Retrospective evaluation of pregnancy outcomes in women with familial Mediterranean fever

First-trimester neutrophil-to-lymphocyte ratio (NLR), systemic immune-inflammation index (SII), and systemic immune-response index (SIRI) as predictors of composite adverse outcomes in pregnant women with Familial Mediterranean fever

OBJECTIVE

To evaluate the utility of the neutrophil-to-lymphocyte ratio (NLR), systemic immune-inflammation index (SII), and systemic immune-response index (SIRI) in the prediction of adverse pregnancy outcomes in pregnant women with Familial Mediterranean fever (FMF) MATERIAL AND METHODS: This retrospective case-control study was conducted between 2019-2023. First-trimester NLR, SII (NLR X platelet count), and SIRI (NLR X monocyte count) values were compared between pregnant women with FMF (n=85) and without FMF (n=105). Thereafter, pregnant women with FMF were divided into two groups: 1) FMF with perinatal complications (n=30), and 2) FMF without perinatal complications (n=55). NLR, SII, and SIRI values were compared between the two subgroups. Finally, an ROC analysis was performed to determine optimal cut-off values for NLR, SII, and SIRI in the prediction of composite adverse pregnancy outcomes.

RESULTS

The FMF group had significantly higher first-trimester NLR, SII, and SIRI values compared to the controls. The FMF with perinatal complications group had significantly higher NLR, SII, and SIRI values than the FMF group without perinatal complications (p<0.05). Optimal cut-off values were 4.89 (80% sensitivity, 78.2% specificity), 1180.6 (76.7% sensitivity, 72.7% specificity), and 1.9 (83.3% sensitivity,72.7% specificity) for NLR, SII, and SIRI, respectively.

CONCLUSION

SII, SIRI, and NLR may be used to predict adverse pregnancy outcomes in pregnant women with FMF.

Fertilization, reproductive system, and pregnancy in familial Mediterranean fever: Clinical state of art

Systemic autoinflammatory diseases have always been one of the most striking and challenging aspects of the art of medicine. Among this fascinating constellation of diseases, familial Mediterranean fever (FMF) is the most common. FMF involves the reproductive system and may cause fertility problems. With the start of the interleukin (IL)-1 inhibitors era, there is a need to reorganize our knowledge on FMF management, particularly in pregnant patients and those experiencing fertilization problems. The primary aim of this review is to gather recent information on the effects of FMF on fertilization and the reproductive system, as well as to shed light on the management of pregnancy in FMF patients.

Pregnancy outcomes in patients with familial Mediterranean fever: systematic review and meta-analysis

OBJECTIVE

The relationship between FMF and pregnancy outcomes remains unclear. This systematic review and meta-analysis aimed to clarify this association.

METHODS

Electronic databases-PubMed, Web of Science, Cochrane, and EMBASE-were searched on 20 December 2022, using specific search terms. Case-control, cohort, and randomized clinical trial studies comparing patients with FMF and healthy controls were considered eligible. We excluded systematic reviews, meta-analyses, case series with fewer than five cases, republished articles without new findings on pregnancy outcomes, studies targeting paternal FMF, and those not published in English. The results were summarized in the form of odds ratios (ORs) and 95% CIs, using a random-effects model. This study was registered in the University hospital Medical Information Network Clinical Trials Registry (Japan) as UMIN000049827.

RESULTS

The initial electronic search identified 611 records, of which 9 were included in this meta-analysis (177 735 pregnancies, 1242 with FMF, and 176 493 healthy controls). FMF was significantly associated with increased odds of preterm deliveries (OR, 1.67; 95% CI, 1.05-2.67; I2 = 22%) and insignificantly associated with increased odds of fetal growth restriction (OR, 1.45; 95% CI, 0.90-2.34; I2 = 0%) and hypertensive disorders during pregnancy (OR, 1.28; 95% CI, 0.87-1.87; I2 = 0%).

CONCLUSION

FMF was significantly associated with preterm delivery and insignificantly associated with fetal growth restriction and hypertensive disorders. All of the included studies were observational studies. Treatment characteristics were not fully collected from the articles, and further analysis of treatments for FMF in pregnancy is still warranted.

