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Terrier B, Darbon R, Durel CA, Hachulla E, Karras A, Maillard H, Papo T, Puechal X, Pugnet G, Quemeneur T, Samson M, Taille C, Guillevin L. French recommendations for the management of systemic necrotizing vasculitides (polyarteritis nodosa and ANCA-associated vasculitides). Orphanet J Rare Dis 2020; 15:351. [PMID: 33372616 PMCID: PMC7771069 DOI: 10.1186/s13023-020-01621-3] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Systemic necrotizing vasculitis comprises a group of diseases resembling polyarteritis nodosa and anti-neutrophil cytoplasmic antibody-associated vasculitis (ANCA): granulomatosis with polyangiitis, eosinophilic granulomatosis with polyangiitis, and microscopic polyangiitis. The definitive diagnosis is made in cooperation with a reference center for autoimmune diseases and rare systemic diseases or a competency center. The management goals are: to obtain remission and, in the long term, healing; to reduce the risk of relapses; to limit and reduce the sequelae linked to the disease; to limit the side effects and the sequelae linked to the treatments; to improve or at least maintain the best possible quality of life; and to maintain socio-professional integration and/or allow a rapid return to school and/or professional activity. Information and therapeutic education of the patients and those around them are an integral part of the care. All health professionals and patients should be informed of the existence of patient associations. The treatment of vasculitis is based on variable combinations of glucocorticoids and immunosuppressants, chosen and adapted according to the disease concerned, the severity and/or extent of the disease, and the underlying factors (age, kidney function, etc.). Follow-up clinical and paraclinical examinations must be carried out regularly to clarify the progression of the disease, detect and manage treatment failures and possible relapses early on, and limit sequelae and complications (early then late) related to the disease or treatment. A distinction is made between the induction therapy, lasting approximately 3–6 months and aimed at putting the disease into remission, and the maintenance treatment, lasting 12–48 months, or even longer. The role of the increase or testing positive again for ANCA as a predictor of a relapse, which has long been controversial, now seems to have greater consensus: Anti-myeloperoxidase ANCAs are less often associated with a relapse of vasculitis than anti-PR3 ANCA.
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Affiliation(s)
| | | | | | | | | | | | - Thomas Papo
- Internal Medicine, CHU Bichat, AP-HP, Paris, France
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Daher A, Sauvetre G, Girszyn N, Verspyck E, Levesque H, Le Besnerais M. Granulomatosis with polyangiitis and pregnancy: A case report and review of the literature. Obstet Med 2020; 13:76-82. [PMID: 32714439 PMCID: PMC7359661 DOI: 10.1177/1753495x18822581] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 12/10/2018] [Indexed: 12/24/2022] Open
Abstract
The association of granulomatosis with polyangiitis and pregnancy is rare and therapeutic options are limited by the risk of teratogenicity and fetotoxicity. There is a paucity of published literature to guide clinical decision-making in these cases. We report the case of a 26-year-old woman with no medical history who presented at 21 weeks of gestation with a bilateral sudden loss of hearing and erosive rhinitis. The diagnosis of granulomatosis with polyangiitis was confirmed radiologically and biologically. Corticosteroids were not enough to stabilize the disease and she received intravenous immunoglobulins with remission. A successful delivery of a healthy male newborn was done at 36 weeks. A review of all published literature on granulomatosis with polyangiitis in pregnancy between 1970 and 2017 is presented. Trial registration: Not applicable.
