Successful Rapid Desensitization to Glatiramer Acetate in a Patient With Multiple Sclerosis.
A 29-year-old gravida 2 para 0 lady presented at 9 weeks of pregnancy for booking (on May 18, 2009) with the history of a first trimester miscarriage. Her LMP was on March 12th, 2009. She mentioned her allergy to folic acid which she noticed in her pre-pregnant state and again in her first pregnancy. She had no other medical/surgical/family history. She had a normal thyroid function test (serum TSH 1.90 mU/l). The patient was clinically moderately anemic. She was prescribed a multivitamin preparation containing methylcobalamin, pyridoxine, and folic acid 5 mg. The lady reported back within 3 days with generalized pruritic maculopapular rashes. The medication was stopped and she was given an oral iron preparation without folic acid. There was no allergic reaction this time. She was also advised to eat folate-rich food (e.g., spinach, etc.). Her Hb was 6.3 g/dl at 19 weeks of gestation and an ultrasound scan at that time revealed an appropriately grown fetus with normal anatomy and adequate liquor. She was followed up at ANC periodically and was kept on the above medication. At 32 weeks of gestation, her Hb was 6.7 g/dl. The platelet count was 2,72,000/cmm. All other screening investigations including plasma glucose, serological tests for hepatitis B and C as well as HIV and syphilis were negative. She had an ultrasound scan on October 23, 2009 (32 weeks?), showing a 31-week-sized baby with AFI of 9.37 and a normal umbilical artery waveform (A/B -2.0). A specialist physician reviewed her at that time and a battery of tests was performed. Hemoglobin electrophoresis showed mild prominence of HbA2/HbE suggesting the HbE trait or an iron deficiency state. Serum iron was normal (124.92 mcg/dl), and total iron binding capacity was high (583.8 mcg/dl). Her serum folate level was found to be normal (viz. 9.12 ng/ml) and so was the vit B12 (259.2 pg/ml). Her liver enzymes were mildly raised (ALT -47.7 U/l, AST -56.5 U/l) and serum albumin was normal (3.49 g/dl). Serum bilirubin was 2.9 mg/dl. Hematologic investigations showed a reticulocyte count of 8.20 %, a leukocyte count of 12,600/cmm (polymorphs 83 %, lymphocytes 14 %, and eosinophils 3 %), PCV 24 %, MCV 80 fl, MCH 22.23 pg, and MCHC 27.74 gm/dl. Peripheral film revealed moderate to severe anisocytosis with microcytes, target cells, and hypochromia. Roy S. (&) Roy M. Nurture Advanced Fertility Centre, ‘Smaran’, Burdwan Rd, Siliguri, Dt-Darjeeling 734001, West Bengal, India e-mail: email@example.com The Journal of Obstetrics and Gynecology of India (December 2012) 62(S1):S33–S34 DOI 10.1007/s13224-013-0371-9