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rheumatologic disorders in pregnancy

Complications: 1) increased risk of pre-eclampsia/eclampsia [1] 2) anti-rheumatic agents, especially DMARDs may be teratogenic Management: - preconception counseling in necessary - fertility of women with rheumatoid arthritis is compartable to normal patients - 75% of women with rheumatoid arthritis experience spontaneous remission of symptoms, generally beginning in the second trimester - discontinue DMARDs prior to conception - exceptions may be hydroxychloroquine & sulfasalazine [2] - most women can safely discontinue therapy for rheumatoid arthritis during pregnancy - discontinue methotrexate 3 months prior to conception [2] - low-dose prednisone, hydroxychloroquine & sulfasalazine may be used during pregnancy if necessary - NSAIDs may be continued during the first & second trimesters but should be discontinued in the third trimester because of the risk of premature closure of the ductus arteriosus in utero - TNF-alpha inhibitors (infliximab, etanercept, & adalimumab) & calcineurin inhibitors (tacrolimus, cyclosporine) may be continued during pregnancy [6] - abatacept, rituximab, & mycophenolate must be discontinued before pregnancy [6] - most pregnant women with rheumatoid arthritis experience a flare after delivery, thus DMARD therapy should be restarted immediately after delivery unless the woman is breastfeeding - with severe rheumatoid arthritis, breastfeeding should be avoided & DMARD therapy restarted

General

pregnancy disorder; obstetric disorder; pregnancy complication rheumatologic disease

References

  1. Journal Watch 24(14):115, 2004 Wolfberg AJ, Lee-Parritz A, Peller AJ, Lieberman ES. Association of rheumatologic disease with preeclampsia. Obstet Gynecol. 2004 Jun;103(6):1190-3. PMID: 15172851
  2. Medical Knowledge Self Assessment Program (MKSAP) 15,16,17. American College of Physicians, Philadelphia 2009,2012,2015
  3. Neeman N, Aronson MD, Schulze JE, Shmerling RH. Improving pregnancy counseling for women with rheumatoid arthritis taking methotrexate. Am J Med. 2009 Nov;122(11):998-1000 PMID: 19854323
  4. Barbhaiya M, Bermas BL. Evaluation and management of systemic lupus erythematosus and rheumatoid arthritis during pregnancy. Clin Immunol. 2013 Nov;149(2):225-35 PMID: 23773975
  5. Ostensen M, Forger F. How safe are anti-rheumatic drugs during pregnancy? Curr Opin Pharmacol. 2013 Jun;13(3):470-5 PMID: 23522967
  6. Seetharaman M (slide show with images) Rheumatoid Arthritis: In and Out of the Joint. Medscape. March 22, 2016 http://reference.medscape.com/features/slideshow/rheumatoid-arthritis