Q:

10/1/2012
How should I start IVIg (or possibly SQ) in a 34 year old pregnant patient (14 weeks), newly recognized agammaglobulinemia, quite healthy until several years ago (previously delivered one healthy child followed by one miscarriage), now with recurrent sinusitis and inflammatory lung disease that is not granulomatous (being worked up by our pulm docs). She has no antibodies to tetanus (vaccinated for a trip to India last year- acquired Salmonella) and no pneumococcal abs. No IgM, IgA, IgE, IgG. B lymphocytes 47 (half the expected minimum range in our lab). Additional w/u pending, but I do not want to delay the IVIg.

Whereas I have many CVID patients who have become pregnant (and I am comfortable with this), I have never started anyone de novo on immunoglobulin at 14 weeks gestation. She had gestational diabetes the last pregnancy. My inclination is to use Gammagard 5% (IgA depleted agent), split the first dose in half, one week apart, to minimize the volume, sugar load, osm, and keep the max rate lower. Or should I just use weekly SQ? Thanks so much for any input.


A:

Thank you for your inquiry.

As you can see from the abstracts copied below, immunoglobulin replacement therapy administered during pregnancy is safe, and there is much literature supporting its use.

Thank you again for your inquiry.

The American Journal of Medicine
Volume 76, Issue 3, Part 1, 30 March 1984, Pages 73–77
Use of intravenous immune globulin in pregnant women with common variable hypogammaglobulinemia.
•Ricardo U. Sorensen, M.D.
•J.Walton Tomford, M.D.1,
•Michael T. Gyves, M.D.1,
•Nancy E. Judge, M.D.1,
•Stephen H. Polmar, Ph.D., M.D.1
Abstract
Two patients with commonvariable hypogammaglobulinemia were treated with immune serum globulin during pregnancy. An intravenous immune serum globulin preparation was used in the last trimester of pregnancy. Both patients tolerated this preparation well and had an uneventful pregnancy. The two term newborns were healthy and had cord blood IgG levels likely to be the result of transplacental transfer of the intravenous immune serum globulin preparation. During pregnancy there is an increase in the IgG distribution space due to plasma volume expansion. Therefore, pregnancy is an indication for these immune serum globulin preparations that can be administered at high doses intravenously in order to confer adequate protection to the mother and the newborn

Arch Gynecol Obstet. 1996;258(3):155-9.
Intravenous immunoglobulin replacement therapy for common variable immunodeficiency during pregnancy.
Osada H, Morikawa Y, Nishiwaki T, Sekiya S.
Source
Department of Obstetrics and Gynecology, Chiba University School of Medicine, Japan.
Abstract
Patients with common variable immunodeficiency (CVID), characterized by impaired antibody production, have a high susceptibility to bacterial infections and need supplements of immunoglobulin G (IgG). We report two pregnancies in a woman with CVID. Differences in the outcome of the two pregnancies suggest the need for adjustment of replacement therapy during pregnancy.

J Perinatol. 1994 Mar-Apr;14(2):114-7.
Intravenous gamma globulin administration to common variable immunodeficient women during pregnancy: case report and review of the literature.
Schaffer FM, Newton JA.
Source
Department of Pediatrics, State University of New York at Buffalo 14222.
Abstract
Women with common variable immunodeficiency have decreased serum concentrations of all immunoglobulin isotypes. Their offspring are at a high risk for the development of neonatal infection caused by the minimal quantity of maternal immunoglobulin G (IgG) transplacentally transported during pregnancy. These patients are usually given frequent doses of exogenous IgG during the third trimester to increase the amount of IgG transported to the fetus. In this article, we describe the results of initiating a therapeutic regimen of high doses (400 mg/kg) of intravenous gamma globulin every 3 weeks starting in the first trimester of pregnancy for a woman with common variable immunodeficiency. In contrast to most reports, this regimen enables the patient to attain high serum IgG levels early in pregnancy, thereby decreasing the possibility of perinatal sepsis. In addition, the need for frequent administration of intravenous gamma globulin during the third trimester is bypassed with the attainment of protective IgG concentrations in the newborn infant.

Clinical uses of intravenous immunoglobulin in pregnancy
•Ann L. Clark, MD,
•Stanley A. Gall, MD
AbstractIntravenousimmunoglobulin was licensed for use in the United States in 1981. Currently, there are only a few Food and Drug Administration–labeled indications for intravenousimmunoglobulin, but up to 50 “off-label” uses are reported in the literature. The obstetric literature contains numerous reports on intravenousimmunoglobulin therapy during pregnancy. This article reviews the properties, pharmacokinetics, mechanisms of action, and side effects of intravenousimmunoglobulin, as well as the reported uses of intravenous immunoglobulin during pregnancy. (Am J Obstet Gynecol 1997;176:241-53).

Sincerely,
Phil Lieberman, M.D.


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