Overview
Noninfectious uveitis in pregnancy shows increased disease activity early in pregnancy, significant reduction in activity in late trimesters, and rebound inflammation postpartum
Infectious uveitis, especially toxoplasma retinochoroiditis, may have a higher incidence of reactivation during pregnancy
When considering treatment, the risks and benefits to the fetus and mother must always be carefully weighed, with knowledge that severe, untreated inflammatory disease in the mother is possibly harmful to the fetus
Clinical Course
- Hormonal changes in pregnancy ultimately decrease cell-mediated inflammation by upregulating Th2 cells and downregulating Th1 cells
These changes are driven by increased levels of estrogen, progesterone, alpha fetoprotein, cortisol, norepinephrine, prolactin, and 1,25-dihydroxyvitamin D
- Improved disease activity in patients with Adamantiades-Behcet’s disease, VKH syndrome, sympathetic ophthalmia, HLA-B27 associated anterior uveitis, rheumatoid arthritis, juvenile idiopathic arthritis (JIA), and multiple sclerosis
There is notable inflammatory rebound in the 6 months after parturition
Potential worsening of systemic lupus erythematosus (SLE) disease activity
Rates of de novo infection and reactivation of toxoplasma retinochoroiditis are increased
- Considerations for immunosuppression:
Although IMT carries risks, it is likely that untreated, severe disease also poses harm to the fetus
- Non-infectious uveitis in pregnancy:
- Prednisone and prednisolone (FDA Pregnancy Category B) are safe during pregnancy and breastfeeding
Dose exceeding 9 mg/day may be associated with fetal cleft palate and a theoretical risk of premature rupture of membranes or chorioamnionitis
Azathioprine (Category D) may be safely continued in pregnant women with severe disease at doses ≤2 mg/kg/day
Methotrexate, mycophenolate mofetil, and alkylating agents (Category X) are known teratogens and must be avoided in pregnancy and discontinued at least 3 months prior to conception
Tacrolimus and cyclosporine (Category C) are safe in low doses but should be avoided during breastfeeding
TNF-α inhibitors (Category B) appear to be safe and well-tolerated in pregnancy
Tocilizumab (Category C) and its effect on pregnancy have not been studied in humans
Rituximab (Category C) may cause neonatal B-cell lymphocytopenia and should be discontinued 1 year prior to conception
- Infectious uveitis in pregnancy:
- Toxoplasma retinochoroiditis:
- Spiramycin 1 g TID is drug of choice during early pregnancy (<18 weeks gestation)
Significantly lowers vertical transmission rate
Licensed in Canada and Europe but available in the USA only directly through the FDA
Trimethoprim/sulfamethoxazole 160/800 mg BID can be used in late second or third trimester
- Syphilitic uveitis:
Intravenous penicillin 18–24 million units/day for 2 weeks