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Lindroos JLV, Bjørk MH, Gilhus NE. Transient Neonatal Myasthenia Gravis as a Common Complication of a Rare Disease: A Systematic Review. J Clin Med 2024; 13:1136. [PMID: 38398450 PMCID: PMC10889526 DOI: 10.3390/jcm13041136] [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: 01/10/2024] [Revised: 02/09/2024] [Accepted: 02/15/2024] [Indexed: 02/25/2024] Open
Abstract
Myasthenia gravis (MG) is a rare autoimmune disease. Transient neonatal myasthenia gravis (TNMG) is caused by pathogenic maternal autoantibodies that cross the placenta and disrupt signaling at the neuromuscular junction. This is a systematic review of this transient immunoglobulin G (IgG)-mediated disease. TNMG affects 10-20% of children born to mothers with MG. The severity of symptoms ranges from minor feeding difficulties to life-threatening respiratory weakness. Minor symptoms might go unnoticed but can still interfere with breastfeeding. Acetylcholine-esterase inhibitors and antibody-clearing therapies such as immunoglobulins can be used to treat TNMG, but most children do well with observation only. TNMG is self-limiting within weeks as circulating antibodies are naturally cleared from the blood. In rare cases, TNMG is associated with permanent skeletal malformations or permanent myopathy. The mother's antibodies can also lead to spontaneous abortions. All healthcare professionals meeting pregnant or birthing women with MG or their neonates should be aware of TNMG. TNMG is hard to predict. Reoccurrence is common among siblings. Pre-pregnancy thymectomy and intravenous immunoglobulins during pregnancy reduce the risk. Neonatal fragment crystallizable receptor (FcRn) blocking drugs for MG might reduce TNMG risk.
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Affiliation(s)
- Jenny Linnea Victoria Lindroos
- Department of Clinical Medicine, University of Bergen, 5020 Bergen, Norway; (J.L.V.L.); (M.-H.B.)
- Department of Neurology, Haukeland University Hospital, 5053 Bergen, Norway
| | - Marte-Helene Bjørk
- Department of Clinical Medicine, University of Bergen, 5020 Bergen, Norway; (J.L.V.L.); (M.-H.B.)
- Department of Neurology, Haukeland University Hospital, 5053 Bergen, Norway
| | - Nils Erik Gilhus
- Department of Clinical Medicine, University of Bergen, 5020 Bergen, Norway; (J.L.V.L.); (M.-H.B.)
- Department of Neurology, Haukeland University Hospital, 5053 Bergen, Norway
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Kumar L, Kachhadia MP, Kaur J, Patel H, Noor K, Gohel RG, Kaur P, Raiyani S, Gohel VA, Vasavada AM. Choices and Challenges With Treatment of Myasthenia Gravis in Pregnancy: A Systematic Review. Cureus 2023; 15:e42772. [PMID: 37663985 PMCID: PMC10469352 DOI: 10.7759/cureus.42772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/31/2023] [Indexed: 09/05/2023] Open
Abstract
Myasthenia gravis (MG) is an autoimmune disease affecting young women in their second and third decades, coinciding with their reproductive years. We aim to explore the choices and challenges in the treatment of MG in pregnancy. Cochrane, PubMed, Google Scholar, and Embase were the four databases systematically searched for studies with patients reporting pregnancy outcomes for women with MG during pregnancy using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) technique. Quality assessment was done using the Joanna Briggs Institute critical tool (JBI, Adelaide, Australia) for methodological quality. From 2000 to 2023, 40 studies from database search results were considered. There is a substantial risk of complications with MG, especially if it appears during pregnancy. In particular, widespread weakness is a cause of severe, life-threatening disorders, but several treatment options are available.
