydroxychloroquine is recommended for all pregnant women, and flares are frequently encountered and must be treated appropriately. De novo glomerulonephritis should be considered when significant proteinuria is found early in pregnancy or an acute kidney injury with active urine is encountered. Biopsy can be safely undertaken in the first trimester. Treatment is often with corticosteroids, azathioprine, and/or tacrolimus. Rituximab is increasingly used for severe disease. Women with glomerulonephritis should ideally be managed in a joint renal-obstetric clinic. This review details the approach to the care of women with glomerulonephritis from prepregnancy counseling, through antenatal care and delivery, to the postpartum period. Special attention is given to medications and treatment of glomerulonephritis in pregnancy.
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10
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Vasanthamohan L, Choo S, Marshall T, Symons YT, Matsui D, Eastabrook G, Solh Z. Peripartum hyperhemolysis prophylaxis and management in sickle cell disease: A case report and narrative review. Transfusion 2020; 60:2448-2455. [PMID: 32851670 DOI: 10.1111/trf.16003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 05/26/2020] [Accepted: 06/29/2020] [Indexed: 01/04/2023]
Abstract
BACKGROUND Sickle cell disease (SCD) is associated with hematologic complications including delayed hemolytic transfusion reactions (DHTRs) and pregnancy-related morbidity and mortality. Hyperhemolysis syndrome (HS) is the most severe form of DHTR in patients with SCD, in which both transfused and native red blood cells are destroyed. Further transfusions are avoided after a history of HS. Immunosuppressive agents can be used as prophylaxis against life-threatening hemolysis when transfusion is necessary. There is a paucity of evidence for the use of HS prophylaxis before transfusions, the continuation of hydroxyurea (HU) in lieu of chronic transfusion, and the use of erythropoiesis-stimulating agents (ESA) in pregnant SCD patients. CASE REPORT We present a case of a pregnant patient with SCD and a previous history of HS. HS prophylaxis was given before transfusion with corticosteroids, intravenous immunoglobulin, and rituximab. In addition, HU was continued during pregnancy to control SCD, along with the use of concomitant ESA to maintain adequate hemoglobin levels and avoid transfusion. We describe a multidisciplinary approach to pregnancy and delivery management including tailored anesthetic and obstetric planning. CONCLUSION This is the first published case of HS prophylaxis in a pregnant SCD patient, with good maternal and fetal outcomes after transfusion. HU and ESAs were able to control SCD and mitigate anemia in lieu of prophylactic transfusions during pregnancy. Further prospective studies are necessary to elucidate the ideal management of pregnant SCD patients with a history of HS or other contraindications to chronic transfusion.
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Affiliation(s)
- Lakshman Vasanthamohan
- Department of Medicine, Division of Hematology, Western University, London, Ontario, Canada
| | - Sheryl Choo
- Department of Obstetrics & Gynecology, Western University, London, Ontario, Canada
| | - Tonisha Marshall
- Department of Obstetrics & Gynecology, Western University, London, Ontario, Canada
| | | | - Doreen Matsui
- Department of Pediatrics, Division of Clinical Pharmacology, Western University, London, Ontario, Canada
| | - Genevieve Eastabrook
- Department of Obstetrics & Gynecology, Western University, London, Ontario, Canada
| | - Ziad Solh
- Department of Medicine, Division of Hematology, Western University, London, Ontario, Canada.,Department of Pathology & Laboratory Medicine, Division of Transfusion Medicine, Western University, London, Ontario, Canada
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Abstract
PURPOSE OF REVIEW To provide an update about the impact of infections in autoimmune rheumatic diseases (ARDs), from the analysis of the role of infections in pregnant women without ARDs, to the identification of maternal-fetal infections and their role in the maternal-fetal outcome of women with ARDs. RECENT FINDINGS Recent studies indicate that patients with ARDs and pregnancy are also susceptible to presenting infections of varying degrees, including serious infections, which contribute to the morbidity and mortality observed in pregnancy and postpartum of these patients.Any type of infectious agent will interact with a hormonal, immunological and metabolic environments modified by ARD, treatments, and by the changes inherent in pregnancy. Therefore, infections in the pregnancy of patients with ARDs should be considered as a risk factor for an unfavorable maternal-fetal outcome. SUMMARY The recognition of infections in the pregnancy of ARDs as a risk factor is the first step to prevent, identify, and treat them in a timely manner, and thus contribute to the favorable course of pregnancy in these patients. Patients with ARDs and major organ involvement, use of high doses of steroids, immunosuppressant and biological therapies, adolescence, and obesity are populations susceptible to developing infections.
