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Demotier S, Orquevaux P, N’Guyen Y. Systemic vasculitis diagnosed during the post-partum period: case report and review of the literature. Matern Health Neonatol Perinatol 2023; 9:2. [PMID: 36755295 PMCID: PMC9906945 DOI: 10.1186/s40748-023-00147-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 02/01/2023] [Indexed: 02/10/2023] Open
Abstract
INTRODUCTION The vasculitis diagnosed specifically in the post-partum period are less well known. We report here such a case followed by a descriptive review of the literature. CASE REPORT A 25 year-old French nurse reported abrupt-onset musculoskeletal pain 15 days after delivery of her first infant. Her first pregnancy was uneventful. The physical examination yielded only bilateral conjunctivitis and purpuric eruption of lower limbs, and complementary investigations evidenced pulmonary renal syndrome in connection with the diagnosis of Granulomatosis with Polyangiitis. METHODS We screened previous articles in Medline database using keywords (i) "post-partum" or "puerperium" (ii)"peripartum" (iii) "pregnancy" associated with "vasculitis". Full texts were obtained from case reports or cases series whose title or abstract included keywords of interest (or synonyms). These references were secondarily excluded if the diagnosis of vasculitis was not confirmed or made before or more than 6 months after delivery and if vasculitis occurred only in the new born or affected only the cerebral vasculature or the retina. RESULTS Fifty-six cases of vasculitis diagnosed in the post-partum period were included, 50 (89.3%) were secondary to an immunological process and 44 corresponded to primary vasculitis, 4 were secondary to Systemic Lupus Erythematosus, 1 to cryoglobulinaemia and 1 to cryoglobulinaemia associated with inflammatory bowel disease. The main primary vasculitis diagnosed were Takayasu Arteritis (n = 10), Eosinophilic granulomatosis with polyangiitis (n = 9), Granulomatosis with Polyangiitis (n = 7), Periarteritis Nodosa (n = 5) and Behcet's disease (n = 4). The first symptom occurred before delivery in 26 (59.1%) and maternal death occurred in 4 (9.1%) out of the 44 primary vasculitis cases. CONCLUSION The vasculitis diagnosed in the post-partum period were mainly primary vasculitis among patients in whom the diagnosis had not been made during pregnancy. In less than half of cases and as described in ours, there were no reported symptoms before delivery. Therefore, the physicians should pay attention to symptoms and keep a high degree of suspicion for vasculitis before as well as after delivery.
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Affiliation(s)
- Sophie Demotier
- grid.139510.f0000 0004 0472 3476Service de Médecine Interne, Maladies Infectieuses Et Immunologie Clinique. Hôpital Robert Debré. Centre Hospitalier Universitaire Reims, 51100 Reims, France
| | - Pauline Orquevaux
- grid.139510.f0000 0004 0472 3476Service de Médecine Interne, Maladies Infectieuses Et Immunologie Clinique. Hôpital Robert Debré. Centre Hospitalier Universitaire Reims, 51100 Reims, France
| | - Yohan N’Guyen
- grid.139510.f0000 0004 0472 3476Service de Médecine Interne, Maladies Infectieuses Et Immunologie Clinique. Hôpital Robert Debré. Centre Hospitalier Universitaire Reims, 51100 Reims, France
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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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Pregnancy-Related Challenges in Systemic Autoimmune Diseases. JOURNAL OF INFUSION NURSING 2017; 38:360-8. [PMID: 26339942 DOI: 10.1097/nan.0000000000000124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The awareness of pregnancy-related physiologic changes and complications is critical for the appropriate assessment and management of pregnant patients with systemic autoimmune diseases. The overlapping features of physiologic and pathological changes, selected autoantibodies, and the use of potentially teratogenic medications can complicate their management during pregnancy. While pregnancy in lupus patients presents an additional risk to an already complex situation, in patients with no disease activity, the risk of a future pregnancy-related complication is relatively low. Anti-Ro and anti-La antibodies increase the risk of neonatal lupus erythematosus, eg, photosensitive rash and irreversible congenital heart block. Antiphospholipid antibodies increase the risk of pregnancy morbidity, eg, fetal loss and early preeclampsia. Pregnancy usually has a positive effect on rheumatoid arthritis; however, a disease flare is common during the postpartum period. Both the rheumatologist and the obstetrician should partner throughout the pregnancy to manage patients for successful outcomes.
