dr. joseph ernest, eds and pregnancy (2011)
DESCRIPTION
Presentation from the EDNF 2011 Learning ConferenceTRANSCRIPT
EDNF 2011 Conference 7/28/11
All rights reserved. 1
Ehlers-Danlos Syndrome and
Pregnancy 2011
J. M. Ernest, MD Chair, Department of Obstetrics and Gynecology
Carolinas Medical Center Charlotte, NC
Member, Professional Advisory Network EDNF
Pregnancy and EDS ! At the end of the presentation, the
attendee should be able to: n Discuss the genetic and collagen changes of
EDS n Discuss the health risks of EDS in women n List 5 complications of pregnancy that are
more common in patients with EDS n Discuss preconceptional counselling for the
patient with EDS n Discuss the evaluation of the pregnant patient
with EDS
EDNF 2011 Conference 7/28/11
All rights reserved. 2
Whale sharks are … vegetarian
Collagen molecule
• X and Y are amino acids
• X generally is proline • Y generally is hydroxyproline
From: Molecular Biology of the Cell, 4th ed; 2002. Chapter V.
EDNF 2011 Conference 7/28/11
All rights reserved. 3
A closer look…
Collagen fibril from rat cartilage
From: Molecular Biology of the Cell, 4th ed; 2002. Chapter V.
EDNF 2011 Conference 7/28/11
All rights reserved. 4
Connective tissue under epithelium
From: Molecular Biology of the Cell, 4th ed; 2002. Chapter V.
Collagen bundles in chick embryo skin
Collagen bundles run at right angles to each other
From C. Ploetz, E.I. Zycband, and D.E. Birk, J. Struct. Biol. 106:73–81, 1991
EDNF 2011 Conference 7/28/11
All rights reserved. 5
Steps in synthesis of collagen fiber
EM of collagen fibril
From: Molecular Biology of the Cell, 4th ed; 2002. Chapter V.
Multiple enzymatic steps provide multiple sites for genetic problems
! If type I collagen abnormality: n Osteogenesis imperfecta - affects bones
! If type II collagen abnormality: n Chondrodysplasia - affects cartilage, bones
! If type III, V collagen abnormality: n EDS - affects skin, blood vessels, GI tract
EDNF 2011 Conference 7/28/11
All rights reserved. 6
NEJM 357;11. Sept 13, 2007
EDS and Collagen
! EDS caused by abnormalities in synthesis, metabolism of collagen
! Collagen is essential component of extracellular matrix
! Collagen family includes >20 proteins encoded by at least 35 non allelic genes scattered on 15 different chromosomes
EDNF 2011 Conference 7/28/11
All rights reserved. 7
Online Mendelian Inheritance in Man
How does a collagen defect affect a woman’s health?
! Prepubertal ! After child-bearing ! During pregnancy
n Maternal effects n Fetal effects
EDNF 2011 Conference 7/28/11
All rights reserved. 8
EDS and women
! Propensity for EDS to affect women n 90% of EDS-HT were female in recent review
! Why? n Muscle pain perception differs in women, men n Muscle size and ligament/tendon structure
differ in women, men n At puberty, sex hormones increase pain
perception in women, muscle strength in men
Castori et al. A J Med Genetics Part A. doi:10.1002/ajmg.a.33585
How may EDS affect pregnancy?
EDNF 2011 Conference 7/28/11
All rights reserved. 9
Physiology of pregnancy
! Hormonal changes ! Hematologic changes ! Cardiovascular changes ! Genitourinary changes
Physiology of pregnancy
! Hormonal changes ! Hematologic changes ! Cardiovascular changes ! Genitourinary changes
EDNF 2011 Conference 7/28/11
All rights reserved. 10
Progesterone levels during pregnancy
Why are increasing progesterone levels important?
