Pemphigoid Gestationis: Early Onset and Blister Formation Are Associated with Adverse Pregnancy Outcomes
- Abstract and Introduction
- Patients and Methods
- Results
- Discussion
Abstract
Background: It is unclear whether clinical features of pemphigoid gestationis (PG), such as timing of onset and severity, may affect pregnancy outcomes or whether the adverse outcomes in pregnancies complicated by PG are related to or worsened by systemic corticosteroid treatment.
Objectives: To evaluate the associations of adverse pregnancy outcomes with clinical features, autoantibody titre of PG, and systemic corticosteroid treatment.
Methods: We conducted a retrospective cohort study recruiting 61 pregnancies complicated by PG from the St John's Institute of Dermatology database which enrolled cases from dermatologists across the U.K., and two tertiary hospitals in the U.K. and Taiwan. Outcome measures included gestational age at delivery, preterm birth, birthweight, low birthweight (LBW, i.e. birthweight < 2500 g), small-for-gestational-age (i.e. birthweight below the 10th percentile for gestational age), fetal loss, congenital malformation, and mode of delivery.
Results: After controlling for maternal age and comorbidity, decreased gestational age at delivery was significantly associated with presence of blisters (P = 0.017) and disease onset in the second trimester (P = 0.001). Reduced birthweight was significantly associated with disease onset in the first and second trimesters (P = 0.030 and 0.018, respectively) as was also LBW [adjusted odds ratio (95% confidence interval) 13.71 (1.22-154.59) and 10.76 (1.05-110.65), respectively]. No significant associations of adverse pregnancy outcomes with autoantibody titre or systemic corticosteroid treatment were found.
Conclusions: Onset of PG in the first or second trimester and presence of blisters may lead to adverse pregnancy outcomes including decreased gestational age at delivery, preterm birth, and LBW children. Such pregnancies should be considered high risk and appropriate obstetric care should be provided. Systemic corticosteroid treatment, in contrast, does not substantially affect pregnancy outcomes, and its use for PG in pregnant women is justified.
Introduction
Pemphigoid gestationis (PG) is a rare autoimmune dermatosis that occurs in 1 : 50 000 pregnancies.[1] PG is characterized by an intensely pruritic eruption of erythematous papules, plaques and blisters. The lesions frequently appear first in the periumbilical area before spreading to other parts of the torso and limbs. PG often occurs in the second and third trimesters of gestation, but can also begin in the postpartum period.[1] The diagnosis of PG can be confirmed by direct immunofluorescence showing linear deposition of complement (C3) and occasionally IgG along the basement membrane zone (BMZ).[1] A circulating IgG1 autoantibody (PG factor) against the BMZ may also be found by indirect immunofluorescence.[2] A significant increase in adverse pregnancy outcomes including preterm birth and small-for-gestational-age, and a reduction in birthweight have been found in pregnancies complicated by PG.[3-5]
Systemic corticosteroid treatment (usually starting at 30-40 mg prednisolone per day) is required to control PG in a third to a half of affected women.[2,4,5] However, compared with the unexposed controls, a higher rate of adverse pregnancy outcomes such as preterm birth and miscarriage as well as a decrease in gestational age at delivery and birthweight has been demonstrated in pregnant women receiving systemic corticosteroid treatment for allergy, asthma, inflammatory bowel disease or other indications.[6,7] To date, it has been unclear whether clinical features of PG, such as timing of onset and severity, may affect pregnancy outcomes or whether the adverse outcomes in pregnancies complicated by PG are related to or worsened by systemic corticosteroid treatment.
The objective of this study was to evaluate the associations of adverse pregnancy outcomes with clinical features of PG (including trimester of onset, extensive involvement, and presence of blisters), PG autoantibody titre, and systemic corticosteroid treatment.
