Azathioprine and breastfeeding: is it safe?

Maternal and fetal outcomes of SLE in pregnancy: a literature review

Systemic Lupus Erythematosus (SLE) is an auto-immune disease in which the immune system assaults its tissues. We aimed to analyse the maternal and foetal outcomes during pregnancy in SLE mothers. A literature search was conducted by two investigators to assess SLE's outcomes on maternal and foetal during pregnancies. We searched PubMed/Medline, Embase, and Google scholar to collect evidence from different research studies, draw the conclusion, and report it. In our investigation, we found out that SLE could cause a spectrum of complications during pregnancy, not only for the mother but also for the foetus. It could affect fertility and cause difficult pregnancies for the couple as well which includes certain complications such as: preterm labour and delivery, high blood pressure (preeclampsia), placental insufficiency, miscarriage or stillbirth, whereas in the foetus SLE can cause mortality, preterm birth, and neonatal lupus (a temporary condition in the baby caused by SLE-related antibodies) and structural abnormalities. The literature suggests that SLE could prove fatal for the foetus and induce many complications in the mother. However, this could be avoided if pregnancy is planned right from the start and proper management is provided to the mother during pregnancy and delivery.p.

2022 Chinese guideline for the management of pregnancy and reproduction in systemic lupus erythematosus

Systemic lupus erythematosus (SLE), a prevalent autoimmune disease predominantly affecting women of childbearing age, presents ongoing challenges despite notable advances in diagnosis and treatment. Although survival rates for SLE patients have significantly improved, pregnancy continues to pose a considerable obstacle. Addressing this critical need for enhanced reproductive and prenatal care, there is a pressing imperative to establish standardized protocols for peri-gestational monitoring and treatment in SLE patients. This guideline is jointly sponsored by the National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), the Chinese Systemic Lupus Erythematosus Treatment and Research Group (CSTAR), and the Chinese Research Committee of Pregnancy and Reproduction in Autoimmune Rheumatic Diseases (CHOPARD). Thirteen pertinent clinical questions have been generated through several rounds of rigorous clinical and methodological expert discussions and selections for a comprehensive understanding of key aspects in this domain. Guided by thorough examination of research evidence and expert perspectives, the formulated recommendations aim to optimize pregnancy success rates, reduce maternal and infant mortality rates, and ultimately enhance the overall well-being of SLE patients.

Infertility, pregnancy and breastfeeding in kidney transplantation recipients: Key issues

Chronic kidney disease (CKD), especially in advanced stages, is an important cause of infertility. In CKD patients, infertility has been linked to multiple factors. The pathophysiology of infertility related to CKD is complex and forked. Correction of modifiable factors can improve fertility in both genders. In males as well as females, successful kidney transplantation offers good chances of restoration of reproductive function. In female renal allograft recipients, recovery of reproductive functions in the post-transplant period will manifest as restoration of normal menses and ovulation. Owing to this improvement, there is a significant risk of unplanned pregnancy, hence the need to discuss methods of contraception before transplantation. In kidney transplant recipients, different contraceptive options for pregnancy planning, have been used. The selection of one contraception over another is based on preference and tolerability. Pregnancy, in renal transplanted females, is associated with physiologic changes that occur in pregnant women with native kidneys. Immunosuppressive medications during pregnancy, in a recipient with a single functioning kidney, expose the mother and fetus to unwanted complications. Some immunosuppressive drugs are contraindicated during pregnancy. Immunosuppressive medications should be discussed with renal transplant recipients who are planning to breastfeed their babies. In addition to antirejection drugs, other medications should be managed accordingly, whenever pregnancy is planned.

Reproductive health after thoracic transplantation: An ISHLT expert consensus statement

Pregnancy after thoracic organ transplantation is feasible for select individuals but requires multidisciplinary subspecialty care. Key components for a successful pregnancy after lung or heart transplantation include preconception and contraceptive planning, thorough risk stratification, optimization of maternal comorbidities and fetal health through careful monitoring, and open communication with shared decision-making. The goal of this consensus statement is to summarize the current evidence and provide guidance surrounding preconception counseling, patient risk assessment, medical management, maternal and fetal outcomes, obstetric management, and pharmacologic considerations.

Pregnancy in Patients with Inflammatory Bowel Diseases-A Literature Review

In recent years, we have faced an increasing incidence of inflammatory bowel disease (IBD), especially among young people, affecting them during their reproductive years. The paucity of data and reduced knowledge regarding the evolution of the disease during pregnancy and the adverse effects of the therapy on the mother and infant increase voluntary childlessness in this group of patients. Depending on the type of IBD, severity and surgical or medical management, this can negatively affect the pregnancy. C-sections and the risk of low-birth-weight babies are higher in women with IBD, independent of active/inactive disease, while preterm birth, stillbirth and miscarriage are associated with disease activity. In the last period, medicinal therapy has evolved, and new molecules have been developed for better control of the lesions, but the effect on pregnancy and breastfeeding is still controversial. We conducted this review by studying the literature and recent research in order to have a better image of the practical management of IBD during pregnancy.

Pregnancy and neuromyelitis optica spectrum disorders: 2022 recommendations from the French Multiple Sclerosis Society

BACKGROUND

In 2020, the French Multiple Sclerosis (MS) Society (SFSEP) decided to develop a national evidence-based consensus on pregnancy in MS. As neuromyelitis optica spectrum disorders (NMOSD) shares a series of commonalities with MS, but also some significant differences, specific recommendations had to be developed.

