Immunomodulatory drugs in pregnancy and lactation

Abstract

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.