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Edwards MH, Curtis EM, Ledingham JM. Postpartum onset and subsequent relapse of eosinophilic granulomatosis with polyangiitis. BMJ Case Rep 2015; 2015:bcr-2015-210373. [PMID: 26106182 DOI: 10.1136/bcr-2015-210373] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Eosinophilic granulomatosis with polyangiitis (EGPA) can affect women of childbearing age. However, reports of the disease in the postpartum period are limited. We present a case of postpartum-onset EGPA that went into clinical remission before relapsing in the subsequent postpartum period. Our patient presented with dyspnoea, arthralgia and rash, shown to be eosinophilic vasculitis, 3 days following the birth of her second child. CT of the thorax showed alveolar shadowing and mediastinal lymphadenopathy. She was treated successfully for EGPA with glucocorticoid therapy. She declined maintenance treatment during remission. Off treatment, she remained disease free throughout her next pregnancy. In the postpartum period she relapsed in an almost identical manner, requiring prolonged glucocorticoid therapy, cyclophosphamide and rituximab. This case highlights the importance of maintenance therapy around pregnancy in individuals with EGPA, and the need for careful monitoring of women with a history of EGPA in the postpartum period.
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Affiliation(s)
- Mark Hiley Edwards
- MRC Lifecourse Epidemiology Unit, Southampton General Hospital, Southampton, UK
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Albahri Z, Minxová L, Lukeš A, Mawiri AA, Štefáčková Š. Churg-Strauss syndrome in childhood: a case report. J Child Neurol 2014; 29:NP98-100. [PMID: 24170259 DOI: 10.1177/0883073813506492] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Churg-Strauss syndrome is a rare form of small-vessel vasculitis. In the current report, we describe the case of a 17-year-old Czech girl predominantly characterized by peripheral neuropathy, the presence of cardiac and pulmonary involvement, hypereosinophilia, asthma, and sinusitis that led to the diagnosis of Churg-Strauss syndrome.
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Affiliation(s)
- Ziad Albahri
- Department of Pediatrics, Faculty hospital, Charles University, Hradec Králové, Czech Republic
| | - Lenka Minxová
- Department of Pediatrics, Faculty hospital, Charles University, Hradec Králové, Czech Republic
| | - Antonín Lukeš
- Department of Pediatrics, Faculty hospital, Charles University, Hradec Králové, Czech Republic
| | - Abdul Al Mawiri
- Department of Internal medicine, Faculty Hospital, Charles University, Hradec Králové, Czech Republic
| | - Šárka Štefáčková
- Deparment of Neurology, Faculty hospital, Charles University, Hradec Králové, Czech Republic
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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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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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Corradi D, Maestri R, Facchetti F. Postpartum Churg-Strauss syndrome with severe cardiac involvement: description of a case and review of the literature. Clin Rheumatol 2009; 28:739-43. [PMID: 19238502 DOI: 10.1007/s10067-009-1143-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2008] [Accepted: 02/12/2009] [Indexed: 01/11/2023]
Abstract
Churg-Strauss syndrome (CSS) is a rare small- or intermediate-vessel necrotizing vasculitis typically characterized by asthma, lung infiltrates, necrotizing granulomas, and hypereosinophilia. In this report, we describe the case of a 35-year-old woman who, during her third trimester of pregnancy, developed dyspnea and, after delivery, severe cardiac failure which required heart transplantation. Diagnosis of CSS was made after performing a myocardial biopsy. We have also undertaken a review of the English-language literature regarding previously reported cases of pregnancies in women suffering from Churg-Strauss syndrome with particular attention to those patients with cardiovascular involvement.
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Affiliation(s)
- Domenico Corradi
- Department of Pathology and Laboratory Medicine, Section of Pathology, University of Parma, Via Gramsci 14, 43100, Parma, Italy.