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Affiliation(s)
- Lakshya Kumar
- Internal Medicine, Pandit Dindayal Upadhyay (PDU) Medical College, Rajkot, IND
| | | | - Jashanpreet Kaur
- Internal Medicine, Mata Gujri Memorial Medical College, Kishanganj, IND
| | - Harshkumar Patel
- Internal Medicine, Pandit Dindayal Upadhyay (PDU) Medical College, Rajkot, IND
| | - Khutaija Noor
- Internal Medicine, Shadan Institute of Medical Sciences, Hyderabad, IND
| | - Rushi G Gohel
- Internal Medicine, Pandit Dindayal Upadhyay (PDU) Medical College, Rajkot, IND
| | - Paramjeet Kaur
- Internal Medicine, Guru Gobind Singh Medical College, Faridkot, IND
| | - Siddharth Raiyani
- Internal Medicine, Pandit Dindayal Upadhyay (PDU) Medical College, Rajkot, IND
| | - Vatsal A Gohel
- Internal Medicine, Karaganda Medical University, Karaganda, KAZ
| | - Advait M Vasavada
- Internal Medicine, M. P. Shah Medical College, Jamnagar, IND
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
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Treatment and Management of Disorders of the Neuromuscular Junction. Neuromuscul Disord 2022. [DOI: 10.1016/b978-0-323-71317-7.00019-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Neykova KK, Milanova M, Ignatov PN. Myasthenia gravis and covid-19 in pregnancy: a review of the literature and case series report. J Matern Fetal Neonatal Med 2021; 35:8308-8316. [PMID: 34582289 DOI: 10.1080/14767058.2021.1973418] [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] [Indexed: 10/20/2022]
Abstract
OBJECTIVES The aim of our study was to investigate the interrelations of symptoms, clinical outcomes and treatment regimens in pregnant women, diagnosed with myasthenia gravis and superimposed COVID-19 infection. METHODS We conducted an observational retrospective study between August, 2020 and July, 2021. Five patients with preexisting MG and superimposed COVID- infection were included in our study. We investigated the duration of MG, the antibody patient status, any present comorbidities, MG baseline treatment and MG severity class prior to the COVID-19 infection, MG severity class and treatment during the COVID-infection, and last but not least, the maternal and fetal clinical outcome. RESULTS None of the participants were hospitalized as they were treated under quarantine at their homes. The most frequently reported complaints were anosmia, headache and fever, which were observed in 3 out of 5 patients. The MG severity was evaluated twice - before and after the quarantine period. Progression to a more advanced stage was found in 2 of our 5 patients. Three of the patients did not require any changes in the prescribed baseline MG treatment. In 2 patients the pyridostigmine dosage had to be increased. One patient received azithromycin and 4 patients were given LMWH (nadroparin) as specific anti-COVID measures. All patients fully recovered and gave birth to healthy newborns. CONCLUSION To our knowledge, this is the first study on pregnant MG patients with superimposed COVID-19 infection. Based on our observations in this study it would seem that the coexistence of MG and COVID-19 infection in pregnancy does not elicit exacerbation in neither of those conditions. Further research is needed to confirm or challenge these findings, especially with the prospects of new virus variants emerging in the future.
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Affiliation(s)
| | - Milena Milanova
- State University Hospital for Treatment of Neurological and Psychiatric Disorders, MBALNP Sv Naum EAD, Sofia, Bulgaria
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Maqbool R, Maqbool M, Zehravi M, Ara I. Acute neurological conditions during pregnancy and their management: a review. Int J Adolesc Med Health 2021; 33:357-366. [PMID: 34420267 DOI: 10.1515/ijamh-2021-0084] [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: 06/19/2021] [Accepted: 07/14/2021] [Indexed: 11/15/2022]
Abstract
Less vascular resistance, higher vascular permeability and improved cardiac output include anatomical and physiological changes related to pregnancy. These are needed to accommodate an increase in plasma volume and ensure significant organ infusion. Nevertheless, increases in oestrogen levels may lead to an increase in the risk of coagulation and thrombosis. Increased levels of progesterone increase the risk of thrombosis due to vasodilation, vascular stasis and edoema in these situations. The increased resistance in preeclampsia maternal systemic blood arteries can create high blood pressure that can interfere with blood flow in numerous organs (including liver, kidneys, brain and placenta). The risk of issues such as pulmonary edoema, placental abruption, pneumonia of aspiration, renal failure, hepatic failure and stroke in pregnant women is increased by Preeclampsia and eclampsia. Some peripheral neuropathies (carpal tunnel syndrome, peripheral facial palsy) and central neurological conditions (seizure, migraine, stroke, epilepsy) may become more common during pregnancy because of the exacerbation of the pre-existing neurologic condition or the onset of neurological disturbance caused by pregnancy physiological changes (such as headache or vascular disorders). During the three trimesters of pregnancy, neurological disorders are both peripheral and central. Therefore, an early and correct diagnosis is required to improve pregnancy care, treatment and perinatal outcomes. The aims of this paper are to identify, define and manage the most prevalent peripheral and centrally occurring neurological disorders in the pregnancy.
