Pregnancy Advice for Women With Rheumatic Disease

Women with arthritis and other rheumatic diseases may worry about becoming pregnant or have concerns even after they are pregnant. Some women with rheumatic diseases may even be advised against becoming pregnant.

The worry comes from uncertainty about how a woman's rheumatic condition will affect the pregnancy as well as how pregnancy will affect her rheumatic condition. If you have arthritis and you are pregnant or if becoming pregnant is a consideration, here are some important things you should know.

With close observation and proper medical management, women with arthritis or other rheumatic conditions can have successful pregnancies.

It's important for pregnant women with arthritis to be under the care of both an obstetrician to manage their pregnancy and a rheumatologist to manage their rheumatic condition. Successful pregnancies are possible with the team approach, but not every pregnancy will be without complications.

The effect of pregnancy on rheumatic disease varies according to the specific condition.

Pregnancy accompanied by rheumatoid arthritis, lupus, antiphospholipid syndrome, and other rheumatic conditions have various characteristics and associated concerns.

• Women with rheumatoid arthritis typically have symptoms which improve during pregnancy but flare again after the birth of the baby. During the period of improvement, it may be possible to reduce or stop some arthritis medications.
• With lupus, typically there are mild to moderate flares which occur during the pregnancy, as well as after the birth.
• Antiphospholipid syndrome is an autoimmune disorder in which the body makes antibodies to its own phospholipids or plasma proteins. The syndrome may occur with systemic lupus erythematosus or another rheumatic disorder. With this condition, there is an increased risk of blood clotting, miscarriage, or hypertension during pregnancy. The time around delivery is most critical.
• Pulmonary hypertension which is sometimes associated with scleroderma, Sjogren's syndrome, lupus, and antiphospholipid syndrome can worsen with pregnancy; that's why pregnancy is not advised with this condition.
• Other rheumatic conditions, including scleroderma without pulmonary hypertension, polymyositis, dermatomyositis, and vasculitis, typically are not affected by pregnancy if the diseases are under control.

Women who have kidney disease related to vasculitis, scleroderma, or lupus are at increased risk of severe hypertension and preeclampsia.

The likelihood of a successful and healthy pregnancy is highest if kidney function and blood pressure are normal and the patient's rheumatic disease is inactive or in remission for at least 6 months prior to conception. This is particularly important for women with lupus. Conversely, women with abnormal kidney function, uncontrolled blood pressure, and active rheumatic disease are typically advised against becoming pregnant.

Congenital heart block can occur in a low percentage of babies born to women with anti-Ro antibodies.

Anti-Ro antibodies are most common in patients with lupus and Sjogren's syndrome. The antibodies get into the fetal circulation and damage the baby's developing heart, leading to a dangerously low heart rate. In some cases, the baby may ultimately need a pacemaker. Pregnant women with anti-Ro antibodies must be closely observed and monitored. Anti-La antibodies can also be problematic during pregnancy.

Inflammation, which is prominent during active rheumatic disease, and some medications used to treat inflammation can be problematic during pregnancy.

It would be optimal for women not to take any medications until they finish pregnancy and nursing. It's not an optimal situation though to be pregnant and have a rheumatic disease, so that must be considered. If medication which is needed to keep a woman's disease under control is taken away, the risk of uncontrolled disease must be weighed against potential risks to the unborn baby.

There is a consensus regarding which anti-rheumatic medications are safe or unsafe to use during pregnancy and lactation (milk production).

A group of obstetricians, rheumatologists, and internists with experience treating pregnant women with rheumatic diseases have agreed on which anti-rheumatic drugs are acceptable to use during pregnancy and lactation.

Drugs acceptable to use during pregnancy and lactation include:

• NSAIDs (nonsteroidal anti-inflammatory drugs) until week 32
• Azulfidine (sulfasalazine)
• Plaquenil (hydroxychloroquine)
• Corticosteroids (under 10 mg when possible)

Drugs acceptable to use during pregnancy but still debated during lactation include:

• Cyclosporine A
• Imuran (azathioprine)

Drugs which are unacceptable during pregnancy and lactation include:

• Methotrexate
• Arava (leflunomide)
• CellCept (mycophenolate)
• Cytoxan (cyclophosphamide)
• Anti-TNF drugs
• Rituxan (rituximab)

(Note; Anti-TNF drugs are increasingly appreciated as being safe during pregnancy and maybe lactation.)

Women considering pregnancy should have their rheumatic condition under control for at least 3 to 6 months before attempting to get pregnant.

It is recommended that all women with rheumatic disease be counseled by a rheumatologist and an obstetrician before attempting to get pregnant. That way their risk of complications can be assessed and a plan to manage both the rheumatic disease and pregnancy can be well-established.

Women at low risk for complications should still see their rheumatologist at regular 3-month intervals to maintain consistency with disease assessment and management.

Women who are considered high risk for complications should also have an obstetric team experienced with high-risk pregnancies. More frequent visits and monitoring will be needed as the pregnancy progresses. Conditions that make a pregnancy high risk include:

• Kidney impairment
• Heart conditions
• Pulmonary hypertension
• Restrictive lung disease
• active rheumatic disease
• In vitro fertilization
• Multiple births
• Previous obstetric problem