OBJECTIVES

To establish recommendations on pregnancy in women with NMOSD.

METHODS

The French Group for Recommendations in Multiple Sclerosis (France4MS) reviewed PubMed and universities databases (January 1975 through June 2021). The RAND/UCLA appropriateness method, which was developed to synthesise the scientific literature and expert opinions on health care topics, was used to reach a formal agreement. Fifty-six MS experts worked on the full-text review and initial wording of recommendations. A sub-group of nine NMOSD experts was dedicated to analysing available data on NMOSD. A group of 62 multidisciplinary healthcare specialists validated the final proposal of summarised evidence.

RESULTS

A strong agreement was reached for all 66 proposed recommendations. They cover diverse topics, such as pregnancy planning, follow-up during pregnancy and postpartum, delivery routes, loco-regional analgesia or anaesthesia, prevention of postpartum relapses, breastfeeding, vaccinations, reproductive assistance, management of relapses, and disease-modifying treatments.

CONCLUSION

Physicians and patients should be aware of the new and specific evidence-based recommendations of the French MS Society for pregnancy in women with NMOSD. They should help harmonise counselling and treatment practise, allowing for better individualised choices.

Pregnancy and multiple sclerosis: 2022 recommendations from the French multiple sclerosis society

OBJECTIVE

The objective of this study was to develop evidence-based recommendations on pregnancy management for persons with multiple sclerosis (MS).

BACKGROUND

MS typically affects young women in their childbearing years. Increasing evidence is available to inform questions raised by MS patients and health professionals about pregnancy issues.

METHODS

The French Group for Recommendations in Multiple Sclerosis (France4MS) reviewed PubMed and university databases (January 1975 through June 2021). The RAND/UCLA appropriateness method was developed to synthesise the scientific literature and expert opinions on healthcare topics; it was used to reach a formal agreement. Fifty-six MS experts worked on the full-text review and initial wording of recommendations. A group of 62 multidisciplinary healthcare specialists validated the final proposal of summarised evidence.

RESULTS

A strong agreement was reached for all 104 proposed recommendations. They cover diverse topics, such as pregnancy planning, follow-up during pregnancy and postpartum, delivery routes, locoregional analgesia or anaesthesia, prevention of postpartum relapses, breastfeeding, vaccinations, reproductive assistance, management of relapses and disease-modifying treatments.

CONCLUSION

The 2022 recommendations of the French MS society should be helpful to harmonise counselling and treatment practice for pregnancy in persons with MS, allowing for better and individualised choices.

A cross-sectional study evidences regulations of leukocytes in the colostrum of mothers with obesity

BACKGROUND

Breastmilk is a dynamic fluid whose initial function is to provide the most adapted nutrition to the neonate. Additional attributes have been recently ascribed to breastmilk, with the evidence of a specific microbiota and the presence of various components of the immune system, such as cytokines and leukocytes. The composition of breastmilk varies through time, according to the health status of mother and child, and altogether contributes to the future health of the infant. Obesity is a rising condition worldwide that creates a state of systemic, chronic inflammation including leukocytosis. Here, we asked whether colostrum, the milk produced within the first 48 h post-partum, would contain a distinct leukocyte composition depending on the body mass index (BMI) of the mother.

METHODS

We collected peripheral blood and colostrum paired samples from obese (BMI > 30) and lean (BMI < 25) mothers within 48 h post-partum and applied a panel of 6 antibodies plus a viability marker to characterize 10 major leukocyte subpopulations using flow cytometry.

RESULTS

The size, internal complexity, and surface expression of CD45 and CD16 of multiple leukocyte subpopulations were selectively regulated between blood and colostrum irrespective of the study groups, suggesting a generalized cell-specific phenotype alteration. In obesity, the colostrum B lymphocyte compartment was significantly reduced, and CD16⁺ blood monocytes had an increased CD16 expression compared to the lean group.

CONCLUSIONS

This is the first characterization of major leukocyte subsets in colostrum of mothers suffering from obesity and the first report of colostrum leukocyte subpopulations in Latin America. We evidence various significant alterations of most leukocyte populations between blood and colostrum and demonstrate a decreased colostrum B lymphocyte fraction in obesity. This pioneering study is a stepping stone to further investigate active immunity in human breastmilk.

Breastfeeding Initiation, Duration, and Associated Factors in Mothers with Systemic Lupus Erythematosus

Objective: To study breastfeeding initiation, duration, and associated factors in patients with systemic lupus erythematosus (SLE), a cross-sectional study comparing with SLE and non-SLE mothers was conducted. Methods: Thirty patients with SLE who had pregnancy outcomes from September 2018 to December 2020 and 120 non-SLE patients (excluding mothers with other immune system diseases) were included in the study. Data on sociodemographic, obstetric, and SLE clinical information were collected. Breastfeeding initiation, breastfeeding duration, and reasons for not initiating breastfeeding were investigated via telephone. Results: The rate in breastfeeding of SLE group was significantly lower than non-SLE group (36.7% versus 86.7%, respectively, p < 0.001; odds ratio 0.059; 95% confidence interval 0.015-0.241). Non-SLE mothers had a longer duration of breastfeeding than mothers with SLE (log-rank p = 0.001). Fearing of the adverse effects of drugs on babies is the main reason (68.4%) for not initiating breastfeeding in SLE group. Infants with high weight and Apgar scores, primipara women, and having a college degree were significantly associated with breastfeeding among patients with SLE. Conclusion: SLE women showed a lower breastfeeding rate and shorter breastfeeding duration. Postpartum medications are safe for lactation in most patients with SLE. Targeted intervention programs that enhance breastfeeding consultations are required for this group.