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Affiliation(s)
- Rubeena Maqbool
- Department of Pharmacology, GMC, Baramulla, Jammu and Kashmir, India
| | - Mudasir Maqbool
- Department of Pharmaceutical Sciences, University of Kashmir, Srinagar, Jammu and Kashmir, India
| | - Mehrukh Zehravi
- Department of Clinical Pharmacy Girls Section, Prince Sattam Bin Abdul Aziz University, Alkharj, Saudia Arabia
| | - Irfat Ara
- Regional Research Institute of Unani Medicine, Srinagar, Jammu and Kashmir, India
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Nicholls-Dempsey L, Czuzoj-Shulman N, Abenhaim HA. Maternal and neonatal outcomes among pregnant women with myasthenia gravis. J Perinat Med 2020; 48:793-798. [PMID: 32739906 DOI: 10.1515/jpm-2020-0163] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 07/02/2020] [Indexed: 11/15/2022]
Abstract
Objectives Myasthenia gravis (MG) is an autoimmune disease affecting the neuromuscular junction marked by weakness and fatiguability of skeletal muscle. MG has an unpredictable course in pregnancy. Our purpose was to evaluate the effect of MG on maternal and neonatal outcomes. Methods Using the United States' Healthcare Cost and Utilization Project Nationwide Inpatient Sample from 2005 to 2015, we conducted a retrospective cohort study consisting of women who delivered during that period. Multivariate logistic regression models, adjusted for baseline maternal demographics and comorbidities, were used to compare maternal and neonatal outcomes among pregnancies in women with and without MG. Results During the study period, 974 deliveries were to women diagnosed with MG. Women with MG were more likely to be older, African American, obese, have Medicare insurance and be discharged from an urban teaching hospital. Women with MG were also more likely to have chronic hypertension, pre-gestational diabetes, hypothyroidism, and chronic steroid use. Women with MG were at greater risk for acute respiratory failure (OR 13.7, 95% CI 8.9-21.2) and increased length of hospital stay (OR 2.5, 95% CI 1.9-3.3). No significant difference was observed in the risk of preterm premature rupture of membranes, caesarean section or instrumental vaginal delivery. Neonates of women with MG were more likely to be premature (OR 1.4, 95% CI 1.2-1.8). Conclusions MG in pregnancy is a high-risk condition associated with greater risk of maternal respiratory failure and preterm birth. Management in a tertiary care center with obstetrical, neurological, anesthesia and neonatology collaboration is recommended.
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Affiliation(s)
- Laura Nicholls-Dempsey
- Department of Obstetrics and Gynecology, Jewish General Hospital, McGill University, Montreal, QC, Canada
| | - Nicholas Czuzoj-Shulman
- Center for Clinical Epidemiology and Community Studies, Jewish General Hospital, Montreal, QC, Canada
| | - Haim Arie Abenhaim
- Department of Obstetrics and Gynecology, Jewish General Hospital, McGill University, Montreal, QC, Canada.,Center for Clinical Epidemiology and Community Studies, Jewish General Hospital, Montreal, QC, Canada
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Case Report: Ocular Myasthenia Gravis Associated with In Vitro Fertilization Procedures. Optom Vis Sci 2019; 95:475-478. [PMID: 29683988 DOI: 10.1097/opx.0000000000001217] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
SIGNIFICANCE Ocular myasthenia gravis is a localized form of myasthenia gravis, which is a postsynaptic disorder of the neuromuscular junction that causes fluctuating weakness of extraocular muscles resulting from autoimmune mechanisms. In women with myasthenia, changes in sex hormone levels and administration of corticosteroids can trigger or worsen symptoms of myasthenia gravis. PURPOSE To describe a case of seronegative ocular myasthenia gravis whose first symptom appeared a day after in vitro fertilization procedure. CASE REPORT A 37-year-old woman suddenly developed mild ptosis and fluctuating diplopia that worsened in the evening. Before the development of symptoms, she had undergone in vitro fertilization procedure and had taken oral steroids. Ocular motility examination revealed an intermittent exotropia in primary gaze at both distance and near. The neostigmine test confirmed her diagnosis as ocular myasthenia gravis. CONCLUSIONS When taking a history for young women with sudden onset of binocular diplopia, steroids and sex hormones should be taken into account, which may trigger or exacerbate symptoms of ocular myasthenia gravis.
