Drugs in Pregnancy                                                                                                   

Pregnancy in RA

Pregnancy fortunately is usually kind to the patient with RA, and the patient usually goes into a partial remission (70% of patients) for its duration, only to get the problem again afterwards- often with worsening severity. My approach is the less the medications the better. Therefore I usually stop everything. The patient who has activity of disease in the pregnancy 30% of patients), I think is most safely managed with low dose cortisone - less than 10mg of prednisone. This is considered to be the safest route in the pregnancy.

Let's discuss individual drugs

NSAIDS: Salicylates - are toxic to the fetus in high dose in animal studies, but not found to cause congenital malformations. But they cause other problems - anemia, prolonged gestation, prolonged labor, peripartum hemorrhage, haematoma / preterm fetal hemorrhages. They must therefore NOT be used in the last several weeks of pregnancy. They are usable in low dose early in pregnancy. The other commercial NSAIDS - can suppress labor Result in premature closure of the fetal ductus arteriosus - required by the fetal circulation. Must not be used in the last several weeks of pregnancy.

Cortisone - has shown to be relatively safe. There is an increase in cleft palate in animals but this has not been shown in humans. High dose causes growth retardation. This would be considered the second line agent of choice after dispirit. BUT the dose must be low. Local cortisone injections ARE SAFE and may be very effective.

Gold- this crosses the placenta. Is teratogenic in fetal mice - but again not seen in humans. Nevertheless I Wouldn’t use it.

Antimalarials...These cross the placenta and theoretically may cause ear and retinal damage. I Wouldn’t use it.---stop if pregnant. Studies however do not show definite problems and many sources maintain that the drug can be used if absolutely necessary.

Penicillamine --Can penetrate the placenta. Fetal connective tissue problems have been described. I wouldn’t use it

Azathioprine.. Reports of growth retardation are seen. Blood abnormality -lymphopenia is seen in the fetus. Transient chromosomal changes can also occur -- Advise against use

Sulphasalazine - No evidence of damage to the fetus is documented. In fact most information comes from patients with inflammatory bowel disease and little information is available in patients with RA. However there are no reports of problems. Use should be restricted to those patients where it is considered as absolutely necessary.

Methotrexate / Chlorambucil / Cyclophosphamide...Can Cause congenital abnormalities, and are contraindicated. They should be stopped at least 3 months before the pregnancy.. If someone gets pregnant on these - do an ultrasound and amniocentesis, to exclude problems and STOP the drug.

NB People planning pregnancy should plan it with the help of the doctor.

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