Outcomes of Children with Fetal and Lactation Immunosuppression Exposure Born to Female Transplant Recipients

Solid organ transplantation (SOT) is a lifesaving procedure for those with end-stage kidney, liver, heart, lung, and intestinal diseases, including females of childbearing age who wish to proceed with pregnancy following transplantation. While there is clear risk associated with use of mycophenolate during pregnancy, the risks associated with use of other immunosuppressant agents are less well understood, and the timing of use in pregnancy may be pertinent when considering the risk versus benefit for individual patients. In addition to overall fetal outcomes, including gestational age, birth weight, and mortality, this review summarizes published literature on additional complications that have been examined in association with maternal use during pregnancy and postpartum while breastfeeding. Compared with non-transplant pregnancies, pregnancies in transplant recipients are associated with lower birth weight and earlier gestational age. Effects associated with particular immunosuppressant agents in the infant include renal dysfunction from calcineurin inhibitors, myelosuppression from azathioprine, and decreased circulating immune cells with several agents. However, these effects are noted to primarily be transient, though the decrease in immune cells may predispose the infant to increased infectious complications in the first year of life. Utilizing relative infant dose estimations, nearly all commonly utilized immunosuppressants are likely safe during breastfeeding given the limited exposure to the infant.

Outcomes of children born to mothers with systemic lupus erythematosus exposed to hydroxychloroquine or azathioprine

OBJECTIVES

HCQ and AZA are used to control disease activity and reduce risk of flare during pregnancy in patients with SLE. The aim of this study was to determine the outcomes of children born to mothers with SLE exposed to HCQ or AZA during pregnancy and breast-feeding.

METHODS

Women attending UK specialist lupus clinics with children ≤17 years old, born after SLE diagnosis, were recruited to this retrospective study. Data were collected using questionnaires and from clinical record review. Factors associated with the outcomes of low birth weight and childhood infection were determined using multivariable mixed-effects logistic regression models.

RESULTS

We analysed 284 live births of 199 mothers from 10 UK centres. The first pregnancies of 73.9% of mothers (147/199) were captured in the study; (60.4%) (150/248) and 31.1% (87/280) children were exposed to HCQ and AZA, respectively. There were no significant differences in the frequency of congenital malformations or intrauterine growth restriction between children exposed or not to HCQ or AZA. AZA use was increased in women with a history of hypertension or renal disease. Although AZA was associated with low birth weight in univariate models, there was no significant association in multivariable models. In adjusted models, exposure to AZA was associated with increased reports of childhood infection requiring hospital management [odds ratio 2.283 (1.003, 5.198), P = 0.049].

CONCLUSIONS

There were no significant negative outcomes in children exposed to HCQ in pregnancy. AZA use was associated with increased reporting of childhood infection, which warrants further study.

Autoimmune hepatitis and pregnancy: considerations for the clinician

INTRODUCTION

Autoimmune hepatitis (AIH) is an immune mediated inflammatory disease of the liver which affects females of reproductive age. AIH poses unique challenges in pregnancy and historically was associated with adverse pregnancy outcomes.

AREAS COVERED

This report aims to review the current evidence for AIH pregnancy outcomes and the use of medical therapies in pregnancy. The disease course of AIH in pregnancy including loss of biochemical response (LOBR) and hepatic decompensation is also reviewed. The importance of preconception counselling and continued monitoring into the post-partum phase are reinforced.

EXPERT OPINION

The lack of prognostic markers and targeted immunosuppression are some of the areas for future development, as this will aid the move towards individualised risk stratification and personalised care.

Pregnancy in Chronic Liver Disease: Before and After Transplantation

Chronic liver disease poses various challenges for women of reproductive age. Cirrhosis, particularly if decompensated, and liver transplantation may impact gestation and perinatal outcomes. Tailored management of underlying liver disease is critical to optimize maternal and fetal wellbeing. Early education, timely intervention, close monitoring, and a multidisciplinary approach are key elements required to minimize complications and increase chances of a safe and successful pregnancy. In this review, we focus on the pregnancy-related implications of chronic liver disease and liver transplantation on women of reproductive age and highlight disease-specific management considerations.

The positive effect of pregnancy in rheumatoid arthritis and the use of medications for the management of rheumatoid arthritis during pregnancy

Rheumatoid arthritis (RA) is an autoimmune systemic inflammatory disorder that is mostly characterised by progressive symmetrical joint destruction, particularly in the wrist and fingers, while it may also affect additional joints and several organs, such as the skin, heart, blood vessels, and lungs. It is identified by raised anti-rheumatoid factor and anti-cyclic citrullinated peptide antibodies. The chemical mediators involved in the activity of RA are IL-1β, TNF-α, and IL-6. Pregnancy exerts a positive effect on RA that helps to modulate the disease condition. Different hypotheses are recommended to explain the ameliorating effect of pregnancy in RA. RA cannot be completely cured. The treatment goal is the attrition of pain and inflammation and the further progression of the disease. Long-term management of RA is carried out using disease-modifying antirheumatic drugs (DMARDs). Therapy of acute flares can be done with Non-steroidal anti-inflammatory drugs (NSAIDs) accompanied by ad interim usage of glucocorticoids. Biologic response modifiers are also available; they act by abolishing the activity of T- cells. However, it is necessary to select the correct treatment regimen when it comes to the management of RA in pregnancy.

