I am often asked by patients and other physicians about the use of aspirin, prednisone, hydroxychloroquine, cyclosporine A, adalimumab, immunoglobulins, and other drugs during pregnancy and lactation. The majority of these drugs are almost always labeled “prohibited or cautioned for use during pregnancy”, which not only leaves patients at a loss, but also puts many medical professionals in a dilemma due to the lack of knowledge about the use of drugs during pregnancy and lactation. Today I will answer them one by one in the hope that they will be helpful, but the specific dose and adjustment of drugs will be determined by the clinician’s comprehensive judgment based on various laboratory results and the patient’s condition.
1.What kind of diseases are the above mentioned drugs for?
They are mainly used for the treatment of autoimmune diseases.
2.What is autoimmune disease?
Autoimmune disease is a state in which the body’s immune system reacts to its own antigens, causing pathological damage to its own tissues or organs, affecting their physiological functions, and eventually leading to various clinical symptoms.
3.Who is at risk of autoimmune diseases?
Autoimmune diseases are prevalent in women and often develop during the reproductive age, and even worsen during pregnancy. Many patients need medication to safely survive pregnancy, especially women with a history of poor fertility are prone to such diseases, such as
Patients with adverse pregnancy history such as ≥ 2 spontaneous abortions, including: empty gestational sac, absence of fetal heartbeat, fetal heartbeat disappearance, fetal death in utero, intrauterine growth retardation, reduced amniotic fluid, preeclampsia, etc.
Patients with empty gestational sac, no fetal heartbeat, or fetal heartbeat disappearance after IVF or ovulation-promoted pregnancy.
Patients with multiple failed IVF-embryo transfer (≥3 times)
Patients with unexplained infertility
Patients with premature ovarian failure
According to the data of our special clinic for habitual abortion, about 20% of the above patients will be screened for autoimmune diseases.
4. What are the common autoimmune diseases?
The most common ones in our Habitual Abortion Clinic are: antiphospholipid syndrome, Hashimoto’s thyroiditis, dry syndrome, systemic lupus erythematosus, rheumatoid arthritis, idiopathic thrombocytopenia, ulcerative colitis, type I diabetes, premature ovarian failure (autoimmune), mixed connective tissue disease, etc.
5.Common features of autoimmune diseases
The cause of the disease is unknown; female predominance; genetic predisposition; the presence of multiple autoantibodies or auto-reactive sensitized lymphocytes in the patient’s serum; overlapping diseases, i.e., a patient may suffer from more than one autoimmune disease at the same time; long duration of the disease, mostly chronic; immunosuppressive therapy can achieve certain efficacy.
6, conventional drug FDA classification / pregnancy / lactation medication principles (only the drugs commonly used during pregnancy are listed)
Drugs
FDA classification
Pregnancy
Lactation
Aspirin
B (Early Pregnancy)
C (after 30 weeks of gestation)
Avoid in late pregnancy; increased risk of premature fetal ductus arteriosus; discontinue 6-8 weeks before delivery.
Use with caution during lactation; risk of inducing neonatal jaundice and kernicterus.
Prednisone
B
The lowest effective dose should be given during pregnancy; use early in pregnancy has an increased risk of neonatal cleft lip and adrenal insufficiency. Prolonged administration of 5-10 mg/d, or higher doses of prednisone in mid to late pregnancy increases the incidence of gestational diabetes, hypertension, sodium retention, premature rupture of membranes, and osteoporosis.
Do not breastfeed until 4 hours after taking the drug
Cyclosporine A (CsA)
C
Use with caution in pregnancy; there is a risk of impaired development and maturation of infant T-, B-, and NK-cells after birth that does not resolve after 1 year
Contraindicated during lactation
Hydroxychloroquine (HCQ)
C
May be used in pregnancy
May be used during lactation
Adalimumab (Anti-TNF-a)
B
Does not cross the placenta in early pregnancy, insufficient data, use with caution in pregnancy
Insufficient experience with human dosing during lactation
Immunoglobulin (IVIG)
C
Can be used in pregnancy
Can be used during lactation
In conclusion, the rational use of drugs during pregnancy and lactation is related to the health of the mother and the baby, and “medicine is toxic in three parts”. The treatment should be tailored to ensure the necessary treatment, while avoiding the blind termination of pregnancies that could be preserved.