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Affiliation(s)
- A Daher
- Internal Medicine Department, CHU de Rouen, Rouen, France
| | - G Sauvetre
- Internal Medicine Department, CHU de Rouen, Rouen, France
| | - N Girszyn
- Internal Medicine Department, CHU de Rouen, Rouen, France
| | - E Verspyck
- Obstetric and Gynecology Department, CHU de Rouen, Rouen, France
| | - H Levesque
- Internal Medicine Department, CHU de Rouen, Rouen, France
| | - M Le Besnerais
- Internal Medicine Department, CHU de Rouen, Rouen, France
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3
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Singh P, Dhooria A, Rathi M, Agarwal R, Sharma K, Dhir V, Nada R, Minz R, Suri V, Jain S, Sharma A. Successful treatment outcomes in pregnant patients with ANCA-associated vasculitides: A systematic review of literature. Int J Rheum Dis 2019; 21:1734-1740. [PMID: 30345645 DOI: 10.1111/1756-185x.13342] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIM Antineutrophil cytoplasmic antibody-associated vasculitides (AAV) are a group of small vessel vasculitis with systemic presentations and considerable morbidity and mortality. Pregnancy in these patients poses a significant therapeutic challenge. There is limited published literature regarding pregnancy in AAV. METHODS Two cases of successful pregnancy outcomes in patients with active AAV are described. A systematic review was conducted on the lines of the PRISMA statement for conducting systemic reviews: PubMed (inception of PubMed until 30 April 2017, English language only) and EmBase databases were searched using the following terms: 'pregnancy' AND 'ANCA associated vasculitis' OR 'granulomatosis with polyangiitis' OR 'eosinophilic granulomatosis with polyangiitis' OR 'microscopic polyangiitis' OR 'Churg-Strauss syndrome' OR 'Wegener's granulomatosis'. RESULTS One hundred and thirty-seven pregnancies were documented in 110 patients of AAV. Vasculitis diagnosis was made before pregnancy in 69, during pregnancy in 32 and after pregnancy in 9 patients. Mean age at the time of pregnancy was 29.3 ± 5.3 years. There were 91 term pregnancies, 28 were preterm pregnancies, 15 abortions and 3 still births; 78 had normal delivery and 26 had caesarian section. CONCLUSION Successful pregnancies have been reported in AAV patients.
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Affiliation(s)
- Pawan Singh
- Department of Pulmonary Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Aadhaar Dhooria
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Manish Rathi
- Department of Nephrology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ritesh Agarwal
- Department of Pulmonary Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Kusum Sharma
- Department of Microbiology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Varun Dhir
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ritambhra Nada
- Department of Histopathology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ranjana Minz
- Department of Immunopathology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Vanita Suri
- Department of Obstetrics and Gynecology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Sanjay Jain
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Aman Sharma
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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4
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Veltri NL, Hladunewich M, Bhasin A, Garland J, Thomson B. De novo antineutrophil cytoplasmic antibody-associated vasculitis in pregnancy: a systematic review on maternal, pregnancy and fetal outcomes. Clin Kidney J 2018; 11:659-666. [PMID: 30288261 PMCID: PMC6165750 DOI: 10.1093/ckj/sfy011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 01/23/2018] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND De novo antineutrophil cytoplasmic antibody-associated vasculitis typically arises in post-reproductive years, but can occur during pregnancy. Concerns of treatment-related teratogenicity persist, while efficacy and safety of new therapies including intravenous immunoglobulin (IVIG) and rituximab are uncertain. There remains a paucity of maternal, fetal and pregnancy outcome data in these women, and therefore a lack of guidance on safe treatment for clinicians. METHODS We conducted a systematic review of the literature and a local, retrospective chart review of women with de novo antibody-associated vasculitis (AAV) in pregnancy. Cochrane, Embase and PubMed databases and relevant conference abstracts were searched. Patient demographics, clinical presentation, management and outcomes (maternal, fetal and pregnancy-related) were analyzed. RESULTS Twenty-seven cases of de novo AAV in pregnancy were included. Women presented were from 5 to 39 weeks' gestation, of which a majority were in the second trimester (median 20 weeks). The median gravida of women was 2 and the median parity was 1. Women were treated with steroids (89%), cyclophosphamide (CYC) (37%), other immunosuppressive agents [azathioprine (AZA), IVIG, plasma exchange (PLEX)] or no therapy (11%). High rates of serious complications, including preeclampsia (29%) and maternal death (7%), were reported; however, most pregnancies resulted in live birth (73%). Prematurity was common; 73% of live births occurred prior to 37 weeks' gestation and 40% prior to 34 weeks' gestation. The majority of infants were born in the third trimester (median 34.5 weeks). Rates of pregnancy termination were high (23%) and only one intrauterine death was reported, shortly after initiation of therapy (4%). Congenital abnormalities were rare, with one infant having a solitary, pelvic kidney (6%) after maternal treatment with steroids, CYC and PLEX. Use of PLEX, IVIG and AZA increased after 2005, whereas CYC use decreased. Remission often occurred postpartum (60%). CONCLUSIONS De novo AAV in pregnancy can result in uncomplicated pregnancies; however, serious maternal risks exist. Further data on potentially pregnancy compatible therapies such as IVIG and rituximab are needed in this population.