Use of medications during pregnancy and breastfeeding for Crohn's disease and ulcerative colitis

Introduction: The peak age of diagnosis of inflammatory bowel disease (IBD) occurs during childbearing years, therefore management of IBD during pregnancy is a frequent occurrence. Maintenance of disease remission is crucial to optimize pregnancy outcomes, and potential maternal or fetal toxicity from medications must be balanced against the risks of untreated IBD.Areas covered: This review summarizes the literature on safety and use of medications for IBD during pregnancy and lactation.Expert opinion: 5-aminosalicylates, corticosteroids and thiopurines are safe for use during pregnancy, while methotrexate and tofacitinib should only be used with extreme caution. Anti-TNF agents (except certolizumab), vedolizumab, ustekinumab and tofacitinib readily traverse the placenta via active transport, therefore theoretically may affect fetal development. Certolizumab only undergoes passive transfer across the placenta, thus has markedly lower cord blood levels making it likely the safest biologic agent for infants. There is reasonable evidence to support the safety of anti-TNF monotherapy and combination therapy during pregnancy and lactation. Vedolizumab and ustekinumab are also thought to be safe in pregnancy and lactation, while tofacitinib is generally avoided due to teratogenic effects in animal studies.

Myasthenia gravis and pregnancy

Myasthenia gravis (MG) is an autoimmune disorder of neuromuscular junction that has higher incidence in younger women than men, which could be related to differences in sex hormones physiology and immune system functioning between males and females. MG can first present during pregnancy and variably affect pregnancy, labor, and postpartum period. In this paper, we had an updated overview on our understanding about MG presentation and its effect on pregnancy and vice versa, therapeutic options for MG pregnant women, management of pregnancy or labor complications in MG patients, and finally fetal and neonatal considerations in MG pregnant women. A multidisciplinary approach, involving obstetricians/gynecologists, neurologists, and anes-thesiologists, plays a pivotal role in improving the clinical outcomes in both MG mothers and their infants during pregnancy, delivery and postpartum.

Immunosuppressive and Immunomodulating Therapy for Atopic Dermatitis in Pregnancy: An Appraisal of the Literature

The aim of this appraisal of the literature is to elucidate the effects of immunosuppressive and immunomodulating agents used to treat atopic dermatitis (AD) on risk factors for fertility, pregnancy, and breastfeeding. Negative side effects of the psychological and physical stresses associated to AD flairs and uncontrolled AD are discussed, in order to evaluate the consequences of abstaining from treatment. Research on pregnancies in Danish women suggests a tendency towards an increased use of topical steroids and ultraviolet light therapy during pregnancy, compared to before conception, confirming the need for these patients to receive treatment, as well as decreased use of systemic treatments, suggesting a tendency towards undertreatment in this patient population. It is important that effective treatment be provided to pregnant women with AD. Here we present an appraisal of current knowledge on treatments for AD and the risks of exposure for the fetus and breastfed infant. Since little is known about the association between AD, pregnancy, and systemic treatment, we generalize conclusions based on studies on treatments of pregnant women who have undergone organ transplantation and who have inflammatory bowel disease, rheumatic disease, and autoimmune disease. The majority of recommendations are therefore based on a low or very low quality of evidence according to the GRADE system. The selected studies reflect the authors’ assessment regarding originality and importance in the context of this appraisal. It is always the treating doctor’s responsibility to stay updated on current literature when treating patients, especially pregnant patients.

Recent progress in maintenance treatment of neuromyelitis optica spectrum disorder

Background

Treatment of neuromyelitis optica spectrum disorder (NMOSD) has so far been based on retrospective case series. The results of six randomized clinical trials including five different monoclonal antibodies targeting four molecules and three distinct pathophysiological pathways have recently been published.

Methods

Literature search on clinical trials and case studies in NMOSD up to July 10. 2020.

Results

We review mechanism of action, efficacy and side effects, and consequences for reproductive health from traditional immunosuppressants and monoclonal antibodies including rituximab, inebilizumab, eculizumab, tocilizumab and satralizumab.

Conclusion

In NMOSD patients with antibodies against aquaporin 4, monoclonal antibodies that deplete B cells (rituximab and inebilizumab) or interfere with interleukin 6 signaling (tocilizumab and satralizumab) or complement activation (eculizumab) have superior efficacy compared to placebo. Tocilizumab and rituximab were also superior to azathioprine in head-to-head studies. Rituximab, tocilizumab and to some extent eculizumab have well-known safety profiles for other inflammatory diseases, and rituximab and azathioprine may be safe during pregnancy.

Rheumatologic Medication Use During Pregnancy

Chronic rheumatic diseases often occur in women of reproductive age, and the effect rheumatic disease has on pregnancy varies depending on the condition. Medical management of rheumatic diseases during pregnancy may prevent joint or organ damage and minimize the adverse effects of the disease itself on pregnancy outcomes. Each patient requires individual assessment to control disease activity while minimizing or avoiding medications with potential maternal or fetal toxicity. An open discussion with shared decision making between patients, obstetricians, rheumatologists, and pharmacists is imperative to create an individualized treatment plan that meets patients' goals. This article will review the current literature for use of disease modifying antirheumatic drugs and biologics during pregnancy and lactation, providing health care professionals with the most up-to-date information available.