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Abstract
Systemic vasculitides, like Takayasu's arteritis, polyarteritis nodosa, Wegener's granulomatosis, Churg-Strauss syndrome, Henoch-Schönlein purpura, or Behçet's disease can affect women of child-bearing years. The rarity of these vasculitides, their frequent fatal outcomes until recent years, and the use of toxic immunosuppressants to treat patients, contra-indicating pregnancy and/or potentially inducing hypofertility or sterility, explain the few pregnancies reported in the literature so far. Notably, it does not seem that pregnancy has a major impact on vasculitis outcome, in contrast with systemic lupus erythematosus, but a specialized management of these pregnant patients is mandatory. There are some reported cases of vasculitis revealed during pregnancy. Even though some of these pregnant patients had a severe disease and died, most of them had a favourable outcome, and a living inborn, providing prompt care and adequate treatment. When vasculitis is already known and treated, pregnancy should at best be planned, when the disease is in sustained remission and all toxic immunosuppressants have been stopped for months. Vasculitis sequella, like hypertension, renal insufficiency, or asthma, must also be taken into account, monitored and appropriately managed throughout the pregnancy and a few weeks following delivery. In case of vasculitis' flare during pregnancy, potential treatments include corticosteroids, intravenous immunoglobulins, azathioprine, plasma exchanges, and, for limited skin manifestations or Behçet's disease, hydroxychloroquine or colchicine. Importantly, when the disease is severe, a delay in the prescription of a stronger, immunosuppressant, chiefly intravenous cyclophosphamide, can be more detrimental, although being potentially toxic, for both the mother and the foetus than an ineffective and/or inappropriate regimen with less active drugs. Safety data on biologics, like rituximab, for pregnant women are very sparse to date and their use is therefore not recommended, unless confronted with a severe and refractory disease, and after referring to a specialized center for vasculitides.
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Affiliation(s)
- Christian Pagnoux
- Pôle de Médecine Interne, Centre de Référence Groupe I Maladies Rares, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Université Paris Descartes, Paris Cedex 14, France.
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Zoulim A, Boza G, Dreyfus M, Artigues N, Ollivier Y, Bienvenu B, Letellier P. Grossesse et vascularite de Churg-Strauss. Rev Med Interne 2008. [DOI: 10.1016/j.revmed.2008.03.282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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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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Doria A, Iaccarino L, Ghirardello A, Arienti S, Zampieri S, Rampudda ME, Tincani A, Todesco S. Seltene autoimmune rheumatische Erkrankungen in der Schwangerschaft. Z Rheumatol 2006; 65:200, 202-6, 208. [PMID: 16670810 DOI: 10.1007/s00393-006-0059-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Autoimmune rheumatic diseases (ARD) affect young females during childbearing age. Over the last decades, improvements in survival as well as quality of life in patients affected with ARD have led to an increased number of pregnancies observed during the course of such diseases. Systemic lupus erythematosus (SLE) is the most frequently observed ARD during pregnancy, and the immunoendocrine changes occurring during pregnancy may influence the course of this disease. Pregnancy can also occur in patients with rare ARD, namely systemic sclerosis, polymyositis/dermatomyositis, systemic vasculitis including Wegener's granulomatosis, Churg-Strauss syndrome, polyarteritis nodosa, microscopic polyangiitis, Takayasu arteritis and Behçet disease. This review focuses on the complications during pregnancy caused by these rare ARD, and we briefly discuss the data published on these disorders. Some guidelines for the management of these conditions during pregnancy will also be provided. However, it is important to note that data on pregnancy outcome are very limited and, in the absence of prospective studies, most of the information derives from case reports and retrospective studies.
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Affiliation(s)
- A Doria
- Division of Rheumatology, Department of Medical and Surgical Sciences, University of Padova, Padova.
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Woywodt A, de Groot K, Bahte S, Schwarz A, Haller H, Haubitz M. Severe relapse of Wegener's granulomatosis during the early postpartum period. Ann Rheum Dis 2006; 65:137. [PMID: 16344503 PMCID: PMC1797990 DOI: 10.1136/ard.2005.037598] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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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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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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