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Ritodrine-Induced Leukocytoclastic Vasculitis in Pregnancy

Staff Physician, Unit of Rheumatology, Obispo Polanco General Hospital, Teruel, Spain

Pilar García-Enguita, MD PhD

Staff Physician, Service of Gynecology and Obstetrics, Obispo Polanco General Hospital

Miguel A Pina-Latorre, MD PhD

Staff Physician, Unit of Neurology, Obispo Polanco General Hospital

Francisco J Lerin-Sánchez, MD

Resident Physician, Service of Internal Medicine, Obispo Polanco General Hospital

Francisco Rodilla-Calvelo, PharmD PhD

Staff Pharmacist, Service of Pharmacy, Obispo Polanco General Hospital

Reprints: Juan C Cobeta-García MD, Unit of Rheumatology, Obispo Polanco General Hospital, Avda. Ruiz Jarabo s/n, E-44002 Teruel, Spain, fax 34 978 621 310, jccobeta{at}hotmail.com

OBJECTIVE: To report 2 cases of pregnant women who presented with leukocytoclastic vasculitis (LV) associated with the administration of ritodrine hydrochloride after undergoing genetic amniocentesis and to review the literature on LV.

CASE SUMMARIES: Case 1. A 40-year-old pregnant woman was diagnosed with autoimmune hypothyroidism at week 12 of her third gestation. At week 14, she underwent a genetic amniocentesis and received oral prophylactic treatment with ritodrine for 10 days. At week 16, she presented with fever, epigastric abdominal pain, polyarthritis, microhematuria, and purpura. Skin biopsy showed LV. Case 2. A 34-year-old pregnant woman had developed polyarthralgias and polyarthritis after receiving ritodrine following genetic amniocentesis in her second gestation. She also underwent a genetic amniocentesis in her third gestation and received ritodrine. Five days later, she presented with fever, polyarthritis, and purpura. A skin biopsy demonstrated LV. The rest of her gestation was normal until week 33, when she developed oligohydramnios and a delay of intrauterine fetal growth. A cesarean section was then performed. After birth, the baby developed tachypnea, anemia, splenomegaly, edema, and renal failure; she died on her 15th day of life.

DISCUSSION: Ritodrine hydrochloride is a ß₂-adrenergic agonist that is used in pregnant women as a tocolytic agent. In our 2 patients, there was a time relationship between the administration of ritodrine and the appearance of LV. In both cases, other causes of vasculitis were excluded in a reasonable way. As of November 4, 2003, only one other case has been found in the literature. An objective causality assessment revealed that the reactions to ritodrine were probable and possible, respectively, in our 2 cases.

CONCLUSIONS: In pregnant women with autoimmune disease, ritodrine should be used with caution because of its ability to induce vasculitis.

Key Words: Henoch-Schönlein purpura, leukocytoclastic vasculitis, pregnancy, ritodrine

Published Online, November 17, 2003. www.theannals.com, DOI 10.1345/aph.1D227