**14. Pemfigus vulgaris during pregnancy**

PV is extremely rare in pregnancy. On the other hand, pregnancy may accelerate or increase PV, as reported in well-known autoimmune diseases such as systemic lupus erythematosus [47]. Babies of mothers with pemphigus may be affected by the disease in many different ways, from stillbirth to transient PV lesions in newborns, due to transplacental transmission of pathogenic anti-Dsg antibodies [48]. The more uncontrolled the disease in the mother and the higher the titers of Dsg antibodies in the mother's serum or umbilical cord blood, the worse the possible outcomes [48]. PV seen during pregnancy can affect the mother, delivery and fetus. While the disease exacerbates mostly in the first, second trimester and postpartum periods, it calms down in the third trimester [49]. The reason for this is probably the increase in the endogenous chorionic corticosteroid hormone and the resulting immunosuppression [50, 51]. However, no change is observed in some patients during pregnancy, and these patients may remain in remission [49]. The postpartum disease worsens in all pemphigus patients who are not treated during pregnancy [52]. If the disease worsens in the first trimester, medical termination of pregnancy may be considered. If the worsening of the disease occurs in the second or third trimester, steroids are a safe treatment option [53].

In the publications on the treatment of autoimmune bullous diseases in pregnancy, it is stated that topical/systemic steroids and AZA can be used safely. In a small number of case reports, it has been reported that rituximab, IVIg, and dapsone may also be safe [54]. AZA is the most commonly used non-steroidal immunosuppressant in pemphigus. If it is necessary to give, the lowest dose should be preferred to prevent fetal damage [55]. The pregnancy category is D. Cyclosporine is believed to be less effective in the treatment of pemphigus but is the most reliable agent in pregnancy [56]. MMF, cyclophosphamide, and methotrexate are drugs that are not preferred or even contraindicated during pregnancy [57].
