From the Journals

Review finds mortality rates low in young pregnant women with SJS, TEN



Investigators who studied mostly young, pregnant women with Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) reported lower than expected mortality rates, but higher rates of C-sections.

The systematic review found that early diagnosis and withdrawal of the causative medications, such as antiretrovirals, were beneficial.

While SJS and TEN have been reported in pregnant women, “the outcomes and treatment of these cases are poorly characterized in the literature,” noted Ajay N. Sharma, a medical student at the University of California, Irvine, and coauthors, who published their findings in the International Journal of Women’s Dermatology.

“Immune changes that occur during pregnancy create a relative state of immunosuppression, likely increasing the risk of these skin reactions,” Mr. Sharma said in an interview. Allopurinol, antiepileptic drugs, antibacterial sulfonamides, nevirapine, and oxicam NSAIDs are agents most often associated with SJS/TEN.

He and his coauthors conducted a systematic literature review to analyze the risk factors, outcomes, and treatment of SJS and TEN in pregnant patients and their newborns using PubMed and Cochrane data from September 2019. The review included 26 articles covering 177 pregnant patients with SJS or TEN. Affected women were fairly young, averaging 29.9 years of age and more than 24 weeks along in their pregnancy when they experienced a reaction.

The majority of cases (81.9%) involved SJS diagnoses. Investigators identified antiretroviral therapy (90% of all cases), antibiotics (3%), and gestational drugs (2%) as the most common causative agents. “Multiple large cohort studies included in our review specifically assessed outcomes in only pregnant patients with HIV, resulting in an overall distribution of offending medications biased toward antiretroviral therapy,” noted Mr. Sharma. Nevirapine, a staple antiretroviral in developing countries (the site of most studies in the review), emerged as the biggest causal agent linked to 75 cases; 1 case was linked to the antiretroviral drug efavirenz.

Approximately 85% of pregnant women in this review had HIV. However, the young patient population studied had few comorbidities and low transmission rates to the fetus. In the 94 cases where outcomes data were available, 98% of the mothers and 96% of the newborns survived. Two pregnant patients in this cohort died, one from septic shock secondary to a TEN superinfection, and the other from intracranial hemorrhage secondary to metastatic melanoma. Of the 94 fetuses, 4 died: 2 of sepsis after birth, 1 in utero with its mother, and there was 1 stillbirth.

“Withdrawal of the offending drug was enacted in every recorded case of SJS or TEN during pregnancy. This single intervention was adequate in 159 patients; no additional therapy was needed in these cases aside from standard wound care, fluid and electrolyte repletion, and pain control,” wrote the investigators. Clinicians administered antibiotics, fluid resuscitation, steroids, and intravenous immunoglobulin in patients needing further assistance.

The investigators also reported high rates of C-section – almost 50% – in this group of pregnant women.

Inconsistent reporting between studies limited results, Mr. Sharma and colleagues noted. “Not every report specified body surface area involvement, treatment regimen, maternal or fetal outcome, or delivery method. Although additional studies in the form of large-scale, randomized, clinical trials are needed to better delineate treatment, this systematic review provides a framework for managing this population.”

The study authors reported no conflicts of interest and no funding for the study.

SOURCE: Sharma AN et al. Int J Womens Dermatol. 2020 Apr 13;6(4):239-47.

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