Immunosuppressive therapy before and during pregnancy may improve obstetric outcomes in pregnancy complicated by dermatomyositis with anti-MDA-5 antibody positivity: A case report

Abstract

Dermatomyositis (DM) is one of the most common autoimmune rheumatic diseases affecting women of childbearing age. Pregnancy may lead to exacerbation of DM, especially of DM with anti-melanoma differentiation-associated gene (MDA) 5 antibody positivity, leading to a poor obstetric outcome. Here, we report consecutive pregnancies complicated by DM with anti-MDA-5 antibodies. A 32-year-old pregnant woman, gravida 3 para 1, presented with fetal growth restriction. Emergency cesarean section was performed because of non-reassuring fetal status at 28 weeks of gestation. Two days postpartum, the patient's hand eczema had worsened and she was diagnosed with DM with MDA-5 antibody positivity. Immunosuppressive therapy using corticosteroids combined with tacrolimus was immediately started, suppressing the DM symptoms. Eighteen months later, she became pregnant again but was then negative for anti-MDA-5 antibodies while continuing immunosuppressive therapy. During pregnancy, the titer of the antibody gradually increased, peaked in the second trimester and declined to near normal range through the third trimester. A male infant weighing 2418 g was delivered at 38 weeks of gestation. Our case demonstrates that controlling of DM activity using immunosuppressive treatment before and during pregnancy may be beneficial to obstetric outcomes.

Keywords: Anti-melanoma differentiation-associated gene 5 antibody; CADM, clinically amyopathic dermatomyositis; DM, dermatomyositis; Dermatomyositis; FGR, fetal growth restriction; Immunosuppressive therapy; SGA, small for gestational age; Tacrolimus; anti-MDA-5, anti-melanoma differentiation-associated gene 5 antibody.

Fig. 1

Pathological examination of the placenta. Macroscopic and microscopic findings of the placenta in FGR (a-c) and non-FGR (d-f) infants. Macroscopic findings of fetal (a, d) and maternal planes (b, e) of placenta. HE staining (original magnification×40) of placental tissue in FGR (c) and non-FGR (f) infants. Arrow head: fibrin deposition.

Fig. 2

Hand eczema. An erythematous eczema over the extensor surface of the metacarpophalangeal joint (a: Gottron's sign) and the flexor surface of interphalangeal joint of the fingers (b: inverse Gottron's sign).

Fig. 3

Clinical course of the patient. After starting treatment, anti-MDA5 antibody titer decreased to the normal range (below 32 index). However, anti-MDA5 antibody titer was elevated again when she became pregnant. Dotted line: 32 index.