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Affiliation(s)
- Nicole L Veltri
- Division of Internal Medicine, Department of Medicine, Queen’s University, Kingston, ON, Canada
| | - Michelle Hladunewich
- Division of Nephrology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Arrti Bhasin
- Division of Nephrology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Jocelyn Garland
- Division of Nephrology, Department of Medicine, Queen’s University, Kingston, ON, Canada
| | - Benjamin Thomson
- Division of Nephrology, Department of Medicine, Queen’s University, Kingston, ON, Canada
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5
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Gallagher KA, Tracci MC, Scovell SD. Vascular arteritides in women. J Vasc Surg 2013; 57:27S-36S. [PMID: 23522715 DOI: 10.1016/j.jvs.2012.10.119] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2012] [Revised: 08/03/2012] [Accepted: 10/26/2012] [Indexed: 12/22/2022]
Abstract
The vasculitides are multiple clinical disease states that are characterized by inflammation of the wall of blood vessels. They are typically classified by the size of the vessel that is affected. Some of the vasculitides are more commonly identified in women, such as the large-vessel vasculitides. In addition, the incidence of some of the medium and small-vessel vasculitides in women has increased during the past several decades. These inflammatory conditions specifically affecting women will be reviewed here. The implications that pregnancy may have on various vasculitides will also be highlighted.
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Affiliation(s)
- Katherine A Gallagher
- Division of Vascular and Endovascular Surgery, University of Michigan Medical Center, Ann Arbor, MI, USA
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Saxby AJ, Pace-Asciak P, Dar Santos RC, Chadha NK, Kozak FK. The rhinological manifestations of women's health. Otolaryngol Head Neck Surg 2013; 148:717-31. [PMID: 23426708 DOI: 10.1177/0194599813477837] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To systematically review the literature and appraise the evidence reporting the effects of women's health, including pregnancy, postpartum, menstruation, oral contraception, menopause, and hormone replacement therapy, on common rhinological pathologies and nasal physiology. DATA SOURCES Systematic search strategy using MEDLINE (1966-2012) and EMBASE (1980-2012) databases. REVIEW METHODS Title review, abstract screening, and then full paper analysis were undertaken by 2 authors independently. Level of evidence was graded according to the Oxford Centre of Evidence Based Medicine 2011 criteria and risk of bias assessment using the Jadad scale for randomized controlled trials and Newcastle-Ottawa Scale for cohort and case-controlled studies. RESULTS Over the 46 years analyzed, the search strategy produced 2904 titles. In total, 314 abstracts were screened, from which 192 full-text articles were evaluated, and 145 research papers met all the criteria for inclusion in the study. Overall, the available evidence was of low quality. Seventy percent of studies (102 of 145) were case reports or case series from which only limited conclusions can be drawn. Only 3% of the included papers (4 of 145) were randomized controlled studies. The remaining data were mainly of a prospective cohort design. Study heterogeneity in design and measured outcomes resulted in data synthesis being limited to a descriptive/exploratory review. Study findings are presented by women's health category and then by rhinological manifestation with important clinical correlations highlighted. CONCLUSION Physiological and hormonal changes occurring as a normal part of women's health have an important influence on rhinological function and disease.
