Effects of antiinflammatory and immunosuppressive drugs on pregnancy and fertility

Gender-related differences in clinical course of crohn?s disease in an Asian population: a retrospective cohort review

CONTEXT

Data from Asian populations about gender-related differences in Crohn's disease are few. Objectives This study was to analyze the clinical characteristics between women and men affected by Crohn's disease.

METHODS

This was a retrospective cohort study to analyze consecutive Crohn's disease patients from Jan 2000 to Dec 2012. Clinical and phenotypic characteristics and treatment outcomes were evaluated.

RESULTS

79 patients (55 male and two of them with positive family history) were diagnosed with Crohn's disease. Ileocolonic disease and inflammatory lesion was the most dominant site of involvement and disease behavior respectively in both men and women. Apart from higher frequency of nausea (45.83 vs 23.64%, P 0.024) and lower body mass index (19.44 vs 22.03 kg/m2, P 0.003) reported in women, no significant gender-related differences in clinical characteristics were observed. Women were more associated with delay use of immunosuppressive therapy (12 vs 36 months, P = 0.028), particularly for those aged less than 40 years old (85 vs 62.6%, P = 0.023). Cox proportional hazard regression analysis revealed that active smoking (HR, 4.679; 95% CI, 1.03-21.18) and delayed use of immunosuppressive therapy (HR, 4.13; 95% CI, 1.01-16.88) were only independent risk factors associated with increased risk of complications.

CONCLUSIONS

There were no significant gender-specific differences in clinical and phenotypic characteristics between male and female Crohn's disease patients. Smoking history and delay use of immunosuppressive therapy were associated with higher risk of complications.

[Guidelines for the management of Crohn's disease]

Crohn's disease (CD) is a chronic inflammatory bowel disease (IBD) with uncertain etiopathogenesis. CD can involve any site of gastrointestinal tract from the mouth to anus and is associated with serious complications such as bowel strictures, perforations, and fistula formation. The incidence and prevalence rates of CD in Korea are still lower than those of Western countries, but have been rapidly increasing during the past decades. Although there are no definitive curative modalities for CD, various medical and surgical therapies are currently applied for diverse clinical situations of CD. However, a lot of decisions on the management of CD are made depending on the personal experiences and choices of physicians. To suggest preferable approaches to diverse problems of CD and to minimize the variations according to physicians, guidelines for the management of CD are needed. Therefore, IBD Study Group of the Korean Association for the Study of the Intestinal Diseases has set out to develop the guidelines for the management of CD in Korea. These guidelines were developed using the adaptation methods and encompass the treatment of inflammatory disease, stricturing disease, and penetrating disease. The guidelines also cover the indication of surgery, prevention of recurrence after surgery, and CD in pregnancy and lactation. These are the first Korean guidelines for the management of CD and the update with further scientific data and evidences is needed.

Pregnancy related issues in inflammatory bowel disease: evidence base and patients' perspective

Inflammatory bowel disease (IBD) affects women of childbearing age and can influence fertility, pregnancy and decisions regarding breastfeeding. Women with IBD need to consider the possible course of disease during pregnancy, the benefits and risks associated with medications required for disease management during pregnancy and breastfeeding and the effects of mode of delivery on their disease. When indicated, aminosalicylates and thiopurines can be safely used during pregnancy. Infliximab and Adalimumab are considered probably safe during the first two trimesters. During the third trimester the placenta can be crossed and caution should be applied. Methotrexate is associated with severe teratogenicity due to its folate antagonism and is strictly contraindicated. Women with IBD tend to deliver earlier than healthy women, but can have a vaginal delivery in most cases. Caesarean sections are generally recommended for women with active perianal disease or after ileo-anal pouch surgery.While the impact of disease activity and medication has been addressed in several studies, there are minimal studies evaluating patients' perspective on these issues. Women's attitudes may influence their decision to have children and can positively or negatively influence the chance of conceiving, and their beliefs regarding therapies may impact on the course of their disease during pregnancy and/or breastfeeding. This review article outlines the impact of IBD and its treatment on pregnancy, and examines the available data on patients' views on this subject.

