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AHPA - Update on the Safety of Pharmacotherapy of Rheumatic Disease in Pregnancy
Marlene Thompson
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February 5 2015 11:00 AM ET — via RheumReports 
This AHPA pre-course, presented by Dharini Mahendira, focused on the treatment of rheumatic disease during pregnancy and breast feeding. Rheumatoid arthritis typically becomes more quiescent during pregnancy and tends to flare after giving birth. There is a higher incidence of preterm births in women with RA (25%) compared to the general population (7%), and the babies also tend to be smaller.
There does not appear to be a difference in disease course during pregnancy in ankylosing spondylitis, although there is an increase in mechanical back strain issues during the 3rd trimester.
Management of inflammatory arthritis in pregnancy
NSAIDs may cause premature ductus arteriosus and decreased amniotic fluid. Therefore, women must stop taking NSAIDs before the end of the 2nd trimester (begin tapering at week 25 with discontinuation by week 32).
Plaquenil is considered safe throughout pregnancy and breast feeding.
Sulfasalazine may reduce sperm count but is considered safe in pregnancy and breast feeding.
There is low placental transfer with prednisone and methylprednisolone. Side effects of steroids may include oral facial clefting if taken during the 1st trimester and premature membrane rupture in the infant. Maternal gestational diabetes and hypertension may occur. For women on high doses of steroids before delivery, it is important to stress dose coverage at delivery.
Methotrexate is contraindicated during pregnancy. Therefore, women should discontinue use of methotrexate at least 3 months prior to conception. Men should also be switched to a different DMARD when trying to conceive.
Leflunomide is contraindicated during pregnancy. A wash-out protocol is indicated for women and men, which includes chlorstyramine 8 g tid for 11 days.
Use of biologics may be considered in women with active RA, AS, or PsA. Placental transfer of anti-TNF agents in cord blood appears to be highest with infliximab, adalimumab and golimumab. The lowest levels are with certolizumab and etanercept.
Does exposure to anti-TNFs cause immunosuppression in infants? Probably. Therefore, no live virus vaccines should be given in the first 6 months of life. This includes vaccines for varicella, measles, mumps, rubella, rotavirus, intranasal influenza and BCG.
Use of rituximab during the 2nd and 3rd trimester has been shown to contribute to hematologic abnormalities.
The decision to continue biologic therapy during pregnancy is based on maternal and fetal health. If a woman is able to stop the anti-TNF in pregnancy, then it should be stopped. If the disease becomes out of control, it is best to consider the health of the mother and child. In these cases, the anti-TNF should be re-started but stopped before the 3rd trimester. Remember, certolizumab and etanercept have the lowest placental transfer.
With respect to breast feeding, NSAIDs, steroids, anti-TNF inhibitors are all considered safe. Rituximab may cross into breast milk so it is best to stop this medication when breast feeding.
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About the Author
Marlene Thompson
Marlene Thompson is an Associate Clinical Professor in Physical Therapy at Western University and an Advanced Physiotherapy Practitioner in Arthritis Care. Marlene′s research interests include models of care, triage, advanced practice roles, and arthritis education.
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