IBD in pregnancy: recent advances, practical management

Inflammatory bowel disease (IBD) poses complex issues in pregnancy, but with high-quality care excellent pregnancy outcomes are achievable. In this article, we review the current evidence and recommendations for pregnant women with IBD and aim to provide guidance for clinicians involved in their care. Many women with IBD have poor knowledge about pregnancy-related issues and a substantial minority remains voluntarily childless. Active IBD is associated with an increased risk of preterm birth, low for gestation weight and fetal loss. With the exception of methotrexate and tofacitinib the risk of a flare outweighs the risk of IBD medication and maintenance of remission from IBD should be the main of care. Most women with IBD will experience a normal pregnancy and can have a vaginal delivery. Active perianal Crohn's disease is an absolute and ileal pouch surgery a relative indication for a caesarean section. Breast feeding is beneficial to the infant and the risk from most IBD medications is negligible.

In utero exposure to Azathioprine in autoimmune disease. Where do we stand?

Azathioprine (AZA), an oral immunosuppressant, is safe during pregnancy. Some reports suggested different impairments in the offspring of mothers with autoimmune diseases (AI) exposed in utero to AZA. These observations are available from retrospective studies or case reports. However, data with respect to the long-term safety in the antenatally exposed child are still lacking. The aim of this study is to summarize the current knowledge in this field and to focus on the need for a prospective study on this population. We performed a PubMed search using several search terms. The actual data show that although the risk of congenital anomalies in offspring, as well as the infertility risk, are similar to those found in general population, there is a higher incidence of prematurity, of lower weight at birth and an intra-uterine delay of development. There is also an increased risk of materno- fetal infections, especially cytomegalovirus infection. Some authors raise the interrogations about neurocognitive impairment. Even though the adverse outcomes might well be a consequence of maternal illness and disease activity, interest has been raised about a contribution of this drug. However, the interferences between the external agent (in utero exposure to AZA), with the host (child genetic susceptibility, immune system anomalies, emotional status), environment (public health, social context, availability of health care), economic, social, and behavioral conditions, cultural patterns, are complex and represent confounding factors. In conclusion, it is necessary to perform studies on the medium and long-term outcome of children born by mothers with autoimmune diseases, treated with AZA, in order to show the safety of AZA exposure. Only large-scale population studies with long-term follow-up will allow to formally conclude in this field. TAKE HOME MESSAGES.

Chronic Kidney Disease and Pregnancy. Obstet Gynecol. 2019;133:1182-1194. [PMID: 31135733 DOI: 10.1097/aog.0000000000003256]

Chronic kidney disease represents a heterogeneous group of disorders characterized by alterations in the structure and function of the kidney. Chronic kidney disease significantly increases the risk of adverse maternal and perinatal outcomes, and these risks increase with the severity of the underlying renal dysfunction, degree of proteinuria, as well as the frequent coexistence of hypertension. Further, renal anatomic changes result in dilatation of the collecting system, and physiologic adaptations include alterations in the balance of vasodilatory and vasoconstrictive hormones, resulting in decreased systemic and renal vascular resistance, increased glomerular filtration rate, and modifications in tubular function. These alterations have important clinical implications and can make the diagnosis of renal compromise challenging. The effect of pregnancy on kidney disease may manifest as a loss of renal function, particularly in the context of concomitant hypertension and proteinuria, and chronic kidney disease, even when mild, contributes to the high risk of adverse pregnancy outcomes, including increased risks of preeclampsia, preterm delivery, and small-for-gestational age neonates. Strategies for optimization of pregnancy outcomes include meticulous management of hypertension and proteinuria where possible and the initiation of preeclampsia prevention strategies, including aspirin. Avoidance of nephrotoxic and teratogenic medications is necessary, and renal dosing of commonly used medications must also be considered. Mode of delivery in women with chronic kidney disease should be based on usual obstetric indications, although more frequent prenatal assessments by an expert multidisciplinary team are desirable for the care of this particularly vulnerable patient population. Obstetricians represent a critical component of this team responsible for managing each stage of pregnancy to optimize both maternal and neonatal outcomes, but collaboration with nephrology colleagues in combined clinics wherein both specialists can make joint management decisions is typically very helpful.

Neuromyelitis optica spectrum disorders and pregnancy: therapeutic considerations

Neuromyelitis optica spectrum disorders (NMOSD) are a type of neurological autoimmune disease characterized by attacks of CNS inflammation that are often severe and predominantly affect the spinal cord and optic nerve. The majority of individuals with NMOSD are women, many of whom are of childbearing age. Although NMOSD are rare, several small retrospective studies and case reports have indicated that pregnancy can worsen disease activity and might contribute to disease onset. NMOSD disease activity seems to negatively affect pregnancy outcomes. Moreover, some of the current NMOSD treatments are known to pose risks to the developing fetus and only limited safety data are available for others. Here, we review published studies regarding the relationship between pregnancy outcomes and NMOSD disease activity. We also assess the risks associated with using disease-modifying therapies for NMOSD during the course of pregnancy and breastfeeding. On the basis of the available evidence, we offer recommendations regarding the use of these therapies in the course of pregnancy planning in individuals with NMOSD.

Neuroimmunologic disorders in pregnancy

Pregnancy influences the course of neuroimmunologic conditions, which include multiple sclerosis (MS), neuromyelitis optica spectrum disorder, and autoimmune encephalitis. The outcomes differ significantly for each disorder, reflecting the impact of hormonal changes, T-cell subsets, and placental factors on disease pathogenesis. In recent years, numerous data have emerged regarding MS activity throughout pregnancy and postpartum. Historically, the misconception that pregnancy worsens MS outcomes led patients to abstain from childbearing. Now, more women with these disorders, empowered by up-to-date information and better baseline disease control, are choosing to conceive. Nevertheless, the management of MS and related disorders in the pregnancy and postpartum period is complicated and requires a nuanced approach. Since standardized treatment guidelines around pregnancy are currently lacking, neurologists, together with obstetricians, must engage patients in a shared decision-making process that weighs the benefits to the mother and risks to the fetus. This chapter outlines the pathophysiology of neuroimmunologic disorders during pregnancy and postpartum, the impact of these diseases on childbearing, including fertility, pregnancy, delivery, and peurperium, as well as existing recommendations for treatment.

