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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 8  |  Issue : 2  |  Page : 118-119

Microscopic polyangiitis, chronic hemodialysis: A successful pregnancy


1 Department of Internal Medicine, Military Training Hospital Mohammed V, Rabat, Morocco
2 Department of Gynecology and Obstetrics, Military Training Hospital Mohammed V, Rabat, Morocco

Date of Web Publication13-Sep-2019

Correspondence Address:
Prof. Mohamed Jira
Department of Internal Medicine B, Military Training Hospital Mohammed V, Hay Riad, Rabat
Morocco
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sjhs.sjhs_35_19

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  Abstract 


Few pregnancies in microscopic polyangiitis (MPA) are described, that a high-risk nursery association and/or fetal. We report the case of a pregnancy carried to a successful conclusion without maternal or fetal complications in a patient followed for MPA in remission with azathioprine as a sequela-stage renal disease dialysis. This observation underlines the importance to plan pregnancy in patients treated for vasculitis, full and sustained remission, and taking into account the consequences of the vasculitis. Treatment decisions in case of relapse during pregnancy are based on the severity of the visceral and the term pregnancy.

Keywords: Antineutrophil cytoplasmic antibody-associated vasculitis, chronic hemodialysis, microscopic polyangiitis, pregnancy


How to cite this article:
Jira M, Raiteb H, Kouach J. Microscopic polyangiitis, chronic hemodialysis: A successful pregnancy. Saudi J Health Sci 2019;8:118-9

How to cite this URL:
Jira M, Raiteb H, Kouach J. Microscopic polyangiitis, chronic hemodialysis: A successful pregnancy. Saudi J Health Sci [serial online] 2019 [cited 2019 Nov 22];8:118-9. Available from: http://www.saudijhealthsci.org/text.asp?2019/8/2/118/264948




  Introduction Top


Microscopic polyangiitis (MPA) is a systemic necrotizing vasculitis affecting small vessels, characterized by renal involvement such as extracapillary glomerulonephritis associated with intra-alveolar hemorrhage (pneumo-renal syndrome) and by the presence of antineutrophil cytoplasmic antibody (ANCA), having antigenic specificity for anti-myeloperoxidase (MPO).[1] Other possible manifestations are comparable to those seen in other necrotizing vasculitis. Pregnancy during MPA is considered an association with high maternal and/or fetal risks. We report a new case of pregnancy occurring in a patient followed up for an MPA, and through the data of the literature, we recall the different aspects of this association.


  Case Report Top


A 41-year-old patient has been followed up for 5 years for a cutaneous, pneumo-renal, neurological manifestation of MPA. The diagnosis was based on the following criteria: febrile syndrome, weight loss of 15 kg in 3 months, purpuric lesions of the lower limbs, ischemic stroke, multineuritis, intra-alveolar hemorrhage, acute renal failure, hematuria, and proteinuria (renal biopsy revealed extracapillary necrotizing glomerulonephritis without immune deposition). ANCAs were positive at 80 (normal<20) with indirect immunofluorescence and perinuclear fluorescence with anti-MPO antigen specificity at 90 U/mL (n < 9) on enzyme-linked immunosorbent assay. The patient was treated with one-bolus cyclophosphamide once every 4 weeks (six boluses), followed by 150 mg/day azathioprine and methylprednisolone bolus (15 mg/kg/day for 3 days in a row), relays with oral prednisone at a rate of 1 mg/kg/day for 1 month, and then, a progressive decrease to 5 mg/day. The evolution was marked by clinical remission; moreover, the renal function was aggravated by evolving toward end-stage renal failure at the dialysis stage.

Obstetrically, the patient had 2-year amenorrhea without contraception. The current pregnancy was fortuitous discovery in front of pelvic pain; the examination found a pale patient with discolored conjunctiva, hypertensive at 160/100 mmHg. The uterine height was 28 cm, and the fetal heart sounds were positive and regular. Obstetrical ultrasound found an evolutionary monofetal pregnancy. Biometrics corresponded to 28 weeks of amenorrhea with an estimated fetal weight of 1117 g and a hydramnios of 32 cm. Uterine Doppler revealed a uterine notch. Biological assessment showed normocytic anemia at 6.5 g/dl.

The treatment consisted of an increase in dialysis sessions at 5/week for 4 h, with a low flow rate of 250 ml/min, a transfusion of four red blood cells, and an administration of 3000 IU of erythropoietin three times a week. She received one cure of corticosteroids (CTs): betamethasone 12 mg intramuscular renewed in 24 h for lung maturity. Blood pressure was controlled by calcium channel blockers and alfa methyldopa. Azathioprine was continued in combination with prednisone whose dose has been increased to 1 mg/kg/day. Weekly obstetric ultrasound surveillance was recommended, and the evolution was marked by the disappearance of the uterine notch and the improvement of the amniotic fluid index which went from 32 to 22 cm. The weight gain was 200 g/week on an average.