Perinatal outcomes and long-term infectious morbidity of offspring born to mothers with familial Mediterranean fever

PURPOSE

To investigate perinatal outcomes and long-term infectious morbidity in children of mothers with familial Mediterranean fever (FMF).

METHODS

A population-based cohort study comparing perinatal outcomes and long-term infectious morbidity of offspring of mothers with and without FMF was conducted. All singleton deliveries between the years 1991-2021 in a tertiary medical center were included. The study groups were followed until 18 years of age for long-term infectious morbidity. A Kaplan-Meier survival curve was used to compare the cumulative incidence of long-term infectious morbidity, and generalized estimation equation (GEE) models as well as Cox proportional hazards models were constructed to control for confounders.

RESULTS

During the study period, 356,356 deliveries met the inclusion criteria. 411 of them were women with FMF. The mean follow-up period interval was 9.7 years (SD = 6.2) in both study groups. Using GEE models, preterm delivery, cesarean delivery, and low birth weight were independently associated with maternal FMF. The total infectious-related hospitalization rate was significantly higher in offspring born to mothers with FMF compared to the comparison group (Kaplan-Meier survival curve, log-rank p < 0.001). Using a Cox proportional hazards model, controlling for gestational age, maternal age, diabetes mellitus, cesarean delivery, and hypertensive disorders, being born to a mother with FMF was found to be an independent risk factor for long-term infection-related hospitalization of the offspring.

CONCLUSION

Maternal FMF was found to be independently associated with long-term infection-related hospitalization of the offspring. This positive correlation may reflect an intra-uterine pro-inflammatory environment which may result in the offspring's long-term susceptibility to infection.

First and second-trimester biochemical serum markers in maternal familial Mediterranean fever: The impact of colchicine use

INTRODUCTION

We aimed to investigate the effects of colchicine use on first and second trimester screening markers in pregnancies complicated with familial Mediterranean fever (FMF) and to evaluate the overall impact of these effects on perinatal outcomes.

METHODS

A retrospective case-control study was conducted in pregnancies complicated with FMF using colchicine and healthy pregnancies as controls without any defined risk factors and medication use. Biochemical markers for the aneuploidy screening, including free ß-hCG and PAPP-A in the first trimester, and AFP, HCG, and unconjugated estriol (uE3) in the second trimester, were recorded, and MoM levels of these markers were compared between the FMF and control groups. Obstetric history and outcomes were also compared between groups. We used propensity score matching to form a cohort in which patients had similar baseline characteristics.

RESULTS

Among 93 eligible pregnant women, 31 women in FMF group and 31 in control group had similar propensity scores and were included in the analyses. Levels of serum-free ß-hCG, PAPP-A and AFP were similar between FMF and control groups (p = 0.671, p = 0.387 and p = 0.963, respectively). For the second-trimester markers, maternal serum uE3 MoM level were significantly lower in the FMF group using colchicine than in the controls (p = 0.045). We also compared these markers according to the daily colchicine dose between FMF subgroups. We did not detect significant difference between the different colchicine treatment modalities (0.5-1 mg/day vs. 1.5-2 mg/day, p > 0.05).

CONCLUSION

Maternal biochemical serum markers of an aneuploidy screening test in the second trimester may be affected by FMF with colchicine use, leading to misinterpretation of the risk level of tests. For these tests with decreased uE3 levels, FMF and colchicine use should be considered as a causative etiology after ruling out common etiologies and confounding factors before recommending invasive diagnostic testing.

Familial Mediterranean fever: perspective on female fertility and disease course in pregnancy from a multicenter nationwide network