Neuromuscular disorders in pregnancy

Many neuromuscular disorders preexist or occur during pregnancy. In some cases, pregnancy unmasks a latent hereditary disorder. Most available information is based on case reports or series or retrospective clinical experience or patient surveys. Of special interest are pregnancy-induced changes in disease course or severity and likelihood for baseline recovery of function postpartum. Labor and delivery present special challenges in many conditions that affect skeletal but not smooth (uterine) muscle; so labor complications must be anticipated. Anesthesia for cesarean section surgery requires special precautions in many disorders. The types of conditions reviewed are broad and include examples of autoimmune, hereditary, and compressive/mechanical processes. Disorders include carpal tunnel syndrome and other focal neuropathies, Bell palsy, myasthenia gravis, and other neuromuscular junction disorders, acute and chronic inflammatory neuropathy, hereditary and acquired muscle diseases, spinal muscular atrophy, amyotrophic lateral sclerosis, channelopathies, autonomic neuropathy, and dysautonomia. Many commonly used therapies have fetal animal but no proven human toxicity concerns, complicating treatment and risk decisions. Weaning off effective therapeutic agents or preemptive aggressive treatment or surgery prior to planned pregnancy is an option in some conditions.

Management of autoimmune blistering diseases in pregnancy and the neonate

The management of autoimmune blistering diseases (AIBD) is therapeutically challenging, particularly in patients who plan to conceive, or are pregnant or breastfeeding. Not only is a patient's immune system altered by pregnancy-associated hormonal changes, but several medications used for AIBD treatment are not recommended for use in pregnancy or lactation. The data acquired regarding the safety and efficacy of these therapeutic interventions are gathered from studies or case reports from other diseases, as the treatment modalities are similar and randomized controlled trials are typically not performed in the setting of pregnancy. Although some medications for AIBD treatment are considered unsafe for use in pregnancy, many effective and tolerable therapies are able to provide benefit to these patients. In fact, most first-line agents may be used in pregnancy, to a given extent. This article discusses the medications used to treat AIBD prior to conception, during pregnancy, and while breastfeeding, as well as highlights those that are contraindicated. The preferred approach to management in these patients is also discussed. Additionally, we present the available information regarding neonates of mothers with a diagnosis of AIBD, including the likelihood, identification, and management of neonatal blistering and the effects from medication exposure in utero.

Immunomodulatory drugs in pregnancy and lactation

Pregnancy presents challenges for women with autoimmune diseases. It is associated with significant physiological, hormonal and immunomodulatory changes which are complex and vary according to the stage of pregnancy

Pregnancy planning and counselling should be offered

Autoimmune diseases such as rheumatoid arthritis tend to improve in pregnancy while systemic lupus erythematosus may increase in activity

During pregnancy the chosen regimen should control or prevent underlying disease activity and minimise risk to the fetus. Ideally, women should be on a stable regimen before conception

Poorly controlled disease is associated with poor outcomes for both mother and fetus, such as higher risks of pre-eclampsia, early delivery and growth restriction of the fetus

Postpartum, there is a sudden fall in hormone concentrations, and a switch to a pro-inflammatory state. This increases the risk of relapse of many autoimmune diseases in particular rheumatoid arthritis, Crohn’s disease and autoimmune hepatitis

Many drugs are compatible with breastfeeding, but there are limited data on many of the new drugs

Drugs in renal disease and pregnancy

This review aims to summarise historic and the latest evidence of commonly used drugs in pregnant women with chronic kidney disease (CKD). Data regarding safety of drugs in breastfeeding are also described. Practical recommendations are made on the use of newer agents that have limited information of use in pregnant women with CKD. Pharmacokinetic and dynamic issues are outlined, and general principles for prescribing drugs in pregnant women with CKD are listed. Resources to investigate drug safety are presented.

Renal disease in pregnancy: Fetal, neonatal and long-term outcomes

Renal disease in women of childbearing age is estimated to be approximately 3%; consequently, renal disease is not an uncommon comorbidity in pregnancy. There has been considerable evidence published over the last 20 years to suggest that renal disease in pregnancy is associated with higher maternal, fetal, and offspring morbidity. Studies published are largely heterogeneous; include unmatched cohort studies; and focus on early neonatal outcomes such as prematurity, small for gestational age, and neonatal unit admission. There appears to be an inverse relationship between maternal renal function and likelihood of neonatal morbidity using these outcome measures. Overall though, data regarding medium-to long-term outcomes for children born to mothers with renal disease are scarce. However, in view of emerging epidemiological evidence regarding cardiovascular programming in intrauterine life in those born premature or small for gestational age, it is likely that this population of children remain at high risk of cardiovascular disease as adults. The scope of this review is to amalgamate and summarize existing evidence regarding the outcomes of infants born to mothers with renal disease. Focus will be given to pregnancy-related acute kidney injury, chronic kidney disease, dialysis, and transplantation.