Female patients suffering from inflammatory bowel diseases are treated less frequently with immunosuppressive medication and have a higher disease activity: a subgroup analysis of a large multi-centre, prospective, internet-based study

BACKGROUND

The introduction of immunosuppressants and biologic agents has led to active debate and research about optimal therapeutic strategies considering risk factors and predictors of clinical outcome in inflammatory bowel disease (IBD). Data about gender-specific treatment differences and risk factors is lacking for IBD. The aim of the present study was to evaluate gender-related differences in the treatment of a distinct IBD patient population treated in the Rhein-Main region, Germany.

METHODS

Data about past medical history, disease status and medical treatment of 986 outpatients treated in ten gastroenterological practices and three hospitals were collected from November 1st 2005-July 31st 2007 and analyzed with regard to gender-related differences in therapy and disease management.

RESULTS

With the exception of an extended disease duration in women, no significant gender-related differences in demographic and clinical characteristics were observed. Men showed a significantly higher remission rate than women (p=0.025), while women received significantly less immunosuppressive medication compared to men (p=0.011). In addition, treatment with immunosuppressants was not different in women with child-bearing potential compared to menopausal women.

CONCLUSION

Our investigation demonstrates for the first time gender-specific differences in the therapeutic management in a large cohort of IBD patients.

The Hopkins Lupus Pregnancy Center: ten key issues in management

There is no consensus on the management of systemic lupus erythematosus (SLE), much less pregnancy in SLE patients. However, several key issues in the management of SLE in pregnancy are commonly faced by rheumatologists, nephrologists, and obstetricians. These include the treatment of SLE activity in pregnancy, the ascertainment of lupus nephritis, treatment of antiphospholipid antibodies, treatment of hypertension, and laboratory monitoring. These key issues will be examined in this chapter.

Drug therapy of inflammatory bowel disease in fertile women

Inflammatory bowel disease (IBD) is a disease that affects women of childbearing age. Active disease at conception increases the risk for adverse outcomes and thus postponement of pregnancy until the disease is in remission is the best advice that physicians can give their IBD patients. The majority of medications used to treat IBD are safe in pregnancy and breastfeeding; active, untreated, or undertreated disease is more deleterious than active therapy.

[Pleading to maintain hydroxychloroquine throughout Lupus pregnancies]

PURPOSE

The use of Hydroxychloroquine (HCQ) during pregnancy has remained controversial for a long time. However, it is generally agreed that pregnancy per se increases disease activity in patients with systemic lupus erythematosus (SLE) and that withdrawal of HCQ at the onset of pregnancy may result in exacerbation of SLE. Therefore, stopping HCQ at the onset of pregnancy may result in exacerbation of SLE which could be detrimental to both mother and fetus.

CURRENT KNOWLEDGE AND KEY POINTS

The available data suggest that HCQ can be continued safely throughout pregnancy. After the first report by Parke of successful continuation of HCQ throughout gestation, more than 250 pregnancies resulting in live births have been reported and no increase in the rate of birth defects have been demonstrated. When studied, no retinal toxicity and ototoxicity have been found in the children. Data concerning lactation and HCQ treatment are rare. However, the amount of HCQ received by children through lactation seems very low.

FUTURE PROSPECTS AND PROJECTS

For patients with SLE already taking HCQ, the benefits of continuing treatment with this medication throughout pregnancy seem to outweigh the hypothetical risks associated with its use. HCQ should probably be maintained throughout pregnancy in these patients with SLE and it does not seem necessary to advise against breastfeeding. Further studies with prospective follow-up of children exposed in utero to HCQ remain however needed to provide a definitive answer.