! Progesterone is a smooth muscle relaxant n Esophagus-more reflux n Stomach-delayed emptying time n Intestinal tract-increased transit time n Uterus-less tone n Blood vessels-vasodilatation n Bronchioles-dilatation
EDNF 2011 Conference 7/28/11
All rights reserved. 11
Physiology of pregnancy
! Hormonal changes ! Hematologic changes ! Cardiovascular changes ! Genitourinary changes
Blood volume during pregnancy
Note dilutional effect of extra plasma volume on hematocrit before RBC production increases
EDNF 2011 Conference 7/28/11
All rights reserved. 12
Physiology of pregnancy
! Hormonal changes ! Hematologic changes ! Cardiovascular changes ! Genitourinary changes
Cardiac output increases
EDNF 2011 Conference 7/28/11
All rights reserved. 13
Physiology of pregnancy
! Hormonal changes ! Hematologic changes ! Cardiovascular changes ! Genitourinary changes
Uterine size increases during pregnancy
EDNF 2011 Conference 7/28/11
All rights reserved. 14
Uterine blood flow increases during pregnancy
Physiology of pregnancy
! Hormonal changes n Increasing levels of progesterone n Delayed intestinal transit n Increased relaxin and joint laxity
! Hematologic changes n Increasing plasma volume
! Cardiovascular changes n Increasing cardiac output
! Genitourinary changes n Enlarging uterus with increasing blood flow
EDNF 2011 Conference 7/28/11
All rights reserved. 15
How may pregnancy impact the patient with EDS?
! …it depends
Classification of EDS
Current designation Type Classic I, II Hypermobility III Vascular IV Kyphoscoliosis VI Arthrochalasia VIIA, VIIB Other
EDNF 2011 Conference 7/28/11
All rights reserved. 16
Classification of EDS
Other Type n Human dermatosparaxis VIIC n X linked V n Assoc. with periodontitis VIII n Fibronectin-deficient X
Types of EDS and gene abnormality
EDNF 2011 Conference 7/28/11
All rights reserved. 17
Classic EDS (Types I, II)
! Majority of reported cases
! Autosomal dominant ! Varying degrees of
hyperextensibility of large, small joints
! Skin fragility ! Easy bruisability
Modified from Wynne-Davies R. J Bone Joint Surgery Br 52: 704, 1970
EDNF 2011 Conference 7/28/11
All rights reserved. 18
Classic EDS (Types I, II)
! Complications that may impact pregnancy: n Mitral valve prolapse/tricuspid insufficiency n Aortic root dilation (also seen in Type III) n Thoracolumbar kyphoscoliosis n Cervical dysfunction n Premature rupture of membranes n Anesthetic issues during labor/delivery n Preterm birth n Extension of episiotomy/perineal laceration n Slowly healing cesarean section incision n Prolapse of uterus/bladder
Classic EDS (Types I, II)
! Complications that may impact pregnancy: n Mitral valve prolapse/tricuspid insufficiency n Aortic root dilation (also seen in Type III) n Thoracolumbar kyphoscoliosis n Cervical dysfunction n Premature rupture of membranes n Preterm birth n Anesthetic issues during labor/delivery n Extension of episiotomy/perineal laceration n Slowly healing cesarean section incision n Prolapse of uterus/bladder
EDNF 2011 Conference 7/28/11
All rights reserved. 19
Stenotic lesions are more risky than MVP or tricuspid insufficiency
Classic EDS (Types I, II)
! Complications that may impact pregnancy: n Mitral valve prolapse/tricuspid insufficiency n Aortic root dilation (also seen in Type III) n Thoracolumbar kyphoscoliosis n Cervical dysfunction n Premature rupture of membranes n Preterm birth n Anesthetic issues during labor/delivery n Extension of episiotomy/perineal laceration n Slowly healing cesarean section incision n Prolapse of uterus/bladder
EDNF 2011 Conference 7/28/11
All rights reserved. 20
Aortic root dilation ! With Marfan’s
syndrome, aortic root dilation >40mm imposes an increased risk of aortic dissection and maternal mortality
! No definitive quantified risk in EDS
! Recommendation:
Consider echocardiagram prior to pregnancy for all patients with EDS at risk for aortic root dilation
Classic EDS (Types I, II)
! Complications that may impact pregnancy: n Mitral valve prolapse/tricuspid insufficiency n Aortic root dilation (also seen in Type III) n Thoracolumbar kyphoscoliosis n Cervical dysfunction n Premature rupture of membranes n Preterm birth n Anesthetic issues during labor/delivery n Extension of episiotomy/perineal laceration n Slowly healing cesarean section incision n Prolapse of uterus/bladder
