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Brondfield MN, Mahadevan U. Inflammatory bowel disease in pregnancy and breastfeeding. Nat Rev Gastroenterol Hepatol 2023:10.1038/s41575-023-00758-3. [PMID: 37002407 DOI: 10.1038/s41575-023-00758-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/20/2023] [Indexed: 06/19/2023]
Abstract
Inflammatory bowel disease (IBD) has a peak age of diagnosis before the age of 35 years. Concerns about infertility, adverse pregnancy outcomes, and heritability of IBD have influenced decision-making for patients of childbearing age and their care providers. The interplay between the complex physiology in pregnancy and IBD can affect placental development, microbiome composition and responses to therapy. Current evidence has shown that effective disease management, including pre-conception counselling, multidisciplinary care and therapeutic agents to minimize disease activity, can improve pregnancy outcomes. This Review outlines the management of IBD in pregnancy and the safety of IBD therapies, including novel agents, with regard to both maternal and fetal health. The vast majority of IBD therapies can be used with low risk during pregnancy and lactation without substantial effects on neonatal outcomes.
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Affiliation(s)
- Max N Brondfield
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Uma Mahadevan
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California San Francisco, San Francisco, CA, USA.
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Luo Y, Acevedo D, Baños N, Pluma A, Castellanos-Moreira R, Moreno E, Rodríguez-García S, Deyà-Martínez A, García-García A, Quesada-Masachs E, Torres M, Casellas M, Grados D, Martí-Castellote C, Antón J, Vlagea A, Juan M, Esteve-Solé A, Alsina L. Expected impact of immunomodulatory agents during pregnancy: A newborn's perspective. Pediatr Allergy Immunol 2023; 34:e13911. [PMID: 36825745 DOI: 10.1111/pai.13911] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 12/19/2022] [Accepted: 01/03/2023] [Indexed: 02/11/2023]
Abstract
The neonatal immune ontogeny begins during pregnancy to ensure that the neonate is well-suited for perinatal life. It prioritizes Th2/M2 and regulatory responses over Th/M1 activity to avoid excessive inflammatory responses and to ensure immune tolerance and homeostasis. Newborns also present increased Th17/Th22 responses providing effective anti-fungal immunity and mucosal protection. Intrauterine exposure to immune modulatory drugs with the placental transfer may influence the natural course of the fetal immune development. The vertical transfer of both biological therapy and small molecules begins during the first trimester through neonatal Fc receptor or placental diffusion, respectively, reaching its maximum transfer potential during the third trimester of pregnancy. Most of the biological therapy have a prolonged half-life in newborn's blood, being detectable in infants up to 12 months after birth (usually 6-9 months). The use of immunomodulators during pregnancy is gaining global interest. Current evidence mainly reports birth-related outcomes without exhaustive analysis of the on-target side effect on the perinatal immune system ontogeny, the infection risk, or the immune dysregulation. The present review will focus on: (1) the main characteristics of the perinatal immune system to understand its specific features and vulnerabilities to immune modulation; (2) the mechanisms of placental transfer of immunomodulators; and (3) the immune changes reported to date in newborns exposed to immunomodulators with emphasis on the current concerns and gaps in knowledge.
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Affiliation(s)
- Yiyi Luo
- Clinical Immunology and Primary Immunodeficiencies Unit, Allergy and Clinical Immunology Department, Hospital Sant Joan de Déu, Barcelona, Spain.,Clinical Immunology Unit, Hospital Sant Joan de Déu-Hospital Clínic, Barcelona, Spain.,Study Group for Immune Dysfunction Diseases in Children (GEMDIP), Institut de Recerca Sant Joan de Déu, Barcelona, Spain
| | - Daniel Acevedo
- Clinical Immunology and Primary Immunodeficiencies Unit, Allergy and Clinical Immunology Department, Hospital Sant Joan de Déu, Barcelona, Spain.,Clinical Immunology Unit, Hospital Sant Joan de Déu-Hospital Clínic, Barcelona, Spain.,Study Group for Immune Dysfunction Diseases in Children (GEMDIP), Institut de Recerca Sant Joan de Déu, Barcelona, Spain
| | - Núria Baños
- BCNatal, Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Déu), Institut Clínic de Ginecologia, Obstetrícia i Neonatologia Fetal i+D Fetal Medicine Research Center, Barcelona, Spain
| | - Andrea Pluma
- Rheumatology Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | | | - Estefania Moreno
- Rheumatology Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | | | - Angela Deyà-Martínez
- Clinical Immunology and Primary Immunodeficiencies Unit, Allergy and Clinical Immunology Department, Hospital Sant Joan de Déu, Barcelona, Spain.,Clinical Immunology Unit, Hospital Sant Joan de Déu-Hospital Clínic, Barcelona, Spain.,Study Group for Immune Dysfunction Diseases in Children (GEMDIP), Institut de Recerca Sant Joan de Déu, Barcelona, Spain
| | - Ana García-García