Safety of hydroxychloroquine in pregnant patients with connective tissue diseases. Review of the literature

Hydroxychloroquine (HCQ) is widely used in the treatment of systemic lupus erythematosus (SLE). Even if it is generally agreed that pregnancy per se increases disease activity in patients with SLE and that withdrawal of HCQ at the onset of pregnancy may result in exacerbation of SLE, use of HCQ during pregnancy has remained controversial for a long time. Parke was the first to propose continuation of HCQ throughout gestation. Currently, more than 250 pregnancies resulting in live births have been reported and no increase in the rate of birth defects have been demonstrated. When studied, no retinal toxicity and ototoxicity have been found. Data concerning lactation and HCQ treatment are rare. However, the amount of HCQ received by children through lactation seems very low. In conclusion, HCQ should probably be maintained throughout pregnancy in patients with SLE and it does not seem necessary to advise against breastfeeding.

Infant with severe penicillamine embryopathy born to a woman with Wilson disease

We report a chromosomally normal infant boy with congenital diffuse cutis laxa, severe micrognathia, contractures of all limbs, and central nervous system abnormalities including agenesis of the corpus callosum, born to a woman taking D-penicillamine (DP) for Wilson disease (WD) throughout her pregnancy. His postnatal course was remarkable for chronic lung disease, profound developmental delays, and probable cortical blindness, as well as resolution of his cutis laxa. Embryopathy is a rare complication in babies born to pregnant women treated with DP, and there have been only seven previous reports of birth defects in exposed infants (three of which had favorable postnatal outcomes). The etiology of the severe outcome in this boy is unclear, but prenatal measurement of maternal copper and zinc levels may be indicated for management.

Autoimmune disease in pregnancy: systemic lupus erythematosus and antiphospholipid syndrome

Autoimmune diseases most commonly occur in women of childbearing age. Although some conditions such as ankylosing spondylitis are more common in men, over 70% of individuals with autoimmune diseases are women. This article focuses on SLE,which is often considered to be the "classic" autoimmune disease,and antiphospholipid syndrome (APS), which is associated with pregnancy loss and placental insufficiency.

Medical management of the pregnant patient with inflammatory bowel disease

Gastroenterologists are not infrequently faced with questions regarding pregnancy when advising or treating their patients with inflammatory bowel disease (IBD). To advise patients effectively, the following factors must be considered: (1) the inheritance patterns of IBD for accurate counseling and family planning; (2) the effects of active IBD versus medications or surgery on fertility; (3) the effects of pregnancy on the course of IBD; (4) the effects and potential risks of active IBD versus those of diagnostic tests, medical treatments, and surgical treatments on the developing fetus; (5) approach to delivery; and (6) the risks of breast-feeding while receiving treatment for IBD.

Safety of hydroxychloroquine in pregnant patients with connective tissue diseases: A study of one hundred thirty-three cases compared with a control group

OBJECTIVE

The use of hydroxychloroquine (HCQ) in pregnancy remains controversial. The recent demonstration that HCQ passes across the placenta, with cord blood concentrations nearly identical to those found in maternal blood, emphasizes the need for careful evaluation of pregnancies in women receiving HCQ. However, only small series of HCQ-treated pregnant women have been reported, and most of these studies had no control group. We now report our experience with 133 pregnancies in women being treated with HCQ, resulting in 117 live births. Results in the HCQ group are compared with those in a control group.

METHODS

One hundred thirty-three consecutive pregnancies in 90 women treated with 200 mg of HCQ either twice daily (122 pregnancies) or once daily (11 pregnancies) were studied. These pregnancies were compared with 70 consecutive pregnancies in 53 women with similar disorders who did not receive HCQ. Electrocardiography was performed in 47 children of mothers treated with HCQ and in 45 children in the control group.