EDNF 2011 Conference 7/28/11
All rights reserved. 21
Kyphoscoliosis in pregnancy
! Increasing lordosis as pregnancy progresses ! Most pregnant women have low back pain in
third trimester ! May be exacerbated with pre-existing
kyphoscoliosis ! Should not affect delivery ! Recommendation:
n Pre-labor anesthesia consult to discuss regional (epidural) anesthetic
n Consider pulmonary function tests to document baseline
EDNF 2011 Conference 7/28/11
All rights reserved. 22
Classic EDS (Types I, II)
! Complications that may impact pregnancy: n Mitral valve prolapse/tricuspid insufficiency n Aortic root dilation (also seen in Type III) n Thoracolumbar kyphoscoliosis n Cervical dysfunction n Premature rupture of membranes n Preterm birth n Anesthetic issues during labor/delivery n Extension of episiotomy/perineal laceration n Slowly healing cesarean section incision n Prolapse of uterus/bladder
Collagen in cervix during pregnancy
First trimester cervix Third trimester cervix
Iwahashi M et al. J Clin Endocrinol Metab 88: 2231–2235, 2003
EDNF 2011 Conference 7/28/11
All rights reserved. 23
Ultrasound appearance of cervix in pregnancy
Normal Dysfunction
AF AF
Ultrasound appearance of cervix in pregnancy
Normal Dysfunction
AF AF
EDNF 2011 Conference 7/28/11
All rights reserved. 24
Cervical dysfunction
! Collagen content of cervix important for maintaining integrity
! With decreased/ abnormal collagen, cervical dilation may occur prematurely
! Result: preterm birth
Recommendation: Consider baseline ultrasonic cervical length at 16-20 weeks gestation
Classic EDS (Types I, II)
! Complications that may impact pregnancy: n Mitral valve prolapse/tricuspid insufficiency n Aortic root dilation (also seen in Type III) n Thoracolumbar kyphoscoliosis n Cervical dysfunction n Premature rupture of membranes n Preterm birth n Anesthetic issues during labor/delivery n Extension of episiotomy/perineal laceration n Slowly healing cesarean section incision n Prolapse of uterus/bladder
EDNF 2011 Conference 7/28/11
All rights reserved. 25
Structure of the amnion and chorion (fetal membranes)
! Amnion: n Single cell layer thick n Avascular n Has basement membrane composed of Type
III collagen (contributes elasticity, strength) ! Chorion
n 2-10 cell layers thick n Vascular
Risk factors for preterm premature rupture of the fetal membranes
! Prior preterm delivery ! Cigarette smoking ! Antepartum bleeding
! Cervical incompetence ! Bacterial vaginosis ! Overdistended uterus
! Alpha-1-antitrypsin deficiency ! Sickle cell disease ! Ehlers-Danlos syndrome
2x risk of PROM
Increased risk of PROM
EDNF 2011 Conference 7/28/11
All rights reserved. 26
Premature rupture of membranes
! Increased risk if fetus has EDS n (50% vs 20% if mother has EDS)
! May result in preterm birth ! May result in intrauterine/fetal infection
! Recommendation: n Treat vaginal infections aggressively n Carefully evaluate signs of PROM n Observe appropriate protocols if PROM occurs
Classic EDS (Types I, II)
! Complications that may impact pregnancy: n Mitral valve prolapse/tricuspid insufficiency n Aortic root dilation (also seen in Type III) n Thoracolumbar kyphoscoliosis n Cervical dysfunction n Premature rupture of membranes n Preterm birth n Anesthetic issues during labor/delivery n Extension of episiotomy/perineal laceration n Slowly healing cesarean section incision n Prolapse of uterus/bladder
EDNF 2011 Conference 7/28/11
All rights reserved. 27
Preterm birth
! 23 weeks: First routine survival ! 28 weeks: 90% survival ! 34 weeks: Latest to offer betamethasone ! 36 weeks: Lung maturity usually complete ! 37 weeks: Term ! 40 weeks: “Due date”
Classic EDS (Types I, II)
! Complications that may impact pregnancy: n Mitral valve prolapse/tricuspid insufficiency n Aortic root dilation (also seen in Type III) n Thoracolumbar kyphoscoliosis n Cervical dysfunction n Premature rupture of membranes n Preterm birth n Anesthetic issues during labor/delivery n Extension of episiotomy/perineal laceration n Slowly healing cesarean section incision n Prolapse of uterus/bladder
EDNF 2011 Conference 7/28/11
All rights reserved. 28
Anesthetic issues during labor
! Regional vs general anesthesia ! With regional (spinal or epidural), avoid hip
