Management of rheumatic and autoimmune blistering disease in pregnancy and postpartum
Section snippets
Overview
Rheumatic and autoimmune blistering skin disease can present management challenges to clinicians when they occur in pregnant women or in those with a desire to become pregnant. Considerations about contraception, planned conception, therapeutic options, and disease control are paramount in optimizing pregnancy outcomes and minimizing the risk to the patient.1
Medication choices include consideration of severity of disease activity, medication safety in pregnancy, efficacy, and tolerability.
Pregnancy safety classifications
Until 2015, the FDA classified pregnancy safety of prescription medications into 5 classes (A, B, C, D, and X) (discussed in “Drug Safety: Pregnancy Rating Classifications and Controversies” in this issue).2 Due to the limited clinical utility of this classification system,3 new medication labeling has been recently instituted to include a summary of risks and a discussion of the supporting data. We refer to the former FDA pregnancy safety classes in this review for their historical relevance.
Safety of medications in pregnancy and lactation
Prepartum considerations
Preconception planning and counseling is critical for optimizing maternal and fetal outcomes during and after pregnancy.[70], [71] First, disease stability should ideally be achieved before conception. It is best to plan for pregnancy after at least 3–6 months of disease quiescence. Second, if patients are contemplating pregnancy but are taking medications that would be contraindicated in pregnancy, then medications must be stopped or changed to safer alternatives as soon as feasible. For
Systemic lupus erythematosus
There are contradictory findings in the literature regarding whether systemic lupus erythematosus (SLE) flares are more common in pregnancy compared with the nonpregnant state. This controversy may be explained in part by discrepancies in the definition of an SLE flare, assessment of disease activity, and the challenge of differentiating normal pregnancy-related complications from increased lupus activity.[20], [72] It has been found that women who meet the criteria for SLE with mucocutaneous
Pemphigus vulgaris
Some patients see improvement in pemphigus vulgaris (PV) during pregnancy, whereas other women may present with PV for the first time during pregnancy.[63], [106] Pregnancy should be timed to a period of disease quiescence when maternal antibody titers are ideally low.107 Adverse outcomes such as neonatal pemphigus and perinatal death have been correlated more with poor maternal disease control and higher maternal antibody titers than with adverse effects of medications used to treat the
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Cited by (25)
Autoimmune bullous diseases in pregnancy: clinical and epidemiological characteristics and therapeutic approach
2021, Anais Brasileiros de DermatologiaCitation Excerpt :The European Crohn's and Colitis Organisation classifies azathioprine as “probably safe” for use during breastfeeding.42 Breastfeeding should take place at least 4 hours after the last dose.44 Mycophenolate mofetil (MPM) is an excellent steroid-sparing agent in autoimmune diseases, including AIBD.
Azathioprine
2020, Comprehensive Dermatologic Drug Therapy, Fourth EditionEffects of hydroxychloroquine on the human placenta—Findings from in vitro experimental data and a systematic review
2019, Reproductive ToxicologyCitation Excerpt :Hydroxychloroquine (HCQ) is an antimalarial and immunomodulatory agent. [1] In pregnancy, HCQ is prescribed for inflammatory conditions associated with adverse perinatal outcomes such as systemic lupus erythematosus (SLE), antiphospholipid syndrome (APS) and placental inflammatory lesions such as chronic histiocytic intervillositis [2,3]. Despite the use of HCQ in pregnancy, the toxicology and effects of HCQ in human placental tissue has not been determined.
Autoimmune bullous diseases during pregnancy: Solving common and uncommon issues
2019, International Journal of Women's DermatologyCitation Excerpt :MMF, which is commonly used as an additional immunosuppressant agent for AIBD, must be discontinued at least 6 weeks before pregnancy. When a woman has a known history of an autoimmune blistering disorder, pregnancy is better planned during a remission state and after at least 3 to 6 months of disease quiescence (Wan et al. 2016). A change in contraindicated medications during the preconception phase is also recommended, with a wait of at least 2 to 3 months to reach a therapeutic effect with the alternative treatment and ensure disease stability first.
Updated recommendations on the use of hydroxychloroquine in dermatologic practice
2017, Journal of the American Academy of DermatologyCitation Excerpt :HCQ treatment during pregnancy has been widely studied in LE patients. There is no evidence HCQ results in congenital defects, stillbirth, prematurity, low birth weight, fetal death, or retinopathy.2,45-48 Importantly, chloroquine can cause fetal retinopathy and should not be administered during pregnancy.
Advances in obstetric dermatology: A better understanding of skin disease in pregnancy
2016, Clinics in Dermatology
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Wan and Imadojemu are co–first authors.