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Affiliation(s)
- Alexander J Saxby
- Division of Otolaryngology, Head and Neck Surgery, Children's and Women's Hospital, Vancouver, BC, Canada.
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7
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Gatto M, Iaccarino L, Canova M, Zen M, Nalotto L, Ramonda R, Punzi L, Doria A. Pregnancy and vasculitis: A systematic review of the literature. Autoimmun Rev 2012; 11:A447-59. [DOI: 10.1016/j.autrev.2011.11.019] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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8
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Said MSM. Upper respiratory tract symptoms, renal involvement and vasculitis: a case report and review of wegener granulomatosis. J Clin Med Res 2011; 2:189-93. [PMID: 21629538 PMCID: PMC3104653 DOI: 10.4021/jocmr412w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/01/2010] [Indexed: 01/10/2023] Open
Abstract
Wegener’s Granulomatosis is a condition associated with systemic vasculitis which can present with upper respiratory tract symptoms initially. On September 2001, a 15-year-old girl presented with symptoms of nasal block for 3 weeks. She later developed joint pains and worsening renal status requiring dialysis. A renal biopsy was performed which showed pauci-immune cresentric glomerulonephritis. Her cANCA levels were positive. She was treated with oral cyclophosphamide and steroids and later responded.
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Affiliation(s)
- Mohd Shahrir Mohamed Said
- University Kebangsaan Malaysia Medical Centre, Jalan Yaacob Latif, Cheras 56000 Kuala Lumpur, Malaysia.
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9
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Abstract
Pregnancy may affect the diagnosis, management, and outcome of infiltrative lung disease (ILD). Conversely, ILD may affect pregnancy. ILD may occur as a result of drugs administered commonly or specifically during pregnancy. Most ILDs predominate in patients older than 40 years and are thus rare in pregnant women. During pregnancy ILD may arise de novo and preexisting ILD may be exacerbated or significantly worsened. Some ILDs generally do not alter the management of pregnancy, labor, or delivery. Preexisting ILD no longer contraindicates pregnancy systematically, but thorough evaluation of ILD before pregnancy is required to identify potential contraindications and adapt monitoring.
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Affiliation(s)
- N Freymond
- Department of Respiratory Medicine, Reference Centre for Rare Pulmonary Diseases, Hospices Civils de Lyon, Louis Pradel Hospital, Lyon, France; University of Lyon I, UMR754 INRA, IFR 128, Lyon, France
| | - V Cottin
- Department of Respiratory Medicine, Reference Centre for Rare Pulmonary Diseases, Hospices Civils de Lyon, Louis Pradel Hospital, Lyon, France; University of Lyon I, UMR754 INRA, IFR 128, Lyon, France
| | - J F Cordier
- Department of Respiratory Medicine, Reference Centre for Rare Pulmonary Diseases, Hospices Civils de Lyon, Louis Pradel Hospital, Lyon, France; University of Lyon I, UMR754 INRA, IFR 128, Lyon, France.
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10
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Devakumar VN, Castelino M, Chow SC, Teh LS. Wegener's granulomatosis in pregnancy: a case report and review of the medical literature. BMJ Case Rep 2010; 2010:bcr09.2009.2296. [PMID: 22242076 PMCID: PMC3029874 DOI: 10.1136/bcr.09.2009.2296] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A Caucasian woman in the third trimester of her sixth pregnancy was diagnosed with Wegener's granulomatosis (WG) following investigation for recurrent ear infections and a persistent dry cough. Chest radiograph showed granulomatous lesions and the c-ANCA (antineutrophil cytoplasmic antibody) was strongly positive. She required pulsed methylprednisolone and cyclophosphamide followed by oral prednisolone and azathioprine to control the disease process during and after pregnancy. Neither the disease nor aggressive treatment adversely affected the pregnancy and she delivered a healthy baby girl by elective induction at 37 weeks. A review of the literature on Wegener's granulomatosis in pregnancy is presented.