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Abstract
The management of myasthenia gravis (MG) during pregnancy requires special skills as both diseases as well as its treatment can have deleterious effects on mother and fetus. MG often affects women in second and third decades of life during the childbearing age. Exacerbations of MG are likely to occur during the first trimester and postpartum period. The treatment of MG during pregnancy needs to be individualized depending on the severity of MG as well as the efficacy of various treatment modalities and their possible harmful effects on pregnancy. In addition, special attention has to be given to avoid drugs and other factors (such as urinary tract infections) which may worsen MG. The key to successful outcome during pregnancy in myasthenic women lies in multidisciplinary care involving obstetricians, neurologists, anesthetist as well as neonatologist. In this review, we discuss various therapeutic options available for the management of MG during pregnancy and provide recommendations based on the current best evidence.
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Affiliation(s)
| | - Manoj Kumar Goyal
- Department of Neurology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Manish Modi
- Department of Neurology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Shi B, Zeng L. Management of Myasthenia Gravis During Pregnancy: A Report of Eight Cases. Open Life Sci 2018; 13:28-33. [PMID: 33817064 PMCID: PMC7874682 DOI: 10.1515/biol-2018-0004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Accepted: 01/08/2018] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND The clinical course of myasthenia gravis (MG) during pregnancy is highly variable and unpredictable. The management of MG in pregnancy has not been standardized. METHODS Eight cases of MG in pregnancy, who were treated and gave birth in our hospital between 2004 and 2012, were retrospectively reviewed. RESULTS In three patients, MG deteriorated during pregnancy. Three patients discontinued their medication for MG during their pregnancy, and the other five patients continued on corticosteroid or pyridostigmine. None of the infants showed any congenital abnormalities. Interestingly, there was a trend towards lower birth weight in infants born to women who had an exacerbation of MG during pregnancy. One patient who had unstable MG before pregnancy and voluntarily discontinued the medication for MG at the beginning of pregnancy, experienced MG exacerbation at the 30th week of pregnancy and gave birth prematurely to an infant with transient neonatal MG at the 34th week. The other seven patients had uneventful full-term pregnancy. CONCLUSION Women with unstable MG should postpone pregnancy to avoid potential risk of MG exacerbation and adverse effects on the fetus. Medication for MG should not be stopped abruptly during pregnancy, particularly for women with unstable MG. MG during pregnancy should be closely monitored and properly controlled.
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Affiliation(s)
- Beibei Shi
- Department of Gynecology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou325027, China
| | - Linchai Zeng
- Department of Gynecology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou325027, China
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Gamez J, Salvado M, Casellas M, Manrique S, Castillo F. Intravenous immunoglobulin as monotherapy for myasthenia gravis during pregnancy. J Neurol Sci 2017; 383:118-122. [PMID: 29246598 DOI: 10.1016/j.jns.2017.10.037] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Revised: 10/04/2017] [Accepted: 10/24/2017] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Pregnant women with myasthenia gravis (MG) are at increased risk of complications and adverse outcomes, including the teratogenic effects of many drugs used to treat MG women of childbearing age. The effectiveness of intravenous immunoglobulins (IVIg) on other autoimmune mediated diseases has been extensively reported in recent years, although little is known about the role of IVIg in the treatment of MG during pregnancy. We designed this study to determine the effectiveness of IVIg as monotherapy during pregnancy for women with MG. MATERIAL AND METHODS Five pregnant MG patients (mean age at delivery 36.4years, SD 5.8, range 29.4-45.2) were studied in 2013-14. Their treatment was switched to monthly IVIg cycles 2months before the pregnancy. Follow-up included monthly neurological QMG throughout the pregnancy and postpartum, obstetrical monitoring during monthly visits in the first two trimesters of the pregnancy, fortnightly visits between week 32 and week 36, and weekly visits after 36weeks, and neonatal follow-up after delivery. RESULTS We observed no exacerbations during pregnancy, delivery or post-partum. The mean QMG score at baseline (before pregnancy) was 7.4 points in five women with generalized forms of MG. The maximum mean value reached during pregnancy was 8.6 points. The mean pregnancy duration was 38 w+5 d. No infant with transient neonatal myasthenia gravis. CONCLUSIONS These results suggest that monotherapy with IVIg during pregnancy in MG patients could be promising, although confirmation is required in studies with larger populations.
