Pregnancy management in women with
Rheumatic and Musculoskeletal Disease
(Part 4)
We continue with the discussion of pregnancy management with women that suffer from rheumatic and musculoskeletal disease (RMD).
The variations of placental transfer and fetal exposure for most biologic therapies depend on the stage of gestation.
The reality is that a majority of RMD therapies contain an Fc IgG1 chemical that does not go or cross into the fetal circulation in significant amounts until the second trimester.
In some cases, using tumor necrosis factor (TNF) inhibitors that include an IgG1 Fc chemical or construct during the third trimester of pregnancy, such as infliximab, etanercept, adalimumab, and golimumab, could result in high levels of placental transfer and significant levels in drug presence in the neonate.
There is quite modest amount of evidence showing that these TNF inhibitors don’t cause adverse effects, especially in the first trimester of pregnancy.
Experts have extensively discussed about the use of these drugs, especially on the issue of when the drugs should no longer be consumed prior to delivery.
Several experts agree if the RMD is under control the drugs may be discontinued by the woman upon entering the third trimester of pregnancy.
On the other hand, if the woman’s RMD is active, the use of drugs may be considered, that the neonate will have significant levels of the drugs for a certain period of time.
The reality is that there are not enough data regarding the compatibility of some drugs or biologics with being pregnant.
As it is now known that these drugs are likely not going to cross the placenta until the second trimester, the experts recommends that non–TNF inhibitor IgG-based molecules are compatible during the periconception period but should be discontinued during pregnancy or the moment a woman finds out that she is on the family way.
Moreover, experts conditionally recommend continuing treatment with anakinra, belimumab, abatacept, tocilizumab, secukinumab, and ustekinumab as the woman tries to get pregnant and to discontinue using the said drugs once the woman is already pregnant.
In the case of the RMD can be controlled via drugs known not to be contraindicated or medicines considered to be compatible with pregnancy, there should be a discussion between patient and doctor and weigh all the options and possibilities, at the same time assess the risks of using the drugs during pregnancy.
Experts may, given certain conditions, recommend to continue using rituximab as the woman is still trying to get pregnant and discontinue using the drug when the woman is already pregnant or if there is severe life- or organ-threatening maternal disease.
Getting some dose of the drugs at the second half of pregnancy may increase risks with having a minimum count of B cells at the time of delivery.
The thing is that there no evidence available on the safety of the new small-molecule agents, tofacitinib, baricitinib, and apremilast, during a woman’s pregnancy.
Experts, however, are of the opinion that recommendations should not be given for women with RMD and pregnant, as small molecules may pass through the placenta.