RESULTS

Eighty-eight percent of pregnancies in the HCQ group and 84% of those in the control group ended successfully with a live birth. The outcomes of pregnancy were not statistically different between groups. One child in each group died of causes related to prematurity. Three malformations were observed in the HCQ group (1 hypospadias, 1 craniostenosis, and 1 cardiac malformation) versus 4 in the control group. On the electrocardiograms, the PR interval and the corrected QT interval were not statistically different between groups. No visual, hearing, growth, or developmental abnormalities were reported in any of the children at the last follow-up (ages 12-108 months; mean age 26 months).

CONCLUSION

Our findings support preliminary evidence for the safety of HCQ therapy during pregnancy. This treatment probably should be maintained throughout pregnancy in patients with systemic lupus erythematosus.

Are there teratogenic risks associated with antidotes used in the acute management of poisoned pregnant women?

OBJECTIVE

We reviewed evidence suggesting teratogenic risk associated with the use of antidotes in the acute management of poisoned pregnant women.

METHODS

Medline, Toxline, and DART/ETIC searches; references of retrieved articles, pertinent databases and textbooks were also searched.

RESULTS

There are case reports or case series of women who received antidotes for poisoning during (*) or after (+) the period of organogenesis who showed no fetal adverse effects. Some antidotes, however, have no teratogenic risk: atropine (cohort/surveillance studies)+, calcium (oral supplement: cohort study)+ and pyridoxine (Bendectin studies). Also, ethanol+, methylene blue (intra-amniotic injection but not oral) and penicillamine* can be considered teratogens but their risks in the treatment of poisonings are unknown. There is no epidemiologic study evaluating the risk of the following antidotes during pregnancy: N-acetylcysteine(*+), BAL (dimercaprol)+, black widow spider antivenin+, calcium EDTA+, crotalidae antivenin, crotalidae polyvalent immune FAB, cyanide antidote kit (amyl and sodium nitrate, sodium thiosulfate), deferoxamine(*+), digoxin immune FAB+, DMSA+, flumazenil+, fomepizole, methylene blue (IV), naloxone, physostigmine, pralidoxime+, protamine+; and parenteral pharmacologic doses of calcium+, folinic acid*, glucagon+, hydroxycobalamin, phytonadione (vitamin K), and pyridoxine.

CONCLUSIONS

Despite the limited evidence supporting the risk of antidote use during pregnancy, antidotes should be used when there is a clear maternal indication to decrease the morbidity or mortality associated with poisoning. The only exception may be penicillamine, which is a teratogen. Better antidotes exist for most poisonings that penicillamine could potentially treat. At this time, there is no known fetal indication for all antidotes. Reporting the use of an antidote during pregnancy should be encouraged, especially if used during the critical period of organogenesis.

The safety of 6-mercaptopurine for childbearing patients with inflammatory bowel disease: a retrospective cohort study

BACKGROUND & AIMS

6-mercaptopurine/azathioprine is effective in IBD patients. However, data regarding toxicity associated with pregnancy are lacking, raising both patients' and physicians' concerns and sometimes resulting in elective abortion.

METHODS

To evaluate potential toxicity of 6-mercaptopurine (6-MP), we reviewed the records of 485 patients who had received the drug. We contacted 462, of whom 155 had conceived at least 1 pregnancy after developing IBD. Pregnancies were analyzed as to whether the patient had taken 6-MP before, or at the time of, conception. These were compared with IBD patients who had their pregnancies before taking 6-MP. We collected data on live births, spontaneous abortions, prematurity, abortions secondary to birth defects, major and minor congenital birth defects, infections, and neoplasia. Outcomes were analyzed comparing pregnancies from men and women who had taken or were currently taking 6-MP to controls.

RESULTS

There was no statistical difference in conception failures (defined as a spontaneous abortion), abortion secondary to a birth defect, major congenital malformations, neoplasia, or increased infections among male or female patients taking 6-MP compared with controls (RR = 0.85 [0.47-1.55], P = 0.59).

CONCLUSIONS

6-MP use before or at conception or during pregnancy appears to be safe. Discontinuation of the drug before and during pregnancy is not indicated.