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Affiliation(s)
- Josep Gamez
- Myasthenia Gravis Unit, Neurology Department, Vall d'Hebron University Hospital, VHIR, European Reference Network on Rare Neuromuscular Diseases (ERN EURO-NMD), Department of Medicine, UAB, Barcelona, Spain.
| | - Maria Salvado
- Myasthenia Gravis Unit, Neurology Department, Vall d'Hebron University Hospital, VHIR, European Reference Network on Rare Neuromuscular Diseases (ERN EURO-NMD), Department of Medicine, UAB, Barcelona, Spain
| | - Manel Casellas
- Myasthenia Gravis Unit, Obstetrics Department, Vall d'Hebron University Hospital, Autonomous University of Barcelona, Barcelona, Spain
| | - Susana Manrique
- Myasthenia Gravis Unit, Anesthetics Department, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Felix Castillo
- Myasthenia Gravis Unit, Neonatology Department, Vall d'Hebron University Hospital, Barcelona, Spain
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Soyoral L, Goktas U, Cegin MB, Baydi V. O uso bem‐sucedido de sugamadex para cesariana em paciente com miastenia grave. Braz J Anesthesiol 2017; 67:221-222. [DOI: 10.1016/j.bjan.2016.12.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Accepted: 08/07/2014] [Indexed: 10/20/2022] Open
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Doden T, Sekijima Y, Ikeda J, Ozawa K, Ohashi N, Kodaira M, Hineno A, Tachibana N, Ikeda SI. Postpartum Anti-N-methyl-D-aspartate Receptor Encephalitis: A Case Report and Literature Review. Intern Med 2017; 56:357-362. [PMID: 28154283 PMCID: PMC5348463 DOI: 10.2169/internalmedicine.56.7442] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
We describe a 24-year-old woman with anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis that developed 3 weeks after normal delivery. She was treated with methylprednisolone, intravenous immunoglobulin, and plasmapheresis, in addition to teratoma excision. However, her recovery was slow, and dysmnesia and mental juvenility persisted even two years after onset. To date, five patients with postpartum anti-NMDAR encephalitis have been reported. All of those patients showed psychotic symptoms and were suspected of having postpartum psychosis in the early period of the encephalitis. Changes in hormonal factors, modification of immune tolerance, or retrograde infection of the ovary may be contributing factors for postpartum anti-NMDAR encephalitis.
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Affiliation(s)
- Tadashi Doden
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Japan
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Huang Y, Wang Y, Zhou Y, Huang Q, Sun X, Chen C, Fang L, Long Y, Yang H, Wang H, Li C, Lu Z, Hu X, Kermode AG, Qiu W. Pregnancy in neuromyelitis optica spectrum disorder: A multicenter study from South China. J Neurol Sci 2016; 372:152-156. [PMID: 28017203 DOI: 10.1016/j.jns.2016.11.054] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2016] [Revised: 11/09/2016] [Accepted: 11/21/2016] [Indexed: 12/18/2022]
Abstract
OBJECTIVE This study aimed to assess the effect of pregnancy on the course of neuromyelitis optica spectrum disorder (NMOSD), and the effect of this disease on pregnancy outcomes. METHODS Consecutive patients with NMOSD were recruited between September 2015 and April 2016 at an outpatient clinic from four referral institutes in South China. Demographic, clinical, and pregnancy data were retrieved by questionnaires to analyze the association between NMOSD and pregnancy, as well as the potential risk factors for relapse. RESULTS Among 249 patients with NMOSD, 55 had pregnancy-related attacks. The annual relapse rate in the first (3.20±6.82) and second (3.25±3.32) 3-month postpartum periods was marginally higher than that before pregnancy (1.44±0.92, p=0.682) and during pregnancy (1.23±1.32, p=0.758). The Kurtzke Expanded Disability Status Scale score increased from 1.55±0.38 before pregnancy to 2.88±2.14 at postpartum (p<0.001). NMOSD significantly increased the premature birth rate in patients after disease onset (8.33%) compared with before disease onset (1.95%, p=0.025). Multivariate analysis showed that negative anti-aquaporin-4 IgG, concomitance with autoimmune diseases/antibodies, and no treatment in remission were risk factors of recurrence. CONCLUSION Our study shows a significant association between pregnancy and NMOSD in the Chinese population. Larger scale prospective studies are warranted in the future.