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Affiliation(s)
- Vinodh Nanjanna Devakumar
- The Royal Oldham Hospital, Rheumatology and Medicine, K Block, Rochdale Road, Oldham, OL1 2JH, UK
- Kendal Drive, Gatley, Cheadle, Cheshire SK84QJ, UK
| | - Madhura Castelino
- Royal Blackburn Hospital, Rheumatology, Rheumatology Department, Blackburn BB2 3HH, UK
| | - Shien-Ching Chow
- Royal Blackburn Hospital, Department of Rheumatology, Haslingden Road, Blackburn BB2 3HH, UK
| | - Lee-Suan Teh
- Royal Blackburn Hospital, Department of Rheumatology, Haslingden Road, Blackburn BB2 3HH, UK
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11
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Soh MC, Hart HH, Bass E, Wilkinson L. Pregnancy complicating Wegener's granulomatosis. Obstet Med 2009; 2:77-80. [PMID: 27582817 PMCID: PMC4989724 DOI: 10.1258/om.2009.080053] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/27/2009] [Indexed: 11/18/2022] Open
Abstract
Pregnancy associated with Wegener's granulomatosis is rare. Therapeutic options are limited. There is a paucity of published literature to guide clinical decision-making in these complex patients. Two cases are presented. Firstly, a 33-year-old woman with generalized Wegener's in remission and off all medications presented with a flare in the third trimester with haemoptysis, raised C-reactive protein and c-anti-neutrophilic cytoplasmic antibody (c-ANCA) levels. Her care was complicated by florid steroid-induced psychosis. With deteriorating disease control, she was treated with pulsed-intravenous cyclophosphamide with a good response. She delivered a healthy baby at 38 weeks. She had a severe postpartum flare. Secondly, a 37-year-old woman with limited Wegener's in remission for the last two years and off all treatment became pregnant after pre-conception counselling. A normal baby was delivered at term. An exhaustive review of all published literature on Wegener's activity in pregnancy is presented along with therapeutic options and recommendations.
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Affiliation(s)
- May Ching Soh
- North Shore Hospital, Waitemata District Health Board, Auckland, New Zealand
| | - Hamish H Hart
- North Shore Hospital, North Shore City, Auckland, New Zealand
| | - Eileen Bass
- National Women's Health, Auckland City Hospital, Auckland District Health Board, Auckland, New Zealand
| | - Lucille Wilkinson
- National Women's Health, Auckland City Hospital, Auckland District Health Board, Auckland, New Zealand
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12
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Zafar U, Sany O, Velmurugan U, Kabukoba JJ. Wegener's granulomatosis in pregnancy: a multidisciplinary approach. J OBSTET GYNAECOL 2009; 28:532-3. [PMID: 18850433 DOI: 10.1080/01443610802234368] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- U Zafar
- Russells Hall Hospital, Dudley, UK.
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13
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Kim SY, Linton JM, Kolasinski SL. Successful treatment of new onset Wegener's granulomatosis with IVIG (intravenous immunoglobulin) during pregnancy: a case report. Mod Rheumatol 2008; 18:177-80. [PMID: 18299958 DOI: 10.1007/s10165-008-0020-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2007] [Accepted: 10/05/2007] [Indexed: 01/31/2023]
Abstract
We describe a patient with limited Wegener's granulomatosis (WG) presenting during pregnancy with aggressive cutaneous involvement. She was treated with a combination of high-dose corticosteroids and intravenous immunoglobulin (IVIG) during her third trimester. The patient had otherwise uneventful pregnancy and a satisfactory outcome for both herself and her newborn. In the English literature, prior to this report, there have been de novo cases of WG in pregnant women that were diagnosed and treated during pregnancy and three cases of WG treated successfully with IVIG during pregnancy.
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Affiliation(s)
- Seo Young Kim
- Division of Rheumatology, Department of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA.
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Abstract
Until recently, the prognosis associated with many forms of systemic vasculitis was quite grim. Advances in this field have allowed us to begin to focus on issues related to quality of life such as fertility, conception, and pregnancy among women with vasculitis. Because the systemic vasculitides are rare diagnoses, many important questions remain unanswered. Overall, it seems that women who have inactive vasculitis may not be subject to unusual complications during pregnancy, but our understanding of the interaction between pregnancy and specific forms of vasculitis continues to evolve.