The aim of this study was to analyze the pregnancy process, especially the Familial Mediterranean fever (FMF) disease course and attack types during pregnancy, and to examine the relationship between disease-related factors and female infertility in FMF patients. The study, which was planned in a multicenter national network, included 643 female patients. 435 female patients who had regular sexual intercourse were questioned in terms of infertility. Pregnancy and delivery history, FMF disease severity and course during pregnancy were evaluated. The relationship between demographic and clinical findings, disease severity, genetic analysis results and infertility was investigated. 401 patients had at least 1 pregnancy and 34 patients were diagnosed with infertility. 154 patients had an attack during pregnancy. 61.6% of them reported that attacks during pregnancy were similar to those when they were not pregnant. The most common attack symptoms were fever, fatigue and abdominal pain-peritonitis (96%, 87%, and 83%, respectively) in the pregnancy period. The disease-onset age, disease activity score, gene mutation analyses, and regular colchicine use (> 90%) were similar between the fertile and infertile groups, while the frequency of previous appendectomy and alcohol consumption rates were higher in individuals with infertility. Our results indicated no significant change in the frequency and severity of attacks during pregnancy. The low rate of infertility (7.8%) in our patients was noted. It has been suggested that the risk of FMF-related infertility may not be as high as thought in patients who are followed up regularly and received colchicine.

Evaluation of fetal cardiac morphology and functions in pregnant women with familial Mediterranean fever

OBJECTIVE

We aimed to evaluate and compare fetal cardiac morphology and functions of pregnant women with familial Mediterranean fever (FMF) and healthy pregnant women.

METHODS

The study included 34 pregnant women with FMF and 68 healthy pregnant women matched with maternal age, gravidity, parity, gestational age, and pre-pregnancy body mass index (BMI) in 34th-37th gestational weeks. Fetal echocardiographic evaluation was performed with two-dimensional (2D) imaging, M-mode imaging, pulsed wave (PW) Doppler, and tissue Doppler imaging (TDI).

RESULTS

Fetal cardiac morphological measures, including cardiothoracic ratio, cardiac axis angle, right and left ventricular area, sphericity index, and ventricular septal thickness was similar in both groups. Compared with the control group, myocardial performance index (MPI), which indicates global myocardial performance, was significantly higher, and ejection time (ET) was significantly shortened in the FMF group. In addition, which shows the diastolic functional parameters such as, tricuspid E wave, E/A, E/E' ratio, and mitral E wave, E/A, E/E' ratio, were significantly higher; tricuspid A and mitral A waves were significantly lower. We found that mitral and tricuspid annular plane systolic excursion (MAPSE and TAPSE) were significantly lower in those with FMF duration over eight years than those with FMF duration less than 8 years.

CONCLUSION

There is no fetal cardiac morphological change in pregnant women with FMF. However, there may be changes in diastolic function. As the maternal FMF duration increases, systolic functions may also change.

A Systematic Review of the Safety of Blocking the IL-1 System in Human Pregnancy

Blockade of the interleukin-1 (IL-1) pathway has been used therapeutically in several inflammatory diseases including arthritis and cryopyrin-associated periodic syndrome (CAPS). These conditions frequently affect women of childbearing age and continued usage of IL-1 specific treatments throughout pregnancy has been reported. IL-1 is involved in pregnancy complications and its blockade could have therapeutic potential. We systematically reviewed all reported cases of IL-1 blockade in human pregnancy to assess safety and perinatal outcomes. We searched several databases to find reports of specific blockade of the IL-1 pathway at any stage of pregnancy, excluding broad spectrum or non-specific anti-inflammatory intervention. Our literature search generated 2439 references of which 22 studies included, following extensive review. From these, 88 different pregnancies were assessed. Most (64.8%) resulted in healthy term deliveries without any obstetrical/neonatal complications. Including pregnancy exposed to Anakinra or Canakinumab, 12 (15.0%) resulted in preterm birth and one stillbirth occurred. Regarding neonatal complications, 2 cases of renal agenesis (2.5%) were observed, and 6 infants were diagnosed with CAPS (7.5%). In conclusion, this systematic review describes that IL-1 blockade during pregnancy is not associated with increased adverse perinatal outcomes, considering that treated women all presented an inflammatory disease associated with elevated risk of pregnancy complications.

[New aspects of rare rheumatic diseases during pregnancy]

For some rare rheumatic diseases the data situation on fertility and pregnancy is still scant. This article attempts to present the data known so far and to derive and supplement some treatment recommendations from the data. A stable disease situation before the pregnancy drastically reduces the risk of complications for mother and child; therefore, an appropriate and timely adjustment of treatment in consultation with patients and gynecologists is important.