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Affiliation(s)
- Yanlu Huang
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Yuge Wang
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Yifan Zhou
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Qiao Huang
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China; Department of Neurology, Zhaoqing No. 2 People's Hospital, Guangzhou, China
| | - Xiaobo Sun
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Chen Chen
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Ling Fang
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Youming Long
- Department of Neurology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Hui Yang
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Honghao Wang
- Department of Neurology, Nanfang Hospital of Nanfang Medical University, Guangzhou, China
| | - Caixia Li
- School of Mathematics and Computational Science, Sun Yat-sen University, Guangzhou, China
| | - Zhengqi Lu
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Xueqiang Hu
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Allan G Kermode
- Centre for Neuromuscular and Neurological Disorders, University of Western Australia, Department of Neurology, Sir Charles Gairdner Hospital, Queen Elizabeth II Medical Centre, Perth, Australia; Institute of Immunology and Infectious Diseases, Murdoch University, Perth, Australia
| | - Wei Qiu
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.
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Affiliation(s)
- Yuko Shimizu
- Department of Neurology; Tokyo Women's Medical University School of Medicine; Tokyo Japan
| | - Kazuo Kitagawa
- Department of Neurology; Tokyo Women's Medical University School of Medicine; Tokyo Japan
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Sikka P, Joshi B, Aggarwal N, Suri V, Bhagat H. Distinguishing Myasthenia Exacerbation from Severe Preeclampsia: A Diagnostic and Therapeutic Challenge. J Clin Diagn Res 2015; 9:QD05-6. [PMID: 26436003 DOI: 10.7860/jcdr/2015/12789.6357] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2015] [Accepted: 06/12/2015] [Indexed: 11/24/2022]
Abstract
Myasthenia gravis is an acquired, autoimmune neuromuscular disorder characterized by voluntary muscle weakness. Pregnant patients may have disease exacerbation, respiratory failure, crisis, adverse drug reaction, surprisingly enough remission at any trimester or postnatal period. Concurrence of myasthenia gravis with severe preeclampsia is a dreadful condition raising diagnostic and management issues. We hereby discuss a case of myasthenic woman who developed severe preeclampsia during pregnancy and presented in last trimester with clinical features mimicking signs of impending eclampsia. Keeping in mind the history of myasthenia gravis, urgent neurology review taken and diagnosis of myasthenic exacerbation was entertained. She responded well to injection neostigmine and in this way inadvertent use of magnesium sulphate was avoided.
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Affiliation(s)
- Pooja Sikka
- Assistant Professor, Department of Obstetrics and Gynaecology, PGIMER , Chandigarh, India
| | - Bharti Joshi
- Research Officer, Department of Obstetrics and Gynaecology, PGIMER , Chandigarh, India
| | - Neelam Aggarwal
- Associate Professor, Department of Obstetrics and Gynaecology, PGIMER , Chandigarh, India
| | - Vanita Suri
- Professor, Department of Obstetrics and Gynaecology, PGIMER , Chandigarh, India
| | - Hement Bhagat
- Associate Professor, Department of Obstetrics and Gynaecology, PGIMER , Chandigarh, India
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Neves AR, Monteiro P, Matos A, Santos Silva I. Anti-MuSK-positive myasthenia gravis diagnosed during pregnancy: new challenges for an old disease? BMJ Case Rep 2015; 2015:bcr-2014-207708. [PMID: 25564591 DOI: 10.1136/bcr-2014-207708] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Myasthenia gravis is an autoimmune disorder affecting predominantly women in their reproductive age. The course of the disease during pregnancy is unpredictable, although it is more difficult to manage earlier in the gestation. Myasthenia gravis with antibodies against the muscle-specific receptor tyrosine kinase (anti-MuSK) has been described as a subtype of disease with more localised clinical features and a poorer response to treatment than acetylcholine receptor antibody (anti-AChR)-positive patients. Few cases have been reported in pregnant women, with deliveries being performed mainly by caesarean section. We report a successful case of vaginal delivery and describe our experience providing the first review of the management of this subtype of disease during pregnancy.