Immunosuppressives and biologics during pregnancy and lactation : A consensus report issued by the Austrian Societies of Gastroenterology and Hepatology and Rheumatology and Rehabilitation

An increasing and early-onset use of immunosuppressives and biologics has become more frequently seen among patients with inflammatory bowel diseases (IBD) and rheumatic disorders. Many women in their childbearing years currently receive such medications, and some of them in an interdisciplinary setting. Many questions arise in women already pregnant or wishing to conceive with respect to continuing or discontinuing treatment, the risks borne by the newborns and their mothers and long-term safety. Together with the Austrian Society of Rheumatology and Rehabilitation, the IBD working group of the Austrian Society of Gastroenterology and Hepatology has elaborated consensus statements on the use of immunosuppressives and biologics in pregnancy and lactation. This is the first Austrian interdisciplinary consensus on this topic. It is intended to serve as a basis and support for providing advice to our patients and their treating physicians.

Pharmacological Approach to Managing Childhood-Onset Systemic Lupus Erythematosus During Conception, Pregnancy and Breastfeeding

Pediatric patients often have poor pregnancy outcomes. Systemic lupus erythematosus predominantly impacts women in their second to fourth decade of life, with childhood-onset disease being particularly aggressive. Reproductive issues are an important clinical consideration for pediatric patients with systemic lupus erythematosus (SLE), as maintaining good disease control and planning a pregnancy are important for maternal and fetal outcomes. In this clinical review, we will consider the safety of medications in managing childhood-onset SLE during conception, pregnancy, and breastfeeding. The developing fetus is at highest risk for teratogenicity from maternal medications during the period of critical organogenesis, which occurs between the first 3-8 weeks following conception. Medications known to be teratogenic, leading to a specific pattern of malformations, include mycophenolic acid, methotrexate, and cyclophosphamide. These should be discontinued prior to a planned pregnancy or as soon as pregnancy is suspected. Hydroxychloroquine is safe and should be continued throughout pregnancy and breastfeeding in those without contraindications to it. Azathioprine and calcineurin inhibitors are felt to be compatible with pregnancy in usual doses and may be used prior to and throughout pregnancy and lactation. Non-fluorinated corticosteroids including methylprednisolone and prednisone are inactivated by the placenta and can be used if needed for maternal indication during gestation. Addition of aspirin may be considered around the 12th week of gestation for prevention of pre-eclampsia. Illustrative cases are presented that demonstrate management of adolescents with childhood-onset SLE through conception, pregnancy, and breastfeeding.

Systemic medications used in treatment of common dermatological conditions: safety profile with respect to pregnancy, breast feeding and content in seminal fluid

Prescribing for pregnant or lactating patients and male patients wishing to father children can be a difficult area for dermatologists. There is a lack of review articles of commonly used systemic medications in dermatology with respect to their effects on developing embryogenesis and their potential transfer across the placenta, in breast milk and in seminal fluid. This paper aims to provide an up to date summary of evidence to better equip dermatologists to inform patients about the effects of systemic medications commonly used in dermatology to treat conditions such as atopic dermatitis, psoriasis and acne, on current and future embryogenesis and fertility.

Lupus Nephritis and Pregnancy: Concerns and Management

Pregnancy associated with lupus, especially lupus nephritis, is often fraught with concern for both the mother and fetus. Thus, it is paramount that care begins preconception so that proper planning in terms of optimizing the medical regimen, discontinuation of fetotoxic agents, and treatment of active disease can occur. It is well known that active nephritis at the time of conception is associated with poor outcomes. Even with quiescent disease, recent data indicate that being lupus anticoagulant-positive, nonwhite or Hispanic, and using antihypertensive medications were all predictors of worse pregnancy outcomes. Further, prior lupus nephritis also predicts higher rates of preeclampsia and HELLP (hemolysis, elevated liver enzymes, low platelet count) syndrome. Differentiating lupus nephritis from preeclampsia often presents as a conundrum, but lupus nephritis can be confirmed by the presence of decreasing complement levels and increasing double-stranded DNA (dsDNA) antibody levels in addition to new onset hypertension and proteinuria. We hope that the more mechanistic approach of measuring angiogenic markers, which are diagnostic for preeclampsia, will be the standard of care in the future. Women with lupus and prior lupus nephritis can have successful pregnancies, but outcomes are dependent on "the art of planning" as well as close communication between the obstetrician, the nephrologist, and the rheumatologist.

Pregnancy: a therapeutic dilemma

Treatment during pregnancy is problematic. The Food and Drug Administration established drug categories to help in the treatment process. First-generation antihistamines are considered safe but they have sedative properties. Second-generation antihistamines cause less adverse reactions but besides cetirizine and loratadine they belong to category C. All retinoids should be avoided during pregnancy due to the risk of fetal malformations. Antimalarial drugs should be considered based on the clinical data. Sulfones can be considered as safe for use during pregnancy only with proper monitoring. Prednisone is administered in pregnancy. Other glucocorticosteroids have a different safety profile. Cyclosporine A treatment should be reserved as rescue therapy in severe stages of the disease. Treatment during pregnancy should be precise when it comes to pregnant woman and safe for the fetus.

Lactation and Management of Postpartum Disease

While much of the existing literature in the field of reproductive rheumatology focuses on fertility, preconception counseling, and pregnancy, there is limited information regarding the postpartum period and lactation. Evidence suggests that many rheumatologic disorders flare after delivery, which, along with limitations in medications compatible with breastfeeding, make this time period challenging for women with rheumatologic conditions. This article discusses rheumatologic disease activity during the postpartum period and reviews the safety during lactation of commonly used medications for the management of rheumatic diseases. Fortunately, many of the commonly used medications are compatible with breastfeeding.

