Critical analysis of pemphigus vulgaris in pregnancy

Human pregnancy is a complex, interesting and challenging interplay between the hormonal and immune systems. The presence of an autoimmune disease adds to this complexity. Presence of pemphigus vulgaris (PV) in a pregnant patient should be considered a "high risk pregnancy", by all health care providers involved, from implantation to post-partum care and thereafter. In this systemic review, data from 90 studies involving 111 pemphigus vulgaris patients who were pregnant has been critically analyzed. Patients who had PV before pregnancy and those who developed it during pregnancy were studied and outcomes were compared and are discussed. Systemic corticosteroids (CS) remain the mainstay of treatment. The role of the placenta in producing endogenous cortisol should be considered in adjusting these doses during the last trimester and post-partum. The data in this analysis clearly demonstrates that the clinical and serological control of and the remission of PV is one of the most important factors that influences and predicts maternal health, gestational complications, post-partum exacerbations, neonatal pemphigus and fetal mortality. Observations from this comprehensive review indicate that PV does not preclude successful pregnancy. Critical outcomes measured are probably similar in women who have PV before pregnancy or develop it during pregnancy. The incidence of neonatal pemphigus was 38%, fetal mortality was 9.8% and post-partum flares occurred in 37% of patients. These observations correlated with lack of control of maternal disease during pregnancy. Frequent maternal and fetal monitoring should be considered. Topical therapy should be encouraged since it may decrease the need for higher doses of CS. Azathioprine appears to be the safest immunosuppressive agent in these patients. When available and affordable intravenous immunoglobulin (IVIg) can provide significant benefits. Mucocutaneous disease had more significant consequences than only cutaneous disease. However 70-80% of the patients had oral disease. Therefore oral health care providers should be aware of pemphigus in pregnancy. In some patients, PV may persist after pregnancy, especially if it was present and active post-partum. Patients with PV in a child-bearing age should be advised to get pregnant when PV is in remission. Optimal outcome requires team-work.