Infertility Causes and Pregnancy Outcome in Patients With Familial Mediterranean Fever and Controls

OBJECTIVE

Recurrent attacks of peritonitis due to familial Mediterranean fever (FMF) may lead to peritoneal adhesions and fallopian tube obstruction. Colchicine, which is the treatment of choice for FMF, may disturb cell division. Secondary amyloidosis, a complication of untreated FMF, may involve the testes and ovaries. Thus, FMF and colchicine may potentially affect fertility and pregnancy in patients with FMF. The aims of the study are to evaluate the causes of infertility and pregnancy outcome in FMF patients and to compare them with 2 groups: non-FMF patients with peritoneal female genital tuberculosis (FGTB) and normal healthy controls.

METHODS

This is a retrospective study in which FMF patients with reproductive disorders were recruited from the National Center of Medical Genetics and Primary Health Care in Yerevan, Armenia. The patients with FGTB and the healthy controls with reproductive problems were recruited successively from a large gynecology clinic in Yerevan. Genetic analyses for FMF were performed using ViennaLab StripAssay.

RESULTS

The FMF group (211 patients) resembles the FGTB group (127 patients) regarding etiologies of infertility. However, in vitro fertilization (IVF) success rate and pregnancy outcome were comparable between the FMF patients and the control group (162 patients). Infertility in patients with FMF was clearly associated with a more severe disease and a lack of adequate colchicine treatment.

CONCLUSIONS

Colchicine medication and controlled FMF disease do not adversely affect the reproductive system and pregnancy outcome. However, a lack of an appropriate colchicine treatment may cause infertility and poor pregnancy outcome.

Association between basal proteinuria levels and pregnancy outcomes in familial Mediterranean fever

We aimed to investigate whether proteinuria in the first trimester of pregnancy in Familial Mediterranean fever (FMF) patients has an impact on pregnancy outcome and perinatal and neonatal outcome of pregnancies. A total of 66 pregnant with FMF were compared with healthy controls at the same gestational weeks. Patients with FMF had a higher antenatal hospitalisation rate (34.8% vs. 6.1%, respectively, p < .01) and higher rate of 2 or more miscarriages. FMF patients with or without obstetric complications also had a similar amount of 24-h urine proteinuria in the first trimester. Patients on colchicine therapy during pregnancy had more frequent attacks in pregnancy (59.3% vs. 18.2%, respectively, p: .012). The rates of preeclampsia, preterm delivery, foetal anomalies, small for gestation age neonates and primary caesarean rate were similar between groups. In conclusion; FMF had no significant impact on pregnancy. Neither attacks in pregnancy nor basal proteinuria were associated with adverse outcomes.Impact statementWhat is already known on this subject? Familial Mediterranean fever (FMF) is an autosomal recessive disease characterised by inflammation of the serosal, synovial and cutaneous tissues with recurrent attacks. One of the most serious complications of FMF is amyloidosis that can cause end-stage renal disease. Outcomes of FMF on pregnancy have been analysed by only few studies. Amyloidosis based on the initial renal function may adversely affect pregnancies. It has been reported that FMF patients with renal amyloidosis may suffer pregnancy complications to a greater extent.What do the results of this study add? There have been few studies on the correlation between FMF, proteinuria and pregnancy outcomes. In our study we found that FMF had no significant impact on pregnancy. Neither attacks in pregnancy nor basal proteinuria were associated with adverse outcomes.What are the implications of these findings for clinical practice and/or further research? Our study suggested that FMF had no relationship between pregnancy outcomes. However, our study population is relatively small. It will contribute to comprehensive studies involving a larger population. Future studies should be performed to investigate the effects of basal proteinuria in pregnancy with FMF.

[IL-1-blockade with Anakinra during pregnancy : Retrospective analysis of efficacy and safety in female patients with familial Mediterranean fever]

OBJECTIVE

To retrospectively assess and analyze the clinical efficacy and safety of off-label interleukin-1 (IL-1) blockade with anakinra during pregnancy of patients with familial Mediterranean fever (FMF).

METHODS

Retrospective analysis of clinical and laboratory parameters making use of an electronic database system. Detailed descriptions of the genotype and phenotype of FMF are given and the course of the pregnancy and fetal development are reported.

