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Rheumatoid arthritis and pregnancy: evolution of disease activity and pathophysiological considerations for drug use.

Hazes JM, Coulie PG, Geenen V, Vermeire S, Carbonnel F, Louis E, Masson P, De Keyser F - Rheumatology (Oxford) (2011)

Bottom Line: This article aims to summarize the current evidence on the evolution of RA disease activity during and after pregnancy and the use of anti-rheumatic drugs around this period.Of recent interest is the potential use of anti-TNF compounds in the preconception period and during pregnancy.Accumulating experience with anti-TNF therapy in other immune-mediated inflammatory diseases, such as Crohn's disease, provides useful insights for the use of TNF blockade in pregnant women with RA, or RA patients wishing to become pregnant.

View Article: PubMed Central - PubMed

Affiliation: Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.

ABSTRACT
It has long been known that pregnancy and childbirth have a profound effect on the disease activity of rheumatic diseases. For clinicians, the management of patients with RA wishing to become pregnant involves the challenge of keeping disease activity under control and adequately adapting drug therapy during pregnancy and post-partum. This article aims to summarize the current evidence on the evolution of RA disease activity during and after pregnancy and the use of anti-rheumatic drugs around this period. Of recent interest is the potential use of anti-TNF compounds in the preconception period and during pregnancy. Accumulating experience with anti-TNF therapy in other immune-mediated inflammatory diseases, such as Crohn's disease, provides useful insights for the use of TNF blockade in pregnant women with RA, or RA patients wishing to become pregnant.

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Evolution of maternal and serum IgG levels during pregnancy [94, 95]. IgG levels of maternal origin in the fetal circulation increase over the course of pregnancy. At the end of gestation, fetal IgG levels exceed those in the maternal circulation, which indicates that the placenta develops an active transport mechanism for IgG molecules. Adapted from Malek A, Sager R, Kuhn P, Nicolaides KH, Schneider H. Evolution of maternofetal transport of immunoglobulins during human pregnancy. Am J Reprod Immunol 1996;36:248–55, with permission from John Wiley & Sons Ltd.
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ker302-F2: Evolution of maternal and serum IgG levels during pregnancy [94, 95]. IgG levels of maternal origin in the fetal circulation increase over the course of pregnancy. At the end of gestation, fetal IgG levels exceed those in the maternal circulation, which indicates that the placenta develops an active transport mechanism for IgG molecules. Adapted from Malek A, Sager R, Kuhn P, Nicolaides KH, Schneider H. Evolution of maternofetal transport of immunoglobulins during human pregnancy. Am J Reprod Immunol 1996;36:248–55, with permission from John Wiley & Sons Ltd.

Mentions: Despite the roles of TNF in establishing and maintaining pregnancy and protecting the fetus, IgG anti-TNF antibodies can probably be safely administered during the first part of pregnancy, since IgG antibodies do not cross the placental barrier in the first trimester. Indeed, transplacental transport of IgG only starts after the first trimester and mainly increases during the third trimester of pregnancy [95]. IgG levels in the maternal circulation decrease during pregnancy, concomitant with a rise of IgG from maternal origin in the fetal circulation starting from Week 13 onwards. At term, IgG levels in the fetus exceed the levels in the maternal circulation, which is indicative of an active transport mechanism (Fig. 2) [96]. Transplacental transport was shown to be most efficient for the IgG1 and least efficient for the IgG2 subclass [96]. IgG is transported over the placenta via pH-dependent receptor-mediated transcytosis, in which maternal IgG binds to the so-called neonatal immunoglobulin constant fragment (Fc fragment) receptor expressed on the syncytiotrophoblast membrane, followed by transcytosis and release of bound IgG in the fetal circulation (Fig. 3) [97–99].Fig. 2


Rheumatoid arthritis and pregnancy: evolution of disease activity and pathophysiological considerations for drug use.

Hazes JM, Coulie PG, Geenen V, Vermeire S, Carbonnel F, Louis E, Masson P, De Keyser F - Rheumatology (Oxford) (2011)

Evolution of maternal and serum IgG levels during pregnancy [94, 95]. IgG levels of maternal origin in the fetal circulation increase over the course of pregnancy. At the end of gestation, fetal IgG levels exceed those in the maternal circulation, which indicates that the placenta develops an active transport mechanism for IgG molecules. Adapted from Malek A, Sager R, Kuhn P, Nicolaides KH, Schneider H. Evolution of maternofetal transport of immunoglobulins during human pregnancy. Am J Reprod Immunol 1996;36:248–55, with permission from John Wiley & Sons Ltd.
© Copyright Policy - creative-commons
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC3198908&req=5

ker302-F2: Evolution of maternal and serum IgG levels during pregnancy [94, 95]. IgG levels of maternal origin in the fetal circulation increase over the course of pregnancy. At the end of gestation, fetal IgG levels exceed those in the maternal circulation, which indicates that the placenta develops an active transport mechanism for IgG molecules. Adapted from Malek A, Sager R, Kuhn P, Nicolaides KH, Schneider H. Evolution of maternofetal transport of immunoglobulins during human pregnancy. Am J Reprod Immunol 1996;36:248–55, with permission from John Wiley & Sons Ltd.
Mentions: Despite the roles of TNF in establishing and maintaining pregnancy and protecting the fetus, IgG anti-TNF antibodies can probably be safely administered during the first part of pregnancy, since IgG antibodies do not cross the placental barrier in the first trimester. Indeed, transplacental transport of IgG only starts after the first trimester and mainly increases during the third trimester of pregnancy [95]. IgG levels in the maternal circulation decrease during pregnancy, concomitant with a rise of IgG from maternal origin in the fetal circulation starting from Week 13 onwards. At term, IgG levels in the fetus exceed the levels in the maternal circulation, which is indicative of an active transport mechanism (Fig. 2) [96]. Transplacental transport was shown to be most efficient for the IgG1 and least efficient for the IgG2 subclass [96]. IgG is transported over the placenta via pH-dependent receptor-mediated transcytosis, in which maternal IgG binds to the so-called neonatal immunoglobulin constant fragment (Fc fragment) receptor expressed on the syncytiotrophoblast membrane, followed by transcytosis and release of bound IgG in the fetal circulation (Fig. 3) [97–99].Fig. 2

Bottom Line: This article aims to summarize the current evidence on the evolution of RA disease activity during and after pregnancy and the use of anti-rheumatic drugs around this period.Of recent interest is the potential use of anti-TNF compounds in the preconception period and during pregnancy.Accumulating experience with anti-TNF therapy in other immune-mediated inflammatory diseases, such as Crohn's disease, provides useful insights for the use of TNF blockade in pregnant women with RA, or RA patients wishing to become pregnant.

View Article: PubMed Central - PubMed

Affiliation: Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.

ABSTRACT
It has long been known that pregnancy and childbirth have a profound effect on the disease activity of rheumatic diseases. For clinicians, the management of patients with RA wishing to become pregnant involves the challenge of keeping disease activity under control and adequately adapting drug therapy during pregnancy and post-partum. This article aims to summarize the current evidence on the evolution of RA disease activity during and after pregnancy and the use of anti-rheumatic drugs around this period. Of recent interest is the potential use of anti-TNF compounds in the preconception period and during pregnancy. Accumulating experience with anti-TNF therapy in other immune-mediated inflammatory diseases, such as Crohn's disease, provides useful insights for the use of TNF blockade in pregnant women with RA, or RA patients wishing to become pregnant.

Show MeSH
Related in: MedlinePlus