and knee stress to minimize risk of dislocation
! Obtain anesthesia consultation PRIOR to labor/delivery
EDNF 2011 Conference 7/28/11
All rights reserved. 29
Classic EDS (Types I, II)
! Complications that may impact pregnancy: n Mitral valve prolapse/tricuspid insufficiency n Aortic root dilation (also seen in Type III) n Thoracolumbar kyphoscoliosis n Cervical dysfunction n Premature rupture of membranes n Preterm birth n Anesthetic issues during labor/delivery n Extension of episiotomy/perineal laceration n Slowly healing cesarean section incision n Prolapse of uterus/bladder
Slowly healing incisions
! Recommendations: n No routine episiotomies n Cesarean section for usual obstetrical reasons n Metal clips vs skin sutures n Delayed suture removal (6+ days)
Elbow
EDNF 2011 Conference 7/28/11
All rights reserved. 30
Classic EDS (Types I, II)
! Complications that may impact pregnancy: n Mitral valve prolapse/tricuspid insufficiency n Aortic root dilation (also seen in Type III) n Thoracolumbar kyphoscoliosis n Cervical dysfunction n Premature rupture of membranes n Preterm birth n Extension of episiotomy/perineal laceration n Slowly healing cesarean section incision n Prolapse of uterus/bladder
Prolapse of uterus
! Recommendation: n Avoid excessive
traction on umbilical cord at time of delivery
EDNF 2011 Conference 7/28/11
All rights reserved. 31
Classic EDS (Types I, II) ! Postpartum hemorrhage more likely
n DDAVP (vasopressin) may be useful ! Neonatal complications
n Prematurity n Breech presentation n Hypotonic, floppy baby with articular hyperextensibility n Recommendation: Avoid operative vaginal delivery (forceps or
vacuum extractor) if fetus likely to be affected
! Prenatal diagnosis n 50% have affected parent; 50% de novo mutation n No prenatal molecular genetic testing available*
*If linkage established in family, or disease-causing mutation has been identified in a family member, testing on research basis may be available
Hypermobility EDS (Type III)
! Autosomal dominant ! Marked joint, spine
hypermobility
! Recurrent joint dislocations ! Skin may be virtually normal ! May have chronic joint and
limb pain
EDNF 2011 Conference 7/28/11
All rights reserved. 32
Hypermobility EDS (Type III)
! Complications that may impact pregnancy: n Similar to Classic types, as well as… n Chronic joint and limb pain
! Prenatal diagnosis n None currently available
Vascular EDS (Type IV)
! Autosomal dominant primarily n New mutations (50%), germinal mosaicism give rise
to patients with negative family history ! No hyperextensibility of large joints, no
hyperelasticity of skin ! Deficiency in Type III collagen
n Found in skin, blood vessels, uterus ! Repeated arterial rupture ! Susceptible to rupture of internal viscera,
including uterus
EDNF 2011 Conference 7/28/11
All rights reserved. 33
Vascular EDS (Type IV)
Vascular EDS (Type IV)
! Complications that may impact pregnancy: n Bowel rupture n Liver rupture n Uterine rupture n Coronary artery dissection/death n External iliac artery rupture/aortic disruption n Vena cava rupture n Postpartum hemorrhage
EDNF 2011 Conference 7/28/11
All rights reserved. 34
Vascular EDS (Type IV)
PREGNANCY IS EXTREMELY RISKY IN PATIENTS WITH
VASCULAR (TYPE IV) EDS
Maternal mortality in Vascular EDS (Type IV)
TOTALS: 135 ~256 11.5-25%
Erez et al. Fetal Diagn Ther 2008; 23: 7-9
EDNF 2011 Conference 7/28/11
All rights reserved. 35
Vascular EDS (Type IV) ! Recommendations
n Preconceptional counselling n If pregnancy continues, elective hospitalization in 3rd
trimester with restriction of physical activity n Monitor for premature rupture of fetal membranes n Constant vigilence for vascular, bowel accidents
! Arterial rupture including aorta ! Colon rupture
n Consider early (32-34 weeks) cesarean delivery to avoid uterine rupture (after steroid administration to enhance fetal lung maturity)
n Observe for post partum hemorrhage n Observe for post partum vascular accidents
Vascular EDS (Type IV)
! Prenatal diagnosis n Biochemical testing available via chorionic
villus sampling at 10-12 weeks gestation if underlying abnormality of Type III collagen has been identified
n Molecular testing of DNA from fetal cells obtained by amniocentesis at 15-18 weeks gestation or from CVS tissue at 10-12 weeks AFTER disease-carrying allele of affected family member has been identified