RESULTS

The data of three patients and a total of four pregnancies under treatedment with anakinra were analyzed. All patients were of Mediterranean origin, fulfilled the Tel Hashomer criteria for diagnosis of FMF and had a confirmed mutation in the MEFV gene. In all patients, treatment with anakinra was initiated due to an insufficient treatment response to colchicine. Anakinra led to a rapid response in all patients. In three pregnancies anakinra treatment was continued during the whole pregnancy, while in one pregnancy anakinra was started in the second trimester because of uncontrolled FMF activity. Fetal development was normal in all pregnancies. In two patients the fetuses were carried to term, while in one patient a primary cesarean section was carried out in week 33 because of an increased risk for complications. All children showed an unremarkable early childhood development without any signs of an existing disease.

CONCLUSION

The data of our retrospective analysis suggest that IL-1-blockade by anakinra is an effective and safe treatment in pregnant women suffering from FMF, which can reliably prevent disease flares. In the four pregnancies presented the use of anakinra did not result in impaired fetal and (early) childhood development.

Development of the autoinflammatory disease damage index (ADDI)

Objectives

Autoinflammatory diseases cause systemic inflammation that can result in damage to multiple organs. A validated instrument is essential to quantify damage in individual patients and to compare disease outcomes in clinical studies. Currently, there is no such tool. Our objective was to develop a common autoinflammatory disease damage index (ADDI) for familial Mediterranean fever, cryopyrin-associated periodic syndromes, tumour necrosis factor receptor-associated periodic fever syndrome and mevalonate kinase deficiency.

Methods

We developed the ADDI by consensus building. The top 40 enrollers of patients in the Eurofever Registry and 9 experts from the Americas participated in multiple rounds of online surveys to select items and definitions. Further, 22 (parents of) patients rated damage items and suggested new items. A consensus meeting was held to refine the items and definitions, which were then formally weighted in a scoring system derived using decision-making software, known as 1000minds.

Results

More than 80% of the experts and patients completed the online surveys. The preliminary ADDI contains 18 items, categorised in the following eight organ systems: reproductive, renal/amyloidosis, developmental, serosal, neurological, ears, ocular and musculoskeletal damage. The categories renal/amyloidosis and neurological damage were assigned the highest number of points, serosal damage the lowest number of points. The involvement of (parents of) patients resulted in the inclusion of, for example, chronic musculoskeletal pain.

Conclusions

An instrument to measure damage caused by autoinflammatory diseases is developed based on consensus building. Patients fulfilled a significant role in this process.

Episode of Familial Mediterranean Fever-Related Peritonitis in the Second Trimester of Pregnancy Followed by Acute Cholecystitis: Dilemmas and Pitfalls

BACKGROUND

Differential diagnosis of acute abdomen in pregnant patients is one of the greatest challenges for the clinician. Occurrence of Familial Mediterranean Fever (FMF) paroxysm of peritonitis and acute cholecystitis during pregnancy is a unique clinical entity that leads to serious diagnostic and therapeutic dilemmas.

CASE REPORT

We present the case of a 33-year-old Armenian patient at 16 weeks' gestational age with a history of FMF, who was admitted twice within 1 month with acute abdomen. The first episode was attributed to FMF and successfully treated conservatively with colchicine. The second episode was diagnosed as acute cholecystitis and led to emergent laparoscopic cholecystectomy and lysis of peritoneal adhesions from previous FMF attacks. The patient presented an uneventful postoperative clinical course and had a normal delivery of a healthy infant at the 39th week of gestation.

CONCLUSIONS

Pregnant patients with acute abdomen should be evaluated with open mind. To the best of our knowledge, this is the first published report of the coexistence of 2 different causes of acute abdomen during pregnancy. Meticulous history and thorough physical, laboratory, and radiologic examination are the keys to reach a correct diagnosis. Treatment of pregnant patients with acute abdomen should be individualized. Administration of colchicine should be continued during conception, pregnancy, and lactation in patients with FMF history. Laparoscopic intervention in pregnant patients with surgical abdomen such as acute cholecystitis is the optimal method of treatment.