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Sica A, Vitiello P, Papa A, Calogero A, Sagnelli C, Casale D, Mottola M, Svanera G, Dodaro CA, Martinelli E, Troiani T, Ciardiello F, Casale B. Use of Rituximab in NHL Malt Type Pregnant in I° Trimester for Two Times. Open Med (Wars) 2019; 14:757-760. [PMID: 31844674 PMCID: PMC6884922 DOI: 10.1515/med-2019-0087] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 07/30/2019] [Indexed: 01/05/2023] Open
Abstract
Administration of rituximab, one of the basic drugs for the therapy of B-cell lymphoproliferative diseases, during pregnancy has been suspected to cause developmental fetal events, particularly if given during the first trimester of pregnancy. Therefore, use in pregnancy is not permitted. Howe ver, several cases of pregnant women being treated with rituximab are reported herein; an exception is often made in cases with grave illness. We describe an exceptional case of a woman with non-Hodgkin lymphoma of the mucosa-associated lymphoid tissue type where rituximab was given as a single agent without interruption during two consecutive pregnancies. This case can certainly supply important indications on the safety of rituximab.
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Affiliation(s)
- Antonello Sica
- Department of Precision Medicine, University of Campania Luigi Vanvitelli, Naples, Italy
- 80131, +393332253315, +3908119573375.
| | - Paola Vitiello
- Dermatology Unit, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Alfonso Papa
- Pain Department, AO Dei Colli - V. Monaldi, Naples, Italy
| | - Armando Calogero
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Caterina Sagnelli
- Department of Mental Health and Public Medicine, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Danilo Casale
- Department of Anesthesia, Reanimation, Intensive Care and Pain Buon Consiglio Fatebenefratelli Hospital, Naples, Italy
| | - Maria Mottola
- Department of Heart Surgery and Transplantations AO Dei Colli - V. Monaldi, Naples, Italy
| | - Gino Svanera
- Department of Medical Area ASLNA2 NORTH, Naples, Italy
| | - Concetta Anna Dodaro
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Erika Martinelli
- Department of Precision Medicine, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Teresa Troiani
- Department of Precision Medicine, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Fortunato Ciardiello
- Department of Precision Medicine, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Beniamino Casale
- Department of Pneumology And Tisiology, AO Dei Colli - V. Monaldi, Naples, Italy
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13
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Nagata M, Kaneko K, Kohno C, Mishima S, Okazaki Y, Murashima A. A case of successful pregnancy following multidrug treatment including rituximab and intravenous immunoglobulin for primary antiphospholipid antibody syndrome refractory to conventional treatment. Mod Rheumatol Case Rep 2019; 4:47-50. [PMID: 33086951 DOI: 10.1080/24725625.2019.1648633] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Antiphospholipid antibody syndrome (APS) is defined by the presence of clinical symptoms caused by antiphospholipid antibodies. When APS occurs during pregnancy, it is conventionally treated with low-dose aspirin or heparin. In cases refractory to conventional treatment, intravenous immunoglobulin (IvIg) is sometimes added. We present the case of an APS patient with severe thrombocytopenia who experienced a successful pregnancy after treatment that included intravenous rituximab and IvIg. As far as we know, this is the first report demonstrating a positive pregnancy outcome in this context. Physicians may consider prescribing not only IvIg but also rituximab during the first trimester of pregnancy in APS patients with severe obstetrical complications and thrombocytopenia refractory to conventional treatment.
