Immunomodulators in general

Immunomodulators include immunosuppressive and immunostimu-latory agents. Chemically defined immunosuppressants, such as aza-thioprine, cyclosporine A, mycophenolate mofetil, and tacrolimus, sirolimus, and everolirnus should be distinguished from monoclonal antibodies. This group includes basiliximab, bevacizumab, daclizu-mab, muromonab-CD3, natalizumab, ranibizumab, and palivizumab. Adalimumab, etanercept, bevacizumab, and infliximab are monoclonal antibodies against human tumor necrosis factor (TNF) n. Corticosteroids also belong to the immunosuppressant drugs (see Chapter 2.15). The group of iminunostimulatory agents includes the interferons, colony-stimulating factors, and Copolymer 1 (i.e. glati-ramer acetate).

Most clinical experience involves pregnancies after kidney and liver transplantation. Long-term therapies include azathioprine,

2.12

cyclosporins and tacrolimus in combination with glucocorticoids (usually prednisolone). If no rejection has occurrcd and if the transplantation has been performed more than 2 years before conception, the outcome of the pregnancy is likely to be good. Women with immunosuppressant therapy are more frequently delivered by cesarean section. More premature births, more children with intrauterine growth retardation and transient neonatal renal function disorders have been reported. However, there is no substantial indication for an elevated risk for congenital malformations or persistent functional déficits in prenatally-exposcd infants.

A study compared pregnancy outcome several years before and after transplantation. It was striking that some complications occurred in both groups with similar percentages - i.e. pre-eclampsia (22%), premature births (46%), lower birth weights (31%), small for gestational age (16%), and infant mortality rate (5%). Only the abortion rate was higher prior to transplantation than afterwards, but the adjusted odd ratios did not differ significantly. In neither of the two groups was there an increased rate of congenital malformations (Kâllén 2005). Therefore, it is conclusive that the complications are mainly due to the severity of maternal disease. The transplantation or the immunosuppressive therapy plays a minor part.

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