The patient was admitted to work at 37 weeks; she gave birth in occipito-pubic position of a newborn female with a 10/10 Apgar score and a birth weight of 2800 g. The suites were simple for the mother and the newborn. Vasculitis remained stable postpartum with a year-long decline.


  Discussion Top


MPA, initially considered a simple microscopic variant of polyarteritis nodosa (PAN), was clearly individualized and recognized as a separate entity in 1994 with the Chapel Hill nomenclature.[2] Few pregnancies have been reported in women with MPA.[3],[4],[5],[6] The fact that MPA has been individualized and its recent distinction with PAN, as well as the risks of infertility induced by vasculitis treatments, also partly explain this fact.[7] It is essential to plan for pregnancy when the vasculitis has been in remission for several months or even years (at least 2 years), and toxic and/or potentially teratogenic immunosuppressive therapy has been discontinued for several months.[3],[4],[6],[7] The activity of vasculitis, the effects of treatment on the mother and the fetus, and the possible sequelae of the disease should be taken into account when pregnancy is considered. Renal failure and high blood pressure can affect the progress of pregnancy, especially during childbirth.[8] The maternal and/or fetal complications reported during MPA are preeclampsia, therapeutic interruption of pregnancy (TIP), fetal death, prematurity, and intrauterine growth retardation.[4],[6] The planning and/or the occurrence of pregnancy in patients treated for vasculitis and in complete remission, without treatment, represents the ideal situation, the outcome of which for the mother and the child is almost always favorable, as the case in our patient. When the vasculitis, known previously, is still active when the pregnancy is started, the care is more delicate. Assessment of vasculitis activity and, therefore, therapeutic decisions are more difficult. Certain biological parameters of inflammation are disturbed by pregnancy; radiological examinations are contraindicated and/or must be kept to a minimum, when they are really necessary. MRI and Doppler ultrasonography do not, to date, permit a complete vascular exploration as conventional angiography, particularly small vessels.[7] The teratogenic risks of ongoing and/or indicated treatments should be discussed and evaluated with obstetricians. An TIP must sometimes be considered. Vasculitis treatment, which is not a problem during pregnancy, is limited to CTs, intravenous immunoglobulin (IV Ig), and azathioprine. Cyclophosphamide (CP) remains, however, the most active drug in case of severe form of the disease. Its use is especially troublesome and contraindicated in theory, during the first trimester and the beginning of the second. It is sometimes possible to attempt to control the disease by a combination of CTs, azathioprine, and/or IV Ig during pregnancy, pending delivery, or a cesarean section, scheduled as soon as possible, before starting the bolus CP.[9] The risk to the mother and pregnancy of a severe, progressive, insufficiently, and/or late controlled vasculitis may, however, be greater than that related to the prescription of CP during pregnancy.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Guillevin L, Mahr A, Cohen P. Systemic necrotizing vasculitides: classifications and therapeutic strategies. Rev Med Interne 2003;24:172-82.  Back to cited text no. 1
    
2.
Jennette JC, Falk RJ, Andrassy K, Bacon PA, Churg J, Gross WL, et al. Nomenclature of systemic vasculitides. Proposal of an international consensus conference. Arthritis Rheum 1994;37:187-92.  Back to cited text no. 2
    
3.
Pagnoux C, Mahendira D, Laskin CA. Fertility and pregnancy in vasculitis. Best Pract Res Clin Rheumatol 2013;27:79-94.  Back to cited text no. 3
    
4.
Milne KL, Stanley KP, Temple RC, Barker TH, Ross CN. Microscopic polyangiitis:First report of a case with onset during pregnancy. Nephrol Dial Transplant 2004;19:234-7.  Back to cited text no. 4
    
5.
Bansal PJ, Tobin MC. Neonatal microscopic polyangiitis secondary to transfer of maternal myeloperoxidase-antineutrophil cytoplasmic antibody resulting in neonatal pulmonary hemorrhage and renal involvement. Ann Allergy Asthma Immunol 2004;93:398-401.  Back to cited text no. 5
    
6.
Pagnoux C, Le Guern V, Goffinet F, Diot E, Limal N, Pannier E, et al. Pregnancies in systemic necrotizing vasculitides: Report on 12 women and their 20 pregnancies. Rheumatology (Oxford) 2011;50:953-61.  Back to cited text no. 6
    
7.
Pagnoux C. Pregnancy and vasculitides. Presse Med 2008;37:1657-65.  Back to cited text no. 7
    
8.
Seo P. Pregnancy and vasculitis. Rheum Dis Clin North Am 2007;33:299-317.  Back to cited text no. 8
    
9.
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 2008;89:457.e1-5.  Back to cited text no. 9
    




 

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