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Affiliation(s)
- Philip Seo
- The Johns Hopkins University, Division of Rheumatology, Baltimore, MD 21224, USA.
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15
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Koukoura O, Mantas N, Linardakis H, Hajiioannou J, Sifakis S. Successful term pregnancy in a patient with Wegener's granulomatosis: case report and literature review. Fertil Steril 2007; 89:457.e1-5. [PMID: 17517407 DOI: 10.1016/j.fertnstert.2007.03.054] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2006] [Revised: 03/19/2007] [Accepted: 03/19/2007] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To present a case of successful term pregnancy in a patient with known Wegener's granulomatosis (WG). DESIGN Case report. SETTING University Hospital, Department of Obstetrics and Gynecology. PATIENT(S) A 22-year-old primigravida pregnant woman with a history of WG diagnosed 5 years before. INTERVENTION(S) The patient was treated with corticosteroids and azathioprine throughout pregnancy, and cyclophosphamide was added postpartum. MAIN OUTCOME MEASURE(S) The disease was in partial remission at the onset of pregnancy, but two relapses occurred, at 33 weeks' gestation and 15 days after delivery. A 3150-g healthy boy was delivered at 37 weeks' gestation. CONCLUSION(S) Pregnancy in patients with WG requires preconceptional planning, careful clinical management, and vigorous treatment of active disease. There are 36 cases of WG in pregnancy reported in the literature. Owing to this rarity, the management is individualized and the pregnancy outcome is variable. Antenatal management and therapeutic options are discussed and a short review of the literature is presented.
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Affiliation(s)
- Ourania Koukoura
- Department of Obstetrics-Gynecology, University Hospital of Heraklion, Crete, Greece
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16
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Affiliation(s)
- E Jwarah
- Department of Obstetrics and Gynaecology, Wexham Park Hospital, UK.
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17
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Mubashir E, Ahmed MM, Hayat S, Latif S, Heldmann M, Berney SM. Wegener Granulomatosis: A Case Report and Update. South Med J 2006; 99:977-88. [PMID: 17004532 DOI: 10.1097/01.smj.0000232210.04881.d3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Wegener granulomatosis (WG) is a systemic disease of unknown etiology characterized by necrotizing granulomatous inflammation, tissue necrosis, and variable degrees of vasculitis in small and medium-sized blood vessels. The classic clinical pattern is a triad involving the upper airways, lungs and kidneys. Ninety percent of patients present with symptoms involving the upper and/or lower airways, and 80% will eventually develop renal disease. WG should be suspected in any patient with progressive or unresponsive sinus disease, glomerulonephritis, pulmonary hemorrhage, mononeuritis multiplex or unexplained multisystem disease. Before the routine use of glucocorticoids and cyclophosphamide, the one year mortality was 82%. However in 1973, Fauci and Wolf discovered that daily prednisone and cyclophosphamide induced complete remission in 75% of patients. The continued use of prednisone and cyclophosphamide for 1 year past remission leads to marked improvement in more than 90% of patients; however, is also associated with serious toxicities. Depending on the disease severity, current treatments employ induction with short-term cyclophosphamide followed by less toxic agents such as methotrexate to maintain disease remission. Although it is a rare disorder, it is pertinent to internists because it is a multisystem disease that presents in a variety of ways. We describe a 63-year-old white male with WG who presented with progressively worsening headaches, bilateral eye redness, epistaxis, hemoptysis and an unintentional 20 pound weight loss, and review the current treatment recommendations.