EDNF 2011 Conference 7/28/11
All rights reserved. 36
Kyphoscoliosis EDS (Type VI)
! Autosomal recessive ! Deficiency of lysyl hydroxylase results in
hydroxylysine-deficient collagen ! Results include those of other forms of
EDS plus scleral fragility ! Severe kyphoscoliosis may lead to
cardiorespiratory failure
Pulmonary function in pregnancy
EDNF 2011 Conference 7/28/11
All rights reserved. 37
Kyphoscoliosis EDS (Type VI)
! Complications that may impact pregnancy: n Severe kyphoscoliosis may worsen as pregnancy
advances n Slow wound healing n Other complications of EDS
! Prenatal diagnosis possible n Screening fetal DNA for mutations in lysyl hydroxylase
gene when disease-causing mutation has been identified in an affected family member
Arthrochalasia EDS (Types VIIA, B)
! Autosomal dominant ! Pronounced joint hypermobility ! Moderate cutaneous elasticity ! Moderate bruising ! Short stature ! Kyphoscoliosis, muscle hypotonia,
frequent dislocations (esp. large joints)
EDNF 2011 Conference 7/28/11
All rights reserved. 38
Arthrochalasia EDS (Types VIIA, B)
! Complications that may impact pregnancy: n Hip instability during vaginal delivery n Other typical EDS complications with skin,
joints
! Prenatal diagnosis available
Anesthesia issues with EDS
! Regional (spinal and epidural) and general have been administered to patients with EDS
! Pros and cons need to be discussed BEFORE labor/delivery with anesthesia
EDNF 2011 Conference 7/28/11
All rights reserved. 39
Preconceptional counseling with EDS
! Which form of EDS does the patient have? n Pregnancy extremely risky in vascular type
! How certain is she of the diagnosis? n Review records/talk with primary MD to
confirm diagnosis ! What problems has she had to date?
n Wound healing n Joint dislocations n Pain n Kyphoscoliosis
Preconceptional counseling with EDS
! Has she had an echocardiogram? n MVP/Tricuspid insufficiency/aortic root dilation
! Does she understand the genetics of her particular type of EDS?
! Has she been pregnant before? ! How did the pregnancy progress?
n Premature rupture of membranes n Cervical dysfunction n Prior child with EDS
EDNF 2011 Conference 7/28/11
All rights reserved. 40
Prenatal evaluation of the pregnant patient with (non-vascular type) EDS
! Review inheritance and potential for prenatal diagnosis
! Review prior pregnancies n Cerclage-pros and cons n Lacerations/poor wound healing
! Discuss premature rupture of membranes/ preterm labor
! Early ultrasound for dating, viability ! Consider echocardiogram for aortic root dilation ! Consider baseline transvaginal cervical length at
16-20 weeks
Prenatal evaluation of the pregnant patient with (non-vascular type) EDS
! Support hose to reduce varicose veins ! Consider pelvic belt for discomfort ! Fluids, fiber to prevent constipation ! Address periodontal disease aggressively ! Discuss vaginal vs cesarean delivery-pros
and cons ! Discuss type of anesthesia before labor
EDNF 2011 Conference 7/28/11
All rights reserved. 41
Intrapartum evaluation of the pregnant patient with (non-vascular type) EDS
! Observe for breech presentation ! Avoid excessive abduction of hips ! Avoid episiotomy, forceps when possible (especially when fetus affected) ! Careful incisional repair for vaginal,
cesarean delivery
Postpartum evaluation of the pregnant patient with (non-vascular type) EDS
! Delayed suture removal after c-section ! Notify pediatricians of inheritance pattern ! Observe for postpartum hemorrhage ! Avoid excessive traction on umbilical cord
EDNF 2011 Conference 7/28/11
All rights reserved. 42
SUMMARY
! Physiologic changes in pregnancy may impact EDS
! Type of EDS important to document ! Pre-pubertal, preconceptional, pregnancy,
and later life periods affected by EDS ! PREGNANCY EXTREMELY RISKY IN
VASCULAR (TYPE IV) EDS
Unanswered pregnancy issues
! Preimplantation genetic diagnosis n Gestational surrogate
! Prepregnancy issues n MRA? n Begin beta blocker (celiprolol)?
! Pregnancy risks n Best management with vascular type n Cervical dysfunction therapy
! Postpartum recommendations n Oxytocin antagonist to reduce vascular accidents?
EDNF 2011 Conference 7/28/11
All rights reserved. 43
Thank you