- Clinical Immunology and Primary Immunodeficiencies Unit, Allergy and Clinical Immunology Department, Hospital Sant Joan de Déu, Barcelona, Spain.,Clinical Immunology Unit, Hospital Sant Joan de Déu-Hospital Clínic, Barcelona, Spain.,Study Group for Immune Dysfunction Diseases in Children (GEMDIP), Institut de Recerca Sant Joan de Déu, Barcelona, Spain
| | | | - Mireia Torres
- Rheumatology Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Manel Casellas
- High Risk Obstetric Unit, Gynecology and Obstetrics Department, Vall de Hebron Hospital Campus, Universitat Autónoma of Barcelona (UAB), Barcelona, Spain
| | - Dolors Grados
- Rheumatology Department, Hospital Universitari d'Igualada, Igualada, Spain
| | - Celia Martí-Castellote
- Clinical Immunology and Primary Immunodeficiencies Unit, Allergy and Clinical Immunology Department, Hospital Sant Joan de Déu, Barcelona, Spain.,Study Group for Immune Dysfunction Diseases in Children (GEMDIP), Institut de Recerca Sant Joan de Déu, Barcelona, Spain
| | - Jordi Antón
- Study Group for Immune Dysfunction Diseases in Children (GEMDIP), Institut de Recerca Sant Joan de Déu, Barcelona, Spain.,Pediatric Rheumatology, Hospital Sant Joan de Déu, Barcelona, Spain.,Universitat de Barcelona, Barcelona, Spain
| | - Alexandru Vlagea
- Immunology Department, Biomedic Diagnostic Center (CDB), Hospital Clínic of Barcelona, Clinical Immunology Unit Hospital Sant Joan de Déu-Hospital Clínic de Barcelona, Barcelona, Spain
| | - Manel Juan
- Clinical Immunology Unit, Hospital Sant Joan de Déu-Hospital Clínic, Barcelona, Spain.,Universitat de Barcelona, Barcelona, Spain.,Immunology Department, Biomedic Diagnostic Center (CDB), Hospital Clínic of Barcelona, Clinical Immunology Unit Hospital Sant Joan de Déu-Hospital Clínic de Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Ana Esteve-Solé
- Clinical Immunology and Primary Immunodeficiencies Unit, Allergy and Clinical Immunology Department, Hospital Sant Joan de Déu, Barcelona, Spain.,Clinical Immunology Unit, Hospital Sant Joan de Déu-Hospital Clínic, Barcelona, Spain.,Study Group for Immune Dysfunction Diseases in Children (GEMDIP), Institut de Recerca Sant Joan de Déu, Barcelona, Spain
| | - Laia Alsina
- Clinical Immunology and Primary Immunodeficiencies Unit, Allergy and Clinical Immunology Department, Hospital Sant Joan de Déu, Barcelona, Spain.,Clinical Immunology Unit, Hospital Sant Joan de Déu-Hospital Clínic, Barcelona, Spain.,Study Group for Immune Dysfunction Diseases in Children (GEMDIP), Institut de Recerca Sant Joan de Déu, Barcelona, Spain.,Universitat de Barcelona, Barcelona, Spain
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Guerrero Vinsard D, Kane SV. Biologics and pregnancy: a clinician's guide to the management of IBD in pregnant women. Expert Rev Gastroenterol Hepatol 2021; 15:633-641. [PMID: 33440996 DOI: 10.1080/17474124.2021.1876562] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Introduction: Women with inflammatory bowel disease (IBD) endorse a tremendous amount of concern about medication exposure during pregnancy and their effects on the fetus. Medical providers caring for this patient population should be well informed and feel comfortable counseling their patients for the best pregnancy outcome possible.Areas covered: It is of particular importance to understand the implications of use of biologics in preconception, pregnancy, and postpartum timeframes. Herein, we aim to inform the clinician about the impact of uncontrolled inflammation during pregnancy, the mechanisms of biologic transport through the placenta, the effects of biologics in maternal and neonatal outcomes, and additional postpartum considerations such as breastfeeding and vaccination safety.Expert opinion: The groundwork already set by previous research in terms of safety of biologic therapy during pregnancy has been reassuring. With the advent of more mechanisms of action but similar protein structure, i.e. they are IgG1 antibodies; the authors anticipate the recommendation of continuation of therapy throughout pregnancy will be sustained.
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Affiliation(s)
| | - Sunanda V Kane
- Division of Gastroenterology and Hepatology, Mayo Clinic Rochester, Rochester, MN, USA
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Laube R, Paramsothy S, Leong RW. Use of medications during pregnancy and breastfeeding for Crohn's disease and ulcerative colitis. Expert Opin Drug Saf 2021; 20:275-292. [PMID: 33412078 DOI: 10.1080/14740338.2021.1873948] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
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.
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Affiliation(s)
- Robyn Laube
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia.,Department of Gastroenterology, Macquarie University Hospital, Sydney, Australia
| | - Sudarshan Paramsothy
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia.,Department of Gastroenterology, Macquarie University Hospital, Sydney, Australia.,Department of Gastroenterology and Hepatology, Concord Repatriation General Hospital, Sydney, Australia
| | - Rupert W Leong
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia.,Department of Gastroenterology, Macquarie University Hospital, Sydney, Australia.,Department of Gastroenterology and Hepatology, Concord Repatriation General Hospital, Sydney, Australia
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