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Affiliation(s)
- Mayu Nagata
- Division of Maternal Medicine, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Kayoko Kaneko
- Division of Maternal Medicine, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Chie Kohno
- Division of Maternal Medicine, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Shuko Mishima
- Division of Maternal Medicine, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Yuka Okazaki
- Division of Maternal Medicine, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Atsuko Murashima
- Division of Maternal Medicine, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
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IL-10 producing B cells rescue mouse fetuses from inflammation-driven fetal death and are able to modulate T cell immune responses. Sci Rep 2019; 9:9335. [PMID: 31249364 PMCID: PMC6597542 DOI: 10.1038/s41598-019-45860-2] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 06/11/2019] [Indexed: 11/26/2022] Open
Abstract
Understanding the mechanisms leading to fetal death following maternal subclinical infections is crucial to develop new therapeutic strategies. Here we addressed the relevance of IL-10 secreting B cells (B10) in the maintenance of the immune balance during gestation. µMT females lacking mature B cells presented normal pregnancies, although their fetuses were smaller and their Treg pool did not expand as in B cell sufficient controls. Pregnant µMT females were more susceptible to LPS despite having less Treg; their fetuses died at doses compatible with pregnancy in WT animals. Adoptive transfer of IL-10 negative B effector cells or B cells from IL-10 deficient mice did not modify this outcome. The transfer of B10 cells or application of recombinant murine IL-10 reduced the fetal loss, associated with a normalization of Treg numbers and cytokine modulation at the feto-maternal interface. B cell-derived IL-10 suppressed the production of IL-17A and IL-6 by T cells and promoted the conversion of naïve cells into Treg. B10 cells are required to restore the immune balance at the feto-maternal interface when perturbed by inflammatory signals. Our data position B cells in a central role in the maintenance of the balance between immunity and tolerance during pregnancy.
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Abstract
Introduction: Lymphoproliferative diseases occurring during pregnancy present the treating physician with unique diagnostic and therapeutic challenges, aiming to achieve maternal cure without impairing fetal health, growth, and survival. Due to the rarity of this complication, there is limited data to guide clinical decision-making, especially regarding the safety of novel emerging therapies. Areas covered: The presented review describes the current practice of treatment for Hodgkin's (HL) and non-Hodgkin's (NHL) lymphoma in the pregnant patient, according to disease stage and trimester of pregnancy. Novel agents for treatment of lymphoma in the setting of pregnancy are discussed. Therapeutic dilemmas and areas of uncertainty are illuminated. Expert opinion: HL and NHL are potentially curable diseases in the pregnant patient with generally good outcomes for the mother and the offspring, when tailoring the treatment according to the individual patient. The complexity of the situation merits shared decision-making with the patient and her family, explicitly outlining the risks and benefits. The pregnant patient is best managed by a multidisciplinary team, familiar with the intricacies of the gestational period, and providing the necessary support and sensitivity. Further studies are needed regarding the safety of novel agents in pregnancy.
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Affiliation(s)
- Anna Gurevich-Shapiro
- a Internal Medicine H , Tel Aviv Sourasky Medical Center , Tel Aviv , Israel.,b Division of Hematology , Tel Aviv Sourasky Medical Center , Tel Aviv , Israel.,c Sackler School of Medicine , Tel Aviv University , Ramat-Aviv , Israel
| | - Irit Avivi
- b Division of Hematology , Tel Aviv Sourasky Medical Center , Tel Aviv , Israel.,c Sackler School of Medicine , Tel Aviv University , Ramat-Aviv , Israel
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Matsuno O, Minamoto S. Flare of eosinophilic granulomatosis with polyangiitis related to pregnancy: Case report and review of the literature. Respir Med Case Rep 2018; 26:23-26. [PMID: 30456168 PMCID: PMC6234254 DOI: 10.1016/j.rmcr.2018.10.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 10/29/2018] [Accepted: 10/30/2018] [Indexed: 11/18/2022] Open
Abstract
Eosinophilic granulomatosis with polyangiitis (EGPA) is characterized by excessive eosinophil accumulation in the peripheral blood and affected tissues with development of granulomatous vasculitic organ damage. It is strongly associated with asthma and ear-nose-throat disease. It often affects patients between the ages of 40 and 60 years. It is unknown whether pregnancy impacts the disease activity of EGPA, including initial diagnosis or relapse. Because of its rarity and age of susceptibility, there are few reported cases describing pregnancy in women with quiescent or active EGPA. Here, we describe a young woman who experienced EGPA relapse during pregnancy and subsequently underwent an elective caesarean section for non-reassuring fetal status at 37 weeks without complication.
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