Wegener’s granulomatosis in pregnancy: A novel approach to management

Glomerular diseases in pregnancy: pragmatic recommendations for clinical management

Our understanding of the various aspects of pregnancy in women with kidney diseases has significantly improved in the last decades. Nevertheless, little is known about specific kidney diseases. Glomerular diseases are not only a frequent cause of chronic kidney disease in young women, but combine many challenges in pregnancy: immunologic diseases, hypertension, proteinuria, and kidney tissue damage. An international working group undertook the review of available current literature and elicited expert opinions on glomerular diseases in pregnancy with the aim to provide pragmatic information for nephrologists according to the present state-of-the-art knowledge. This work also highlights areas of clinical uncertainty and emphasizes the need for further collaborative studies to improve maternal and fetal health.

Granulomatosis with polyangiitis and pregnancy: A case report and review of the literature

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.

Successful treatment outcomes in pregnant patients with ANCA-associated vasculitides: A systematic review of literature

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.

A case of ANCA-associated vasculitis presenting de novo in pregnancy, successfully treated with rituximab

Antineutrophil cytoplasm antibody (ANCA)-associated vasculitides are rare small vessel vasculitides of unknown cause. The pathogenic role of MPO-ANCA in the vasculitides has been supported using various animal models, with B-cells playing a role in the disease pathogenesis. Pregnancy in the presence of an autoimmune disease such as vasculitis is often associated with significant morbidity. Little is known about the outcomes when women present with de novo vasculitis during pregnancy, and the appropriate management of such presentations is unclear. We describe a case of a 33-year-old female presenting in her second pregnancy with new onset ANCA vasculitis at 12 weeks' gestation. She was successfully treated with prednisolone and rituximab, and delivered a healthy 2.8 kg boy at 36 weeks' gestation with no clinical manifestations of vasculitis or neutropenia in the neonate.

The rhinological manifestations of women's health

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.

Pregnancy complicating Wegener's granulomatosis

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.

Advances in the use of biologic agents for the treatment of systemic vasculitis

PURPOSE OF REVIEW

Due to the well known toxicities of cyclophosphamide, substantial interest exists in finding other therapies to treat primary systemic vasculitis. Biologic agents have been proposed as an alternative to cyclophosphamide for these disorders because of their recent success in treating other rheumatic diseases. This article reviews the current state-of-the-art therapy with regards to the use of biologic agents as treatments for systemic vasculitis.

RECENT FINDINGS

The greatest amount of experience with these agents for the treatment of systemic vasculitis is with antitumor necrosis factor agents, pooled intravenous immunoglobulin, and anti-B-cell therapies such as rituximab. Intravenous immunoglobulin is already a standard therapy for Kawasaki's disease, but should also be considered for the treatment of vasculitis associated with antineutrophil cytoplasmic antibodies when standard therapies are either ineffective or contraindicated. Early experience with tumor necrosis factor inhibitors indicates that they may be effective for the treatment of Takayasu's arteritis, but their role in the treatment of other forms of vasculitis remains controversial. Early experience with rituximab for the treatment of several forms of vasculitis has been quite promising, but must be confirmed by ongoing randomized clinical trials.

SUMMARY

Biologic agents represent the next evolution in treatment for the primary systemic vasculitides. Greater understanding of these diseases has allowed us to move further away from nonspecific, highly toxic therapies toward a more directed approach. As our experience with these agents increases, they will likely form the keystone of treatment in the near future.

A case of granuloma in the occipital lobe of a patient with Wegener's granulomatosis

We report a case of Wegener's granulomatosis (WG) with central nervous system (CNS) involvement in a woman who complained of bilateral visual disturbance. The intracranial necrotizing granulomatous lesion was confirmed by MR imaging and brain biopsy. After high-dose oral corticosteroid treatment, not only clinical manifestations but also laboratory tests improved. Moreover, the CNS lesion completely regressed. This suggests that high-dose corticosteroid alone might be effective in treating WG with CNS involvement.

Successful treatment of new onset Wegener's granulomatosis with IVIG (intravenous immunoglobulin) during pregnancy: a case report

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.

Pregnancy and vasculitis

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.

Successful term pregnancy in a patient with Wegener's granulomatosis: case report and literature review

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.

Intravenous immunoglobulin treatment in vasculitis and connective tissue disorders

Vasculitis syndromes and connective tissue disorders are heterogeneous and mostly rare multisystem disorders with various autoimmune mechanisms driving tissue inflammation and remodeling, ischemic and hemorrhagic tissue damage. While the nervous system can be affected by most of these diseases, the pathogenesis for neural involvement is often ambiguous and elusive for the clinician. Intravenous immunoglobulins (IVIG) have been used for the treatment of most of these disorders. However, a thorough review of the literature indicates that the role for IVIG has to be discussed for individual entities, has often only anecdotal evidence, and is particularly hard to define with respect to neurological manifestations. This review gathers the available evidence on the efficacy of IVIG in neurologically relevant rheumatic diseases, leading to recommendations for their clinical use.

Wegener's granulomatosis presenting during pregnancy with acute limb ischemia

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.