Colchicine for cardiovascular medicine

Colchicine is an ancient drug with anti-inflammatory effects especially on neutrophils. These cells are critically involved in pericardial and atherosclerotic plaques inflammation, thus representing a new potential target for new therapies to treat and especially prevent cardiovascular events such as pericarditis, atrial fibrillation triggered by inflammation and ischemic vascular events. The aim of the present review is to briefly review the essential pharmacology and explore potential efficacy and safety of colchicine for new emerging cardiovascular indications.

Familial Mediterranean Fever With Complete Symptomatic Remission During Pregnancy

Familial Mediterranean fever (FMF) is an inherited autosomal recessive disorder, ethnically restricted and commonly found among populations surrounding the Mediterranean Sea. FMF is the most prevalent autoinflammatory disease; is characterized by recurrent, self-limited episodes of fever with serositis; and is caused by Mediterranean fever gene (MEFV) mutations on chromosome 16. We describe a case of adult-onset FMF with complete symptomatic remission during pregnancy, without the use of colchicine. A 25-year-old woman had presented with periodic fever, abdominal pain, and vomiting since she was 21. Her abdominal computed tomography scan showed intestinal nonrotation. She underwent exploratory laparotomy and appendectomy for her symptoms 1 year prior. She had a symptom-free pregnancy period, but abdominal pain and fever recurred after delivery. Mutation analysis of the MEFV gene revealed two point mutations (p.Leu110Pro and p.Glu148Gln). We report an adult female patient with FMF in Korea with complete symptomatic remission during pregnancy.

Protective effects of colchicine in an experimental rat endometriosis model: histopathological evaluation and assessment of TNF-α levels

OBJECTIVE

Endometriosis is an estrogen-dependent chronic inflammatory disease observed in reproductive period. The aim of the present study is to assess the efficacy of colchicine, widely used to treat many inflammatory diseases, in an experimental rat endometriosis model.

STUDY DESIGN

Experimental endometriosis was constituted with implantation of autogenous endometrial tissue. Rats were divided randomly into 2 groups as colchicine group (n = 8) and control group (n =8). Although oral 0.1 mg/kg colchicine was administered 4 weeks to the colchicine group, the same amount of saline solution was administered to the control group. Before and after 30 days of treatment period, peritoneal and tissue tumor necrosis factor α (TNF-α), the volumes and histopathological properties of the implants were evaluated.

RESULTS

Although the implant volume decreased significantly in the colchicine group (89.2 ± 13.4 mm(3) to 35.2 ± 4.5 mm(3), P < .05), the implant volume increased in the control group (85.1 ± 14.2 mm3 to 110.3 ± 10.5 mm(3), P < .05). When compared to the control group, the colchicine group had significantly lower histopathologic sores (1.4 ± 0.2 vs 2.6 ± 0.4, P < .001). Although peritoneal fluid TNF-α levels were significantly decreased in the colchicine group (45.2 ± 5.3 pg/mL vs 12.1 ± 5.2 pg/mL, P < .001), the peritoneal fluid TNF-α levels were significantly increased in the control group after the treatment (44.2 ± 3.5 pg/mL vs 61.3 ± 12.2 pg/mL; P < .001). Tissue TNF-α levels were significantly lower in the colchicine group when compared to the control group (45.4 ± 8.6 pg/mL vs 71.3 ± 11.2 pg/mL; P < .001).

CONCLUSION

Colchicine resulted in regression of endometrial implant volumes in experimental rat endometriosis model and decreased peritoneal and tissue TNF-α levels.

The impact of familial Mediterranean fever on reproductive system

Familial Mediterranean fever (FMF) is an autosomal recessive disease characterized by recurrent attacks of fever, peritonitis, pleuritis, arthritis, or erysipelas-like skin lesion. FMF is the most common periodic febrile syndrome affecting more than 150,000 people worldwide. The majority of patients develop FMF before the age of 20. FMF may cause amyloidosis, which mainly affects the kidneys but may also be accumulated in other organs such as the heart, gastrointestinal tract, and reproductive organs. FMF being a systemic disorder with a risk for amyloidosis, affecting patients in their childbearing years, and with its lifelong colchicine therapy raises concern about its effect on the reproductive system. In this article, we review the impact of FMF and its treatment to the reproductive system of male and female patients, pregnancy, and lactation.