Pregnancy and neonatal outcomes in women with immune mediated inflammatory diseases exposed to anti-tumor necrosis factor-α during pregnancy: A systemic review and meta-analysis.

BACKGROUND: Anti-TNFα is increasingly used as treatment for immune mediated inflammatory diseases (IMID), such as inflammatory bowel disease (IBD), rheumatoid arthritis (RA) and psoriasis (PS). However, the impact of anti-TNFα during pregnancy on mother and newborn is under debate. This requires a sound knowledge of the effects of this treatment on pregnancy and neonatal outcomes. OBJECTIVES: To assess pregnancy and neonatal outcomes after anti-TNFα therapy during pregnancy in women with IMID, specifically IBD, RA and PS. METHODS: We performed a systematic review and meta-analysis of 39 studies assessing pregnancy and neonatal outcomes of women with IMID exposed to anti-TNFα agents during pregnancy. We used a random-effects model to determine pooled outcome measures. RESULTS: An increased risk of preterm births (OR 1.45, 95% CI = 1.16 to 1.82, p = 0.001) and infections in newborns (OR 1.12, 95% CI = 1.00 to 1.27, p = 0.05)) was seen for women in the combined group of IMID exposed to anti-TNFα compared to diseased controls. Specifically for IBD patients exposed to anti-TNFα, the risk was increased for preterm birth (OR 1.66, 95% CI = 1.14 to 2.42, p = 0.009), and low birth weight (OR 1.49, 95% CI = 1.01 to 2.20, p = 0.047) compared to diseased controls. Combined data from studies of women with RA and PS, showed no increased risk for adverse pregnancy outcome after exposure to anti-TNFα. Most children of mothers with IMID received vaccination according to national vaccination schemes and only minor adverse events were reported. CONCLUSION: Exposure to anti-TNFα agents during pregnancy is associated with increased risk of preterm birth and infections in newborns of women with IMID compared to diseased controls. The risk of preterm birth and low birth weight was increased in women with IBD specifically. The increased risk of infections in newborns underlines the importance of vaccination, which seems to be safe in children exposed to anti-TNFα. Delay of vaccination is therefore unnecessary in these children. These data may aid in balancing the continuing anti-TNFα therapy versus the risk of adverse pregnancy outcomes.

[Elevated liver enzyme levels; not exclusive to liver disease]. / Leverenzymstoornissen: niet alleen bij leverziekten.

BACKGROUND: Underlying liver disease is usually, quite rightly, suspected in patients with raised liver enzyme levels. Thesecan, however, actually have a different cause, such as a muscular disease. CASE DESCRIPTION: A 41-year-old woman was referred to a gastroenterology clinic with unexplained elevated liver enzymelevels and fatigue. She had experienced mildly raised liver enzyme levels 10 years previously; following analysis these were interpreted as due to 'non-alcoholic fatty liver disease'. Further questioning revealed that the patient had also recently been experiencing muscular pain and had difficulty with rising from a sitting position. Laboratory investigation revealed elevated aminotransferase and creatinine kinase (CK) levels. The symptoms and the abnormal laboratory results were found to be due to a mutation of the ANO5 gene. CONCLUSION: A mild liver enzyme disorder can indicate a muscular disease. It is sensible to measure CK levels early, in order to distinguish between a muscular disease and other causes of the raised liver enzyme level. This may prevent unnecessary, invasive and expensive diagnostics.