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Affiliation(s)
- Eisha Mubashir
- Center of Excellence for Arthritis and Rheumatology, Section of Rheumatology, Department of Medicine, Louisiana State University Health Sciences Center, Shreveport, LA, USA
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18
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Spezielle Arzneimitteltherapie in der Schwangerschaft. ARZNEIVERORDNUNG IN SCHWANGERSCHAFT UND STILLZEIT 2006. [PMCID: PMC7271219 DOI: 10.1016/b978-343721332-8.50004-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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19
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Bessias N, Moulakakis KG, Lioupis C, Bakogiannis K, Sfyroeras G, Kakaletri K, Andrikopoulos V. Wegener's granulomatosis presenting during pregnancy with acute limb ischemia. J Vasc Surg 2005; 42:800-4. [PMID: 16242573 DOI: 10.1016/j.jvs.2005.05.038] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2005] [Accepted: 05/18/2005] [Indexed: 11/27/2022]
Abstract
We report a rare case of a pregnant woman with Wegener's granulomatosis whose disease involved the lungs, the spleen, and a limb. Wegener's granulomatosis was clinically manifested in the 34th week of pregnancy with pulmonary infiltrates, splenic infarcts, and acute limb ischemia. Successive thrombectomies failed to maintain arterial flow in the distal limb due to the development of active vasculitis. Thrombosis of the tibial arteries and recurrence of thrombosis was a persistent clinical observation. In the meantime, a cesarean section was performed, with a successful delivery of a healthy male newborn. Because of the recent cesarean section, the patient did not undergo thrombolysis. The woman finally underwent amputation of the limb. According to the reviewed literature, this is the sixth reported case of Wegener's granulomatosis presenting with digital ischemia and the first manifested during pregnancy.
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Affiliation(s)
- Nikolaos Bessias
- Department of Vascular Surgery, Red Cross Hospital, Athens, Greece
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20
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Doria A, Iaccarino L, Ghirardello A, Briani C, Zampieri S, Tarricone E, Gambari PF. Pregnancy in rare autoimmune rheumatic diseases: UCTD, MCTD, myositis, systemic vasculitis and Beçhet disease. Lupus 2004; 13:690-5. [PMID: 15485105 DOI: 10.1191/0961203304lu1098oa] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The physiological adaptation of the immune system to pregnancy can potentially affect the course of all autoimmune rheumatic diseases (ARD), conversely the autoimmune processes characteristic of these conditions may compromise the foetal outcome. Unfortunately, very few reports on pregnancy outcome in patients with rare ARD are available. In this paper, we briefly review the data published until now on these disorders. Some general guidelines which were elaborated for more prevalent ARD seem to be valid also for such rare conditions: 1) patients should be correctly informed on the risk of becoming pregnant; 2) pregnancies should be planned when the disease is in remission since it increases the probability of successful maternal and foetal outcome; 3) patients should be regularly monitored during gestation and postpartum by a multidisciplinary team including rheumatologist, obstetrician, and neonatologist; 4) in the case of disease relapse an adequate treatment, even aggressive if necessary, should be recommended since active disease can be more detrimental for foetus than drugs; 5) pregnancies complicated by the onset of rare ARD have a particularly severe prognosis; in these cases a prompt treatment and very close clinical surveillance are indicated.
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Affiliation(s)
- A Doria
- Division of Rheumatology, Department of Medical and Surgical Sciences, University of Padova, Padova, Italy.
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21
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Affiliation(s)
- M C Cid Xutglà
- Grupo de Investigación sobre Vasculitis Sistémicas. Servicio de Medicina Interna General. Hospital Clínico. Facultad de Medicina. Universidad de Barcelona. IDIBAPS (Instituto de Investigaciones Biomédicas August Pi i Sunyer). Barcelona. Spain
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22
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Abstract
Little is known about pregnancy in patients with vasculitis because of the nature of these diseases and the potential for infertility to occur from effective treatments. However, with the expanding armamentarium of therapeutic options that do not affect reproductive function, it is anticipated that more vasculitis patients will entertain the possibility of conception and consider the outcomes of pregnancy. Relevant issues include the effects of the vasculitis on pregnancy, the effects of the pregnancy on vasculitic disease activity, and the impact of medications used during the peripartum period. Although available data are limited and fall short in many regards, there is support for successful outcomes of pregnancy when conception occurs in disease remission. Maternal and fetal outcome is optimized by the establishment of a multidisciplinary team that can provide preconception evaluation and counseling followed by frequent monitoring throughout the pregnancy and the postpartum period.