Azathioprine and anti-TNF alpha therapies in Crohn's disease: a review of pharmacology, clinical efficacy and safety

Crohn's disease (CD), a chronic relapsing inflammatory condition of the intestines, is a common cause of gastrointestinal morbidity in young people. Although the aetiology of CD is unknown, host, genetic and environmental influences are clearly important. Glucocorticoids remain the mainstay of treatment for active CD, however only two-third of patients will respond and side effects are considerable. Surgery is often undesirable or impracticable and therefore alternative medical strategies have been sought. In recent years, there has been much interest in two areas of IBD therapy-the use of established immunomodulators, and the development of novel biological therapies. In this review, we have selected two areas of particular controversy-the use of purine analogues (azathioprine (AZA) and 6-mercaptopurine (6-MP)) and the introduction of anti-tumour necrosis factor alpha (TNFalpha) therapy and have examined the data for efficacy, safety and tolerability of these medications.

Cyclophosphamide therapy in a serious case of lupus nephritis during pregnancy

Systemic lupus erythematosus (SLE) flare is common, and renal involvement is one of the most serious problems during pregnancy. Aggressive immunosuppressive therapy should be considered for patients with diffuse proliferative lupus nephritis. These individuals are at high risk for progression to end-stage renal disease. Immunosuppressive drugs can cause significant toxic and teratogenetic effects. In this report, we describe the case of a pregnant patient with lupus nephritis who was treated with cyclophosphamide. The patient was in the second trimester of her first pregnancy and did not respond to corticosteroid therapy. She underwent intensive in-hospital care while she was on cyclophosphamide therapy. Both mother and baby were well at delivery.

Pregnancy in vasculitis

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.

Review article: the treatment of inflammatory bowel disease with 6-mercaptopurine or azathioprine

The thioguanine derivative, azathioprine, is a prodrug of 6-mercaptopurine that is further metabolized by various enzymes present in the liver and gut. Azathioprine and 6-mercaptopurine have been used in the treatment of inflammatory bowel disease, i.e. ulcerative colitis and Crohn's disease, for more than 30 years. However, widespread use of azathioprine or 6-mercaptopurine in inflammatory bowel disease is of more recent origin, the primary reason being a long-standing debate on the efficacy of these agents in inflammatory bowel disease. Both drugs are slow acting, which is why clinical efficacy cannot be expected until several weeks or even months of treatment have elapsed. Consequently, azathioprine and 6-mercaptopurine have no place as monotherapy in the treatment of acute relapsing inflammatory bowel disease. Today, azathioprine and 6-mercaptopurine are the most commonly used immunomodulatory drugs in the treatment of inflammatory bowel disease. Their clinical effects are probably identical, although their exact mode of action is still unknown. The mode of action of azathioprine is thought to be multifactorial, including conversion to 6-mercaptopurine (which acts as a purine antimetabolite), possible blockade of thiol groups by alkylation, inhibition of several pathways in nucleic acid biosynthesis (preventing proliferation of cells involved in the determination and amplification of the immune response) and damage to DNA through the incorporation of thiopurine analogues. However, 6-thioguanine nucleotides may accumulate in toxic doses in myeloid precursor cells, resulting in life-threatening myelosuppression. Azathioprine and 6-mercaptopurine are further known to alter lymphocyte function, reduce the number of lamina propria plasma cells and affect natural killer cell function. The purpose of this comprehensive review is to suggest guidelines for the application of azathioprine and 6-mercaptopurine in the treatment of inflammatory bowel disease.

Systemic lupus during pregnancy with refractory alveolar haemorrhage: recovery following termination of pregnancy

A case of refractory pulmonary hemorrhage in a pregnant 22-year-old with systemic lupus is presented. The clinical difficulty of management of pulmonary haemorrhage and lupus flare during pregnancy are discussed.

