Seema Chopra, MD; Vanita Suri, MD; Rashmi Bagga, MD; Meenakshi R. Thami, MD; Aman Sharma, MD; Pardeep Bambery, MD

Disclosures

Medscape J Med. 2008;10(1):17 

In This Article

Introduction

Patients with autoimmune diseases face several pregnancy-related problems as well as disease flares during and after pregnancy. Dermatomyositis /polymyositis (DM/PM) is an uncommon medical disorder complicating pregnancy. It may start before, during, or even after pregnancy.[1,2] Optimal outcome can be anticipated when the pregnancy is undertaken with the disease in remission.[3] Pregnancy outcome is especially poor with disease onset or flare early in the gestation compared with an exacerbation in the second or third trimester, when the fetal prognosis is usually good.[4]

Unlike systemic lupus erythematosus (SLE), for which pregnancy has been well studied and reported, there are only a few case reports in the literature detailing this physiologic event in patients with DM/PM. We report on the outcome of 3 pregnancies in 2 women with DM/PM.

Mrs. SB, a 28-year-old primigravida with a diagnosed case of dermatomyositis for the past 6 years, was supervised in our antenatal clinic. She had a history of intermittent painless swelling over the extremities, along with alopecia and photosensitivity at 12 years of age, for which she did not seek any medical advice. She was first seen in the rheumatology clinic of our institution at 22 years of age. At this time she had muscle pain, weakness, and facial rash. Investigations revealed a raised erythrocyte sedimentation rate (ESR) and creatine phosphokinase (CPK); antinuclear antibodies (ANA) were diffuse positive on immunofluorescence; and the muscle biopsy confirmed the diagnosis of DM. The disease did not show adequate improvement with steroids alone but responded well to the addition of methotrexate. Treatment was continued for the next 3 years.

At the time of conception, the disease had been in remission, and she was not on medication for her medical disorder for a period of over 6 months. Her disease remained quiescent throughout the pregnancy. Maternal and fetal surveillance was uneventful until late in the third trimester when she developed hypertension. Labor was induced with oxytocin at 37+5 weeks for gestational hypertension. She delivered vaginally a live-born female child weighing 2815 g and with normal Apgar score. Both the mother and the child were discharged in a satisfactory condition. There was no postpartum exacerbation of the disease.

With the disease in remission, she conceived spontaneously for the second time after 3 years and received antenatal care in our clinic. Unlike her first pregnancy, her blood pressure remained normal, but the fetus had intrauterine growth restriction (IUGR) at 32 weeks on ultrasonography, which incidentally revealed low-lying placenta as well, and therefore she was admitted for safe confinement. She delivered a live-born, small-for-date baby girl weighing 2170 g by emergency cesarean section for antepartum hemorrhage at 36 weeks. The intraoperative as well as postoperative period was uneventful.

Mrs. S, a 25-year-old primigravida, was diagnosed with PM (after muscle biopsy) and lichen planus pigmentosus in the rheumatology clinic of our institution at 20 years of age when she had presented with increased patchy skin pigmentation and proximal muscle weakness, as well as a raised ESR and CPK. Her symptoms improved on steroids and methotrexate. The drugs were stopped after 4 years in the preconceptional period, and low-dose steroids were restarted after conception.

She received antenatal care in our clinic. Maternal follow-up was uneventful, with the disease in remission on steroids until late in the third trimester when she developed hypertension. Fetal surveillance revealed IUGR. In view of maternal hypertension and fetal growth restriction, labor was induced with oxytocin at 36 weeks' gestation. A live-born, small-for-date baby boy weighing 1540 g and with normal Apgar score was delivered by emergency lower segment cesarean section for fetal distress. She had an uneventful postoperative period and both the mother and the baby were discharged in a satisfactory condition.

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