Pregnancy & Rheumatic Disease

It was standing room only this afternoon as Lisa Sammaritano provided a comprehensive review of pregnancy in rheumatic diseases. Connective tissue diseases (CTDs) should be well-controlled for at least 6 months prior to conception, with medications that are safe to use in pregnancy. Patients with underlying disease-related organ damage may need to think about options outside of pregnancy, including using a surrogate carrier or adoption. Medications should be reviewed to ensure that they are safe in pregnancy. Antibody status including antiphospholipid antibodies and Ro/La antibodies should be evaluated.

We know that RA typically improves during pregnancy. Old data suggests 70-75% will achieve remission during pregnancy whereas more recent studies suggest a rate of only about 50%. Interestingly, patients with seronegative disease have a higher probability of remission in pregnancy compared to those with seropositive disease. In well-controlled RA patients, pregnancy outcomes are similar to those in the general population. Prednisone use is associated with low birthweight and preterm delivery. MTX should be discontinued prior to pregnancy, although the time to do this is controversial. TNFi's may be continued through pregnancy, but should probably be stopped around 30 wks, when immunoglobulins are actively transported across the placenta. If TNFi's are continued through pregnancy, live vaccines should be avoided for the 1st 6 months of life. Low-dose prednisone can be used in the 3rd trimester, and stress dose steroids can be considered at delivery if needed. Post-partum flares are common, and there should be a management plan in place prior to delivery. Perhaps we should be continuing sulfasalazine and hydroxychloroquine throughout pregnancy to minimize peripartum and postpartum flares.

Patients with other forms of peripheral inflammatory arthritis seem to behave similarly to those with RA. In SpA patients, axial symptoms often worsen throughout pregnancy, but it is hard to differentiate between normal pregnancy symptoms and back flares.

Sjogren's patients tend to do relatively well during pregnancy. Antibodies to SSA and SSB are associated with risk of neonatal CHB and neonatal lupus, which may be reduced with hydroxychloroquine during pregnancy.

We have little data on other CTDs. Early studies of patients with systemic sclerosis demonstrated a high maternal mortality (10%) from hypertension, renal failure and cardiovascular disease. More recently, we have found that these patients do relatively well, particularly if their blood pressure is well controlled. Risk of renal crisis is associated with early diffuse disease. For this reason, pregnancy should be delayed in early disease, since this is when the risk of renal crisis is highest.

Inflammatory myositis has been associated with overall good maternal and fetal outcomes. The most severe risk is with patients who have new onset of disease during pregnancy. Pregnancy complications are more frequent in PM than DM, particularly in those with joint involvement and positive Jo1 antibodies. Management should be individualized and includes prednisone, AZA, and IVIG.

Vasculitis in pregnancy has been associated with a higher risk of preterm birth and miscarriage. Flares can occur but maternal death is rare if disease is well-controlled prior to pregnancy. In Takayasu's disease, maternal complications can occur in up to 44% of cases. The most common adverse events include hypertension and preeclampsia. Rare complications include CHF, MI, CVA, aortic aneurysm formation or rupture, all of which have the highest risk at the time of delivery. If possible, pre-conception MRA could be helpful to assess extent of disease. In addition to obstetrics and obstetrical medicine, anesthesia involvement may be required, particularly at the time of delivery.

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