Treating inflammatory bowel disease during pregnancy: risks and safety of drug therapy

The safety of drug therapy for inflammatory bowel disease during pregnancy is an important clinical concern. Current available information is largely derived from animal studies and clinical experience among patients with inflammatory bowel disease and autoimmune disorders and organ transplant recipients. However, these data are confounded by various factors including difficulty projecting the results of animal studies to humans, methodological deficiencies of some studies, insufficient experience with certain agents, difficulty distinguishing the fetal effects of underlying disease from drug therapy and a need to consider the impact of background rates of adverse fetal outcomes which apply to all pregnancies. In inflammatory bowel disease, the effects of active inflammation on the fetus are believed to be more harmful than those of drug treatment, and therapy is often justified to induce or maintain remission during pregnancy. The choice of appropriate treatment is determined by the severity of the disease and the potential for drug toxicity. No causal relationship has been established between exposure to sulfasalazine or other 5-aminosalicylic acid drugs and the development of congenital malformations. These drugs may be used with relative safety during pregnancy and lactation. Considerable experience with corticosteroids have shown them to pose very small risk to the developing fetus. Current evidence indicates that maternal use of azathioprine is not associated with an increased risk of congenital malformations, though impaired fetal immunity, growth retardation or prematurity is occasionally observed. Preliminary evidence derived from patients with inflammatory bowel disease show no significant fetal toxicity following first trimester exposure to mercaptopurine, though its elective use in pregnancy is controversial. Cyclosporin is not teratogenic, but may be associated with growth retardation and prematurity. Pregnancy should be avoided in women treated with methotrexate because of its known abortifacient effects and risk of causing typical malformations. Although treatment with metronidazole or ciprofloxacin for short durations appear to be devoid of adverse fetal reactions, the effect of prolonged exposure as required in Crohn's disease remains unknown.

Women's health

Symptoms reliably attributable to menopause are vasomotor symptoms and vaginal dryness. Other symptoms are not directly related to the menopause. HRT or ERT are effective in providing symptom relief and preventing disease prevalent in postmenopausal women. HRT or ERT is beneficial in women with RA. Little data concerns safety in SLE patients, but there are theoretical advantages to using HRT or ERT in women with SLE and two studies that indicate it is safe. Other forms of treatment are available to women who cannot or will not use HRT or ERT.

Complete congenital heart block: a review and case study

Complete congenital heart block (CCHB) is a rare disease of the newborn that carries significant morbidity and mortality. It generally occurs as a result of the presence of maternal autoantibodies that are transferred to the fetus and affect the fetal heart, or it may be associated with a congenital structural abnormality of the heart. Infants with CCHB are at risk for diminished cardiac output and the subsequent development of congestive heart failure. Many infants require the placement of a cardiac pacemaker. It is essential that the nurse caring for these infants have a good understanding of the disease process and be familiar with the unique problems that these infants and their families may encounter.

Corticosteroids during pregnancy

In pregnancy, pharmacokinetics of corticosteroids changes. Systemic corticosteroids are not teratogenic. Pregnant women receiving corticosteroid therapy suffer the same side effects and benefits as do treated women who are not pregnant. Clinical experience suggests no abnormalities of children of mothers treated with usual doses of prednisone and methylprednisolone throughout pregnancy, but premature rupture of amniotic membranes and low birthweight babies may occur. Betamethasone and dexamethasone are used to treat the fetus. The effect on the fetus of bolus doses of methylprednisolone is unknown. Very little corticosteroid ingested by the mother enters her breast milk. Corticosteroid therapy in pregnancy is appropriate to control clinically active maternal illness; to treat an in utero infant suffering from neonatal lupus-associated carditis; in stress doses (in corticosteroid-treated patients) for labor and delivery: and, pre-delivery, to induce fetal lung maturation.

