By Howard H. Tessler, MD
This retrospective review found that uveitis activity changed with the stage of pregnancy, with the rate of flare-ups decreasing during the second trimester.
I found this paper particularly useful since I have many patients with chronic or recurrent uveitis who are or will be pregnant. It is helpful to know that their disease may be less active during the second and third trimesters of pregnancy.
I do not use steroid-sparing immunomodulatory agents during pregnancy in order to protect the fetus from the risk of these agents and found it surprising that cyclosporine and methotrexate were listed as agents used during pregnancy in two patients in this cohort.
The study’s authors reviewed the charts of 47 subjects with a history of noninfectious uveitis predating their pregnancy. They assessed uveitis activity one year before pregnancy, during pregnancy and at one year postpartum.
Although rates of flare-ups during the first trimester and prepregnancy were similar, flare-up rates began to fall in the second trimester, reaching their lowest level in the third trimester. After delivery, flare-up rates rebounded within six months to levels similar to those of prepregnancy. Even so, 40 percent of subjects were found to have remained inactive during the first postpartum year.
They note that the 14 patients with multiple pregnancies included in the study showed no correlation in the rates of flare-ups during corresponding periods of their first and second pregnancies. Also, despite remarkable reduction in flares, the percentage of patients using topical and systemic corticosteroids, steroid sparing immunomodulatory therapy or nothing at all was no different among the cohort in the ante-partum, pregnancy and postpartum periods.
The authors write that pregnancy is associated with a distinct immune dysfunction. Elevated levels of estrogen and progesterone suppress Th1 associated-immunity and upregulate Th2-associated immune responses. In addition, maternal regulatory T cells demonstrate plasticity, with the ability to switch between aggressive and tolerant phenotypes in response to circulating infectious agents or fetal cells, respectively.
They say that this study has key implications for the management of pregnant uveitis patients. Having demonstrated that uveitis tends to improve during the later stages of pregnancy, clinicians may consider decreasing uveitis medications during this time, thus minimizing the risk of medication-associated side effects on the fetus. Clinicians also may wish to conduct more intensive follow-up after delivery in anticipation of postpartum disease relapse.