Management of systemic lupus erythematosus during pregnancy: challenges and solutions

Systemic lupus erythematosus (SLE) is a chronic, multisystem autoimmune disease predominantly affecting women, particularly those of childbearing age. SLE provides challenges in the prepregnancy, antenatal, intrapartum, and postpartum periods for these women, and for the medical, obstetric, and midwifery teams who provide their care. As with many medical conditions in pregnancy, the best maternal and fetal-neonatal outcomes are obtained with a planned pregnancy and a cohesive multidisciplinary approach. Effective prepregnancy risk assessment and counseling includes exploration of factors for poor pregnancy outcome, discussion of risks, and appropriate planning for pregnancy, with consideration of discussion of relative contraindications to pregnancy. In pregnancy, early referral for hospital-coordinated care, involvement of obstetricians and rheumatologists (and other specialists as required), an individual management plan, regular reviews, and early recognition of flares and complications are all important. Women are at risk of lupus flares, worsening renal impairment, onset of or worsening hypertension, preeclampsia, and/or venous thromboembolism, and miscarriage, intrauterine growth restriction, preterm delivery, and/or neonatal lupus syndrome (congenital heart block or neonatal lupus erythematosus). A cesarean section may be required in certain obstetric contexts (such as urgent preterm delivery for maternal and/or fetal well-being), but vaginal birth should be the aim for the majority of women. Postnatally, an ongoing individual management plan remains important, with neonatal management where necessary and rheumatology followup. This article explores the challenges at each stage of pregnancy, discusses the effect of SLE on pregnancy and vice versa, and reviews antirheumatic medications with the latest guidance about their use and safety in pregnancy. Such information is required to effectively and safely manage each stage of pregnancy in women with SLE.

Neuromyelitis optica and pregnancy

Neuromyelitis optica (NMO) and the associated NMO spectrum disorders are demyelinating disorders affecting the spinal cord and optic nerves. It has prominent female predominance and many of these patients are in their childbearing years. As pregnancy seems to have a major impact on this disease course, in this review, recent studies with a focus on this disease and pregnancy and safety of available treatment options during this period are discussed.

A Review of the Course and Treatment of Non-Infectious Uveitis during Pregnancy

Inflammatory conditions such as autoimmune uveitis often occur in women of childbearing age. During pregnancy, women may experience exacerbations of their disease in the first trimester. In the later stages of pregnancy, however, the uveitis tends to remain less active. The management of uveitis during pregnancy is a challenging task, forcing the physician to re-evaluate the patient's current therapy and offer alternative options that pose the least risk to the patient and fetus. This article will review treatments widely used for uveitis, including corticosteroid therapy, anti-metabolites, calcineurin inhibitors, and biologic therapy. It will evaluate the use of these medications in pregnancy and the postpartum state.

Managing inflammatory bowel disease in pregnancy: current perspectives

Inflammatory bowel disease (IBD) affects many women of childbearing age. The course of IBD is closely related to pregnancy outcomes with poorly controlled IBD increasing the risk of prematurity, low weight for gestation, and fetal loss. As such, women with IBD face complex decision making weighing the risks of active disease versus those of medical treatments. This review summarizes the current evidence regarding the safety and efficacy of IBD treatments during pregnancy and lactation aiming to provide up-to-date guidance for clinicians. Over 50% of women have poor IBD- and pregnancy-related knowledge, which is associated with views contrary to medical evidence and voluntary childlessness. This review highlights the effects of poor patient knowledge and critically evaluates interventions for improving patient knowledge and outcomes.

Management of Eosinophilic Esophagitis During Pregnancy

There are currently limited data on the management of eosinophilic esophagitis (EoE) during pregnancy. At our center, however, we have followed several pregnant women with EoE and others have asked pertinent questions in pre-pregnancy counseling. The relatively young age of patients with EoE implies that many practitioners will also encounter patients with these questions. In this review, we use four cases to prompt a discussion about concerns focused on the safety of steroids and diet therapy during pregnancy and breast-feeding, potential nutritional risks with dietary elimination, how to optimize therapy, and whether endoscopic evaluation for monitoring of disease activity is safe during pregnancy and breast-feeding. An additional concern is whether the disease could progress during pregnancy and breast-feeding if no therapies are used. Although there are no studies specifically examining pregnant EoE patients, we have reviewed the literature relevant to this population as informed by the treatment of inflammatory bowel disease patients during pregnancy, where these issues have been studied in more depth. Providers who care for EoE patients who could become pregnant should familiarize themselves with these issues.

Management of rheumatoid arthritis during pregnancy: challenges and solutions

Rheumatoid arthritis, a chronic inflammatory autoimmune disease with significant physical disability, affects women three times more frequently than men, often in their childbearing years. Parenthood decisions can be challenging, often affected by perceptions of their disease state, health care needs, and complex pharmacological treatments. Many women struggle to find adequate information to guide them on pregnancy planning, lactation, and early parenting in relation to their chronic condition. The expanded availability and choice of pharmacotherapies have supported optimal disease control prior to conception and enhanced physical capabilities for women to successfully overcome the challenges of raising children but require a detailed understanding of their risks and safety in the setting of pregnancy and breastfeeding. This review outlines the various situational challenges faced by rheumatologists in providing care to men and women in the reproductive age group interested in starting a family. Up to date evidence-based solutions particularly focusing on the safe use of disease-modifying antirheumatic drugs and biologic response modifiers to assist rheumatologists in the care of pregnant and lactating women with RA are reviewed.