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Affiliation(s)
- Ana Raquel Neves
- Department of Obstetrics B, Maternidade Bissaya Barreto-Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Pitorra Monteiro
- Department of Obstetrics B, Maternidade Bissaya Barreto-Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Anabela Matos
- Department of Neurology, Centro Hospitalar Universitário de Coimbra, Coimbra, Portugal
| | - Isabel Santos Silva
- Department of Obstetrics B, Maternidade Bissaya Barreto-Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
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Soyoral L, Goktas U, Cegin MB, Baydi V. Successful use of sugammadex for caesarean section in a patient with myasthenia gravis. Braz J Anesthesiol 2014; 67:221-222. [PMID: 28236874 DOI: 10.1016/j.bjane.2014.08.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Accepted: 08/07/2014] [Indexed: 10/24/2022] Open
Abstract
Myasthenia gravis is an autoimmune disorder that is characterized by muscle weakness that fluctuates, worsening with exertion, and improving with rest. Diagnosis of myasthenia gravis is made following clinical and physical examination and is confirmed by serum immunoassays to measure autoantibody levels. Myasthenia gravis especially when associated with pregnancy is a high-risk disease, and its course is unpredictable. We described the second report about use of sugammadex after rocuronium for a caesarean delivery with myasthenia gravis, but, unlike our case that formerly was diagnosed with myasthenia gravis, the patient was extubated on postoperative successfully and we did not encounter any respiratory problems.
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Affiliation(s)
- Lokman Soyoral
- Yuzuncu Yil University, Faculty of Medicine, Department of Anaesthesiology and Reanimation, Van, Turkey
| | - Ugur Goktas
- Yuzuncu Yil University, Faculty of Medicine, Department of Anaesthesiology and Reanimation, Van, Turkey.
| | - Muhammed Bilal Cegin
- Yuzuncu Yil University, Faculty of Medicine, Department of Anaesthesiology and Reanimation, Van, Turkey
| | - Volkan Baydi
- Yuzuncu Yil University, Faculty of Medicine, Department of Anaesthesiology and Reanimation, Van, Turkey
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Cheung KW, Shek NWM, Chan KH. An unusual cause of postpartum collapse: undiagnosed myasthenia gravis. J OBSTET GYNAECOL 2014; 33:528-9. [PMID: 23815217 DOI: 10.3109/01443615.2013.782274] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- K W Cheung
- Department of Obstetrics and Gynaecology, Queen Mary Hospital, University of Hong Kong, Hong Kong SAR, China.
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Haider B, von Oertzen J. Neurological disorders. Best Pract Res Clin Obstet Gynaecol 2013; 27:867-75. [DOI: 10.1016/j.bpobgyn.2013.07.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2013] [Accepted: 07/25/2013] [Indexed: 10/26/2022]
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Ankola A, Sulica L, Murry T. Laryngeal dystonia gravidarum: Sudden onset of adductor spasmodic dysphonia in pregnancy. Laryngoscope 2013; 123:3127-30. [DOI: 10.1002/lary.24225] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2013] [Revised: 05/03/2013] [Accepted: 05/03/2013] [Indexed: 11/09/2022]
Affiliation(s)
- Ashish Ankola
- Albert Einstein College of Medicine, Bronx; New York U.S.A
| | - Lucian Sulica
- Department of Otolaryngology-Head and Neck Surgery; Weill Cornell Medical College; New York New York
| | - Thomas Murry
- Department of Otolaryngology-Head and Neck Surgery; Weill Cornell Medical College; New York New York
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Pregnancy in congenital myasthenic syndrome. J Neurol 2012; 260:815-9. [DOI: 10.1007/s00415-012-6709-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2012] [Revised: 09/12/2012] [Accepted: 10/08/2012] [Indexed: 10/27/2022]
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Pal J, Rozsa C, Komoly S, Illes Z. Clinical and biological heterogeneity of autoimmune myasthenia gravis. J Neuroimmunol 2011; 231:43-54. [DOI: 10.1016/j.jneuroim.2010.10.020] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Mays J, Butts CL. Intercommunication between the neuroendocrine and immune systems: focus on myasthenia gravis. Neuroimmunomodulation 2011; 18:320-7. [PMID: 21952684 PMCID: PMC3221261 DOI: 10.1159/000329491] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Crosstalk exists between the nervous, endocrine, and immune systems, and perturbations in these interactions have been associated with disease. This includes production of neuroendocrine factors that alter immune system activity and increase susceptibility to or severity of immune-related conditions, such as myasthenia gravis (MG)--a T-cell-dependent, B-cell-mediated autoimmune disorder. MG results from impairment of transmission to the neuromuscular junction and involves the thymus--especially in early-onset disease, but the exact mechanism by which the thymus impacts disease is unclear. MG afflicts millions of individuals worldwide each year, and both men and women can develop symptoms. However, prevalence and age of onset differs between men and women. Women exhibit higher incidence and earlier age of onset compared to men, and disease fluctuates during pregnancy. This suggests that sex hormones play a role in influencing disease outcome. In this review, we will consider what is known about the manifestation of MG, theories on how different forms of MG are influenced or alleviated by steroid hormones, current treatment options, and what measures could be important to consider in the future.