Pregnancy in SLE

The effect of pregnancy on disease activity in systemic lupus erythematosus remains controversial. Studies on lupus flares in pregnancy are discussed, including prospective data on severity of flares and organ involvement from the Hopkins Lupus Pregnancy Center. The major fetal concerns of miscarriage (due to the antiphospholipid antibody syndrome), pre-term birth (largely due to pre-eclampsia or premature rupture of membranes) and neonatal lupus, are reviewed.

Azathioprine in inflammatory bowel disease, a safe alternative?

Azathioprine and its metabolite 6-mercaptopurine are effective in the treatment of inflammatory bowel disease. They are mostly used for reduction of the use of steroids, maintenance therapy after remission induction by cyclosporin and treatment of fistulae in Crohn's disease. Adverse effects occur in about 15% of patients. The main side effects are pancreatitis, allergic reactions, fever and bone marrow suppression. Symptoms, management and prevention are discussed. A blood monitoring schedule is suggested. Azathioprine and 6-mercaptopurine seem to be safe in pregnancy. There may be a slight increased risk for developing a non-Hodgkin's lymphoma.

Infertility in women with pemphigus vulgaris and other autoimmune diseases

BACKGROUND

Pemphigus vulgaris (PV) is an autoimmune disease. Autoimmune diseases may adversely affect reproductive function and could result in infertility.

OBJECTIVE

Our purpose was to describe nine young women with PV and infertility.

METHODS

A retrospective study was performed. Clinical characteristics, immunopathologic features, treatment, clinical course, and long-term follow-up were determined.

RESULTS

Eight of nine patients were unable to become pregnant. One patient became pregnant during a period of remission. In eight of the nine patients, the cause of infertility was ovarian. Anti-sperm antibodies were present in two of the patients.

CONCLUSION

Some patients with PV may have infertility. No definitive conclusion about the frequency of infertility in these patients or its relation to PV can be drawn. However, these observations indirectly demonstrate that there may be important interactions between the immune and hormonal systems.

Immunosuppressive drug use during pregnancy

Women with rheumatic diseases frequently need treatment throughout pregnancy and lactation. Physicians must confront the dual challenge of monitoring the possible effects of the underlying maternal disease and the medications on both mother and child. It is essential that the maternal disease be well controlled before, during, and after pregnancy to ensure the best possible outcome for the mother and child. Corticosteroids have been used extensively and safely in pregnant patients with systemic lupus erythematosus and rheumatoid arthritis; there have been no reports of congenital malformations in the exposed infants. There is considerable experience using azathioprine during pregnancy if the maternal condition requires use of a cytotoxic drug; there has been no increased risk of congenital malformations in the exposed infants. There is limited information on the safety of other medications, including 6-mercaptopurine, cyclophosphamide, and cyclosporine. Methotrexate is contraindicated during pregnancy, and chlorambucil should be avoided because there are other effective immunosuppressive agents available for use. Corticosteroids (prednisone and methylprednisolone) can be used safely during lactation. All other immunosuppressive medications, azathioprine and 6-mercaptopurine, chlorambucil, cyclophosphamide, cyclosporine, and methotrexate, are contraindicated during lactation.

Pregnancy and rheumatoid arthritis

Amelioration of rheumatoid arthritis (RA) occurs in about three quarters of pregnancies. Most women who improve experience initial relief in the first trimester. RA almost invariably recurs within 3 to 4 months of delivery. The effect of pregnancy upon the risk of first developing RA is similar in some respects but also differs from that observed in women with established disease. Analogous to women with established disease, the chance of a woman first developing RA is significantly reduced during pregnancy but increased in the first year post partum; thereafter risk is decreased. There is no indication of any adverse effects of RA on pregnancy outcome. Although limited, some medications can be used during pregnancy and during lactation without jeopardizing the well-being of the fetus.