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Affiliation(s)
- Carol A Langford
- Immunologic Diseases Section, Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland 20892, USA.
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23
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Abstract
The pregnant woman is susceptible to a variety of respiratory complications. When a pregnant patient presents with an abnormal chest x-ray or a pulmonary complaint, an understanding of the pathophysiology of pregnancy will guide the clinician in establishing a diagnosis. Pregnancy brings about many changes to a woman's body. One of the more intriguing is a decrease in the T helper cells, resulting in a state of relative immunosuppression. Despite this, the prevalence of infectious pneumonia is not increased in pregnancy. Complications from pneumonia, however, are increased in the pregnant host. Most notably are increases in both mortality related to influenza infection and the risk for dissemination of coccidioidomycosis. Other physiologic changes predispose the pregnant woman to certain disease processes. Hypercoagulability associated with pregnancy results in a marked increase in the incidence of thromboembolic disease. Although rare, pregnancy is also associated with other embolic phenomena including amniotic fluid embolism, air embolism, and trophoblastic embolism. Because of the increases in intravascular volume and cardiac output that occur in pregnancy, women with underlying structural heart disease will frequently present for the first time or have an exacerbation of their disease. This is especially true of mitral stenosis. Peripartum cardiomyopathy also can occur, and for the majority of patients, the heart remains damaged for life. Finally, although uncommon, lymphangioleiomyomatosis will often present or become exacerbated during pregnancy. Patients with this disorder need to be counseled concerning the increased risk associated with pregnancy. This paper reviews the various respiratory complications associated with pregnancy.
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Affiliation(s)
- S Ie
- Tulane University School of Medicine, New Orleans, Louisiana, USA
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Auzary C, Huong DT, Wechsler B, Vauthier-Brouzes D, Piette JC. Pregnancy in patients with Wegener's granulomatosis: report of five cases in three women. Ann Rheum Dis 2000; 59:800-4. [PMID: 11005781 PMCID: PMC1752998 DOI: 10.1136/ard.59.10.800] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Five cases of pregnancy occurring in three women with previously diagnosed Wegener's granulomatosis are described. The disease was diffuse in one case and localised in the other. Initial treatment consisted of a combination of corticosteroids and intravenous cyclophosphamide in two women, and methotrexate in one. Four pregnancies ended in live births despite pre-eclampsia in two cases. One therapeutic abortion was induced because of encephalocele. Comparable reported cases were reviewed to examine the implications of immunosuppressive treatment on the fetus. A relapse occurred during pregnancy in 40% of the cases, but in 25% if only pregnancies beginning during inactive disease were taken into account. No other indicator for maternal and fetal outcome was obvious. Pregnancy should be planned after complete disappearance of disease activity. In the case of a relapse a combination of immunosuppressive drugs and corticosteroids should be chosen rather than corticosteroids alone because the outcome of pregnancy is poor in cases of undertreatment. Prematurity remains common.
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Affiliation(s)
- C Auzary
- Department of Internal Medicine, Hôpital de Bicêtre, 78 avenue du general leclerc, 94270 Le Kremlin-Bicetre, France
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25
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Abstract
Vasculitis is a clinicopathologic process characterized by inflammation and necrosis of blood vessels. Classification schemes for systemic vasculitis depend on the size of the involved blood vessels, the anatomic site, and the clinical manifestations. The most common primary types of vasculitis are Wegeners granulomatosus, polyarteritis nodosa, and Churg-Strauss vasculitis. There is limited information on pregnancy outcome and medication use in these patients because most of the primary vasculidities occur in older individuals and they are more common in men.
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Affiliation(s)
- R Ramsey-Goldman
- Department of Medicine, Northwestern University School of Medicine, Chicago, IL, USA
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