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Affiliation(s)
- Jacqueline Mays
- Laboratory of Viral Diseases, National Institute of Allergy and Infectious Diseases/National Institutes of Health, US Food and Drug Administration, Bethesda, Md., USA
| | - Cherié L. Butts
- Laboratory of Immunology, Division of Therapeutic Proteins, Office of Biotechnology Products, Center for Drug Evaluation and Research, US Food and Drug Administration, Bethesda, Md., USA
- *Cherie Butts, Laboratory of Immunology, Division of Therapeutic Proteins, Office of Biotechnology Products, Center for Drug Evaluation and Research, US Food and Drug Administration, 8800 Rockville Pike (HFD-122), Building 29A, Room 3B19, Bethesda, MD 20892 (USA), Tel. +1 301 827 1843, E-Mail
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Bayrak AO, Sandikci U, Yon SK, Onar MK. Manifestation of Lambert-Eaton myasthenic syndrome during last trimester of pregnancy. Int J Neurosci 2010; 120:439-41. [PMID: 20504215 DOI: 10.3109/00207451003721900] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Lambert-Eaton myasthenic syndrome (LEMS) is a rare immune-mediated disorder of neuromuscular junctions. The knowledge of the effects of pregnancy on the course of patients with LEMS is limited. Here we describe a patient without a history of previous known illness who has complained of weakness during the last trimester of her pregnancy, delivered a healthy baby and was diagnosed with non-paraneoplastic LEMS during the postpartum period. With this case we wanted to emphasize the effects of pregnancy on the course of patients with LEMS.
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Affiliation(s)
- Ayse Oytun Bayrak
- Department of Neurology, Faculty of Medicine, Ondokuzmayis University, Samsun, Turkey.
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Pénisson-Besnier I. Traitement de la myasthénie auto-immune. Rev Neurol (Paris) 2010; 166:400-5. [DOI: 10.1016/j.neurol.2009.09.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2009] [Revised: 05/22/2009] [Accepted: 08/03/2009] [Indexed: 11/16/2022]
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Abstract
PURPOSE OF REVIEW To review some management issues in myasthenic disorders that are not part of the immune interventions. These are mainly related to pharmacotherapy of these conditions and side effects of various medications, but also referred to acute management of respiration in myasthenic crises. RECENT FINDINGS Antisense compound inhibiting acetylcholine esterase has positive therapeutic effects during short-term administration, but further studies are needed to confirm its chronic effects. Pyridostigmine seems not to have an additional effect to 3-4 diaminopyridine in Lambert Eaton myasthenic syndrome. Bilevel positive airway pressure and other external respiratory supportive systems may prevent in some myasthenic crises the need for intubation or at least shorten it. Statins can aggravate myasthenia gravis but the risk is not well quantified, and these compounds are not completely contraindicated in myasthenia. SUMMARY Further research of the above findings is still necessary to make them a solid conclusion for the management of the myasthenias.
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Díaz-Manera J, Rojas-García R, Illa I. Treatment strategies for myasthenia gravis. Expert Opin Pharmacother 2009; 10:1329-42. [DOI: 10.1517/14656560902950619] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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