Complications of cyclophosphamide therapy

Cyclophosphamide is a powerful immunosuppressive agent that is commonly used clinically to treat neoplastic and inflammatory diseases affecting various sites, including the head and neck. The pharmacology of cyclophosphamide is reviewed with an emphasis on its toxicities and strategies for minimizing therapeutic adverse effects. Principles of therapy are discussed and illustrated by the use of cyclophosphamide in the treatment of Wegener's granulomatosis, a form of systemic vasculitis with prominent head and neck manifestations.

Factors associated with fetal losses in severe systemic lupus erythematosus

We evaluated factors associated with fetal losses in patients with severe lupus in a nested case-control study. We assessed separately 73 pregnancies that occurred in 46 women from a cohort of 633 Systemic Lupus Erythematosus (SLE) patients. They had at least one pregnancy after SLE diagnosis, one or more of our severity criteria and all had taken immunosuppressive drugs. Included data were related to disease severity, anti-phospholipid syndrome (APS), anticardiolipin antibodies (a-CL ab), and drugs received during pregnancy. Cases were pregnancies with fetal wastage; controls were pregnancies with live-born children. The mean age at pregnancy was 26.6 +/- 4.5 years. Cases had longer disease duration, 6.1 +/- 3.5 years vs 4.5 +/- 4.3 of controls (p = 0.02); higher prevalence of renal involvement, hemolysis and recurrent venous thrombosis (p < 0.05); they also tended to have a greater prevalence of a-CL ab, and previous fetal losses (p = 0.06). Cases used azathioprine more frequently than controls (p = 0.04). Univariate analysis showed an association of renal involvement, hemolytic anemia, azathioprine or cyclophosphamide prescription during pregnancy, previous fetal losses and APS with fetal wastage. Immunosuppressive drugs and the APS remained significant in the multivariate analysis (p = 0.05; F = 0.01). Factors related with fetal losses in women with severe SLE were: longer disease duration, ingestion of immunosuppressive drugs during pregnancy and any related manifestation of APS. We did not find macroscopic malformations in live-children of women that took azathioprine during pregnancy.

Incidence of ovarian failure in systemic lupus erythematosus after treatment with pulse cyclophosphamide

OBJECTIVE

To investigate the incidence of ovarian failure after pulse cyclophosphamide treatment in systemic lupus erythematosus (SLE) and to compare this with two control groups: SLE patients treated with azathioprine, and a healthy age matched population.

METHODS

All women patients with SLE treated with pulse cyclophosphamide in our department were identified and questioned concerning menstrual history. All the hospital notes were reviewed and details recorded on dose of cyclophosphamide, duration of treatment, side effects and lowest pretreatment neutrophil and leucocyte counts during the course of treatment. Disease controls were recruited from our department and healthy controls from the local family health services authority (FHSA) register.

RESULTS

Incidence of ovarian failure in the premenopausal cyclophosphamide treated group was 54% and the incidence of premature menopause (occurring before age 40 years) was 41%. Increasing age at start of treatment showed a linear trend with incidence of ovarian failure (p = 0.01). Using logistic regression, increasing duration of treatment was related to incidence of ovarian failure (p = 0.047 in those treated age 35 years or younger). An association between the lowest neutrophil count throughout the treatment period, when taken immediately before each planned cyclophosphamide pulse, and the incidence of ovarian failure was also demonstrated (p = 0.04 in those treated before age 40 years).

CONCLUSION

Ovarian failure--in particular, premature failure after treatment with pulse cyclophosphamide--is common. Factors associated with increased risk include greater age at start of treatment, longer period of treatment, and greater degree of marrow suppression as assessed by the neutrophil count immediately before each planned cyclophosphamide pulse.

Anticardiolipin syndrome, aspirin therapy and fetal malformation

A patient with systemic lupus erythematosus and elevated cardiolipin antibody levels was given low-dose aspirin therapy prior to and throughout her third pregnancy to minimize the risk of miscarriage. She delivered a boy at 38 weeks with the skeletal deformity of two thoracic hemivertebrae. The putative role of aspirin causing this birth defect is discussed.